Barbara Cimaglio, Deputy Commissioner, ADAP

1. Barbara Cimaglio, Deputy Commissioner, ADAP Prescription Drug Abuse in Vermont: The Problems and our ResponseNASADAD Public Policy CommitteeOctober 17, 2011

2. The Epidemiological Data Prescription Drug Misuse inVermont

4. BRFSS Rx Misuse

6. Prescription Drug MisuseYRBS * *2011 significantly lower than 2009 & 2007

7. Pain Relievers or Stimulants, 2009 Source: VT YRBS

8. Prescription Drug Use in the Treatment System

9. Admissions to Publicly-Funded Treatment among All Vermonters

10. Admissions to Publicly-Funded Treatment among All VT Adolescents

11. Number of People Abusing Prescription Drugs Treated by State Fiscal Year

12. Opiates are the Main Prescription Drug Category Seen in the Treatment System

13. Data on Prescriptions in VPMS

14. Vermont Prescription Monitoring System* • “VPMS” • Timely and easily accessed patient information for both licensed prescribers and pharmacists to assist with patient clinical management • *Launched by Dept of Health in 2009, as established under Act 205.

15. The VPMS : • Is an online, clinical tool for reviewing patients’ complete schedule II-IV drug history.* • Helps track the prescribing and dispensing of controlled substances — those drugs most likely to lead to abuse, addiction or patient harm if not used properly. • May help identify and manage patients who are in need of substance abuse treatment. • Is a venue for coordination of care and medication prescribing between health providers, patients and pharmacists through increased clinical information.

16. Provides useful feedback to prescribers on their own prescribing trends • Alerts providers to their patients whose total prescription use for a given time period exceeds pre-determined threshold levels through quarterly mailings • Database contains prescriptions dispensed on or after July 1, 2008. • May become an expected part of best practice • *Pharmacies are required by law to report their data every seven (7) days to the VPMS.

17. Vermont Prescription Monitoring System (VPMS) 7 / 1 / 2009 – 6 / 30 / 2010 Total Number of Persons Receiving Schedule II – IV Prescriptions andTotal Number of Schedule II – IV Prescriptions by Age

18. Vermont Prescription Monitoring System (VPMS) 7 / 1 / 2009 – 6 / 30 / 2010 Total Number of Schedule II – IV Prescriptions By DEA Schedule • Schedule II drugs are those with high abuse potential. Such drugs are filled with a written prescription and no refills. Examples include drugs containing amphetamine/ ethamphetamine (Dexedrine, Ritalin, Concerta) or drugs containg codeine, hydrocodone, methadone, morphine, oxycodone, opium (Percocet, OxyContin). • Schedule III drugs are those with moderately high abuse potential. Such drugs are filled with a written or telephone prescription with refills. Examples include: Tylenol with codeine; buprenorphine; hydrocodeine combination products (Vicodin, Lortab); opium combination products; anabolic steroids. • Schedule IV drugs are those with moderate abuse potential. Such drugs are filled with a written or telephone prescription with refills. Examples include: sedatives (Xanax, Valium, Ambien, Sonata); anticonvulsants. • Pain relievers containing opiates fall into each Schedule depending upon the amount of opiate in the dosage. • Source: Drug Enforcement Agency

19. Vermont Prescription Monitoring System (VPMS) 7 / 1 / 2009 – 6 / 30 / 2010 Total Number of Schedule II – IV Prescriptions By Selected Therapeutic Classes Opiate agonists are pain relievers containing opiates. Benzodiazepine sedatives are anti-anxiety medication while other sedatives include sleeping medications. Anticonvulstants are used primarily to treat epilepsy and bipolar disorder. Stimulants and amphetamines are used primarily to treat ADD/ADHD. Buprenorphine-containingdrugs comprise the majority of opiate partial agonists in VPMS. These 7 classes represent 98% of the total prescriptions in VPMS. Androgens, antitussives, barbiturate sedatives, and NSAIDs have between 1,000 - 10,000 prescriptions representing 1.9% of the total. Ten classes have fewer than 1,000 prescriptions representing 0.1% of the total.

20. How are we addressing the problems? Strategic Directions

21. Strategic Plan for Prescription Drug Abuse PreventionFall, 2011 • Education • Medical School • Primary Care Practices • Tracking & Monitoring • VPMS – best practice

22. Strategic Plan (con't) • Proper Medication Disposal • Patient Education • Take Back events • Enforcement • Positive ID for controlled substance pick-up • Training on diversion

23. Health Care Reform • Behavioral health is central to health • Screening, intervention and specialty treatment will be components of enhanced medical homes & community health teams

24. Prevention System: • Community coalitions • Youth serving organizations • Vermont Alcohol and Drug Information Clearinghouse • Regional prevention consultant network • Student Assistance Programs (early intervention)

25. Screening, Brief Intervention & Referral to Treatment (SBIRT) • Embedding screening, brief intervention, referral • & treatment of substance abuse problems within • primary care settings such as emergency centers, • community health care clinics, and trauma • centers helps to: • Identify patients who don’t perceive a need for treatment, • Provide them with a solid strategy to reduce or eliminate substance abuse, and • Move them into appropriate services. 25

26. Resiliency Recovery Oriented System of Care (RROSC) • Specialty Treatment: • Changes to the system of care will improve access for • consumers in order to move them into long-term • recovery, with treatment being one avenue for success. • This systems transformation seeks to connect treatment • to the larger and more enduring process of recovery, to • transition from recovery initiation to stable recovery • maintenance, and to connect residential treatment to the • communities it serves.

27. Prescription Drug Abuse Work Group • Started in October of 2008 • State level stakeholders meeting to share information on prescription drug abuse • Developing Vermont Prescription Drug Abuse Plan for Fall, 2011 • Partnership – US Attorney & VDH • AHS Community Meetings • AHS Field Directors and community stakeholders (e.g. local hospitals, prescribing physicians, mental health and substance abuse providers, Departments of Public Safety and Corrections), began hosting meetings in March 2010 to identify ways communities can address prescription drug abuse, including buprenorphine

28. ADAP Sponsored Hospital Grand Rounds Series Universal Precautions for Addiction Drug addiction is a disease for which anyone seeking medical treatment may be at risk. Awareness and screening are imperative. Compassionate Clinical Approaches • Some of the most difficult patients to manage may be those struggling with both the disease of addictions as well as pain management challenges. A variety of motivational and joining skills have been presented. Pain Management Strategies • October 2009: Two Day Conference -Managing Chronic Pain While Keeping the “Control” in Controlled Substances • Online Pain Management Webinars: • UVM Medical Student Summer Project: Evaluation of the medication disposal projects in Vermont

29. Coordination of Office Based-Medication Assisted Therapies II (COB-MAT II) • Coordinated effort between DVHA and ADAP • Provides care management services to physicians involved in the Capitated Program for the Treatment of Opiate Dependency. • Pilot - DVHA Chronic Care Managers were placed in four buprenorphine practices in Vermont to provide guidance in the use of the Vermont Buprenorphine Practice Guidelines. • Promulgation of rule for practices treating opiate dependent patients.

30. Redesign of MAT System • Hub & Spoke Model • Hub in 5 geographic locations: • Induction, tapers, case management, counseling, consultation • Spokes – physician practices

31. Pharmacy Home • The Pharmacy Home program, administered by the DVHA (Medicaid) Program Integrity (PI) unit, is for beneficiaries in the buprenorphine program. • DVHA PI staff work with the beneficiary and their providers to identify a pharmacy home and/or provider home. • Beneficiaries choose a convenient pharmacy where they can obtain medications that are prescribed by their primary care or specialist provider in an effort to help receive consistent and effective medication therapy. • Exceptions exist to allow more than one provider when applicable.

33. Resources: www.communityofcompetence.com http://www.mainebenzo.org/2009conference.htm Vermont Medical Society http://www.vtmd.org From the home page, click on Education, then on Opioid Dependence, Information and Links. That will bring you to Opioid Therapies for Patients with Chronic Pain (2008) Managing Chronic Pain While Keeping Control Part 1https://webdemo.ganconference.com/?meeting=7951532Managing Chronic Pain While Keeping Control Part 2https://webdemo.ganconference.com/?meeting=2840263Managing Chronic Pain While Keeping Control Part 2https://webdemo.ganconference.com/?meeting=9039293