Community Collaboration • Engage business leaders to discuss the opioid problem • Increase public education • Support efforts to hire people in recovery • Reclassify drug possession as a misdemeanor – Reduce number of offenders going to jail for drug possession – Remove barriers to people in recovery from acquiring employment
LMS Opioid Symposium Heal Pain Danesh Mazloomdoost, M.D. Danesh Mazloomdoost, MD is a Johns Hopkins & MD Anderson trained anesthesiologist, pain, and regenerative specialist. As an international speaker, author, and advocate for reform in pain management, Dr. Danesh consults with private and governmental organizations to develop protocols for pain that minimize opioid dependency, improve patient satisfaction and health outcomes. His new book, Fifty Shades of Pain: How to Cheat on your Surgeon with a Drugfree Affair has become an Amazon international best- seller in ten categories. He is now the Medical Director of Wellward Regenerative Medicine in Lexington Kentucky, the flagship for a new and sustainable approach to managing pain while avoiding drugs or surgery.
HEAL pain Danesh Mazloomdoost, MD Medical Director Info@Wellwardmed.com
Healing Beyond Medicine
Rx - Opioid Acute Opioid Response Rx - Opioid Rx - Opioid Pain Generator Rebound Pain Intensity Healing Beyond Medicine Opioid effect on pain score Time Mauermann et al. Anesthesiology 2016 Feb;124(2):453-63
6) Acute pain < 3days • Acute pain course < 3 days 24-72hrs 1-3 wks Resolve • > 7 days rare and often reflects Healing Beyond Medicine undiagnosed pathology
Onset of Dependency Chronic Use risk spikes at 3 days Long-term use > 1 year • 6% for >1 day • 13.5% >8 days • 29.9% >31 days Healing Beyond Medicine (7% of all Rx) Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006 – 2015. MMWR Morb Mortal Wkly Rep 2017;66:265 – 269. DOI: http://dx.doi.org/10.15585/mmwr.mm6610a1.
Chronic Opioid Response Rx - Opioid Rx - Opioid Rx - Opioid Rx - Opioid Pain Intensity Healing Beyond Medicine Time
Physiologic Pain Opioids Opioid Pain Healing Beyond Medicine
walk on a broken leg
Opioid-naïve patients undergoing surgery 6.5% become opioid dependent Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. Published online April 12, 2017
Pain ≠ Disease Pain = Disease Mess enger age Healing Beyond Medicine
Dissecting Pain Injury PAIN Tissue Nerves Healing Beyond Medicine
Biomedica Primary l Care for (Regenerat Pain ive) Kinesthe Psycholog tic ical (Function (Behavior al & Healing Beyond Medicine Movemen Lifestyle) ts)
heal
H ear E nvision A lleviate L everage
Pain Mapping precision accuracy Healing Beyond Medicine Hearing…
Healing Beyond Medicine Envisioning…
• Desensitization • Somatic Blocks • Autonomic Blocks • Neuroablation • Neural Modulation • Dorsal Column • Peripheral Nerve Healing Beyond Medicine Alleviating…
Cellular Healing Healing Beyond Medicine Leverage…
Healing Cycle Injury Rehabilita Inflammat tion ion Healing Beyond Medicine Proliferati Regeneratio on n
Injury Rehabilita Inflamma Injury tion tion Proliferat Regeneratio ion n Healing Beyond Medicine Järvinen et al Muscles, Ligaments and Tendons Journal 2013; 3 (4): 337-345
Injury Inflammatio Rehabilita Inflammation tion n Regeneratio Proliferat n ion Healing Beyond Medicine
Injury Rehabilita Inflamma Proliferation tion tion Proliferatio Regeneratio n n Healing Beyond Medicine
Injury Rehabilita Inflamma Regeneration tion tion Regenera Proliferat ion tion Healing Beyond Medicine
Injury Rehabilitati Inflamma Rehabilitation on tion Regenerat Proliferat ion ion Healing Beyond Medicine
Cellular Healing • Prolotherapy: Chemical-induction • Autologous growth factors: PRP, PL, PR • Allogenic growth factors: placental & amniotic derivatives • Xenogenic tissue matrices Healing Beyond Medicine • Mesenchymal Cells, SVF, CFUs Leverage…
Regenerative Outcomes: WHO WILL HEAL FASTER? Healing Beyond Medicine
optimize
info@wellward.com Healing Beyond Medicine
LMS Opioid Symposium First Responders Battalion Chief Chad Traylor Joined the Lexington Fire Department in 2003. Began career assigned to a fire engine and after completing paramedic training transferred to an ambulance. Throughout the years has held the assignments of a Company Officer, Hazardous Material Team Leader, District Major, Special Operations Commander and is currently the EMS Battalion Chief.
LMS Opioid Symposium Emergency Physician Ryan Stanton, M.D. EM doc with Central Emergency Physicians at Baptist Health Lexington. Chief Medical contributor for WKYT TV and producer of “The Doc Is In”, the weekly heath segment airing in 6 TV markets throughout the southeast. Medical Director for Lexington Fire/EMS and on track traveling physician for the AMR/NASCAR Safety Team. National Spokesperson for the American College of Emergency Physicians and producer of the ACEP Frontline Podcast. Dr. Stanton has been speaking around the country regarding opioids for the past 10+ years and is currently involved with the KHA SOS initiative.
LMS Opioid Symposium Health Department Kraig Humbaugh, M.D. As Commissioner of Health, Kraig E. Humbaugh, MD, MPH is the chief executive officer and medical director for the Lexington-Fayette County Health Department. He is a board-certified pediatrician who has practiced medicine for over twenty-five years in community, academic and public health settings. Dr. Humbaugh earned his undergraduate degree from Vanderbilt University, studied as a Fulbright Scholar at the University of Otago in New Zealand, and received his medical degree from Yale University. He holds a Master of Public Health degree from Johns Hopkins University.
Reducing Harm Among People who Inject Drugs Lexington Medical Society’s Opioid Symposium October 16, 2019 Kraig E. Humbaugh, MD, MPH Commissioner, Lexington-Fayette County Health Department kraig.humbaugh@ky.gov
WHAT IS A NEEDLE EXCHANGE? ▪ A public health program designed to reduce the negative health consequences of injection drug use: “ Meeting people where they are .” ▪ Provides new, sterile needles and syringes ▪ Provides safe disposal site for contaminated needles and syringes ▪ Needle exchange programs are proven to reduce the spread of HIV, hepatitis C, and other blood-borne infections, without leading to increased drug use in communities. They can decrease needle stick injuries. ▪ Under Kentucky law, only health departments can operate needle exchange programs. 65
Logistics of Lexington’s Exchange • When: Mondays 1-4 PM; Wednesdays 3-6:30 PM; Fridays 11 AM-4 PM • Where: Lexington-Fayette Co HD: 650 Newtown Pike • What: Free, anonymous, modified needs – based needle exchange • Uses trained health department employees who often have other “day jobs” at the health department • Cost to agency: about $500,000 per year. Compare to lifetime cost of one new case of HIV (>$350,000)or cost of treating one case of hepatitis C ($30,000-$50,000)
MONTHLY VISITS TO NEEDLE EXCHANGE PROGRAM: 28,228 Visits by 5,059 Clients September 4, 2015 – September 6, 2019 1400 1200 1000 800 93% 600 93% 91% 93% 90% 91% 92% 87% 87% 86% 90% 90% 85% 92% 88% 92% 84% 89% 91% 77% 88% 85% 400 85% 87% 86% 81% 87% 87% 84% 79% 76% 77% 66% 68% 79% 72% 200 62% 69% 23% 79% 34% 24% 15% 14% 16% 32% 23% 21% 19% 13% 13% 15% 15% 58% 12%9% 8% 9%12%9%10% 83% 28% 14% 13% 16% 10%8% 8% 7% 10%7% 7% 61% 61% 75% 38% 21% 13% 13% 11% 61% 57% 18% 76% 31% 82% 42% 39% 43% 39% 39% 21% 25% 17% 0 24% Sep '15 Oct Nov Dec Jan '16 Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan '17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan '18 Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan '19 Feb Mar Apr May Jun July Aug First Visit Repeat Visit 67
AGE DISTRIBUTION OF NEEDLE EXCHANGE PROGRAM CLIENTS (n=5024) September 4, 2015 – September 6, 2019 68
REPORTED DRUG OF CURRENT USE AT CLIENT ENCOUNTER September 4, 2015 – September 6, 2019 2% 2% 2% 21% Heroin Methamphetamine Suboxone Oxycodone Cocaine 73%
SELF-REPORTED FIRST TIME CLIENT PARTICIPATION IN TREATMENT/RECOVERY PROGRAMS March 3, 2018 – September 6, 2019 PAST PARTICIPATION IN A NUMBER OF TIMES IN TREATMENT/RECOVERY PROGRAM TREATMENT/RECOVERY PROGRAM (n =1515) (n=988)
TOTAL NEEDLES RECEIVED & DISTRIBUTED, LFCHD NEEDLE EXCHANGE PROGRAM Total Number of Needles Received Total Number of Needles Distributed September 4, 2015-September 6, September 4, 2015-September 6, 2019 2019 943,506 1,152,346 Ratio of needles received to needles distributed: 0.82 : 1 71
Other Harm Reduction Strategies • Needle exchange is one part of a comprehensive harm reduction plan. • Additional services offered on-site at the exchange through partnerships with community partners, under a confidential, medical/provider model: • rapid HIV and hepatitis C testing (with AVOL) • hepatitis A and B vaccination • referrals to counseling and treatment (with LFUCG, New Vista, Chrysalis House)- over 200 • naloxone training and distribution (with LFUCG)
Naloxone Distribution • As of September 6, 2019, 2976 naloxone kits have been distributed for use in the community setting. • Training is done by health department nurses and takes about 15-20 minutes total. • Participants are taught how to recognize an overdose, how to administer naloxone nasal spray and to call emergency medical services • More trainings, including community events, are planned. • A media campaign is being developed to encourage people to carry and use naloxone when needed. 73
Kraig Humbaugh, MD, MPH Commissioner of Health Lexington-Fayette County Health Department kraig.humbaugh@ky.gov
LMS Opioid Symposium County Prosecutor Lou Anna Red Corn Fayette Commonwealth’s Attorney Lou Anna Red Corn was appointed Fayette Commonwealth’s Attorney in 2016, and elected to the position in 2018. She has been a prosecutor in the office since 1987. Lou Anna serves the state’s prosecutors as treasurer and Best Practice Committee Co-Chair of the Commonwealth Attorney’s Association, she is the current state’s representative to the National District Attorneys Association and the nation’s prosecutor representative on the National Children’s Alliance Board of Directors, the organization that accredits the country’s Children Advocacy Centers.
LMS Opioid Symposium HEAL Program Michelle Lofwall, M.D. Michelle Lofwall MD is a Professor of Behavioural Science and Psychiatry and the Bell Alcohol and Addictions Chair at the University of Kentucky Center on Drug and Alcohol Research. She is the medical director of the First Bridge outpatient opioid use disorder (OUD) treatment clinic that provides comprehensive care to patients discharging from the emergency room and inpatient medical/surgical services. Her clinical research has been funded by the National Institutes of Health and industry with a focus on OUD. She was as an expert panel member on SAMHSA’s newly published Substance Treatment Improvement Protocol (TIP 63) for Medication Treatment of OUD, a board member of the American Society of Addiction Medicine, an invited speaker to the National Academy of Medicine and recipient of several medical student teaching and mentorship awards.
NIH HEALING C OMMUNITIES S TUDY U PDATE M ICHELLE L OFWALL , MD P ROFESSOR C OLLEGE OF M EDICINE C ENTER ON D RUG AND A LCOHOL R ESEARCH 77 77
S UBSTANCE U SE R ESEARCH AT UK • The University of Kentucky has established 6 research priority areas, which grew out of a 2014 Board of Trustees Retreat. These highlight a focus on research where: • The needs of Kentuckians and the Commonwealth are most pressing; and, • The University can continue to compete successfully for external research support. ( see: https://www.research.uky.edu/research-priorities-initiative ) • The UK Substance Use Priority Research Area (SUPRA) mission is to prevent and reduce the burden of substance use disorder (SUD) through conducting and translating multidisciplinary and innovative research to inform clinical services, training, public health practice and policy. 78
T HE HEAL ING C OMMUNITIES S TUDY A partnership with the National Institutes of Health (NIH), the National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) The funding announcement required specific evidence-based prevention and treatment interventions, including: prevention efforts related to opioid overdose; screening and assessment of opioid misuse and OUD; linkages and engagement in treatment; use of medications to treat OUD; and ongoing recovery support services. Integrated evidence-based interventions will be delivered in multiple settings and are required to include healthcare, behavioral health, and justice settings. 79
T HE HEAL ING C OMMUNITIES S TUDY The primary aim is to develop an evidence-based integrated strategy to reduce opioid-related overdose deaths by 40% in three years in at least 15 highly affected communities by: ➢ Increasing distribution of naloxone (Narcan) ➢ Increasing the number of individuals receiving medication treatment for opioid use disorder ➢ Increasing retention of people in treatment beyond 6 months ➢ Increasing the number of people receiving recovery support services 80
T HE HEAL ING C OMMUNITIES S TUDY $87 million was awarded to the University of Kentucky (one of four states to receive the award). Massachusetts, New York, and Ohio were also awarded. Our project is being conducted in partnership with numerous federal, state, community, public health, criminal justice, behavioral health, and health care partners. HEALing Communities Study – Kentucky is led by Dr. Sharon Walsh, Director of the UK Center on Drug and Alcohol Research 81
HCS Sites Massachusetts New York Ohio Kentucky Rural Urban
C OUNTY S ELECTION FOR HEAL ING C OMMUNITIES : K ENTUCKY Design 120 Counties in Kentucky Counties with ≥ 25 opioid overdose deaths per 100,000 residents 48 counties with > 25 opioid overdose deaths per 100k in 2017 48 in 2017 Counties without ‘ suppressed data ’ (i.e., ≥ 5 opioid 35 overdose deaths) Counties with justice infrastructure (i.e., jails) 28 Counties with treatment infrastructure (i.e., ≥ 1 25 provider licensed to prescribe medication) Counties with public health infrastructure 19 (i.e., SSP) Counties not already involved in a 16 major UK intervention project The served area encompasses over 1.8 million people (approximately 41% of the state’s population). 83
HEAL ING C OMMUNITIES : K ENTUCKY Projects were required to target at least 15 counties or cities highly affected by overdose, defined as: ➢ A rate of 25 opioid related overdose deaths per 100,000 persons or higher in the past year ➢ The Kentucky HEALing Communities counties had an average rate of 45.7 opioid-related overdose deaths per 100,000. ➢ Combined total of at least 150 opioid-related overdose fatalities ➢ The Kentucky HEALing Communities counties had a total 764 opioid-related overdose deaths in 2017. ➢ 30% of the counties/cities must be rural ➢ 44% of Kentucky HEALing Communities counties are rural 84
HEAL ING C OMMUNITIES : K ENTUCKY The project will be guided by local community coalitions and the following potential strategies: Expand access to overdose- reversing naloxone Provide peer support Link people leaving services to help jail and on people through probation/parole to recovery treatment and naloxone Reduce barriers to Link clients of harm medication treatment reduction programs and improve to treatment and retention in care naloxone Reduce high-risk prescribing and increase safe disposal of medications 85
T HE HEAL ING C OMMUNITIES S TUDY : K ENTUCKY C ARE T EAMS ➢ Every county in the project will receive a “Care Team” ➢ Communities will be engaged in a communication campaign to reduce stigma and improve awareness of services Community Coordinator Local coalition (ASAP Board) Treatment Care Jail Care Syringe Service Probation and Navigator Navigator Program Parole Prevention Prevention Specialist Specialist 86
T HE HEAL ING C OMMUNITIES S TUDY : K ENTUCKY S USTAINABILITY Train-the-trainer overdose education and naloxone training for local health department staff, local pharmacists, and first responders Rigorous evaluation of what works and what does not work could inform intervention rollout for other parts of the state Detailed cost-effectiveness analysis will be shared with policy-makers at the state and local level so that they can consider it in future program funding decisions 87
LMS Opioid Symposium Where to Get Help, MAT, Psychotherapy Mark Jorrisch, M.D., DFASAM Immediate Past President of KYSAM, distinguished Fellow of ABAM, Board Certified Internal Medicine and Addiction Medicine, practice at BHG Lexington, an OTP offering both methadone and buprenorphine, and at the MORE Center in Louisville, an OTP offering methadone.
Mark Jorrisch MD DFASAM Methadone Maintenance Treatment No disclosures
Heroin and the Reward Pathway Euphoria Heroin This is the reason (di-acetyl- heroin is Withdrawal Normal morphine) preferred over very morphine lipophilic by injection rapidly opioid crosses the Tolerance & Physical Dependence users blood brain barrier in Initial use Chronic use the Reward Alford DP. http://www.bumc.bu.edu/care/ Pathway
Development of Substance Use Disorders Involves Multiple Factors Biology Environment (Genes/Development) Drug / Alcohol Use Brain Mechanisms Substance Use Disorder
Reward & Reinforcement is… Ventral Tegmental ...in part Area (VTA) controlle Nucleus d by mu Accumbens with receptor projections s in the to Prefrontal Reward Cortex Pathway Dopaminer gic system Leshner AI. Hosp Pract. 1996
Longitudinal Trends in Recovery After 5 years <15% 100% It takes a year of relapse abstinence before 86% 86% 90% % Sustaining Abstinence Through Year 8 <50% relapse 80% 70% 66% 60% 50% 36% 40% 30% 20% 10% 0% 1 to 12 months 1 to 3 years 3 to 5 years 5+ years (n=157; OR=1.0) (n=138; OR=3.4) (n=59; OR=11.2) (n=96; OR=11.2) Duration of Abstinence at Year 7 Dennis ML et al. Eval. Rev. 2007
Medically Supervised Withdrawal Management (“Detox”) Low rates of retention in treatment High rates of relapse post-treatment < 50% abstinent at 6 months < 15% abstinent at 12 months Increased rates of overdose due to decreased tolerance O’Connor PG. JAMA. 2005. Mattick RP, Hall WD. Lancet. 1996. Stimmel B et al. JAMA. 1977.
Medications to Treat Opioid Use Disorders Goals Options Alleviate signs/symptoms of Opioid Antagonist physical withdrawal Naltrexone (full antagonist) Opioid receptor blockade Diminish and alleviate drug Opioid Agonist craving Methadone (full agonist) Normalize and stabilize Buprenorphine (partial agonist) perturbed brain neurochemistry
Naltrexone Mu-opioid receptor Oral naltrexone (generic and brand antagonist Revia) Well tolerated Not a controlled substance, no special Duration of action 24-48 hours prescribing restrictions FDA approved 1984 Patients physically dependent must be opioid IM injection extended- release free for a minimum of 7-10 days before naltrexone (Vivitrol) treatment IM injection (w/ customized needle) Also FDA approved for the treatment of once/month alcohol use disorders FDA approved 2010
Naltrexone Summary Difficulty starting — must be fully Good for patients who do not withdrawn from opioid; > short- want opioid agonist therapy Limitations acting (6 days); long-acting opioids Benefits No risk of diversion (not a (7-10 days) controlled substance) Not recommended for pregnant women. Pregnant women who are No risk of overdose by drug physically dependent on opioids itself should receive treatment using Can be administered in any methadone or buprenorphine setting (office-based or OTP) Not suitable for patients with severe Long-acting formulation liver disease Loss of tolerance to opioids increases the Treats both opioid use disorder risk of overdose if relapse occurs and alcohol use disorder Kampman, K. et al. (2015). The ASAM National Practice Guideline
Methadone Hydrochloride Oral: 80-90% bioavailability liquid, Full opioid agonist tablet, and disket formulations Proper dosing for OUD Duration of action 20-40 mg for acute withdrawal 24-36 hours to treat OUD > 80 mg for craving, “opioid blockade” 6-8 hours to treat pain Can be administered parenterally (IV, SQ or IM) at 80% of the total daily oral dose administered in a divided dose every 12 hours (e.g., 40 mg by mouth every day = 16 mg IV every 12 hours) Mercadante S. (2013) Handbook of Methadone Prescribing and Buprenorphine Therapy.
Methadone Maintenance in OTP Daily nursing assessment Highly Weekly individual and/or group counseling Random supervised drug testing structured Psychiatric services Medical services Observed daily → “Take Methadone homes” based on stability and time in treatment. Max: 27 take homes. Varies by dosing state, county and individual clinics
Methadone Summary: Benefits Decreases Increases Increases overall Decreases illicit hepatitis and treatment survival opioid use HIV retention seroconversion Decreases Increases Improves birth criminal activity employment outcomes Joseph et al. Mt Sinai J Med. 2000;67:347-364.
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