Post on 06-Mar-2021
Substance Use Disorder ResponseTeresa Koeller, MD, FASAM, Medical Director, Addiction Medicine
Dan Cole, CMPE, Assistant Vice President, Medical Specialties
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St. Elizabeth Physicians• 518 Providers
• 372 Physicians
• 146 Advanced Practice Providers
• 1670 Associates (including providers)
• 40 Specialties & Services
• 117 Practices
• 30 Primary Care• 3 Hospitalist Programs
• 11 Heart & Vascular
• 6 OB/GYN
• 1 Express Care, 4 Urgent Care
• 3 states / 9 Counties
• All eligible PCPs designated Level 3 PCMH
• Participating in the CMMI Comprehensive Primary Care Initiative
• Serving over 315,000 patients
In 2017
• Nearly 1.5 million visits
• Over $320 million in revenue132
179
239
346 378 404437
487 511 518
0
100
200
300
400
500
600
December31, 2009
December31, 2010
December31, 2011
December31, 2012
December31, 2013
December31, 2014
December31, 2015
December31, 2016
December31, 2017
February1, 2018
Number of SEP Providers
40 Specialties & ServicesPrimary Care
• Family Medicine• Internal Medicine• Pediatrics• Internal Medicine/Pediatrics
• Occupational Medicine/Business Health• Hospitalists• Express Care• Urgent Care
Specialty Care
• Addiction Medicine• Bariatric Surgery• Behavioral Health• Breast Surgery• Cardiology• Colon & Rectal Surgery• Dermatology & Aesthetics• Electrophysiology• Emergency General
Surgery• Endocrinology• Gastroenterology
• General Surgery• Geriatrics• Holistic Health• Infectious Disease• Medical Oncology• Nephrology• Neurology• Obstetrics & Gynecology• Ophthalmology• Pain Management/Spine
• Physiatry• Podiatry • Pulmonology• Radiation Oncology• Rheumatology• Sleep Medicine• Surgical Oncology• Urogynecology• Urology• Vascular Surgery• Wound Care
2.16.18
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Complications of Opioid Use
Societal Implications:
• Loss of job
• Broken families
• Homelessness
• Legal problems, jail, felonies
• Loss of potential income/under-education
• Illiteracy
• Lack of transportation
• Under Employment
• Societal & economic impact
Medical Complications:
• HIV
• Viral Hepatitis
• Syphilis
• Infectious Diseases
o Endocarditis
o Septic joints
o Cellulitis/abscess
• Hypogonadism
• Local tissue damage
• Neonatal Abstinence Syndrome
• Overdose/Death
Cost:
• HIV- $600,000 per patient NAS $66,000/treatment
• Heart Valve Replacement- $170,000 Hepatitis $90,000/treatment
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Northern Kentucky Heroin OverdosesSt. Elizabeth Emergency Departments
252447 545
745
1168
1584
2061
0
500
1000
1500
2000
2500
2011 2012 2013 2014 2015 2016 2017
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HIV and HEP C Risk In Northern Kentucky
Total HIV Cases:
34 2015
25 2016
37 2017
In 2017, a total
of 18 people
reported
injection drug
use among
their risk
factors,
compared to
only 5 in 2016
Northern Kentucky’s Hep C rates are 19 times greater than the average rate in the United States.
Of the 220 counties on the CDC’s “high risk” list for an HIV and HEP C outbreak, 25% are in Kentucky.
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Community education Prescription take-back boxes Drug abuse screenings
St. Elizabeth Response – Call to Action
Reduce the Supply
Establish a Regional Infrastructure
Advocate for Change
Reduce the Demand:
Prevent
Treat
Support
Protect (from Harm)
Strategies from Collective Plan St. Elizabeth Role Other Leadership Needed
Law enforcement for dealers Community watch
Patient education Provider education
Law enforcement Legislators
Continue leadership team Community education Impact analysis
Active role on leadership team Community education Submit data on impact
Heroin Impact Response Leadership Team
Heroin legislation Naloxone distribution Payment for services
Advocating for bills Narcan kit distribution SBIRT screenings
Legislators Cabinet for H&FS Medicaid MCOs
Community education SBIRT screenings Prescribing education and standards
Public health dept. Law enforcement Community pharmacies
Inpatient/detox Longer-term residential Medically-assisted Wraparound services Provider education
IP/IOP/OP services Supported CHNKY Hazelden 12-step Add IP bed capacity Increase suboxone prescribers (MDs) Bridge Clinic Vivitrol / rapid detox Increase residential treatment options Treatment options in jail
NorthKey Children’s Home of NKY Transitions Brighton Center Others
Community collaboration Develop 12-step program Employment opportunities Housing
Mental Health First Aid Resource guide Hazeldon program Navigation services (staffed)
Community/social service organizations Economic development/ housing
authorities NKY employers
Naloxone distribution Education to IDUs*, others Needle access
Narcan kits in EDs IDU education Naloxone MD order set Addiction clinic(s)
Legislators Cabinet for H&FS Public health dept.
* Injection Drug User (IDU)
ST. E
FOCUS
AREAS
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Prevention
Treatment
Support
Restore/Replace
Protect
St. Elizabeth Response
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SEP Partnered with Hazelden/Betty Ford
● Provide training and implementation of the
COR 12 Treatment Model.
● Develop centralized program to provide
medication assisted treatment in conjunction
with 12 Step Facilitated therapy to the patient
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Medication Assisted Treatment
Goals
• “Harm Reduction”
• Decrease deaths, disease transmission
• Prevention or reduction of withdrawal symptoms
• Prevention or reduction of opioid craving
• Prevention of relapse to use of addictive opioids
• Restoration to or toward normalcy of any physiologic function disrupted by opioid use
Potential Outcomes
• Decreases impulsive behavior
• Helps to develop structure
• Decreases criminal activity
• Increases retention in treatment
• Increases engagement in socially productive roles
• Increases employability
• Decreases overall chaos in patient’s life/family
MAT can help improve overall function of patients and assist living a ‘normal’ and productive life.
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Medication Assisted Treatment Drug
Options
Methadone – full agonist
Buprenorphine – partial opiate agonist at the mu receptor. Slow dissociation from mu receptors, long duration of action. Milder withdrawal symptoms on discontinuation
Oral Naltrexone – opioid antagonist
Long-Acting Naltrexone Injection
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Three Medication Pathways
12 Step Facilitated Groups in Conjunction With…
Abstinence-based
Agonist Therapy
Naltrexone
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First Pathway
Short Term Medications
Detox
Residential Treatment
Intensive Outpatient Treatment
Outpatient Therapy
Sober Living
Therapeutic Techniques
Cognitive Behavioral Therapy
Motivational enhancement therapy
Contingency Management
12 Step Facilitated Therapy
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Current StateSt. Elizabeth Physicians
Addiction Medicine and Recovery Program
• 1 FT Board Certified Addictionologist, 1 FT APRN and 8 PT Moonlighter MDs
• 3 Independently Licensed Clinical Counselors performing
o 12 Step Facilitated Groups
o 2 Pregnancy Groups, 10 Adult Groups
• Individual Counseling and Assessments
• Developed relationships with
o community behavioral health programs
o residential treatment and detox
• Created enterprise wide education programs on SBIRT
• Case Management
• Baby Steps Program for treatment of chemically dependent pregnant women
• ED Bridge Program
• Peer Support
• SUN Behavioral Health
• Provide Vivitrol treatment for clients of drug court
• Addiction Services Council Help Line
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Intensive Outpatient Treatment
Family Groups
Inpatient Evaluation and Treatment
Residential Treatment
Telemedicine
Ambulatory Detox
Develop Vivitrol program with jails
Methadone – OTP
Develop system-wide Peer Support
Future StateSt. Elizabeth Physicians
Addiction Medicine and Recovery Program
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Addiction is a chronic disease, not a moral failing—and one that must be addressed comprehensively across multiple service systems to be effective. We have set six community wide goals:
Moving our community from shock to programming and hope
Goal 1: To convene and connect across system to create realistic, sustainable solutions.
We need to better align our efforts. Although much has been accomplished, we need to dig deeper into the roots of addiction in order to prevent it from happening, or intervening early in the trajectory of use with effective treatment.
Goal 2: Prevent the adoption of unhealthy behaviors among 9-25 years old.
We need to address childhood adversity. We have learned that toxic stress or traumatic events in childhood are a significant risk factor for substance use disorders.
Goal 3: Decrease the infectious diseases associated with drug use.
We must have the tools to prevent the spread of diseases & increase access to health care services.
Goal 4: Decrease premature deaths due to drug overdoses.
We must broaden our reach to meet people where they are. The effectiveness of Quick Response Teams we will replicate that work into all areas where possible.
Goal 5: Provide evidence-based treatment specific to each person’s SUD to restore health.Health care providers must identify and manage people most at risk for addiction. Patients who call the NKY Helpline, and those who enter an emergency department for a SUD-related issue, must be appropriately and quickly assessed to be referred to the right treatment facility that is unique to their needs. These places are touch-points for screening, prevention services, and referral to treatment.
Goal 6: Provide comprehensive supports to people recovering from substance use disorders to restore
self-sufficiency and to quickly address recurrences.
Recovery support must be prioritized and coordinated. Recovery support has been disjointed and we
must make the alignment and coordination of community-based recovery services a priority.
17 Supporting Strategies: Advocacy, Communication, and Measuring Progress
Strong FamiliesResilient Children
Supportive Communities
Easy Access toBiopsychosocial
CareDisease
Management
Support for Re-entryPersonal
EmpowermentCareer
Development
NKY Hub for Transformative Action (NKY ASAP, Health Departments, HIRT, ODCP/SEH)
Outcomes
NKY Board for Transformative Leadership for Substance Use Disorders
Restoration and Recovery
Patient-Centered CarePositive Youth
DevelopmentHealth and Protection
Fewer OverdosesDeaths
Infectious Diseases
Impact Zone
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What can your community do now?
1. Acknowledge that your community has an issue with Substance Use Disorder
2. Support residential recovery programs
3. Support and help grow community educational programs
1. Town hall meetings
2. Awareness education on the complexity of the epidemic
4. Consider syringe access programs
5. Consideration of stigma and empathy education
6. Consider distributing Narcan to first responders and families of SUD population
7. Assisted people in recovery with
1. Employment opportunities
2. Transportation
3. Housing post residential treatment
4. Childcare assistance while in recovery
5. Life skills assistance
8. Support and collaborate with detention center and jails on educational programs
1. Nurturing families program
2. Vivitrol\Medication Assisted Treatment programs
3. Post release safe recovery assistance
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Speaker Information:
Dan Cole, CMPE
St. Elizabeth Physicians, Assistant Vice President, Medical Specialty 513-236-5536
Email: dan.cole@stelizabeth.com
Teresa Koeller, MD, FASAM
St. Elizabeth Physicians, Medical Director, Addiction Medicine and Recovery Center
Email: tkoeller@gmail.com
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