Opioid Dependence in Missouri Cheryl Marcum Missouri State

Opioid Dependence in Missouri Cheryl Marcum, Missouri State Opioid Treatment Authority AATOD 2015

Total of 13 OTP’s in MO: 9 Non- Contracted: • Nine non-contracted, private-pay clinics • Located in mostly rural areas with exception to one private clinic in St. Louis and Kansas City • Currently have three applications to initiate OTP’s in more rural areas • Hope to have 16 in MO by 2016

DMH contracted Comprehensive Substance Treatment and Rehabilitation (CSTAR) Opioid Providers • Missouri has four contracted Opioid Treatment Providers • Two in Kansas City and two in St. Louis • Current Wait List • Approximately 550 consumers waiting for treatment • Priority Populations • Pregnant Women • IV Drug Users • Individuals who are HIV positive

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Geographic Distribution of heroin users who enter treatment Large Population in Eastern Region Counties Notes: Served between 2008 and 2010 (N=6, 710). Data source: Missouri Department of Mental Health, Division of Alcohol and Drug Abuse

Medications for Treatment • Methadone - When properly prescribed: • • • Agonist: Compound that activates brain receptors Should not be intoxicating or sedating on stabilizing dose Does not interfere with ordinary activities Relieves cravings associated with heroin addiction Medically safe Approved for treatment for more than 30 years • Buprenorphine / Suboxone • Partial Agonist: Compound that partially activates receptors and blocks further activation • Causes weaker opiate effects • Less risk for overdose • Not all patients respond to buprenorphine • Approved for treatment of narcotic addition in 2002 • Physician limited to 100 patients • Naltrexone • Antagonist: Compounds that block activation of receptors. • (Poor patient compliance) • Vivitrol (injectable naltrexone) • Approved for treatment of narcotic addiction in October 2010 Data source: National Institute on Drug Abuse

Percent of Treatment Admissions • United States • Heroin: Stable • 14% of all treatment admissions • Other opiates: Increasing • 1% of all treatment admissions in 1999 to 7% in 2009 • Missouri • Heroin: Increasing • 4. 6% of all treatment admissions in 1999 to 7. 4% in 2009 • Other opiates: Increasing • <1% of all treatment admissions in 1999 to 5. 5% in 2009 Data source: Substance Abuse and Mental Health Services Administration. Treatment Episode Dataset (TEDS)

Demographics at Treatment Admission Other Opiates Heroin • Gender: • Male: 59% • Female: 41% • Race: � � • Caucasian: 62% • African-American: 37% • Average Age: 33 • Legal Status: • On Parole: 11% • On Probation: 31% • Injection Use: 66% • Referral Source: • Self: 51% • Criminal Justice: 34% Gender: Race: � � � Caucasian: 93% African-American: 6% Average Age: 32 Legal Status: � � Male: 51% Female: 49% On Parole: 8% On Probation: 34% Injection Use: 25% Referral Source: � � Self: 47% Criminal Justice: 35% Data source: Missouri Department of Mental Health, Division of Alcohol and Drug Abuse

Average Length of Treatment Engagement For Individuals Receiving Medication Treatment for Opioid Addiction in 2010 1200 1000 1, 002 days 800 600 400 200 0 Methadone N=1, 698 76 67 29 67 Suboxone Vivitrol Naltrexone No Medication N=325 N=80 N=55 Note: Individuals placed on Medication Assisted Treatment tend to have greater severity of addiction. Data source: Missouri Department of Mental Health, Division of Alcohol and Drug Abuse N=4, 687

Number Served in Treatment for Opioid Dependence Number Served in Calendar Year 2010 By Primary Substance Problem Other Opiates and Synthetics; 2068; 28% Hydrocodone (Vicodin); 381; 5% Oxycodone (Oxycontin), 663, 9% Heroin; 4182; 57% Data source: Missouri Department of Mental Health, Division of Alcohol and Drug Abuse

Percent of treatment Admissions • United States • Heroin: Stable • 14% of all treatment admissions • Other opiates: Increasing • 1% of all treatment admissions in 1999 to 7% in 2009 • Missouri • Heroin: Increasing • 4. 6% of all treatment admissions in 1999 to 7. 4% in 2009 • Other opiates: Increasing • <1% of all treatment admissions in 1999 to 5. 5% in 2009 Data source: Substance Abuse and Mental Health Services Administration. Treatment Episode Dataset (TEDS)

Methadone Maintenance treatment Outcomes • In FY 2010: • 78% of the random drug tests administered to individuals in treatment were clean of illegal drugs • Missouri’s four publicly-funded Opioid Treatment Clinics had 83 babies born free of illegal drugs Data source: Missouri Department of Mental Health, Division of Alcohol and Drug Abuse

Age at Death for Heroin-Related Deaths 2010 Age at Death Significant Impact on Young Adults 90 60 30 0 <20 20 -24 25 -29 30 -34 35 -39 age 40 -44 45 -49 50 -54 55 -59 Data source: Missouri Department of Health and Senior Services, Section of Epidemiology for Public Health Practices, Bureau of Health Informatics 60+

Regional Differences 2009 Heroin-Related Deaths per 100, 000 population 7. 06 8 High rates in Eastern Region 1. 30 0. 64 0. 33 0. 07 0 Central Eastern Northwest Southeast Southwest 20 Includes nonurban areas 12. 90 9. 38 8. 67 5. 74 6. 91 6. 35 3. 66 0 St Louis Co St Louis Jefferson St Charles Franklin City Lincoln Warren Data source: Missouri Department of Health and Senior Services, Section of Epidemiology for Public Health Practices, Bureau of Health Informatics

Missouri Division of Alcohol and Drug Abuse OPIOID TREATMENT PROGRAM MONTHLY REPORT The information on this form is required by the Certification Standards for Alcohol and Drug Abuse Programs. Please complete and submit by the 5 th of every month NAME OF PROGRAM: Month: For each item below, provide data for each of the four treatment lengths listed in the columns. CENSUS DATA Number: DRUG SCREEN DATA (reduction of illicit drug use) Random drug screens conducted: Number of drug screens positive for any drug: Percent positive for any drug: Consumers in Treatment Year: Less Than 3 Months 3 -6 Months 6 -12 Months More Than 12 Months Total #DIV/0! - - #DIV/0! Number of drug screens positive for opiates: - Percent positive for opiates: Drug screens positive for marijuana & methadone only Percent positive for marijuana and methadone only PERFORMANCE OUTCOMES Number of consumers employed full or part time: Percent employed: Number of consumers attending job training or school: Percent in school: Number of consumers who are homemakers: Percent homemakers: #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! - #DIV/0! Number of consumers with a medically documented disability: - Percent disabled: ADMINISTRATIVE WITHDRAWAL & PHASE VI #DIV/0! #DIV/0! Number of consumers undergoing administrative withdrawal: - Percent administrative withdrawal: Number undergoing voluntary withdrawal: Percent voluntary withdrawal: CENSUS BY CONSUMER PHASE Number of consumer in Phase I: Percent Phase I: Number of consumers in Phase II: Percent Phase II: Number of clients in Phase III: Percent Phase III: Number of consumers in Phase IV: Percent Phase IV: Number of consumers in Phase V: Percent Phase V: Number of consumers in Phase VI: Percent Phase VI: PREGNANCY CENSUS & DRUG FREE BIRTH DATA Number of pregnant consumers in OTP treatment only Number of births by consumers in OTP treatment only Number of drug free births in OTP treatment only #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! - #DIV/0! - #DIV/0! - -

Other Recovery Supports/Options in MO All of Missouri substance use disorder treatment programs must provide for medicationassisted recovery, either on-site or with a referral process… Missouri offers both social-setting detoxification and modified-medical detoxification choices… Outpatient detoxification is possible with correct medications… Specialized treatment for women and children… Utilize Residential Support with methadone or buprenorphine maintenance from an OTP… Working with Drug Courts/Family Courts… Referring for treatment at OTP’s… Educating more hospital, physicians and schools with training about opioid dependence… Attending Health Fairs to address medical aspects of treatment at an OTP… Finding MH treatment biggest barrier to fully addressing Disease Model… DBH working on creating fidelity measurements for integrating SA/MH treatment at SA providers…

Comments From OTP’s • St. Louis (East): “Seen an increase in prescription pill use, but heroin remains the drug of choice…”; “…increase in female admissions… in the 18 -22 year group. ” • Columbia (mid-State): “…Older patients tend to struggle with pain medication addiction, while our younger patients struggle with heroin. ”; “… more male patients…” 62% male/38% female… • St. Joseph (Northwest): “… more prescription medication use than heroin…”; “more male clients. . ” • West Plains (South Central): “Prescription medication is more prevalent than heroin…”; “…ages are primarily 22 -49…” • Kansas City (West): “…see a transition from prescription medication to heroin…”; “… a lot of poly-substance dependence… methamphetamines, marijuana and K 2”

Resources for Providers Anti-Discrimination Resources - Medication-Assisted Treatment: • Educating Courts, Other Government Agencies and Employers About Methadone (2009) - This publication explains how individuals in methadone maintenance programs and other forms of Medication Assisted Treatment, as well as their treatment programs and advocates, can advocate for their rights so that they can get in or stay in the treatment they need – without discrimination. The focus is on discrimination by the child welfare system and criminal justice system – including driving under the influence, jails and prisons, and probation and parole. Helpful Resources to Address Discrimination Against People in Medication-Assisted Treatment (2009) - List of useful resources for educating employers, courts and others about Medication Assisted Treatment, including why methadone and buprenorphine do not impair physical or mental functioning when provided to individuals stabilized on the appropriate dose. • • • Know Your Rights: Are You in Recovery from Alcohol or Drug Problems? Rights for Individuals on Medication-Assisted Treatment (2009) - This brochure is a companion piece to Know Your Rights: Are You in Recovery from Alcohol or Drug Problems? and describes the specific legal issues faced by people in Medication-Assisted Treatment for opiate addiction. (Funded by Partners for Recovery, an initiative of the Center for Substance Abuse Treatment of the U. S. Department of Health and Human Services). Know Your Rights – Training Materials - The Legal Action Center has conducted numerous Know Your Rights trainings across the country for people in the recovery and their allies. Funded by the Partners for Recovery Initiative of the U. S. Substance Abuse and Mental Health Services Administration (SAMHSA), these trainings cover anti-discrimination laws that protect individuals with alcohol and drug problems from discrimination in employment, housing, and elsewhere. They also cover anti-discrimination protections for individuals who also have a criminal record. Click here for the materials distributed at these trainings. Legality of Denying Access to Medication Assisted Treatment in the Criminal Justice System (2011) - A report that explains why criminal justice agencies violate Federal anti- discrimination laws and the United States Constitution when they deny access to medications, such as methadone and burprenorphine, to treat opiate addiction. The report was written at the request of the American Association for the Treatment of Opioid Dependence (AATOD), who, along with the Center, has a longstanding interest in expanding the use of these medications in criminal justice settings. Methadone Maintenance Treatment: Memorandum of Driving & Psychomotor Studies and Background Information about Methadone Treatment (April 2000) - This packet of information contains (1) a memorandum summarizing recent literature and studies about the effect of methadone treatment on patients’ driving ability as well as psychomotor and intellectual functioning, (2) the actual articles and studies referenced in the memorandum, and (3) background information about methadone treatment. It is a very useful resource for people trying to combat discrimination based on participation in methadone treatment