september 6–9, 2018

Opioid Crisis:

New Approaches for the Long-Term Health and Well-Being of Patients and Their Communities

Sarah Shoemaker, PhD, PharmD

Health Services Researcher
Abt Associates

As the national emergency of opioid addiction continues to take a toll on Americans across all the States, the Forum heard an update on the scope of the current problem and solutions that are working in some States. Sarah Shoemaker, PhD, PharmD, of Abt Associates, a research and consulting company, provided the background for the session, noting that, in 2016, the number of overdose deaths involving opioids was 5 times higher than in 1999. On average, 115 Americans die every day from an opioid overdose, Dr. Shoemaker reported. The 2016 National Survey on Drug Use and Health found that 2.1 million Americans had opioid use disorder, 11.5 million admitted to misusing opioids, and 2.1 million said they misused opioids for the first time in that year.

Where are we at? Overdose

SOURCE: National Vital Statistics System Mortality File.

Opioid addiction is a complex problem with a range of trajectories, Dr. Shoemaker noted, and it requires a multi-sector response involving healthcare, treatment, the justice system, first responders, child and family services, and the community. As State Senators, you have a critical role in driving legislation and policies for the States to address the opioid epidemic, Dr. Shoemaker observed. Her recommendations focused on:

Set limits on opioid prescribing

Improve data and information sharing

Increase access to and capacity for medication-assisted treatment (MAT) for addiction

Increase availability of the overdose reversal drug--naloxone

Intercept people everywhere to get them into addiction treatment

Set Limits on Opioid Prescribing

Using opioids to treat acute pain can lead to long-term use. The risk of long-term opioid use increases sharply after the 3rd and 5th day of the initial prescription. According to the CDC, long- term use also increases with a second prescription or refill, a 700 morphine milligram equivalents (MME) cumulative dose, and an initial 10- or 30-day supply.

Probability of Continued Opioid Use

SOURCE: Centers for Disease Control and Prevention, 2017.

The probability of long-term use increases based on the length of an initial prescription.

In about a fourth of US counties, enough opioid prescriptions were dispensed for every person to have one. An estimated 1 out of 5 patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings. (Daubresse et al., 2013) And primary care providers account for about half of opioid pain relievers dispensed (Daubresse et al., 2013).

Where are we at? Prescribing

SOURCE: CDC Source: QuintilesIMS Transactional Data Warehouse 2006–2016.

One approach to rein in the opioid epidemic is to change prescribing practices among providers. The overall national opioid prescribing rate declined from 2012 to 2016, and in 2016, the prescribing rate had fallen to the lowest it had been in more than 10 years at 66.5 prescriptions per 100 persons (over 214 million total opioid prescriptions).  To date, 28 States have enacted laws to limit opioid prescribing with statutory limits ranging from 3 to 14 days, or placing limits on total morphine milligram equivalents (MME) prescribed. Other States have other entities imposing limits.

Improve Data and Information Sharing

The Centers for Disease Control and Prevention (CDC) has funded 29 State health departments to maximize their Prescription Drug Monitoring Programs (PDMP) and enhance opioid surveillance, and enable data-sharing on overdoses. For example, providing prescriber “dashboards” to identify outliers who prescribe more than their peers.

Most States have a PDMP, Dr. Shoemaker observed; however, accessing and sharing the data especially across states is still a work-in-progress. Integrating the PDMP into electronic health records with one-click access or delegating authority to additional staff, such as nurses, will enhance PDMP use, Dr. Shoemaker noted.

Increase Access and Capacity for Medically Assisted Treatment (MAT)

Another significant structural problem is the shortfall of effective substance abuse treatment capacity in the US, Dr. Shoemaker said. An estimated 19.9 million adults aged 18 or older needed substance use treatment in 2016, including 7.3 million adults who needed treatment for an illicit drug use problem and 15.1 million who needed treatment for an alcohol use problem.  Only 2.1 million adults received substance use treatment at a specialty facility during that year.

To meet this unmet need and expand access, States need to build and increase the addiction intervention workforce. Dr. Shoemaker recommended that States leverage county agencies and large, regional providers, as well as peer support specialists. States may require providers to offer MAT and can increase the number of providers in primary care who treat addiction. She advocated for expanded coverage of addiction treatment, perhaps through Medicaid programs.

Funding for State efforts is also available through a variety of Federal programs. CDC funding has been used by the States to improve coordination and interventions among the community, health systems, law enforcement, and payers, so that people with opioid misuse or addiction have access to treatment.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has also funded a number of programs including training first responders on overdose treatment and working with community health systems to expand access to medication-assisted treatment (MAT) for opioid addiction, increasing identification and treatment of pregnant women with addiction, and increasing long-term support for recovery.

The Health Resources and Services Administration (HRSA) also has funded rural community health centers to increase access to MAT through grants for health centers and to rural communities to implement opioid use disorder prevention programs, as well as treatment and recovery interventions.

Increase Availability of Naloxone

Naloxone is a drug that can reverse an opioid overdose. Dr. Shoemaker recommended that States simplify the process for obtaining naloxone and revise their naloxone laws to expand who can receive the drug, (including third-party prescriptions for family, friends, and professionals) and who can distribute the drug, such as allowing pharmacists or non-medical professionals to distribute it without a prescription.

[Note:  Naloxone is available with a prescription in any State; however, now the drug can be purchased over-the-counter (without a prescription) in 46 States from some retailers. A prescription is still required in Delaware, Hawaii, Maine, Michigan, Nebraska, Oklahoma, and Wyoming.  See: https://www.samhsa.gov/capt/sites/default/files/resources/naloxone-access-laws-tool.pdf]

Intercept People Everywhere to Get Them Into Addiction Treatment

Dr. Shoemaker reported on an innovative “Angel Program” first pioneered in the Gloucester, Massachusetts police department and now replicated in 160+ similar programs. When opioid addicts are brought into a police station, instead of being charged for a crime, they are escorted by an “angel” in the local police station to a treatment center. Some programs provide significant wrap-around services or a peer support person to shepherd the person through treatment and recovery.

Delaware’s Three-Year Action Plan
to Combat Opioids

Bethany Hall-Long, PhD, RNC, FAAN

Lt. Governor

Delaware and Professor of Nursing and Joint Faculty in Urban Affairs
University of Delawares

Delaware’s Lt. Governor, Bethany Hall-Long, reported progress on the State’s “Three-Year Action Plan” to combat opioid abuse. The Plan is a roadmap for the Governor and members of the General Assembly to address the challenges of the epidemic. The integrated plan addresses prevention, treatment and recovery for mental health, substance use, and co-occurring disorders.

According to Dr. Hall-Long, Delaware has about 30,000 adults and 9,000 children suffering from a substance use disorder or a mental illness. As many as 1 in 5 Delawareans will suffer from some form of a mental illness in any given year. In the State’s prisons, 82% of inmates have a mental illness or substance use disorder, making the prison system the largest treatment provider. There were more than 300 overdose fatalities in 2016, an increase of 35% over 2015.

In the 9 years that Dr. Hall-Long served in the State Senate, she introduced about 1000 bills related to healthcare and chaired the Governor’s Mental Health Task Force. “Find a champion in the legislature to take the lead on opioid legislation,” Dr. Hall-Long advised the Forum. Most of the Senators at the Forum had sponsored some legislation related to opioid abuse.

Several routes lead to opioid addiction, she observed. Addiction can be the result of overprescribing for pain management, but it also arises from people self-medicating to deal with mental health issues such as anxiety, depression, or bipolar disorder.

Opioid abuse affects the States’ economic health in many ways, from the cost of care for overdose survivors left with physical and mental impairments, to the costs of the justice and health systems, loss of worker productivity, and the social costs of families destroyed by addiction.

Delaware’s Behavioral Health Consortium

A Mental Health Taskforce was convened to explore the causes for increasing rates of addiction and mental illness and to evaluate solutions. The Taskforce identified several factors contributing to the increase including the stigma associated with mental illness. A number of structural deficiencies also were recognized including a lack of funding to meet the costs of preventing or treating addiction, lack of early intervention, lack of trained personnel to address the issue, lack of access to treatment, and gaps in service delivery and transitions of care.

A fragmented spectrum of interventions had evolved to address the diverse aspects of the opioid epidemic, Dr. Hall-Long noted. A Senate Bill established the Behavioral Health Consortium to coordinate the State’s private and public bodies to reduce current silos, establish greater access to care, and combat addiction and improve mental health services.

The Consortium gathered input from grassroots advocacy groups, non-profits, providers, health systems, first responders and community members to collaborate to tackle the the opioid crisis. Community forums sponsored by the Behavioral Health Consortium saw packed audiences and produced hundreds of recommendations to address the opioid epidemic.

The best ideas come from the streets, from the people, the families, and the communities that are affected. Community Forums were guided by two questions:

Question 1:  When you think about mental health and addiction (behavioral health), how behaviors affect health, and how people feel about their health where you live, what is happening in your community?

Question 2:  What is the number 1 thing we in Delaware can do to deal with mental health related issues and the issues we are facing in behavioral health?

Community Action

Education was a priority, therefore, public awareness programs and education campaigns were deployed statewide. The Consortium also recommended expansion of K-5 Wellness Centers, targeting Title I funded elementary schools within identified risk “hotspots.” By partnering with health systems and Primary Care Providers, they sought to create greater access to care for vastly underserved populations, and developed a comprehensive Community Health Worker Program with culturally competent individuals to perform basic health assessment and care. This created a critical touch point for individuals suffering from addiction.

Criminal Justice Approaches

Some of the recommendations affected the criminal justice system. “You want to get the bad guys,” Dr. Hall-Long acknowledged. To accomplish this, the Prescription Drug Monitoring Program (PDMP) was strengthened to identify “doctor shoppers,” people who go to multiple doctors to get opioid prescriptions, and also to pinpoint providers who overprescribe opioids.

With the PDMP ramped up, the Justice Department’s Overdose Fatality Review Commission receives geocoded information about where people are dying from overdoses and from what drugs. This helps pinpoint where drugs are prevalent and allows targeting high impact areas and properly dispatching resources to these areas, while working with providers and first responders. Furthermore, sellers who mix fentanyl with heroin now face murder charges.  A 911 Good Samaritan law made it possible for someone to bring a person who had overdosed to a hospital emergency room, without risking legal action.

Creating A System of Care

Dr. Hall-Long stated that addressing the opioid epidemic also requires a strong focus on mental health issues. Many of the community’s recommendations focused on the larger issues of mental health. The public focused on two themes: first, stop people from overdosing and dying; and, second, improve access to treatment. Community input made it clear that providing greater access to care transforms those who are affected by the opioid epidemic.

To meet these objectives, Delaware established the nation’s first integrated overdose system of care. The system integrates first responders, police departments, fire service, paramedics, emergency rooms, and wrap-around service providers so that individuals who recover from an overdose receive a multifaceted approach to care, addressing both their medical and social needs, to prevent a relapse. The program sets up standards for “stabilization centers” that take over caring for overdose patients once they are released from hospitals or by first responders. “Delaware is the first State in the nation to create a system that, instead of sending someone home or to jail, will hopefully get them into treatment,” Dr. Hall-Long said.

Funding the Programs

Current funding for the Delaware Division of Substance Abuse and Mental Health (DSAMH) is $23 million. The Behavioral Health Consortium is allocated an additional $5 million, which funds the Delaware Health Information Network and supports the transformation needed to establish the system of care. Funding also was generated via Medicaid expansion and local school district dollars were used for school education programs. Funding generated by CMS waiver and hospital “community benefit” dollars was allocated to Community Health Worker programs.

Delaware’s initial Three-Year Action Plan is being led by six Committees focused on:

1. Access & Treatment

2. Changing Perceptions & Stigma

3. Corrections & Law Enforcement

4. Data & Policy

5. Education & Prevention

6. Family & Community Readiness

“We anticipate that early intervention, coordinated treatment from health providers, and increased programs will directly impact population health outcomes,” Dr. Hall-Long concluded.

Tennessee Commission on Pain and Addiction Medicine

David M. Stern, MD

Robert Kaplan Executive Dean and Vice-Chancellor for Clinical Affairs
for the University of Tennessee’s College of Medicine

Dr. David Stern’s introduction to his presentation was heart-breaking, as he described his son’s death from an opioid overdose 10 years ago. This tragedy led to Dr. Stern’s career commitment to finding solutions to the opioid epidemic. Dr. Stern, who serves on the Tennessee Commission on Pain and Addiction Medicine, reported on the Commission’s formulation of evidenced-based pain and addiction medicine competencies for management of pain, proper prescribing of pain medication, and diagnosis and treatment of those suffering from addiction.

Hub: focal point of addiction medicine (ADM) expertise

Substance use disorder and mental health issues are interrelated and their treatment must be integrated, Dr. Stern noted. Like cancer care, effective treatment for substance use disorder requires integrated care from multiple specialists, including addiction specialists, case managers, mental health counselors, and peer navigators. People are going to relapse, he said, we need to have an integrated approach that re-routes them back into multidimensional and multifactorial treatment programs.

Several Hubs are established throughout the State and include addiction medicine specialists, behavioral health specialists, social workers, nurse care managers, case managers, and peers. They participate as integral partners in formulating patient treatment plans and steering patients to treatment centers best-suited to their needed level of care.

The Hubs leverage telecommunications technologies to provide tele-education, tele-consultation, and tele-medicine resources to law enforcement, vulnerable populations, emergency medical services personnel, and healthcare providers, as well as to community sites such as churches, jails, courts, treatment centers, and veterans groups.

Durable Recovery

A key theme for Dr. Stern is the concept of durable recovery. As a medical professional, he recognizes that “substance/opioid use disorder is a chronic, relapsing, medical disorder with episodic acute events (overdoses), which requires comprehensive individualized treatment plans and wrap-around services to keep a child from overdosing.”

Durable recovery requires significant life changes, including moving people out of environments that foster drug abuse and providing education, workforce preparation, and job placement. “If people get launched into a career that is not just a minimum wage job but a real career, they don’t want to risk losing that position,” Dr. Stern observed. “They are able to develop medical, social, and financial assets that they value and that act as a deterrent to relapse.”

To achieve this, the program has partnered with Tennessee Colleges of Applied Technology (TCATs) to enroll and train people who participate in the substance use recovery programs. The results have been impressive. Among graduates who were matched with a Peer Navigator as a mentor, 80% have been successful in finding and keeping job placements. If a relapse occurs, the Navigator gets the graduate back into treatment.

Peer Navigators

Tennessee’s program leverages the power of peers for addiction recovery support. Peer Navigators are themselves on the continuing journey of recovery and are sensitive to addiction issues. They believe that substance use disorder is a chronic relapsing disease and that recovery is possible. As advisors and mentors, they see without stigma and are able to provide empathetic and respectful support. They can establish immediate rapport and have the capacity to listen, understand and present hope.

Peer counselors receive training comparable to masters-level counselors. They have personal relationships with law enforcement and emergency services who can call them whenever someone in their care is ready for treatment. The Peer Navigator consults with the Hub personnel to identify the appropriate treatment center, accompanies the person to a treatment center and supports them in accessing needed housing, employment, and educational services to change their lives. This program has the potential to be economically feasible and sustainable, Dr. Stern reported.

Mobile Community Health Team

As understanding of the social determinants of health and population health management improves, it has become apparent that the addiction specialists have to be located where they are needed. Therefore, Tennessee developed a Mobile Community Health Team that includes Nurse Care Managers and Behavioralists who work in the communities where substance use disorder is highest. They coordinate with primary care providers and Hub services to provide better accessibility and quality of care for patients with substance use disorder.

Community Engagement

Tennessee’s integrated program to address substance use disorders engages the whole community.

Legislation

Stressing the need for reimbursement, Dr. Stern pointed out, “If treatment is paid for, people with substance abuse disorders will seek it out.” He also emphasized the need to incentivize an integrated, comprehensive approach based on an outpatient/office treatment model. “What is the critical infrastructure you need to create an integrated system of care?” he asked. Many States have agencies working in silos to address the opioid epidemic. They need to share information and training, Dr. Stern pointed out. “This is an exercise in community medicine,” he concluded.

For more on the Opioid Crisis: <more>

Discussion

Sen. David Long (IN): What are the economic consequences of the opioid crisis, and how are States funding these programs?

Dr. Hall-Long: It’s critical to get boots on the ground to stop the bleeding. Delaware allocated $250,000 to a peer mentor program and insurance companies matched that. In addition, pharmaceutical companies may provide naloxone. The $50 cost for naloxone can prevent $500,000 in long-term recovery costs, or in Neonatal Intensive Care Unit (NICU) costs for a baby born with Opioid Abstinence Syndrome.

Dr. Stern: The Council of Economic Advisers estimated that, in 2015, the economic cost of the opioid crisis was $504.0 billion, or 2.8% of GDP that year. The biggest part is the loss of productivity in the workforce, plus the costs of expensive hospital and emergency department visits. Community-based programs of prevention and treatment can prevent these visits and accrue substantial savings.

Sen. Robert Stivers (KY): The key issue is that the opioid crisis affects the whole economy of the state. It creates broken households, leaving children vulnerable and interfering with their education. The crisis raises the costs of incarceration and strains the judicial system. When you consider that 70% of opioid deaths are Medicaid recipients, it suggests the government is the biggest payer for drugs that are killing people. Are there alternatives to opioids so we can reduce the number of avenues that lead to addiction? Is marijuana a gateway drug or an alternative for pain management?

Dr. Shoemaker: Different States see marijuana as an alternative for pain management. The FDA guidelines on chronic pain recommend using alternative non-drug pain management approaches, but often these are not available, especially in rural areas.  The key is to identify people who have received long-term opioid prescriptions and follow them to determine if they need medically-assisted treatment to stop using the opioids.

Dr. Stern: Marijuana does have some medical uses such as for hyperemesis and migraine. But it is a dangerous drug and is not appropriate for young people whose brains are still developing. Opioids are meant for short-term pain relief. The critical need is for integrated pain management and addiction prevention programs.

Dr. Hall-Long: We need greater enforcement of parity laws requiring insurers to pay for mental health services, including opioid addiction treatment, on the same basis as other medical or surgical benefits. Some States are suing the pharmaceutical companies who market opioids and may be looking for an Opioid Settlement similar to the Tobacco Settlement.

Sen. Ginny Burdick (OR): There have been compelling anecdotes about the use of marijuana to manage pain. There are cannabidiol (CBD) formulations with low concentrations of the psychoactive element that have been used to treat pain and seizures. Furthermore, there is no known lethal dose of marijuana. But marijuana is currently a Schedule 1 drug. The Federal government should change it to a Schedule 2 drug so that research can be done to determine its potential for pain management, as well as to assess its risk for addiction.

Dr. Stern: Cannabinoids have complex actions at a number of receptors that are poorly understood. We don’t know if its effects can be closely controlled or regulated. The risk is that long periods of marijuana use while the brain is developing can lead to neurological handicaps.

Sen. Ronald Kouchi (HI): What have been the outcomes in those States that allow medical or recreational marijuana use? What are the impacts on law enforcement, healthcare costs, emergency services, etc?

Dr. Shoemaker: Oregon and Washington, allow medical or recreational marijuana use, had lower opioid-related mortality rates than the national average. But there are still stigma issues that result in lack of treatment; in fact, in some rural setting healthcare staff refuse to work with addicts.  [Editor: The National Institute on Drug Abuse provides state-by-state data of opioid deaths at: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state]

Sen. Drew Perkins (WY): Has our focus on “drug-free workplaces” and the use of drug-testing become a disincentive for people to work? Some companies have stopped drug testing because they can’t find enough workers who pass the drug test. When you establish programs with the applied technology schools, putting addicts and schools together, what happens with drug-testing and drug-free workplaces?

Dr. Stern: The value of the applied technology schools is to get addicts onto a career track that they don’t want to lose. We are selective about what career paths we recommend. For example, we would not put an addict into a Licensed Practical Nurse program where exposure to drugs would be routine.  We select the program that will work for the individual, where the drug history will not be an obstacle and where we are sure a real job will exist for them. We partner with companies that have specific needs for skilled workers.

When you are in recovery, every day is another challenge to stay the course because addiction is a relapsing disorder. We have a low bar for getting into our programs and we provide continuous mentorship with monthly contacts. But the addict has to participate. Non-attendance is a signal that intervention is needed, and they will be sent back for treatment.

Editorial Note: In the week following this forum, the US Senate passed a package of bills aimed at the nation’s opioid epidemic, which includes 70 bills covering $8.4 billion in funding for programs across multiple agencies. The package provides funding to the National Institutes of Health to research a nonaddictive painkiller. Another provision clarifies that the FDA has the authority to require prescriptions for opioids to be packaged in set amounts, such as three or seven days. The package also funds “new federal grants for treatment centers, training emergency workers and research on prevention methods.” The House passed its own package earlier in summer 2018.

Speaker Biography

Sarah Shoemaker, PhD, PharmD

Sarah J. Shoemaker, PhD, PharmD, a Principal Associate with Abt Associates, is a health services and implementation researcher who conducts research and provides technical assistance on opioid prescribing and management, medication management and safety, primary care transformation, and quality improvement. She has led dozens of studies for the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), and other agencies. Dr. Shoemaker currently serves as Co-PI on a trio of CDC-funded projects to implement the CDC Guideline for Prescribing Opioids for Chronic Pain via quality improvement (QI), coordinated care, and clinical decision support. Additionally, she led development of 16 QI measures aligned to the CDC guideline and is supporting an Opioid QI Collaborative of several large healthcare systems implementing the guideline and measuring their progress using the QI measures. Dr. Shoemaker’s work has been widely disseminated in peer-reviewed publications, conference presentations and posters, and in evidence-based resources available from AHRQ and CDC. She serves on the editorial advisory board of several journals and served as a guest editor for journal supplements on implementation science and primary care practice improvement. Dr. Shoemaker received her pharmacy doctorate from Creighton University and her doctor of philosophy from the University of Minnesota..

Bethany Hall-Long, PhD, RNC, FAAN

Bethany Hall-Long was sworn in as Delaware’s 26th Lt. Governor on January 17th, 2017.

 Born and raised on her family’s farm in Sussex County with her two older brothers, Bethany graduated from Indian River High School where she met her high school sweetheart, Dana. After graduation, she went on to pursue her childhood dream of becoming a nurse at Thomas Jefferson University in Philadelphia.

Upon graduation, she and her husband, Dana, moved to Charleston, South Carolina, where she pursued her MSN in community health nursing, while Dana was stationed there as a member of the United States Navy. During Dana’s last tour at the Pentagon, Bethany completed her PhD in health policy and nursing administration from George Mason University, and served as a fellow for the U.S. Senate as well as the U.S. Department of Health and Human Services.

Their love of Delaware, and desire to be close to their families caused Bethany and Dana to move back and make their home in Middletown with their son, Brock.

Bethany has been a member of the UD Nursing Faculty now for nearly twenty years. She also holds a distinguished record at the University of Delaware (UD). She was the first nursing faculty at UD to receive the University-wide excellence in teaching award and is currently a Professor of Nursing and Joint Faculty in Urban Affairs. Her research and community service record with at-risk groups such as pregnant teens, diabetics, homeless and the mentally ill, makes her a nationally recognized health scientist.

From 2002-2017, Bethany served as a member of Delaware’s legislature, first as a Representative and then as a Senator. She served as the chair of the Health and Social Services committee where her efforts were aimed at ensuring a stronger, healthier Delaware by combating addiction, focusing on a stronger mental health system, fighting cancer, and health inequities in our state. She also served as a member of the capital budget Bond Committee where Bethany focused on building Delaware’s infrastructure, modernizing our schools, repairing our highways, and protecting our environment and open space.

Descended from Colonel David Hall, a judge, lawyer and 15th Governor of Delaware (1802), serving the community is in her blood. Her great-grandfather, David C. Hall, was elected to the Delaware House of Representatives (1916-1920).

Bethany has always been, and will continue to be a strong voice for all of Delaware.

David M. Stern, MD

Dr. David Stern is currently Robert Kaplan Executive Dean and Vice-Chancellor for Clinical Affairs for the University of Tennessee’s College of Medicine and the University of Tennessee Health Sciences Center.

He comes to this position after a career as a physician-scientist mainly at the College of Physicians & Surgeons of Columbia University, and administrative experience as a Dean at Both the Medical College of Georgia and University of Cincinnati’s College of Medicine.

After completing college at Yale and medical school at Harvard, Dr. Stern began a long stint in New York at the College of Physicians & Surgeons of Columbia University.  He started as an intern in internal medicine in 1978.  By the time he left New York for Georgia in 2002, he was the Carrus Professor and Director of the Center for Vascular and Lung Pathobiology.

Dr. Stern's research work focused on properties of the blood vessel wall, especially in chronic vascular disorders such as diabetes and Alzheimer’s disease.

During the course of building the research Center at Columbia, Dr. Stern became fascinated with building programs at academic medical centers.

That led him into administration and his first job as a medical school Dean and Chief Clinical Officer at the Medical College of Georgia in Augusta.  Dr. Stern spent three years in Georgia where he was known for his rapid recruitment of many department chairs, promoting clinical excellence in the faculty practice plan, enhancing the school’s focus on diversity, and forging a strong partnership between the school and the health system.

In July of 2005, Dr. Stern assumed the Deanship at the University of Cincinnati College of Medicine.  In 2008, he also became the Vice-President for Health Affairs.  His focus was on building collaborative programs, especially with Cincinnati Children’s Hospital Medical Center, reaching out to the community through the founding of a strong community advisory board, developing centers of excellence, reengineering the faculty practice plan, and providing a foundation for the university’s health system (UC Health).

During his tenure at the University of Cincinnati, he catalyzed the formation of a Joint Cancer Program between the College of Medicine, University Hospital and Children’s Hospital, recruited multiple department chairs and center/institute directors, completed a strategic plan for the College with its key partners, facilitated the securing of a CTSA award from the NIH, pushed the practice plan to increased clinical effectiveness and profitability, and designed a health system for the university with an urban and suburban campus, as well as a closely aligned physicians group.

He assumed the position of Executive Dean and Vice-Chancellor for Health Affairs at the University of Tennessee’ Health Science Center in the spring of 2011.

Dr. Stern is married to Dr. Kathleen Stern, a classmate from their days in medical school.  They have two sons.

115 Americans die every day from an opioid overdose.

As State Senators, you have a critical role in driving legislation and policies for the States to address the opioid epidemic.

The risk of long-term opioid use increases sharply after the 3rd and 5th day of the initial prescription.

The probability of long-term use increases based on the length of an initial prescription.

To date, 28 States have enacted laws to limit opioid prescribing with statutory limits ranging from 3 to 14 days.

In 2016, 2.1 million US adults received substance use treatment. But 19.9 million needed it.

Naloxone is a drug that can reverse an opioid overdose.

When opioid addicts are brought into a police station, instead of being charged for a crime, they are escorted by an “angel” in the local police station to a treatment center.

“Find a champion in the legislature to take the lead on opioid legislation,” Dr. Hall-Long advised the Forum.

Opioid abuse affects the States’ economic health in many ways.

A Senate Bill established the Behavioral Health Consortium to coordinate the State’s private and public bodies to reduce current silos, establish greater access to care, and combat addiction and improve mental health services.

Delaware established the nation’s first integrated overdose system of care. The system integrates first responders, police departments, fire service, paramedics, emergency rooms, and wrap-around service providers.

Delaware’s initial Three-Year Action Plan is being led by six Committees focused on:

1. Access & Treatment

2. Changing Perceptions & Stigma

3. Corrections & Law Enforcement

4. Data & Policy

5. Education & Prevention

6. Family & Community Readiness

Substance use disorder and mental health issues are interrelated and their treatment must be integrated.

Substance/opioid use disorder is a chronic, relapsing, medical disorder with episodic acute events (overdoses), which requires comprehensive individualized treatment plans and wrap-around services to keep a child from overdosing.

Among graduates who were matched with a Peer Navigator as a mentor, 80% have been successful in finding and keeping job placements.

Tennessee’s integrated program to address substance use disorders engages the whole community.

States have agencies working in silos to address the opioid epidemic. They need to share information and training.

Sen. David Long (IN)

Sen. Robert Stivers (KY)

Sen. Ginny Burdick (OR)

Sen. Ronald Kouchi (HI)

Sen. Drew Perkins (WY)

The National Institute on Drug Abuse provides state-by-state data of opioid deaths at:
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state

When you are in recovery, every day is another challenge to stay the course because addiction is a relapsing disorder.

Sarah Shoemaker,
PhD, PharmD

Bethany Hall-Long,
PhD, RNC, FAAN

David M. Stern, MD

CONTACT

Senate Presidents’ Forum

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Hastings-on-Hudson, NY 10706

 

Tel: 914-693-1818

Copyright © 2018 Senate Presidents' Forum. All rights reserved.

september 6–9, 2018

Opioid Crisis:

New Approaches for the Long-Term Health and Well-Being of Patients and Their Communities

Sarah Shoemaker, PhD, PharmD

Health Services Researcher
Abt Associates

As the national emergency of opioid addiction continues to take a toll on Americans across all the States, the Forum heard an update on the scope of the current problem and solutions that are working in some States. Sarah Shoemaker, PhD, PharmD, of Abt Associates, a research and consulting company, provided the background for the session, noting that, in 2016, the number of overdose deaths involving opioids was 5 times higher than in 1999. On average, 115 Americans die every day from an opioid overdose, Dr. Shoemaker reported. The 2016 National Survey on Drug Use and Health found that 2.1 million Americans had opioid use disorder, 11.5 million admitted to misusing opioids, and 2.1 million said they misused opioids for the first time in that year.

115 Americans die every day from an opioid overdose.

Where are we at? Overdose

SOURCE: National Vital Statistics System Mortality File.

Opioid addiction is a complex problem with a range of trajectories, Dr. Shoemaker noted, and it requires a multi-sector response involving healthcare, treatment, the justice system, first responders, child and family services, and the community. As State Senators, you have a critical role in driving legislation and policies for the States to address the opioid epidemic, Dr. Shoemaker observed. Her recommendations focused on:

Set limits on opioid prescribing

Improve data and information sharing

Increase access to and capacity for medication-assisted treatment (MAT) for addiction

Increase availability of the overdose reversal drug--naloxone

Intercept people everywhere to get them into addiction treatment

As State Senators, you have a critical role in driving legislation and policies for the States to address the opioid epidemic.

Set Limits on Opioid Prescribing

Using opioids to treat acute pain can lead to long-term use. The risk of long-term opioid use increases sharply after the 3rd and 5th day of the initial prescription. According to the CDC, long- term use also increases with a second prescription or refill, a 700 morphine milligram equivalents (MME) cumulative dose, and an initial 10- or 30-day supply.

The risk of long-term opioid use increases sharply after the 3rd and 5th day of the initial prescription.

Probability of Continued Opioid Use

SOURCE: Centers for Disease Control and Prevention, 2017.

The probability of long-term use increases based on the length of an initial prescription.

The probability of long-term use increases based on the length of an initial prescription.

In about a fourth of US counties, enough opioid prescriptions were dispensed for every person to have one. An estimated 1 out of 5 patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings. (Daubresse et al., 2013) And primary care providers account for about half of opioid pain relievers dispensed (Daubresse et al., 2013).

Where are we at? Prescribing

SOURCE: CDC Source: QuintilesIMS Transactional Data Warehouse 2006–2016.

One approach to rein in the opioid epidemic is to change prescribing practices among providers. The overall national opioid prescribing rate declined from 2012 to 2016, and in 2016, the prescribing rate had fallen to the lowest it had been in more than 10 years at 66.5 prescriptions per 100 persons (over 214 million total opioid prescriptions). To date, 28 States have enacted laws to limit opioid prescribing with statutory limits ranging from 3 to 14 days, or placing limits on total morphine milligram equivalents (MME) prescribed. Other States have other entities imposing limits.

To date, 28 States have enacted laws to limit opioid prescribing with statutory limits ranging from 3 to 14 days.

Improve Data and Information Sharing

The Centers for Disease Control and Prevention (CDC) has funded 29 State health departments to maximize their Prescription Drug Monitoring Programs (PDMP) and enhance opioid surveillance, and enable data-sharing on overdoses. For example, providing prescriber “dashboards” to identify outliers who prescribe more than their peers.

Most States have a PDMP, Dr. Shoemaker observed; however, accessing and sharing the data especially across states is still a work-in-progress. Integrating the PDMP into electronic health records with one-click access or delegating authority to additional staff, such as nurses, will enhance PDMP use, Dr. Shoemaker noted.

Increase Access and Capacity for Medically Assisted Treatment (MAT)

Another significant structural problem is the shortfall of effective substance abuse treatment capacity in the US, Dr. Shoemaker said. An estimated 19.9 million adults aged 18 or older needed substance use treatment in 2016, including 7.3 million adults who needed treatment for an illicit drug use problem and 15.1 million who needed treatment for an alcohol use problem.  Only 2.1 million adults received substance use treatment at a specialty facility during that year.

In 2016, 2.1 million US adults received substance use treatment. But 19.9 million needed it.

To meet this unmet need and expand access, States need to build and increase the addiction intervention workforce. Dr. Shoemaker recommended that States leverage county agencies and large, regional providers, as well as peer support specialists. States may require providers to offer MAT and can increase the number of providers in primary care who treat addiction. She advocated for expanded coverage of addiction treatment, perhaps through Medicaid programs.

Funding for State efforts is also available through a variety of Federal programs. CDC funding has been used by the States to improve coordination and interventions among the community, health systems, law enforcement, and payers, so that people with opioid misuse or addiction have access to treatment.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has also funded a number of programs including training first responders on overdose treatment and working with community health systems to expand access to medication-assisted treatment (MAT) for opioid addiction, increasing identification and treatment of pregnant women with addiction, and increasing long-term support for recovery.

The Health Resources and Services Administration (HRSA) also has funded rural community health centers to increase access to MAT through grants for health centers and to rural communities to implement opioid use disorder prevention programs, as well as treatment and recovery interventions.

Increase Availability of Naloxone

Naloxone is a drug that can reverse an opioid overdose. Dr. Shoemaker recommended that States simplify the process for obtaining naloxone and revise their naloxone laws to expand who can receive the drug, (including third-party prescriptions for family, friends, and professionals) and who can distribute the drug, such as allowing pharmacists or non-medical professionals to distribute it without a prescription.

Naloxone is a drug that can reverse an opioid overdose.

[Note:  Naloxone is available with a prescription in any State; however, now the drug can be purchased over-the-counter (without a prescription) in 46 States from some retailers. A prescription is still required in Delaware, Hawaii, Maine, Michigan, Nebraska, Oklahoma, and Wyoming.  See: https://www.samhsa.gov/capt/sites/default/files/resources/naloxone-access-laws-tool.pdf]

Intercept People Everywhere to Get Them Into Addiction Treatment

Dr. Shoemaker reported on an innovative “Angel Program” first pioneered in the Gloucester, Massachusetts police department and now replicated in 160+ similar programs. When opioid addicts are brought into a police station, instead of being charged for a crime, they are escorted by an “angel” in the local police station to a treatment center. Some programs provide significant wrap-around services or a peer support person to shepherd the person through treatment and recovery.

When opioid addicts are brought into a police station, instead of being charged for a crime, they are escorted by an “angel” in the local police station to a treatment center.

Delaware’s Three-Year Action Plan
to Combat Opioids

Bethany Hall-Long, PhD, RNC, FAAN

Lt. Governor

Delaware and Professor of Nursing and Joint Faculty in Urban Affairs
University of Delawares

Delaware’s Lt. Governor, Bethany Hall-Long, reported progress on the State’s “Three-Year Action Plan” to combat opioid abuse. The Plan is a roadmap for the Governor and members of the General Assembly to address the challenges of the epidemic. The integrated plan addresses prevention, treatment and recovery for mental health, substance use, and co-occurring disorders.

According to Dr. Hall-Long, Delaware has about 30,000 adults and 9,000 children suffering from a substance use disorder or a mental illness. As many as 1 in 5 Delawareans will suffer from some form of a mental illness in any given year. In the State’s prisons, 82% of inmates have a mental illness or substance use disorder, making the prison system the largest treatment provider. There were more than 300 overdose fatalities in 2016, an increase of 35% over 2015.

In the 9 years that Dr. Hall-Long served in the State Senate, she introduced about 1000 bills related to healthcare and chaired the Governor’s Mental Health Task Force. “Find a champion in the legislature to take the lead on opioid legislation,” Dr. Hall-Long advised the Forum. Most of the Senators at the Forum had sponsored some legislation related to opioid abuse.

“Find a champion in the legislature to take the lead on opioid legislation,” Dr. Hall-Long advised the Forum.

Several routes lead to opioid addiction, she observed. Addiction can be the result of overprescribing for pain management, but it also arises from people self-medicating to deal with mental health issues such as anxiety, depression, or bipolar disorder.

Opioid abuse affects the States’ economic health in many ways, from the cost of care for overdose survivors left with physical and mental impairments, to the costs of the justice and health systems, loss of worker productivity, and the social costs of families destroyed by addiction.

Opioid abuse affects the States’ economic health in many ways.

Delaware’s Behavioral Health Consortium

A Mental Health Taskforce was convened to explore the causes for increasing rates of addiction and mental illness and to evaluate solutions. The Taskforce identified several factors contributing to the increase including the stigma associated with mental illness. A number of structural deficiencies also were recognized including a lack of funding to meet the costs of preventing or treating addiction, lack of early intervention, lack of trained personnel to address the issue, lack of access to treatment, and gaps in service delivery and transitions of care.

A fragmented spectrum of interventions had evolved to address the diverse aspects of the opioid epidemic, Dr. Hall-Long noted. A Senate Bill established the Behavioral Health Consortium to coordinate the State’s private and public bodies to reduce current silos, establish greater access to care, and combat addiction and improve mental health services.

A Senate Bill established the Behavioral Health Consortium to coordinate the State’s private and public bodies to reduce current silos, establish greater access to care, and combat addiction and improve mental health services.

The Consortium gathered input from grassroots advocacy groups, non-profits, providers, health systems, first responders and community members to collaborate to tackle the the opioid crisis. Community forums sponsored by the Behavioral Health Consortium saw packed audiences and produced hundreds of recommendations to address the opioid epidemic.

The best ideas come from the streets, from the people, the families, and the communities that are affected. Community Forums were guided by two questions:

Question 1:  When you think about mental health and addiction (behavioral health), how behaviors affect health, and how people feel about their health where you live, what is happening in your community?

Question 2:  What is the number 1 thing we in Delaware can do to deal with mental health related issues and the issues we are facing in behavioral health?

Community Action

Education was a priority, therefore, public awareness programs and education campaigns were deployed statewide. The Consortium also recommended expansion of K-5 Wellness Centers, targeting Title I funded elementary schools within identified risk “hotspots.” By partnering with health systems and Primary Care Providers, they sought to create greater access to care for vastly underserved populations, and developed a comprehensive Community Health Worker Program with culturally competent individuals to perform basic health assessment and care. This created a critical touch point for individuals suffering from addiction.

Criminal Justice Approaches

Some of the recommendations affected the criminal justice system. “You want to get the bad guys,” Dr. Hall-Long acknowledged. To accomplish this, the Prescription Drug Monitoring Program (PDMP) was strengthened to identify “doctor shoppers,” people who go to multiple doctors to get opioid prescriptions, and also to pinpoint providers who overprescribe opioids.

With the PDMP ramped up, the Justice Department’s Overdose Fatality Review Commission receives geocoded information about where people are dying from overdoses and from what drugs. This helps pinpoint where drugs are prevalent and allows targeting high impact areas and properly dispatching resources to these areas, while working with providers and first responders. Furthermore, sellers who mix fentanyl with heroin now face murder charges. A 911 Good Samaritan law made it possible for someone to bring a person who had overdosed to a hospital emergency room, without risking legal action.

Creating A System of Care

Dr. Hall-Long stated that addressing the opioid epidemic also requires a strong focus on mental health issues. Many of the community’s recommendations focused on the larger issues of mental health. The public focused on two themes: first, stop people from overdosing and dying; and, second, improve access to treatment. Community input made it clear that providing greater access to care transforms those who are affected by the opioid epidemic.

To meet these objectives, Delaware established the nation’s first integrated overdose system of care. The system integrates first responders, police departments, fire service, paramedics, emergency rooms, and wrap-around service providers so that individuals who recover from an overdose receive a multifaceted approach to care, addressing both their medical and social needs, to prevent a relapse. The program sets up standards for “stabilization centers” that take over caring for overdose patients once they are released from hospitals or by first responders. “Delaware is the first State in the nation to create a system that, instead of sending someone home or to jail, will hopefully get them into treatment,” Dr. Hall-Long said.

Delaware established the nation’s first integrated overdose system of care. The system integrates first responders, police departments, fire service, paramedics, emergency rooms, and wrap-around service providers.

Funding the Programs

Current funding for the Delaware Division of Substance Abuse and Mental Health (DSAMH) is $23 million. The Behavioral Health Consortium is allocated an additional $5 million, which funds the Delaware Health Information Network and supports the transformation needed to establish the system of care. Funding also was generated via Medicaid expansion and local school district dollars were used for school education programs. Funding generated by CMS waiver and hospital “community benefit” dollars was allocated to Community Health Worker programs.

Delaware’s initial Three-Year Action Plan is being led by six Committees focused on:1. Access & Treatment2. Changing Perceptions & Stigma3. Corrections & Law Enforcement4. Data & Policy5. Education & Prevention6. Family & Community Readiness

“We anticipate that early intervention, coordinated treatment from health providers, and increased programs will directly impact population health outcomes,” Dr. Hall-Long concluded.

Tennessee Commission on Pain and Addiction Medicine

David M. Stern, MD

Robert Kaplan Executive Dean and Vice-Chancellor for Clinical Affairs
for the University of Tennessee’s College of Medicine

Dr. David Stern’s introduction to his presentation was heart-breaking, as he described his son’s death from an opioid overdose 10 years ago. This tragedy led to Dr. Stern’s career commitment to finding solutions to the opioid epidemic. Dr. Stern, who serves on the Tennessee Commission on Pain and Addiction Medicine, reported on the Commission’s formulation of evidenced-based pain and addiction medicine competencies for management of pain, proper prescribing of pain medication, and diagnosis and treatment of those suffering from addiction.

Hub: focal point of addiction medicine (ADM) expertise

Substance use disorder and mental health issues are interrelated and their treatment must be integrated, Dr. Stern noted. Like cancer care, effective treatment for substance use disorder requires integrated care from multiple specialists, including addiction specialists, case managers, mental health counselors, and peer navigators. People are going to relapse, he said, we need to have an integrated approach that re-routes them back into multidimensional and multifactorial treatment programs.

Substance use disorder and mental health issues are interrelated and their treatment must be integrated.

Several Hubs are established throughout the State and include addiction medicine specialists, behavioral health specialists, social workers, nurse care managers, case managers, and peers. They participate as integral partners in formulating patient treatment plans and steering patients to treatment centers best-suited to their needed level of care.

The Hubs leverage telecommunications technologies to provide tele-education, tele-consultation, and tele-medicine resources to law enforcement, vulnerable populations, emergency medical services personnel, and healthcare providers, as well as to community sites such as churches, jails, courts, treatment centers, and veterans groups.

Durable Recovery

A key theme for Dr. Stern is the concept of durable recovery. As a medical professional, he recognizes that “substance/opioid use disorder is a chronic, relapsing, medical disorder with episodic acute events (overdoses), which requires comprehensive individualized treatment plans and wrap-around services to keep a child from overdosing.”

Substance/opioid use disorder is a chronic, relapsing, medical disorder with episodic acute events (overdoses), which requires comprehensive individualized treatment plans and wrap-around services to keep a child from overdosing.

Durable recovery requires significant life changes, including moving people out of environments that foster drug abuse and providing education, workforce preparation, and job placement. “If people get launched into a career that is not just a minimum wage job but a real career, they don’t want to risk losing that position,” Dr. Stern observed. “They are able to develop medical, social, and financial assets that they value and that act as a deterrent to relapse.”

To achieve this, the program has partnered with Tennessee Colleges of Applied Technology (TCATs) to enroll and train people who participate in the substance use recovery programs. The results have been impressive. Among graduates who were matched with a Peer Navigator as a mentor, 80% have been successful in finding and keeping job placements. If a relapse occurs, the Navigator gets the graduate back into treatment.

Among graduates who were matched with a Peer Navigator as a mentor, 80% have been successful in finding and keeping job placements.

Peer Navigators

Tennessee’s program leverages the power of peers for addiction recovery support. Peer Navigators are themselves on the continuing journey of recovery and are sensitive to addiction issues. They believe that substance use disorder is a chronic relapsing disease and that recovery is possible. As advisors and mentors, they see without stigma and are able to provide empathetic and respectful support. They can establish immediate rapport and have the capacity to listen, understand and present hope.

Peer counselors receive training comparable to masters-level counselors. They have personal relationships with law enforcement and emergency services who can call them whenever someone in their care is ready for treatment. The Peer Navigator consults with the Hub personnel to identify the appropriate treatment center, accompanies the person to a treatment center and supports them in accessing needed housing, employment, and educational services to change their lives. This program has the potential to be economically feasible and sustainable, Dr. Stern reported.

Mobile Community Health Team

As understanding of the social determinants of health and population health management improves, it has become apparent that the addiction specialists have to be located where they are needed. Therefore, Tennessee developed a Mobile Community Health Team that includes Nurse Care Managers and Behavioralists who work in the communities where substance use disorder is highest. They coordinate with primary care providers and Hub services to provide better accessibility and quality of care for patients with substance use disorder.

Community Engagement

Tennessee’s integrated program to address substance use disorders engages the whole community.

Tennessee’s integrated program to address substance use disorders engages the whole community.

Legislation

Stressing the need for reimbursement, Dr. Stern pointed out, “If treatment is paid for, people with substance abuse disorders will seek it out.” He also emphasized the need to incentivize an integrated, comprehensive approach based on an outpatient/office treatment model. “What is the critical infrastructure you need to create an integrated system of care?” he asked. Many States have agencies working in silos to address the opioid epidemic. They need to share information and training, Dr. Stern pointed out. “This is an exercise in community medicine,” he concluded.

States have agencies working in silos to address the opioid epidemic. They need to share information and training.

For more on the Opioid Crisis: <more>

Discussion

Sen. David Long (IN): What are the economic consequences of the opioid crisis, and how are States funding these programs?

Dr. Hall-Long: It’s critical to get boots on the ground to stop the bleeding. Delaware allocated $250,000 to a peer mentor program and insurance companies matched that. In addition, pharmaceutical companies may provide naloxone. The $50 cost for naloxone can prevent $500,000 in long-term recovery costs, or in Neonatal Intensive Care Unit (NICU) costs for a baby born with Opioid Abstinence Syndrome.

Dr. Stern: The Council of Economic Advisers estimated that, in 2015, the economic cost of the opioid crisis was $504.0 billion, or 2.8% of GDP that year. The biggest part is the loss of productivity in the workforce, plus the costs of expensive hospital and emergency department visits. Community-based programs of prevention and treatment can prevent these visits and accrue substantial savings.

Sen. Robert Stivers (KY): The key issue is that the opioid crisis affects the whole economy of the state. It creates broken households, leaving children vulnerable and interfering with their education. The crisis raises the costs of incarceration and strains the judicial system. When you consider that 70% of opioid deaths are Medicaid recipients, it suggests the government is the biggest payer for drugs that are killing people. Are there alternatives to opioids so we can reduce the number of avenues that lead to addiction? Is marijuana a gateway drug or an alternative for pain management?

Dr. Shoemaker: Different States see marijuana as an alternative for pain management. The FDA guidelines on chronic pain recommend using alternative non-drug pain management approaches, but often these are not available, especially in rural areas.  The key is to identify people who have received long-term opioid prescriptions and follow them to determine if they need medically-assisted treatment to stop using the opioids.

Dr. Stern: Marijuana does have some medical uses such as for hyperemesis and migraine. But it is a dangerous drug and is not appropriate for young people whose brains are still developing. Opioids are meant for short-term pain relief. The critical need is for integrated pain management and addiction prevention programs.

Dr. Hall-Long: We need greater enforcement of parity laws requiring insurers to pay for mental health services, including opioid addiction treatment, on the same basis as other medical or surgical benefits. Some States are suing the pharmaceutical companies who market opioids and may be looking for an Opioid Settlement similar to the Tobacco Settlement.

Sen. Ginny Burdick (OR): There have been compelling anecdotes about the use of marijuana to manage pain. There are cannabidiol (CBD) formulations with low concentrations of the psychoactive element that have been used to treat pain and seizures. Furthermore, there is no known lethal dose of marijuana. But marijuana is currently a Schedule 1 drug. The Federal government should change it to a Schedule 2 drug so that research can be done to determine its potential for pain management, as well as to assess its risk for addiction.

Dr. Stern: Cannabinoids have complex actions at a number of receptors that are poorly understood. We don’t know if its effects can be closely controlled or regulated. The risk is that long periods of marijuana use while the brain is developing can lead to neurological handicaps.

Sen. Ronald Kouchi (HI): What have been the outcomes in those States that allow medical or recreational marijuana use? What are the impacts on law enforcement, healthcare costs, emergency services, etc?

Dr. Shoemaker: Oregon and Washington, allow medical or recreational marijuana use, had lower opioid-related mortality rates than the national average. But there are still stigma issues that result in lack of treatment; in fact, in some rural setting healthcare staff refuse to work with addicts.  [Editor: The National Institute on Drug Abuse provides state-by-state data of opioid deaths at: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state]

The National Institute on Drug Abuse provides state-by-state data of opioid deaths at:
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state

Sen. Drew Perkins (WY): Has our focus on “drug-free workplaces” and the use of drug-testing become a disincentive for people to work? Some companies have stopped drug testing because they can’t find enough workers who pass the drug test. When you establish programs with the applied technology schools, putting addicts and schools together, what happens with drug-testing and drug-free workplaces?

Dr. Stern: The value of the applied technology schools is to get addicts onto a career track that they don’t want to lose. We are selective about what career paths we recommend. For example, we would not put an addict into a Licensed Practical Nurse program where exposure to drugs would be routine.  We select the program that will work for the individual, where the drug history will not be an obstacle and where we are sure a real job will exist for them. We partner with companies that have specific needs for skilled workers.

When you are in recovery, every day is another challenge to stay the course because addiction is a relapsing disorder. We have a low bar for getting into our programs and we provide continuous mentorship with monthly contacts. But the addict has to participate. Non-attendance is a signal that intervention is needed, and they will be sent back for treatment.

When you are in recovery, every day is another challenge to stay the course because addiction is a relapsing disorder.

Editorial Note: In the week following this forum, the US Senate passed a package of bills aimed at the nation’s opioid epidemic, which includes 70 bills covering $8.4 billion in funding for programs across multiple agencies. The package provides funding to the National Institutes of Health to research a nonaddictive painkiller. Another provision clarifies that the FDA has the authority to require prescriptions for opioids to be packaged in set amounts, such as three or seven days. The package also funds “new federal grants for treatment centers, training emergency workers and research on prevention methods.” The House passed its own package earlier in summer 2018.

Speaker Biography

Sarah Shoemaker, PhD, PharmD

Sarah J. Shoemaker, PhD, PharmD, a Principal Associate with Abt Associates, is a health services and implementation researcher who conducts research and provides technical assistance on opioid prescribing and management, medication management and safety, primary care transformation, and quality improvement. She has led dozens of studies for the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), and other agencies. Dr. Shoemaker currently serves as Co-PI on a trio of CDC-funded projects to implement the CDC Guideline for Prescribing Opioids for Chronic Pain via quality improvement (QI), coordinated care, and clinical decision support. Additionally, she led development of 16 QI measures aligned to the CDC guideline and is supporting an Opioid QI Collaborative of several large healthcare systems implementing the guideline and measuring their progress using the QI measures. Dr. Shoemaker’s work has been widely disseminated in peer-reviewed publications, conference presentations and posters, and in evidence-based resources available from AHRQ and CDC. She serves on the editorial advisory board of several journals and served as a guest editor for journal supplements on implementation science and primary care practice improvement. Dr. Shoemaker received her pharmacy doctorate from Creighton University and her doctor of philosophy from the University of Minnesota..

Bethany Hall-Long, PhD, RNC, FAAN

Bethany Hall-Long was sworn in as Delaware’s 26th Lt. Governor on January 17th, 2017.

 Born and raised on her family’s farm in Sussex County with her two older brothers, Bethany graduated from Indian River High School where she met her high school sweetheart, Dana. After graduation, she went on to pursue her childhood dream of becoming a nurse at Thomas Jefferson University in Philadelphia.

Upon graduation, she and her husband, Dana, moved to Charleston, South Carolina, where she pursued her MSN in community health nursing, while Dana was stationed there as a member of the United States Navy. During Dana’s last tour at the Pentagon, Bethany completed her PhD in health policy and nursing administration from George Mason University, and served as a fellow for the U.S. Senate as well as the U.S. Department of Health and Human Services.

Their love of Delaware, and desire to be close to their families caused Bethany and Dana to move back and make their home in Middletown with their son, Brock.

Bethany has been a member of the UD Nursing Faculty now for nearly twenty years. She also holds a distinguished record at the University of Delaware (UD). She was the first nursing faculty at UD to receive the University-wide excellence in teaching award and is currently a Professor of Nursing and Joint Faculty in Urban Affairs. Her research and community service record with at-risk groups such as pregnant teens, diabetics, homeless and the mentally ill, makes her a nationally recognized health scientist.

From 2002-2017, Bethany served as a member of Delaware’s legislature, first as a Representative and then as a Senator. She served as the chair of the Health and Social Services committee where her efforts were aimed at ensuring a stronger, healthier Delaware by combating addiction, focusing on a stronger mental health system, fighting cancer, and health inequities in our state. She also served as a member of the capital budget Bond Committee where Bethany focused on building Delaware’s infrastructure, modernizing our schools, repairing our highways, and protecting our environment and open space.

Descended from Colonel David Hall, a judge, lawyer and 15th Governor of Delaware (1802), serving the community is in her blood. Her great-grandfather, David C. Hall, was elected to the Delaware House of Representatives (1916-1920).

Bethany has always been, and will continue to be a strong voice for all of Delaware.

David M. Stern, MD

Dr. David Stern is currently Robert Kaplan Executive Dean and Vice-Chancellor for Clinical Affairs for the University of Tennessee’s College of Medicine and the University of Tennessee Health Sciences Center.

He comes to this position after a career as a physician-scientist mainly at the College of Physicians & Surgeons of Columbia University, and administrative experience as a Dean at Both the Medical College of Georgia and University of Cincinnati’s College of Medicine.

After completing college at Yale and medical school at Harvard, Dr. Stern began a long stint in New York at the College of Physicians & Surgeons of Columbia University.  He started as an intern in internal medicine in 1978.  By the time he left New York for Georgia in 2002, he was the Carrus Professor and Director of the Center for Vascular and Lung Pathobiology.

Dr. Stern's research work focused on properties of the blood vessel wall, especially in chronic vascular disorders such as diabetes and Alzheimer’s disease.

During the course of building the research Center at Columbia, Dr. Stern became fascinated with building programs at academic medical centers.

That led him into administration and his first job as a medical school Dean and Chief Clinical Officer at the Medical College of Georgia in Augusta.  Dr. Stern spent three years in Georgia where he was known for his rapid recruitment of many department chairs, promoting clinical excellence in the faculty practice plan, enhancing the school’s focus on diversity, and forging a strong partnership between the school and the health system.

In July of 2005, Dr. Stern assumed the Deanship at the University of Cincinnati College of Medicine.  In 2008, he also became the Vice-President for Health Affairs.  His focus was on building collaborative programs, especially with Cincinnati Children’s Hospital Medical Center, reaching out to the community through the founding of a strong community advisory board, developing centers of excellence, reengineering the faculty practice plan, and providing a foundation for the university’s health system (UC Health).

During his tenure at the University of Cincinnati, he catalyzed the formation of a Joint Cancer Program between the College of Medicine, University Hospital and Children’s Hospital, recruited multiple department chairs and center/institute directors, completed a strategic plan for the College with its key partners, facilitated the securing of a CTSA award from the NIH, pushed the practice plan to increased clinical effectiveness and profitability, and designed a health system for the university with an urban and suburban campus, as well as a closely aligned physicians group.

He assumed the position of Executive Dean and Vice-Chancellor for Health Affairs at the University of Tennessee’ Health Science Center in the spring of 2011.

Dr. Stern is married to Dr. Kathleen Stern, a classmate from their days in medical school.  They have two sons.

september 6–9, 2018

Opioid Crisis:

New Approaches for the Long-Term Health and Well-Being of Patients and Their Communities

Sarah Shoemaker, PhD, PharmD

Health Services Researcher
Abt Associates

As the national emergency of opioid addiction continues to take a toll on Americans across all the States, the Forum heard an update on the scope of the current problem and solutions that are working in some States. Sarah Shoemaker, PhD, PharmD, of Abt Associates, a research and consulting company, provided the background for the session, noting that, in 2016, the number of overdose deaths involving opioids was 5 times higher than in 1999. On average, 115 Americans die every day from an opioid overdose, Dr. Shoemaker reported. The 2016 National Survey on Drug Use and Health found that 2.1 million Americans had opioid use disorder, 11.5 million admitted to misusing opioids, and 2.1 million said they misused opioids for the first time in that year.

115 Americans die every day from an opioid overdose.

Where are we at? Overdose

SOURCE: National Vital Statistics System Mortality File.

Opioid addiction is a complex problem with a range of trajectories, Dr. Shoemaker noted, and it requires a multi-sector response involving healthcare, treatment, the justice system, first responders, child and family services, and the community. As State Senators, you have a critical role in driving legislation and policies for the States to address the opioid epidemic, Dr. Shoemaker observed. Her recommendations focused on:

Set limits on opioid prescribing

Improve data and information sharing

Increase access to and capacity for medication-assisted treatment (MAT) for addiction

Increase availability of the overdose reversal drug--naloxone

Intercept people everywhere to get them into addiction treatment

As State Senators, you have a critical role in driving legislation and policies for the States to address the opioid epidemic.

Set Limits on Opioid Prescribing

Using opioids to treat acute pain can lead to long-term use. The risk of long-term opioid use increases sharply after the 3rd and 5th day of the initial prescription. According to the CDC, long- term use also increases with a second prescription or refill, a 700 morphine milligram equivalents (MME) cumulative dose, and an initial 10- or 30-day supply.

The risk of long-term opioid use increases sharply after the 3rd and 5th day of the initial prescription.

Probability of Continued Opioid Use

SOURCE: Centers for Disease Control and Prevention, 2017.

The probability of long-term use increases based on the length of an initial prescription.

The probability of long-term use increases based on the length of an initial prescription.

In about a fourth of US counties, enough opioid prescriptions were dispensed for every person to have one. An estimated 1 out of 5 patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings. (Daubresse et al., 2013) And primary care providers account for about half of opioid pain relievers dispensed (Daubresse et al., 2013).

Where are we at? Prescribing

SOURCE: CDC Source: QuintilesIMS Transactional Data Warehouse 2006–2016.

One approach to rein in the opioid epidemic is to change prescribing practices among providers. The overall national opioid prescribing rate declined from 2012 to 2016, and in 2016, the prescribing rate had fallen to the lowest it had been in more than 10 years at 66.5 prescriptions per 100 persons (over 214 million total opioid prescriptions). To date, 28 States have enacted laws to limit opioid prescribing with statutory limits ranging from 3 to 14 days, or placing limits on total morphine milligram equivalents (MME) prescribed. Other States have other entities imposing limits.

To date, 28 States have enacted laws to limit opioid prescribing with statutory limits ranging from 3 to 14 days.

Improve Data and Information Sharing

The Centers for Disease Control and Prevention (CDC) has funded 29 State health departments to maximize their Prescription Drug Monitoring Programs (PDMP) and enhance opioid surveillance, and enable data-sharing on overdoses. For example, providing prescriber “dashboards” to identify outliers who prescribe more than their peers.

Most States have a PDMP, Dr. Shoemaker observed; however, accessing and sharing the data especially across states is still a work-in-progress. Integrating the PDMP into electronic health records with one-click access or delegating authority to additional staff, such as nurses, will enhance PDMP use, Dr. Shoemaker noted.

Increase Access and Capacity for Medically Assisted Treatment (MAT)

Another significant structural problem is the shortfall of effective substance abuse treatment capacity in the US, Dr. Shoemaker said. An estimated 19.9 million adults aged 18 or older needed substance use treatment in 2016, including 7.3 million adults who needed treatment for an illicit drug use problem and 15.1 million who needed treatment for an alcohol use problem.  Only 2.1 million adults received substance use treatment at a specialty facility during that year.

In 2016, 2.1 million US adults received substance use treatment. But 19.9 million needed it.

To meet this unmet need and expand access, States need to build and increase the addiction intervention workforce. Dr. Shoemaker recommended that States leverage county agencies and large, regional providers, as well as peer support specialists. States may require providers to offer MAT and can increase the number of providers in primary care who treat addiction. She advocated for expanded coverage of addiction treatment, perhaps through Medicaid programs.

Funding for State efforts is also available through a variety of Federal programs. CDC funding has been used by the States to improve coordination and interventions among the community, health systems, law enforcement, and payers, so that people with opioid misuse or addiction have access to treatment.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has also funded a number of programs including training first responders on overdose treatment and working with community health systems to expand access to medication-assisted treatment (MAT) for opioid addiction, increasing identification and treatment of pregnant women with addiction, and increasing long-term support for recovery.

The Health Resources and Services Administration (HRSA) also has funded rural community health centers to increase access to MAT through grants for health centers and to rural communities to implement opioid use disorder prevention programs, as well as treatment and recovery interventions.

Increase Availability of Naloxone

Naloxone is a drug that can reverse an opioid overdose. Dr. Shoemaker recommended that States simplify the process for obtaining naloxone and revise their naloxone laws to expand who can receive the drug, (including third-party prescriptions for family, friends, and professionals) and who can distribute the drug, such as allowing pharmacists or non-medical professionals to distribute it without a prescription.

Naloxone is a drug that can reverse an opioid overdose.

[Note:  Naloxone is available with a prescription in any State; however, now the drug can be purchased over-the-counter (without a prescription) in 46 States from some retailers. A prescription is still required in Delaware, Hawaii, Maine, Michigan, Nebraska, Oklahoma, and Wyoming.  See: https://www.samhsa.gov/capt/sites/default/files/resources/naloxone-access-laws-tool.pdf]

Intercept People Everywhere to Get Them Into Addiction Treatment

Dr. Shoemaker reported on an innovative “Angel Program” first pioneered in the Gloucester, Massachusetts police department and now replicated in 160+ similar programs. When opioid addicts are brought into a police station, instead of being charged for a crime, they are escorted by an “angel” in the local police station to a treatment center. Some programs provide significant wrap-around services or a peer support person to shepherd the person through treatment and recovery.

When opioid addicts are brought into a police station, instead of being charged for a crime, they are escorted by an “angel” in the local police station to a treatment center.

Delaware’s Three-Year Action Plan
to Combat Opioids

Bethany Hall-Long, PhD, RNC, FAAN

Lt. Governor

Delaware and Professor of Nursing and Joint Faculty in Urban Affairs
University of Delawares

Delaware’s Lt. Governor, Bethany Hall-Long, reported progress on the State’s “Three-Year Action Plan” to combat opioid abuse. The Plan is a roadmap for the Governor and members of the General Assembly to address the challenges of the epidemic. The integrated plan addresses prevention, treatment and recovery for mental health, substance use, and co-occurring disorders.

According to Dr. Hall-Long, Delaware has about 30,000 adults and 9,000 children suffering from a substance use disorder or a mental illness. As many as 1 in 5 Delawareans will suffer from some form of a mental illness in any given year. In the State’s prisons, 82% of inmates have a mental illness or substance use disorder, making the prison system the largest treatment provider. There were more than 300 overdose fatalities in 2016, an increase of 35% over 2015.

In the 9 years that Dr. Hall-Long served in the State Senate, she introduced about 1000 bills related to healthcare and chaired the Governor’s Mental Health Task Force. “Find a champion in the legislature to take the lead on opioid legislation,” Dr. Hall-Long advised the Forum. Most of the Senators at the Forum had sponsored some legislation related to opioid abuse.

“Find a champion in the legislature to take the lead on opioid legislation,” Dr. Hall-Long advised the Forum.

Several routes lead to opioid addiction, she observed. Addiction can be the result of overprescribing for pain management, but it also arises from people self-medicating to deal with mental health issues such as anxiety, depression, or bipolar disorder.

Opioid abuse affects the States’ economic health in many ways, from the cost of care for overdose survivors left with physical and mental impairments, to the costs of the justice and health systems, loss of worker productivity, and the social costs of families destroyed by addiction.

Opioid abuse affects the States’ economic health in many ways.

Delaware’s Behavioral Health Consortium

A Mental Health Taskforce was convened to explore the causes for increasing rates of addiction and mental illness and to evaluate solutions. The Taskforce identified several factors contributing to the increase including the stigma associated with mental illness. A number of structural deficiencies also were recognized including a lack of funding to meet the costs of preventing or treating addiction, lack of early intervention, lack of trained personnel to address the issue, lack of access to treatment, and gaps in service delivery and transitions of care.

A fragmented spectrum of interventions had evolved to address the diverse aspects of the opioid epidemic, Dr. Hall-Long noted. A Senate Bill established the Behavioral Health Consortium to coordinate the State’s private and public bodies to reduce current silos, establish greater access to care, and combat addiction and improve mental health services.

A Senate Bill established the Behavioral Health Consortium to coordinate the State’s private and public bodies to reduce current silos, establish greater access to care, and combat addiction and improve mental health services.

The Consortium gathered input from grassroots advocacy groups, non-profits, providers, health systems, first responders and community members to collaborate to tackle the the opioid crisis. Community forums sponsored by the Behavioral Health Consortium saw packed audiences and produced hundreds of recommendations to address the opioid epidemic.

The best ideas come from the streets, from the people, the families, and the communities that are affected. Community Forums were guided by two questions:

Question 1:  When you think about mental health and addiction (behavioral health), how behaviors affect health, and how people feel about their health where you live, what is happening in your community?

Question 2:  What is the number 1 thing we in Delaware can do to deal with mental health related issues and the issues we are facing in behavioral health?

Community Action

Education was a priority, therefore, public awareness programs and education campaigns were deployed statewide. The Consortium also recommended expansion of K-5 Wellness Centers, targeting Title I funded elementary schools within identified risk “hotspots.” By partnering with health systems and Primary Care Providers, they sought to create greater access to care for vastly underserved populations, and developed a comprehensive Community Health Worker Program with culturally competent individuals to perform basic health assessment and care. This created a critical touch point for individuals suffering from addiction.

Criminal Justice Approaches

Some of the recommendations affected the criminal justice system. “You want to get the bad guys,” Dr. Hall-Long acknowledged. To accomplish this, the Prescription Drug Monitoring Program (PDMP) was strengthened to identify “doctor shoppers,” people who go to multiple doctors to get opioid prescriptions, and also to pinpoint providers who overprescribe opioids.

With the PDMP ramped up, the Justice Department’s Overdose Fatality Review Commission receives geocoded information about where people are dying from overdoses and from what drugs. This helps pinpoint where drugs are prevalent and allows targeting high impact areas and properly dispatching resources to these areas, while working with providers and first responders. Furthermore, sellers who mix fentanyl with heroin now face murder charges. A 911 Good Samaritan law made it possible for someone to bring a person who had overdosed to a hospital emergency room, without risking legal action.

Creating A System of Care

Dr. Hall-Long stated that addressing the opioid epidemic also requires a strong focus on mental health issues. Many of the community’s recommendations focused on the larger issues of mental health. The public focused on two themes: first, stop people from overdosing and dying; and, second, improve access to treatment. Community input made it clear that providing greater access to care transforms those who are affected by the opioid epidemic.

To meet these objectives, Delaware established the nation’s first integrated overdose system of care. The system integrates first responders, police departments, fire service, paramedics, emergency rooms, and wrap-around service providers so that individuals who recover from an overdose receive a multifaceted approach to care, addressing both their medical and social needs, to prevent a relapse. The program sets up standards for “stabilization centers” that take over caring for overdose patients once they are released from hospitals or by first responders. “Delaware is the first State in the nation to create a system that, instead of sending someone home or to jail, will hopefully get them into treatment,” Dr. Hall-Long said.

Delaware established the nation’s first integrated overdose system of care. The system integrates first responders, police departments, fire service, paramedics, emergency rooms, and wrap-around service providers.

Funding the Programs

Current funding for the Delaware Division of Substance Abuse and Mental Health (DSAMH) is $23 million. The Behavioral Health Consortium is allocated an additional $5 million, which funds the Delaware Health Information Network and supports the transformation needed to establish the system of care. Funding also was generated via Medicaid expansion and local school district dollars were used for school education programs. Funding generated by CMS waiver and hospital “community benefit” dollars was allocated to Community Health Worker programs.

Delaware’s initial Three-Year Action Plan is being led by six Committees focused on:1. Access & Treatment2. Changing Perceptions & Stigma3. Corrections & Law Enforcement4. Data & Policy5. Education & Prevention6. Family & Community Readiness

“We anticipate that early intervention, coordinated treatment from health providers, and increased programs will directly impact population health outcomes,” Dr. Hall-Long concluded.

Tennessee Commission on Pain and Addiction Medicine

David M. Stern, MD

Robert Kaplan Executive Dean and Vice-Chancellor for Clinical Affairs
for the University of Tennessee’s College of Medicine

Dr. David Stern’s introduction to his presentation was heart-breaking, as he described his son’s death from an opioid overdose 10 years ago. This tragedy led to Dr. Stern’s career commitment to finding solutions to the opioid epidemic. Dr. Stern, who serves on the Tennessee Commission on Pain and Addiction Medicine, reported on the Commission’s formulation of evidenced-based pain and addiction medicine competencies for management of pain, proper prescribing of pain medication, and diagnosis and treatment of those suffering from addiction.

Hub: focal point of addiction medicine (ADM) expertise

Substance use disorder and mental health issues are interrelated and their treatment must be integrated, Dr. Stern noted. Like cancer care, effective treatment for substance use disorder requires integrated care from multiple specialists, including addiction specialists, case managers, mental health counselors, and peer navigators. People are going to relapse, he said, we need to have an integrated approach that re-routes them back into multidimensional and multifactorial treatment programs.

Substance use disorder and mental health issues are interrelated and their treatment must be integrated.

Several Hubs are established throughout the State and include addiction medicine specialists, behavioral health specialists, social workers, nurse care managers, case managers, and peers. They participate as integral partners in formulating patient treatment plans and steering patients to treatment centers best-suited to their needed level of care.

The Hubs leverage telecommunications technologies to provide tele-education, tele-consultation, and tele-medicine resources to law enforcement, vulnerable populations, emergency medical services personnel, and healthcare providers, as well as to community sites such as churches, jails, courts, treatment centers, and veterans groups.

Durable Recovery

A key theme for Dr. Stern is the concept of durable recovery. As a medical professional, he recognizes that “substance/opioid use disorder is a chronic, relapsing, medical disorder with episodic acute events (overdoses), which requires comprehensive individualized treatment plans and wrap-around services to keep a child from overdosing.”

Substance/opioid use disorder is a chronic, relapsing, medical disorder with episodic acute events (overdoses), which requires comprehensive individualized treatment plans and wrap-around services to keep a child from overdosing.

Durable recovery requires significant life changes, including moving people out of environments that foster drug abuse and providing education, workforce preparation, and job placement. “If people get launched into a career that is not just a minimum wage job but a real career, they don’t want to risk losing that position,” Dr. Stern observed. “They are able to develop medical, social, and financial assets that they value and that act as a deterrent to relapse.”

To achieve this, the program has partnered with Tennessee Colleges of Applied Technology (TCATs) to enroll and train people who participate in the substance use recovery programs. The results have been impressive. Among graduates who were matched with a Peer Navigator as a mentor, 80% have been successful in finding and keeping job placements. If a relapse occurs, the Navigator gets the graduate back into treatment.

Among graduates who were matched with a Peer Navigator as a mentor, 80% have been successful in finding and keeping job placements.

Peer Navigators

Tennessee’s program leverages the power of peers for addiction recovery support. Peer Navigators are themselves on the continuing journey of recovery and are sensitive to addiction issues. They believe that substance use disorder is a chronic relapsing disease and that recovery is possible. As advisors and mentors, they see without stigma and are able to provide empathetic and respectful support. They can establish immediate rapport and have the capacity to listen, understand and present hope.

Peer counselors receive training comparable to masters-level counselors. They have personal relationships with law enforcement and emergency services who can call them whenever someone in their care is ready for treatment. The Peer Navigator consults with the Hub personnel to identify the appropriate treatment center, accompanies the person to a treatment center and supports them in accessing needed housing, employment, and educational services to change their lives. This program has the potential to be economically feasible and sustainable, Dr. Stern reported.

Mobile Community Health Team

As understanding of the social determinants of health and population health management improves, it has become apparent that the addiction specialists have to be located where they are needed. Therefore, Tennessee developed a Mobile Community Health Team that includes Nurse Care Managers and Behavioralists who work in the communities where substance use disorder is highest. They coordinate with primary care providers and Hub services to provide better accessibility and quality of care for patients with substance use disorder.

Community Engagement

Tennessee’s integrated program to address substance use disorders engages the whole community.

Tennessee’s integrated program to address substance use disorders engages the whole community.

Legislation

Stressing the need for reimbursement, Dr. Stern pointed out, “If treatment is paid for, people with substance abuse disorders will seek it out.” He also emphasized the need to incentivize an integrated, comprehensive approach based on an outpatient/office treatment model. “What is the critical infrastructure you need to create an integrated system of care?” he asked. Many States have agencies working in silos to address the opioid epidemic. They need to share information and training, Dr. Stern pointed out. “This is an exercise in community medicine,” he concluded.

States have agencies working in silos to address the opioid epidemic. They need to share information and training.

For more on the Opioid Crisis: <more>

Discussion

Sen. David Long (IN): What are the economic consequences of the opioid crisis, and how are States funding these programs?

Dr. Hall-Long: It’s critical to get boots on the ground to stop the bleeding. Delaware allocated $250,000 to a peer mentor program and insurance companies matched that. In addition, pharmaceutical companies may provide naloxone. The $50 cost for naloxone can prevent $500,000 in long-term recovery costs, or in Neonatal Intensive Care Unit (NICU) costs for a baby born with Opioid Abstinence Syndrome.

Dr. Stern: The Council of Economic Advisers estimated that, in 2015, the economic cost of the opioid crisis was $504.0 billion, or 2.8% of GDP that year. The biggest part is the loss of productivity in the workforce, plus the costs of expensive hospital and emergency department visits. Community-based programs of prevention and treatment can prevent these visits and accrue substantial savings.

Sen. Robert Stivers (KY): The key issue is that the opioid crisis affects the whole economy of the state. It creates broken households, leaving children vulnerable and interfering with their education. The crisis raises the costs of incarceration and strains the judicial system. When you consider that 70% of opioid deaths are Medicaid recipients, it suggests the government is the biggest payer for drugs that are killing people. Are there alternatives to opioids so we can reduce the number of avenues that lead to addiction? Is marijuana a gateway drug or an alternative for pain management?

Dr. Shoemaker: Different States see marijuana as an alternative for pain management. The FDA guidelines on chronic pain recommend using alternative non-drug pain management approaches, but often these are not available, especially in rural areas.  The key is to identify people who have received long-term opioid prescriptions and follow them to determine if they need medically-assisted treatment to stop using the opioids.

Dr. Stern: Marijuana does have some medical uses such as for hyperemesis and migraine. But it is a dangerous drug and is not appropriate for young people whose brains are still developing. Opioids are meant for short-term pain relief. The critical need is for integrated pain management and addiction prevention programs.

Dr. Hall-Long: We need greater enforcement of parity laws requiring insurers to pay for mental health services, including opioid addiction treatment, on the same basis as other medical or surgical benefits. Some States are suing the pharmaceutical companies who market opioids and may be looking for an Opioid Settlement similar to the Tobacco Settlement.

Sen. Ginny Burdick (OR): There have been compelling anecdotes about the use of marijuana to manage pain. There are cannabidiol (CBD) formulations with low concentrations of the psychoactive element that have been used to treat pain and seizures. Furthermore, there is no known lethal dose of marijuana. But marijuana is currently a Schedule 1 drug. The Federal government should change it to a Schedule 2 drug so that research can be done to determine its potential for pain management, as well as to assess its risk for addiction.

Dr. Stern: Cannabinoids have complex actions at a number of receptors that are poorly understood. We don’t know if its effects can be closely controlled or regulated. The risk is that long periods of marijuana use while the brain is developing can lead to neurological handicaps.

Sen. Ronald Kouchi (HI): What have been the outcomes in those States that allow medical or recreational marijuana use? What are the impacts on law enforcement, healthcare costs, emergency services, etc?

Dr. Shoemaker: Oregon and Washington, allow medical or recreational marijuana use, had lower opioid-related mortality rates than the national average. But there are still stigma issues that result in lack of treatment; in fact, in some rural setting healthcare staff refuse to work with addicts.  [Editor: The National Institute on Drug Abuse provides state-by-state data of opioid deaths at: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state]

The National Institute on Drug Abuse provides state-by-state data of opioid deaths at:
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state

Sen. Drew Perkins (WY): Has our focus on “drug-free workplaces” and the use of drug-testing become a disincentive for people to work? Some companies have stopped drug testing because they can’t find enough workers who pass the drug test. When you establish programs with the applied technology schools, putting addicts and schools together, what happens with drug-testing and drug-free workplaces?

Dr. Stern: The value of the applied technology schools is to get addicts onto a career track that they don’t want to lose. We are selective about what career paths we recommend. For example, we would not put an addict into a Licensed Practical Nurse program where exposure to drugs would be routine.  We select the program that will work for the individual, where the drug history will not be an obstacle and where we are sure a real job will exist for them. We partner with companies that have specific needs for skilled workers.

When you are in recovery, every day is another challenge to stay the course because addiction is a relapsing disorder. We have a low bar for getting into our programs and we provide continuous mentorship with monthly contacts. But the addict has to participate. Non-attendance is a signal that intervention is needed, and they will be sent back for treatment.

When you are in recovery, every day is another challenge to stay the course because addiction is a relapsing disorder.

Editorial Note: In the week following this forum, the US Senate passed a package of bills aimed at the nation’s opioid epidemic, which includes 70 bills covering $8.4 billion in funding for programs across multiple agencies. The package provides funding to the National Institutes of Health to research a nonaddictive painkiller. Another provision clarifies that the FDA has the authority to require prescriptions for opioids to be packaged in set amounts, such as three or seven days. The package also funds “new federal grants for treatment centers, training emergency workers and research on prevention methods.” The House passed its own package earlier in summer 2018.

Speaker Biography

Sarah Shoemaker, PhD, PharmD

Sarah J. Shoemaker, PhD, PharmD, a Principal Associate with Abt Associates, is a health services and implementation researcher who conducts research and provides technical assistance on opioid prescribing and management, medication management and safety, primary care transformation, and quality improvement. She has led dozens of studies for the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), and other agencies. Dr. Shoemaker currently serves as Co-PI on a trio of CDC-funded projects to implement the CDC Guideline for Prescribing Opioids for Chronic Pain via quality improvement (QI), coordinated care, and clinical decision support. Additionally, she led development of 16 QI measures aligned to the CDC guideline and is supporting an Opioid QI Collaborative of several large healthcare systems implementing the guideline and measuring their progress using the QI measures. Dr. Shoemaker’s work has been widely disseminated in peer-reviewed publications, conference presentations and posters, and in evidence-based resources available from AHRQ and CDC. She serves on the editorial advisory board of several journals and served as a guest editor for journal supplements on implementation science and primary care practice improvement. Dr. Shoemaker received her pharmacy doctorate from Creighton University and her doctor of philosophy from the University of Minnesota..

Bethany Hall-Long, PhD, RNC, FAAN

Bethany Hall-Long was sworn in as Delaware’s 26th Lt. Governor on January 17th, 2017.

 Born and raised on her family’s farm in Sussex County with her two older brothers, Bethany graduated from Indian River High School where she met her high school sweetheart, Dana. After graduation, she went on to pursue her childhood dream of becoming a nurse at Thomas Jefferson University in Philadelphia.

Upon graduation, she and her husband, Dana, moved to Charleston, South Carolina, where she pursued her MSN in community health nursing, while Dana was stationed there as a member of the United States Navy. During Dana’s last tour at the Pentagon, Bethany completed her PhD in health policy and nursing administration from George Mason University, and served as a fellow for the U.S. Senate as well as the U.S. Department of Health and Human Services.

Their love of Delaware, and desire to be close to their families caused Bethany and Dana to move back and make their home in Middletown with their son, Brock.

Bethany has been a member of the UD Nursing Faculty now for nearly twenty years. She also holds a distinguished record at the University of Delaware (UD). She was the first nursing faculty at UD to receive the University-wide excellence in teaching award and is currently a Professor of Nursing and Joint Faculty in Urban Affairs. Her research and community service record with at-risk groups such as pregnant teens, diabetics, homeless and the mentally ill, makes her a nationally recognized health scientist.

From 2002-2017, Bethany served as a member of Delaware’s legislature, first as a Representative and then as a Senator. She served as the chair of the Health and Social Services committee where her efforts were aimed at ensuring a stronger, healthier Delaware by combating addiction, focusing on a stronger mental health system, fighting cancer, and health inequities in our state. She also served as a member of the capital budget Bond Committee where Bethany focused on building Delaware’s infrastructure, modernizing our schools, repairing our highways, and protecting our environment and open space.

Descended from Colonel David Hall, a judge, lawyer and 15th Governor of Delaware (1802), serving the community is in her blood. Her great-grandfather, David C. Hall, was elected to the Delaware House of Representatives (1916-1920).

Bethany has always been, and will continue to be a strong voice for all of Delaware.

David M. Stern, MD

Dr. David Stern is currently Robert Kaplan Executive Dean and Vice-Chancellor for Clinical Affairs for the University of Tennessee’s College of Medicine and the University of Tennessee Health Sciences Center.

He comes to this position after a career as a physician-scientist mainly at the College of Physicians & Surgeons of Columbia University, and administrative experience as a Dean at Both the Medical College of Georgia and University of Cincinnati’s College of Medicine.

After completing college at Yale and medical school at Harvard, Dr. Stern began a long stint in New York at the College of Physicians & Surgeons of Columbia University.  He started as an intern in internal medicine in 1978.  By the time he left New York for Georgia in 2002, he was the Carrus Professor and Director of the Center for Vascular and Lung Pathobiology.

Dr. Stern's research work focused on properties of the blood vessel wall, especially in chronic vascular disorders such as diabetes and Alzheimer’s disease.

During the course of building the research Center at Columbia, Dr. Stern became fascinated with building programs at academic medical centers.

That led him into administration and his first job as a medical school Dean and Chief Clinical Officer at the Medical College of Georgia in Augusta.  Dr. Stern spent three years in Georgia where he was known for his rapid recruitment of many department chairs, promoting clinical excellence in the faculty practice plan, enhancing the school’s focus on diversity, and forging a strong partnership between the school and the health system.

In July of 2005, Dr. Stern assumed the Deanship at the University of Cincinnati College of Medicine.  In 2008, he also became the Vice-President for Health Affairs.  His focus was on building collaborative programs, especially with Cincinnati Children’s Hospital Medical Center, reaching out to the community through the founding of a strong community advisory board, developing centers of excellence, reengineering the faculty practice plan, and providing a foundation for the university’s health system (UC Health).

During his tenure at the University of Cincinnati, he catalyzed the formation of a Joint Cancer Program between the College of Medicine, University Hospital and Children’s Hospital, recruited multiple department chairs and center/institute directors, completed a strategic plan for the College with its key partners, facilitated the securing of a CTSA award from the NIH, pushed the practice plan to increased clinical effectiveness and profitability, and designed a health system for the university with an urban and suburban campus, as well as a closely aligned physicians group.

He assumed the position of Executive Dean and Vice-Chancellor for Health Affairs at the University of Tennessee’ Health Science Center in the spring of 2011.

Dr. Stern is married to Dr. Kathleen Stern, a classmate from their days in medical school.  They have two sons.