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Opioid Awareness - Report Review: The Mayor's Task Force to Combat the Opioid Epidemic in Philadelphia

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The OHP's Antonio Boone presented at the June 2017 meeting of the Positive Committee on the recent report from the Mayor's Task Force to Combat the Opioid Epidemic in Philadelphia.

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Opioid Awareness - Report Review: The Mayor's Task Force to Combat the Opioid Epidemic in Philadelphia

  1. 1. OPIOID AWARENESS REPORT REVIEW: THE MAYOR’S TASK FORCE TO COMBAT THE OPIOID EPIDEMIC IN PHILADELPHIA
  2. 2. OPIOID EPIDEMIC REPORT What is Happening ◼ Prescription Opioid Sales ◼ Opioid Use ◼ Overdoses Impact ◼ On Families ◼ On the Criminal Justice System The Mayor's Task Force ◼ Process ◼ Community Input ◼ Monitoring and Evaluation Recommendations ◼ Overdose Prevention ◼ Treatment ◼ Involvement of the Criminal Justice System Act 139
  3. 3. WHAT IS HAPPENING ◼ Prescription opioid medications such as: Vicodin, Percocet, OxyContin have fueled this current crisis. ◼ Nationally 4 out of 5 new heroin users have their first exposure to opioids via prescription pain medication. ◼ The opioid epidemic in Philadelphia has reached epidemic levels in recent years due to the rise of fentanyl, a synthetic opioid that began appearing in that test results of opioid overdose victims in 2014.
  4. 4. PRESCRIPTION OPIOID SALES ◼ Drug Enforcement Agency(DEA) suggests that opioid sales in Philadelphia doubled between 2000 and 2012. ◼ Healthcare providers continue to prescribe large quantities of pain medication than medically appropriate. ◼ Between 100,000 and 200,000 Philadelphians receive more than one opioid pain medication prescription each year. ◼ National Survey on Drug Use and Health states between 50,000 and 60,000 people misused a prescription opioid pain meds in the last year.
  5. 5. OPIOID USE ◼ 90% of people who are prescribed opioids do not transition to heroin use. ◼ But the large number of people receiving prescription opioids makes it easier for other individuals to make the transition. ◼ The transition is likely to occur in Philadelphia-Camden area due to the high purity and low cost of heroin. ◼ There are an estimated 70,000 heroin users in Philadelphia. ◼ Likely more, does not include individuals who receive care in a private treatment system. ◼ 14,000 people were treated for opioid use disorder in Philadelphia’s system from October 2015 to September 2016. By 2016 Fentanyl was found in nearly half of overdose deaths
  6. 6. OVERDOSES ◼ 907 people died from drug overdoses in Philadelphia during 2016. 702 in 2015 three times the number of homicides. ◼ Fentanyl is 50 to 100 times stronger than morphine ◼ Found in 412 drug overdose decedents ◼ Fatal overdoses predominantly occur among Hispanic-white males aged 45-54. ◼ Consequence of older adults becoming dependent on drugs due to the over-prescribing of opioids. ◼ 2014- PA Physician General Rachel Levine signed a statewide “standing order” enabling any Pennsylvanian to obtain naloxone from a pharmacy without an individual prescription.
  7. 7. IMPACT-FAMILIES Effect of drugs on families includes ◼ Compromised physical and mental health ◼ Increased health care costs ◼ Loss of productivity at school/work ◼ Reduced quality of life ◼ Increased crime and violence ◼ Abuse and neglect. Neonatal Abstinence Syndrome(NAS) may interfere with a child’s brain development, mental functioning and behavior. ▪ NAS increased more than three-fold from 3 per 1,000 births (2002) to 11 per 1,000 live births (2015).
  8. 8. IMPACT- FAMILIES Adverse Childhood Experiences (ACE), stressful or traumatic events that are strongly related to the development of a wide range of health problems. The Philadelphia Urban ACE Study surveyed nearly 2,000 Philadelphians between 2012-2013. Data showed ◼ 40% of respondents experienced greater than or equal to four ACEs. ◼ Approximately 35% grew up with substance abuse in their household. ◼ Substance use becomes increasingly likely across adolescence, rates peaking among people in their 20’s. ◼ 74% of adults 18-30 years old admitted to substance use disorder treatment programs began using at the age of 17 or younger.
  9. 9. IMPACT- CRIMINAL JUSTICE SYSTEM ◼ Incarceration itself is a risk factor for developing substance use disorder. ◼ Philadelphia Department of Prison processes 30,000 individuals for intake each year, averaging over 6,000 people per day. ◼ 40% participate in behavioral health treatment (primarily pharmacological care) ◼ 17% who are mentally ill ◼ 14% living with Hepatitis C ◼ 3% living with HIV ◼ 14% tested positive for opioids (15% of females tested and 12% of males tested) ◼ Pregnant women with opioid use disorder receive methadone for the duration of the pregnancy. ◼ 300 inmates receive methadone annually.
  10. 10. IMPACT- CRIMINAL JUSTICE SYSTEM ◼ Opportunities for Prevention and Treatment Interventions for Offenders Needing Support (OPTIONS) ◼ A cognitive behavioral treatment program that is offered withdrawal management support(detox) ◼ 1,500 people also participate in substance use disorder counseling through the OPTIONS program. ◼ Inmates who participate in withdrawal management will experience reduced tolerance to opioids and are at greater risk for overdose. ◼ Dept. of Prisons provides withdrawal management 8,000 times annually ◼ Of the 3,172 people who died of unintentional drug overdose from 2010-15, 782 (25%) were incarcerated in Philadelphia Department of Prisons.
  11. 11. PHILADELPHIA TREATMENT COURT The court is determined to treat substance use disorder as a root cause of criminal activity, providing an alternative or supplement to normal proceedings. ◼ Treatment Court can offer post-plea deals that deliver a network of treatment and supportive services: ◼ Recovery housing ◼ Vocational training ◼ Employment placement ◼ Enrolled more than 4,800 participants and graduated more than 3,100 participants. ◼ In the past five years 890 participants have accepted to Treatment Court representing 74% of all referrals. ◼ Self reported opioid use increased from 22% in 2015 to 37% in March 2017. ◼ 78% of participants successfully completed Treatment Court in 2016. ◼ Shown reduced recidivism when compared to drug offenders, reducing rates of rearrest and reconviction from 6% to 26%.
  12. 12. THE MAYOR’S TASK FORCE- PROCESS ◼ Taskforce composed of over 100 experts, stakeholders and community members. ◼ Arthur C. Evans, Commissioner, Department of Behavioral Health and Intellectual disability Services ◼ Thomas D. Farley, Health Commissioner, Philadelphia Department of Public Health ◼ Formed 5 subcommittees 1. Public Education and Prevention Strategies 2. Service Access, Best Practices, and Treatment Providers 3. Overdose Prevention and Harm Reduction 4. Justice System, Law Enforcement, and First Responders 5. Data Analysis and Sharing ◼ Each subcommittee was lead by two co-chairs and met five times for two hours from January 18, 2017 to March 20, 2017.
  13. 13. THE MAYOR'S TASK FORCE- COMMUNITY INPUT The task force organized four community listening sessions over a two week period between January and February 2017. ◼ Sessions were held in the Northwest, North, South/West, Northeast areas of Philadelphia. ◼ Total attendance for all four sessions was 463 community members. 116 people attended each session. ◼ 42 of Philadelphia’s 47 populated zip codes were represented. ◼ 86% of attendees have been directly impacted themselves or know someone directly impacted by the opioid epidemic. ◼ 84% reported that they felt seriously listened to by city officials and task force members on possible solutions.
  14. 14. THE MAYOR’S TASK FORCE- COMMUNITY INPUT Common themes expressed at the four Community Listening Sessions: ◼ Opioid Prescribing ◼ Impose harsher restrictions on doctors illegally prescribing opioids ◼ Improve monitoring of doctors distributing and prescribing opioids. ◼ Public Education ◼ Increase early intervention and education opportunities for at-risk children and populations ◼ Increasing Treatment Access and Availability ◼ Increase medication-assisted treatment (MAT) for opioid use disorder ◼ Increase the length of time that individuals remain engaged in treatment. ◼ Make available innovative alternative treatments for pain management, such as acupuncture and EEG biofeedback. ◼ Public Safety ◼ Establish drug-free communities so persons in recovery do not have to be tempted by drug dealers while participating in or after returning from treatment. ◼ Government Coordination and Communication ◼ Facilitate partnerships between the city and communities in fighting the epidemic ◼ Increase understanding and partnership between DHS and recovering mothers.
  15. 15. THE MAYOR’S TASK FORCE- MONITORING AND EVALUATION Task Force recommended that the City establish high-level substance use surveillance program that would: ◼ Develop an opioid epidemic data report to establish a baseline and monitor the epidemic. ◼ Establish use of real time data to support a rapid response plan ◼ Use data matched across departments to identify barriers and opportunities for optimal systems interactions with individuals. ◼ Develop an evaluation plan to assess the progress and impact of the actions taken as a result of the Mayor's Opioid Task Force Report. ◼ Developed a set of core metrics to monitor progress on the opioid epidemic: ◼ Opioid prescription rate per 1,000 population* ◼ Buprenorphine prescription rate per 1,000 population* ◼ Behavioral health treatment rate for patients with a primary diagnosis of opioid use disorder* ◼ Medication-assisted treatment rate for patients with a primary diagnosis of opioid disorder*. ◼ Fatal overdoses ◼ Nonfatal overdoses
  16. 16. RECOMMENDATIONS- PREVENTION AND EDUCATION 4. Improve health care professional education ◼ Healthcare professional school and provider organizations should require and have standard for broad, competency-based training for all levels of healthcare professionals(dentists, pharmacists, physical therapists, counselors and social workers). ◼ Focusing on pain, pain management and substance abuse disorder. ◼ The city should continue to encourage professional schools and organizations to share their curricula on pain management and addiction. ◼ National survey data shows that half of PCP are “very” concerned about the risk of substance use disorder or death related to opioid use, fewer are concerned about tolerance, impaired cognition and sedation. ◼ “In order to reduce the liberal prescribing of opioid pain medication, the city should support evidence-based approaches to changing prescribing behavior. Monitoring Metric: number of opioid pills sold
  17. 17. RECOMMENDATIONS- TREATMENT 6. Increase the provision of medicated assisted treatment(MAT) ◼ MAT is considered as a vital evidence-based treatment by numerous national professional organizations. ◼ Integrating MAT into treatment settings will ease patients burden of navigating the complex treatment system. ◼ All barriers to MAT should be identified and reduced. Monitoring Metric: Publicly insured opioid use disorder clients participating in MAT. 10. Provide safe housing, recovery, and vocational supports The city should work with other systems and elected officials to: ◼ increase safe permanent supporting housing, recovery houses, vocational support and recovery support services. ◼ Eliminate barriers to longer retention at treatment facilities ◼ End housing discrimination against individuals enrolled in MAT ◼ NIMBY(Not In My Backyard) is a major barrier to new treatment programs and engagement of elected officials is necessary. ◼ There is a shortage of safe housing and vocational supports. ◼ Not having affordable housing makes it more difficult to achieve good health. Monitoring Method: Number of individuals housed that have opioid use disorder.
  18. 18. RECOMMENDATIONS- TREATMENT 7. Expand treatment access and capacity ◼ The Drug Enforcement Agency and National Survey on Drug Use and Health estimate that 122,000 and 150,000 Philadelphians are in need of substance use disorder treatment. 1. Increase the number of sites in the city offering addiction treatment services. 2. Expand weekend and evening operations for facilities at multiple levels of care. 3. Identify gaps in substance use disorder treatment capacity for special populations and increase capacity of treatment slots and providers to engage these populations at all levels of care. 4. Partner with the state to resolve identification issues 5. Create a web-based database for the general public and provider access to identify available treatment slots in real time. 6. Integrate information on how to access treatment into public education campaigns 7. Expand the capacity of crisis centers and emergency departments. In Philadelphia to assess and treat individuals with opioid use disorder. 8. Improve the quality of assessments for individuals entering treatment by adopting ASAM(American Society of Addiction Medicine) criteria. 9. Increase use of peer recovery specialist to support individuals in their recovery throughout behavioral health and medical settings. Monitoring Method: People treated for opioid use disorder in the public behavioral health system.
  19. 19. RECOMMENDATIONS- OVERDOSE PREVENTION 12. Expand naloxone availability ◼ Engage with government agencies, community based organizations, health care providers, and private citizens. ◼ The use of naloxone by laypeople has been linked to reductions in overdose death rate. ◼ Should be available to persons at risk of overdose through 4 main areas: 1. Governmental and quasi-governmental agencies such as fire, police, homeless outreach agencies 2. Harm reduction programs 3. Take-home programs from hospital emergency department, prisons discharge and opioid treatment programs 4. Direct request at pharmacies ◼ Distribution centers should include training on: ◼ Recognition of overdose ◼ Administration of naloxone ◼ Treatment service ability ◼ Harm reduction messages Monitoring Metrics: doses of naloxone distributed/administered, by agency/ Nonfatal drug overdoses treated in hospital emergency depts./ Fatal drug overdoses
  20. 20. RECOMMENDATIONS- OVERDOSE PREVENTION 13. Further explore comprehensive user engagement sites(CUES) Walk-in setting locations in which central services are provided to reduce substance use and fatal overdoses ◼ Referral to treatment and social services ◼ Wound care ◼ Medically supervised drug consumption ◼ Access to sterile injection equipment and naloxone Safe Consumption Facilities(SCF) have been operating in Europe, Australia and Canada since 1988 and have been shown to: ◼ Reduce overdose death, disease transmission (including HIV, Hepatitis C and B) injection related infections and other adverse health outcomes. ◼ Serve as an access point for D&A treatment, medical services and housing services, reducing the burden on Emergency depts., Police, and Fire. ◼ Improve public order and neighborhood safety by reducing public drug consumption and improper disposal of drug use equipment. The pilot program should be rigorously evaluated for health and community outcomes to guide future decisions. Monitoring Metrics: Community impact assessment
  21. 21. RECOMMENDATIONS- OVERDOSE PREVENTION 15. Address homelessness among opioid users The city should expand outreach and specialized programs to meet the needs of individuals with opioid use disorder who are homeless such as City’s Safe Heaven, Journey of Hope and Housing First programs. ◼ Housing first provides access to housing for homeless individuals without restriction for those suffering from substance use disorder. ◼ This strategy has been proven to reduce homelessness, shelter costs and health care costs ◼ Shown to increase substance use disorder and mental health treatment among its participants. ◼ Successfully implemented in Canada and many United States cities including Philadelphia. Monitoring Metric: Individuals with opioid use disorder placed in Safe Heavens and Housing First programs
  22. 22. RECOMMENDATIONS- INVOLVEMENT OF THE CRIMINAL JUSTICE SYSTEM 18. Provide Substance abuse disorder assessment and treatment in the Philadelphia Department of Prisons ◼ PDP should provide substance abuse treatment to all inmates upon entry and comprehensive treatment during incarceration with continuum of care plan upon release. ◼ Should include a plan to obtain an identification card to facilitate treatment. ◼ Treatment during incarceration increases: ◼ Likelihood of engagement in treatment post-incarceration ◼ Reduced recidivism ◼ Increase abstinence ◼ Decreased overdose morbidity. ◼ Inmates who participated in MAT were twice as likely to engage in treatment upon re-entry. Monitoring Metric: Inmates for opioid use disorder while incarcerated/ Inmates with opioid use disorder released with continuum of care plan.
  23. 23. ACT 139 ◼ Act 139 provides limited immunity from charge and prosecution for possession of drugs and drug paraphernalia for individuals who experience drug overdose and are in need of medical care and for those who seek medical care in good faith for a person experiencing an overdose so long as certain conditions are met. ◼ Provides limited immunity from charge and prosecution for certain drug crimes for both a person acting in good faith who seek medical assistance for someone having a drug overdose and the person suffering from one. ◼ Overdose rates in Pennsylvania have increased by 89% since 1999. In 2011 it had the 14th highest overdose mortality rate in the country. ◼ In 2014 Senate Bill 1164 was passed unanimously in the summer of 2014, signed by Governor Wolf on September 30th , when it be came Act 139. ◼ Dr. Rachel Levine , Pennsylvania Physician General signed standing order enabling any Pennsylvanian to obtain Naloxone from a pharmacy with an individual prescription.
  24. 24. ACT 139 Immunity only applies to the following crimes ◼ Unlawful possession of a controlled substance or counterfeit substance ◼ Unlawful purchase or receipt of a controlled substance ◼ The possession or non-sale distribution of 30 grams or less of marijuana or 8 grams or less of hashish ◼ The use of, or possession with intent to use drug paraphernalia ◼ The delivery of, possession with intent to deliver or manufacture with intent to deliver, drug paraphernalia ◼ The unlawful possession of more than thirty doses as a dispensed prescription of more than three trade packages of anabolic steroids.
  25. 25. WHAT CAN BE DONE City Agencies are: ◼ Providing naloxone to EMS staff and police officers. ◼ Funding and supporting drug treatment providers to offer treatment for people addicted to opioids. ◼ Working to disrupt criminal networks that are distributing fentanyl Health care providers can: ◼ Reduce their prescribing of opioids ◼ Obtain naloxone and learn how to use it. ◼ Register for and use prescription drugs monitoring program database when prescribing opioids. PDPH is: ◼ Working with the Mayor's Task Force to combat the opioid epidemic to develop a plan to better prevent prescription opioid addiction, increase treatment for those who are dependent and treat drug overdoses. ◼ Distributing guidelines to physicians and other prescribers on reducing inappropriate prescribing of opioids. ◼ Developing a media campaign warning consumers about the inherent risks of prescription opioids.

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