IHS Prescription Drug Abuse Workgroup Report Out 2016 National Combined Councils June 23, 2016
History--Purpose/Overview • Recognizing that prescription drug abuse and deaths due to overdose from prescription medications is a national epidemic, the Indian Health Service convened a workgroup on this issue at the National Combined Councils meeting in Rockville, MD on July 11, 2012. • The workgroup developed a number of recommendations that were grouped around six (6) focus areas: – Patient care – Policy development/ implementation – Education – Monitoring – Medication storage/disposal – Law enforcement.
HHS Year in Review • HHS Secretary’s Opioid Initiative–March 2015 1) Prescriber training 2) Access to Naloxone 3) Access to Medication Assisted Treatment https://aspe.hhs.gov/sites/default/files/pdf/107956/ib_OpioidInitiative.pdf
HHS Year in Review • National Heroin Taskforce—July 2015 Findings: • Substance use disorders are brain diseases that can be successfully treated; • Education and intervention at all levels are essential, including activities to prevent drug-related harms, especially overdose prevention tools; • Appropriate treatment options must be readily available, affordable, and easily accessible, and • Millions of Americans are in recovery from heroin and other opioid use disorders; their progress should be highlighted to encourage others to enter treatment.
HHS Year in Review • Presidential Memo—October 2015 – Addressing Prescription Drug Abuse and Heroin Use 1) Adequate training of medical professionals on appropriate pain medication prescribing practices—within 18 months and repeated every 3 years 2) Increased utilization of naloxone 3) Increased access to medication-assisted therapy (MAT) for opioid dependence 4) Reduced utilization of methadone
HHS Year in Review • Protecting Our Infants Act (POIA)— – November 2015 – Requires the Department of Health and Human Services (HHS) to review its activities related to prenatal opioid use, including neonatal abstinence syndrome, and develop a strategy to address gaps in research and gaps and overlap in programs. – Components: 1. An assessment of existing research on neonatal abstinence syndrome; 2. An evaluation of the causes, and barriers to treatment, of opioid use disorders among women of reproductive age and recommendations on preventing opioid use disorders in these women; 3. An evaluation of, and recommendations on, treatment for pregnant women with opioid use disorders and the effects of prenatal opioid use on infants; and 4. An evaluation of the differences in prenatal opioid use between demographic groups and recommendations on reducing disparities. https://www.congress.gov/bill/114th-congress/senate-bill/799
CDC http://www.cdc.gov/drugoverdose/prescribing/guideline.html
CDC Guideline Elements • Start low—go slow • Avoid initiating opioids for chronic pain if possible— use non-opioid treatments if possible • Routinely assess functional status: harms vs benefits – 1-4 weeks after opioid initiation – Following dose escalation • Use caution when prescribing >50MMEs – Exceeding 90MMEs—recommend additional documentation; risk vs benefits, specialty referral options • Co-prescribe naloxone • Monitoring: including PDMP and UDS • Acute pain: recommend no more than a 3 day supply; rarely greater than 7 day supply
IHS PDA Workgroup Subgroups • Patient Care • Policy • Education • Monitoring • Disposal/Storage • Enforcement
Websites • www.ihs.gov/painmanagement • www.ihs.gov/odm
Naloxone Access First Responders • Program Elements – BIA MOU approved in December 2015 – Toolkit: • Standing Order • Draft MOU language for tribal sites • Standardized Forms • Training manual; training slides • Status – Training sessions hosted in OK, AZ, ND, SD, WY, MT, NM • Max.gov site maintained
Naloxone Access Co-Prescribing • Toolkit – Draft Collaborative Practice Agreement for pharmacists – Documentation templates – Training sessions – RPMS Report and Information Processor program—assist with identification of high risk patients (MMEs, concurrent benzo) – Increasing capacity
Perinatal Substance Use Blackfeet Service Unit, Browning, MT • Background: – Rapidly increasing numbers of infants born to mothers under the influence of or recently taken no-prescribed substances of abuse identified by perinatal testing at the % Infants Born Drug Exposed Series1 Series2 60.00 50.00 42.00 40.00 28.00 20.00 20.00 20.00 20.00 0.00 2008 2012 2016 Current Condition : Now all pre-natals and deliveries are being tested and the number of drug exposed infants is increasing at a high rate. Possible Root Causes: 1. Drug Availability 2. Low Socioeconomic Status 3. Lack of prevention education 4. Lack of hope among population 5. Lack of available rehabilitation options 6. Fear of losing infants 7. Lack of family support/structure
Perinatal Substance Use • Workgroup Goals: – Design and seek to implement a culturally appropriate clinical model suitable for IHS that addresses the treatment and maintenance of Opioid Use Disorders in pregnancy. – Work with partners (AAP, ACOG) to seek national guidelines for develop additional training resources. – Explore effective integrated models of care
Education • IHS Essential Training on Pain and Addiction – Updated curriculum – 1832 I/T/U providers trained – 966 of 2109 (46%) IHS mandated workforce • PCSS-OBOT – Via a partnership with the American Osteopathic Academy of Addiction Medicine (AOAAM) and SAMHSA, Buprenorphine Waiver Trainings are freely available to all I/T/U providers
IHS Pain & Addiction ECHO Time Changes Starting on July 6 th
1 st Wednesday: Eastern/Central Time Focus
2 nd Wednesday: Mountain Time Focus
3 rd Wednesday: Pacific Time Focus
4 th Wednesday: Alaska Time Focus
Monitoring • Finalized Draft IHS Chapter 32— – Prescription Drug Monitoring Programs – Best Practices: • Prescriber registration with state PDMP • Prospective queries (new patient, dose escalation) • Use of delegate accounts • Dispenser reporting • Pharmacist query with outside prescription and every 3 months for a refill
Enforcement • Tribal Healing to Wellness Courts Summary approved for inclusion on IHS Pain Management Website – Designed to inform I/T/U leadership of the Wellness Court model to promote collaboration with tribal judiciary systems and support the expansion of the Wellness Court model • Controlled Substance Utilization Best Practice Guide for I/T/U Leadership: Reconciling with proposed Indian Health Manual Chapter 7 (Pharmacy) revision – Currently pending review and approval
Upcoming Initiatives • In Progress: – PDA Workgroup Transitioning to Committee – Comprehensive 5-year Work-Plan prepared – Special General Memo—Essential Training on Pain and Addictions prescriber requirement – Chapter 30 Update—Chronic Pain Management – Medication Assisted Treatment
MAT • Develop best practice guidelines to assist sites with assessment of local capacity and program development to increase access to MAT • Publish survey to identify current status, identify barriers, identify perceptions (community & prescribers) • Develop YouTube video series for community members • Publish Opioid detoxification strategies on website
Upcoming Initiatives • Planned – Metrics workgroup formed: identify meaningful budget and program metrics – Harm Reduction: • Naloxone: expand co-prescribing; CMO Grand Rounds • Syringe Exchange Programs
Needs • Patient Care Subgroup: – Increased membership and participation • Mid-level providers, nursing, addiction specialists, behavioral health practitioners • Local leadership awareness and support of concepts – Pain management: Chapter 30, SGM for Training – Harm reduction – MAT: assess capacity and participate in community collaboratives to create holistic treatment models
Subgroup Leads • Chairs: CAPT Stephen (Miles) Rudd, MD; CAPT Cynthia Gunderson, PharmD • Patient Care: CDR Ted Hall, PharmD • Policy: Stephen Sanders, MD • Education: Chris Fore, PhD • Monitoring: LCDR Hillary Duvivier, PharmD • Disposal/Storage: CAPT Tracie Patten, PharmD • Enforcement : CDR Michael Verdugo, PharmD; CDR David Axt, PharmD
Recruitment & Retention and Workforce Development Workgroup (RRWDW) National Combined Councils Meeting June 22, 2016
Hiring Challenges • Rural/frontier locations • Travel restrictions • Pay and benefits • Training for managers/leaders • Acceptable housing • Accurate job analysis and determination of competencies • Employment for spouses • Finding qualified applicants • Choice of schools • Individuals blocking panels • Permanent leadership • Credentialing and privileging • Availability of support staff • Tribal shares • Available funding
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