1. ADDRESSING THE OPIOID CRISIS
VERMONT’S RESPONSE

3. ADDICTION 101 Etiology: Genetics, stress, exposure
Pathology: Primarily brain structure and function
Symptoms: Radiating consequences
Phenomenology: Suffering, misunderstood, stigmatized
Treatment: Effective treatments, no cures

4. TOP GENERIC PRESCRIPTIONS WHAT’S #1?
Hydrocodone + acetaminophen [Vicodin]( n=122,806,850)
18. Oxycodone + acetaminophen [Percocet] (n=28,705,243)
46. Propoxyphene + acetaminophen [Darvon] (n=14,274,354)
51. Oxycodone (n=12,652,375)
114. Fentanyl patch (n=4,914,785)
121. Methadone (n=4,558,532)
170. Morphine (n=2,740,358)
192. Hydromorphone [Dilaudid] (n=2,272,481)
Top 200 generic drugs by units in SDI’s Vector One® National

5. PAIN IS BIG BUSINESS U.S. SPENDING (2014)
IMS Health, National Prescription Audit, Dec 2013

6. OPIOID PRESCRIPTIONS HAVE SKYROCKETED OVER PAST 20 YEARS
It has dropped a little bit in 2013 to 207 million.

7. OVERDOSE DEATHS FROM OPIOIDS INCREASED 200% SINCE 2000
CDC, National Center for Health Statistics, National Vital Statistics System

8. OVERDOSE DEATH IN VERMONT
INCREASED IN EVERY COUNTY
Source: 
NOTES: † Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug-poisoning deaths are defined as having ICD–10 underlying cause-of-death codes X40–X44 (unintentional), X60–X64 (suicide), X85 (homicide), or Y10–Y14 (undetermined intent).
‡ Estimates are based on the National Vital Statistics System multiple cause-of-death mortality files (1). Age-adjusted death rates (deaths per 100,000 U.S. standard population for 2000) are calculated using the direct method. Populations used for computing death rates for 2011–2014 are postcensal estimates based on the 2010 U.S. census. Rates for census years are based on populations enumerated in the corresponding censuses. Rates for noncensus years before 2010 are revised using updated intercensal population estimates and may differ from rates previously published.
* Estimate does not meet standards of reliability or precision. Death rates are flagged as “Unreliable” in the chart when the rate is calculated with a numerator of 20 or less.
§ Smoothed county age-adjusted death rates (deaths per 100,000 population) were obtained according to methods described elsewhere (3–5). Briefly, two-stage hierarchical models were used to generate empirical Bayes estimates of county age-adjusted death rates due to drug poisoning for each year during 2002–2014. These annual county-level estimates “borrow strength” across counties to generate stable estimates of death rates where data are sparse due to small population size (3,5). Estimates are unavailable for Broomfield County, Colo., and Denali County, Alaska, in 2002; these counties did not appear in the mortality files until 2003 (6,7). Additionally, Bedford City, Virginia was added to Bedford County in 2014 and no longer appears in the mortality file in County boundaries are consistent with the vintage bridged-race population file geographies (6)
Source: Centers for Disease Control and Prevention, Drug Poisoning Mortality: United States,
January 2016

9. TRANSITION ACROSS THE U.S. FROM PRESCRIPTION OPIOIDS TO HEROIN

10. TRANSITION ACROSS THE NORTHEAST EVEN MORE DRAMATIC

11. WHAT ABOUT VERMONT? THE TRANSITION IS DEADLY
Source: Vermont Department of Health Vital Statistics System
Vermont Department of Health

12. WHY THE TRANSITION? FROM PRESCRIPTION OPIOIDS
Some are expensive or have seen prices increase
Many preferred opioids hard to find
Abuse deterrent formulations
Wiser providers
New prescribing guidelines

13. WHY THE TRANSITION? TO HEROIN
Cost and availability:
Heroin is cheaper
Heroin is easier to get
Heroin is easier to inject
Heroin is purer than ever

14. THE NEW HEROIN CONSUMER IF YOU PLAN ON PROFILING
Previous era heroin users:
Young, minority male living in urban centers
Unemployed
New era heroin users:
Young and middle-aged, white male/female living in a suburban/rural area
Employed

15. 3 FDA-APPROVED MEDICATIONS FOR TREATING OPIOID USE DISORDERS*
METHADONE
BUPRENORPHINE
NALTREXONE
*MEDICATION-ASSISTED TREATMENT (MAT)

16. VERMONT’S RESPONSE A MODEL FOR THE REST OF THE COUNTRY
Openly acknowledged by Governor as public health crisis
Creation of “HUB” and “SPOKE” model
HUB: Specialty care Opioid Treatment Programs (OTPs) for methadone, buprenorphine and naltrexone
SPOKE: General Office-based Opioid Treatment (OBOT) practices for buprenorphine and naltrexone
Financing and workforce to support practice
Activities to increase access and availability--quantity
Activities to ensure quality

17. PATIENT-CENTERED MEDICAL HOME
ADDICTION AS CHRONIC MEDICAL CONDITION
Specialty
Care
OTP
Primary Care
OBOT
PCMH
Community Health Team

18. OTP HUB GROWTH TRIPLED IN PAST 3 YEARS

19. OBOT SPOKE GROWTH MUCH SLOWER---ABOUT 30%

21. PROGRESS NOT PERFECTION BIG DENT, LITTLE DENT OR NO DENT AT ALL?
Addiction has no silver bullet cure, medication is one component of the potential for a good outcome
How long should medication be necessary?
OBOT expansion in small to medium size practices but not in large or hospital practices
Need to evaluate outcomes (costs $)
Vision for recovery: With MAT or not