Governor Corbett s Heroin and Other Opioids Workgroup. Report and Recommendations for Reducing Heroin and Other Opioid Abuse and Overdose

Transcription

1 Governor Corbett s Heroin and Other Opioids Workgroup Report and Recommendations for Reducing Heroin and Other Opioid Abuse and Overdose September 2014

2 September 30, 2014 The Honorable Tom Corbett Governor Commonwealth of Pennsylvania 225 Main Capitol Building Harrisburg, Pennsylvania Dear Governor Corbett: On behalf of the members of the Governor s Heroin and Other Opioids Workgroup, I am pleased to present you with our Report and Recommendations for Reducing Heroin and Other Opioid Use and Overdose. In recent years, there has been a sharp escalation of deaths resulting from heroin and other opioids. This epidemic has spread across Pennsylvania, reaching more and more of our families and children. We know that one in four families struggle with a substance abuse problem. Coroners reports since 2009 have shown there have been more than 3,000 deaths due to overdose. This does not include many other uncounted related deaths from accidents, diseases, medical complications and suicides. Additionally, addiction results in the loss of employment and productivity, increased crime and healthcare costs, shattered families and unnecessary human suffering across Pennsylvania. While no one sets out to become addicted, we know that approximately 80 percent of heroin users began with abusing prescription opioids, many of which were legitimately prescribed. In the past year, the Federal Drug Administration has strengthened the warning labels on longlasting opioids to warn of their addictive potential, even when they are taken as prescribed. Further, physical dependence can develop when prescription opioids are used for as little as two weeks. You established this workgroup to develop a comprehensive, multi-faceted approach to address the problem of heroin and other opioid use and overdose deaths. Accordingly, you tasked all state agencies under your jurisdiction to provide input in developing such a plan. Your call for a comprehensive response reflected the underlying reality that all agencies in state government and indeed, all Pennsylvanians are in some manner impacted by substance use disorders and their potentially devastating consequences.

3 The Honorable Tom Corbett -2- September 30, 2014 Your workgroup and its subcommittees created five categories under which 13 total recommendations were identified. While the charge was to establish strategies to reduce heroin and other opioid use and overdose, our recommendations in many cases necessarily address the more overarching issue of substance use disorders in general. I believe that you will find the recommendations have the potential for a broad, substantive impact that will improve public health, reduce crime and save taxpayers dollars. I offer my sincere appreciation to the members of the workgroup for their dedication and commitment to this initiative. On behalf of the Governor s Heroin and Other Opioids Workgroup, I thank you for your wise and outstanding leadership in not only establishing this particular initiative, but for your overall commitment to addressing the issues of substance use disorders, and to the citizens of Pennsylvania who live with its costly and often life-threatening impact. Sincerely, Gary Tennis Secretary Department of Drug and Alcohol Programs

4 TABLE OF CONTENTS Executive Summary 1 Introduction 4 A. Safe and Effective Use of Prescription Opioids 6 Safer Prescribing Practices: Recommendation A.1 7 Safer Dispensing Practices: Recommendation A.2 8 Reforms to Workers Compensation: Recommendation A.3 10 Prescription Drug Monitoring Program: Recommendation A.4 11 B. Access to Treatment 14 Provider Education: Recommendation B.1 14 Benefit Education: Recommendation B.2 16 Increased Access through Public Private Partnerships: Recommendation B.3 18 Expansion of Restrictive Intermediate Punishment: Recommendation B.4 20 C. Licensing: Professional Interventions 23 Health-related Boards: Recommendation C.1 23 Business-related Boards: Recommendation C.2 25 D. Education: Prevention, Intervention and Outreach 28 Evidence-based Prevention: Recommendation D.1 28 Information Dissemination: Recommendation D.2 30 E. Overdose Response 32 Naloxone: Recommendation E.1 32 Good Samaritan: Recommendation E.1 33

5 EXECUTIVE SUMMARY Governor s Heroin and Other Opioids Workgroup Recommendations September 2014 Similar to rising trends across the nation, overdose deaths in Pennsylvania have been on the rise over the last two decades. To strengthen and expand current initiatives, Governor Corbett held a press conference on May 9, 2014, calling for a unified and concerted effort across all of state government to deal with these issues. Stemming from this event, Governor Corbett then convened the Governor s Heroin and Other Opioids Workgroup, with the Department of Drug and Alcohol Programs appointed as the lead agency for this initiative. All cabinet-level agencies and other state offices under the Governor s jurisdiction were directed to recommend multidisciplinary initiatives to effectively combat opioid abuse and the loss of life by drug overdose in the commonwealth. The workgroup first convened in June 2014 and met on various occasions throughout the process. Five strategic subcommittees were formed to specifically address the most critical areas of concern. The recommendations which follow are the collective result of this effort. The plan provides a comprehensive approach with the overarching goal of increasing public and private collaboration to stop the cycle of addiction and stem the growing heroin and opioid abuse and overdose epidemic statewide. A. SAFE AND EFFECTIVE USE OF PRESCRIPTION OPIOIDS Mis-prescribing and overprescribing opioid analgesics too often lead to the illicit use of prescription opioids and, ultimately, heroin. Because of this, specific strategies for prescribing and dispensing prescription medications have been considered as an effective mechanism for reducing excessive availability of substances that are abused. Recommendation A.1 Support Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Non-Cancer Pain and the Pennsylvania Emergency Department Pain Treatment Guidelines and encourage adoption of prescribing guidelines for other healthcare contexts by taking all necessary steps to educate all prescribers across the commonwealth. Recommendation A.2 Establish a public-private partnership between the insurance industry and appropriate state agencies to reduce opioid misuse and overdose. Recommendation A.3 Encourage and support legislative efforts to address unsafe and excessive prescribing practices in the context of Workers Compensation. Recommendation A.4 Encourage and support legislative efforts regarding expansion of access to the existing Prescription Drug Monitoring Program database and prepare for enactment. 1

6 B. ACCESS TO TREATMENT Like diabetes, hypertension, asthma and other chronic illnesses, substance use disorders are progressive, chronic, and eventually fatal if not treated. Individuals who have a substance use disorder should have adequate access to clinically appropriate care. Recommendation B.1 Increase healthcare provider education and awareness by encouraging appropriate training for physicians and other healthcare providers regarding substance use disorders, screening and expeditious referral to treatment. Recommendation B.2 Increase education and awareness to the commonwealth workforce and their family members about substance use disorders, including access to care via the State Employee Assistance Program and the Pennsylvania Employees Benefit Trust Fund. Recommendation B.3 Increase public-private partnerships to adequately and appropriately address substance use disorders via: a) Cross-agency training to increase awareness about drug addiction, including the dangers of opioid misuse, overdose prevention and appropriate overdose response methods; b) Establishing collaborative partnerships with third party insurers including HealthChoices Managed Care Organizations, Medicare, and Pharmacy Benefit Managers to improve awareness of treatment benefits and access to care to ensure timely assessment, referral and engagement in the clinically appropriate intensity and duration of care; and, c) Addressing the drug addiction and overdose issue through the State Healthcare Innovation Plan. Recommendation B.4 Work in collaboration with the Pennsylvania District Attorneys Association, appropriate state agencies and other entities to expand availability of Restrictive Intermediate Punishment treatment diversion sentences for offenders currently being sentenced to county jail or to low-level state prison sentences, and explore appropriate ways of effectuating the diversion post-arrest rather than at sentencing. C. LICENSING: PROFESSIONAL INTERVENTIONS In order for substance use disorders to be treated in a similar fashion as other chronic illnesses, it is necessary for healthcare and other licensed professionals to have an understanding about the disease of addiction, as well as the recovery process. Most individuals in the early stages of the disease are in the workforce. Therefore, strategies to address substance use and abuse with these individuals have greater efficacy and are more cost effective. 2

7 Recommendation C.1 Develop and implement an education program for the health-related boards administered by the Department of State s Bureau of Professional and Occupational Affairs. Recommendation C.2 Develop an education and engagement program, coordinating with Department of Drug and Alcohol Programs, Department of State s Bureau of Professional and Occupational Affairs, Division of Professional Health Monitoring Programs and the Department of Labor and Industry that has maximum impact on the overall lost productivity and profits aspects of drug addiction. D. EDUCATION: PREVENTION, INTERVENTION AND OUTREACH It is necessary for everyone in Pennsylvania, professionals and citizens alike, to be made aware of the dangers of medication misuse, addiction and recovery, and how to prevent and respond to overdose. Recommendation D.1 Establish an informal, internal Executive Prevention Council of the top prevention experts from the Pennsylvania Commission on Crime and Delinquency and the Departments of Drug and Alcohol Programs, Education, and Public Welfare, to identify best practices and evidence-based substance use disorder prevention programs and establish sound parameters for the utilization and funding of such programs to ensure that taxpayer dollars are spent wisely and effectively. Recommendation D.2 Distribute information internally to employees and externally to the general public through all commonwealth agencies that engage in information dissemination (Department of Drug and Alcohol Programs will help to identify brochures, web-based, social media, and other resources that will be effective, based on up-to-date research). E. OVERDOSE RESPONSE While most of the initiatives identified in this report will likely take time to actually impact overdose rates, there are immediate, life-saving measures that can be implemented on the scene of an overdose, such as increased access to Narcan (naloxone hydrochloride). Furthermore, individuals are not likely to receive necessary emergency help if others present at the scene are fearful of legal ramifications should they make a call to 911. Recommendation E.1 Support and anticipate current legislative efforts aimed to prevent opioid-related overdose deaths by expanding access to naloxone for concerned third parties, in conjunction with appropriate training, and by permitting limited legal protections for witnesses seeking medical help at the scene of an overdose. 3

8 INTRODUCTION Over the last two decades the abuse of prescription medications has skyrocketed, which has correlated with an increase in heroin use. Tragically, this has led to historically unprecedented levels of overdose-related deaths. The Pennsylvania Department of Health (DOH), Bureau of Health Statistics and Research reports an increase in overdose deaths from 2.7 to 15.4 per thousand from Between 2009 and 2013, nearly 3,000 heroin-related overdose deaths were identified by county coroners in Pennsylvania. 2 This does not include those deaths that were otherwise attributed to car accidents, medical complications, homicide, etc. The heroin epidemic has spread to rural and suburban communities previously unharmed by such widespread heroin abuse, and instead of this upward trend flat-lining or decreasing, abuse and overdose continue to escalate, resulting in the loss of life across every age group and demographic. Under the leadership of Governor Tom Corbett, a number of initiatives have been underway to address this epidemic. The Healthy Pennsylvania Prescription Drug Take-Back Program, through a grant from the Pennsylvania Commission on Crime and Delinquency (PCCD) and the Staunton Farms Foundation, provided 203 prescription drug take-back boxes in 33 counties statewide. This safe and secure way to dispose of unused medications has resulted in the collection of more than 8,000 pounds of prescription drugs since the beginning of the 2014 calendar year. More boxes have been purchased and will continue to be installed throughout the state. In order to address the over-prescribing of opioids, Pennsylvania Physician General Dr. Carrie DeLone and Department of Drug and Alcohol Programs (DDAP) Secretary Gary Tennis convened the Safe and Effective Prescribing Practices and Pain Management Task Force. This task force, consisting of medical professionals, associations and regulatory agencies, was founded to develop opioid prescribing guidelines. After eight months, the task force finalized two sets of guidelines establishing the best and safest prescribing and pain management practices: one addressing prescribing for chronic non-cancer pain and one for use in hospital emergency departments. These guidelines have since been adopted by major medical provider groups in Pennsylvania, beginning with the Pennsylvania Medical Society. The task force is currently working to establish a third and final set of guidelines to address the safe prescribing of opioids by dentists and will expand our current efforts to promote the widespread use of these guidelines with members of all prescribing healthcare professions. 1 United States. Pennsylvania Department of Health. Epidemiologic Query and Mapping System. Pennsylvania Department of Health, Sept Web.1 Aug (These data were provided by the Bureau of Health Statistics and Research, Pennsylvania Department of Health. The Department specifically disclaims responsibility for any analyses, interpretations, or conclusions.) 2 Shanaman, S. M., & Zappone, C. J. (2013). Heroin overdose death report. Retrieved from 4

9 In July 2013, in response to upward trends in heroin and fentanyl overdoses, Secretary Tennis convened an Overdose Rapid Response Task Force to improve real-time communication regarding drug trends between emergency healthcare providers, law enforcement and drug treatment providers, and to improve our treatment interventions for those who survive overdoses. Treatment access is also addressed in the Governor s federally approved Healthy Pennsylvania plan. This plan increases healthcare access to uninsured individuals through the Private Coverage Option which establishes a new commercial benefit plan for approximately 600,000 eligible Pennsylvanians between the ages of 21 and 64 with incomes of up to 133 percent of the Federal Poverty Level. Individuals who are eligible will be able to choose between at least two health plans offered by participating insurance carriers in their area. Coverage under this plan will include drug addiction treatment. To strengthen and expand current initiatives, Governor Corbett held a press conference on May 9, 2014, calling for a unified and concerted effort across all of state government to deal with the heroin/opioid abuse and overdose crisis in the commonwealth. Governor Corbett convened the Governor s Heroin and Other Opioids Workgroup, with DDAP appointed as the lead agency for this initiative. All cabinet level agencies and other state offices under the Governor s jurisdiction were directed to recommend multi-disciplinary initiatives to effectively combat opioid abuse and the loss of life by drug overdose. The workgroup convened in June 2014 and met on various occasions throughout the process. Five strategic subcommittees were formed to specifically address the most critical areas of concern. Key recommendations were identified through a careful process that considered issues and strategies that would have the greatest impact in the most timely and cost-effective manner. The recommendations which follow are the collective result of this effort. The plan provides a comprehensive approach with the overarching goal of increasing public and private collaboration to stop the cycle of addiction and stem the growing heroin and opioid abuse and overdose epidemic statewide. 5

10 A. SAFE AND EFFECTIVE USE OF PRESCRIPTION OPIOIDS Over the last two decades, there has been a significant increase in the accessibility to and the abuse of prescription medications. The number of prescriptions written for opioids has escalated from 76 million in 1991 to nearly 207 million in In addition to the increased number of prescriptions written and dispensed, a greater social acceptability regarding the use of medications for a variety of purposes has also contributed to the extensive availability of prescription medications, and specifically, opioid analgesics. 4 Similarly, overdose deaths due to prescription opioid pain relievers alone have more than tripled in the past 20 years, escalating to 16,651 deaths in the United States. 5 Researchers at the Centers for Disease Control and Prevention (CDC) reported that overall drug overdose was the leading cause of injury death in Among individuals 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes. 6 It is important to note that these numbers include those individuals who are or will become addicted and consequently abuse their medications, as well as those who use their medications as prescribed, but may fall victim to overdose as a result of other high-risk circumstances. Such situations include taking a combination of prescribed medications without knowing the implications for interaction, having a personal or family history of addiction, having a high-risk medical condition that may increase the potential for opioid overdose (e.g., Sleep Apnea, Chronic Obstructive Pulmonary Disease), and medication compliance or error especially in the elderly, such as taking a repeat dose within too short a period of time. 7 In fact, some data suggests that 60 percent of prescription opioid deaths occur in patients without a history of substance abuse who are taking opioids prescribed by one practitioner. 8 3 Opioid Prescriptions Dispensed by US Retail Pharmacies. IMS Health, Vector One: National, Years , Data Extracted 201. IMS Health, National Prescription Audit, Years , Data Extracted Retrieved from 4 Volkow, N. D. (2014). Prescription Opioid and Heroin Abuse. Retrieved from 5 (see footnote 3) 6 Centers for Disease Control and Prevention. (2014). Prescription Drug Overdose in the United States: Fact Sheet. Retrieved from 7 Richards, K. L. (2007). Opioid use linked to sleep apnea. Retrieved from 8 Edwards, E. & Read, E. (2014). Prescription opioid overdose: Providing a safeguard for at-risk patients. Retrieved from Providing-a-Safeguard-for-At-Risk-Patients# 6

11 Safer Prescribing Practices Mis-prescribing and overprescribing narcotic analgesics too often leads to the illicit use of prescription opioids and, ultimately, to heroin use. This occurs when a narcotic pain medication has been prescribed for a legitimate medical necessity and the patient inadvertently develops a dependency to the opioid. As tolerance to the medication increases and the desired effect cannot be maintained through prescription opioids, heroin is often substituted because it is more easily available and significantly more affordable. As is commonly reported in media sources and elsewhere, the street price of heroin has dropped considerably. Approximately 80 percent of individuals who have progressed to heroin initially abused prescription pain medications. 9 The excessive availability of prescription opioids for legitimate or illicit use and the propensity for an individual who develops a dependency to their medication to switch to heroin, attests to the need for improved practices in the safe prescribing and dispensing of prescription opioids. As previously indicated, The Safe and Effective Prescribing Practices and Pain Management Task Force, a group comprised of medical professionals, associations and regulatory agencies, has finalized two sets of guidelines establishing the best and safest prescribing and pain management practices: one addressing prescribing for chronic non-cancer pain and one for use in emergency departments. The task force is currently working to establish another set of guidelines to address safe prescribing of opioids by dentists. There is a need for widespread promotion and use of the guidelines by all healthcare prescribers in order to appropriately treat patients while curtailing the availability of these potentially addictive opioids. Recommendation A.1 Support Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Non-Cancer Pain and the Pennsylvania Emergency Department Pain Treatment Guidelines and encourage adoption of prescribing guidelines for other healthcare contexts by taking all necessary steps to educate all prescribers across the commonwealth. Goals to Achieve: A.1.1 Increase adoption and implementation of the Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Non-Cancer Pain, the Pennsylvania Emergency Department Pain Treatment Guidelines, and any other similarly developed guidelines for the prescribing of opioids. 9 Muhuri, P. K., Gfroerer, J. C., & Davies, M. C. (2013). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. Retrieved from 7

12 Implementation Plan: a) Continue meetings of the Safe and Effective Prescribing Practices and Pain Management Task Force. b) Work with prescriber associations to educate members about prescribing guidelines. c) Promote prescribing guidelines through information dissemination avenues, such as stakeholder websites, state agency websites and other initiatives. d) Communicate with insurers via the Pennsylvania Insurance Department (PID) about prescribing guidelines proposed in Recommendation A.2. Insurers may provide information to their credentialed clinicians regarding the guidelines and encourage their adoption. e) Inform HealthChoices insurers and prescribers, through the Department of Public Welfare (DPW), about the guidelines and encourage their adoption and use. 10 f) Inform the Pharmaceutical Assistance Contract for the Elderly (PACE) prescribers about the prescribing guidelines through the Pennsylvania Department of Aging s (PDA) academic detailing team and through PACE website offerings. g) Collaborate between the Department of Health, Pennsylvania Medical Society and other identified partners to determine the data sets that are necessary for evaluating the degree of implementation of the prescribing guidelines and the effectiveness of revised prescribing practices in reducing the incidence of opioid addiction and overdose. h) Review and revise the guidelines based upon data analysis. Safer Dispensing Practices Safe and effective prescribing of opioids by healthcare professionals is only one avenue by which access to, and availability of, potentially addictive medications can be curtailed. A closer look at payer mechanisms and ways in which monitoring by insurers and prescription benefit managers can occur is warranted as another potential opportunity to effectively reduce the excessive availability of substances that are abused or misused. PACE is a robust prescription drug program administered by PDA that currently has protocols in place to reign in unnecessary or unsafe prescription drug dispensing. PACE will not reimburse the prescription unless the pharmacist or physician documents its medical necessity and it complies with established dispensing guidelines. The program recognizes exceptional 10 Note: HealthChoices is the name of Pennsylvania's managed care program for Medical Assistance recipients. 8

13 circumstances in connection with the application of therapeutic criteria and reimbursement edits. PDA states that these guidelines for approval and reimbursement have resulted in more controlled and decreased opioid dispensing. While other health insurers may not, under current rules and regulations, be able to wholly adopt standards as robust as those in the PACE program, PID, DOH, and DDAP shall collaborate with insurance stakeholders (public and private) to scrutinize the PACE standards to determine which could be adopted in order to reduce dangerous and wasteful opioid and other addictive drug prescribing. This public-private partnership has tremendous potential for innovative strategies to address prescription monitoring through dispensing and payment, resulting in significant cost savings to insurers as well as reducing the number of new individuals becoming addicted or overdosing. Recommendation A.2 Establish a public-private partnership between the insurance industry and appropriate state agencies to reduce opioid misuse and overdose. Goals to Achieve: A.2.1 Work with insurers regarding substance use disorders in order to increase awareness among benefit providers and improve understanding about how to effectively approach this issue. A.2.2 Examine possible mechanisms through which insurers might prevent new occurrences of drug addiction and curtail existing drug addiction through potential monitoring and payment practices in dispensing opioids including tactics employed by the PACE program. Implementation Plan: a) Facilitate a dialogue with representatives of the major health insurers in Pennsylvania and the appropriate state agencies about substance use disorders, related contributing factors, PACE program protocols, and the proper protocol when dealing with consumers seeking coverage for addiction treatment services. b) Facilitate a dialogue with representatives from major malpractice insurers to explore the feasibility of premium reductions for physicians who take continuing medical education credits to learn the Prescribing Guidelines. 9

14 c) Consider utilizing cost-containment strategies, through the process described above, such as tiering and steering, to leverage patient cost-sharing as a means of deterrence. d) Examine the need for ongoing meetings among stakeholders regarding these topics and to establish mutually agreed upon strategies to be used to reduce prescription misuse and overdose response through this partnership. e) Review the PACE program and technology to consider if there are any similar strategies that can be implemented to combat drug addiction in private health insurance. f) Engage public insurers in a similar discussion. g) Implement any agreed upon monitoring and system strategies identified that would reduce medically unnecessary quantities of prescribed opioids. Reforms to Workers Compensation Similar to the issues addressed with prescribing practices outlined in A.1 and A.2 as it relates to healthcare professionals and third party payers, an even greater level of overprescribing and dispensing of prescription opioids occurs within the Workers Compensation (WC) program. According to a study by the National Council on Compensation Insurance, narcotic drugs account for nearly one quarter of WC prescription costs. 11 Furthermore, 71 percent of WC claimants on chronic opioid therapy for longer than three months are misusing or abusing their pain medications, rather than using them as prescribed. 12 Prescribing practitioners are often not adequately assessing risk (e.g., personal or family history of addiction) for abuse or monitoring appropriate use of the opioid medications. Consequently, workers being prescribed opioids for pain are at unacceptably high risk of becoming addicted. 13 This is not only problematic for the individual, but it also dramatically escalates costs within the WC program due to a delay in workers re-entering the workforce, the cost of over-prescribing, and healthcare costs triggered by subsequent drug addiction. The Pennsylvania WC program is also hindered by practitioners excessively prescribing and directly dispensing opioid analgesics. Legislation has been introduced in Pennsylvania in support of reforms to this program but has yet to be enacted. It is expected that proposed 11 Lipton, B., Laws, C. & Li, L. (2009). Narcotics in workers compensation. Retrieved from 12 Bradner, T. (2014). State: Pain meds contributing to workers comp costs. Retrieved from html 13 New lockton report analyzes prescription drug abuse and its effect on workers' compensation. (2012, Sep 20). PR Newswire Retrieved from 10

15 legislation would lead to less prescribing and dispensing of opioids, resulting in far safer prescribing practices for Pennsylvania s workers, who deserve healthcare that makes them healthier, not sicker. Recommendation A.3 Encourage and support legislative efforts to address unsafe and excessive prescribing and dispensing practices in the context of Workers Compensation. Goals to Achieve: A.3.1 Increase legislative awareness of how policies and regulation can be used to reduce unsafe and excessive prescribing and dispensing practices in the context of WC, resulting in safer healthcare practices for Pennsylvania s workforce. A.3.2 Engage WC insurers in a dialogue about ways to deter unsafe and excessive prescribing practices. Implementation Plan: a) Continue to convey information to the members of the General Assembly, documenting the current state of unsafe prescribing and dispensing of opioids in the WC context, and the critical need for the passage of related legislation. b) Convene a discussion between the major WC insurers in Pennsylvania with appropriate state agencies to facilitate a dialogue to develop effective strategies to address unsafe and excessive prescribing practices. Prescription Drug Monitoring Program Pennsylvania needs a strong Prescription Drug Monitoring Program (PDMP) that can be utilized by prescribers and dispensers. Realizing this need, Governor Corbett identified legislation creating a modernized PDMP as a major component of his Healthy Pennsylvania plan unveiled in September of According to the National Alliance for Model State Drug Laws, a PDMP is a statewide electronic database which collects designated data on substances dispensed in the state. The PDMP is housed by a specified statewide regulatory, administrative or law 11

16 enforcement agency. The housing agency distributes data from the database to individuals who are authorized under state law to receive the information for purposes of their profession. 14 PDMPs are a proven, effective and relatively inexpensive means through which prescribers and dispensers can prevent and reduce prescription drug abuse, overdose, and diversion. They are one of the CDC s top five policy recommendations for preventing prescription drug overdose and have been widely adopted across the nation. 15 PDMPs are effective in reducing diversion of controlled substances, improving clinical decision-making and assisting in every aspect of the effort to curb the prescription drug abuse epidemic. 16 The Office of National Drug Control Policy indicates that there are 35 states that currently have operational PDMPs, and 11 additional states and one U.S. territory that have passed legislation authorizing the development of a PDMP. According to their website, Several studies show PDMPs are effective when fully utilized. For example, a 2010 study found that when PDMP data were used in an emergency room, 41% of cases had altered prescribing after the clinician reviewed PDMP data with 61% of the patients receiving fewer or no opioid pain medications than had been originally planned by the physician prior to reviewing the PDMP data. 17 PDMPs also address the widespread problem of prescription drugs being diverted to people using them without prescriptions. More than three out of four people who misuse prescription painkillers use drugs prescribed to someone else. 18 Effective monitoring programs can provide prescribers and dispensers with critical information regarding a patient s prescription history. PDMP information can also help healthcare professionals identify high-risk patients who would benefit from early interventions or referral to drug addiction treatment. Separate legislation to expand and modernize the state s current, limited database has been passed by both houses in the Pennsylvania General Assembly but has not yet reached the Governor s desk. Given the fact that about 80 percent of heroin users began by misusing prescription opioids, the monitoring and control of prescription medications surely will reduce illicit drug use, reduce addiction and crime, and save lives. 14 Zacharoff, K. L. (2011). Prescription drug monitoring: A helpful resource in your state? Retrieved from 15 Centers for Disease Control and Prevention. (2011). Policy Impact: Prescription painkiller overdoses. Retrieved from 16 Hansen, H., Noe, C. E. & Racz, G. B. (2014). The evolving role of opioid treatment in chronic pain management. Retrieved from 17 Office of National Drug Control Policy. (2011). Prescription drug monitoring programs. Retrieved from 18 Centers for Disease Control and Prevention. (2013). Policy impact: Prescription painkiller overdoses. Retrieved from 12

17 Recommendation A.4 Encourage and support legislative efforts regarding expansion of access to the existing Prescription Drug Monitoring Program database and prepare for enactment. Goals to Achieve: A.4.1 Disseminate national research demonstrating the effectiveness of the expanded access to the PDMP database as evidenced in other states. A.4.2 DOH and DDAP will begin to immediately prepare for the implementation of a PDMP, in anticipation of enactment of PDMP legislation. Implementation Plan: a) Identify and synthesize outcomes of PDMP implementation in other states to determine the best options for Pennsylvania. b) Educate the General Assembly about outcomes of PDMP implementation in other states. c) Determine how the PDMP will work with health electronic records to avoid duplicate reporting by providers and dispensers. 13

18 B. ACCESS TO TREATMENT Addiction, or substance use disorder, occurs when the brain s natural reward circuit is overstimulated or when the brain s communications system is disrupted. This is a non-voluntary, physiological response that can occur when using substances including alcohol, illicit drugs or prescription medications. While an individual may initially choose to use substances recreationally or as a medical treatment, once there has been a re-routing of the brain circuitry, a relapsing brain disease occurs which is chronic, progressive and potentially fatal. 19 Although not everyone who uses a potentially addictive substance develops an addiction, many do. Like diabetes, hypertension, asthma and other chronic illnesses, effective treatments are available to treat drug addiction. Addicted individuals should have adequate access to treatment with clinical integrity (sufficient intensity and length of stay). 20 Unfortunately, there are many barriers that exist in accessing such care including individuals not understanding the signs and symptoms of addiction, not knowing how to get help for themselves or a family member once an issue has been identified, or being in denial due to widespread societal stigma associated with this disease. The Governor s Healthy Pennsylvania plan makes substantial strides in assisting individuals in getting the care that is needed by increasing access to insurance coverage. While this has a significant impact, the overarching issues of stigma and a general lack of understanding about drug addiction and symptom identification could continue to impede access to services. Furthermore, when an insured individual recognizes the need for help, an improved understanding of their substance use disorder benefit coverage and how to receive assistance in a timely manner will create even greater access to care and delivery of covered benefits. Provider Education Although the logical first line of assistance in recognizing, diagnosing and obtaining referral regarding any illness would be with one s primary healthcare provider, this is often not the case for drug addiction. 19 National Institute on Drug Abuse. (2014). Drugs, brains, and behavior: The science of addiction. Retrieved from 20 Wyatt, S. A., & Dekker, M. A. (2007). Improving physician and medical student education in substance use disorders. J Am Osteopath Association, 5 (107), Retrieved from 14

19 An emphasis must be placed on adequate training in medical school, residency, and continuing medical education (CME) courses to better physician understanding of addiction issues. 21 A leading national drug addiction expert, Dr. Tom McLellan, states that of the 164 medical schools in the United States, the University of Pennsylvania is the only one with a full course in substance use disorders as part of undergraduate medicine. Of the other 163 medical schools, only another seven to 10 "cover substance use disorders as part of at least a one semester course in behavioral medicine," attesting to the fact that, in general, physicians get minimal, if any, formal training in drug addiction. 22 When physicians and other healthcare providers are sufficiently trained regarding substance use disorders, screening and referral to appropriate addiction treatment, the disease can actually be prevented or arrested. The result is a cost savings in both the healthcare setting and the local community, and ultimately lives are saved. Therefore, improved care as it relates to substance use disorders and overdose can be encouraged through accessible and reliable training. Recommendation B.1 Increase healthcare provider education and awareness by encouraging appropriate training for physicians and other healthcare providers regarding substance use disorders, screening and expeditious referral to treatment. Goals to Achieve: B.1.1 Work with the Safe and Effective Prescribing Practices and Pain Management Task Force to identify stakeholders, materials and mechanisms for training healthcare providers regarding substance use disorders and how to promote inclusion of education through medical school and other healthcare professional school curriculums and CME opportunities. B.1.2 Identify and promote existing training resources currently available to physicians and other healthcare workers and work through public-private partnerships to encourage their widespread dissemination and use. 21 The National Center on Addiction and Substance Abuse at Columbia University. (2000). Missed opportunity: national survey of primary care physicians and patients on substance abuse. Retrieved from 22 A.T. McLellan (personal communication, August 5, 2014). 23 Fleming, M., Manwell, L. B., (1999). Brief intervention in primary care settings: A primary treatment method for at-risk, problem and dependent drinkers. Alcohol Res Health, 23, Ockene, J. K., Adams, A., Hurley, T. G., Wheeler, E. V. & Hebert, J. R. (1999). Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: Does it work. Arch Intern Med. (159),

20 B.1.3 Spearhead specific initiatives to establish a bridge between healthcare providers and members of drug and alcohol treatment programs and the recovery community. B.1.4 Engage state licensing boards and related entities, as referenced in C.1, to communicate the importance of training in drug addiction issues, including pre-licensing training and CME requirements, as well as presentations to the boards, which could be facilitated by DDAP. B.1.5 Research the reintroduction of the Pain Management Training Module of the PACE physician education program to include information about the increased use of opioids and ways to reduce it. B.1.6 Examine expanding DDAP s training curriculum to include physician and other heathcare provider training. Implementation Plan: a) Work with the Safe and Effective Prescribing Practices and Pain Management Task Force and the healthcare professional associations to promote inclusion of drug addiction and treatment information to healthcare professionals through various avenues. b) Work with healthcare professional associations to better inform healthcare professionals of existing training resources and CMEs. c) Include addiction and treatment information in the PACE physician training program and begin implementation. d) Post information and links to drug education and awareness resources for provider access on DOH s website. e) Identify outreach strategies for communicating and encouraging physician and other healthcare professional training regarding drug addiction and treatment through partnerships with the Safe and Effective Prescribing Practices and Pain Management Task Force and other stakeholder groups. f) Enroll and train an increasing number of prescribers annually through the PACE training program. Benefit Education: Commonwealth Workforce In addition to the need for additional physician training and education, another significant obstacle occurs when a drug addiction has been identified but the individual is unaware of the benefits for treatment that are available to him or her. There is a unique opportunity to 16

21 significantly reduce stigma and improve access to care through the commonwealth workforce. Awareness and education about signs and symptoms of substance use disorders, risk of opioid overdose and how to access appropriate treatment should be provided to the approximately 300,000 employees and retirees of the commonwealth workforce, and their dependents. Recommendation B.2 Increase education and awareness to the commonwealth workforce and their family members about substance use disorders, including access to care via the State Employee Assistance Program and the Pennsylvania Employees Benefit Trust Fund. Goals to Achieve: B.2.1 Increase employee awareness of substance use disorders including the dangers of opioid misuse, overdose prevention and appropriate overdose response methods through cross-agency training. B.2.2 Increase substance use disorder education, awareness of benefits and access to care through the naturally occurring networks and contacts that exist between active and retired employees and their family members. Implementation Plan: a) Develop and provide articles to employees through the Office of Administration (OA) and their State Employee Assistance Program (SEAP) vendor that deals with substance use disorders, particularly on the use of heroin and other opioids and publish them through the Employee Bulletin Board. b) Provide information to employees on how to access substance abuse treatment through OA and the Pennsylvania Employees Benefit Trust Fund (PEBTF) in their Active Employee and Retiree newsletters on a regular basis. 17

22 Increased Access through Public Private Partnerships In addition to expanding awareness to commonwealth employees and agencies about addiction and treatment, this awareness must be expanded to citizens across Pennsylvania. Anyone with third party insurance should know not only what their benefits are, but how to access them. Currently, there are a number of major health insurers in the state through which either employer sponsored or individually purchased health insurance coverage is issued. These insurers offer a multitude of plans. While Pennsylvania Act 106 of 1989 outlines minimum benefits for drug addiction treatment services that must be provided through most group health plans underwritten in the state, individuals may be unaware of what the minimum coverage benefits are and the medical necessity criteria that supports them. 25 Benefits within a plan might also vary beyond the minimum standards, such as those required by the Mental Health Parity and Addiction Equity Act. There should be purposeful strategies to assist insured individuals in understanding and accessing their benefits that take into account the idiosyncrasies of the disease of addiction, such as denial, stigma and impaired cognitive functioning. A complex procedure for accessing drug and alcohol treatment in itself creates a serious barrier to accessing treatment. Due to the physiological and psychological characteristics of drug addiction, treatment access must coincide with individual readiness. A basic understanding by insurers of drug addiction will strengthen our healthcare system s ability to provide services in a timely and appropriate manner, will get more individuals into recovery, and will lower healthcare costs. A public private partnership to work through these issues, to develop crosssystems trainings and effective protocols regarding addiction and referral to treatment will save health insurers money, create a healthier population and reduce crime. Recommendation B.3 Increase public-private partnerships to adequately and appropriately address substance use disorders via: a) Cross-agency training to increase awareness about drug addiction, including the dangers of opioid misuse, overdose prevention and appropriate overdose response methods; b) Establishing collaborative partnerships with third party insurers including HealthChoices Managed Care Organizations, Medicare, and Pharmacy Benefit Managers to improve awareness of treatment benefits and access to care to ensure timely assessment, referral and engagement in the clinically appropriate intensity and duration of care; and, c) Addressing the drug addiction and overdose issue through the State Healthcare Innovation Plan. 25 Note: To reference Act 106: 18

23 Goals to Achieve: B.3.1 Work with state agencies and third party payers to increase awareness and educate their employees regarding substance use disorders, and in particular, opioid abuse. B.3.2 Work with insurers to identify and establish appropriate and effective protocols for guiding an insured to a timely assessment, referral and engagement in the clinically appropriate level of care and duration of treatment. B.3.3 Address the issue of addiction and opioid overdose through the State Innovation Model (SIM). This will include seeking opportunities within the State Health Improvement Plan (SHIP) and the SIM project implementation strategy (if selected for federal funding) to foster effective practice guidelines for Physical Health Managed Care Organizations and Behavioral Health Managed Care Organizations (BH-MCOs) to reduce problems associated with opioid use and other substance use disorders. The approach should address prevention, intervention and treatment strategies for statewide application. B.3.4 Develop effective approaches to help prevent, intervene and treat individuals covered through the HealthChoices Behavioral Health Managed Care system and county-based programs through collaboration between The Office of Mental Health and Substance Abuse Services (OMHSAS) and other DPW program offices, DDAP, counties, BH-MCOs and other stakeholders. Implementation Plan: a) Design an employee training program, in conjunction with the insurer discussion addressed in Recommendation A.2, for insurers to deliver to consumer service center staff, regarding addiction treatment and protocols. b) Establish and implement protocols regarding timely assessment, referral and engagement in the clinically appropriate intensity and duration of care, to ensure positive and cost-effective outcomes, as part of the insurer discussion addressed in Recommendation A.2. c) Convene the necessary partners to establish basic opioid overdose prevention and response training to be added to DDAP s selection of courses for delivery to a broad representation of healthcare and insurance stakeholders in both the public and private sectors. d) Make addiction training resources available to the Transformation Center and medical homes staff as well as Accountable Care Organizations and Accountable Provider 19