Opiate Use and Misuse in Oregon

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Opiate Use and Misuse in Oregon Efforts from a
Healthcare for the Homeless Clinic
Rachel Solotaroff, MD, MCR Medical Director,
Central City Concern May 2, 2013
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Objectives

• Brief introduction of the opiate crisis in our
  community and in our clinic
• Our process as a clinic and a community in
  understanding and addressing this crisis
• Lessons learned

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Disclosures

• No financial relationships to disclose
• I am a clinician and colleague not an expert
• I am an incrementalist not a trailblazer

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background
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Central City Concern
CCCs Mission To provide comprehensive
solutions to ending homelessness and achieving
self-sufficiency

• Continuum of integrated services
• Affordable housing
• Addictions treatment
• Mental health services
• Recovery support
• Employment services
• Primary care

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Old Town Clinic

• Integrated into CCC in 2001
• Healthcare for the Homeless Clinic
• 3500 patients 15,000 PCP visits
• 35 percent uninsured
• 99 percent at 100 FPL or below
• 60-80 percent homeless
• High prevalence of addiction mental health
  disorders
• Internal medicine integrated BH, Pharmacy OT
• Strong complementary medicine department (ND,
  Acup)
• Social medicine curriculum with OHSU Dept. of
  Medicine
• Other robust academic partnerships (Pharm,
  PMHNP, OT)

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Opiate use and abuse in Oregon Where we stood
in 2008
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Deaths due to Drug Poisoning in Oregon
Oregon Health Authority, Office of Disease
Prevention and Epidemiology
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Hospitalizations
Oregon Health Authority, Office of Disease
Prevention and Epidemiology
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Whos At Risk?
Oregon Health Authority, Office of Disease
Prevention and Epidemiology
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The Role of Methadone
Supportive Housing
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Methadone Grams Sold and Death Rate.
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Factors Among Methadone Decedents

• 41 prescribed methadone 30 no Rx
• Prescriptions 43 pain 26 methadone
  maintenance
• In 77, abuse contributed to death
• 75 history of substance abuse
• 21 history of substance abuse treatment
• 52 history of mental illness
• Sample N56

Oregon Health Authority, Office of Disease
Prevention and Epidemiology
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Pain Medication Misuse

• 2013 Oregon is THE highest state for
  nonmedical use of prescription pain relievers
• 6.4 of all persons gt12 years
• 7.4 of persons 12-17 years
• 15 of persons 18-25 years

2008 Oregon is 5th highest state for nonmedical
use of prescription painkillers 6.6 of persons
gt12 years 8.2 of persons 12-17 years 17.9 of
persons 18-25 years highest in any US state
SAMHSA- 2008, 2013 National Survey on Drug Use
and Health, state level data
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Summary

• 53 of drug overdoses in Oregon associated with
  prescription opioids
• Overall 540 increase in since 1999
• Methadone 1,500 increase in deaths since 1999
• 33 of all drug-related deaths (licit and
  illicit) associated with methadone

Oregon Health Authority, Office of Disease
Prevention and Epidemiology
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Addressing the epidemic
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Back at Home

• Providers
• - Aware of lack of evidence and risks of
  opiates
• - Trying to grapple with patient expectation
  that a pill will make me pain free
• - Lack of patient engagement with alternative
  modalities for pain management
• - Clinic sessions clogged with patients needing
  refills
• - Calls from the Medical Examiner when a death
  occurred
• Staff
• - Struggling with phone calls and walkins for
  refills
• - Managing behavioral issues when refills not
  granted as expected

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Step 1 Establish Uniform Oversight and
Prescribing Guidelines

• Controlled Substances Review Committee
• Reviews all episodes of serious misuse or
  misconduct
• Reviews all requested new starts on chronic
  opiate therapy
• Provides guidance for complex pain management
  cases
• Early prescribing guidelines
• When to refer to CSRC
• Prescribing to patient on methadone maintenance,
  in AD treatment
• Process for new opiate starts
• Other contra-indicated substances

Chelminski et al. BMC Health Services Research
2005, 53 
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Step 2 Integration of non-pharmacologic pain
management and addiction

• Occupational Therapy/Group Visits
• Naturopathic Medicine/Acupuncture
• Education series for providers
• Trigger Point Injections
• Musculoskeletal Exam
• Physiatry 101
• Integrated Chronic Pain and Addictions Program
• Hot Sauce
• Led by CADC
• 12-week curriculum
• Focus on triggers, relapse prevention,
  alternative pain management

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Patient, Staff and Provider Response

• Providers
• Relieved at no longer having to go at it alone
  makes being strict less personal enables
  discussions around public health concerns
• Appreciative that we were no longer a juice
  bar still feel patients need to embrace
  acceptance of their responsibility in pain
  management
• Unclear of net benefitof Hot Sauce program
• Staff
• Perceived decreased burden of phone calls and
  walk-ins
• Patients
• Some felt groups were supportive and helpful
  others felt they were a waste of time
• Empathy with providers over having to answer to
  some committee

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Step 3 Community-Wide Approach

• Multnomah County Health Department Guidelines
  2011
• Instituted dosage ceiling limit on chronic opiate
  therapy
• Established absolute contra-indications to COT
• Established conditions for which chronic opiates
  could not be prescribed
• Community Response Get on the train, or get run
  over by the train
• Oregon Prescription Drug Monitoring Program, 2011

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Our Current Controlled Substances Policy

• ABSOLUTE CONTRAINDICATIONS
• Any history of diversion
• No functional improvement
• No complete workup for pain diagnosis
• Active substance abuse
• No non-pharmacological modalities tried, or
  unwillingness to try them
• Greater than 120mg daily of morphine equivalents
  (40mg methadone)
• Use of marijuana (licit or illicit)

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Our Current Controlled Substances Policy

• RELATIVE CONTRAINDICATIONS (moving toward
  absolute)
• High opiate risk score
• No BH screening or undertreated BH condition
• History of suicide attempt
• Currently on methadone maintenance
• History of misuse/overuse
• Concurrent use of benzodiazepines
• While we have made judicious exceptions in these
  areas, evidence and clinical experience are
  showing poor results

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Strengthening Our Systems and Supports
Graduation Criteria -- Level 3 completion of
Hot Sauce -- Level 2 Progress toward
goals Engaged in Behavioral health (if
nec) Reduction in opiate dosage

• High addiction risk
• Brief relapse
• Early Recovery
• Minimal support

Risk Management -- UDS q 3 months -- pill count
q 6 months -- ADRs q 3 months -- PDMP
annually
Level Two

• Low addiction risk BUT
• Low self-management
• Low social supports
• Low function/activity

• Low addiction risk
• Good self-management
• Good support
• Good function/activity

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4 weeks
Income Employment Volunteering, Train
ing, Jobs
PCP Appt 1
PCP Appt 2
HP, Record Review, UDS, OPDMP query
If BH Screen
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(No Transcript)
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Lessons learned
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Lessons Learned

• Absolute necessity and benefit of guidelines and
  review committee to which we all adhere
• Cognitive dissonance between population level
  data and the patient sitting in front of you
• While its great to have so many wellness
  resources, patient still needs to be engaged and
  receptive
• Addictions/Chronic Pain program such as Hot
  Sauce is innovative, but integration of suboxone
  has been the game-changer
• Need better focus on/understanding of
  intersection of trauma, addictions and chronic
  pain

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Thank you!