THOUGHTS ON A MARKET APPROACH TO CURBING SUBSTANCE USE DISORDER John J. Dreyzehner, MD, MPH Commissioner 1 September 20, 2017
Cumberland Plateau Health District, Southwest Virginia 2
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Back in 2005… Accidental Prescription Drug Deaths SW Virginia 2003 (n=168) • 70.8% were male Average Age 36.8 Years • • 40.5% were married • 67.3% had a history of drug abuse • 53.0% had a history of pain • 39.9% had a history of chronic illness 39.9% had a history of mental illness • • 22.0% were in the construction/extraction occupations • 19.0% were disabled • 10.1% were homemakers • 7.1% had a previous overdose “Society doesn’t have all the answers for people bent on abuse and not caring enough about who they harm − at some point it is about a personal decision.” 4
Supply Drives the Market… Potential Buyers 5
…And the Market Can be Constrained Potential Buyers Prevention 6
The Dopaminergic Reward Center Nicotine Sex THC Glucose Yeah! Physical Endorphins Activity (Endogenous Opiates) 7
What does “epidemic” really mean? A simplified schematic of “transmission” in the substance abuse epidemic: Abuse Ab se Resis sistant tant Misuse se Abuse Ab se (Relig eligio ious) Over erdo dose se Resis sistant tant Misuse se Ab Abuse se Ab Abuse se Misuse se Misuse se (Rec ecovery) Resis sistant tant (Bad ad Abuse Ab se- Misuse se Misuse se Relati lationsh ship) ip) Pregnancy ancy Ab Abuse se NAS Social networks can mitigate or create risk • Not everyone who misuses will abuse • Not everyone who overdoses will die • Not all misuse/abuse with pregnancy will result in NAS • 8 Resistance/Immunity- some have innate or acquired “resistance” •
Public Health Approach to the Opioid Abuse Epidemic Tennessee Department of Health Strategic Map, 2016 Adopted 1/11/16 Reduce Opioid Misuse, Abuse & Overdose C A B D E Improve Improve Increase Utilization Increase Access to Improve Primary Monitoring and Regulation and of Treatment Appropriate Pain Prevention Surveillance Enforcement (2º Prevention) Management Improve education Provide prescriber/ Destigmatize & approach Require pain management Optimize use of clinic physicians to have for consumers, dispenser education on addiction as a 1 the CSMD specialty certification families & HCWs regulation & enforcement treatable chronic illness Develop a model for Improve collaboration Expand use of optimal Link other data sources Expand SBIRT desirable integrated 2 prescribing guidelines to the CSMD with law enforcement training and use pain practices Expedite investigations Expand appropriate Increase access for Actively support Improve the high risk supporting Board oversight 3 uninsured community coalitions patient model use of MAT of prescribers Work with academic Develop a high risk Expand treatment Expand efforts to Eliminate “Pill Mills” partners to improve prescriber model for alternatives to 4 reduce NAS training of prescribers individuals and practices incarceration Facilitate community Partner with Mental Health Describe how patient Develop a high risk Improve legislation to interventions, including to expand treatment care is impacted by 5 dispenser model allow proactive regulation safe disposal of drugs options for opioid misuse sudden clinic closure Advocate for Prescription Expand the availability Reduce harm Improve proactive use of for Success including 6 and use of Naloxone from needle use clinical monitoring tools treatment and care Expand and Strengthen Key Partnerships and Collaborative Infrastructure Secure/Realign Resources and Infrastructure to Implement Comprehensive Approaches Use Data, Evaluation and Research to Inform Interventions and Continuous Improvement
Some Bright Spots in Tennessee Pain Clinics in TN 333 350 300 250 180 200 150 100 50 0 2014 2017
…Constraining the Market Law Enforcement, Medication Assisted PDMPs, Preventing Pill Therapy, Inpatient, Outpatient, 12 Step, Mills, Regulatory Board Investigations, Etc. Etc. Potential Buyers Prevention Fulfilling The Brain’s Reward Center, Working Upstream to Keep the Brain from being Hijacked 11
THANK YOU 12
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