Safe Med LA Los Angeles County’s Prescription Drug Abuse Coalition Gary Tsai, MD, FAPA, FASAM Medical Director and Science Officer Substance Abuse Prevention and Control County of Los Angeles Department of Public Health
Outline • Opioid Epidemic: Framing the Issue • Safe Med LA – “9‐6‐10 Blanket Approach” • 9 Action Teams • 6 Priority Areas • 10 Key Objectives • Summary 1
Framing the Issue: Scope of the Opioid Epidemic 2
Opioid Use on a Global Scale United World Population States 5% Rest 95% Global Opioids Hydrocodone Rest Rest 20% 1% United United States States 99% 80% 3 Manchikanti, L (2010). Therapeutic Use, Abuse, Nonmedical use of Opioids: A Ten‐Year Perspective, Pain Physician, 13, 401‐435
ED Visits and Hospitalizations in LAC, 2005‐2014 Rx Opioid‐related Heroin‐related 16,000 500 31% 72% 14,000 From 2005‐2014 From 2005‐2014 400 12,000 10,000 300 8,000 217% 34% From 2005‐2014 200 6,000 From 2005‐2014 4,000 100 2,000 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 ED Visits Hospitalizations 4 Emergency Department and Inpatient Discharge Data Set. Office of Statewide Health Planning and Development. 4 California Department of Public Health.
Opioid‐Related Deaths in LAC, 2006‐2013 469 434 424 410 386 381 377 360 2006 2008 2010 2012 5 Emergency Department and Inpatient Discharge Data Set. Office of Statewide Health Planning and Development. California Department of Public Health.
Rate of ED Visits by Race and Gender in LAC (per 100,000 pop) Rx Opioid‐related Heroin‐related 18 250 15 200 12 150 9 100 6 50 3 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 White Black Latino Other Men Women 6 Emergency Department and Inpatient Discharge Data Set. Office of Statewide Health Planning and Development. 6 California Department of Public Health.
Prescriptions Filled in LAC, 2012 N = 9,605,765 SEDATIVES 40.3 HYDROCODONE OXYCODONE 10.9 67.0 OPIOIDS 43.9 CODEINE 10.6 MORPHINE 3.9 FENTANYL 2.1 STIMULANTS 6.6 MUSCLE RELAXANTS 1.9 OTHER 5.6 HORMONES 3.2 OTHER 4.2 7 Department of Justice, California Prescription Drug Monitoring Program (PDMP)/Controlled Substance Utilization Review and Evaluation System (CURES) data.
Safe Med LA • Safe Med LA is a broad, cross‐sector coalition that is taking a coordinated and multi‐pronged approach to comprehensively address prescription drug abuse in Los Angeles County www.SafeMedLA.org • Core Rationale – Given that the reasons for prescription drug abuse are complex, multi‐factorial, and involve numerous entities, the solution will need to be similarly broad and inclusive. – “Blanket approach” Addressing complex problems along the full continuum of interventions to avoid the phenomenon of addressing one aspect of the issue only to lead to worsening of another, interconnected aspect of the problem. – Organize and coordinate various concurrent projects that involve prescription drug abuse into a unified effort • LA County Prescription Drug Abuse Medical Task Force • LA Overdose Prevention Task Force • Department of Health Services (DHS) Pain Management Workgroup • Safe Drug Drop‐Off Boxes at LASD Stations 8
Coalition Members • Cross‐sector, public‐private representation*: ‐ County Departments (Health ‐ Health Providers (LAC DHS, UCLA Health Services, Mental Health, Public System, KP, HealthCare Partners, LA LGBT Health, Public Works, Sheriff’s) Center, Exer Urgent Care, Venice Family Clinic, Synovation Medical Group, ‐ Health Plans (LA Care, Health Net, AltaMed, Facey, Providence, US Kaiser Permanente, Blue Shield of HealthWorks, etc.) California, Care 1 st , Molina, Anthem Blue Cross, Cigna, etc.) ‐ Behavioral Health Providers (Tarzana Treatment Centers, Behavioral Health ‐ Healthcare Organizations Services, Prototypes, JWCH Institute, LA (Community Clinic Association of Community Health Project, Homeless Los Angeles County, LA County Health Care Los Angeles, etc) Medical Association, Hospital Association of LA County, LA Dental ‐ Others (Pharmacist Associations, City of Society, Health Services Advisory Long Beach, City of Pasadena, etc) Group, etc.) 9 *Note: Above list of Safe Med LA participants is not exhaustive
Safe Med LA – Strategic Plan • Five‐year strategic plan * guides the work of Safe Med LA. – Overall goal Decrease prescription drug abuse deaths in LAC by 20%. – “9‐6‐10” Approach • 9 Action Teams focusing on • 6 priority areas with • 10 key objectives *More information on the Los Angeles County Prescription Drug Abuse Strategic Plan and Safe Med LA is available at: http://publichealth.lacounty.gov/sapc/Plan/StrategicPlan.htm 10
9 Action Teams 11
Priority I: Education and Training Objective 1: Provide community education to increase public awareness of the risks of prescription drug abuse, safe use/storage/disposal, and available resources for help. Objective 2: Educate and train health care professionals (e.g., physicians and pharmacists) on best practice guidelines for safe prescribing and identifying prescription drug misuse through screenings. Objective 3: Provide training and education to help the criminal justice community (e.g., law enforcement, court, lawyers, etc.) better understand prescription drug abuse and navigate the interface between public health and law enforcement. Overview Priority II: Treatment and Overdose Prevention Objective 4: Expand access to medication‐assisted treatment for individuals addicted to prescription drugs. Objective 5: Expand access to naloxone for overdose prevention. 6 Priority Priority III: Tracking, Monitoring, and Data Exchange Objective 6: Promote increased utilization of the statewide Prescription Drug Monitor Program (PDMP) in Areas California, known as the Controlled Substance Utilization Review and Evaluation System (CURES), in order to decrease misuse and diversion of prescription drugs. Objective 7: Increase data collection and information sharing across agencies and organizations to enhance safe practices and reduce poor outcomes related to prescription drug abuse. with Priority IV: Safe Drug Disposal Objective 8: Support convenient, safe, and environmentally responsible prescription drug disposal programs in Los Angeles County that are free to the public to help decrease the supply of unused prescription drugs in 10 Key homes and the community. Priority V: Enforcement Objectives Objective 9: Collaborate with law enforcement to identify and address improper practices that threaten public health, such as indiscriminate prescribing by “pill mills” and inappropriate "doctor shopping" in order to secure prescription drugs. Priority VI: Community Trends and Policy For more details: Objective 10: Seize opportunities to positively influence policy, at the local as well as State and Federal www.SafeMedLA.org levels, by identifying and communicating community factors that are contributing to prescription drug abuse. 12
Medication‐Assisted Treatment Action Team • Focuses : – Leverage learning collaborative model to expand access to MAT (buprenorphine, naltrexone, etc) within the primary care, mental health, and substance use settings. – Increase number of prescribers in LAC who are waivered to prescribe buprenorphine. – Increase number of buprenorphine prescriptions provided in LAC. 13
MAT Hub & Spoke Approach 3 Primary MAT hubs in LA County Vivitrol (long‐acting naltrexone) Buprenorphine Established 2 learning collaboratives to expand MAT: Primary care providers SUD providers. Developing MOUs between referring and accepting providers to formalize processes. 14
Medication‐Assisted Treatment: Key Points • MAT availability would ideally match the inavailability of inappropriate or unnecessary opioids . • Funding and availability of MAT on Medicaid/Medicare/health plan formularies is critical. • Scaling up the use of MAT will require engaging prescribers (MDs/DOs/NPs/PAs) in all areas of the health sector , including physical and mental health, as well as the SUD community. • Learning collaboratives have been an effective way to facilitate the culture change and knowledge transfer necessary to expand the number of MAT prescribers. 15
Naloxone in Los Angeles County • Where we started from: – LA Overdose Prevention Task Force since 2006 focused on expanding naloxone access focused on direct service, policy, & research. – Small network of naloxone distribution programs based out of SUD treatment provider network. • Where we are going: – Expand naloxone access to those at highest risk for opioid overdoses. • Jail naloxone distribution program • Expand naloxone distribution programs via SUD providers leverage increased access via the Drug Medi‐Cal Organized Delivery System Waiver • Engage and activate the pharmacist community to help expand naloxone access across health systems (physical health, mental health, SUD) – Ensure first responders, including law enforcement, have access to naloxone. 16
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