opening remarks governor brian sandoval’s opioid state...

Opening Remarks 9/22/2017

1

Governor Brian Sandoval’sOpioid State Action Accountability

Meeting

September 25, 2017

Opening Remarks

• Governor Brian Sandoval

Public Comment

• This public is asked to please limit remarks to3 minutes

• Kelly Marschall, Social Entrepreneurs, Inc.

• Sarah Boxx, Social Entrepreneurs, Inc.

Review of 2016 Prescription DrugAbuse Prevention Summit

Recommendations

Orienting to Results & CollectiveEfforts

• Working as a State toaddress a complexproblem

• Sharing a summary ofthe recommendationsby the 2016 Summit byTrack

Governor’s PrescriptionDrug Abuse Summit

• Held in August, 2016• 2-Day Event• Over 450 persons

from across theNevada attended toinform strategies andrecommendations


2

Track 1:PrescriberEducation

& Guidelines

Track 2:TreatmentOptions &

Third-PartyPayers

Track 3:

DataCollection &Intelligence

Sharing

Track 4:CriminalJustice

Interventions

Recommendations Made inFour Interrelated Tracks

Collective Impact: 5 Essential Elements

•• Common agendaCommon agenda

•• Shared measurementShared measurement

•• Mutually reinforcing activitiesMutually reinforcing activities

•• Continuous communicationContinuous communication

•• Backbone supportBackbone support

1. Design and Implement Data DrivenCollaborative Systems for Decision-Makingto Address the Crisis

2. Implement Public Awareness toEducate, Inform, and Engage the Public,Prescribers, Physicians, and Community-Based Organizations About the Crisis

3. Ensure Sufficient Infrastructure andResources to Address the Crisis

Summit Cross Cutting Themes How We Will Get There:Recommendations from the Summit

EnhancedInfrastructureand Resources

Funding and Resource Inputs

Data DrivenSystems

Educationand

Awareness

Policy Changes

Collaboration

Leveraging What’s Working Nationally & In Nevada

A. Prescribing GuidelinesB. Prescriber EducationC. Discharge Planning & ProceduresD.Oversight of Pain Management Clinics

Track 1: PrescriberEducation &Guidelines

1Components to be included:

Utilize CDC guidelines and adapt them to meetNevada’s needs

Incorporate close monitoring, and ensure thatguidelines extend beyond prescribers to pharmacists

Guidelines need to be developed/adopted in alignmentwith provider competency requirements

Examine lessons learned from Washington and otherStates that have adopted guidelines to determine whatlimitations and referral practices need to be in place

Look at Washington guidelines related to referralpractices

Prescribing Guidelines1A


3

• Julia Peek, Deputy Administrator, Division ofPublic and Behavioral Health, Department ofHealth and Human Services

Overview of Grant andState Funding

Adoption of prescribing mandates:

The adoption of prescribing guidelines needs tosupport – rather than supersede – the clinicalmanagement of individual patients

Patient needs related to pain management andaddiction treatment need to be distinct in the waythey are described, defined and treated

Medicaid, MCO’s and third party payers need to beactively involved in implementation design


Considerations need to be made related to multiple facets of apatient’s story – including stage of life, individual history andcircumstance, functioning, and whether pain is acute orchronic

Prescribers need reimbursement policies that align withguidelines and allow sufficient time for patient counseling andeducation

Adopted guidelines need to undergo regular revision toremain relevant, evidence-based and responsive to the needsof Nevada’s culture

Prior to adoption, 100% of licensed prescribers should havethe opportunity to review and provide feedback


Prescriber Training: The science behind pain management (including

genetic and social influencers) and alternativemethods to treatment A “hands on” approach to integrated care, where

pain is viewed in the context of other specialties andother disciplines (psychologists, psychiatrists, socialworker) Address provider-patient

relationship/communication, including empathyskills Patient assessment/risk assessment

Prescriber Education1 B

Curriculum and Continuing Education

Adoption of a “whole person” approach: Whentalking about pain, there is no one size fits all

Trauma-informed care

Weaning, substitution, effect of age onmedications, psychosocial dynamics,appropriateness of medications at variousstages of pain management


Curriculum and Continuing Educationo Need curriculum and CME based on CDC guidelines/NV

guidelines to be adopted

o Evidence-based education/training guidelines need tobe uniform across related disciplines

Implementation of the (ECHO model™) hub-and-spoke knowledge-sharing network andlearning community to educate and supportclinicians to provide excellent specialty careto patients in their own communities



4

Adopt a multidisciplinary approach to dischargeplanning that includes social workers, RNs, andreferral providers

Initiate MAT prior to discharge, as appropriate

Define the role of pharmacists in discharge plan,following 2015 guidelines of the College ofPsychiatric and Neurologic Pharmacists

Ensure that behavioral health issues are assessedand addressed in discharge plan

Discharge Planning andProcedures

1 C

Ensure that ER providers and staff have up-to-dateresource information for warm-hand offs tosupportive services Provide overdose death and hospital data back to the

prescribing clinician (link PDMP to hospital and deathdata) Ensure that information needed for successful

transitions in care is provided, including Naloxoneadministration and response, and collateralinformation from involved by-standers

Electronic bed capacity inventory forreferral/transfer to SUD/BH treatment


1 C

EMS and criminal investigation teams thatrespond to an overdose:

oImplement overdose response teams thatwork in partnership with recoverycommunities

Use PDMP to flag patients who have beentreated for overdose


1 C

No consensus on how pain management clinicsare, and should be, defined. Consensus on theserecommendations:• Involve medical board, pharmacy board, and other

prescriber licensing boards to determine how painclinics are defined

• Tie oversight to non-punitive education on guidelinesfor all prescribers and staff

• Incorporate review of how pain managementspecialists classify themselves in terms of boardcertification in the oversight process

Pain Management Clinics1D

2

A. Opioid ManagementB. Coverage for Non Opioid Pain Management

TherapiesC. Early InterventionD. Overdose Education & Naloxone Distribution

Track 2: TreatmentOptions & Third PartyPayers

Opioid Management

Unprecedented access to prescription drugs has led toan increased need for medication assisted treatmentthrough opioid treatment programs. Nevada should adopt guidelines for comprehensive

opioid treatment management across all payers Guidelines should be developed by reviewing what

other states/systems have already developed aroundthis issue and creating a customized version forNevada Guidelines should be established by a multidisciplinary

team

2 A


5

Opioid Management

Address Medicaid Barriers Billing for MAT is sometimes problematic as

there are not clearly understood billing codes Develop a Medicaid approved provider options

in rural parts of the state Reduce payment and administrative barriers to

Medicaid

2 A Opioid Management

Address Access Barriers Expand access to MAT within the criminal justice

field (institutions, parole, and after-care settings),including providing support to those that arehomeless Utilize existing policies (ex: suboxone waiver) to

expand access to MAT – this will require outreach toqualified providers and revised payment structure Eliminate barriers such as fail first

2 A

Opioid Management

Address Access Barriers Address workforce shortage issues (especially in the

rural areas) and expand alternative service optionssuch as telemedicine and mobile units Ensure patient centered care which allows the full

range of service options to meet each patient’sneeds Incentivize care coordination through appropriate

payment structure

2 A Non-Opioid TreatmentManagement

A wide range of non-opioid treatment options* should be madeavailable to meet the unique needs of each patient. If forced toprioritize therapies, options which should be offered include:

o Chiropractic

o Acupuncture

o Cognitive Behavioral Health

Each of these therapies should be clearly defined tocommunicate what kinds of care within each therapy are covered

Therapies offered should be supported by evidence-basedresults of success

*15 options identified at the summit

2 B

Non-Opioid TreatmentManagement

Enhance provider education, training and experiencewhich would support non-opioid treatment delivery

• Behavioral Health Providers need to understand the rolethey could play in pain management services

• Physicians need to know what non-opioid painmanagement services exist and how to connect patientsto those resources

Address the dis-incentives associated with physicians“prescribing” non-opioid treatment options (dispositionof clientele, client dissatisfaction, time associated withtreatment option which is not adequately reimbursed)

2 B Non-Opioid TreatmentManagement

Increase educational component totraining/licensing about the variety of therapyoptions available which support pain management

Need to develop a multidisciplinary team to supportMedicaid and solution implementation

Need to address compounding treatment/recoveryfactors such as housing and transportation

2 B


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Early Intervention

Expand Use of SBIRT among providers and withcomplimentary professionals

Encourage/require physicians issue screenings

Embed screenings into electronic health records andprovide training to support utilization

Pharmacist directed SBIRT

Establish a statewide forum for sharing best practiceinformation on SBIRT and integrated care

2 C Early Intervention

Use behavioral health tele-medicine withinprimary care settings/clinics who can conductSBIRT and other behavioral health services

Address federal regulations that limitcommunication efforts between behavioral healthand primary health care professionals

Resource directory geared towards healthprofessionals about community resourcesavailable to patients (Healthiernv.org)

Look at IMPACT model out of University of WA

2 C

Access to Care

Expand telemedicine options

Address transportation barriers

Case coordination needs to be provided as acomponent of comprehensive care. Peerleadership models also promote access to care

Partner with existing providers (trustedcommunity resources – like schools) to act as anaccess point

2 C Access to Care

Partner (with Universities) to secure resources andimplement mobile services in rural areas Examine Rural Veteran’s Programs in Oregon and

Washington as potential models for increasingaccess to care in rural areas Use of community health workers as a component

of care

2 C

Overdose Education &Naloxone Distribution

Reach priority groups for education and distribution Expand access to Naloxone:

o Make multiple naloxone doses available toindividuals who have been prescribed Naloxone sothat multiple family members have it available.

o Enable over the counter access to anyone wantingNaloxone.

o Ensure that treatment providers have access toNaloxone (homeless/substance abuse programs)

Ensure training and education is available to everyonewho may administer naloxone.

2 D3

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A. Prescription Drug Monitoring ProgramB. Empowerment of Nevada's Occupational

Licensing BoardsC. Law Enforcement Data SharingD. Public Health Data

Track 3: DataCollection &Intelligence Sharing


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Ensure Health Insurance Portability andAccountability Act (HIPAA) compliance between datasystems

Ensure a mechanism for State Boards to report backto PDMP

Facilitate access to lock in health plans

Mandate providers receiving state dollars sign up tosubmit data in PDMP and make this a requirement oflicensing

Evaluate requiring a second signature forprescription/pain specialists/behaviorists

PDMP3 A

• Boards all agree they need to do more and havebeen working more collaboratively. They arecrafting language for a bill draft and needLegislative support to:

– Shorten the time frame to obtain records andlengthen check in to a 60-day dispensinglicense

• Facilitate access to medical records forinvestigation

EmpoweringLicensing Boards3 B

• Address the issue of phantom prescribers, whoare licensees not on the books

• Boards will engage in a unified public awarenesscampaign general public, practitioners, andpharmacists

• The Boards have agreed to a website foranonymous complaints about prescribers or anyhealth care practitioner

• Identify trends, doctor shop by using PDMP

EmpoweringLicensing Boards3 B

Use a Fusion Center to model reports using de-identified data on trends (Look at NewHampshire model for their partnership withpublic health, law enforcement, etc.)

Create centralized data center with the technicalexpertise and resources for analyzing andextracting information specific to thepartners’/communities’ needs. Ensure data iscomplete, accurate, and useful, adheres toHIPAA and other privacy standards

Data (Joint Session on LawEnforcement Data Sharing)

3 C

Use data to drive policy and resourcedecisions; and help direct investigations.Data includes: Addiction analysis data Prescriber/payer data Coroner data re: over dose deaths

Examine what the Drug EnforcementAdministration (DEA) is doing in ClarkCounty and expand it statewide.


3 C

Utilize coroners, PDMP, and Public Health as astarting place to establish an agreement fordata sharing

Improve timeliness and distribution of data(e.g., death records, hospital over doses,Emergency Medical Services/Fire data re:overdoses and naloxone distribution, etc.)

Add local health departments into theinformation sharing partnerships


3 C


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Evaluate feasibility of implementing a dashboard(in development through DPBH)

There is a need for both identified and de-identified data and agreements about how data iscollected and reported

Work with coroners to improve the reporting theirdata related to overdoses

Collect data from PDMP, and Public Healthincluding local health districts and workforce data

Use predictive analytics for best practiceidentification and public education

Public Health Data3 D

• Promote use of the Health Insurance Exchange(HIE) to obtain more/better data with greaterparticipation

• Integrate data system and reporting consistently,so data sets ask the same question acrossmultiples systems

• Use memorandums of understanding (MOU) toput formal data sharing agreements into place

• Utilize shared resources across state systems tostrengthen data collection and sharing

• Allow access for research and evaluation

Public Health Data3 D

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A. Deterrents for Criminal ActivityB. Prescription Drug DisposalC. Law Enforcement Data SharingD. Sequential Intercept Model

Track 4: CriminalJustice Interventions Amend Nevada Statute to mimic federal

thresholds for trafficking Schedule 1substances

Lower thresholds for determining felonyclasses (suggested levels: 4 to less than 12grams – C felony, 12- 28 grams – B felony, 28grams or more – A felony)

In addition to changes in weights, determinenumber of pills and lowered pill quantity

Deterrents forCriminal Activity

44 AA

Expand penalties – conspiracy is a C felonyand considered too low

Enhance penalties for medical/otherprofessional provider convicted of crime[related to opioids]

Allow aggregation in order todemonstrate/prosecute conspiracy; expandpenalties for conspiracy


44 AA

Suggested approaches to expand lawenforcement partnerships and data access tobetter target over-prescribers,traffickers/criminal include:o Develop policies and procedures for using PDMP

database to send alerts and help investigateoverprescribing. Could use National CrimeInformation Center (NCIC) policies/procedures asexample

o Add state and local partners to participate on theDEA task force to connect cross state trafficking


44 AA


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Suggested approaches to expand lawenforcement partnerships and data access(con’t)

o Build on and formalize partnerships betweenagencies, provide a single point of contact foreach agency. Use the High Intensity DrugTrafficking Area program (HIDTA) framework.Formalize how executive supervisorscommunicate


44 AA

Nevada has a robust year-round prescription drugtake back program that is run through the State’smany prevention coalitions. Nevada has struggled tofind a sustainable solution for prescription drugdisposal

There was agreement that Nevada should adopt astatewide strategy for sustainable, effective drugdisposal

A variety of disposal options and suggested policiesand practices were outlined for future evaluation

Drug Disposal44 BB

Covered under Track 3: Data Collection and IntelligenceSharing

Law EnforcementData Sharing

44 CC

Promote successful implementation of SIM

Leverage Certified Community BehavioralHealth Clinics (CCBHCs)

Leverage presumptive eligibility opportunitiesfor enrollment and Targeted CaseManagement (TCM)

Certified peer mentors/navigators

Sequential InterceptModel (SIM)

44 DD

Thank You!

More Information about the Summit:

Contact Information

Social Entrepreneurs Inc. 775.324.4567Project Contact: [email protected] or [email protected]

http://gov.nv.gov/uploadedFiles/govnvgov/Content/News_and_Media/RX/FinalSummitReport.pdf

• Julia Peek, Deputy Administrator, Division ofPublic and Behavioral Health, Department ofHealth and Human Services

Overview of Grant and StateFunding


10

Helping People. It’s who we are and what we do.

Brian SandovalGovernor

Richard WhitleyDirector

State of Nevada

Department of Health and Human Services

High level overview of grant and state fundingfor opioid abuse prevention and treatment activities

Julia Peek, MHA, CPMDeputy Administrator, Community Services

September 25, 2017

56Helping People. It’s who we are and what we do.

Nevada’s Funding VisionNevada’s Funding Vision

Transparency Evidence-based

Infrastructure Building

Data-drivenSustainability

Nevada-centric

SystemicCollective Impact

Prevention for States (PFS)• Grantor: Centers for Disease Control and

Prevention• Current funding period: 8/1/16-7/31/19• Current amount: $369,450, with an additional

$789,182 supplement• Primary activities:

Expand and improve proactive reporting Conduct public health surveillance with PMP data and disseminate quarterly reports Identify and provide technical assistance to high-burden communities and counties to address

problematic prescribing Create an opioid data dashboard Link deaths, hospitalizations, and prescriptions of individuals Create mapping of funded activities to find gaps Policy analysis and implementation CDC’s statewide media campaign Link health data sets and law enforcement data sets


Enhanced State Surveillance of Opioid-InvolvedMorbidity and Mortality (ESOOS)

• Grantor: Centers for Disease Control andPrevention

• Current funding period: 9/1/17-8/31/19

• Current amount: $387,763

• Primary activities: Increase timeliness of aggregate nonfatal opioid

overdose reporting

Increase the timeliness of fatal opioid overdose and

associated risk factor reporting

Disseminate surveillance findings to key stakeholders

working to prevent or respond to opioid overdoses


State Targeted Response to the Opioid Crisis (STR)• Grantor: Substance Abuse and Mental Health Services

Administration

• Current funding period: 5/1/17- 4/30/19

• Current amount: $5,663,328

• Primary activities: Treatment Infrastructure (Hub and Spoke Model)

Law enforcement collaboration

Naloxone purchase and distribution center

Training and education activities for health care providers,

who care for people with opioid use disorder or who are at

risk for opioid overdose.

Linkage to treatment services , including mobile outreach


Strategic Framework Partnership for Success (PFS)

• Grantor: Substance Abuse and Mental Health ServicesAdministration


• Current amount: $2,207,505

• Primary activities: Reduce the nonmedical use of prescription drugs among

persons 12 and older and the consequences that result

from such use, with a focus on persons ages 12-25

Implement a comprehensive prevention strategy through

community education, social marketing/media, physician

training, and drop boxes/Take Back events through 13

funded coalitions



11

Substance Use Block Grant (SUBG)• Grantor: Substance Abuse and Mental Health

Services Administration• Current funding period: 4/1/17-9/30/19• Current amount: $16,890,245 (total award, not

just opioid efforts)• Primary activities:

Target efforts to encourage the use of PrescriptionDrug Monitoring System by prescribers

Provide education on the use of naloxone andeducation on the Good Samaritan Law

Direct treatment services Jail diversion


Nevada Rural Opioid Overdose Reversal Program (NROOR)

• Grantor: Health Resources and ServicesAdministration

• Current funding period: 9/1/15-8/1/17• Current amount: $99,538• Primary activities:

Provide Naloxone administration training to EMSpersonnel

Provide initial stock of Naloxone to EMS services thatdid not have it in their formulary

Provide patient education, substance abuse treatmentreferrals, and intranasal Naloxone to opioid overdosepatients upon discharge


Attorney General Volkswagen Settlement

• Current funding period: 10/17 – 6/19

• Primary activities: Design and implement a program that promotes awareness and understanding

of the dangers and consequences of prescription drug misuse

Connect those at risk of developing prescription drug dependency or abuse to

preventive services

Provide education on the dangers of prescription misuse, neonatal exposure,

youth accidental overdose

Provide resources for chronic pain management and preventative service

programs to avert prescription drug misuse and dependency.

Provide the locations of where unused prescription drugs can be taken for

disposal and destruction.

Promote awareness of proper storage of prescription drugs

Naloxone for law enforcement


Harold Roger Prescription Drug Monitoring (RenoPolice Department)

• Grantor: Bureau of Justice Assistance


• Current amount: $492,993

• Primary activities: Analyze PDMP data in order to identify high-risk

populations, geographic hotspots, and the

relationship between heroin arrests and opioid

prescriptions


Nevada State General Funds

• SFY 18/19

• Serves as maintenance of effort (GFUND) forSUBG

• Primary activities:

– Direct treatment services

– Primary prevention services

– Jail diversion


Funding based on Priorities

• Harold Rogers (BJA)• STR (SAMSHA)• PFS (CDC)• ESOOS (CDC)• SUBG (SAMSHA)

• STR (SAMSHA)• Settlement (AG)• SUBG (SAMSHA)• General Fund• Harold Rogers (BJA)

• STR (SAMSHA)• SUBG (SAMSHA)• General Fund• NROOR (HRSA)

• STR (SAMSHA)• PFS (SAMSHA)• PFS (CDC)• SUBG (SAMSHA)• NROOR (HRSA)• Settlement (AG)

PrescriberEducation

andGuidelines

TreatmentOptions andThird Party

Payers

DataCollection

andIntelligence

Sharing

CriminalJustice

Interventions



12

Helping People. It’s who we are and what we do. 67

Contact Information

Julia Peek, Deputy Administrator, Community ServicesT: (775) 684-5280 |E: [email protected]

Progress Reports

• Legislation and Policy

• Data Collection and Sharing

• Naloxone

• Substance Abuse Treatment

• Prescription Drug Take Back and Disposal

• Oversight of Controlled Substance Prescribing

• Law Enforcement

Legislation and Policy

• Summit Recommendations Areas

– Track 1: Opioid Education

– Track 2: Prescribing Guidelines

– Track 3: Empowerment of Occupational LicensingBoards

– Track 4: Criminal Deterrent

Data Collection and Sharing

• Summit Recommendation Area

– Track 3: Data Collection and Intelligence Sharing


Brian SandovalGovernor

Richard WhitleyDirector

State of Nevada


Data Collection and Intelligence Sharing

Kyra Morgan, MSChief Biostatistician


Julia Peek, MHA, CPMDeputy Administrator, Community Services

September 25, 2017

PrescriberEducation

andGuidelines

TreatmentOptions andThird Party

Payers

DataCollection

andIntelligence

Sharing

CriminalJustice

Interventions


Prescription Drug MonitoringProgram

Empowerment of Nevada’sOccupation Licensing Boards

Law Enforcement DataSharing

Public Health Data

Major Themes of Summit for DataCollection and Intelligence

Sharing


13

Former CDC Director, Tom Freidannoted Nevada as one of the model

states that improved policy to addressthe opioid issues…

this is also true when it comes tocommunication and data sharing


Updated Dataon Nevada’s

OpioidProblem

74

“*Data are preliminary andsubject to changes.”

Data Source? Methodology?Timing?


Scope of the Opioid Problem

Mortality

Hospitalizations

Prescriptions

76

LawEnforcement

Treatment

EmergencyMedicalServices

geographically demographically


PoisonControl

Prescribing Patterns

77

Opioid Painkiller Prescriptions per 100, 2011-2016

*definitions vary slightly between US and NV opioid prescriptions and populations used to calculate rates(Sources: Guy et al., 2017; Office of Public Health Informatics and Epidemiology; Prescription MonitoringProgram)

NV (PMP)

US

NV (CDC Estimates)

Helping People. It’s who we are and what we do.78

Opioid Painkiller PrescribingRates Per 100, by County, 2016

County Rate

Carson City 105.4

Churchill 106.8

Clark 84.3

Douglas 102.0

Elko 71.7

Esmeralda 72.5

Eureka 92.7

Humboldt 75.5

Lander 85.2

Lincoln 60.7

Lyon 130.0

Mineral 158.2

Nye 155.6

Pershing 69.5

Storey 146.9

Washoe 87.5

White Pine 99.9

Statewide 87.5

(Sources: Office of Public HealthInformatics and Epidemiology;Prescription Drug MonitoringProgram)



14

EmergencyMedicalServices

79

Number of EMS Calls Requiring

Naloxone Administration by County,

2014-2016

County Number

Carson City 49

Churchill 1

Clark 1089

Douglas 14

Elko 47

Esmerelda 0

Eureka 1

Humboldt 0

Lander 0

Lincoln 0

Lyon 86

Mineral 3

Nye 6

Pershing 0

Storey 3

Washoe 513

White Pine 4


Hospitalizations


3,8994,268

4,582 4,5905,099

6,609

8,210

599 646 600 653 576 578 576

2,2942,526

2,824

3,532

3,963

5,074

6,782

779 791 766 732 749 756 791

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2010 2011 2012 2013 2014 2015 2016

Opioid-Related Hospitalizations (ED and IP), by ICD Group, Nevada Residents, 2010-2016

Opioid Related Disorders

Poisonings

Opioid Related Disorders

Poisonings

Poisonings are defined by an ICD 9/10 code of 965.0/T40.0-T40.4, T40.6 as the primary diagnosis.Opioid Related Disorders are defined by an ICD 9/10 code of 304.0/F11.2, 304.7, 305.5/F11.1, F11.9, E850.0-E850.2 as any contributingdiagnosis.Sources: Office of Public Health Informatics and Epidemiology, Hospital Inpatient and Emergency Department Billing Data. Data collected bythe Center for Health Information Analysis.

Mortality

81

Opioid-related Deaths per 100,000, 2011-2016

*Data are preliminary and subject to change**Includes ICD-10 codes as underlying cause of death: X40-X44, X60-X64, X85, Y10-Y14, as contributing cause of

death: T40.0-T40.4, T40.6(Sources: CDC Wonder; Office of Public Health Informatics and Epidemiology; Electronic Death Registry System)

NV

US


Opioid-related Death Rates, by Race/Ethnicity, 2015

(Sources: Office of Public Health Informatics and Epidemiology; Electronic Death Registry System)

Hispanic/Latino

White

Black

Asian/Pacific Islander

American Indian/Alaska Native

Mortality

Opioid-related Death Rates, by Age, 2015

(Sources: Office of Public Health Informatics and Epidemiology; Electronic Death Registry System)

<15

15-24

25-34

35-44

45-54

55-64

65+


Nevada’sDashboard


Ongoing Data Collectionand Sharing Information

84


15

Public Health Data• Great opportunities to improve analytics

through CDC grants and additional datasets– Coroner data

– PDMP

– EMS

• Overdose Reporting, AB 474– Physicians, Nurses, Veterinarians, and Physician

Assistants will be required to report.

– Internal review of draft regulations occurring now,then promulgation process will start.

– This will address the timeliness issue with thecurrent datasets.


Prescription Drug Monitoring Program• Monthly transmission• Ability to:

– determine first versus reoccurring prescriptions;– match data to hospitalizations and mortality;– assess prescribing patterns;

• Ex: Nye County has the highest prescribing rates forresidents. Between 2011 and 2016, there were 357,038total prescriptions written for Nye County residents. Weare analyzing which prescribers are most likely toprescribe to Nye County residents.

– assess possible “doctor shopping” behaviors; assessif education/outreach to prescribers if impactingtheir prescribing behaviors, and,

– develop “report cards” for prescribers.


Sharing of data between lawenforcement and public health

• Two main purposes:– Situational awareness: identify arrests or encounters

related to opioids and share health data with lawenforcement partners

– Ensure continuity of care at reentry

• Sharing of data successfully with:– Lyon County Detention Center (weekly),

– Carson City Detention Center (annually, asrequested),

– Nevada Department of Corrections (annually), and

– Nevada Division of Parole and Probation (monthly)


Sharing of data between lawenforcement and public health

• Challenges:– Periodicity

– Missing variables that may be helpful to describe theissue and link to treatment services

• Next Steps:– Proposed regulations to allow for data sharing - LCB

File No. R084-17. Will eliminate the need for DUAs.

– Determine if a single data system can be used to sharedata and refer to treatment.

– Formally use Fusion Center for information sharing

– Shorten time-frames for analysis and reporting


Helping People. It’s who we are and what we do. 89

Contact Information

Julia Peek, Deputy Administrator, Community ServicesT: (775) 684-5280 |E: [email protected]

Kyra Morgan, Chief BiostatisticianT: (775) 684-4161 |E: [email protected]

Naloxone

• Summit Recommendations Area

– Track 2: Overdose Education and NaloxoneDistribution


16

The Nevada Rural Opioid OverdoseReversal (NROOR) Project:

Successes and Lessons Learnedin implementing a

HRSA-funded naloxone program

Project Personnel

• Karla D. Wagner, Ph.D., Associate Professor, NROOREvaluator– [email protected]

• Christopher E. Marchand, M.P.H., NROOR and Project ECHOProject Director

– [email protected]

• Evan Klass, M.D., Senior Associate Dean, Office of StatewideInitiatives, NROOR Medical Director

• Bobbie Sullivan, Education Coordinator, Emergency MedicalSystems

Funding: HRSA 15-146

Partnership members

• University of Nevada, RenoSchools of Medicine andCommunity Health Sciences

• Nevada Department of Health andHuman Services (State EMSProgram)

• Nevada Rural Hospital Partners

• Desert View Hospital (lead granteeand participating hospital)

• South Lyon Medical Center(participating hospital)

• Grover C. Dils Medical Center(participating hospital)

• Mt. Grant General Hospital

Context

• Rural areas in the US experiencing dramatic increases inopioid overdose

• 2015 HRSA Rural Opioid Overdose Reversal RFA to fund:– Purchase and placement of opioid overdose devices (i.e.,

naloxone) in rural communities

– Training of licensed healthcare professionals and emergencyresponders

• Recently passed SB 459 authorized BLS EMS providers(e.g., EMTs) in Nevada to administer naloxone

NROOR Project Aims

1. Purchase naloxone for rural EMTs working in BasicLevel Services (BLS) Agencies

2. Train rural EMS providers and other healthprofessionals in overdose recognition and response

3. Provide take-home naloxone for rural patientsreceiving care for overdose in rural hospitals

4. Demonstrate improved and measurable healthoutcomes among rural patients being treated by ruralEMS and healthcare professionals

Project Service Areas:

• Esmeralda County

• Eureka County

• Lincoln County

• Lyon County

• Mineral County

• Nye County

• White Pine County


17

AIM 1: PURCHASE NALOXONE

Purchased:

• 500 prefilled syringes of naloxone & 2,500 IMneedles

• 156 IN NARCAN kits for ED discharge

AIM 2: EMT TRAINING EVALUATION

Methods

• State EMS delivered training in opioid overdose responseand naloxone administration to 117 EMTs in participatingagencies

• Anonymous pre-/post-test surveys collected demographicinformation, knowledge and attitudes about overdose,naloxone, and SB 459

• Evaluation plan included collecting data from state EMS datasystem on patient outcomes (e.g., time to naloxoneadministration, patient status, etc.)

Results

117 EMTs trained fromFebruary – April 2016

Median years served as EMT =5 (range: 0-35)

85% were volunteer EMTs

Results: Knowledge & Attitudes

• Significant improvement in overdose knowledgescores, though overall knowledge of overdosesymptoms was already high (most >80% correct)

• Significant improvement in naloxone knowledge scores– To be expected, since EMTs were newly authorized to use

naloxone via SB459

• Significant improvement in self-assessed overdoseresponse competence and reduction in overdoseresponse concerns


18

Results: SB 459 Knowledge

Only 37.6% had heard of SB459 before the training inSpring 2016

50

18

0 20 40 60 80 100

Persons at risk, witnesses, LEOs, EMTs,paramedics

Who is allowed to possess naloxone? (% correct)

Pre Post

*

* P <0.05

Results: SB 459 Support

65

89

31

48

82

24

0 20 40 60 80 100

Allowing family members, friends to administernaloxone in the event of an overdose?

Allowing first responders to administer naloxone inthe event of an overdsoe?

Providing limited immunity from prosecution forsimple drug possession to anyone who calls 911 in

the event of an overdose?

% of Respondents Expressing Support for

SB 459 Naloxone Provisions

Pre Post

*

* P <0.05

AIM 3: PROVIDE TAKE HOMENALOXONE FOR ED DISCHARGE

Take home naloxone for ED discharge

• Hospitals were hesitant to implement take homenaloxone distribution upon ED discharge– Two hospitals did some (~12 doses distributed, maybe

more)

• Logistics of standing orders & distribution protocolswere challenging

• Lack of information and/or concerns related toliability protections and other provisions in SB 459

AIM 4: DEMONSTRATE IMPROVEDPATIENT OUTCOMES

Results: Patient Outcomes

• Based on review of available NEMSIS data andcalls to participating agencies, only 5 doses ofnaloxone administered by NROOR EMTs sinceSpring 2016

• Calls to agencies and interviews with EMTsongoing– Data suggest they are not being called to opioid

overdose emergencies with the expected frequency


19

CHALLENGES ANDSUCCESSES/LESSONS LEARNED

Successes: Purchased Naloxone

• Modeled our application on previous grants tobuy AEDs for rural communities

• Though the RFA appeared focused on firstresponders, we successfully included distributionof take home naloxone for ED discharge

• Purchased >500 doses of naloxone (most toexpire November 2017)

Successes: EMT Training

• 117 rural EMTs trained over 2-3 week period

• Successful partnership between UNR and State EMS todeliver and evaluate training

• Evaluation results– Statistically significant improvement in almost all naloxone

knowledge questions

– Opioid overdose competency and concerns scales showedsignificant improvement

– Knowledge of and support for naloxone provisions inSB459 increased (though support is not overwhelming)

– Favorable review by EMTs

Challenges: Funding logistics

• HRSA RFA required partnership with a ruralentity

• While this was an innovative partnership,administrative and logistical issues slowedimplementation

• Naloxone purchased in bulk and set to expirethis fall

Challenges:Lack of SB459 knowledge and hesitance from

some prescribers

• “Not on my license”

– Despite liability protections in SB 459, some doctorsdidn’t know about or trust the law, resulting in hesitanceto write standing orders and/or facilitate distribution

• Now in 2017, knowledge about SB 459 amonghealth care providers and prescribers is still low

– Don’t know, don’t understand, or don’t trust

• More information and interpretation could reassureproviders

Lesson Learned:Need Better Data

• HRSA proposal was written using statewide hospitalbilling data, based on ER admissions and opioidoverdose deaths

• Though we established the significance and saw aneed, the experience of EMTs in the NROOR serviceareas does not appear to match– Only 5 doses of NROOR naloxone had been administered

– Data suggest few NROOR EMTs encounter opioid overdosein their regular practice

• Ongoing surveillance and will help better targetresources


20

Lessons Learned: Need CentralizedCoordination

• NROOR was a one-time, one-year grant, partnership betweenUNR, EMS, and hospitals

– Need a plan for sustainability

• Lack of knowledge among providers still an issue that requirescoordinated communication and reassurance

• Unclear where parties should seek information about statewideopioid overdose response, interpretation of laws, guidance onprocedures/protocols for take home naloxone and distribution

• Centralized coordination would help support sustainable andintegrated response

NALOXONE ACCESS EFFORTS

Opportunities for expanded access to naloxone

Target population Strategies Considerations

High risk populations(drug users, OD patients,recent detox orincarceration)

Distribution through CBOs,jails, treatment centers,health departments, EDsPharmacy sales

Prescribers need more info &reassurance about SB459Prescribers need models for standingordersCost to purchase at pharmacies

Chronic pain patients Co-prescriptionPharmacy sales

Need to implement risk screeningNeed co-prescribing protocols

Uniformed firstresponders

Equip with naloxone Alleviate liability concernsNeed data on who arrives first(targeted deployment)More info about 911 Good Sam

Bystanders (friends,family members, othersin position to assist)

Distribution through CBOs,treatment centers, healthdepartmentsPharmacy sales

More information about who shouldcarry, how to obtainCost to purchase at pharmacies

Statewide Naloxone Distribution Update

• Redistribution of NROOR Naloxone

• Establishing Community Partners for Distribution

• Virtual Dispensary

Redistribution of NROOR Naloxone

• 400 prefilled syringes distributed to rural BLS agenciesbased on EMS data and hospital ED data

• Post-project naloxone inventory indicates unreliabledata used for distribution plan

• With only 5 doses of naloxone administered by ruralEMTs, it highlights the need for improved datacollection and reporting systems

• Remaining NROOR naloxone will be redistribute toTrac-B Exchange in Las Vegas and Northern NevadaHOPES in Reno to be used before it expires

Establishing Community Partners forNaloxone Distribution

• Trac-B Exchange

• Northern Nevada HOPES

• Clark County Correctional Facility

• Law Enforcement and Court System

• Community Paramedicine


21

Virtual Dispensary

• Innovative resource that will prevent maldistribution ofnaloxone

• Participating organizations will have the appropriateformulary stock of naloxone at all times

• Naloxone is much less likely to expire without being used

• Efficient use of resources – No need for Nevada to store orship naloxone, and funds are spent wisely leaving morefunding available for other initiatives

Provider Education

• NROOR focus shifting to academic detailing and otherprovider education activities (SB 459 & AB 474)

• Project ECHO Nevada:– Expand existing Pain Management ECHO clinic from once

per month to twice per month

– Launched Medication Assisted Treatment (MAT) ECHOclinic September 27th, it will take place twice per month

– ECHO Nevada infrastructure remains available as a rapidinformation dissemination resource – legislation andregulation updates, public health emergencies, sharing ofbest practices

Conclusion: Major contributions of NROOR

• Increased awareness & educational moments– Trained 117 EMTs– Purchased naloxone

• Statewide and national visibility• Created a model that can be modified based on lessons

learned– Bulk naloxone purchase set to expire“virtual” naloxone

dispensary center

• SAMHSA STR building upon and expanding NROORefforts as appropriate– Naloxone access– Provider education

Substance Abuse Treatment


– Track 1: Discharge Planning

– Track 2: Early Intervention

Update on Nevada’s Efforts to Build a SustainableUpdate on Nevada’s Efforts to Build a Sustainableand Sufficient Treatment Infrastructureand Sufficient Treatment Infrastructure

Governor’s Opioid State Action AccountabilityGovernor’s Opioid State Action AccountabilityTaskforceTaskforce

September 25, 2017September 25, 2017

Department of Health and Human Services 125

Stephanie Woodard, Psy.D.DHHS Senior Advisor on Behavioral Health

Opioid State Targeted Response (STR)Grant

• $5.6M Awarded

– 80% Treatment

– 20% Prevention

– This funding is to support states to build theinfrastructure for long-term sustainability

– Prevention funding is targeted; secondary andtertiary, not primary

• Grant funding cycle runs May 2017-April 2019


22

Needs Assessment Development

• Medicaid

• Emergency Management

• Geo-mapping Prescription MonitoringProgram

• Opioid Surveillance Reports

• Prescriber Survey

• Other data sources as they become available


Key ActivitiesNevada’s Opioid STR Grant included several promising and best practices tobe implemented to meet the goals of the grant for the prevention andtreatment of Opioid Use Disorder. This funding opportunity allows Nevada toaddress the unique needs of its communities and establish a sustainable,coordinated, recovery-oriented system of care using:• The Collaborative Opioid Prescribing Model within a Hub and Spoke

System,• Overdose response and treatment engagement programs with peer

supports,• Overdose education and naloxone distribution,• Prescriber education and expansion of office based opioid treatment,• Coordinators for Perinatal Addiction Treatment and Law Enforcement,• Enhanced data collection (WITS) and information sharing between public

health and law enforcement,• Maximizing existing resources including Medicaid reimbursement.


Integrated Opioid Treatment and Recovery Centers

IOTRC to provide at a minimum

Formal Written Care Coordination Agreements to

Provide (IOTRC may choose to offer these services

internally)

● Behavioral Health Screening/Assessment

● Medical Evaluation

● FDA Approved Medication for OUD Treatment

● ASAM Level 1 Ambulatory Withdrawal

Management

● Toxicology Screening

● ASAM Level 1 Outpatient

● Overdose education and naloxone

distribution

● Psychiatry

● Mobile Recovery

● Peer/Recovery Support Services

● Care Coordination

● Supported employment

● Enrollment into Medicaid, TANF, SNAP, WIC

● Engagement with criminal justice entities (e.g.

police, judicial, correction)

● Opioid Treatment Provider for Methadone

● ASAM Level 3.2 and Level 3.7 Withdrawal

Management

● OB/Perinatal providers

● Office-Based Opioid prescribers

● ASAM Level 3.1 and Level 3.5 Residential

Services

● Transitional Housing per SAPTA Division

Criteria

● COD and other Community-based service

providers

● Wellness Promotion

● FQHC partnership

● HIV/Hep C Testing


Integrated Opioid Treatment and Recovery

Centers

DHCFP – MCO’s

Required contract changes

Based on ASAM

Formal Care Coordination Agreements

May be OTP, FQHC, CCBHC

Requires:

Provider standards

Certification

Cross-walk to reimbursement

Establish quality/outcome measures

Develop payment methodology

Propose in DHCFP FY 2019 Budget

IOTRC

FQHCsOBOTSubstanc

e AbuseTreatme

ntProvider

Withdrawalmanagement: 3.5and 3.7

InpatieInpatient andresiden

tialservice

s

Transitional

Housing

OpioidTreatmentProgram/Methadon

e Unit

CCBHC

Education, Training, and Technical Assistance

Prescribers• Academic Detailing for Naloxone Co-Prescribing• Project ECHO: Non-pharmacological Treatments for

Pain• Project ECHO: Medication Assisted Treatment• AB474 Prescribing Guidelines and Patient Information• Prevention and Treatment of Neonatal Abstinence

Syndrome• Effective Use of MAT in an Opioid Dependent

Population**SAMHSA Sponsored


Education, Training, and Technical Assistance

First Responders, EMS, and Law Enforcement

• Overdose Education and Naloxone Distribution

• Good Samaritan Law

• Partnership with the LEAD program in Las Vegas

Judicial System

• Enhancing Court Efficacy Through EmergingAddiction Science: Justice Leaders System ChangeInitiative (Reno 9/26-28; Vegas December 2017)



23

Emergency Department/InpatientDischarge

Ensure individuals are provided appropriate follow-up after dischargeto reduce mortality

• Appropriate discharge requirements (HCQC)• Determine feasibility and acceptability of hospital

based interventions (overdoseeducation/naloxone distribution; buprenorphineinduction; screening and referral to treatment;peer supports)

• Mobile Recovery Outreach Teams-Urban• Community Paramedicine for post-acute follow-

up-Rural


Overdose Education/Naloxone Distribution

Distribute Naloxone to individuals with high-risk foroverdose

• Overdose survivors; Release/discharge from controlledenvironment following detox: jails, detox facilities,residential treatment centers, prison; Individuals whoself-identify as at-risk: i.e. needle exchanges

• Determine community based organizations to store anddistribute

• Develop a Naloxone Virtual Dispensary

• Coordinate efforts with AG’s Office for law enforcement*


Data and Information ExchangeIncrease data and information sharing between public health andlaw enforcement

• Law Enforcement Coordinator for AG’s office

• EMS EHR*

• AB474 Regulation Development*

Data collection and analysis on outcomes: Treatment EpisodeData Set (SAPTA)

• On-boarding of WITS data repository and billing/claims system

Streamline Certification Applications

• On-board CLICS system for on-line certification application


Treatment Policy Issues

Division of Health Care Finance and Policy

Technical bulletin for Medication AssistedTreatment

https://www.medicaid.nv.gov/Downloads/provider/web_announcement_1447_20170921.pdf


Buprenorphine/Naloxone

• To initiate therapy:

Covered without Prior Authorization (PA)approval for an initial prescription of seven daysor less.

An ICD diagnosis related to opioid dependencemust be written on the prescription andtransmitted on the claim.


• To re-initiate therapy

Buprenorphine/Naloxone will be coveredwithout PA approval to re-initiate therapy for aprescription of seven days or less for recipientswith a gap in treatment.

An ICD diagnosis related to opioid dependencemust be written on the prescription andtransmitted on the claim. .


24

Buprenorphine/NaloxonePrior authorization approval is required to exceed the seven-day limit.Approval will be given if all of the following criteria are met anddocumented:Nevada Medicaid encourages recipients to participate in formalsubstance abuse counseling and treatment.a. The recipient is 16 years of age or older; andb. The recipient has a diagnosis of opioid dependence; andc. Requests for a diagnosis of chronic pain will not be approved; andd. There is documentation the recipient has honored all of their

office visits; ande. The medication is being prescribed by a physician with a Drug

Addiction Treatment Act (DATA) of 2000 waiver who has a unique“X” DEA number; and


• All of the following are met:

• 1. The recipient will not utilize opioids,including tramadol, concurrently with therequested agent; and

• 2. If the recipient is currently utilizing anopioid, medical documentation must beprovided stating the recipient will discontinuethe opioid prior to initiation of buprenorphineor buprenorphine/naloxone.


• g. Requests for buprenorphine will be approved ifone of the following is met:

• 1. The recipient is a pregnant female;• 2. There is documentation that the recipient is

breastfeeding an infant who is dependent onmethadone or morphine;

• 3. The recipient has had an allergy to abuprenorphine/naloxone; or

• 4. The recipient has moderate to severe hepaticimpairment (Child-Pugh B to C)

Buprenorpine/Naloxone

• Requests that exceed the quantity limit mustmeet all of the following:

• 1. There is documentation in the recipient’smedical record that the requested dose is thelowest effective dose for the recipient; and

• 2. The treatment plan has been provided.

Prior Authorization approval will be for one year.

Medicaid Services Manual Chapter 1200 Appendix A Page 50

Buprenorpine/Naloxone –Managed Care

• Each MCO requires a prior authorization andhas a quantity limit of 7 days there aredifferent nuisances between each MCO.

• The Drug Utilization Review Board of Nevadawill work to continually align criteria acrossFFS and all three MCO plans.


Medication Assisted Treatment Access

MAT Technical Assistance from SAMHSA

Designation of Dr. DiMuro as State OpioidTreatment Authority

Change in Division Criteria NAC 458.118

MAT access in all certified programs

Development of IOTRC certification

Treatment Episode Data modernization



25


Plan of Safe Care

Ensure access to care for all women in need oftreatment

Develop treatment programs for pregnant andparenting women with treatment and recoveryneeds

Support efforts related to NAS safe discharges


Contact Information

Stephanie Woodard, Psy.D.

DHHS Senior Advisor for Behavioral Health

Opioid STR, Project Director

CCBHC, Project Director

[email protected]



– Track 4: Prescription Drug Disposal

Prescription Drug Take Backand Disposal

NevadaPrescription DrugTake Back Efforts

Governor’s Opioid StateAction Accountability

Taskforce

September 25, 2017

JTNN Coalition (Washoe County) began PrescriptionDrug Round Ups in October 2009 with 39,471 pillscollected. In April 2017, 224,416 pills were collected(1,044 pounds). Most northern and rural coalitionsreplicated JTNN’s model and began Round Ups thenext year.

September 2010 DEA began organizing Take Back Dayswith 1,622 pounds collected. In April 2017, 4,192 poundwere collected.

In 2013 coalitions purchased drug collection boxes forevery law enforcement agency, except Las VegasMetro. Coalitions began promoting usage of the boxes.

Today, all counties collect Rx drugs, either through dropboxes or Take Back Days.

History

All Take Back efforts are coordinated with local lawenforcement.

Take Back locations occur at localbusinesses(pharmacies, drug stores, grocery stores).

What is collected is determined at the local level.

Most communities coordinate Take Back events inconjunction with National DEA Take Back days held inApril and October.

Some communities utilize DEA to collect the drugs anddispose of them.

Structure


26

Amounts Amounts

Amounts

Amounts collected and disposed of byDEA

DEA Collections

Date Pounds Date Pounds

Sept. 2010 1,622 April 2014 3,412

April 2011 1,189 Sept. 2014 2,594

Oct. 2011 2,185 Sept. 2015 2,547

April 2012 2,908 April 2016 3,776

Sept. 2012 2,060 Oct. 2016 3,079

April 2013 2,409 April 2017 4,192

Oct. 2013 1,777

Amounts collected and disposed of bylocal law enforcement

Clark County:

Oct. 2016 – 4 locations – 342 pounds

April 2017 – 8 locations – 1,052 pounds

Elko County:

1 year period - July 2015 to June 2016

687 pounds

Other Collections

Other efforts conducted during Take Back events

Promotion of dropboxes

Distribution of lockboxes

Drug tracking cardsand pill counters

Distribution of Deterrabags

General education onRx drugs

Community Education


27

Disposal of syringes

Storage of drugs from drop boxesbetween Take Back events

Risks associated with handling the drugsby law enforcement

Disposal sites

Consistent data collection

Current Challenges

Thank youfor

listening!

Linda Lang

Nevada StatewideCoalition Partnership

[email protected]


28


– Track 1: Prescribing Guidelines

– Track 1: Prescribing Education

– Track 1: Oversight of Pain Management

– Track 3: Empowerment of Occupational LicensingBoards

Oversight of ControlledSubstance Prescribing

Governor’s Opioid State ActionAccountability Meeting

J. David Wuest, Deputy Executive Secretary, Nevada Board of PharmacyEdward Cousineau, Executive Director, Nevada Board of Medical Examiners

164

Cathy Dinauer, Executive Director, Nevada Board of NursingSandra Reed, Executive Director, Nevada Board of Osteopathic Medicine

Oversight of Controlled Substance Prescribing

Objectives

165

• Past

• Present– Governor’s Task Force Meeting (May 2015)– Senate Bill 459 (2015)– Comprehensive Planning Meeting (June 2016)– Governor’s Summit (August 2016)– Assembly Bill 474 (2017)– Senate Bill 59 (2017)

• Future

Past

166

• Collaboration, Partnerships, and InformationSharing– Collaborative activities not focused on controlled

substances (CS)

• Naloxone– Only available by prescription

– Few doses ever dispensed for outpatient use

– Public had very little knowledge of the medication

Past

167

• PMP

– Only contained prescription data

– Only identified doctor shoppers and notifiedprescribers through unsolicited reports

– No data pushing capabilities

– Only 20% of prescribers registered

Past

168

• Prescriber education/guidance on prescribing CS– CDC guidelines (March 2016)– No statutory or regulatory mandates– No CE requirements on the misuse and abuse of CS

• Disciplinary action against a licensee for inappropriateCS prescribing– Infrequent complaints of CS practices– Minimal regulatory guidance regarding CS prescribing

practices– Lower investigative priority


29

Present

169

• Opioid Management• Coverage for Non Opioid Pain

Management Therapies• Early Intervention• Overdose Education &

Naloxone Distribution

• Prescription MonitoringProgram

• Empowerment of Nevada’sOccupational Licensing Boards

• Public Health Data

• Deterrents for CriminalActivity

• Prescription Drug Disposal• Law Enforcement Data Sharing• Sequential Intercept Model

• Prescribing Guidelines• Prescriber Education• Discharge Planning &

Procedures• Oversight of Pain

Management Clinics

Governor’s Prescription Drug AbuseSummit Report

170

Track 1:Prescriber

Education &Guidelines

Track 2:Treatment

Options & ThirdParty Payers

Track 3:Data Collection& Intelligence

Sharing

Track 4:Criminal Justice

Interventions

Track 1: Prescriber Education &Guidelines

171

Track 1:Prescriber


Track 2:Treatment



Sharing


Interventions

Prescribing Guidelines

Prescriber Education

Track 2: Treatment Options & ThirdParty Payers

172

Opioid Management

Early Intervention

Overdose Education & NaloxoneDistribution

Track 1:Prescriber


Track 2:Treatment



Sharing


Interventions

Track 3: Data Collection & IntelligenceSharing

173

Track 1:Prescriber


Track 2:Treatment



Sharing


Interventions

Prescription Monitoring Program (PMP)

Empowerment of Nevada’s Licensing Boards

Law Enforcement Data Sharing

Public Health Data

Track 4: Criminal Justice Interventions

174

Track 1:Prescriber


Track 2:Treatment



Sharing


Interventions

Deterrents for Criminal Activity

Law Enforcement Data Sharing

Prescription Drug Disposal


30

Collaboration, Partnerships, andInformation Sharing

Past Present

175

– Collaborative activities notfocused on CS

• Licensing boards quarterly meetings• AB 474 White Paper• SB 59

– Law enforcement, medical examiners andcoroners reporting to the PMP

• Violations of NRS 453– Fraudulent/altered prescriptions– Illegal possession of illicit drugs or

prescription CS– Sales or trafficking of CS– Others

• Overdoses (fatal and non-fatal)• Reports of stolen prescription drugs

• Grants– DHHS – CDC grant

• Providing PMP data (monthly downloads) for:– Trend analysis– Dashboard– Geomapping

– Reno Police Department- Harold Rogers Grant• Linking prescription opioid use to heroin arrests

Naloxone

Past Present

176

• Only available byprescription

• Few doses ever dispensedfor outpatient use

• Public had very littleknowledge of themedication

• Available without prescription throughupdated pharmacy regulations

• Worked with Governor’s office andmanufacturers to procure at reducedprice

– Department of Public Safety (DPS) able toobtain at a reduced cost

• Many doses dispensed for outpatientuse

• Education– CEs

• Shared information with providers,community groups, not-for-profitagencies regarding naloxone availability

– Newsletter• Reached out to 8,500 pharmacists

educating them on new rules regardingfurnishing naloxone

PMP

Past Present

177

• Only contained prescriptiondata

• Only identified doctorshoppers and notifiedprescribers throughunsolicited reports

• No data pushing capabilities

• Only 20% of prescribersregistered

• Will contain prescription, lawenforcement, medical examiners,and coroner data.

• Identifies doctor shoppers, andhigh prescribers and providesunsolicited reports to prescribers,licensing boards, and lawenforcement

– AB 474 provides uniform method forinvestigating PMP reports

• PMP can push data to prescribers– Email capabilities, PMP

announcements can be provideddirectly from PMP to prescribers

• Prescriber registration will be 100%with AB 474

Prescriber Education/Guidance onPrescribing CS

Past Present

178

• CDC guidelines (March2016)

• No statutory or regulatorymandates

• No CE requirements on themisuse and abuse of CS

• AB 474 – Prescribingguidelines– For initial prescriptions (limited

to 14 days), treatment after 30,90, 365 days

– Enforce illegality of samples

• 2 hour mandatory CErequirement– Licensing boards working

together and have conductedCEs for MDs, DOs, dentists,RNs, APRNs, optometrists,pharmacists and federal andstate law enforcement.

Disciplinary Action Against a Licenseefor Inappropriate CS Prescribing

Past Present

179

• Infrequent complaints of CSpractices

• Minimal regulatoryguidance regarding CSprescribing practices

• Lower investigative priority

• Licensing boards will adoptnecessary regulations

Nevada State Board of MedicalExaminers

180

• Education and Outreach– KnowYourPainMeds.com (February 21, 2017)– AB 474 White paper to website and e-blasted to all our licensees.– Finalizing brochures to distribute to licensees in both English and Spanish, which include

information on how to obtain Naloxone (available through prescription or pharmacist).– Presenting to residents at the University Medical Center on October 24, 2017. We are also

planning a joint presentation with Dr. DiMuro to our licensees.– Scheduling a radio interview with Lotus radio group to explain to the public the new

requirements for prescribing CS.– Working with the Nevada State Medical Association on joint outreach for licensees.– Working with Project ECHO, University of Nevada School of Medicine in promoting

educational clinics regarding pain management.• Enforcement

– Now have a dedicated attorney, investigator, and staffer focusing exclusively on prescribingcases.

– Held a workshop to update our regulations to require additional CMEs, as required by AB 474.– Staff has received authority from the Board at the September 8, 2017 Board meeting to

implement regulations for discipline to be imposed for prescribing violations, and theproposed regulation has been sent to the LCB.


31

181 182

Nevada State Board of OsteopathicMedicine

183

• Currently, the BOM oversees the following:– Total licensees as of September 18, 2017: 1,570– Active DOs (Doctors of Osteopathic Medicine): 1,142– Active PAs (Physician Assistants): 140– Inactive DOs: 75– Special Licenses (Residents): 209– DOs Special from adjoining states: 4

• Workshop/Hearing for AB 474:– Will hold a workshop on October 10, 2017 and a hearing on December 12, 2017, for the

regulations currently being written to comply with the above laws. Regulations would consistof the following:

• Addressing CE requirements regarding prescribing CS• No regulation will be written regarding Sec. 41 of AB 474 because the process set out in AB 474

contains good guidance and authority that will supplement the already robust existing enforcementregime regarding inappropriate prescribing of opioids by the Board’s licensees.

• Outreach:– Placed links to a helpful table of provisions of AB474 and links to AB474 on web site.– Sent a newsletter in July outlining the legislation, and will send in email blasts to licensees in

September 2017, the information sheets summarizing the requirements of AB474.– Will hold several informational webinars in November 2017 to licensees regarding AB474.

Nevada State Board of Nursing

• Background– Number of APRNs licensed in Nevada: 1657– Number of APRNs with prescribing privileges: 1517

• Prescriber Education– Distribution of AB 474 White Paper to all licensee holders– Two live legislative update to APRNs– Multiple emails of materials to APRNs– Multiple presentations regarding SUDS and legislative update to various stakeholders– Education to licensees regarding Naloxone

• Common Agenda / Continuous Communication– Meetings with Governor’s office and other stakeholders– Multiple meetings with boards regarding AB 474 implementation

• Prescription Monitoring Report– Reports received and investigations opened– Hired APRN consultant

• Regulations– Regulations currently contained in NAC Chapter 632 regarding investigation and discipline

adequately provide for enforcement of AB 474

Nevada Board of Pharmacy

185

• Is in the process of adopting regulations toensure compliance with AB 474 and SB 59.

Future

186

• Implementation of AB 474 (January 1, 2018)

• Continue collaboration and improvement incommunication

• Continuing education for practitioners

• Shared measurements

• PMP software enhancements and improvementsto meet requirements of AB 474 and SB 59

• Timely adoption of necessary regulations

• Solicitation of grants


32

CONTACT INFORMATION

187

• Nevada Board of Pharmacy

– J. David Wuest, Deputy ExecutiveSecretary

• Email: [email protected]

• Phone: 775-850-1440

• Nevada Board of Nursing

– Cathy Dinauer, Executive Director• Email: [email protected]

• Phone: 775-687-7700

• Nevada Board of MedicalExaminers

– Edward Cousineau, ExecutiveDirector

• Email: [email protected]

• Phone: 775-688-2559

• Nevada Board of OsteopathicMedicine

– Sandra Reed, Executive Director• Email: [email protected]

• Phone: 702-732-2147

Law Enforcement


– Track 4: Criminal Justice Interventions

Daniel NeillAssistant Special Agent in Charge, DEA Las Vegas

Keith CarterDirector, Nevada HIDTA

Second highest state ranking for oxycodoneand hydrocodone prescriptions

Source area for diverted pharmaceuticals toother cities and states

Increase in heroin usage stemming from abuseof pharmaceuticals Illicit market for prescription drugs remained stable

Fentanyl and U-47700 abuse

Prescription drug related deaths outpace allother drug types Overdose deaths have increased since 2014

Oversight from the manufacturer to the user Doctors overprescribing opioids

“Cappers” – individuals who recruit a number ofpeople to obtain prescriptions

Pharmacies eager to fill the prescriptions

Illicit manufacturing of tablets Pill press for faux prescription drugs

Expansion of health care fraud Medicaid fraudulent billing

Coordination with DOJ’ Special Prosecutor forNevada

Diversion scheme: Medicare patients sell medication to drug trafficker

Drug trafficker supplies local distributors

Local distributors sell the medication to out of townclients

Doctors willing to prescribe opioids without alegitimate medical condition

Recommendation of specific pharmacies bydoctors

Pharmacy shopping

Tourism has created multi-state businessventures


33

Enforcement and Regulatory

Tactical Diversion Squad/Pharm-Net

DEA

Nevada Department of Public Safety

Las Vegas Metro Police Department

North Las Vegas Police Department

Henderson Police Department

Diversion

Regulatory arm of DEA

Compliance for doctors and pharmacies

Sponsored 122 hours of cost free training to lawenforcement on opioids and diversion

Partnered with public health and localcoalitions

Overdose Awareness Day

Distribution of overdose kits to the public

Opioid Task Force in Southern Nevada

Partnered with UNLV and the Licey Institute tobring the Substance Use & Behavioral HealthSummit

Prescription Opioid Investigations

2017 FBI Las Vegas Strategy

Prescription Drugs/Opioid Threat

UNCLASSIFIED//FOUO

UNCLASSIFIED//FOUO

196

Presidential Priorities

On August 10, 2017, PresidentTrump declared the country’sopioid crises a nationalemergency.

Instructed Administration to useall appropriate emergency andother authorities to respond tothe crises

197

2017 FBI Las VegasStrategy

FBI Health Care Fraud Priorities

Target egregious health carefraud offenders suspected ofhealth care fraud violations,with an emphasis on theopioid threat

198



34

Staffing

Congressionally funded Special Agents (SA)assigned to work Health Care Fraud

Located in both Las Vegas and Reno

Established an FBI Health Care Fraud TaskForce (HCFTC)

Pending approval by the Interim FinanceCommittee, the Nevada Office of theAttorney General plans to assign a full-timeinvestigator to the HCFTC.

199


Working Group

Monthly Opioid Working Group

Participants include FBI, HHS, DEA,United States Attorney’s Office,Nevada Office of the AttorneyGeneral, Las Vegas MetropolitanPolice Department, FDA

Collaboration with ongoinginvestigative strategies

200


Accomplishments in2017

On July 17, 2017, Dr. Robert Rand pled guiltyto involuntary manslaughter and unlawfuldistribution of oxycodone. Sentencing datewill be October 23, 2017.

On August 1, 2017, Dr. Henri Westelaar wassentenced to 120 months imprisonment,$1,100 assessment, and a $2,500,000 fine fordistribution of oxycodone and othercontrolled substances, and moneylaundering.

Four new investigations have been opened,which have been a direct result of increasedengagement and outreach to thecommunity.

201


Expectations 202

Continue to work joint investigationswith federal, state and local partners

Identify and target most egregiousperpetrators

Utilize appropriate investigativetechniques for high impactinvestigations, prosecution, andaggressive asset forfeiture


Public Awarenes 203

Education of opiateaddiction in public andprivate school systems

Chasing the Dragon, TheLife of an Opiate Addict


SSA Christina D. Burt

FBI Las Vegas

HCF/CFC

702-584-5770

204



35

DEPARTMENT OF JUSTICE

UNITED STATES ATTORNEY’S OFFICE

KILBY MACFADDEN, ASSISTANT UNITED STATESATTORNEY

Opioid Fraud and Abuse Prosecutor, District of Nevada

Grams ofPrescription

OpioidsDelivered(per 1,000

People)

Highest Quarter ofOverdose Rates

(by County)

ODAG OpioidInitiative

Opioid InitiativeUSAOs

Office of Deputy Attorney GeneralOpioid Fraud & Abuse Task Force

USAO

District of NevadaFBI DEA

HHSState & Local Partners

Kilby Macfadden, AUSA

[email protected]

702-388-5069

opening remarks governor brian sandoval’s opioid state...

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