new mexico department of health initiatives: responding to ... · • use of multiple data sources...
TRANSCRIPT
New Mexico Department of Health Initiatives: Responding to
the Opioid EpidemicChris Trujillo, Pharm.D.
Prescription Drug Overdose PreventionEpidemiology and Response Division
Outline• Objectives• Data• Key Interventions• Additional approaches to reduce drug overdose
• Surveillance• Drug Overdose Notifiable Condition
Objectives• Pharmacist
1) Describe overdose death and intervention related data2) Identify controlled substance prescribing patterns in New Mexico3) Describe methods to improve opioid prescribing practice, expand access to
naloxone, and expand availability of medication assisted treatment4) Define Notifiable Condition and how it is used in Public Health5) Describe how a drug overdose notifiable condition can be used to intervene at
various levels to overdose. • Technician
1) List methods to improve opioid prescribing practice, expand access to naloxone, and expand availability of medication assisted treatment
2) Define Notifiable Condition and how it’s used in Public Health3) List 3 ways in which a drug overdose notifiable condition can be used to reduce
overdose.
Data
7.7
24.8
3.4
19.8
0
5
10
15
20
25
3019
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
0920
1020
1120
1220
1320
1420
1520
16
Deat
hs p
er 1
00,0
00 p
erso
ns
Year
Drug Overdose Death RatesNew Mexico and United States, 1990-2016
New MexicoUnited States
Rates are age adjusted to the US 2000 standard populationSource: United States (CDC Wonder); New Mexico (NMDOH BVRHS/SAES, 1990-1998,2016 ; NM-IBIS, 1999-2015)
Drug Overdose Death Rates Leading States, U.S., 2016
Rank State Deaths per 100,000 1 West Virginia 52.02 Ohio 39.13 New Hampshire 39.04 Pennsylvania 37.95 Kentucky 33.56 Maryland 33.27 Massachusetts 33.08 Delaware 30.8
9 Rhode Island 30.810 Maine 28.711 Connecticut 27.412 New Mexico 25.2
U.S. 19.8
Sources: CDC Wonder Rates are age-adjusted to the 2000 US Standard Population.
West Virginia
New Mexico
0
10
20
30
40
50
60
2010 2011 2012 2013 2014 2015 2016
Deat
hs p
er 1
00,0
00 p
eopl
e
Drug Overdose Death Rates for the 12 States with the Highest Rates in 2016,
2010-2016
Rates are age adjusted to the US 2000 standard populationSource: National Center for Health Statistics, CDC via CDC Wonder
Other states: OH, NH, PA, KY, MD, MA, RI, DE, ME, CT
0.010.020.030.040.050.060.070.080.090.0
100.0
Rio
Arrib
aCa
tron
San
Mig
uel
Linc
oln
Guad
alup
eHi
dalg
oCo
lfax
Gran
tSi
erra
Sant
a Fe
Taos
Qua
yM
ora
Bern
alill
oTo
rran
ceVa
lenc
iaEd
dyO
tero
Soco
rro
Chav
esSa
ndov
alDe
Bac
aSa
n Ju
anCi
bola
Dona
Ana
Lea
Luna
Roos
evel
tLo
s Ala
mos
McK
inle
yCu
rry
Uni
onHa
rdin
gN
ew M
exic
o
Deat
hs p
er 1
00,0
00 p
opul
atio
n
Drug Overdose Death Rate by County, NM, 2012-2016
Rates are age adjusted to the US 2000 standard populationSource: Bureau of Vital Records and Health Statistics, UNM/GPS population estimates
Drug overdose deaths and death rates, 2012-2016: How New Mexico Counties Compare
Each == 20 Deaths
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.090
-92
91-9
3
92-9
4
93-9
5
94-9
6
95-9
7
96-9
8
97-9
9
98-0
0
99-0
1
00-0
2
01-0
3
02-0
4
03-0
5
04-0
6
05-0
7
06-0
8
07-0
9
08-1
0
09-1
1
10-1
2
11-1
3
12-1
4
13-1
5
14-1
6*
Deat
hs p
er 1
00,0
00 p
opDrug Overdose Death Rates for Selected Drugs, NM
1990-2016 3-year Moving Average
Heroin Rx Opioids Methamphetamine Cocaine Benzodiazepines AlcoholRates adjusted for specificity of reporting (2010-2012)Drug categories are not mutually exclusiveRates are age adjusted to the US 2000 standard populationSource: Office of the Medical Investigator, UNM/GPS population estimates
Methamphetamine in NM, 2013-2017
Year % of OD Deaths Involving methamphetamine2013 15.62014 21.12015 22.32016 25.82017 (half) 29.5
• The fraction of all OD deaths that involve meth has doubled over the period and is closing in on a third.
Source: New Mexico Vital Records Death Data
Opioids
Benzodiazepines
Stimulants
Barbiturates
Muscle Relaxants
Other
Number of prescriptions filled
Number of Controlled Substance Prescriptions Filled by Drug Type, NM, 2016
Source: New Mexico Prescription Monitoring Program
0 20 40 60 80 100 120
oxycodonealprazolam
fentanylhydrocodone
methadonediazepam
clonazepammorphine
lorazepamtramadolzolpidem
Overdose death involvements
Top Rx Drugs in Overdose Death, NM, 2016
Deaths may involve more than one drugSource: NM Office of the Medical Investigator
257,549 262,756274,956
258,120 247,273
175,266 180,082191,173
174,262 163,512
97,080 97,711 99,029 96,231 93,526
0
100,000
200,000
300,000
2016Q3 2016Q4 2017Q1 2017Q2 2017Q3
Patie
nts
Source: NM PMP *The PMP platform changed in Q4 2016
Controlled substance patients
Patients receiving opioids
Patients receiving benzodiazepines
Controlled Substance, Opioid and Benzodiazepine Prescribing, 2016-2017
26,047 26,364 25,46024,240
22,913
0
10,000
20,000
30,000
2016Q3 2016Q4 2017Q1 2017Q2 2017Q3
Patie
nts
Source: NM PMP *The PMP platform changed in Q4 2016
Patients with Concurrent Opioids and Benzodiazepines (>=10 days overlap), 2016-2017
High Dose Opioid Prescriptions, 2016-2017
50,114 48,986 49,42846,358
43,250
39,638 39,674 40,385 38,889 37,510
0
10,000
20,000
30,000
40,000
50,000
60,000
2016Q3 2016Q4 2017Q1 2017Q2 2017Q3
Pres
crip
tions
fille
d
Number of high dose (>=90 MME/day) opioid prescriptions excluding buprenorphine/naloxone
Number of high-dose(>=40 DME/day) benzodiazepine prescriptions filled
Source: NM PMP *The PMP platform changed in Q4 2016
Patients with Overlapping Prescriptions, 2016-2017
5,408 5,466
4,6644,854 4,678
3,299 3,3292,937 2,908 2,908
0
1,000
2,000
3,000
4,000
5,000
6,000
2016Q3 2016Q4 2017Q1 2017Q2 2017Q3
Patie
nts
Overlapping prescriptions of opioids from different prescribers (>=10 days total overlap)
Overlapping prescriptions of benzodiazepines from different prescribers (>=10 days total overlap)
Source: NM PMP *The PMP platform changed in Q4 2016
Patients with Multiple Prescribers and Pharmacies, 2016-2017 4 or more prescribers or 4 or more pharmacies in 3 months
4,0223,758 3,859
3,6473,435
0
2500
5000
2016Q3 2016Q4 2017Q1 2017Q2 2017Q3
Patie
nts
Source: NM PMP *The PMP platform changed in Q4 2016
Board of Dental Health Care
Board of NursingBoard of Osteopathic
Medical Examiners
Board of PharmacyBoard of PodiatryBoard of Psychologist
Examiners
Certified Nurse Midwives
New Mexico Medical Board
Total Opioid MME Filled, by Board, 2017 Q2
NM Prescribers with at least 20 patients who filled controlled substance prescriptionsSource: New Mexico Board of Pharmacy Prescription Monitoring Program
Board of Dental Health Care
Board of Nursing Board of Osteopathic Medical Examiners
Board of PharmacyBoard of Podiatry
Board of Psychologist Examiners
Certified Nurse Midwives
New Mexico Medical Board
Total Benzodiazepine DME Filled, by Board, 2017 Q2
NM Prescribers with at least 20 patients who filled controlled substance prescriptionsSource: New Mexico Board of Pharmacy Prescription Monitoring Program
Pharmacy naloxone
Medication Assisted Treatment
4,2824,669
4,872 5,0125,260
0
1000
2000
3000
4000
5000
6000
2016Q3 2016Q4 2017Q1 2017Q2 2017Q3
Patie
nts
Total Buprenorphine/Naloxone Treatment Patients, 2016-2017
Buprenorphine/naloxone patients (>=10 days)
Source: NM Prescription Monitoring Program
Key Interventions
Improve Prescribing Practices• Prescription Monitoring Program (PMP)
• 2016 Legislation requiring mandatory PMP use• Identify patients at risk, deter doctor/pharmacy shopping, and provide interventions• Strengthen and enforce licensing board rules/regulations• PMP may be linked to electronic health records and emergency department records
• Educational opportunities to get trained or retrained in pain management• Academic detailing – 1 on 1 sessions for providers
• NMDOH working with Workers’ Compensation Administration to improve their prescribing practices
• Guidelines• 2016 CDC Opioid Prescribing• NM Hospital Association emergency department
Increasing Access to Naloxone• 2016 Naloxone legislation passed• Statewide standing orders - Individual prescription no longer necessary
• Pharmacists• Law Enforcement• Schools
• Law Enforcement carry-and-administer naloxone• Criminal Justice (detention center) naloxone upon release• Harm Reduction
• Syringe services• Overdose prevention and education
• NMDOH working with Medicaid to ensure naloxone products are covered
Increase Medication Assisted Treatment (MAT)
• NMDOH determining how to track MAT, inpatient, and other types of outpatient treatment
• Buprenorphine/naloxone can be tracked using PMP• DEA can provide number of providers with waivers• Medicaid methadone patients
• Nurse practitioners and physician assistants can now obtain waivers for prescribing buprenorphine for opioid use disorder
• NMDOH facilitating MAT trainings for providers
Additional NMDOH initiatives
Surveillance and Targeting Strategies• NMDOH drug epidemiologists analyze data from various sources• Vital Records and Health Statistics
• Death Data• Office of the Medical Investigator
• Drug(s) involved in the death• Hospital discharge data
• Hospitalizations• Emergency Department data• Use of multiple data sources allows a better understanding of drug use, misuse,
and overdose• Data linkage is done between data systems, for example between the PMP and
death data together to provide picture of drug use in New Mexico• Data used to target overdose prevention strategies and interventions
Notifiable Diseases or Conditions• Notifiable condition means a disease or condition of public health significance required by
statute or these rules to be reported to the department of health (NMAC 7.4.3.13)• Emergency Reporting – immediate reporting to NMDOH
• Severe Infectious Disease• Acute Illness involving large #s of persons in same area• Intentional or accidental release of chemicals or biologic agents• Foodborne/Waterborne
• Routine – report within 24 hours to NMDOH• Infectious Disease• Tuberculosis• STDs• Occupational Illness and Injury• Adverse Vaccine reactions• Environmental Exposures• Injuries – includes Drug Overdose, firearm, traumatic brain injury, older adult falls
• NMDOH had drug overdose as a notifiable condition prior to this project but wants to provide services in addition to performing surveillance.
Concerns
• Involuntary, regulation-driven overdose referrals• People may not call 911 if they know reports are sent to “The State”
• So far, not an issue• Fear of police involvement is a valid concern, especially for those on probation/parole
• Patient privacy • Regulations allow NMDOH to request reports• NMAC 7.4.3. Control of Disease and Conditions of Public Health Significance
• 7.4.3.10 EMERGENCY DEPARTMENT REPORTING:• Paragraph B. Confidentiality: All emergency department visit reports are confidential. Disclosure to any person
of report information, except for disclosure of a notifiable condition for the purpose of prevention or control of diseases and other health conditions, is prohibited unless disclosure is required by law.
• Patients may believe their providers will treat them worse or fire them if they know about the overdose
• So far, not an issue
Implementation
• Developed case definition for drug overdose • Using ICD-10-CM T-Codes 36-50
• Emergency Department report criteria “Poisoning by, adverse effects of, and exposure to noxious substances including”:
• Overdose of Drugs• Wrong drug given or taken• Drug taken inadvertently• Accidents in the use of drugs• Medicaments and biological substances• Self Inflicted poisoning – accident or intentional
Case Definition
Implementation (continued)
• Individual experiences overdose• Shows up in emergency department• Hospital Staff (usually ED charge nurse) fills out report form• Secure fax sent to NMDOH• Drug overdose prevention coordinator receives report
• Checks 1 year PMP history• Contacts provider(s) and/or pharmacies, if necessary
• File securely sent to community partner for case management – referral• Partner agrees to: assess for level of care, accept into clinical care, harm reduction, or
other services• Refer to higher level of care as needed• Communicate outcomes to NMDOH
Drug Overdose Report Form• New report form
developed• Input from other
programs at NMDOH with notifiable conditions and ED staff
Drug OD Report-based Interventions
• Improve prescribing• Use the PMP to check controlled substance history• Contact prescribers• Contact pharmacies
• Expand access to naloxone• Hospital/ED based distribution
• Treatment• Link to treatment services: recovery support, etc.• Medication assisted treatment (MAT)
Improve Prescribing
• Decrease high risk prescribing• Upon review of PMP report, factors which prompt provider call:
• High dose >90 MME• Chronic > 12 weeks • Combo benzos and opioids• Overlapping opioids• Multiple providers/pharmacies• Early refills• Other questionable observations (cash, filling at pharmacies far from
residence, etc.)• Upon recognition of risk factor above, NMDOH contacts prescriber(s)
Naloxone
• How do we assure the individual who experienced opioid OD gets naloxone?
• Refer to local case management program• Provide medication directly to patient, family, or friend upon
discharge• Handing someone a paper prescription not ideal
• If not given product, patient should know where to get naloxone• Local pharmacy• Syringe services• Public Health Office• Community organizations
Treatment
• NMDOH screens OD report forms• ODs due to non-controlled substances or accidental misuse not
referred• Community partner accepts referral to asses for level of care
• Accept clients into clinical care• Provide harm reduction or other services as appropriate• Refer clients to higher levels of care as needed• Communicate to NMDOH the outcome of each referral
• Pathways Program (case management program)• RAC Health and Human Services• Care coordination across multiple pathways (SUD, pregnancy, behavioral,
social services, etc.)• Pathways can refer to medication assisted treatment providers
Successes
• Prescribers unware of OD – have been appreciative of notification• More motivation to follow up with patient sooner rather than later• Prescribers may use more caution when refilling opioids and benzos• Taper benzos and/or find alternatives• Reinforcement of providing naloxone – multiple visits to ED• ID patient misuse of opioids – contact pharmacy• Referrals to treatment – connected to substance abuse counseling• Naloxone being provided through community partners• Patients have not been fired from medical care providers
Challenges
• Reporting definition – confusion about what hospital should report• Buy-in from hospital staff• Timeliness of reports sent• Lag from time when OD report received to when patient is contacted by
community partner• Manual fax as opposed to electronic submission• Prescribers not returning calls• Patient contact info inaccurate• Naloxone distribution from hospital challenging• Not enough peer support and only used for select patients
Conclusions• NM overdose death rates did not change in 2017 compared to 2016 while
most other states had large increases• Benzodiazepine and methamphetamine OD deaths continue to increase• High risk prescribing decreasing gradually• Compliance with licensing board PMP regulations needs improvement• MAT use continues to increase• Naloxone dispensing from pharmacies is increasing• Prescribers are now being notified of fatal overdose if cause of death,
determined by OMI, lists active/recent Rx for controlled substance• We have more work to do!
