1 Screening For Substance Abuse: Opiate Abuse and Overdose-These Children Belong To UsKim C. Brownell MD Adult and Child Psychiatrist Hub Medical Director, ACCESS-MH CT Institute of Living/Hartford Hospital   Robert Dudley, MD, MEd, FAAP  Pediatrician  Community Health Center, New Britain  CT Chapter VP, AAP With special thanks to our colleagues J. Craig Allen, M.D. Medical Director, Rushford, ACCESS-MH CT Psychiatrist, Sam Silverman, M.D., Director of Medical Education, Rushford and Barbara Ward-Zimmerman, PhD. who have graciously shared their slides with us over the years.

2 Financial Disclosure We have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. We do not intend to discuss an unapproved/investigative use of a commercial product/device in our presentation.

3 Session Objectives Brief review of the Adolescent Substance Abuse Issue nationally and locally Describe the AAP recommendations for substance use screening. Review the use of a tracking system or chronic disease registry Understand the SBIRT methodology and how to apply it in a primary practice setting . Be able to use and interpret a standardized, validated substance abuse screen: (CRAFFT). Provide brief, meaningful interventions around substance use Navigate issues of adolescent confidentiality Develop a process and access the resources available to refer to higher levels of care when needed Review billing and reimbursement for substance abuse screening

4 Primary Care AdvantageLongitudinal, trusting relationship Family centeredness Opportunities for prevention and anticipatory guidance Opportunities to intervene early Experience in coordinating with specialists Familiarity with chronic care principles and practice improvement Comfort with diagnostic uncertainty

5 AUSA Tracy Lee Dayton, US Attorney’s Office, District of [email protected]

6 Young Adults 17% of 8th graders, 33% of 10th graders & 47% of 12th graders report alcohol use in the past month 11% of 8th graders, 21% of 10th graders & 28% of 12th graders report binge drinking (5 drinks in a row) in the past two weeks Johnston, O’Malley, Bachman, et al. Monitoring the Future Survey,

7 % with Alcohol DisorderAge at First Use and Later Risk Alcohol Marijuana % with Alcohol Disorder Age at First Drink Source: Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence. Arch Pediatr Adolesc Med. 2006;160:

8 Increase in Opiate Prescriptions, 1991-2013No. of Rx’s (millions) Nearly threefold increase in 22 years from 76 million to 207 million prescriptions. Volkow ND. America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. Natl. Inst. Drug Abus Available at:

9 Rates of opioid misuse by 12th gradersSource: Johnston LD, et al., Monitoring the Future – National Results on Adolescent Drug Use: Overview of Key Findings, 2011

10 AUSA Tracy Lee Dayton, US Attorney’s Office, District of [email protected]

11 AUSA Tracy Lee Dayton, US Attorney’s Office, District of [email protected]

12 AUSA Tracy Lee Dayton, US Attorney’s Office, District of [email protected]

13 AUSA Tracy Lee Dayton, US Attorney’s Office, District of [email protected]

14 Adolescence Provides a Window of OpportunityBrain is undergoing significant changes Vulnerable to risk-taking behavior and addiction A child who resists substance use completely until the age of 21, unlikely to suffer SUD during lifetime. Mental health and substance use are interrelated Co-occurring disorders Among youth (12-17yo) with a past year of SUD, over 23% had a major depressive episode in the past year. Substance use may be used as coping mechanism Suicide % tested positive for alcohol History of trauma

15 90% 75% 46% 12% Adolescent Substance Use:America’s #1 Public Health Problem A Problem of Epidemic Proportion 90% 75% 46% Of high school Students have Used addictive substances Of Americans started smoking, drinking, or using other drugs before age 18 12% Of high school Students are current users Of high school Students are addicted Why is Adolescence the Critical Period? Brain not fully developed= Increased chance that teens will Take risks Addictive substance have a Greater negative impact on the developing brain

16 Adolescence Use Related to Range of ProblemsDennis, M. L., & McGeary, K. A. (1999, fall). Adolescent alcohol and marijuana treatment: Kids need it now. TIE Communique, 10–12. (Retrieved from Adolescent%20Problems/youth_need_treat.html on May 7, 2008.) Office of Applies Studies. (1995). National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration. Source: Dennis & McGeary, 1999; OAS, 1995

17 Addiction is a Developmental Disease that starts in Childhood and Adolescence1.8 TOBACCO THC 1.6 ALCOHOL 1.4 1.2 1.0 % in Each Age Group to Develop First-time Dependence 0.8 0.6 0.4 Most new cases of drug dependence develop during adolescence. Perhaps there is something special (“sensitive”) about adolescence for developing addiction. 0.2 0.0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Age Age for tobacco, alcohol and cannabis dependence, as per DSM IV National Epidemiologic Survey on Alcohol and Related Conditions, 2003

18 Adolescents have different sensitivity to alcohol intoxication Compared to adults, adolescent show Decreased dysphoria with hangover Decreased sedation, motor impairment with acute intoxication Increased social facilitation with intoxication Increased memory disruption Silveri and Spear 1998;Markwiese et al. 1998; Schuckit 1995. not experience the same degree of incoordination and sleepiness are relatively resistant to the motor–impairing and sedative effects of alcohol) (Silveri and Spear 1998). more sensitive to alcohol–induced disruptions in spatial memory (Markwiese et al. 1998). less intense reaction may increase likelihood drink more heavily and more often (Schuckit 1995).

19 Effect of Drug Use on the Adolescent BrainShort term effects include: Impaired short-term memory, impaired motor coordination, altered judgment, decreased impulse control Long term effects include: Altered brain development, cognitive impairment, increased vulnerability to psychiatric disorders, and increased vulnerability to all substance use disorders FOR THE REST OF THEIR LIVES Three leading causes of death are closely tied to substance abuse Impaired short-term memory, making it difficult to learn and to retain information Impaired motor coordination, interfering with driving skills and increasing the risk of injuries Altered judgment, decreases impulse control, increasing the risk of sexual behaviors that facilitate the transmission of sexually transmitted diseases     Addiction Altered brain development Cognitive impairment, with lower IQ among more frequent users Increased risk of developing mood and anxiety disorders and other SUD Increased risk of chronic psychosis disorders (including schizophrenia) in persons with a predisposition to such disorders Risk of seizure, irreversible damage

20 AAP Recommendations Periodicity schedulePsychosocial/behavioral assessment at every well-child visit Depression screening at every well-child visit (11 y – 21 y) Alcohol and drug use assessment at every well-child visit (11y – 21 y) And appropriate acute care visits Periodicity deserves mentioning.SUD screening is recommended at every well visit and appropriate acute care visits. What is an appropriate acute care visit? Think about it. As an adult, is there a single medical visit you’ve been to in the past 2 years where you have not at minimum been asked about tobacco and/or alcohol use? It’s worth asking myself, “What indicator do I have that screening for substance use is absolutely unnecessary in the adolescent who appears before me today?” It may be a URI, but did they really need to come in for that, or is it their only way of asking for the real help they seek? To simplify things for the project, one option is to decide if the adolescent does not have a documented screening in the previous year, one should be performed, regardless of whether it is a health maintenance or acute care visit.

21 Questionnaires  Screening can be helpful (remember general considerations about screening) For initial recognition To confirm concerns already raised To have something to follow to gauge need for treatment or change of treatment Helps you remember the questions to ask

22 But recall screening limitationsPredictive value can be low Quality of responses probably depends on how screen is presented Difficulties with literacy and culture/language

23 Tool Selection Useful Resources for Selecting Measures Include:American Academy of Pediatrics’ Mental Health Toolkit (2010) Appendix chart in: Weitzman, C., & Wegner, L. (2015). Promoting optimal development: Screening for Behavioral and Emotional Problems. Pediatrics, 135(2), Massachusetts General Hospital School Psychiatry Program & Madi Resource Center Massachusetts Primary Care Behavioral Health Screening Toolkit

24 Key Steps to Implementing a Screening ProgramAssess current office protocols Identify a clinical champion and an administrative champion to maintain the initiative as a priority Select screening tool(s) Map the workflow Identify system supports (networking with community partners is key) Conduct staff orientations Share process and outcome data at regular intervals with staff and modify procedures as needed Tips from MassHealth: -Meet as an entire office group to plan for implementation -Identify at least two screening champions on staff. It is best if one is a clinical practitioner and the other an administrative staff person on the business side of the practice, e.g., office manager, billing manager. A champion is defined as someone who is well respected within the office and can be an advocate of the proposed change. These individuals can serve as point persons when others have questions - Identify a starting point. The office might consider having one clinician start screening first, or all clinicians may start with one particular age group. Another possibility is to choose one day of the week when all clinicians screen. Expand program as staff become accustomed to the process - Delineate who is to be involved in each step of the program - Centralize the community referral information so it is readily available to all staff -Experience has shown that behavioral health (or developmental) screening in primary care settings involves office staff members at every stage of the visit, from the person who greets families when they arrive, to the person submitting insurance claims after the appointment -The office’s weekly or monthly staff meeting is an ideal time for the initial group meeting to discuss behavioral health screening and for ongoing discussion o f program effectiveness and need for revisions -Distribution of screening forms: options include mailing the form in advance; giving the form at the time of arrival at the front desk (preferred option by most practices because it produces highest rate of completion and least disruption to office flow; and give at the time the patient enters the examination room -Prepare parents and patients for behavioral health screening. A simple way to do this is to put posters or pamphlets in the waiting area and exam rooms to introduce the concept and value of behavioral health screening -Revise process as needed

25 Consider developing a patient registry: It helps to recognize developmental and behavioral health issues as chronic conditions Maintain ongoing follow up PCP office should serve as the patient’s medical home Use a chronic care model for treatment. This can involve a “Chronic Disease Registry” in your office which could look like: -a cardex -an excel spread sheet -an electronic data bank Some offices will designate one person (medical assistant or nurse)to be in charge of all matters involving developmental and behavioral health issues e.g. ADHD diagnosis and follow up This person can help you with efficiency by making sure parents complete all relevant paperwork and that you have the results of Vanderbilt screening in a timely fashion. They can also obtain copies of any formal psycho educational testing done by school or specialists

26 Example Patient RegistriesEHR registry extracts patients with A1C >9% Care manager invites patient to a visit or interdisciplinary group medical appointment; design individualized plans to address areas of need (e.g., nutrition, exercise, pharmacological, behavioral health) Diabetic Patients with Recent Increase of A1C >9%

27 Take Away Messages Have an approach to identify and support youth affected by behavioral health concerns including substance abuse issues Consider using a validated screening tool Develop a chronic disease registry or tracking system Learn about coding and reimbursement so that you can be paid appropriately for doing the right thing Establish an office crisis plan for managing suicidal or dangerously impaired patients

28 Screening Strategy for Primary Care SettingsAssess for Substance Use Reassess regularly NO YES Assess for at-risk use NO YES Brief Behavioral Counseling for at-risk use Assess for disorder NO YES Refer for treatment of alcohol use disorder

29 Other Relevant AAP RecommendationsPediatrician should be able to have time with the adolescent without the parent in the room. If problem is discovered, discuss with patient how to disclose information to parent. It is suggested that you discuss limits of confidentiality with teen BEFORE you assess substance use beyond initial screener. States vary widely on what can remain confidential and at what ages. Use your clinical judgment, but be very aware of laws in your state.

30 SBIRT Mnemonic for… Screening Brief Intervention Referral to Treatment

31 Screening Casts a wide netIs applied to everyone in a target group – in this case, adolescents Not simply a yes or no answer; each level of use requires a response Kids do stupid things; substance use helps them do stupid things more stupidly- Even one-time use can lead to injury, violence, or risky sexual behavior! Just a few quick reminders of what a screening is. Screening is applied to a general population, to identify presymptomatic, pre-disease states, so that prevention and earlier intervention may be applied in an effective way. We don’t screen who we think we should screen, we screen everyone in a target group. Youth substance use screening is not just diagnostic, it’s to guide anticipatory guidance.

32 Adolescent Substance Use Screening & Assessment ToolsBrief Screens Screening to Brief Intervention (S2BI) Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD) Alcohol Screening & Brief Intervention for Youth (NIAAA/AAP) Assessment Guides Car, Relax, Alone, Friends/Family, Forget, Trouble (CRAFFT) Drug Abuse Screening Test - Adolescent Version (DAST-A) Alcohol Use Disorders Identification Test (AUDIT) There are a handful of screening and assessment options from which to choose. We are going to use S2BI as an illustration, but you may have existing requirements within your healthcare organization which you are required to use. NIAAA SBI is effective, but only covers alcohol. BSTAD at minimum has limitations including the specificity of some of the questions which may lend to underreportiing of use. Notice CRAFFT appears here as the highlighted model assessment guide. Many individuals and systems use CRAFFT as their initial screener. As we shall see, most kids do not require the CRAFFT because they report non-use.

33 Brief Intervention Focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. Brief intervention can be used as a stand-alone treatment for those at-risk as well as a vehicle for engaging those in need of more intensive levels of care. BI lasts, on average, 6-8 minutes but generally takes no longer than 15 minutes. A motivational interviewing approach is used which focuses on raising the individuals’ awareness of substance use and its consequences and motivating them toward positive behavioral change.

34 Motivational Interviewing:The Basis of a Brief Motivational Intervention Motivational Interviewing (MI) is a collaborative, patient-centered form of guiding to elicit and strengthen motivation for change. The Spirit of MI: Respects patient’s autonomy Fosters patient-centered collaboration Evokes/elicits patient’s own reasons for change Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). New York, New York: The Guildford Press. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). New York, New York: The Guildford Press. Miller W.R., Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychoter, 2009; 37: . Adolescent Substance Abuse: New Strategies for Primary Care

35 Core Assumptions of MI 1. Motivation is a state, NOT a traitMotivational interviewing is a directive, patient-centered counseling style that encourages patients to explore ambivalence and discover intrinsic motivation to change. Rollnick & Miller (1995) Motivational interviewing is based on 2 core assumptions: Motivation is a state that can be influenced by intra-personal interactions. Lecturing, directing or ordering an patient to change an entrenched or pleasurable habit will result in resistance (decreased motivation), while collaborative exploration of ambivalence will result in increased motivation. Ambivalence is normal. Making a lifestyle change is difficult, and thoughtful people will have moments when they are more or less motivated to adopt a change. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). New York, New York: The Guildford Press. Miller W.R., Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychoter, 2009; 37: Adolescent Substance Abuse: New Strategies for Primary Care

36 2. Ambivalence to change is normalAmbivalence is normal. Making a lifestyle change is difficult, and thoughtful people will have moments when they are more or less motivated to adopt a change. Stress, frustration, anger or resistance may indicate that an individual is considering the implications of change very seriously. Adolescent Substance Abuse: New Strategies for Primary Care

37 A Good Motivational Guide Will:Ask the person where he/she wants “to go” Listen to and respect what the person wants Inform the person about options to achieve their goal and see what makes sense to them

38 The four principles of motivational interviewing (EDRS):Express empathy: The provider makes a genuine effort to understand the client’s perspective and an equally genuine effort to convey that understanding to the client. This is an inherent element of reflective listening. Develop discrepancy: Listen for strategies that facilitate the client’s identification of discrepant elements of a particular behavior or situation. Example, values versus behaviors: client values being a responsible parent; however, the client is having difficulty tackling a heroin addiction. Areas of discrepancy may include: past versus present; behaviors versus goals. Roll with resistance –avoid argumentation: This is the provider’s ability to diminish resistance, connect with the client and move in the same direction. Avoid arguments. Expressing empathy, understanding why a client has a particular belief might be the intervention. Adjust to client resistance rather than opposing it directly. Support self-efficacy: This is the provider’s ability to support the client’s hopefulness that change or improvement is possible. Focus on the client’s strengths, previous successes, efforts and concerns. Key words: hope and optimism. Be optimistic.

39 Referral To Treatment Provides those identified as needing more intensive treatment with access to specialty care. The effectiveness of the referral process to specialty treatment is a strong measure of SBIRT success. Individuals will be referred to either Brief Treatment (BT) or more intensive treatment based on the primary care provider’s assessment after screening and discussion with patient. High risk individuals who are not willing to participate in more intensive treatment should be offered BT as an alternative.

40 Treatment Know your community resources!!!Rushford Intake-all referrals Outpatient treatment for adolescents available in Meriden and Glastonbury. Residential treatment for adolescent males ages at Stonegate in Durham, CT. Don’t be discouraged-it may take repeated encouragement with help from parents/caregivers to follow-through on recommended referrals. You can use AMHSA’s Substance Abuse Treatment Facility Locator Remember you are never alone in CT! ACCESS-MH CT is here to help. Co-localization or full integration of services is idea, l but may not be realistic for your practices. Start to build a database and network of specialty providers.

41 ACCESS-Mental Health CTHartford Hospital Wheeler Clinic, Inc Yale Child Study Center James- see other powerpoint for photos – please merge. Also – please add MAP first then photos of docs.

42 Committee on Substance AbuseAAP Policy Statement: Substance Use Screening, Brief Intervention, and Referral to Treatment for Pediatricians Committee on Substance Abuse Pediatrics 2011;128;e1330;originally published online October 31,2011;DOI: /peds :Volume 128, Number 5, November 2011ppe1330- Levy SJ, Williams JF, AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. Substance Use Screening, Brief Intervention, and Referral to Treatment. Pediatrics. 2016;138(1) e

43 Getting started: ScreeningS2BI developed at Boston Children’s Hospital uses a combination of S2BI + CRAFFT However, if screen negative, you lose the CAR question Also unclear with new screens if they will be reimbursable SO

44 For the purpose of this discussion, we will be using the CRAFFT as an example. Who can administer the CRAFFT? 1) the physician 2) a member of your office staff 3) the patient-via a self-administered written or electronic survey. Screening for substance use is most useful when conducted confidentially without a parent or guardian present. **Before screening, both patients and parents should be well informed about the confidentiality policy followed in your practice setting, including the safety- related limits that justify whether to continue or break confidentiality.**

45 CRAFFT –Screening Tool for Substance Use: 3 screening questions + “CAR” from CRAFFT1.Drink any alcohol (more than a few sips)? 2.Smoke any marijuana or hashish? 3.Use anything else to get high? (“Anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff.”) No to all (1+2+3) still =C All patients are asked the “C” (or “car”) question to determine if they have placed themselves at risk by riding with an alcohol- or drug-“influenced” or intoxicated driver. *Those who answer “yes” to any of the opening questions are asked all 6 CRAFFT questions*

46 CRAFFT

47 CRAFFT -This slide shows the written version of the measure. There is also an interview format, with the same questions on a card that is included in your toolkit.

48

49 Opening Questions

50 No to all (1+2+3) still =C

51 The CAR question Have you ever ridden in a CAR driven by someone (including yourself)who was “high” or had been using alcohol or drugs?

52 No to all (1+2+3) AND a NO to C Positive reinforcement

53 Yes To Car Question

54 Contact For Life www.sadd.org/contract.htm

55 Yes To ANY

56

57 Brief Advice

58 Brief Assessment

59 No Signs of Acute Danger

60 Signs of Addiction

61 Signs of Acute Danger

62 SBIRT Effectiveness SBIRT has been found to: Research has shown:Large numbers of individuals at risk of developing serious alcohol or other drug problems may be identified through screening in health care and other social service settings. SBIRT has been found to: Decrease the frequency and severity of drug and alcohol use Reduce the risk of trauma (car crashes, violence, suicide attempts) Reduce risky behavior (unprotected sexual encounters, DUI) Increase the percentage of individuals who enter specialized substance abuse treatment Improve quality-of-life measures (employment, housing stability, education status)  SBIRT has also been associated with fewer hospital days and fewer emergency department visits. Cost- benefit and cost-effectiveness analyses demonstrate net-cost savings from these interventions.

63 Substance Abuse and SBIRT Resources WAIT21.org

64 Reimbursement for ScreeningCPT Codes: Overview 96110 (developmental screening, with scoring and documentation, per standardized instrument), covers office overhead, i.e., the practice and malpractice expenses in the use of a screening instrument (nonphysician may give the instrument to the patient, score, and record but physician reviews) CT Medicaid requires specification of results: Positive or Negative (effective August 1, 2014) 96127 (brief emotional or behavioral assessment, with scoring and documentation, per standardized instrument) Code became effective nationally: January 1, 2015 CT Medicaid requires specification of results: Positive or Negative 99420 covers administration and interpretation of health risk assessment instruments, e.g., postpartum depression screening Coding Resource AAP Coding Hotline: Download the CT Provider Bulletin: PB HIPPA Update.pdf An additional code; 99408 (alcohol and/or substance abuse (other than tobacco) structured screening AND brief intervention services, 15 – 30 minutes, youth ages 14 and up

65 Getting Paid for SBIRT:Billing and Coding Full screen only : CPT diagnosis : alcohol V79.1 drugs V82.9 Full Screen plus Brief Intervention >/= 15 min Medicare G0396 >/= 30 min Medicare G0397

66 In summary remember to complete the steps using: TSATool(s) used Score(s) Achieved Action(s) taken-guidance provided to parents/child, referral made, etc.

67 The AAP recommends that pediatricians:Become knowledgeable about all aspects of SBIRT. Become knowledgeable about the spectrum of substance use and the patterns of nicotine, alcohol, and other drug use, particularly by the pediatric population in their practice area. Ensure appropriate confidentiality. Screen all adolescent patients for tobacco, alcohol, and other drug use with a formal, validated screening tool, such as the CRAFFT screen, at every health supervision visit and appropriate acute care visits, and respond to screening results with the appropriate brief intervention. Becoming familiar with motivational-interviewing techniques. Develop close working relationships with qualified and licensed professionals and programs that provide the range of substance use prevention and treatment services, including tobacco cessation, that are necessary for comprehensive patient care. Facilitate patient referrals through familiarity with the levels of treatment available in the area. Make referrals to adolescent-appropriate treatment for youth with problematic use or a substance use disorder. Remember that psychiatric disorders can co-occur in adolescents who use psychoactive substances. Remain familiar with coding regulations, strategies, and updates for billing. Advocate that heath care institutions and payment organizations provide mental health and substance use services across the pediatric/adolescent ages and developmental stages while ensuring parity, quality, and integration with primary care and other health services.

68 Prevention and early intervention can make a huge difference in the life of the future adult in front of you As Dr. Duby indicated, delayed initiation of substance use drastically reduces the likelihood of developing addiction. Put another way, individuals with severest SUD initiate use at younger age. You’re involved in this project because you recognize that substance use problems arise in youth, and their roots are often at much more tender ages than some of our bias would suggest. Delaying or preventing substance use can drastically reduce SUD, injury, and other negative sequelae of youth substance use. This is why our role can be so impactful.

69 Opiate Abuse Epidemic Nationally and LocallyThe CDC has declared this an epidemic. Overdose deaths from legal opioid drugs surged by 16.3% to 18,893. Overdose deaths from heroin climbed by 28% to 10,574.

70 Any type of opioid can trigger latent chronic addiction brain disease Opioids are any of various compounds that bind to specific receptors in the central nervous system and have analgesic (pain relieving) effects including prescription medications such as oxycodone and hydrocodone and illicit substances such as Heroin Opioid addiction is federally described as a progressive, treatable brain disease ASAM Addiction definition: Chronic, relapsing brain disease characterized by compulsive drug seeking behavior and drug use despite harmful consequence Any type of opioid can trigger latent chronic addiction brain disease 1.9 million Americans live with opioid pain reliever addiction and 517,000 are addicted to heroin. (NSDUH Report, 2015) Marcia Angell, M. D., is Senior Lecturer in the Department of Social Medicine at Harvard Medical School. She stepped down as Editor-in-Chief of the New England Journal of Medicine on June 30, 2000

71 “Overdosing is an accident that shouldn't be punished by death“Overdosing is an accident that shouldn't be punished by death.  Opioid overdoses are non intentional accidents due to a metabolic inefficiency caused when dose exceeds capacity for breakdown. Similar to any other drug toxicity but with an exceedingly high lethality.” Sam Silverman, MD. American Board of Addiction Medicine fellowship program Director, Rushford President Connecticut Chapter American Society of Addiction Medicine

72 Motor vehicle safety: A public health achievementMotor-Vehicle–Related Deaths Per Million Vehicle Miles Traveled (VMT) and Annual VMT, by Year—United States, Source: US Department of Health and Human Services

73 CDC has declared this an epidemic

74 Pre-test In Connecticut, is it legal for a pharmacist to give out Narcan/naloxone without a doctor’s prescription? a.) Yes b.) No In Connecticut, the number of deaths from unintentional opioid overdose in 2015 are trending to be ______ 2014? a.) equal to b.) less than c.) greater than 3. What demographic poses the highest risk for an unintentional opioid analgesic overdose death? a.) b.) c.) 45-54 4. Opioid Overdose Education and Naloxone Rescue Kit distribution programs in a community has been shown to a.) Increase the rates abuse of heroin and opioid analgesics b.) Increase referrals to treatment programs c.) Decrease the number of opioid overdose deaths d.) b and c

75 CME involving safe prescribing of opioids MD, APRN, PA and dentistsPassed June 30, Public Act No “AN ACT CONCERNING SUBSTANCE ABUSE AND OPIOID OVERDOSE PREVENTION” Authorizing Pharmacists to dispense or administer opioid antagonists once certified (list to follow). Mandatory use of the PMP if prescribing controlled substances for more than 72 hours and every 90 days for chronic treatment MD, APRN, PA and dentists CME involving safe prescribing of opioids MD, APRN, PA and dentists SUMMARY: currently, pharmacists may only dispense or administer drugs with a prescription. This bill allows licensed pharmacists if they have been trained and certified under a Department of Consumer Protection (DCP) commissioner-approved program

76 BY HOWARD KOH, MD, MPH on SEPTEMBER 2, 2015Who is abusing opioids? Young people (Partnership for Drug-Free America, 2005) College students (McCabe et al., 2005) Elderly (SAMHSA, 2005) Women (Manchikanti,2006; Green et al., 2008) Chronic pain patients (Butler et al., 2004, 2008; Passik et al.,2006) Street drug users (Davis & Johnson, 2008) Geographic patterns: greater in rural areas, but also seen among street-based users in large cities (Paulozzi et al., 2009; Brownstein et al., 2009) **Three-quarters of new users of heroin, initially began using prescription painkillers for nonmedical reasons. ** JAMA Forum: Community Approaches to the Opioid Crisis BY HOWARD KOH, MD, MPH on SEPTEMBER 2, 2015 Young people (Partnership for Drug-Free America, 2005) College students (McCabe et al., 2005) Elderly (SAMHSA, 2005) Women (Manchikanti,2006; Green et al., 2008) Chronic pain patients (Butler et al., 2004, 2008; Passik et al.,2006) Street drug users (Davis & Johnson, 2008) Exhibits geographic patterns: greater in rural areas, also seen among street-based users in large cities (Paulozzi et al., 2009; Brownstein et al., 2009)

77 Pain Management in the Patient with Psychological Co-MorbiditiesSource: National Vital Statistics System, 2012 Pain Management in the Patient with Psychological Co-Morbidities 5/14/2015

78 Risk Factors for Opioid OverdoseRecent emergency medical care for opioid intoxication/overdose Receiving prescriptions from multiple pharmacies and prescribers Daily opioid doses > 100 mg (morphine equivalents) Comorbid renal dysfunction, hepatic disease, or respiratory diagnoses (smoking/COPD/emphysema) History of opioid addiction or other substance use disorder Concurrent use of benzodiazepines or alcohol Comorbid mental illness Release from incarceration or discharge from a treatment facility Release from incarceration or discharge from a treatment facility Receiving a methadone prescription for pain management College of Psychiatric and Neurologic Pharmacists, 2015;

79

80 In 2013 the national average for opioid overdose deaths per 100,000 was 7.7Massachusetts 14.9 Connecticut 15.3 Rhode Island 20.4 Opioid overdose death rate higher in R.I. than in Massachusetts Rhode Island death rate — 20.4 per 100,000 — exceeds both neighboring states, according to Journal analysis Providence Journal April 28, 2015

81 2015 ? 616 In 2014 504 opioid related overdose deathsFor every overdose death, More than 30 people go to the emergency department for misuse or abuse 2015 ? 616 In deaths from car crashes RATE IN 2014 ACCORDING TO PROVIDENCE JOURNAK In the state of Connecticut from 2012 to 2014 the number of overdose deaths primarily involving heroin tripled. According to the Connecticut Chief Medical Examiner’s Office, those number will rise again in 2015 from 325 to nearly 390 .  The total number of accidental drug-induced intoxication deaths for opioids (heroin in combination with or attributable to other opioids oxycodone (ie. Percocet), hydrocodone (ie. Vicodin), fentanyl and buprenorphine ect) are on track to rise by over 20 percent from 504 to 616.

82 Strategies to address overdoseScreening and Brief Intervention and Referral Prescription monitoring programs Paulozzi et al. Pain Medicine 2011 Prescription drug take back events Safe disposal Safe opioid prescribing education Albert et al. Pain Medicine 2011; 12: S77-S85 Expansion of opioid agonist treatment Clausen et al. Addiction 2009:104; Safe injection facilities Marshall et al. Lancet 2011:377; Opioid Overdose Education and Naloxone Distribution Maxwell et al. J Addict Dis 2006:25; 89-96 Evans et al. Am J Epidemiol 2012; 174: 302-8 Coffin PO, et al. Ann Intern Med. 2013;158(1):1-9. Walley et al. BMJ 2013; 346: f174 https://www.scopeofpain.com/ BU ASAM

83 Rationale for Opioid Overdose Education and Naloxone DistributionMost opioid users do not use alone Known risk factors: Mixing substances, abstinence, using alone, unknown source Opportunity window: opioid OD takes minutes to hours and is reversible with naloxone Bystanders can be trained to recognize signs and symptoms of OD Fear of police can delay or interfere with timely intervention

84 Naloxone ≠ Suboxone ≠ NaltrexoneAbout Naloxone Naloxone reverses opioid-related sedation and respiratory depression = pure opioid antagonist Not psychoactive, no abuse potential May cause withdrawal symptoms May be administered IM, IV, SC, IN Acts within 2 to 8 minutes Lasts 30 to 90 minutes, overdose may return May be repeated Narcan® = naloxone Naloxone ≠ Suboxone ≠ Naltrexone

85 Who benefits most from Narcan training & prescription?Patients: with history or suspected history of substance abuse treated for opioid poisoning or intoxication at ED beginning Methadone or Buprenorphine therapy for addiction with higher-dose opioid prescriptions (>100 mg morphine equivalent/day) rotated from one prescription opioid to another with opioid prescriptions and: Benzodiazepine prescription Anti-depressant prescription Smoking, COPD, asthma, or other respiratory illness Renal dysfunction, hepatic illness, cardiac disease, HIV/AIDS Concurrent alcohol use

86 Narcan locator/ opioid prescribing / and other resources https://www.indiegogo.com/projects/naloxone-saves-lives#/ https://www.scopeofpain.com/

87 Narcan locator/ opioid prescribing / and other resourcesThe CO*RE/ASAM ER/LA Opioid REMS Course January 11, 2016 | Live Webinar | FREE CME January 16, 2016 | Westin La Paloma Resort & Spa | Tucson, AZ The ASAM National Practice Guideline on Medications to Treat Opioid Use January 25, 2016 | Live Webinar | FREE CME January 27, 2016 | Live Webinar | FREE CME Rushford intake

88 Pharmacies with naloxone certified pharmacistsBridgeport, Main Street Pharmacy 2117 Boston Ave Tel: Bristol, Beacon Prescriptions, 57 South St. Centerbrook, Quality Care Drug 33 main St Enfield, Able Care Pharmacy & Medical Supplies 15 Palomba Dr. T F Hartford, Hartford Healthcare Community Pharmacy, 85 Seymour St Dan Gleason Higganum, Higganum Pharmacy. 23 Killingworth Rd Naugatuck, CVS pharmacy in 98 Bridge St. (203)   New Haven, Visels Pharmacy 714 Dixwell Ave Norwalk, CIRCLE CARE Center Pharmacy 618 West Avenue  Oxford, Oxford Pharmacy 100 Oxford rd my phone number is   Frank Diaferio RPh Rockville, Rockville Pharmacy 40 West Main st,  phone Southington, Walgreens Pharmacy 359 Main St Phone (Iwona Zalewska) Beacon Pharmacy Southington, CT 609 North Main St Waterbury, Bunker Hill Pharmacy 256 Bunker Hill Ave West Hartford, Suburban Pharmacy 344 North Main St 5/14/2015

89 Post-test In Connecticut, is it legal for a pharmacist to give out Narcan/naloxone without a doctor’s prescription? a.) Yes b.) No In Connecticut, the number of deaths from unintentional opioid overdose in 2015 are trending to be ______ 2014? a.) equal to b.) less than c.) greater than 3. What demographic poses the highest risk for an unintentional opioid analgesic overdose death? a.) b.) c.) 45-54 4. Opioid Overdose Education and Naloxone Rescue Kit distribution programs in a community has been shown to a.) Increase the rates abuse of heroin and opioid analgesics b.) Increase referrals to treatment programs c.) Decrease the number of opioid overdose deaths d.) b and c

90 Who should be treating this problem?

91 All of us

92 These Children Belong To Us

93 AAP MAT (Medication-Assisted-Treatment) ResourcesTreating Youth With Opioid Use Disorder With opioid use disorder being identified in younger patients, it is critical for pediatricians to become trained and approved to provide medication-assisted treatment to youth. There is an insufficient number of providers of this life-saving service, fewer still with the willingness and developmental expertise to provide it to adolescents and emerging adults. This 8-hour online course is free to AAP members and will allow them to apply for a waiver to prescribe buprenorphine as part of treatment of young people with opioid use disorder and learn about the use of naltrexone. The course can be accessed at www.aap.org/mat

94 Treatment options Pharmacologic treatment options: MethadoneBuprenorphine Naltrexone Alpha adrenergic agonists (clonidine) Psychosocial support: 12 step programs Cognitive Behavioral Therapy, Motivational Enhancement Therapy etc

95 Buprenorphine Suboxone© Subutex©

96 What is buprenorphine? Partial µ-opioid agonistHigh receptor affinity and receptor occupancy: 95% occupancy at 16 mg (Greenwald et al, 2003) Blockade or attenuated effect of the use of additional opioids Lower intrinsic activity than full agonists: Favorable safety profile due to “ceiling” effect Lower street value Lower abuse potential (Walsh and Eissenberg, 2003)

97 Pharmacologic benefitsSlow receptor dissociation: Longer duration of action Milder withdrawal Lower physical dependence liability than full agonists Limited development of tolerance Ceiling effect on respiratory depression Increased safety against overdose

98 Mu Receptor Associated with opioid addiction Mu is for morphineOpioid Receptor Types Mu Receptor Associated with opioid addiction Mu is for morphine Morphine for Morpheus Greek God of Dreams Activation produces analgesia, but also euphoria

99 Receptor DissociationDISSOCIATION is the speed (slow or fast) of disengagement or uncoupling of a drug from the receptor With buprenorphine and methadone the dissociation is slower Therefore receptor remains occupied and adding a substance results in lower or no euphoric response Mu Receptor Bup dissociation is slow Therefore Full Agonists can’t bind

100 Partial /Full Agonist Activity Levels% Mu Receptor Intrinsic Activity 10 20 30 40 50 60 70 80 90 100 Full Agonist (e.g. heroin) But due to its “ceiling” maximum opioid agonist effect is never achieved Partial Agonist (e.g. buprenorphine) Like full agonists, partial agonist drugs produce increasing mu opioid receptor specific activity at lower doses no drug high dose DRUG DOSE low dose

101 Effects of buprenorphine on -opioid receptor availabilityBup 0 mg Bup 2 mg Bup 16 mg Bup 32 mg 0 - 4 - MRI Binding potential (Bmax/Kd)

102 Staying in Treatment Pharmacologic treatment in combination with psychosocial interventions significantly enhances treatment effectiveness: Retention after 1-year treatment, 75% and 0% in buprenorphine and placebo groups respectively (Kakko et al, 2003) Pharmacotherapy helps patients stay in treatment: Reduces illicit drug use due to decreased cravings and withdrawal symptoms Reduces mortality by up to 4-fold (Kreek and Vocci, 2002)

103 Once opiate addicted, why isn’t it easy to stop?Withdrawal from opioids is associated with an extremely unpleasant syndrome: Physical pain (muscle aches, cramps) Nausea and vomiting Diarrhea Dysphoria Depression Irritability and anxiety Dysregulation of brain reward systems

104 Protracted Withdrawal StateAn altered mental state that follows acute Opioid Withdrawal Syndromes May lasts for weeks to months May include insomnia, dysphoria, and opioid craving No clearly specific pharmacologic treatments for this state but it may explain… …why opioid agonist maintenance treatment outcomes are so much better than abstinence based treatment outcomes …why longer duration of tapering agonist drugs as a withdrawal treatment has better outcome than a short taper

105 Federal Opioid Legislation (CARA) Comprehensive Addition and Recovery Act:The bill is an attempt to address the growing rate of overdose deaths from heroin and other opioids Comprehensive Addition and Recovery Act: 1. Expands access to medication-assisted treatment 2. Further expands access to naloxone 3. Expands access to prescription drug monitoring programs 4. Expands prevention and education efforts 5. The bill provides no new funding to address the issue For more information on resources available in Connecticut for addiction to heroin and opioids, go to 1. Expands access to medication-assisted treatment Seen as a critical avenue to address opioid addiction, the bill would allow nurse practitioners and physician assistants to prescribe buprenorphine. Previously, prescriptions for buprenorphine, which is commonly marketed as Suboxone, were limited to doctors, who could only prescribe it to 100 patients. The bill also creates a Department of Health and Human Services grant program to expand medication-assisted treatment. “Extending the prescriptive authority for buprenorphine based medications to nurse practitioners and physician assistants is crucial and should be a game changer in the fight against the epidemic of opioid overdoses,” said J. Craig Allen, MD, an addiction medicine specialist and medical director at Rushford, which is part of the Hartford HealthCare Behavioral Health Network. Dr. Allen said the legislation should allow nurse practitioners and physician assistants, working closely with physicians, to prescribe life-saving medications. He said physicians who prescribe Suboxone are currently scarce, with filled caseloads, so this expansion would greatly increase access for those suffering from this disorder. Dr. Allen added that successful treatment of opioid use disorders requires incorporating medication-assisted treatment into psychosocial treatments. The Behavioral Health Network has extensive experience with this model of care which emphasizes coordination between medical and non-medical addiction treatment providers, with specialized MAT treatment centers located across the state Further expands access to naloxone Naloxone, an opioid overdose-reversing drug, can bring people back from the brink of death when used by first responders. The new legislation aims to expand access to the drug, already readily available in Connecticut, on a national level. A key stipulation would be expanded access for law enforcement and first responders. A growing contingent of people have also seen a benefit of getting the drugs in to the hands of family and friends of addicts. 3. Expands access to prescription drug monitoring programs A tool of growing importance when dealing with the opioid crisis, the prescription monitor program allows doctors to see a patient's prescription history to avoid doctor shopping or other avenues of abuse. With this legislation, nurse practitioners and physician assistants would be able to access the programs as well. 4. Expands prevention and education efforts Another key strategy to addressing the opioid crisis is education and prevention. By properly educating teens, young adults and their families, they will be less likely to get addicted to dangerous drugs, research shows. The bill would increase efforts towards education and prevention. 5. The bill provides no new funding to address the issue Across Connecticut, and likely across the country, those on the front lines of the issue have said there's too small a pool of resources and money to properly address the crisis, which has grown in impact year-to-year. Legislators from Connecticut have been among those pressing for new funding to be attached to the bill. The legislation authorizes federal grants from the Justice Department and HHS, but does not fund them. Members in the House and Senate tried to amend it to include hundreds of millions of dollars in support, but the final bill did not include it. For more information on resources available in Connecticut for addiction to heroin and opioids, go to

106 https://www.scopeofpain.com/ BUASAM

107

108 Suboxone SUBOXONE® (buprenorphine and naloxone) Sublingual Film (CIII) is a prescription medicine indicated for treatment of opioid dependence and should be used as part of a complete treatment plan to include counseling and psychosocial support. Treatment should be initiated under the direction of physicians qualified under the Drug Addiction Treatment Act. This requires the physician to complete training, apply for a a waiver and receive a special DEA number that starts with an X SUBOXONE Film can be abused in a manner similar to other opioids, legal or illicit. SUBOXONE Film contains buprenorphine, an opioid that can cause physical dependence with chronic use. Physical dependence is not the same as addiction. Do not stop taking SUBOXONE Film suddenly without talking to your doctor. You could become sick with uncomfortable withdrawal symptoms because your body has become used to this medicine.

109 Suboxone continued… SUBOXONE Film can cause serious life-threatening breathing problems, overdose and death, particularly when taken by the intravenous (IV) route in combination with benzodiazepines or other medications that act on the nervous system (ie, sedatives, tranquilizers, or alcohol). It is extremely dangerous to take nonprescribed benzodiazepines or other medications that act on the nervous system while taking SUBOXONE Film. You should not drink alcohol while taking SUBOXONE Film, as this can lead to loss of consciousness or even death. Death has been reported in those who are not opioid dependent. Your doctor may monitor liver function before and during treatment. SUBOXONE Film is not recommended in patients with severe hepatic impairment and may not be appropriate for patients with moderate hepatic impairment. However, SUBOXONE Film may be used with caution for maintenance treatment in patients with moderate hepatic impairment who have initiated treatment on a buprenorphine product without naloxone.

110 Suboxone continued… Accidental or deliberate ingestion by a child may cause respiratory depression that can result in death. If a child is exposed to one of these products, medical attention should be sought immediately. Instruct patients never to give these products to anyone else, even if he or she has the same signs and symptoms. They may cause harm or death. Advise patients that selling or giving away buprenorphine-containing products is against the law.

111 Suboxone continued… Pediatric UseThe safety and effectiveness of SUBOXONE sublingual film have not been established in pediatric patients. This product is not appropriate for the treatment of neonatal abstinence syndrome in neonates, because it contains naloxone, an opioid antagonist. Buprenorphine is a Schedule III narcotic under the Controlled Substances Act. Under the Drug Addiction Treatment Act (DATA) codified at 21 U.S.C. 823(g), prescription use of this product in the treatment of opioid dependence is limited to physicians who meet certain qualifying requirements, and who have notified the Secretary of Health and Human Services (HHS) of their intent to prescribe this product for the treatment of opioid dependence and have been assigned a unique identification number that must be included on every prescription

112 Suboxone continued… Clinical guidelines for buprenorphine treatment and general information on the treatment of addiction is available through numerous sources such as the following: Substance Abuse and Mental Health Services (SAMHSA) Center for Substance Abuse Treatment (CSAT) Web site at American Society of Addiction Medicine Web site at and the American Academy of Addiction Psychiatry website at For more information, call our toll-free help line at SUBOXONE ( ) or visit our Web site at Please see enclosed full Prescribing Information Attachment to Pharmacist Brochure: SAMPLE 42

113 Suboxone continued… Attachment to Pharmacist Brochure: SAMPLE 42 CFR Part 2.31 Consent Form 1.I (name of patient) ________________________________{time} Authorize: 2. Dr.___________________________________________________________________ 3. To disclose: (kind and amount of information to be disclosed) Any information needed to confirm the validity of my prescription and for submission for payment for the prescription. 4. To: (name or title of the person or organization to which disclosure is to be made) The dispensing pharmacy to whom I present my prescription or to whom my prescription is called/sent/faxed, as well as to third party payors. 5. For (purpose of the disclosure) Assuring the pharmacy of the validity of the prescription, so it can be legally dispensed, and for payment purposes. 6. Date (on which this consent is signed)___________________________________ 7. Signature of patient _________________________________________________ 8. Signature of parent or guardian (where required)

114 Suboxone Cautions: age, pregnancy, breastfeeding, liver functionPregnancy: Based on animal data, buprenorphine (the active ingredient in SUBOXONE) may cause fetal harm Nursing mothers: Caution should be exercised when SUBOXONE is administered to a nursing woman Safety and effectiveness of SUBOXONE in patients below the age of 16 has not been established Administer SUBOXONE with caution to elderly or debilitated patients SUBOXONE sublingual film is not recommended for use in patients with severe hepatic impairment and may not be appropriate for patients with moderate hepatic impairment

115 Special urine cups phone | ext 126/ toll free: / fax: Fern Ave #703 Shreveport, LA 71105 website | americanscreeningcorp.com WE pay $4.00/per cups for 13 panel.  J. Craig Allen, MD Medical Director

116 Answers from AAP All 3 options provided will allow pediatricians to obtain their waiver. It’s your preference as to which method works best for you. The course is strictly clinical management. It will not connect you with referral sources for therapy. The hope is that you will be able to provide treatment to any adolescent patients of yours that you find have an opioid use disorder. Also, there is a directory of buprenorphine providers at assisted-treatment/physician-program-data/treatment-physician-locator It is possible for youth not currently being seen by you may contact you for treatment. I have heard that many buprenorphine prescribers are hesitant to treat youth, making it all that more important that pediatricians become treatment providers.

117 Questions about MAT from a pediatricianThere are several options for training:  https://www.aap.org/en-us/my-aap/Pages/Pediatric- Online-Waiver-Training.aspx?nfstatus=200&nftoken=966886f caa-b25b- 6b2c1ca92f8c&nfstatusdescription=Set+the+cookie+token • Online 8-Houre Course • Live 8-Hour Course • Half Online / Half Live Option Will it matter which option to choose from? (Learning style only) And will the training help identify who to partner with for counseling and other support. In other words is the intention to be a resource for our patients or for new patients in the community?  

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119 Conclusion: SBIRT can be time-efficient, SBIRT is effective,Remember it is all about promoting child health and mitigating risk! Substance use issues do not have to be solved in one visit, whenever possible, it is always best to keep services within the medical home.

120 WAIT21.ORG Why Wait? 90% of those that struggle with addiction started before age If you smoke drink or use before age 21 – you have a 1 in 4 chance of becoming addicted. After 21 , it is a 1 in 25 chance Annual recovery rate for addiction is about 5% / year– total number of people affected is about 40 million Addiction is third leading Cause of Death in USA

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122 Questions/comments