ADDRESSING THE OPIOID CRISIS VERMONTS RESPONSE ADDICTION 101

ADDRESSING THE OPIOID CRISIS VERMONT’S RESPONSE

ADDICTION 101 Etiology: Genetics, stress, exposure Pathology: Primarily brain structure and function Symptoms: Radiating consequences Phenomenology: Suffering, misunderstood, stigmatized Treatment: Effective treatments, no cures

TOP GENERIC PRESCRIPTIONS WHAT’S #1? Hydrocodone + acetaminophen [Vicodin]( n=122, 806, 850) 1. 18. Oxycodone + acetaminophen [Percocet] (n=28, 705, 243) 46. Propoxyphene + acetaminophen [Darvon] (n=14, 274, 354) 51. Oxycodone (n=12, 652, 375) 114. Fentanyl patch (n=4, 914, 785) 121. Methadone (n=4, 558, 532) 170. Morphine (n=2, 740, 358) 192. Hydromorphone [Dilaudid] (n=2, 272, 481) • Top 200 generic drugs by units in 2010. SDI’s Vector One® National

PAIN IS BIG BUSINESS U. S. SPENDING (2014) IMS Health, National Prescription Audit, Dec 2013

OPIOID PRESCRIPTIONS HAVE SKYROCKETED OVER PAST 20 YEARS

OVERDOSE DEATHS FROM OPIOIDS INCREASED 200% SINCE 2000 CDC, 2014. National Center for Health Statistics, National Vital Statistics System 7

OVERDOSE DEATH IN VERMONT INCREASED IN EVERY COUNTY Source: Centers for Disease Control and Prevention, Drug Poisoning Mortality: United States, 2002 -2014 January 2016

TRANSITION ACROSS THE U. S. FROM PRESCRIPTION OPIOIDS TO HEROIN

TRANSITION ACROSS THE NORTHEAST EVEN MORE DRAMATIC

WHAT ABOUT VERMONT? THE TRANSITION IS DEADLY Total opioid Rx opioid Heroin Fentanyl 76 69 61 41 47 38 61 50 45 37 34 20 9 9 5 6 12 2011 2012 2013 5 0 2010 25 34 32 29 18 2014 2015 Source: Vermont Department of Health Vital Statistics System Vermont Department of Health

WHY THE TRANSITION? FROM PRESCRIPTION OPIOIDS Prescription opioids: Some are expensive or have seen prices increase Many preferred opioids hard to find Abuse Wiser New deterrent formulations providers prescribing guidelines

WHY THE TRANSITION? TO HEROIN Cost and availability: Heroin is cheaper Heroin is easier to get Heroin is easier to inject Heroin is purer than ever

THE NEW HEROIN CONSUMER IF YOU PLAN ON PROFILING Previous era heroin users: Young, minority male living in urban centers Unemployed New era heroin users: Young and middle-aged, white male/female living in a suburban/rural area Employed

3 FDA-APPROVED MEDICATIONS FOR TREATING OPIOID USE DISORDERS* METHADONE BUPRENORPHINE NALTREXONE *MEDICATION-ASSISTED TREATMENT (MAT)

VERMONT’S RESPONSE A MODEL FOR THE REST OF THE COUNTRY Openly acknowledged by Governor as public health crisis Creation of “HUB” and “SPOKE” model HUB: Specialty care Opioid Treatment Programs (OTPs) for methadone, buprenorphine and naltrexone SPOKE: General Office-based Opioid Treatment (OBOT) practices for buprenorphine and naltrexone Financing and workforce to support practice Activities to increase access and availability--quantity Activities to ensure quality

PATIENT-CENTERED MEDICAL HOME ADDICTION AS CHRONIC MEDICAL CONDITION Specialty Care OTP Primary Care PCMH OBOT Community Health Team

OTP HUB GROWTH TRIPLED IN PAST 3 YEARS 3000 2500 Census 2000 Chit/FGI/Addison 1500 Wash/Lam/Orange Windam/Windsor Essex/Orl/Cal 1000 Rutland/Benn 500 0 1 2 3 4 5 6 7 2013 8 9 10 11 12 1 2 3 4 5 6 7 2014 Month 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 2015 Date of Last update: 11/24/2015

OBOT SPOKE GROWTH MUCH SLOWER---ABOUT 30% 2 500 2 331 140 2 000 1 837 126 120 114 Total # MD prescribing to ≥ 10 pts Spoke Staff FTEs Hired Medicaid Beneficiaries 100 80 1 500 72 60 1 000 54 40 44, 94 500 20 0 5, 5 2013 Q 1 2013 Q 2 2013 Q 3 2013 Q 4 2014 Q 1 2014 Q 2 2014 Q 3 2014 Q 4 2015 Q 1 2015 Q 2 2015 Q 3 Medicaid Beneficiaries Prescribers and Spoke Staff FTEs Hired 160

PROGRESS NOT PERFECTION BIG DENT, LITTLE DENT OR NO DENT AT ALL? Addiction has no silver bullet cure, medication is one component of the potential for a good outcome How long should medication be necessary? OBOT expansion in small to medium size practices but not in large or hospital practices Need to evaluate outcomes (costs $) Vision for recovery: With MAT or not