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NACoA  Webinar�  April  14,  2015    

Kimberly  Jeffries  Leonard,  PhD      

Deputy  Director  Center  for  Substance  Abuse  Treatment  

Substance  Abuse  and  Mental  Health  Services  Administra<on  U.S.  Department  of  Health  &  Human  Services  

HALTING  THE  YOUTH  OPIOID  EPIDEMIC:  CONGREGATIONS  AND  COMMUNITY-­‐CENTRIC  SOLUTIONS    

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CommuniOes  In  Crises:  PrescripOon  Pain  Relievers  &  Heroin  

•  The  threat  from  controlled  prescrip<on  drug  (CPD)  abuse  is  persistent;  and  opioid  analgesics  are  the  most  commonly  abused  CPD.  –  CPD  overdose  deaths  con<nue  to  be  a  major  public  health  issue  

–  Pain  relievers  are  second  only  to  marijuana  as  the  first  drug  of  abuse    

•  Heroin  use  is  increasingly  a  concern,  notably  in  the  Northeast  and  North  Central  regions  of  the  country.  

   

www.dea.gov/resource-center/dir-ndta-unclass.pdf 4  

è 32%  of  individuals  with  chronic  pain  are  es<mated          to  have  addic<ve  disorders.  è 29-­‐60%  of  people  with  opioid  addic<ons  report  chronic  pain.  • Each  day,  46  people  die  from  an  OD  of  prescrip<on  pain  analgesics  in  the  U.S.  

è Officials  across  the  country  report  that  prescrip<on  opioid  drug  users  are  turning  to  heroin  as  a  cheaper,  more  easily  obtained  alterna<ve.  

CommuniOes  In  Crises:  The  Pain-­‐Rx  Drug-­‐Heroin  ConnecOons  

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2011  Congressionally  Mandated  InsOtute  of  Medicine  Report  on  Pain  

è Recognized  the  serious  problems  of  diversion  and  abuse  of  opioid  drugs,  as  well  as  ques<ons  about  their  long  term  usefulness.    

è Determined:  • When  opioids  are  prescribed  and  monitored  appropriately,  they  can  be  safe  and  effec<ve  

•  The  effec<veness  of  pain  treatments  depends  greatly  on  the  strength  of  the  clinician–pa<ent  rela<onship  

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Intertwined  Challenges,  Intertwined  SoluOons:    Research  and  PracOce  

è HHS  Convened  2014  Scien<fic  Workshop:  What  do  we  really  know  about  prescrip<on  opioids  &  pain  management?  •  Insufficient  data  on  efficacy,  risks,  &  best  prac<ce  guidelines  for  long-­‐term  use  of  opioids  for  pain  management  – Documented  adverse  effects  of  opioid  use  &  misuse  

• Need  to  develop  client-­‐centric,  individualized,  pain  management    plans  based  on  more  robust  scien<fic  evidence  

•  Escalate  &  accelerate  research  efforts;  and  rapid,  effec<ve  transla<on  of  research  to  evidence-­‐based  prac<ce  

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PrescripOon  Pain  Analgesics  &  Heroin  

U.S.  Snapshot  

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Specific  Illicit  Drug  Dependence  or  Abuse  in  the  Past  Year  among  Persons  >12  years  old    in  2013  

Numbers in Thousands

4,206

1,879

855

517

469

423

277

132

99

0 1,000 2,000 3,000 4,000 5,000

Marijuana

Pain Relievers

Cocaine

Heroin

Stimulants

Tranquilizers

Hallucinogens

Inhalants

Sedatives

SAMHSA  NSDUH  2014  

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Past  Year  Heroin  Use    among  Persons  >12  years  old  

+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.

Note: Estimated numbers for the age groups may not sum to the total due to rounding.

404+

314+

398+ 379+

560

373+

455+

582 621 620

669 681

51 36 48 37 37 24 41 34 28 54 31 31

122+ 96+ 118+ 159+ 147+ 142+ 149+ 183 211 230

272 244 231+ 182+

232+ 184+

376

207+ 265

364 382 336

366 406

0

100

200

300

400

500

600

700

800

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Numbers in Thousands

Total

Aged 26 or Older

Aged 12 to 17

Aged 18 to 25

SAMHSA  NSDUH  2014   10  

Top  Six  Substances  for  Admissions  to  Substance  Abuse  Treatment  

SAMHSA  Treatment  Episode  Data  Set  (TEDS),  2014  

è Six  substance  groups  accounted  for  96%  of  all  TEDS  admissions  aged  >12  in  2012:  Alcohol,  marijuana,  heroin,  cocaine,  methamphetamine/amphetamines,  and  opiates  other  than  heroin.  

•  Admission  rates  for  opiates  other  than  heroin  were  higher  in  2012  than  in  2002  in  48  states  repor<ng  in  both  years,  while  it  decreased  marginally  for  New  Mexico.  

•  Overall  heroin  admission  rates  were  lower  in  2012  than  in  2002,  but  rates  in  2012  were  higher  in  35  of  the  48  states  and  jurisdic<ons  repor<ng  in  both  years.    

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è Treatment  admission  rate  for  opiates  other  than  heroin  was  236%  higher  in  2012  than  in  2002.    

è Rates  increased  2002  through  2011,  &  decreased  in  2012.  

SAMHSA  TEDS  2014  

Primary  Opiates*/SyntheOcs  Admission  Rates    2002-­‐2012  (Per  100,000  >  12  years  old)  

*non-­‐heroin  

12  12

1 The Other category includes the sources "Wrote Fake Prescription," "Stole from Doctor's Office/Clinic/Hospital/Pharmacy," and "Some Other Way."

Note: The percentages do not add to 100 percent due to rounding.

Free from Friend/Relative

(5.1%) Bought/Took from

Friend/Relative (4.9%)

Drug Dealer/ Stranger (1.4%)

One Doctor (83.8%)

More than One Doctor

(3.3%)

Bought on Internet (0.3%)

Other1 (1.2%)

Free from Friend/ Relative (53.0%)

Bought/Took from Friend/Relative

(14.6%)

Drug Dealer/ Stranger (4.3%)

Bought on Internet (0.1%)

Other1 (4.3%)

One Doctor (21.2%)

More than One Doctor (2.6%)

Source Where User Obtained

Source Where Friend/Relative Obtained

Source  of  PrescripOon  Pain  Relievers  for  Most  Recent  Nonmedical  Use  among  Past  Year  Users  

2012-­‐2013,  >  12  years  old    

SAMHSA  NSDUH  2014  

~68%  came  from  relaOves    and  friends  

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Percentage  of  Heroin  IniOates  by  Prior  and  Past  Year  Dependence/Abuse  of  NMPR  

SAMHSA  CBHSQ  2013  NMPR:  Nonmedical    Prescrip<on  Pain  Reliever  Use    

0.0%  

10.0%  

20.0%  

30.0%  

40.0%  

50.0%  

20.5%  

31.3%  

48.2%  Persons  12-­‐49  yrs  old  (2002-­‐2011)    

No  prior  use     Prior  use  &  past  yr  dependence/abuse    

Prior  use  but  no  past  yr  dependence/abuse    

%  Heroin  Ini<ates  

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Changes  in  Heroin  Use  in  RelaOon  to  OxyConOn  ReformulaOon  

Dart  RC  et  al.  N  Engl  J  Med  2015;372:241-­‐248  

Heroin

OxyContin

15  15

94.6%  

3.7%   1.7%  Didn't  feel  they  needed  Tx  

Felt  they  needed  Tx  but  made  no  effort  

Felt  they  needed  Tx  and  made  effort  

Tx  =  treatment  

Unmet  Needs:  Over  20  Million  Individuals  in  the  U.S.  went  Untreated  for  SUDs  in  2012  

SAMHSA  NSDUH  2013  

Individuals  >12    years  old  

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SoluOons:  Health  Care  Reform  &  the  ACA  

è Expanded  Coverage  è Free  Preven<ve  Care    è 10  Essen<al  Health  Benefits  

è MHPAEA    

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Good  News:  ACA  Medicaid  Expansion  

Current  as  of  March  6,  2015  

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è All  Marketplace  plans  and  many  others  must  cover  a  number  of  preven<ve  services  w/out  charging  you  a  copayment  or  coinsurance  when  done  by  network  providers,  even  if  you  haven’t  met  your  yearly  deduc<ble.  

è Adult  services  include:  ● Alcohol  misuse  screening  and  counseling    ● Tobacco  use  screening  &  cessa<on  interven<ons  ● Depression  screening  ● HIV  screening  for  everyone  ages  15-­‐65,  &  other  ages  for  those  at  higher  risk  

Health  Care  Reform  &  the  ACA:      Free  PrevenOon  Services  for  Adults  

hpps://www.healthcare.gov/preven<ve-­‐care-­‐benefits/  

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è Alcohol  and  Drug  Use  assessments  for  adolescents  è Depression  screening  for  adolescents  è Developmental  screening  for  children  under  age  3  è Behavioral  assessments  for  children  of  all  ages:  

‒ Ages:  0  to  11  months,  1  to  4  years,  5  to  10  years,  11  to  14  years,  15  to  17  years  

è HIV  screening  for  adolescents  at  higher  risk  è And  more…  

Health  Care  Reform  &  the  ACA:      Free  PrevenOon  Services  for  Children  

hpps://www.healthcare.gov/preven<ve-­‐care-­‐benefits/children/  

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Overdose  is  common  for  opioid  users  

è OD  common  among  opioid-­‐users  •  ≥  50  -­‐  70%  of  IDUs  personally  experience  or  witness  OD  

è OD  commonly  witnessed    • Median  #  of  life<me  witnessed  OD  is  5  

è Majority  of  OD-­‐related  deaths  occurs  in    company  of  others  

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OD  is  costly  

è Cost  of  prescrip<on  opioid  abuse  is  about  $55.7  B/year    •  20.4  B/  year  for  OD-­‐related  costs  »  2.2  B  direct  costs    

•  Medical  care:  Hospital,  ED,  Ambulance  

»  18.2  B  indirect  costs    •  Lost  produc<vity  from  absenteeism  and  mortality  

è $37,274  cost  per  opioid  overdose  event  

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Basic  OD  educaOon:  

1.  PrevenOon  -­‐  the  risks:  •  Effects  of  abs<nence  on  tolerance  •  Riskier  use  behavior  (using  alone,  unknown  supplier)  •  Impact  of  medical  comorbidi<es    

2.  RecogniOon  of  OD    •   Warning  signs  of  OD  

3.  Response  -­‐  What  to  do  •  Seeking  emergency  support  •  Rescue  breathing  •  Naloxone  administa<on  

Prevent,  treat,  and  reduce  

OD  &  its  sequelae    

Treatment & Recovery Prevention OD Reduction

SCIENCE-BASED STRATEGIES

+ +

CongregaOon  and  Community-­‐Centric  SoluOons:  MulO-­‐Tiered  

 

Examples  of  SAMHSA  PrevenOon  Strategies  

Prevent,  treat,  and  reduce  

OD  &  its  sequelae    

Treatment & Recovery Prevention OD Reduction

è New  Strategic  Ini<a<ve  focused  on  community-­‐based  preven<on  of  prescrip<on  drug  abuse  

è Ongoing    Community  &  Prescriber  Educa<on  and  Outreach  

è State-­‐run  Prescrip<on  Drug  Monitoring  Programs  (PDMPs)  

+ +

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SAMHSA’s  PrevenOon  of  Substance  Abuse  and  Mental  Illness  Strategic  IniOaOve  

     è Key  goal  is  to  prevent/reduce  Rx  Drug  SUDs:  

• Comprehensive  preven<on,  treatment,  &  recovery  programs  

• Public/prescriber  educa<on  &  clinical  support  tools  

• Collabora<on  with  states’  public  health  &  Medicaid  authori<es,  &  other  key  stakeholders  

• PDMP  integra<on  with  health  care  systems  • OD  preven<on;  &  reduc<on  of  OD  morbidity  and  mortality  

 

Examples  of  SAMHSA’s  Treatment  &  Recovery  Efforts      

Prevent,  treat,  and  reduce  

OD  &  its  sequelae    

Treatment & Recovery Prevention OD Reduction

è Block  Grants  +  Discre<onary  Grants  for  treatment  &  recovery  services  that  address  health  determinants  

è Treatment  locators  &  treatment  guidelines    è Opioid  Treatment  Programs  Cer<fica<on  &  monitoring  è Technical  assistance  &  clinical  support  tools  

+ +

SAMHSA  Locators  for  Service  Providers  &  Access  to  Opioid  SUD  Services  

hpp://dpt2.samhsa.gov/treatment/directory.aspx    

hpp://buprenorphine.samhsa.gov/bwns_locator/    

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High  Rates  of  Overdose  (OD)  

• Over 43,000 deaths 2/2 opioid overdoses. • Rate in 2013 nearly double that of 1999

• More OD deaths in the United States involve opioid analgesics than either heroin or cocaine combined

• In 2013 in Maryland: • OD is the leading cause of accidental death for adults. • 858 drug and alcohol-related intoxication deaths

Examples  of  SAMHSA’s  Overdose    ReducOon  Strategies  

Prevent,  treat,  and  reduce  

OD  &  its  sequelae    

Treatment & Recovery Prevention OD Reduction

è Naloxone:  SAMHSA’s  Block  Grant  Funds  can  be  used  by  states  to  support  community-­‐level  overdose  educa<on  and  naloxone  toolkits  

è Dissemina<on  of  scien<fic  evidence    

+ +

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Responding  to  Opioid  OD:  Naloxone  

• Competitive antagonist • Rapidly disappears from serum

• Half-life of ≈60 min.

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Does  opioid  overdose  educaOon  and  naloxone  distribuOon  (OEND)  work?  

è  Feasible  to  introduce  in  urban  environments  »  Piper  et  al.  Subst  Use  Misuse  2008:  43;  858-­‐70  »  Doe-­‐Simkins  et  al.  Am  J  Public  Health  2009:  99:  788-­‐791  »  Enteen  et  al.  J  Urban  Health  2010:87:  931-­‐41  »  Bennep  et  al.  J  Urban  Health.  2011:  88;  1020-­‐30  » Walley  et  al.  JSAT  2013;  44:241-­‐7    

è  Programs:    -­‐  Located  at  detox  centers,  syringe  access  sites,  drop-­‐in  centers    -­‐  Fail  to  target  prescrip<on  opioid  users  or  those  concerned  about      s<gma  of  IDU  

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OEND  programs  change  behavior  

è  ParOcipants  showed  increased  knowledge  and  skills  (rescue  breaths,  calling  911,  staying  with  paOent  AND  using  naloxone)  

»  Green  et  al.  Addic<on  2008:  103;979-­‐89  »  Tobin  et  al.  Int  J  Drug  Policy  2009:  20;  131-­‐6  »  Wagner  et  al.  Int  J  Drug  Policy  2010:  21:  186-­‐93  

 

è Do  not  lead  to  increase  in  use  or  riskier  use  •  Seal  et  al.  J  Urban  Health  2005:82:303-­‐11  »  Tobin  et  al.  Int  J  Drug  Policy  2009:  20;  131-­‐6  »  Wagner  et  al.  Int  J  Drug  Policy  2010:  21:  186-­‐93  

 

è May  lead  to  decreased  use  or  willingness  to  engage  in  treatment  

•  Seal  et  al.  J  Urban  Health  2005:82:303-­‐11  

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Growing  #  of  OEND  naOonally  

•  15  states  and  DC  •  188  Programs  •  53,032  People  enrolled  

•  10,171  OD  rescues  

In  2010:    

If given naloxone, people use it!

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*Since  August  2013  

Over  43,000  downloads*  

Revised  in  2014    

hpp://store.samhsa.gov/product/Opioid-­‐Overdose-­‐Preven<on-­‐Toolkit/SMA14-­‐4742  

DisseminaOon  of  ScienOfic  Evidence:  SAMHSA’s  Opioid  Overdose  Toolkit  

è Free  resource  for  individuals,  families,  communi<es,  &  clinicians.  

è Educates  individuals,  families,  first  responders,  community  members,  &  clinicians.  

è Provides  prac<cal,  plain  language  informa<on  about  steps  to  take  to  prevent  opioid  overdose  and  to  treat  overdoses  including  the  use  of  naloxone.  

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Screening  

•  Who  to  screen?  •  All  pa<ents  admiped  to  general  medicine  firms  regardless  of  admission  diagnosis.    

•  Who  is  at  risk?  Think  risky  users  and  risky  use  • Use:  

•  Current  injec<on  drug  use  •  History  of  prior  OD  •  Using  >100  mg  of  morphine  equivalents  per  day  

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Risky  users  

•  Impaired  metabolism  •  ESLD,  ESRD    

•  At  risk  for  respiratory  depression:      COPD,  Severe  OSA  

•  Concurrent  benzo/and  heavy  etoh  use  +  

Opioids  at  any  dose  

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Examples  of  SAMHSA’s    DiscreOonary  Funding  Areas  

Opioid  Treatment  Programs  (OPT)   Drug  Free  Communi<es  

Screening,  Brief  Interven<on,  and  Referral  to  Treatment  (SBIRT)  

Criminal  Jus<ce  Ac<vi<es  

Recovery  Community  Services  Program  (RCSP)  

Partnerships  for  Success  State  and  Tribal  Ini<a<ve  

Health  Informa<on  Technology   Access  to  Recovery  (ATR)  Pregnant  and  Post  Partum  Women     Treatment  Systems  for  Homeless  

Children  and  Families   Minority  AIDS  (MAI)  

Addic<on  Technology  Transfer  Centers  (ATTCs)    

Workforce  Development  38  

Your  Guidance  is  EssenOal  for  Developing  Policies,  Programs,  &  IniOaOves  

Finding  SoluOons:  Stakeholders  Are  Key  

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“We  need  all  stakeholders  to  come  together”    

“Opioid  drug  abuse  is  a  devasta0ng  epidemic  facing  our  na0on.  I  have  seen  firsthand,  in  my  home  state  of  West  Virginia,  a  state  struggling  with  this  very  real  crisis,  the  impact  of  opioid  addic0on.  That’s  why  I’m  taking  a  targeted  approach  to  tackling  this  issue  focused  on  

preven0on,  treatment  and  interven0on.  I  also  know  we  can’t  do  this  alone.  We  need  all  stakeholders  to  come  

together  to  fight  the  opioid  epidemic.”    

-­‐-­‐  Secretary  Burwell    

40  

Closing  Thoughts:  Achieving  Balance  

hpp://healthyamericans.org/reports/drugabuse2013/      

hpp://www.painpolicy.wisc.edu  

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Closing  Thoughts:    PrevenOon  is  EffecOve,  Treatment  Works,  People  Recover  

“People  in  recovery  are  not  strangers:  they  are  our  family  members,  friends,  colleagues,  

and  neighbors.”    -­‐-­‐  President  Obama  

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THANK  YOU,  Kimberly.Leonard@samhsa.hhs.gov  

 

SAMHSA:  Helping  People  Help  Themselves