local progress on addiction - scioto county medical...
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Local Progress on Addictionin Scioto County, Ohio
Lisa Roberts RN / Portsmouth City Health DepartmentDr. Darren Adams DO / Scioto County CoronerJone Stone BSN RNC-OB, / SOMC Maternity DepartmentDr. Michael Martin MD/ Scioto County Health CommissionerHon. Judge Alan Lemons/ Scioto County Probate Court
KY WV
OH
Overview and History of the Opioid Epidemic
Public Health Nurse Coordinator/ Drug-Free Communities Support Program Portsmouth City Health Department
Disclosures
The speaker and members of this presentation do not have a conflict of interest in this topic.
There is no commercial support for this program.
ObjectivesWe will:
Discuss the opioid epidemic and death rate in Scioto County, OhioExplain the programs and local responsesHighlight steps taken to decrease recurring opioid overdoses
Our Objectives are to:
Describe the addiction epidemic in a small rural community and how it is being addressed
Discuss programs developed in the juvenile court systemDiscuss local programs and intervention strategies for communities
Fatal Drug Overdose U.S. 2002-2014 A 14 year span…….
2002 2014
Ohio now has the highest number of fatal OD’s of all states.West Virginia maintains the highest rate.
OHIO Fatalities 2000-2014
OHIO Opiate Treatment 2001-2014
OHIO NAS Newborns 2004-2014
OHIOThe state of the state:
- 2015 #1 in number of deaths from accidental fatal OD- Total 3,050 deaths
Scioto County Data/ History and Risk Factors:
Risks:Appalachian-Distressed County; population 75,000Ohio’s original epicenter for opioid problems
2000- First cluster of “pain clinics” across the river (KY)2002- First pill mill established in Portsmouth (OH)By 2010- 12 illegitimate Pain Clinics had operated in Scioto County in a “family tree” fashion. Between 2002-2011 Home to a leading prescriber of oxycodone in the nation-three different times
2010: Scioto County saw 9.7M pain pills dispensed (123 pills/person)-Highest in Ohio
Results:Highest fatal OD 2010-2012 in stateHighest opioid addiction rate in OhioHighest rate of NASHighest rate of drug incarcerations in Ohio Huge increase in Hepatitis C rates-highest in Ohio
* In April 2011, DEA led raids on Scioto County Pain Clinics.
* Ohio HB93 “the Pill Mill Bill”passed as an Emergency Measure.Pain Management now regulated.
Scioto County organized: Key state and federal grants to address the problem
2010 “Prescription for Community Recovery” One of two counties funded by ODH BHPRR to reduce fatal overdose (state grant).
2012- HIDTA Designation by Congress (federal grant)
2012 “Project DAWN” Naloxone Pilot Project
2012 “Drug Free Communities Support Program” from the White House Office of National Drug Control Policy (federal grant)
These programs seeded a comprehensive sustainable community response to the opioid epidemic
Formed a Community Coalition
Use data to inform strategies, target high-risk populations, and issue Public Health Alerts
Implemented population-based programs designed to:
Prevent new initiates to opioid abuse• Community awareness • Created/Promoted safe and responsible prescribing of opioids through guidelines, training, and PMP enhancements• Alternatives to opioids for pain• Youth prevention initiatives
Treat the addicted and reduce harms associated with Opioid Use Disorders• Piloted Ohio’s first Community-Based Naloxone Program• Started a Syringe Exchange Program to reduce BBP diseases and link participants to recovery services• Expanded access to addiction treatment including Medication-Assisted Treatment• Expanded Drug Courts to provide oversight and improve addicted offender and family Outcomes
Progress: Scioto County- Opioid Consumption 2010-2016
15% decrease in opioids dispensed per capita
48% decrease inaverage Daily MED
per capita
Progress: Scioto County High School Surveys 2013-2016Non-Medical Use of Rx dropped in all grades declined across all grades
First Project DAWN Program established Scioto County in 2012.Since expanded to 48 programs in 35 Ohio counties. Naloxone use being expanded to non-traditional First Responders (LE, FD, lay savers.) Ohio has passed laws to increase and ease access 2016 Naloxone made available in select pharmacies through a medical protocol Good Samaritan Law passed to encourage 911 calls
Since 2012 hundreds of overdose reversals in SCIOTO COUNTY and thousands across Ohio
Naloxone for Overdose Reversal
State Public Awareness Campaign ODH/OhioMHAS
* 15 counties with highest fentanyl deaths got Billboards and statewide PSA’s* Pharmacies in Scioto County dispensing naloxone without a Rx are all CVS, Kroger
http://www.odh.ohio.gov/stopoverdoses
Scioto County Non-EMS Naloxone Administration 2012-2016
2012 2013 2014 2015 2016
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Scioto County, Ohio Naloxone Administrations Non-EMS 2012-2016
Top 220 US Counties for Hepatitis C Considered at risk for HIV Outbreaks-2015 Source: CDC
“Prevention NOT Permission” SEP at the Portsmouth City Health Department
There is much emphasis on SEP’s now, both federally and at the state level
Federal:
• CDC has endorsed SEP’s as an effective method to reduce the spread of BBP
• In 2015 Congress lifted the ban on funding for SEP
State:
• Effective Sept. 2015, Ohio Boards of Health can establish a “Blood borne Pathogen Prevention Program” without declaring an emergency
• PCHD hosts teams from other Health Departments to assist them in starting SEP’s.
State and Local Efforts:
• In 2016 the “Prevention NOT Permission” SEP exchanged 115,000 syringes
• The Prevention NOT Permission SEP functions as a GATEWAY to Healthcare, Immunization against Hepatitis A and B, early detection of Hepatitis C and HIV, and referral to Addiction Treatment.
Syringe Exchange Programs: The Evidence is SupportiveThe current opiate epidemic is directly related to rising rates of Hepatitis C,
Hepatitis B, and HIV
Syringe Exchange Programs have been associated with:
52% reduction in new cases of HIV;
65% reduction in new cases of Hepatitis C when combined with MAT ;
61% reduction in new cases of Hepatitis B;
Increased entry into substance abuse treatment and healthcare
Reduction of dangerous needles in public places
Cost effectiveness. Price of 1 syringe averages .50 cents
Cost of treating Hepatitis C $95,000
Cost of treating HIV $400,000
Progress: Scioto County New Cases of Acute Hepatitis C 2010-2016
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Scioto County New Acute Cases of Hepatitis C2010-2016
Live Surveillance of ED Visits: Early Warning EpiCenter ALERT: Scioto County Residents “Drug” Classifier Anomaly, November 5-6, 2015.Nov 1 spike was “highest to date” / Nov. 6, 2015 spike “highest in history”
Approx 350 people in 12 mo.Average 29/monthAverage age 32.7
CDC in Scioto County11-5-15
Scioto County has implemented EMS policies and Public Health notification for sudden spikes in OD (usually related to illicit Fentanyl)
“Fake” pills contain cheap illegally manufactured Fentanyl. Made to look like real pills.
Emergency Room Visits 2007-2016 Scioto County Actual Number as detected by EpiCenterElectronic Surveillance System
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Series1 172 152 156 158 134 183 204 241 339 291
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Scioto County, Ohio Drug-Related ED Visits 2007-2016
August 31, 2016 IOAD Scioto County* Targeted Outreach in highest OD burden area (east Portsmouth)
ALS ADAMHS Board The Broken Need a Healing The Counseling Center Drug Free Communities Support Program HopeSource Mahajan Therapeutics PCHD Port45 Recovery Pike County Recovery Council Recovery Gateway SOLACE
Took 11 into Addiction Treatment that day
The “Troops”
The IOAD Memorial/Awareness March
IOAD Social Media Campaign #IOADScioto
Maternal Substance Abuse and Neonatal Impact
Nurse Manager, Maternity Southern Ohio Medical Center
Scioto County has the highest rate of newborns suffering from Neonatal Abstinence Syndrome (this is more than 8 X higher than the state average) Source: OhioMHAS
Neonatal abstinence syndrome(NAS; ICD-9 779.5) per 1,000 livebirths in Ohio by county of patientresidence. On average, there were8.8 discharges for NAS per 1,000
live births statewide between 2009and 2013. Counties with the
highest rates of NAS dischargeswere Scioto (76.0), Lawrence
(66.7) and Pike (57.7).
Maternal and Newborn History 2003-2009
Wrote our first Maternity policy on toxicology screening for mothers and newborns (2003)
Educated our Pediatricians and nursing staff on the Newborn Finnegan assessment tool for Neonatal Abstinence Syndrome (NAS) screening (2003)
Pediatricians started using morphine to withdraw newborns (2003)
Developed a defined role for Social Service and Scioto County Children’s Services
Started communication with Nationwide Children’s Hospital about NAS
Did not transfer newborns for withdrawal if that was their only diagnosis
Newborn toxicology screens were urine and meconium (2003)
Sought out as much education and information as we could find
It was challenging to know what was best for the patients
It was challenging to know how to interact with the families
Maternal and Newborn History (cont.) 2010
2010 Challenges:
Managing the parents and families in our unit
Having a reliable newborn specimen that parents had not discarded or tampered with
Knowing which mothers to screen
Managing a newborn length of stay for withdrawal inside a newborn nursery
Determining a therapeutic dose (Morphine: 0.08 for all newborns) and a weaning protocol that was not individualized by Pediatricians
Maternal and Newborn History (cont.)
Progress from 2010-2013:Worked with US Drug Testing Lab to implement umbilical cord testing
Established a SOMC Maternal Neonatal Substance Abuse Task ForceMembers: Dr. Adams, Dr. Turjoman, Social Service, OB, and ED.
Connected with Director of the Stepping Stones Program and set up Maternity Workgroup ( SS House Director, SOMC OB, Scioto County Children’s Service, Valley View Prenatal Clinic)
SOMC requested assistance from The Counseling Center to educate 100% of our Maternity Staff about addiction
Worked with our Coders on documentation/reimbursement issues for NAS
Obstetricians made a decision to do 100% screens on maternal admissions and outpatient triage (2011)
Quality Improvement Projects
Nationwide Children’s NAS Rural Collaborative (2013-2015)Between 2004-2008 NCH experienced a six fold increase in NAS admissions and had a LOS between 31-58 days
SOMC was invited to participate in this with four other hospitals (Marion, Adena, Licking, Genesis)
NCH Aim: to reduce the LOS by 25% by Sept. 2015
Interventions that occurred during the project:
Staff/Parent education on swaddling, kangaroo care
Volunteer Program
OT consult on all newborns started on morphine (SOMC OT went to NCH to train)
Educated our RN and OT staff on non pharmacological interventions
Quality Improvement Projects (cont.)
Ohio Perinatal Quality Collaborative (2014-2017) (funded by CMS) Team: Dr. Adams, Dr. Turjoman, Social Service, and OB
Participated with 50 hospitals in Ohio
Aim: Reduce variation in identification and treatment of NAS and standardize non pharmacologic and pharmacologic care practices
OPQC Hospitals LOS was at 19.3 when started in 2014 and 18.5 in 2016
Interventions:
Improve scoring with Finnegan Assessment (RN scoring accuracy)
Standardize pharmacological and non pharmacological bundles
Standardize nutrition (formula and calories)
Progress To Date
2017: Dual Finnegan Scoring *
Implementation of a Morphine Protocol dose based on newborn weight with initiation, escalation, stabilization, and weaning phases. *
Formula: Similac Sensitive 22 calorie*
Skin to Skin
On going protocols changes to support staff safety as they manage the families in our unit
* LOS decrease from 12.4 to 9.6 days
Percent of Positive Maternal Toxicology Screens
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2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Maternal
4.4% 4.6%
8.8%9.4%
12.0% 11.7%
10.5%
13.4%
2009 2010 2011 2012 2013 2014 2015 2016
% P
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Percent of Positive Neonatal Toxicology Screens
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Neonatal
5.0%
7.0%7.7%
9.4%
11.9%12.5%
10.0%
12.9%
2009 2010 2011 2012 2013 2014 2015 2016
% P
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Newborn Care: Percent of Newborns Screened for NAS
0%
5%
10%
15%
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2012 2013 2014 2015 2016
25% 24% 26%
18.6%21.9%
% of Newborns Screened for NAS
(292) (295) (304)
(221)(262)
% of Newborns screened with Finnegan scoring and cord toxicology based on total birthsTotal Births: 2012: 1,174 2013: 1,229 2014:1,149 2015: 1,186 2016: 1,194
Newborn Care: NAS Newborns Treated Pharmacologically
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Diagnosis of NAS Average Length of Stay
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2011 2012 2013 2014 Jan-Jul 2015 Aug 2015-Dec2016
17.419.0
11.6 11.2 12.4 11.5
Number of Days
2011 2012 2013 2014 Jan-Jul 2015 Aug 2015-Dec 2016
Aug 2015 – Dec 2016: 9.6 LOS with Morphine Only
Future Considerations:
Maternal Buprenorphine prenatal weaning*
Is there a better place for NAS care other than inpatient Newborn Nurseries?
More research is needed to determine the best pediatric care and education needs of the opiate exposed newborn
*Newborn LOS decreased from 9.7 days to 5 days in weaned group
Scioto County Coroner
Unintended consequence of Ohio’s opioid crackdown…….* Heroin and illicit Fentanyl use and deaths increase
OHIOBetween 2010-2015 Rx Opioid deaths declined about 50%.......• Offset by enormous increases in• Fentanyl (825%) and Heroin (114%) fatalities
-50% +825%+114%
#1 Brown#2 Montgomery#3 Clermont#4 Butler#5 Adams
#6 Scioto#7 Clinton#8 Clark#9 Jefferson#10 Ross
OHIO Fatal Overdose 2010-2015
Progress: Scioto County # 6 after being #1 for a decade
Scioto County: 2015 there was a total 29 Accidental Overdose decedents• 100% involved multiple drugsAge groups:• Largest segment were 35-44 y/o (39%)• Second largest was 45-54 y/o (32%)
Scioto County, Ohio 2015 Accidental Fatal Overdose ILLICIT DRUGS detected by toxicology:• 72% were positive for heroin• 14% were positive for Methamphetamine
Scioto County, Ohio2015 Accidental Fatal Overdose Of Prescription Opioid mentions by toxicolgy:• 47% involved Morphine/Codeine• 21% involved Fentanyl• 14% involved Oxycodone• 10% involved Hydrocodone• No Buprenorphine or Methadone
Geographical Drug Fatality Map Scioto County , 2016
Autopsy Data, Scioto County 2016
Direct Drug in Blue Drug Related in Gray
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Fatal Overdose involving Opiates Scioto County, Ohio 2010-2016
Prescription opioids Heroin Fentanyl
Rx
Heroin
Fentanyl
Scioto County Fatal Overdose with Opioid Involved 2010-2016 Source: Ohio Dept. of Health
Fatal Overdose: Ohio Versus Scioto County 2010-2015
Progress: Introduction of fentanyl has interfered with sustained progress in Scioto County but ……..to a lesser degree than the state as a whole.
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Ohio Accidental Fatal OD2010-2015
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Scioto County Accidental Fatal OD2010-2015
36.3% Increase
Scioto County Health CommissionerMedical Director SOLACE, Inc. and Recovery Gateway
State Licensed AoD Treatment Program
SOLACE, Inc.
• Established 7-2015
• Out-patient Treatment Facility specializing in opioid addicted clients
• Provides Medications (Buprenorphine, Vivitrol) to clients along with counseling,
case-management, medical management, and other supportive services.
State Licensed AoD Treatment Program
Recovery Gateway:
• Housed within Portsmouth City Health Dept.
• State certified AoD Treatment Facility
• Based on “hub and spoke” model for HIV case management
• Serves as an access point for people seeking addiction treatment or other medical or social services
• Provides for a Field Case Manager to conduct outreach and follow-up on
complex cases for high-risk AoD clients (recent OD, active IV injectors, Probation, non-compliant with treatment)
• Collaborates with ED and Judicial Systems to inter-refer
• Refers OUT to appropriate levels of care when indicated
• Provides counseling and Vivitrol for relapse-prevention
Scioto County Court of Common PleasProbate- Juvenile DivisionFamily Reunification through Recovery Court
Scioto County has the highest rate of incarceration for drug offenses in Ohio (nearly six times the state average). Source: Ohio MHAS 2015
This map displays Ohio prison incarcerations for drugoffenses by committing county. A snapshot of the prison population on January 1, 2015showed there were 7,458 drug-related incarcerations witha statewide average rate of 6.4
incarcerations per 10,000 persons.Scioto (37.9), Highland (27.7) and Adams (27.4) counties hadthe highest drug-related
incarceration rates per 10,000 persons.
Scioto County Court of Common PleasProbate/ Juvenile Division
• In 2014, established a specialized docket to address the drug problem in families.
• “Family Reunification and Recovery Court” (FRRC) is Ohio Supreme Court Certified
• The purpose of the Family Reunification through Recovery Court is to more effectively deal with parents and caregivers who are addicted and unable to properly care for their children.
Progress: Community Support/ a strong Recovery CommunityOhio’s National March Against Heroin March 31, 2017
2,000 attended$1M in treatment scholarshipsFREE Event/ Raised $$ for NarcanCompletely conducted by Recovery Community