Rahul Gupta, MD, MPH, MBA, FACPChief Medical and Health OfficerSenior Vice President

MARCH 19, 2019

The March of Dimes

Mission and the Opioid

Crisis

OBJECTIVES

• Discuss March of Dimes Priorities

• Discuss the Opioid Crisis

• The West Virginia Case Study: A cross-sector approach

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CONFLICTS OF INTEREST

None

3

MARCH OF DIMES LEADS THE FIGHT FOR THE HEALTH OF ALL MOMS AND BABIES.

OUR MISSION

PRIORITIES

1. Prematurity and its causes including substance use

2. Maternal mortality and morbidity

3. Address underlying factors including inequities and access issues

Slide 6

Hispanic

PRETERM BIRTH RATES AND GRADES BY STATE

Preterm is less than 37 weeks gestation based on obstetric estimate.

Source: National Center for Health Statistics, 2017 natality data

2018 PREMATURE BIRTH REPORT CARD

MARCHOFDIMES.ORG/REPORTCARD

Slide 7

Preterm is less than 37 weeks gestation. Gestational age based on obstetric estimate. Preterm-related is a grouping of causes ofdeath each determined to be a direct consequence of preterm birth (44 ICD-10 codes). Source: National Center for Health Statistics, 2013 period linked birth/infant death data

Prepared by March of Dimes Perinatal Data Center, July 2015

PREMATURITY AND ITS COMPLICATIONS ARE THE LEADING CONTRIBUTORS TO INFANT DEATH

PRETERM-RELATED

A grouping of causes of death each

determined to be a direct consequence of

preterm birth (44 ICD – 10 codes).

National Center for Health Statistics

(NCHS) researchers developed this list of

causes to more fully assess the impact of

preterm birth on infant mortality in the US.

Preterm-related, 36.3%

All other causes, 31.8%

Birth defects20.4%

SIDS, 6.7%

Accidents4.9%

Causes of Infant Mortality 2013

RACE & ETHNICITY IN UNITED STATES

In United States, the preterm birth rate

among black women is 49% higher than the rate

among all other women.

13.4

10.8

9.2

8.9

8.6

0 2 4 6 8 10 12 14

Percentage of live births in 2014-2016 (average) born preterm

Ra

ce

/Eth

nic

ity

Asian/Pacific Islander

White

Hispanic

American Indian/Alaska Native

Black

Preterm is less than 37 weeks gestation based on obstetric estimate.

Race categories include only women of non-Hispanic ethnicity.

Source: National Center for Health Statistics, 2014-2016 natality data

2018 PREMATURE BIRTH REPORT CARD

MARCHOFDIMES.ORG/REPORTCARD

EQUITY AS A CROSS-CUTTING ISSUE

DISPARITIES IN PRETERM BIRTH

Maternal Mortality and Morbidity

U.S. Maternal Mortality and Morbidity

Slide 11

Launched October 2018

#BLANKETCHANGEFOR MOMS AND BABIES THIS ELECTION

MATERNAL MORTALITY

Slide 12

Blanket Memorial

on the

National Mall

12#BlanketChange

*Pregnancy-related mortality ratio is the number of pregnancy-related deaths per 100,000 live births. A pregnancy-related death is

the death of a w oman during pregnancy or w ithin one year of the end of pregnancy from a pregnancy complication, a chain of

events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. Source: CDC,

2011-2013 (https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html)

Prepared by March of Dimes Perinatal Data Center, February 2018.

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EQUITY AS A CROSS-CUTTING ISSUE

DISPARITIES IN MATERNAL DEATH

Slide 14

Maternity Care

Desert Report

14#BlanketChange

READ THE REPORT

Slide 15

OUTCOMES FOR MOMS AND BABIES ARE IMPACTED BY:

Healthcare system: Access

to care, hospital & provider

policies, insurance status

Personal health: Nutrition

and access to healthy

foods, overall health status

including stress

Social environment:

Educational status, social

stress, job opportunities, work

policies for familiesBuilt environment: Housing,

neighborhood safety, proximity

to child care & employment

Behavioral health: alcohol,

tobacco, and drug use

Slide 16

THE OPIOID EPIDEMICAs a Demand-Supply Issue

Slide 17

The Opioid Crisis

Slide 18

Opioid-involved Overdose Deaths, 1999-2015

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Slide 19

Opioid Epidemic - An Evolving Crisis

Supply-side drivers

Demand-side drivers

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Slide 20U.S. Prescribing Rate Maps | Drug Overdose | CDC Injury Center, 2017

State Opioid Prescribing Rates, 2016

OPIOID USE DISORDER AND NAS

Slide 2121

Prescriptions Filled in the U.S.Total Prescriptions filled per capita, 2016

All Products, Retail Channel

Source: QuintilesIMS Xponent, 2017

OPIOID USE AMONG WOMEN

About 1 in 3women of reproductive age filled an opioid prescription

between 2008 – 2012.

Ailes EC, Dawson AL, Lind JN, et al. MMWR. 2015 Jan 23;64(2):37-41.

0

1

2

3

4

5

6

7

1999 2014

Per

1,00

0 de

liver

ies

Haight SC, Ko JY, Tong VT, et al. MMWR. 2018 Aug 10; 67(31):845-849.

Opioid use disorder rates at delivery increased by more than

4-foldduring 1999 to 2014.

Outcomes Associated With Prenatal Opioid Exposure

??

Every 15 minutes,

a baby was born with NAS

Nearly 100 babies

each day

Syndrome (NAS)

Babies born with NASexperience

serious medical problems

Winkelman, Villapiano, Kozhimannil, Davis & Patrick, 2018

In 2014, for NAS total

hospital costs in the US were over

$563 million

CHALLENGES TO MOTHERS, INFANTS & CHILDREN (WV)

25

Foster Care Placements Up

Over 50%

5% of Infants Diagnosed with

NAS

Early Intervention Costs

Lack of SUD Treatment

Options

SUD Increasingly Noted in Infant Death Reviews

Maternal Deaths Increased 72%

from 2014-2016

Changes in Opioids Filled

Rank State

%

Change Rank State

%

Change

1 Florida 0.3% 27 Washington -5.6%

2 Georgia -0.3% 28 New York -6.2%

3 Louisiana -2.2% 29 Iowa -6.5%

4 Arkansas -2.2% 30 Kentucky -6.6%

5 Wyoming -2.3% 31 California -6.6%

6 Texas -2.9% 32 Virginia -6.6%

7 Alaska -3.4% 33 New Jersey -6.6%

8 Alabama -3.5% 34 Delaware -6.7%

9 Utah -3.6% 35 Maryland -7.0%

10 Nebraska -3.9% 36 Michigan -7.0%

11 Mississippi -3.9% 37 New Mexico -7.8%

12 Idaho -4.1% 38 Oregon -7.9%

13 Kansas -4.2% 39 Colorado -8.1%

14 Illinois -4.2% 40 District of Columbia -8.2%

15 South Carolina -4.3% 41 Wisconsin -8.3%

16 South Dakota -4.7% 42 Pennsylvania -8.6%

17 Nevada -4.9% 43 Ohio -9.0%

18 Montana -5.0% 44 Minnesota -9.7%

19 Missouri -5.0% 45 Vermont -10.2%

20 North Carolina -5.1% 46 Rhode Island -10.5%

21 Hawaii -5.2% 47 Connecticut -10.8%

22 North Dakota -5.2% 48 Maine -12.0%

23 Oklahoma -5.2% 49 Massachusetts -12.7%

24 Indiana -5.3% 50 New Hampshire -13.8%

25 Arizona -5.5% 51 West Virginia -15.6%

26 Tennessee -5.6% 52 Puerto Rico N/A

Percent Change in Filled Prescriptions, 2016 vs 2015

Opioid Products

All states = -5.6% annual percentage of change

Source: QuintilesIMS Xponent, 2017

U.S. total Opioidprescriptions

2015 = 227,780,915

U.S. total Opioidprescriptions

2016 = 215,051,279

Slide 27

Prescribing Remains a Major Issue

Slide 28

Opioid Epidemic - An Evolving Crisis

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Supply-side drivers

Demand-side drivers

Slide 2929Source: Betz, Michael. The Link Between Economic Conditions and Overdose Deaths in OH, WV, KY, PA; The Ohio State University.

- Community economic disadvantage

- Mental health problems

- Relational problems

- Health conditions (chronic pain, sedentary life styles, etc.)

DEMAND-SIDE FACTORS

Slide 30

Are Skills Transferable?

Ohio’s

Industries2000 2015

Manufacturing 15.4 10.4

Government and government enterprises

Retail trade 11.7 10.1

Health care and social assistance

9.9 12.8

Accommodation and food services

6.4 7.2

11.512.1

1992

< HS HS 2-YEAR BACHELORS

2016

< HS HS 2-YEAR BACHELORS

Slide 31

Considerations

▪ Half of prime age men NLF use daily pain medication (Krueger 2017)

▪ LFP is lower in and fell in counties where prescription rates are higher (Kreuger 2017)

▪ County employment growth in low-paying industries served as a protective factor against OD deaths, effect more for males (Betz and Jones)

▪ Currently 47 million workers with HS degree or less

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Slide 32

WEST VIRGINIA CASE STUDY

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Slide 33

Comprehensive Response Strategy

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Innovation in Treatment

Slide 34

CROSS SECTOR APPROACH

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Health Statistics Center

Corrections

Medicaid

Emergency Medical Services

Chief Medical

Examiner

Board of Pharmacy

Behavioral Health

Create a model

Identify risk factors

Identify opportunities for intervention

WEST VIRGINIA SOCIAL AUTOPSY CASE STUDY

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881

Preliminary Occurrence

Deaths

830

Preliminary Resident Deaths

(Matched against death records, CSMP,

Medicaid, EMS, BBHHF, and Corrections)

2016 Overdose Fatality Analysis:Healthcare Systems Utilization, Risk Factors, and Opportunities for Intervention

SOCIAL AUTOPSY ON OVERDOSE DEATHS 2016

FINDINGS

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WEST VIRGINIA OVERDOSE FATALITY ANALYSIS

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3 x more likely if the decedent

had 3+ prescribers

70 x more likely if decedent filled

prescriptions at 4+ pharmacies

7 out of 10 decedents were on Medicaid 3 out of 10 decedents received Naloxone

31%

OPIOID RESPONSE PLAN PROCESS

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Public Health Expert PanelJohns Hopkins University, Marshall University

West Virginia University

Public Engagement

Review of the Proposed

Report

Public Comments

Public Meeting

Governor Justice and WV Legislature

State Health Officer Office of Drug Control Policy

Input from Subject-Matter

Experts

OPIOID RESPONSE PLAN SUBMISSION

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WV OPIOID OVERDOSE EXPERT PANEL

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Senate Bill 272

Senate Bill 273

POLICY DEVELOPMENT - 2018

Slide 43

Additional Policies

Making naloxone available without a prescription or third-party prescribing

Overdose response training for professionals and laypersons and community-based naloxone education and distribution programs

Good Samaritan and Prescribing laws

PDMP and CME requirements for prescribers

MAT Expansion

Harm Reduction Programs at community level

Drug Diversion and Control

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BOTTOM LINE…

• The drug crisis began as a supply problem but continues to evolve

• Local economic conditions influence overdoses

• Epidemic of epidemics

• Cross-sector partnerships and communication is key to implementing a comprehensive response strategy

© 2019 March of Dimes

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