The Opioid Crisis - Transcript

Moderator: Haley McCalla
Presenters: Sarah Bacon, PhD.
Date/Time: March 27, 2019, 1:00 – 2:00 pm ET

Good afternoon, everyone. I’m Haley McCalla, an ORISE fellow appointed to CDC’s Center for Preparednes and Response, Division of Emergency Operations. Thank you for joining us for the EPIC webinar titled “The opioid crisis.

” We’ll hear from Dr. Sarah Bacon. If you don’t wish to complete this, please leave at this time.

You can earn credits for this webinar. It can be found at emergencyCDC give/EPIC. The course action code is EPIC0327 with all letters capitalized.

To repeat the course access code to receive continuing education units is in all caps EPIC0327. Today’s webinar is interactive. To make a comment, click the chat button on your screen and enter your thoughts.

To ask a question, please use a Q & A button. The Q & A session will begin after our presenter has finished. Closed captioning is available for this webinar.

The button to enable this function can be found either at the top or bottom of your screen. We are very fortunate today to have Dr. Bacon as our speaker.

Dr. Bacon is a program director for prevention for estates and the data driven presentation initiative. He’s a practice oriented scientist with experience in public health.

The common thread is her commitment to using data and science to make communities safer. Sarah began her time as CDC in 2010 in the division of violence prevention where she was the lead scientist for the national centers in excellence and youth violence prevention. A strategic initiative for preventing violence in hybrid communities.

While much of her work focusing on evaluation, Sarah is also fully immersed in implementation science and has experience with implementation realities that often challenge our scientific agendas. We moved to the division of unintentional injury prevention in 2015 where she leads the division state-based opioid overdose prevention efforts. A key part of her role involves informing the development of CDC scientific and programmatic directions for opioid overdose.

She holds a PhD in criminology. She spent four years on the faculty of the college of rimmology and criminal justice at Florida State University. Thank you for joining us today, Dr.

Bacon. Please begin.

Thank you, Haley. Good afternoon, everyone. I’m always eager to connect with folks about the importance of this issue and the work we’re doing here at CDC along with a number of other federal partners to address the evolving opioid epidemic.

So I hope I’ll share something useful with you today. And I look forward to some questions and conversations at the end of my presentation. We frequently hear and talk about the opioid overdose epidemic or crisis.

It is in the media and national conversation enough that we’re kind of used to hearing this language. But let’s take a few minutes to look at the data and to really remember what this means in terms of how it is impacting our communities and our lives. So starting really from the big picture at the national level, take a look at this progression of heat maps.

These show drug overdose mortality rates or deaths. With blue and green and the cooler colors indicating lower age adjusted death rates, and the warmer colors indicate increasing and high rates of deaths from opioid overdose. Red indicating the highest rates.

You can see from looking at that progression over time from 2000-2005-2010-2016 that we move from a lot of very cool spots in 2000 to more and more hot spots overtime culminating to a pretty red and orange map in 2016. This shows us the drug overdose deaths in a county by relatively short period of time. We can see the intensity of the problem exists not only in terms of the rate and the speed of growth, but also with respect to the absolute numbers themselves.

In 2017, for example, there were over 70,200 drug overdose deaths. And opioids were involved in about 2/3 of those. If you are like me, numbers that large with respective people are difficult to wrap your head around.

Here’s another way to look at it and put it into perspective. As it currently stands about 130 Americans die every day from an opioid overdose. That’s 130 people every day.

On the next slide we’ll impact the data and these numbers a little bit more. Look at which specific substances are driving these trends. From 1999 through 2017, almost 400,000 people died from an overdose involving an opioid.

And that’s whether you are talking about a prescription or an elicit opioid. When we look across this time span, we see that there are three interrelated, but also distinct waves or phases of the epidemic. So the first wave which is depicted by the purple line began with increased prescribing of opioids in the 1990s.

With overdose death involving prescription opioids increasing since at least 1999. I’ll note here that with respect to this wave, when I say prescription opioids, I’m talking about natural and semisynthetic opioids, and I’m also talking about methadone. This is really where it all started.

With the dramatic increase in the rate of prescribing, even though the amount of pain that Americans were reporting during this time frame remained unchanged. We’ll talk about that a bit more in a later slide when I share more about CDC’s prevention efforts. You can see this second wave starting here roughly in 2010 where this yellow line shows the rapid increase in overdose deaths involving heroin.

So in the face of continuing troubling rates with respect to prescription opioids, we’re also seeing in addition to that, a shift to significant increases from elicit opioids, and in this case with the second wave particularly from heroin. Shortly thereafter in 2013, the very dark blue or almost black line shows the precipitous increase of deaths involving synthetic opioids. This is the third wave of the epidemic.

Particularly indicating here are deaths from elicitly manufactured fentanyl. Over these three waves, you can see there appears to be some leveling off of the first two. Those for prescription opioids, including methadone, and for heroin.

Of course a lot of work remains to be done with respect to those substances. While we are are encouraged by the direction of these trends very recently, the absolute number and the burden here is still painfully high. But you can also see that we have not yet turned the trend or tide with respect to the third wave of synthetic opioids.

A bit later in the presentation, I’ll tell you a lot more about what CDC is doing on all of these fronts. First though, on the next slide, I want to share one more dimension of the overall trends of this epidemic. And show — I show you these data to remind all of us that it isn’t really just an opioid epidemic.

This is a drug overdose epidemic. We’re seeing increased evidence from some jurisdictions and some data the deaths from things like cocaine and methamphetamines are also on the rise. Death rates from these drugs have more than doubled.

In some cases for specific substances have tripled. At times we see the use is connected with opioids. That’s not always the case.

As we work our way through the opioid overdose prevention and response efforts, it is really important that we be forward looking to ensure that we are also building the tools and resources that we need to prevent misuse and overdose from other drugs. We talk a lot at CDC about fatal overdose events or overdose mortality. As our work with our partners unfolds in very applied settings though, we remain very much in touch with the reality that these overdose deaths are one tragic outcome that represent the tip of an iceberg of other associated harms.

Every one person who died from an opioid overdose represents preventible outcome for the 13 people who suffer with heroin addiction. For the 35 people who suffer with addiction to prescription opioids, and for the hundreds and thousands of Americans who report some other form of either misuse or exposure to opioids. Even beyond what is depicted in this graphic are the countless family members, friends, children, and communities that are so deeply wounded by the consequences of this overdose crisis.

The reach is so extensive, and ubiquitous, that I imagine, unfortunately, everyone joining us today has been affected in some way or another by the crisis. It is very real for all of us. The impact of the opioid crisis can even be felt when we look at the overdose U.

S. life expectancy. So this graphic shows us the impact of the 12 leading causes of death on life expectancy.

And you can see in those sort of bottom panel here that opioid-involved poisoning decreased life expectancy by over two months in just the last five years, between 2000, and 2015. So I hope at this point to have convinced you all that this truly is a crisis. And it is truly a pressing issue of national importance.

I would like to now pivot to a more positive take on what we’re doing about this and tell you about some of our efforts here at CDC. Our north star is to prevent opioid overdose and deaths. All of our work is captured in the five domains represented here on this slide.

So I’m going to use the rest of my time to give you examples illustrations of the work underway with conducting surveillance and research, building state, local, and tribal capacity, supporting providers, health systems, and payers, partners with public safety, and empowering consumers to make safe choices. I want to caveat my remarks that the elevations are intended to convey the flavor and work that we’re doing with respect to each of these domains. This is not a comprehensive catalog or inventory of all of the work that we have underway here with CDC and our other partners.

I think it will give everyone a sense of our strategic directions and where our focus lies. First I want to briefly mention we have funding and touch points in every state D. C.

and several U. S. territories.

The names and funding that we use may vary from state to state. The focus of each of the funding mechanisms may differ slightly. The main point that I want to convey with the slide is that access to CDC resources and technical assistance and scientific expertise is available no matter where you live.

Regardless of the funding status of your state or your community, our resources are available to you. So I’m not going to talk much more about funding. Again that’s just sort of the mechanism that we use to connect with partners to do the work.

But I do want to quickly mention our current open funding opportunity. Overdose data to action. This is an open application period right now.

States, territories, and certain eligibility localities are hard at work on their applications to submit in early May. We’re really excited to see what work we can continue to do with our partners under our more stream-lined and comprehensive award. As you saw on the previous slide, one of our strategic pillars is conducting surveillance.

Better data means better prevention and better response. So this is really at the core of a lot of our opioid work. We partner with our recipients and other partners and stakeholders to ensure that we have the that that systems, but also the data standards and infrastructure in place that’s required to use the data.

We focus on more non-specific data. They come from the emergency departments and EMS and first responders partners. They use the data to protect rapid shifts in patterns or substances that maybe involved in overdoses.

We also support our partners in ensewerring that information is then used and shared with the necessary partners that can act on it. For example, that may include our harm-reduction partners that may want to get word out in the communities about changes in the lethality or the potency of the drug supply. It may mean communicating with the police, fire, and first responders partners who may need to be prepared to respond to different levels of overdose in the field.

We also focus on getting more complete fatal overdose data to inform our continuing effort to understand the risk factors to increase or mitigate the risk of overdose events. On the next slide you’ll see we also do a lot of work that focusing on enhancing and maximizing the use of prescription drug monitoring programs, or PDMPs. They maybe called PMP in your state.

PDMP is a line of course with our strategy of getting better, faster, and more timely data. They also help us achieve the work of the second pillar or domain, which was building state, local, and tribal capacity to respond to the epidemic. PDMPs very quickly are state-run database that collect patient specific prescription information at the point of dispensing.

PDMPs are among the most promising state level interventions to improve opioid prescribing, and also to inform clinical practice and to protect those patients that maybe at heightened risk of opioid misuse, abuse, our overdose. PDMPs can help providers identify patients who maybe misusing opioids or other prescription drugs. It can provide public health authorities with timely information about the patient behaviors that contribute to the epidemic.

They can use the PDHP data to determine hot spots or geographic areas within a state that maybe disproportionately affected and have higher rates of prescribing and target interventions in the areas. So things like academic details or other forms of clinician education and prescriber support. Given the promise that PDMPs hold to prevent opioid abuse, misuse, and overdose, we support our recipients as they implement strategies to improve the functionality of PDMPs, and to scale up the use of PDMP data to interand intrastate interoperability.

In addition to the direct funding we work hard to build and disseminate other actionable resources. Here at CDC we have the scientific capacity and the appetite to take a look at existing practices and see which of those have been subjected to really rigorous data driven evaluation. We can take a critical look at the evaluation to see what we should be highlighting or sharing with the shared partners.

This is one example of that work. It offers a really nice, accessible list of what our partners can be doing that has been tested and has been shown to be effective. The evidence-based strategies that are captured in this kind of menu cover things like effective practices with respect to Naloxone which is an life-saving drug that reverses the effect of an overdose.

And also best practices from medication-assisted treatment which is an evidence-based approach to opioid abuse disorder treatment that uses drugs to help people manage their disease. A new frontier for us that we are exploring and supporting is the integration of state and local efforts. A lot of the resources that are required for effective opioid prevention and response exist at the state level.

But we’ve also found that effective expressions of our prevention and response efforts are more likely to unfold at the local level. We also see that localities are driving a lot of the innovation that we’re anxious to subject to rigorous evaluation. We want to get everyone connected and talking to each other.

I also want to note here this really goes beyond integration of state and local public health partners. They are, of course, essential. We really need everyone at the table.

We need to work across the spectrum of stakeholders. The last several years of experience has brought us into communication and true partnership with a much, much border and more diverse range of partners than what we worked with before. We need public health, of course.

We also needs clinicians and care providers, we need law enforcement, first responders, legislators, we need our technology and I. T. infrastructure partners, we need harm-reduction partners, we need the faith community, we need schools.

Really we need anyone and effort that’s part of the communities that are affected by the epidemic. They can and should be a part of our prevention and response work. We know that this is much easier said than done.

There are a lot of bridges to build and common languages to discover in order to have the meaningful integration. We think it is a worthwhile investment. We’re committed to supporting our partners in the area both with respect to funds and with respect to technical assistance and insight.

The final example that I want to offer today in terms of how we are supporting increased capacity manage our state, local, and tribal partners has to do with ensuring a system’s level approach to connecting individuals in need of care with the services that provide that care. At CDC we are not engaged in the direct provision of care or treatment or service delivery. That’s not really our lane.

But we do have a responsibility to ensure there’s a bridge from the identification of risk to the mitigation of that risk. And people get really lost in our health care system. It can be really hard to navigate.

When withdrawal is coming on, it is unrealistic for us to place the ownous on the individual. It is unrealistic to place it on the support of family and friends. We need a system’s level aroach to ensuring that we are building those bridges and getting folks delivered to the care they need.

Linkages to care are the bridges that connect the work of public health with other agencies and the other partners that do provide that care. We embrace the philosophy that any door is the right door. While we support linkage to evidence-based treatment for opioid use disorder, like medication-assisted treatment, for example, we also support other processes and systems that just ensure that our public health system and the doors that are playing a positive role in keeping people connected to some form of care may ultimately lead them to care for their opioid abuse disorder.

These systems and solutions may simply be about establishing communications and protocols with other service partners, or maybe just about building the technology that supports and facilitates that communication from one system to another. Examples that we’ve seen so far have linkage to care include things like peer navigators, handover settings, pre-arrest division, and postrelease linkages, and community health workers. We’re really excited to see what our partners have generated in terms of innovation in the space.

The third strategic pillar that I mentioned is supporting providers and health systems in being a part of the solution. I mentioned earlier that the rapid increase in opioid prescribing started around 1999. The quadrupling of opioid prescribing was accompanied by a rapid increase in overdose deaths.

From 1999 to 2017, almost 218,000 people died in the use specifically related to prescription opioids. Opioid deaths involving prescription opioids were five times higher in 2017 than they were in 1999. Opioid prescribing hit its peek around 2012 with over 249 million opioid prescriptions written thattee.

That’s enough for every American to have had their own bottle of pills. So we know if overprescribing was a part of the problem to start with, then changing prescribing behavior can be a part of the solution. In recognition of that fact, the CDC in March of 2016 published our guideline for prescribing opioids for chronic pain.

To help address the overdose crisis and prevent overdose deaths. These guidelines are intended to be for use in primary care settings, for adults with chronic pain, and they are not intended to be used for patients with active cancer or inpalliative or end-of-life care. But we though that well intended physicians are the most common source of non-medical use of prescription opioids.

Whether through direct prescription or more likely physicians are the initial source of a prescription for someone else that was then passed along. We call this the friends and family plan. As you can see on the graphic, for every group of non-medical users of opioids, they most likely obtained those opioids either directly from a physician as you can see here in the light purple bar for every age and every frequency of non-medical use.

Or from more likely from a friend or a family member as shown on the turquoise bar. So in the next slide you’ll see that the guideline is intended to help put some parameters around what safe prescribing looks like. It provides recommendations to primary care providers about the appropriate prescribing of opioid pain medications to improve pain management and patient safety.

There are 12 recommendations in the guideline. But three principles are key in driving each of these. The first is that non-opioid therapy is the preferred choice for chronic pain outside of end-of-life care.

Second when opioids are the appropriate choice, the lowest possible effective dosage should be prescribed. And third, is that providers should exercise caution when prescribing opioids and monitor their patients very closely using the prescription drug monitoring program and other means of staying connected with their patients. Of course providers should weigh both the risks and benefits to prescribing opioids for patients with chronic pain.

We recognize that CDC that the guideline is not a one-size-fits-all approach. It is important to note that CDC is not a regulatory agency. Unlike, for example, the FDA.

The recommendations in the guideline are voluntary. They are not prescriptive standards. It is practical information that’s intended to provide recommendations about appropriate prescribing of opioid pain medications to improve both pain management and patient safety.

We understand and are committed to ensuring that prescribers and clinicians have the tools and resources they need. Research suggests that after clinical guidelines are published, there’s moderate knowledge of recommendations and fairly low levels of adoption unless we also offer intensive approaches to communicate the recommendation and guideline providers through the implementation. So in the spirit of ensuring awareness and appropriate application of our guideline, we offer several tools and resources to accompany the guideline itself.

First we know that we need to distill the information. So that means translating the guidelines and communicating it in user friendly language and tools. We also know that we need to support capacity.

We need to build skills through trainings through organizations and providers who are expected to use the guidance. Finally we need to support the delivery of the strategies, in particular implement activities and evaluate actions for further improvement. In our case, we’re achieving this work through our relationships with health systems and ensurers.

Our approach is guided by four pillars to ensure appropriate and responsible implementation of the guideline. We’re doing the translation and communication of the recommendations within the guideline. We’re doing extensive clinical education, training, and outreach.

We’re working with health system strategies and interventions that enhance the implementation of the recommendations at the point of care, and offering insurer intervention through pharmacy reimbursement and management techniques. Evidence thus far suggests that the guideline has been effective in changing prescribing behavior. We’ve seen declines in high-rate prescribing.

That’s people on very high doses of opioids. We’ve seen declines with opioid prescriptions which is a risk factor for overdose. And we’ve seen a decline in the overall number of opioid prescriptions.

Again we’re committed to ensuring that our guideline is applied as intended and that prescribers and clinicians have all of the tools that they need to make the right choice for their patients. Our fourth strategic direction has to do with partnering with public safety. There are a lot of examples of how this work is unfolding at the federal level and also how we’re supporting it at the state and local level.

The one that I want to draw your attention to today is our opioid response strategy. Which began in 2015 and now covered 24 states. This is a partnership between CDC and 11 high intensity drug trafficking areas or HIDAs.

They are a grand traffic within the office of national drug control policy. They aim to disrupt drug trafficking organizations. They’ve connected with us to help their approach.

We’re helping communities reduce fatal and non-fatal opioid overdoses by developing and sharing information about heroin and fentanyl and other opioids across agencies and discipline. It is really about data sharing and staying connected with each other about what our various lenses on the epidemic are telling us. And also by offering evidence-based intervention strategies.

More specifically there are four goals that direct our collaboration with the HIDTAs. It allows public health, law enforcement, and others to respond quickly and effectively address opioid overdose, incident, and trends through communication. The second is to develop and support strategic and evidence-based responses that generate immediate reductions in the number of overdose related fatalities.

Third is to promote and support efforts to prevent opioid misuse. And secondly to implement discussions in all of the strategy, goals, and activities. Our last strategic direction is to empower consumers to make safe choices.

This is, I think, the perfect place to end my talk and come full circle back to the very real people and the very real lives that are affected by this epidemic. I’m going to show you now a collection of vignettes from our Rx awareness campaign which is intended to help everyone understand the risks associated with opioids, and empower people to have important conversations with their health care providers. If you want to see more of these videos, they are available.

You can check out entire series of our Rx Awareness Campaign of vignettes on a link that will aware at the end of this vignette that will play for you now. [music].

Everybody knows somebody who is struggling with opioids.

I got my wisdom teeth taken out. I must have got a 30-day script. I took them in three days.

My son was 20 when he was prescribed opioids.

Nothing mattered more than getting the fix.

My son Steve didn’t want to die. His prescription opioids killed him.

With that, I will close the formal part of the presentation. We can open up for questions and conversation.

Thank you so much, Dr. Bacon, for a wonderful presentation. Jonathan, do we have any questions from the Q & A?

We have quite a few questions. This perhaps is expected. It’s been an issue that arises that brings out some concern in people on multiple sides of the issue.

So we’re focusing on the more general questions here. If people have specific questions, you can send them to EPIC@CDC. gov.

We can pass those questions on to the presenters. So the first question is: what are some ways that community-level prevention programs can use PDMP/PMP data other than prescriber, pharmacy, clinical prevention efforts?

We talk a lot about the PDMP data as either a clinical-decision-making support tool as I think is what you are saying that you know about and want to hear about other applications. The second way we talk about the power and influence of PDMP data is as a public health surveillance tool. What I mean by that is simply saying that the PDMP data can tell us where you have high rates of prescriptions going out into the communities.

It doesn’t have to be patient specific. It doesn’t have to be prescriber specific. You can look at county level, for example, and see where there are rates of aberrant rates of prescribing that might suggest the need to generate some proactive prevention and response resources in the particular community.

If there are counties or communities within your state where you are seeing very high rates of opioid prescribing, it may mean you want to connect with your harm reduction coalitions to ensure that the affected communities have access to Naloxoen, which is the life-saving drug that reverses the effect of an opioid. You may want to do some outreach through faith-community partners, and schools, in terms of educating consumers about the risk of consuming opioids in combination with other drugs. Also ensuring that members of the community are aware of treatment resources that maybe available for folks that maybe at heightened risk and may be experiencing suffering with addiction.

They might be interested in getting connected with care. We know there are care resources available. A lot of the folks who need treatment services and care are not getting it so that’s one of the areas where we are really interested in putting some strategic effort and attention.

I think the PDMP data is an important way for us to decide which communities that should be a priority in.

Okay. The next question is: does CDC have any recommendations on the use of opioids in the acute-hospital-based setting is this.

At this point we don’t have formal recommendations in acute-care settings. We are working with a number of partners who have generated recommendations for the settings. To offer not necessarily a formal guideline but some benchmarks with what safe and appropriate prescribing may look like in those settings.

At this time, we could direct you to some resources generated by other partners. Stay tuned for something specifically on the CDC on that front.

Next question is: how would you distinguish between accidental overdoses versus suicide attempts?

That’s a great question. It is a really tough question. It is part of what some of our data enhancement efforts is intended to get at.

I mentioned our efforts to improve the data around fatal overdose events. Part of that is through the state unintentional drug overdose reporting system or SUDORS. It gathered rich data that helps us understand the context and circumstances that surrounded the fatal overdose event.

If it is a not fatal event, we have a patient to talk with to understand whether there was intend. For fatal events, in the absence of a note, it is very difficult to make that determination. But there are frequently some contextual clues or variables that at the scene of the event.

We want to build the data systems that are capable of gathering that information so that it is available to our medical examiner, coroner partner, law enforcement, and first responder partners, partners in mental and behavioral health and substance abuse prevention. It is always going to be a situation that we’ll have to piece together. And a lot of our efforts that are directed at improving the richness of our fatal overdose data will begin to get at that question.

Thank you. We’ve received two requests for a future version of this webinar in Spanish. I can tell you we will give some serious discussion.

I can’t commit to anything. I can certainly can appreciate the fact that there are people who are interested in this information. The next question is: linkage to care is important to reduce control of opioid, heroin, and cocaine epidemic.

Do we have any drug treatment spots for all of the substance users that will need real treatment for their opioid problem? I believe the question he’s asking is: are there places to go to?

Yes. Yes, there are. A lot of our efforts are ensuring and intended to address exactly that question and making sure folks are aware of what the actual real and available resources are in their communities.

For example, our partners at SAMSA and at NIDA, have worked on some fantastic resources that convey real-time availability of treatment spaces. Whether it is in-patient or out-patient treatment availability. So a lot of the work that we’re supporting our partners to engage in is making sure those resources are available.

Folks are aware of them and using them and to do the quality improvement to make sure they are as usable and accessible as possible. One of the challenges again is ensuring the message is getting to the right person. In addition to ensuring that people suffering with addiction themselves have access to and awareness of those resources, we also really want to focus on ensuring that our health systems and emergency department and paramedics, and also the friends and family of people suffering with addiction or just at risk of overdose are aware of those resources as well.

The linkage to care conversation is — has been taking shape for several years now. This is really the first formal foray into the space. What are the resources that people should be linked to and how can we ensure that we have the strategies and the communication across partners in place to make people aware of resources.

Thank you. The next question is: have seen any decrease in drug deaths associated with any particular data group which has been reported?

I’m not exactly sure what is meant by data group. I will say I think — you know, I think you could define that any number of ways if we’re talking about geographic differences, yes. We have absolutely seen differences in the rates of decline by geography.

A lot of that has to do with the availability of the drug supply in different parts of the country and the lethality associated with, again, for example, the manufactured fentanyl which is really volatile and unpredictable in terms of the potency and lethality associated with that. So I think it really depends on whether you are looking across geography, across age groups, we have seen some unfortunate increases among younger populations, and so, yes. We are being careful to pay attention to different rates of growth or hopefully declines across different segments of the population.

Thank you. We are seeing a few questions here that are more of a clinical nature. Questions about how to define chronic pain or questions about alternative treatments for pain decides opioid use.

What I have to say to that is this is outside of the scope of the presentation. If you have a particular question send it to EPIC@CDC. gov.

We’ll pass them on, even if we can’t answer them in the format. The next question is: can the PMP data be used across state lines?

Yes. That’s something we’re working hard to support our state partners to improve and expand and enhance. PDMPs are all state-level authorized entities.

So a lot of the sharing across state lines is determined by each state’s specific policy and legislative status. Each state may look a little bit different. Over the last two or three years, we’ve seen dramatic and encouraging growth with respect to what we call interstate data sharing.

Both with respect to developing the technological capacity to share data across state lines, the technology to integrate the data into the typical clinician work flow so it is part of the electronic health record or whatever they are looking at for a patient at the point of care. We also have seen tremendous growth and progress, we think, with respect to the political and cultural will to do that. To share data with other states and other jurisdictions to ensure that clinicians have access to a complete picture of the prescribing history of the patient who is sitting in front of them at that moment.

Thank you. We got a question from one person who asks if you can repeat what you mentioned pertaining to the work that’s done by collaborating with HIDTA.

Yes. The HIDTAs. The high intensity drug trafficking areas are a grant program operated through the White House’s Office of National Drug Control Policy.

Their mission has to do with addiction and stopping the drug supply. In the course of doing their work, they recognized they were encountering what a lot of public health questions and challenges. We’re collaborating in the form of opioid response strategy which is now impacting or unfolding in 24 states.

And it is really sort of the combination of data sharing and awareness. So, for example, what do law enforcement data tell us that health data don’t necessarily tell us? Do they paint a different picture of what the epidemic might look like in a specific jurisdiction? And vice versa. How can the public health data be used to complement the understanding by law enforcement data.

The data is the first piece, and then using data to inform action. We look at what the data tells us and use that to inform a combination of strategies that really sit at the intersection of public health and public safety. Not just for prosecution, arrest, et cetera, but really no understand how law enforcement and first responder partners can be part of an arm of implementing public health solutions and strategies.

One of my personal interest right now in understanding better is prearrest diversion. If the law enforcement officer encounters an individual who has broken a law but is perhaps more of a status offense, they can see that person is in need of treatment services, they may opt to connect with a treatment provider or harm-reduction partner to connect that person with care and services rather than starting the process of the criminal justice response that they have typically done before. That’s just one example.

There are others. We’re excited about the collaboration in particular, because so often it is our law enforcement, public safety, and first responder partners that are first on the scene of any overdose event.

Great. Thank you. I’m going to read a comment.

Normally we are reading questions. It is one comment that stood out. It was from Jennifer Pearson.

We would add libraries to your list of partners. That’s because — we’ve had interaction with the public library association wind up being involved in the opioid response.

Jennifer, thank you. I appreciate that comment. We have heard that from other partners as well.

Libraries are very much a part of the a community, and in certain communities are the life blood of the community. As I said, our linkage to care philosophy is any door is the right door. Anywhere that provides a venue or a setting for us to connect with folks who are in need of some sort of treatment or services is absolutely an appropriate venue for us to then get them connected with a system of care and the services that they need.

Thank you for that. I will actually make sure that the language is reflected in the future conversations.

I’m going to read a question. The we is — the question is: who do we contact for more treatment being available in the community? The waiting list are frightening. People with addiction need help now rather than months from now.

People with addiction need help right now. There’s a lot of evidence that shows us. If had been is in the emergency room — someone is in the emergency room, that’s the most important example to get started on medication-assisted treatment.

The closer they get to experiencing the effects of withdrawal, the more likely they are to return to opioids. That’s exactly what the linkage to care is attended to address. In your specific community I would recommend a couple the of starting places.

First would be your local whether it is city or county public health department. They should be connected with whatever behavioral or mental health services where available in your community to get folks connected with treatment resources that are available. There are also state-level resources.

Your state-level substance abuse authority, for example, who should have an inventory or catalog of what the treatment resources are that are available. We’re also able to help you make the noise if they are inadequate. We would love to hear from you.

If they don’t get you exactly what you need, we need to hear about that. In our work to link people to care, we have a responsibility to make sure the care is available to them.

Great. Thank you. The next question is: in our area in southeast Missouri people that are not getting treatment because of the lack of insurance and also there’s a small amount of treatment facilities in the area is what she’s trying to say.

There’s limited access to treatments. Can you address what options people have in that situation?

We’re working really hard to develop better and more options for you than the ones I can identify today. We recognize that’s a deficit and something that needs to be addressed. Again I’ll just clarify that CDC’s role is not in terms of generating direct treatment or provision of services.

This is really a question that could be more fully and richly addressed by my colleagues at SAMSA, or with your local substance abuse prevention and mental health and behavioral health partners. Having said that, again our commitment is to linkage to care. We recognize particularly in rural and frontier populations, it is a big challenge even if if there’s availability of services, it is tough to get folks to the services.

We are investing in various forms as a form of connection to care. Sometimes people just literally need a ride. It is that simple and that logistically straightforward.

People just need a ride to get their MAT, or get the treatment services they need. We’re supporting those sort of efforts. We’re also really interested in exploring the options associated with telemedicine and telehelp.

There are certain restrictions involving medication and prescriptions. But we’re aggressively pursuing some options associated with telemedicine to ensure that everyone across the state has access to the resources they need.

Okay. The next question is: are there any states tracking if overdoses are occurring with just opioids or are they combined with others, like stimulants or benzodiaopine. They are wondering if patients on the combination would be at high risk.

Yes. In fact, most states are tracking those data. 33 of them are doing it through the assistance of our enhanced surveillance of opioid overdose in states program and through the SUDORS system that I mentioned.

Drug toxology data is requested and usually reported. There are limitations associated with that. Particularly with respect to delineating which opioids or which specific substances are in a decedent’s system.

Sometimes it is a matter of having access to the toxicology and drug-testing equipment, and sometimes it is a matter of public health and clinical chemistry keeping up with elicit chemistry and new drug formulations that are emerging and having the capacity to detect those. More specifically to your question regarding use with other non-opioid substances, this is absolutely an important area for focus. I mention briefly earlier that combination of opioids with benzos, is particularly problematic.

It does dramatically increase the risk of an overdose event. We pay very careful attention to that. We mention that sort of new frontier in the reality this is not just an opioid overdose epidemic.

This is really a drug overdose epidemic. Because exactly the data you are asking about is how we know that we are also looking at cocaine, psychostimulants, methamphetamine, sort of co-occurring epidemics. Sometimes the drugs are used in combination with opioids, and sometimes on their own.

We’re using data to make sure that all sates have the infrastructure, technology, and resources of equipment available to do the level of drug specificity testing.

Thank you. We’ve received a couple of questions about faith-based organizations and how they can be part of this. Or if they can be a resource for addicts.

Can you comment on that?

Yes. We have a lot of really energized and fantastic conversations with our faith-based community partners. To me this is taking a trusted resource and point of conversation and connection in any given community and ensuring that those partners who already are part of the community and have earned the trust of community members have the tools and resources that they need to take care of their community, of their faith-based community.

So with respect to what I’ve talked about today, I view the faith community very much as one of those sort of points of entry for linkage to care. It is a safe haven and hopefully one of the communities where we don’t struggle with the stigma as much as we do in some other settings that are attached with opioid use disorder and also some of the treatment options available to folks. So a lot of our work supporting state and local integration will necessarily involve the faith community as messengers and communicators and people that we need to equip with the resouses to get folks connected — resources to get folks connected to care.

Thank you. One more question. It is probably appropriate to close it off with this question.

It is something that you and I discussed earlier. Peggy asked targeting physicians makes them not to prescribe. How do we encourage them to treat the patients that require the opioids?

That’s an important question. That’s one that we pay a lot of attention to here. You know, I think the language Peggy is telling of targeting physicians — the guidelines are intended as a resource and a tool and something that should make patient care easier and more simple for clinicians.

We do understand that at times, if you don’t then provide the alternatives and the resources, that physicians have opted to treating people that are already on high morphine milligram equivalents and recognize some of the consequences that come with that. That’s why we are so committed to and working really hard to make sure in addition to the guideline, physicians and clinicians have access to everything else they need to continue offering appropriate care to any patient, even while staying in accordance with the guideline. We’ve offered guidelines to tapering and how to get doses done by while managing pain, but moving toward a safer level for patients.

We also are doing a lot of work exploring other effective forms of pain management. Non-opioid and sometimes even non-pharmacologic approaches to pain management so patients can get the pain management they need and deserve, but can also be assistive in moving toward safer levels of opioid use. So thank you for that question.

This will now close our Q & A session. I just want to thank Dr. Bacon again for her time.

Thank y’all so much for participating with your comments and questions. If we didn’t get to your question, please e-mail it to EPIC@CDC. gov.

We’re happy to forward that to Dr. Bacon. Tea’s presentation has been recorded.

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gov/E accident IC. The course access is EPIC0327 with all letters capitalized. Thank you again, everyone.


Page last reviewed: April 8, 2019