Virginia Opioid Addiction ECHO*

Project ECHO:

June 1, 2018

*ECHO: Extension of Community Healthcare Outcomes

Agenda

VCU Team

Clinical Director Mishka Terplan, MD, MPH, FACOG, FASAM

Administrative Medical Director ECHO Hubs and Principal Investigator

Vimal Mishra, MD, MMCi

Clinical Expert

Program Manager

Practice Administrator

IT Support

Lori Keyser-Marcus, PhD

Nanah Fofanah, MPH, CPH

David Collins, MHA

Vladimir Lavrentyev, MBA

Introductions

Fatal drug overdose has been the leading cause of unnatural death in Virginia since 2013

Opioid Epidemic and Virginia

At least 1,420 people died last year due to drug overdose

Project ECHO will likely build capacity and create access to high-quality addiction care at local communities

SAMHSA Buprenorphine Treatment Practitioner Locator Data

Opioid Epidemic and Virginia

Statewide Administrator

Academic hub Academic hub Academic hub

Clinical hub will rotate every 12-16 weeks

Bi-Weekly 2 hour tele-ECHO Clinics

Every tele ECHO clinic includes a 30-minute talk followed by case discussions

Talks will be developed and delivered by inter-professional experts in substance use disorder

https://www.vcuhealth.org/explore-vcu-health/for-medical-professionals/project-echo

Project ECHO Clinical Leadership

Clinical Directors Mishka Terplan, MD, MPH, FACOG, FASAM (VCU)

Richard Lawrence Merkel, MD, PhD (UVA)

Cheri W. Hartman, PhD (Virginia Tech Carilion)

Administrative Team

Administrative Medical Director ECHO Hub and Principal Investigator

Program Manager

Practice Administrator

IT Support

Vimal Mishra, MD, MMCi

Nanah Fofanah, MPH, CPH

David Collins, MHA

Vladimir Lavrentyev, MBA

Benefits to Participating Clinicians

• Free continuing education credit

• Opportunity to present actual patient cases, in a de-identified format, and receive specialty input

• Addiction treatment training, including management of naloxone/ buprenorphine (e.g. Suboxone)

• Access to a virtual learning community for access to treatment guidelines, tools, and patient resources

• Professional interaction with colleagues with similar interest

• Recording: By participating in this clinic you are consenting to be recorded. If you do not wish to be

recorded, please email ProjectECHO@vcuhealth.org

• Protect Patient Privacy

• VCU Health CME is offering 2 AMA PRA Category 1 Credits™.

• Participation and discussion is welcomed

Helpful Reminders

• Rename your ZOOM screen: Please rename yourself on your screen with your full name

• All participants are Muted during the call, Please Unmute yourself before speaking. If you have a

question, use the ‘hand-raised’ future in ZOOM or type your question in the Chat box.

• If you called with a phone to hear audio, please make sure your computer or device is Muted.

• Speak to the Camera, avoid distractions and for ZOOM issues (such as echoing, audio level etc.), use the

chat function to speak with the clinic IT team (Vlad)

Helpful Reminders

What to Expect

I. Overview

II. Introductions

III. Didactic Presentation

IV. Case presentationsI. Case1

I. Case summary II. Clarifying questions III. Recommendations

II. Case 2 I. Case summary II. Clarifying questionsIII. Recommendations

V. Closing and questions

Lets get started!Didactic Presentation

Virginia Opioid Addiction ECHO: Didactic Presentation

Open to all practicing and licensed M.D.s, D.O.s, and Community-based clinicians

Developer: Miriam Komaromy, MD, The ECHO Institute™

Reviewer/Editor: Joe Merrill, MD, University of Washington

Presenter: Dr. Mishka Terplan

Harm Reduction of Opioids

Disclosures

Dr. Mishka Terplan and Dr. Lori Keyser-Marcus have no financial conflicts of interest to disclose

There is no commercial or in-kind support for this activity.

Objectives

• Describe approaches to reduce harm from Opioids including:

• monitoring of the PMP, naloxone co-prescribing, medication storage and disposal, and screening for infectious disease

• Identify Virginia regulatory requirements for harm reduction

What is Risk Management or Harm Reduction:

• Taking precautionary measures to reduce the likelihood of a loss, or to reduce the severity of a possible loss.

Examples:

• Installing a Security System.

• Seatbelts, Airbags

• 2015 - Nine car models recorded driver death rates of zero

• attributed to safety features such as electronic stability control and design improvements

Principles of Harm Reduction

“Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with substance use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use substances.”

www.harmreduction.org

Principles of Harm Reduction

• Some people who have risky use of opioids or have an opioid use disorder are not ready, willing, or able to stop using

• This can result in a wide range of negative consequences for the individual and for society

• Consequently, approaches have been developed to reduce the most harmful aspects of drug use

Drug Epidemics and Prevention: primary, secondary and tertiary

Monitoring Drug Epidemics and the Markets that Sustain Them Using ADAM IIAndrew Golub, PhD; Henry Brownstein, PhD; August 2012

Overdose Risk Factors

• More than 100 mg of oral morphine equivalents daily 1

• Recent release from controlled environment• Incarceration 2

• Treatment 3

• Release after emergency care for overdose

• Mixing opioids with benzos, alcohol, other drugs 4

• Medical conditions (renal, hepatic, pulmonary diseases, HIV)

1. Bohnert et al., 2011; Dunn et al., 2010; 2. Binswanger et al., 2013; Binswanger et al., 2007; 3. Strang et al., 2003; 4. Powis et al., 1999

http://store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf

Strategy 1: Prevent, recognize, & manage opioid overdose

What an overdose looks like:

• Blue lips

• Blue finger tips

• Small pupils

• Pale skin

• Shallow/labored breathing

• Non-responsive to voice or sternal rub

Reversing an overdose:

• Assess the scene (safety)

• Assess the person

• Call 911

• Rescue breathing

• Administer naloxone

STRATEGY 3: Ensure Ready Access to Naloxone

• Naloxone is an opioid antagonist

• High affinity for mu opioid receptor

• Displaces opioid from receptor

• Prevents other opioids from binding

• Works within minutes

• Lasts 20-90 mins

• FDA approved for IV, SC, IM, IN use

• Opioid overdose-related deaths can be prevented when naloxone is administered in a timely manner

STRATEGY 3: Ensure Ready Access to Naloxone

• Virginia Department of Health dispensing Narcan Nasal through the local health departments

1. In conjunction with REVIVE trainings: REVIVIE trainers work with their health depts. To have training with someone from the dept. who will dispense medication during training.

2. ON a walk-in basis: Call health department to ensure Naloxone dispensing staff is available

• Naloxone-Virginia Statewide Standing Order: serves as a prescription for all Virginians- residents can now request Naloxone directly from the pharmacy without going to their provider first

• Order authorizes current license practicing pharmacist in VA to dispense Intranasal or Auto-Injector formulation of Naloxone as of April 2018

http://dbhds.virginia.gov/behavioral-health/substance-abuse-services/revive

List of health department director who serve point of contacts http://dbhds.virginia.gov/assets/document-library/archive/library/substance%20abuse%20services/Revive/Health-District-Directors.pdf

Naloxone-Virginia Statewide Standing Order:http://www.vdh.virginia.gov/content/uploads/sites/4/2016/11/Standing-Order-w-o-DEA-FINAL.pdf

Writing a Prescription for Nasal Naloxone

http://www.prescribetoprevent.org/wp-content/uploads/2012/11/naloxone-one-pager-in-nov-2012.pdf

• There is now a high concentration Naloxone product (4mg/0.1ml) designed for intranasal use• This reduces the amount of fluid insufflated into the nose allowing for greater retention.

• 49 states now have Prescription Drug Monitoring Programs

• Many are requiring prescribers check the PDMP

https://www.slideshare.net/TTITAMU/the-effects-of-drugs-on-driving

Virginia PMP

How to Access the Virginia PMP:

• Navigate to: https://virginia.pmpaware.net

• Click the ‘Reset Password’ button on the homepage.

• Instructions will be emailed to you for resetting your password.

• Once you have reset your password, you will be logged into the system.

• To request patient reports, please review the How to Make a Request Guide.

https://www.dhp.virginia.gov/dhp_programs/pmp/

Prescription Monitoring Program

• State-based

• Interoperable with North Carolina

• Virginia’s PMP is now fully integrated with more than half of U.S. states.

• VA and OTPs don’t report into PMP – therefore any opioid pharmacotherapy that is dispensed (as opposed to prescribed) won’t be in there

PMP Best Practice

• Unsolicited reporting: proactive dissemination of prescription history of individuals who meet the criteria for questionable activity

• e.g.. Obtaining the same scripts for controlled substance from 4 or more prescribers and filling at 4 or more pharmacies in 6 months

• Establish interstate data sharing: to tackle doctor shopping across state lines. Virginia now has interstate data sharing with North Carolina as of 2018

• Share data with researchers for prevention, surveillance and early warning systems: this helps researchers to identify populations in need of interventions, to describe trends in prescribing and data is used in drug abuse surveillance and prevention efforts.

http://www.pdmpassist.org/pdf/Resources/BriefingOnBestPractices_final_april_2012.pdf

PMP Best Practice

• Collect and report prescription data for Schedule II-V controlled substances: this allows for more accurate estimate of questionable behavior and enables prescribers and pharmacist to have the information to exam a full spectrum of controlled substances.

• Collect data using the most recent ASAP standard: Use of the most recent American Society for Automation in Pharmacy (2016 ASAP 4.2) standard increases PMP effectiveness by facilitate cross-state data sharing, multi-state data analysis and organizational collaboration using prescription history data.

• Expand access to PMP data: this increase impact and effectiveness of PMP’s

http://www.pdmpassist.org/pdf/Resources/BriefingOnBestPractices_final_april_2012.pdf

PMP Best Practice

• Confidentiality, security, and privacy provisions regarding the collected data: distribution of PMP reports to unauthorized users is prohibited; violation carry several penalties including license revocation

• Education and outreach to stakeholders on how to access and utilize prescription history reports: is needed to expend PMP utilization

http://www.pdmpassist.org/pdf/Resources/BriefingOnBestPractices_final_april_2012.pdf

Safe Medication Storage and Disposal

American Medical Association Task Force to Reduce -3 steps to promote safe storage and disposal

1. Talk to your patients

• More than 70% of people misusing opioid analgesics get them from family and friends

2. Remind your patients

• To store medications out of children’s reach and to not share prescriptions

3. Urge your patients to safely dispose of expired, unwanted and used medications

• Use of pharmacy and law enforcement “take back” resources

Safe Medication Storage and Disposal

• Medicine Take-back Options

• Disposal in Household trash: Drug disposal bags available from local health depts.

• Place unused medication in the pouch

• Fill halfway with Warm Tap Water

• Gently Shake

• Flush potentially dangers meds in the toilet

http://www.vdh.virginia.gov/content/uploads/2016/11/img_0614.jpg

Household Trash Disposal

FDA consumer updates https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm

Figure 1: Source of prescription pain relievers for the most recent nonmedical use amongst past year users aged 12 and older: annual average, 2013 and 2014

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUHs), 2013 and 2014

Needle Exchange as Harm Reduction

• Virginia’s first needle exchange program could be open later this year in Far Southwest Virginia to tackle spread of Hep C due to Opioid epidemic

• Potentially in or around Wise County: Population of about 40,000 with 120 opioids related deaths between 2007-2017

http://www.roanoke.com/news/local/virginia-s-first-needle-exchange-could-open-this-year-as/article_64f92a6b-4990-5554-8145-9e3c72ded303.html

Harm Reduction Behaviors

• Use clean syringes

• Use new syringes (sharp tip reduces abscesses)

• Cleanest water you can find–bring a water bottle, use top of the toilet bowl rather than, the bottom

• Use your own equipment (including cottons and cookers)

http://center4si.com/wp-content/uploads/2016/05/Harm-Reduction-Strategies-.pdf

Harm Reduction Behaviors

• Clean injection site with alcohol wipe or soap /water

• Rotate injection sites (cuts down on scarring)

• Use vitamin C powder and water to dissolve drug for

• injection– not lemon juice or vinegar

http://center4si.com/wp-content/uploads/2016/05/Harm-Reduction-Strategies-.pdf

Harm Reduction Behaviors

• Safer sex-use condoms

• Know your HIV/HCV status – get tested

• Strategic positioning-If you share and know you are HIV/ HCV negative, use first

http://center4si.com/wp-content/uploads/2016/05/Harm-Reduction-Strategies-.pdf

Harm Reduction Behaviors

• Clean up after yourself – make sure not to infect others

• If sharing, do a dry divide – split the drugs on a clean surface before adding water

• If a dry divide is not possible, use a sterile syringe to draw up the water and divide the shot

http://center4si.com/wp-content/uploads/2016/05/Harm-Reduction-Strategies-.pdf

Harm Reduction Behaviors

Lower risk of OD:

• Know your dealer

• Don’t use alone

• Do a tester shot/ snort some first

• Avoid mixing drugs/ alcohol

http://center4si.com/wp-content/uploads/2016/05/Harm-Reduction-Strategies-.pdf

Harm Reduction Behaviors

• Get Narcan/ Naloxone

• Use in safe places and Leave doors unlocked

• Have an Overdose Prevention Plan – discuss with friends and family

• Use Chapstick

• Self-care, take care of wounds

http://center4si.com/wp-content/uploads/2016/05/Harm-Reduction-Strategies-.pdf

Virginia Regulatory Requirements for Harm Reduction

VDH established standards and protocols for Comprehensive Harm Reduction (CHR) Programs for the provision of sterile and proper disposal of used hypodermic needles and syringes:

1. Standard 1–CHR programs are required to develop a time-phased work plan with process measures that demonstrates the program’s ability.

2. Standard 2–CHR programs are required to identify the communities/localities in which they will provide services…

http://www.vdh.virginia.gov/content/uploads/sites/10/2017/06/CHR-Standards-and-Protocol-rev-24.10.18.pdf

Virginia Regulatory Requirements for Harm Reduction

3. Standard 3–CHR programs are required to demonstrate readiness of the communities/localities in which they will operate.

4. Standard 4–CHR programs are required to provide appropriate disposal of used hypodermic needles and syringes.

5. Standard 5–CHR programs must provide sterile hypodermic needles and syringes and other injection supplies at no cost to participants

http://www.vdh.virginia.gov/content/uploads/sites/10/2017/06/CHR-Standards-and-Protocol-rev-24.10.18.pdf

Virginia Regulatory Requirements for Harm Reduction

6. Standard 6–CHR programs must ensure reasonable and adequate security of program sites, equipment, and personnel.

7. Standard 7–CHR programs must be able to verify that a hypodermic needle, syringe, or other injection supplies were obtained from their program

8. Standard 8–CHR programs must be able to verify which personnel the program authorizes to purchase, transport, distribute, and collect hypodermic needles and syringes.

http://www.vdh.virginia.gov/content/uploads/sites/10/2017/06/CHR-Standards-and-Protocol-rev-24.10.18.pdf

Virginia Regulatory Requirements for Harm Reduction

9. Standard 9–CHR programs must directly provide the following services in addition to distribution of sterile needles and syringes and disposal of used hypodermic needles and syringes

10. Standard 10–CHR programs must provide the following services, either directly or through a documented referral process, with a verification feedback mechanism

http://www.vdh.virginia.gov/content/uploads/sites/10/2017/06/CHR-Standards-and-Protocol-rev-24.10.18.pdf

Key Points…

• We can help our patients to stay safe even if they are not motivated/able to stop using drugs

• Safer opioid prescribing and use of the prescription monitoring program are ways of decreasing the supply of opioids

• Syringe exchange, overdose prevention education, naloxone prescribing, HIV/HCV screening and treatment, syringe exchange programs are ways of decreasing harms to individual patients who use drugs

Language and Harm Reduction

Words to Avoid

• Addict

• Alcoholic

• Drug problem, drug habit

Words to Use

• Person with substance use disorder

• Person with alcohol use disorder

• Substance use disorder

Use supportive and non-judgmental language to prevent and reduce stigma

https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing%20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20Substance%20Use%20Disorders.pdf

Language and Harm Reduction

Words to Avoid

• Drug abuse

• Drug abuser

• Clean

Words to Use

• Drug misuse, harmful use

• Person with substance use disorder

• Abstinent, not actively using

https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing%20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20Substance%20Use%20Disorders.pdf

Language and Harm Reduction

Words to Avoid

• Dirty

• A clean drug screen

• A dirty drug screen

Words to Use

• Actively using

• Testing negative for substance use

• Testing positive for substance use

https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing%20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20Substance%20Use%20Disorders.pdf

Language and Harm Reduction

Words to Avoid

• Former/reformed addict/alcoholic

• Opioid replacement, methadone maintenance

Words to Use

• Person in recovery, person in long-term recovery

• Medication assisted treatment

https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing%20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20Substance%20Use%20Disorders.pdf

Risk Reduction strategies for OUD

• Reduce the stigma/prejudice surrounding this disease

• Increase access to evidence-based treatment

• Teach safer injection practices and safer use

Risk Reduction strategies for OUD

• Never use alone, same dealer, test shot, aseptic technique

• Provide access to needle & syringe exchange

• Consider implementing sites for safer injection

• Increase access to naloxone for overdose prevention

References

American Medical Association (2014). 3 steps for physicians to boost safe storage, disposal of Opioids. Available at https://wire.ama-assn.org/delivering-care/3-steps-physicians-boost-safe-storage-disposal-opioids

Botticelli MA, Koh HK. Changing the language of addiction. JAMA October 4, 2016;316(13):1361

Broyles LM, Binswanger IA, Jenkins JA, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response.

Subst Abus. 2014;35(3):217-21

Campbell G1, Nielsen S1, Larance B1, et al. Pharmaceutical Opioid Use and Dependence among People Living with Chronic Pain: Associations Observed within the Pain and Opioids in Treatment (POINT) Cohort. Pain Med. 2015 Sep;16(9):1745-58. doi: 10.1111/pme.12773. Epub 2015 May 22.

CDC Guidelines for prescribing opioids for chronic pain: United States 2016. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Diversion Control Division. National drug prescription take back. https://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html

PMP Center of Excellence (2012). PMP Center of Excellence Briefing: Best Practices for Prescription Monitoring Programs. http://www.pdmpassist.org/pdf/Resources/BriefingOnBestPractices_final_april_2012.pdf

Office of National Drug Control Policy (2016). DRAFT: Changing the Language of Addiction. https://www.ghdonline.org/uploads/ondcp_proposal_for_language_about_drug_use_10_4_2016.pdf

References

PRAXIS Training for Massachusetts Addiction Professionals (2016). Sexual behaviors and harm reduction strategies

SAMHSA Opioid Overdose Prevention Toolkit: http://store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf

The Roanoke Times (2018). Virginia's first needle exchange could open this year, as localities seek support for the programs. http://www.roanoke.com/news/local/virginia-s-first-needle-exchange-could-open-this-year-as/article_64f92a6b-4990-5554-8145-9e3c72ded303.html

Society of Addiction Medicine. (2011). Public Policy Statement: Definition of Addiction. Chevy Chase, MD: American Society of Addiction Medicine. Available at http://www.asam.org/docs/publicypolicy-statements/1definition_of_addiction_long_4-11.pdf?sfvrsn=2

Virginia Department of Behavioral Health and Developmental Services. REVIVE-Opioid Overdose and Naloxone Education for Virginia. http://dbhds.virginia.gov/behavioral-health/substance-abuse-services/revive

References

Virginia Department of Health (2018).Virginia Standards and Protocols for Comprehensive Harm Reduction Programs (2018). http://www.vdh.virginia.gov/content/uploads/sites/10/2017/06/CHR-Standards-and-Protocol-rev-24.10.18.pdf

Virginia Department of Health (2016). How to dispose of unused medicine. http://www.vdh.virginia.gov/blog/2016/11/15/how-to-dispose-of-unused-medicine/

References

Courses are available to providers:

http://www.OpioidPrescribing.com [SAMHSA])

www.prescribetoprevent.org

Virginia Department of Behavioral Health and Developmental Services: REVIVE! Opioid Overdose and Naloxone Education for Virginia: Training for Lay rescuers & Lay Rescuer Training of Trainers

Email and visit for more information.

revive@dbhds.virginia.gov

http://dbhds.virginia.gov/behavioral-health/substance-abuse-services/revive

Helpful information for laypersons:

Project Lazarus at –

http://www.projectlazarus.org

Massachusetts Health Promotion Clearinghouse at –

http://www.maclearinghouse.org

References

Questions ?

Case Presentation

Case 1:

Case Presentation

Case 2:

Scheduled TeleECHO Clinics

Bi-Weekly Fridays 12-2pm

1. May 18: Introduction to Opioid Use Disorder

2. June 1: Harm Reduction of Opioids

3. June 15: Counselling and Other Support for Treatment of Opioid Use Disorders

4. June 29: Introduction to Motivational Interviewing

5. July 13: Identifying Addiction in Primary Care

6. July 27: Medications for Treatment of Opioid Use Disorders

How to Access Your Evaluation and Claim Your CME

Shaun McCafferty

Step 1 - Go to https://vcu.cloud-cme.com/aph.aspx and click “Sign In” on the top left

Step 2 – Sign in using the appropriate option for your account.

If you are a VCU Health employee you will sign in using your VCU Health ID and windows password. All others will use your email and password

If you have never logged in with us before and are not a VCU Health employee, your password was set to Password1

Step 3 – Once signed in, click the “My CME” or “My CE” button.

Step 4 – Click on Evaluations and Certificates.

• Evaluations and Certificates – This option allows you to view evaluations that need to be completed for existing activities you have attended and also allows you to view, print or email certificates for activities you have already completed an evaluation for in CloudCME. This is where you will claim credit, fill out evaluations, and download your certificates.

Please contact VCU Health CME directly with any problems or questions at (804) 828-3640 or cmeinfo@vcuhealth.org

Scheduled TeleECHO Clinics

Bi-Weekly Fridays 12-2pm

1. May 18: Introduction to Opioid Use Disorder

2. June 1: Harm Reduction of Opioids

3. June 15: Counselling and Other Support for Treatment of Opioid Use Disorders

4. June 29: Introduction to Motivational Interviewing

5. July 13: Identifying Addiction in Primary Care

6. July 27: Medications for Treatment of Opioid Use Disorders

Questions ?