LEARNINGS FROM THE OPIOID CRISIS

William A Hazel Jr. M.D.

Senior Advisor for Innovation and Community Engagement

Distinguished Visiting Professor of Public Policy

Schar School of Policy and Government

George Mason University

September 21, 2019

G E O R G E M A S O N U N I V E R S I T Y

1999 ESTIMATED

DRUG

OVERDOSE

DEATHS

G E O R G E M A S O N U N I V E R S I T Y

2004 ESTIMATED

DRUG

OVERDOSE

DEATHS

G E O R G E M A S O N U N I V E R S I T Y

2009 ESTIMATED DRUG

OVERDOSE DEATHS

G E O R G E M A S O N U N I V E R S I T Y

2014 ESTIMATED

DRUG

OVERDOSE

DEATHS

G E O R G E M A S O N U N I V E R S I T Y

DRUG ENFORCEMENT AGENCY ARCOS DATABASE

6

G E O R G E M A S O N U N I V E R S I T Y

O F F I C E O F T H E

A S S I S T A N T S E C R E T A R Y F O R P L A N N I N G A N D E V A L U A T I O N

12-MONTH DRUG OVERDOSE MORTALITY

(PREDICTED)

24

50000

55000

60000

65000

70000

75000

11

/1/2

01

5

12

/1/2

01

5

1/1

/20

16

2/1/

201

6

3/1

/20

16

4/1

/20

16

5/1

/20

16

6/1/

201

6

7/1

/20

16

8/1

/20

16

9/1

/20

16

10/1

/20

16

11

/1/2

01

6

12

/1/2

01

6

1/1/

201

7

2/1/

201

7

3/1

/20

17

4/1/

201

7

5/1

/20

17

6/1/

201

7

7/1

/20

17

8/1/

201

7

9/1/

201

7

10/1

/20

17

11

/1/2

01

7

12

/1/2

01

7

1/1

/20

18

2/1/

201

8

3/1

/20

18

4/1

/20

18

5/1

/20

18

6/1/

201

8

7/1/

2018

8/1/

2018

9/1/

2018

10/1

/20

18

11/1

/20

18

12/1

/20

18

1/1/

2019

2/1/

201

9

12

MO

NTH

MO

RTA

LITY

12 MONTHS ENDING IN MONTH

HHS OPIOIDS TEAMGOALReduce US drug overdose mortality

by at least 15% (>10,000 lives)

by January2021

3.4% Decrease Since

Corresponding 12-month Interval

Source: CDC National Vital Statistics System,

reported August2019

G E O R G E M A S O N U N I V E R S I T Y

O F F I C E O F T H E

NUMBER OF INDIVIDUALS RECEIVING PHARMACOTHERAPY FOR OUD

345,443

520,398

46,860

382,867

581,613

450,247

648,864

64,02073,260

0

100000

200000

300000

400000

500000

600000

700000

Methadone NaltrexoneBuprenorphine

2016 2017 2018

921,692

8A S S I S T A N T S E C R E T A R Y F O R P L A N N I N G A N D E V A L U A T I O N

1,028,500

1,172,371

0

200000

400000

600000

800000

1000000

1200000

1400000

2016 2017 2018

Total Number receiving MAT

(all types)

Source: 2018NSDUH

G E O R G E M A S O N U N I V E R S I T Y

G E O R G E M A S O N U N I V E R S I T Y

G E O R G E M A S O N U N I V E R S I T Y

G E O R G E M A S O N U N I V E R S I T Y

12

Source: CDC

G E O R G E M A S O N U N I V E R S I T Y

G E O R G E M A S O N U N I V E R S I T Y

G E O R G E M A S O N U N I V E R S I T Y

G E O R G E M A S O N U N I V E R S I T Y

19.3

33.9

7.8

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0Neonatal Abstinence Syndrome,

Three-Year Average Annual Rates per 1000 Live Births by Health District: Far Southwest Region, Virginia, 1999-2014

Cumberland Plateau

Lenowisco

Mount Rogers

16

G E O R G E M A S O N U N I V E R S I T Y

VIRGINIA’S RESPONSE

CultureChange

Interdict theIllegalSupply

Initiating and

Maintaining Recovery

Prevention

Addressing the Harm to

Self and Others

G E O R G E M A S O N U N I V E R S I T Y

RISK MITIGATION MEASURES

• Made naloxone available without prescription

• Passed good Samaritan law to encourage reporting of overdoses

• Changed laws regarding new mothers with Substance Use Disorder to keep cases open with Social Services

• Created a framework for needle exchange (two have been approved)

• Supported Therapeutic Court development

• Supported jail treatment programs

G E O R G E M A S O N U N I V E R S I T Y

IMPLEMENTATION OF CDC OPIOID PRESCRIBING GUIDELINES

19

65,975

20,390

268,464

82,420

$168,897.84

$48,576.22

0

50000

100000

150000

200000

250000

300000

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Decrease in Opioid Quantity, Cost and Days Supply (FFS)Form Virginia Department of Medical Assistance Services

Days Supply Total Quantity FFS Paid

Implementation of CDC Guidelines

BOM Emergency Opioid Prescribing Regulations

G E O R G E M A S O N U N I V E R S I T Y

Over a million pills NOT dispensed!!

Courtesy of the Virginia Department of Health Professions

IMPACT OF OPIOID PRESCRIBING REGULATIONS IN VIRGINIA

Year Fewer Prescriptions

Shorter Duration Fewer Longer

2015 325,695 143K or 44% of Rx <7days 41K or 13% of Rx for 22-30 days

2018 189,668 123K or 65% of Rx <7days 11K or 6% of Rx for 22-30 days

G E O R G E M A S O N U N I V E R S I T Y

PROVIDING SUD SERVICESTRANSFORMING THE DELIVERY SYSTEM OF MEDICAID SUD SERVICES

Addiction and Recovery Treatment Services (ARTS):Transforming the Delivery System of Medicaid SUD Services

21

ARTSInpatient Detox

Residential Treatment

Partial Hospitalization

Intensive Outpatient Programs

Opioid Treatment Program

Office-Based Opioid

Treatment

Case Management

Peer Recovery Supports

Effective July 1, 2017

Effective April 1, 2017

ARTS creates a fully integrated physical and behavioral health continuum of care

G E O R G E M A S O N U N I V E R S I T Y

VCU Evaluation: Outcomes From First Year of ARTS

More Medicaid members are receiving treatment for all Substance Use Disorders (SUD) and Opioid Use Disorder (OUD)

22

Before ARTS(Apr 2016-Mar 2017)

After ARTS(Apr 2017-Mar 2018)

% Change

↑57%Members with SUD receiving treatment

Members with OUD receiving treatment

15,703 24,615

↑48%10,092 14,917

G E O R G E M A S O N U N I V E R S I T Y

VCU Evaluation: Outcomes From First Ten Months of ARTS

Fewer inpatient hospitalizations related to Substance Use Disorder (SUD) and Opioid Use Disorder (SUD)

23

Before ARTS(Apr 2016-Jan 2017)

After ARTS(Apr 2017-Jan 2018)

% Change

↓4%Hospitalizations Related to SUD

Hospitalizations Related to OUD

3,520

12,650

↓6%2 3,315

13,182

The “Pillars” of Children’s Funding

# of Floors = # of Types of Services Provided

Bricks = Funding Streams Blue= General Funds Red = Federal Funds Orange = Grants

9 Agencies~70 Streams

4 Agencies~50 Streams

2 Agencies~10 Streams

6 Agencies21 Streams

Family Support Services

Early Childhood

Engagement

Child Welfare & Society

Workforce Development

Physical Health

Mental Health

Education

Juvenile Justice

Education

Food & Nutrition Programs

Family Support Services

Workforce Development

Family Support Services

Juvenile Justice

Engagement

Education

Child Welfare & Society

G E O R G E M A S O N U N I V E R S I T YCITY OF RICHMOND

$151

$1,071

$560 $560

($735)

($436)

$8

($1,000)

($800)

($600)

($400)

($200)

$0

$200

$400

$600

$800

$1,000

$1,200

Mo

nth

ly D

iscr

etio

nar

y In

com

e

Discretionary Monthly Income, After Taxes & Expenses

Hourly and Annual Pay

G E O R G E M A S O N U N I V E R S I T Y

• Opioid overdoses are one symptom of Substance Use Disorder

• Substance Use Disorder is a subset of chronic behavioral health conditions

• Treat the symptoms and address the underlying issues. Move upstream.

• Our job is to continually adapt and improve the systems.

• Build systems that are adaptable, scalable, and “interoperable”.

• Think in terms of system alignment – Collective Impact• Set goals

• Create measures – share the data across systems

• Choose mutually reinforcing “evidence informed” activities

• Communicate

• Be sure there is an infrastructure – someone has to be responsible or no one is.

KEY POINTS

Opioid Use Disorder

Prevention PlaybookA PRODUCT OF THE NATIONAL INTEROPERABILITY COLLABORATIVE

Premises of the Playbook

There exists substantial research on and strategies for

treatment of opioid use disorders

There are less well defined and replicated strategies for

prevention

Community-based collaborations are necessary to

address the opioid crisis

Collaborators seek evidence-based practices to

counter opioid use disorders

Elements of the Prevention Playbook

The foundations for collaboration

The explanation of a play

References to evidence supporting the play’s success

The theory of change implied by the play

Links to supporting resources

The foundation of collaborative plays

Multidisciplinary Collaboration

Information sharing across boundaries

Measuring outcomes

Evidence-based strategies11 POTENTIAL PLAYS

Common themes of prevention plays

Reduce the likelihood of an opioid use disorder

Up-front risk reduction (reduce early childhood

adverse experiences)

Alternatives to opioid use in pain mitigation

Reduce the supply of illicit drugs

Common themes of prevention plays

Improve Pain Management practices

Reduce the long-term use of opioids for pain management

Improve and expand prescription drug monitoring programs

Reduce the risk of treatment through education

Make provisions for safe disposal of unused opioids

Encourage the use of non-opioid formulations for pain management

Common themes of prevention plays

Prevent recurrence of an opioid use disorder

Shift policy from arrest and charging to diversion

to drug treatment programs

Provide medication assisted treatment to

inmates

Expand treatment programs after incarceration

HHS Opioid Strategy

https://www.hhs.gov/opioids

O F F I C E O F T H E

35A S S I S T A N T S E C R E T A R Y F O R P L A N N I N G A N D E V A L U A T I O N

• HHS launched its 5-point Opioid Strategy in April 2017

• Provides the overarching framework to leverage HHS expertise and resources of

HHS agencies in a strategic and coordinatedmanor