Addressing the Opioid Epidemic through a Public Health Lens

MONICA BHAREL, MD, MPH

MASSACHUSETTS COMMISSIONER OF PUBLIC HEALTH

Massachusetts Department of Public Health

Massachusetts DPH will be a national leader in innovative, outcomes-

focused public health based on a data-driven approach, with a focus on

quality public health and health care services and an

emphasis on the social determinants and eradication of health disparities.

355486 505 587

494 554 635 617 587 610 532 613698

918

1,321

1,5971,465

1,379

1,751

1,979

0200400600800

1,0001,2001,4001,6001,8002,0002,200

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

Num

ber o

f dea

ths

Opioid-Related Deaths, Unintentional/UndeterminedMassachusetts: January 2000- December 2016

Confirmed Estimated

74% OF OPIOID DEATHS IN 2016 HAD THE PRESENCE OF FENTANYL

Opioid-related deaths in Massachusetts

Monica Bharel, MD, MPH Commissioner, Massachusetts Department of Public Health

The opioid epidemic burden in Massachusetts

Prevention Intervention Treatment Recovery

Governor Baker’s Opioid Working Group

Prevention Intervention Treatment Recovery

Governor Baker’s Opioid Working Group

Adopted by all 4 medical schools, 3 dental schools and

all PA and APRN programs in MA

Preventing Prescription Drug Misuse: Screening, Evaluation, and Prevention

1. Evaluate a patient’s pain using age, gender, and culturally appropriate evidence-based

methodologies.

2. Evaluate a patient’s risk for substance use disorders by utilizing age, gender, and culturally appropriate evidence-based communication skills and assessment methodologies, supplemented with relevant available patient information, including but not limited to health records, family history, prescription dispensing records (e.g. the Prescription Drug Monitoring Program or “PMP”), drug urine screenings, and screenings for commonly co-occurring psychiatric disorders (especially depression, anxiety disorders, and PTSD).

3. Identify and describe potential pharmacological and non-pharmacological treatment

options including opioid and non-opioid pharmacological treatments for acute and chronic pain management, along with patient communication and education regarding the risks and benefits associated with each of these available treatment options.

Medical Core Competencies: Primary Prevention Domain

Treating Patients At-Risk for Substance Use Disorders: Engage Patients in Safe, Informed, and Patient-Centered Treatment Planning

4. Describe substance use disorder treatment options, including medication-assisted

treatment, as well as demonstrate the ability to appropriately refer patients to addiction medicine specialists and treatment programs for both relapse prevention and co-occurring psychiatric disorders.

5. Prepare evidence-based and patient-centered pain management and substance use disorder treatment plans for patients with acute and chronic pain with special attention to safe prescribing and recognizing patients displaying signs of aberrant prescription use behaviors.

6. Demonstrate the foundational skills in patient-centered counselling and behavior change in the context of a patient encounter, consistent with evidence-based techniques.

Medical Core Competencies: Secondary Prevention Domain

Managing Substance Use Disorders as a Chronic Disease: Eliminate Stigma and Build Awareness of Social Determinants

7. Recognize the risk factors for, and signs of, opioid overdose and demonstrate the correct

use of naloxone rescue.

8. Recognize substance use disorders as a chronic disease by effectively applying a chronic disease model in the ongoing assessment and management of the patient.

9. Recognize their own and societal stigmatization and biases against individuals with substance use disorders and associated evidence-based medication-assisted treatment.

10. Identify and incorporate relevant data regarding social determinants of health into treatment planning for substance use disorders.

Medical Core Competencies: Tertiary Prevention Domain

Prevention Intervention Treatment Recovery

Governor Baker’s Opioid Working Group

MassPAT: The new PMP

Reversing an Overdose: Use of Naloxone

Bystanders

First Responders

Pharmacies/Prescribers

Prevention Intervention Treatment Recovery

Governor Baker’s Opioid Working Group

• Adding hundreds of new treatment beds across the state; • Over 1,800 sober homes certified • Reinforcing the requirement that all DPH licensed addiction

treatment programs must accept patients who are on methadone or buprenorphine medication;

• Issuance of Division of Insurance guidelines to commercial insurers on the requirement for insurers to cover the cost of medically necessary clinical stabilization services for up to 14 days without prior authorization;

• Strengthening the state’s commitment to residential recovery programs through rate increases.

Treatment and Recovery: General Progress To-Date

Substance Use, Treatment, Education and Prevention Law (STEP)

Ch. 52 of the Acts of 2016

• 7 day limit on a first time opioid prescription; allows for a

pharmacist partial fill • Patient voluntary non-opioid directive (12/16) • SBIRT must be implemented in schools by June 2018 • Amends the Civil Liberties law so that any person who

administers naloxone is not liable for injuries resulting from the injection

• Requires substance abuse evaluation in ED when present for an OD (7/16)

Data mapping: Chapter 55

PDMP

APCD Spine

Death Records

BSAS Treatment

Toxicology

Summarized APCD

MATRIS (ambulance)

OCME Intake

Town/Zip Level Data

Summarized Casemix

Dept of Corrections

MA Sheriff’s Association

System Attributes

• Data encrypted in transit & at rest

• Limited data sets unlinked at rest

• Simplified structure using summarized data

• Linking and analytics “on the fly”

• No residual files after query completed

• Analysts can’t see data • Automatic cell suppression • Possible resolution to issues

related to 42 CFR part 2

Data Sources

DPH

CHIA (MassHealth)

EOPSS

Jails & Prisons

All Doors Opening

• Significant coordination within DPH

• Financial and technical support from MassIT’s Data Office

• CHIA takes on role as linking agent

• Coordination across agencies (legal & evaluation)

• Volunteer analytic support from academia and industry

Chapter 55 Data Structure

Births (NAS)

DRAFT - FOR POLICY DEVELOPMENT ONLY

* Note: Houses of Correction data was unavailable at the time this report was written. As such, assessment does not reflect HOC inmate outcomes.

*

DRAFT - FOR POLICY DEVELOPMENT ONLY

Data mapping: Key Finding

The risk of opioid overdose death following incarceration is 56 times higher than for the general public.

869.4 opioid deaths / 100,000

15.4 opioid deaths/ 100,000

0

100

200

300

400

500

600

700

800

900

1000

Former Inmates All Others

Comparison of Opioid Death Rates Among Former Inmates to the Rest of State (2013 - 2014)

Does an abnormally high

amount of prescribing physicians increase a

patient’s risk of fatal overdose?

Instances of multiple provider

episodes, meaning a single patient having

access to opiate prescriptions from

more than 1 provider

Individuals who obtain opioid prescriptions from

more than 1 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.

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.

STATUTE QUESTION ANALYTIC QUESTION PRELIMINARY FINDING

Data mapping– Key Findings

Data visualization of findings from Chapter 55 Report

Monica Bharel, MD, MPH Commissioner, Massachusetts Department of Public Health

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

The Chapter 55 digital story has videos, interactive maps and charts

Hover pointer to any city on the map, and the city’s average

annual Opioid-related Death Rate

per 100,000 People (over 5

years) will appear

Monica Bharel, MD, MPH Commissioner, Massachusetts Department of Public Health

Addressing the Opioid Epidemic through a Public Health Lens

MONICA BHAREL, MD, MPH

MASSACHUSETTS COMMISSIONER OF PUBLIC HEALTH