1. SIHC MAT PROGRAM
Hafifa Shabaik, PhD, RN, Quality Measures RN/Program Coordinator
Young Suh, MD Medical Director/Program Director
Southern Indian Health Council, Inc.
February 2019

5. Opioid Crisis

6. Drug Overdose Deaths in the U.S.
Number of Drug Overdose Deaths Per Year
2017
More than 4 times higher than 1999
More than peak HIV deaths in 1995
More than peak gun deaths in 1993
More than peak car crash deaths in 1972
NCHS, National Vital Statistics System, Mortality
SOURCES:

7. Opioid Overdose Deaths in the U.S. 1999 – 2016
Drug overdose deaths continue to increase in the United States.
From 1999 to 2016:
More than 630,000 people have died from a drug overdose.
More than 350,000 (56%) people died from an overdose involving any opioid, including prescription and illicit opioids. And 66% in alone.
In 2016, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 5 times higher than in 1999.
On average, 115 Americans die every day from an opioid overdose.
For American Indians and Alaska Natives, 8.4 per 100,000 experience opioid related fatalities, representing 3 times the death rate for Black Americans and Hispanic Whites.
SPEAKER NOTES:
This rise in opioid overdose deaths can be outlined in three distinct waves.
The first wave began with increased prescribing of opioids in the 1990s , with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 1999.
The second wave began in 2010, with rapid increases in overdose deaths involving heroin.
The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids – particularly those involving illicitly-manufactured fentanyl (IMF). The IMF market continues to change, and IMF can be found in combination with heroin, counterfeit pills, and cocaine. 
SOURCES:

9. THE OPIOID EPIDEMIC Pharmaceutical Companies Healthcare System
Claimed that prescription opioids were not addictive
Healthcare System
Physicians began to prescribe opioids at greater rates
Addictive Properties
Misuse, abuse and diversion led to the spread of addiction and opioid overdoses
Cheaper Alternatives
Illicit manufacturing drastically increasing the number of deaths from opioids.
*Roughly 25% of patients misuse prescribed Opioids for chronic pain
*80% of Heroin users misused prescription opioids first

10. OPIOIDS
What is an opioid?
Derived from opium, that activate opioid receptors, commonly used for pain relief.
Includes:
Prescription opioids: hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine, codeine, and fentanyl.
Illicitly produced opioids: heroin and fentanyl.
Opioids used in medication assisted treatments: Methadone and buprenorphine (Suboxone)

14. Of people prescribed opioids for chronic pain develop OUD1.
DEVELOPING OUD
Opioids reduce the sensation of pain broadly and can make a person feel relaxed and produce a state of euphoria.
When used for extended time or without medical need, one can develop opioid dependence/opioid use disorder.
“Uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences.”
Believed to be associated with the brain’s reward pathways (dopamine).
Ending the use of opioids can be difficult on one’s own. There is no one treatment option best for everyone, but medications are available to assist patients in their path toward wellness and recovery.
8-12%
Of people prescribed opioids for chronic pain develop OUD1.
1 – NIH National Institute on Drug Abuse

15. SIHC Approach
safe, effective, non-addictive strategies to manage chronic pain
new, innovative medications and technologies to treat opioid use disorders
improved overdose prevention and reversal interventionsto save lives and support recovery

16. MEDICATION-ASSISTED TREATMENT (MAT)
Wellness
Behavioral health
Social services
Primary care
Traditional health
Medication Assisted Treatment (MAT) is the use of federally approved medications, in combination with counseling and behavioral health therapies, to provide a “whole- patient” approach to the treatment of substance use disorders.
Opioid Use Disorder

17. MAT AT SIHC
The Office-Based MAT Program at SIHC is a funded program through the Tribal Opioid Response Grant by the Substance Abuse and Mental Health Services Administration.
The goals of the MAT program is to increase access to medication assisted treatment for opioid use disorder in our community by providing:
Increasing # providers with DEA waivers
Referral to counseling/behavioral health services
Care coordination
Drug screening
Prescription drug monitoring
Community outreach and education

18. (MAT) MEDICATION ASSISTED TREATMENT
The use of medications in conjunction with behavioral therapies and counseling to treat substance use disorder and prevent overdose.
Medication
Methadone
Buprenorphine
Naltrexone
Mechanism
Agonist
Partial Agonist
Antagonist
Reduce/eliminate withdrawal symptoms X
Block effects of other opioids
Reduce/eliminate opioid cravings
Methadone:
Clinic-based opioid agonist that does not block other narcotics while preventing withdrawal while taking it.
Naltrexone:
Office-based non-addictive opioid antagonist that blocks the effects of other narcotics; daily pill or monthly injection.
Buprinorphine:
Office-based opioid agonist/ antagonist that blocks other narcotics while reducing withdrawal risk. A partial agonist medication that does not reproduce opioid effects even at higher doses and thus has lower abuse liability

19. OPIOID OVERDOSE
The brain has many receptors for opioids. An overdose occurs when too much of an opioid (heroin, OxyContin, Percocet) fits in too many receptors, stopping the person’s breathing.
Naloxone has a stronger affinity to the opioid receptors than opioid drugs, so it knocks the opioids off the receptors for a short time. This allows the person to breathe again and reverses the overdose.

20. CHALLENGES IN MAT Stigma
Stigma continues to be the primary obstacle in increasing a community’s capacity to address this epidemic.
Treatment availability gap
Classic forms of treatment and culture may not be supportive

21. ADRESSING CHALLENGES Stigma Treatment availability gap:
Community Outreach and Education at health fairs and events
MAT on ROAM
Practice non-judgement (educate staff and providers about appropriate language and terms)
Treatment availability gap:
Encouraging providers at SIHC to obtain DEA waivers to prescribe buprenorphine
Collaborating with Kumeyayy Family Services and La Posta Substance Abuse Centers
To increase access to counseling
Referral to Behavioral Health Services
Honoring cultural beliefs and practices
By ensuring that our policy and procedures emphasize the community and family, the importance of relationships and respect for clients, especially elders and practice an open-door policy.

24. References
Eidman, M. & Antony, V. (2018). DHCS Tribal MAT Project Powerpoint Presentation. California Consortium for Urban Indian Health.
Legha, R., Raleigh-Cohn, A., Fickenscher, A., & Novins, D. (2014). Challenges to providing quality substance abuse treatment services for American Indian and Alaska Native communities: perspectives of staff from 18 treatment centers. BMC psychiatry, 14, 181.
Rieckmann, T., Moore, L., Croy, C., Aarons, G. & Novins, D. (2017). National overview of medication-assisted treatment for American Indians and Alaska Natives with substance use disorders. Psychiatric Services, 68(11).
Substance Abuse and Mental Health Services Administration (2018). Medication-Assisted Treatment. Retrieved from:
Venner, K. L., Donovan, D. M., Campbell, A., Wendt, D. C., Rieckmann, T., Radin, S. M., Momper, S. L., … Rosa, C. L. (2018). Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives. Addictive Behaviors, 86,