Massachusetts Responds to the Opioid Epidemic Using Data To Inform Policy and Programs Monica Bharel, MD MPH Commissioner of Public Health

Data For Massachusetts 2017 Q4 Quarterly Report and Chapter 55

Opioid Related Overdose Deaths

379506 526 614

514 575 660 642 622 638 560656 742

961

1,352

1,648

2,083

1,501

1,768

2,1551,977

0200400600800

1,0001,2001,4001,6001,8002,0002,2002,400

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Num

ber

of d

eath

s

Figure 2. Opioid1-Related Deaths, All IntentsMassachusetts Residents: 2000 - 2017

Confirmed Estimated

8.3% decline

The rate of fentanyl present in the toxicology of opioid-related overdose deaths continues to rise, reaching 83 percent this year, while the rate of prescription opioids and heroin present in opioid-related overdose deaths continues to decline

0102030405060708090

100

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3

2014 2015 2016 2017

Perce

nt

Year and Quarter

Figure 4. Percent of Opioid Deaths with Specific Drugs PresentMA: 2014-2017

Fentanyl¹

Likely Heroin

Prescription Opioid²

Benzodiazepine

Cocaine

Opioid Overdose Death Rates by County 2011 - 2013 2014 - 2016 vs.

The age-adjusted opioid-related overdose death rate for Hispanics doubled over a three-year period (2014-2016)

Prescription Monitoring Program – Data Trends

• Registered MassPAT providers conducted over 1.5 million searches. There was an increase of 35,000 searches in Q4 over Q3 2017.

• Approximately 594,000 Schedule II opioid prescriptions reported to the MA PMP in Q4 2017, which is a 30% decrease from Q1 2015 (n = 841,990 Schedule II opioid prescriptions)

• Approximately 268,000 people in Massachusetts received prescriptions for Schedule II opioids in Q4 2017, which is 30% less than Q1 2015, when there were 390,532 individuals receiving Schedule II opioids

Chapter 55 of the Acts of 2015 • Signed into law in August 2015

• Required a comprehensive report to the state legislature and cross-agency collaboration to address 7 specific questions about opioid-related deaths

• Specified major data sets across government

• Overcame legal barriers for use of some data

Data Mapping

Chapter 55: Partners Coming Together Academic

•Brandeis University •Boston University •Brown University •Harvard Medical School •Harvard School of Public Health •Massachusetts College of Pharmacy and Health Sciences •Massachusetts Institute of Technology •Northeastern University •Tufts University •University of Massachusetts Amherst •University of Massachusetts Boston •University of Massachusetts Medical School

State and Federal Government Agencies

Hospitals & Private Industry

•Baystate Health •Beth Israel Deaconess Medical Center •Boston Medical Center •Brigham & Women’s Hospital •Children’s Hospital •GE •IBM •Liberty Mutual •Massachusetts General Hospital •Massachusetts League of Community Health Centers •McKinsey & Company •The MITRE Corporation •Partners Healthcare •PwC •Rand Corporation

• Boston Public Health Commission • Center for Health Information and Analysis • Department of Housing and Community Development • Department of Mental Health • Department of Correction • Department of Public Health • Executive Office of Health and Human Services • Executive Office of Public Safety and Security

• Federal Bureau of Investigation • High Intensity Drug Trafficking Area (NE) • Health Policy Commission • Massachusetts Sheriffs’ Association • MassIT • Office of the Chief Medical Examiner • State Auditor’s Office

Chapter 55 Phase 1 Report – Key Finding

DRAFT - FOR POLICY DEVELOPMENT ONLY

0

0.5

1

1.5

2

2.5

Engaged in OAT Not Engaged in OAT

Cum

ulat

ive

Inci

denc

e of

Dea

th (%

)

Cumulative Incidence of Opioid-Related Death by OAT Status Following a non-fatal overdose,

patients treated with methadone and/or buprenorphine (Opioid Agonist Treatment or “OAT” that block the effect of opioids) were significantly less likely to die; however, very few patients (~5%) engage in OAT following a non-fatal overdose.

Ch. 55 Phase 1 Report– Key Findings

DRAFT - FOR POLICY DEVELOPMENT ONLY 12

Statute Question Analytic Question Preliminary Findings

1. Instances of multiple provider episodes, meaning a single patient having access to opiate prescriptions from more than 1 provider

Does an abnormally high amount of prescribing physicians increase a patient’s risk of fatal overdose?

Individuals who obtain prescriptions for opioids from more than one doctor may be at greater risk of death. Based on observed data, the use of 3 or more prescribers is associated with a 7-fold increase in risk of fatal opioid overdose.

2. Instances of poly-substance access, meaning a patient having simultaneous prescriptions for an opiate and a benzodiazepine or for an opiate and another drug which may enhance the effects or the risks of drug abuse or overdose

Does the addition of benzodiazepines to opioids increase the risk of fatal opioid overdose relative to taking opioids alone?

Preliminary findings support the hypothesis of increased risk of fatal overdose associated with concurrent use of opioids and benzodiazepines. Based on observed data, the use of benzodiazepines concurrent to opioids is associated with a 4-fold increase in risk of fatal opioid overdose. Future analysis should include other drugs.

Year 2 Report Organization

Re-Estimating Baseline

Time line and Influences

At –Risk Populations

Chapter 55 – Key Finding

DRAFT - FOR POLICY DEVELOPMENT ONLY

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

2011 2012 2013 2014 2015

% O

UD

in M

A Po

pula

tion

Estimated OUD Population Rises Significantly Between 2011-2015

• Approximately 4% of individuals age 11 and older have OUD in Massachusetts.

• There was a sharp increase in 2013.

• This estimate is more than double previously reported figures.

Nonfatal Overdoses (NFO)

• Recorded nonfatal overdoses increased by about 200% between 2011 and 2015. • The total exceeded 65,000. It is probably an underestimate. • Multiple naloxone administrations up 27% since 2013.

-

10,000

20,000

30,000

2011 2012 2013 2014 2015

Estim

ated

# N

FOs

Total Nonfatal Opioid Overdoses Rise Sharply Between 2011 and 2015*

* MATRIS data only available from 2013 - 2015. EMS transports estimated.

Time From Initial Rx to Overdose Death

0

20

40

60

80

100

% S

uviv

ing

of T

hose

W

ho D

ied

0 ------ Months from Initial Prescription ------ 60

Average Survival Time For Those Who Died of Opioid Overdose was 36 Months

Persons with Histories of Incarceration

0.0

500.0

1000.0

1500.0

2000.0

Incarceration History No Incarceration HistoryDea

th R

ate

Per 1

00,0

00

Opioid Death Rate 120 Times Higher for Individuals with Histories of Incarceration

Persons Experiencing Homelessness

0

100

200

300

400

Homeless (Modeled) Not HomelessDea

th R

ate

Per

100

,000

Opioid Death Rate 30 Times Higher

for the Homeless Individuals

Individuals with Serious Mental Illness

30.3 34.1 37.0

86.1* 95.6

12.8 -

20

40

60

80

100

120

Anxiety Depression ADHD SMI Neuro Cog MADea

ths

Per 1

00,0

00

Very High Rates of Fatal Opioid Overdoses for Persons with Some Mental Health Diagnoses

*Among MassHealth members only

Pregnant and Postpartum Risk

3.6 2.4 2.5

0.7 0.7

1.9 2.1

0 1 2 3 4 5

181—365 days after delivery

43—180 days after delivery

0—42 days after delivery

Third Trimester

Second Trimester

First Trimester

1 year before delivery, prior to conception

Overdose Events / 1 Million Person Days

Rate of Opioid Overdose Events Increase Sharply After Delivery for OUD Mothers

Data visualization

http://www.mass.gov/chapter55/

Governor Baker’s Opioid Working Group

Safe Prescribing

• Rx 7-day limit • Check Prescription Monitoring Tool

• Prescriber Education

Core Competencies • Medical Schools • Dental Schools • Advance Practice Nursing

• Physician Assistants • Community Health Centers • Social Work Programs

www.mass.gov/StateWithoutStigma

Parent Campaign Launched • Rx opioid misuse • Parents of middle and high school age kids

• Tips for how to start a conversation

Stop Addiction Before It Starts www.mass.gov/PareLaAdiccion

27

Access to Naloxone (Narcan®)

• First Responders • Bystanders • Pharmacies • Community Bulk Purchasing Program

Treatment • >700 more Tx beds since 2015

• Ended use of prison for women with SUD

• Expanded Office Based Treatment

• Treatment for High-Risk Populations

Recovery

• 2000 + sober home beds certified

• Recovery Coaches • Recovery Support in emergency rooms

Additional Resources • Massachusetts Helpline:

• www.helplinema.org

• Massachusetts Responds to The Opioid Epidemic: • With links to current stats & Chapter 55 Report • Mass.gov/opioidresponse

• Stop Addiction Before It Starts:

• Mass.gov/stopaddiction