Physicians Engaged in Prevention

1. Physicians Engaged
in Prevention
Presenters:
• Yngvild Olsen, MD, MPH, Medical Director, Institutes for Behavior
Resources, Inc.
• Daniel Raymond, Policy Director, Government Relations Manager, Harm
Reduction Coalition
• Angela Conover, Director, Media and Community Relations, Partnership
for a Drug-Free New Jersey
Advocacy Track
Moderator: Daniel Blaney-Koen, JD, Senior Legislative Attorney,
American Medical Association Advocacy Resource Center, and
Member, Rx and Heroin Summit National Advisory Board

2. Disclosures
Angela Conover; Yngvild Olsen, MD, MPH; Daniel
Raymond; and have disclosed no relevant, real,
or apparent personal or professional financial
relationships with proprietary entities that
produce healthcare goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Specify roles for physicians and medical professionals
in responding to the nation’s Rx drug abuse epidemic.
2. Explain how policies supporting PDMP, MAT and
naloxone access can work together to reduce opioid
abuse.
3. Describe a state program that educates physicians
about Rx drug abuse and its link to heroin abuse and
engages them in prevention efforts.
4. Provide accurate and appropriate counsel as part of
the treatment team.

5. Advocacy Track: Physicians Engaged
in Prevention
Yngvild Olsen, MD, MPH
Medical Director
Institutes for Behavior Resources, Inc.
American Society of Addiction Medicine (ASAM)
Chair, Public Policy Committee

6. DISCLOSURES
Yngvild Olsen, MD, MPH, has disclosed no
relevant, real or apparent personal or professional
financial relationships with proprietary entities
that produce health care goods and services.

7. Objectives
1. Specify roles for physicians and medical
professionals in responding to the nation’s Rx drug use
epidemic.
2. Explain how policies supporting PDMP, MAT and
naloxone access can work together to reduce opioid
misuse and addiction.
3. Describe a state program that educates physicians
about Rx drug use and its link to heroin addiction and
engages them in prevention efforts.
4. Provide accurate and appropriate counsel as part of
the treatment team.

8. Multiple Points for Intervention
Recovery
1. Prevention
4. Overdose
Response
Program/Naloxone
3. TREATMENT and RECOVERY
SUPPORT SERVICES
3. TREATMENT and RECOVERY
SUPPORT SERVICES
2. Screening

9. Safer Opioid Prescribing
• Prescription Drug Monitoring Programs
• CDC Guideline for Prescribing Opioids for
Chronic Pain – United States, 2016
• CME requirements for chronic pain/opioid
prescribing

10. Prescription Drug Monitoring Program
(PDMP)
• PDMP Center of Excellence at Brandeis
University:
– “Evidence continues to accumulate that prescription drug monitoring
programs (PDMPs) are effective in improving clinical decision-making,
reducing doctor shopping and diversion of controlled substances, and
assisting in other efforts to curb the prescription drug abuse epidemic.”
1 Prescription Drug Monitoring Program Center of Excellence at Brandeis, Briefing on PDMP Effectiveness, Updated
September 2014.
http://www.pdmpexcellence.org/sites/all/pdfs/Briefing%20on%20PDMP%20Effectiveness%203rd%20revision.pdf

11. Understanding Risk Factors for Addiction
Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department
of Health and Human Services

12. Screening (and Assessment)
• Goals:
– Identify aberrant medication related behaviors
– Screening for presence of diagnostic criteria for
opioid use disorder related to prescription opioids
• SBIRT (Screening, Brief Intervention, Referral
to Treatment)
• Multiple screening instruments

13. Substance Use Disorder Diagnostic
Criteria, DSM-V
Severity measured by number of symptoms; 2-3 mild,
4-6 moderate, 7-11 severe
More use than intended Excessive time spent in acquisition
Unsuccessful efforts to cut down
Craving for the substance
Activities given up because of use
Continued use despite consistent social
or interpersonal problems
Failure to fulfill major role obligations Tolerance*
Use despite negative effects Withdrawal*
Recurrent use in hazardous situations
• These do not apply if the medication is prescribed and no other diagnostic
criteria are met

14. Addiction Definition
– A primary, chronic disease of brain reward, motivation,
memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological,
social and spiritual manifestations.*
– A chronic, relapsing disease characterized by
compulsive drug seeking and use despite harmful
consequences as well as neurochemical and molecular
changes in the brain.**
*American Society of Addiction Medicine
**National Institute on Drug Abuse (NIDA)

15. Chronic Disease
• No cure!
• Goal is life long management
• Disease severity may change over time but risk
of symptom recurrence is always present
• Effective treatment often combines
medications and behavioral interventions
• Behavior change is a key part of management
• Behavior change occurs in stages

16. Agonist Treatment & Relationship to
Heroin Overdose Deaths
Patients in Methadone Treatment
Heroin Overdose Deaths
Patients in BUP Treatment
1995 1997 1999 2001 2003 2005 2007 2009
0
2000
4000
6000
8000
10000
12000
0
100
200
300
400
OverdoseDeaths
PatientsTreated
Schwartz, et al., American Journal of Public Health, 2013

17. Boston Medical and Surgical Journal,
October, 1916
Back to the Future…

18. Why Is It So Hard to Engage Healthcare
Professionals in Addiction Treatment?
• Deep historical barriers
– 1914 -1935: Shift in public perception, legal framework, and
medical involvement in addiction treatment: Addiction criminalized
– 1920 – 1970: Addiction seen as moral failing
– 1974: First legal recognition of opioid agonist therapy to treat
opioid use disorder but created separate DEA classification for
physicians who dispense opioids for addiction treatment
• Stigma
• New opportunities but little training
– 2000-2002: Drug Addiction Treatment Act (DATA 2000) and
buprenorphine approval
– 2006 and 2010: FDA approval of injectable naltrexone for alcohol
use disorder and then opioid use disorder relapse prevention
– No universal addiction training in medical school

19. Treatment need for opioid abuse or dependence exceeds
capacity for opioid agonist medication assisted treatment
Source: Jones CM, Campopiano M, Baldwin G, McCance-Katz E. National and state treatment need and capacity for opioid agonist medication assisted treatment. AJPH. 2015

20. Naloxone Co-Prescribing
• Saves lives
• Easy to prescribe
• Little data to guide who should get it
• Recommended for those at high risk of overdose
– History of overdose and/or addiction
– High doses of opioids
– Complicating medical conditions
– Low opioid tolerance at risk for resuming opioids
– High risk medication combinations

21. Naloxone Saves Lives!
Walley AY et al. BMJ 2013;346:f174

22. Resources
ASAM National Practice Guideline for the Use of
Medications in the Treatment of Addiction
Involving Opioid Use
http://www.asam.org/docs/default-
source/practice-support/guidelines-and-consensus-
docs/national-practice-guideline.pdf
PCSS-MAT and PCSS-O
http://pcssmat.org/
http://pcss-o.org/

23. Three key policies that need to work
together to end the opioid crisis:
PDMPs, MAT, naloxone
Daniel Raymond, Policy Director
Harm Reduction Coalition
raymond@harmreduction.org
www.harmreduction.org

24. Disclosure statement
Daniel Raymond has disclosed no relevant, real
or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.

25. 42 States Have Naloxone Access Laws
Source: LawAtlas Policy Surveillance Report, LawAtlas.org, PHLR

26. 4 Quadrants Framework for Naloxone
Access
Community
1st
Responders
Prescribers Pharmacies

27. Community-based Overdose Education
& Naloxone Distribution (OEND)
• Pioneered in the late ‘90s by harm reduction
programs reaching out-of-treatment heroin users
• Diverse settings: syringe exchange, health
departments, recovery organizations, parents
groups, drug treatment, drug courts….
• Largest evidence base: feasibility, acceptability,
impact, cost-effectiveness
• Through June 2014, OENDs provided over
150,000 naloxone kits & received reports of
26,463 overdose reversals

28. OEND programs as of June 2014
Wheeler E, Jones TS, Gilbert MK, Davidson PJ; Centers for Disease Control and Prevention
(CDC). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United
States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Jun 19;64(23):631-5.

29. First responders & law enforcement
• Basic EMS (vs. Advanced) more common in
rural areas (high overdose rates), but
traditionally scope of practice has not allowed
them to administer medications – now
shifting to allow for naloxone
• Rapid uptake of naloxone by law enforcement
(Department of Justice toolkit; grant support
in Comprehensive Addiction & Recovery Act)

30. Naloxone Prescribing
Influential early adopters of naloxone prescribing to
at-risk patients:
• Project Lazarus in North Carolina integrated
naloxone co-prescribing for patients receiving
opioids into a broader overdose prevention and
opioid safety initiative
• The Veterans Administration Opioid Overdose
Education and Naloxone Distribution programs
have provided trained and naloxone to over
12,000 veterans as of December 2015

31. Naloxone Prescribing Levels Low
Jones CM, Lurie PG, Compton WM. Increase in Naloxone
Prescriptions Dispensed in US Retail Pharmacies Since 2013.
Am J Public Health. 2016 Apr;106(4):689-90.

32. Approaches to Naloxone Prescribing
• CDC Opioid Prescribing Guidelines: “consider
offering naloxone when prescribing opioids to
patients at increased risk for overdose”
• Prescribe to Prevent:
http://prescribetoprevent.org/
• Opioid safety vs. overdose – San Francisco
Department of Public Health naloxone co-
prescription academic detailing

33. Pharmacy access to naloxone
• Naloxone remains a prescription drug, but can be
dispensed by pharmacists under some circumstances
• Pharmacy access to naloxone possible in many states
under standing orders or collaborative practice
agreements
• Large chains & independent pharmacies moving
quickly in many states
• On-going dialogue about whether naloxone
could/should be over-the-counter
“Over the Counter” Naloxone Access, Explained, Corey Davis, 3/1/16,
https://www.networkforphl.org/the_network_blog/2016/03/01/745/over_the_counter_naloxone_access_exp
lained
OTC Opioid Overdose Antidote: Why is it not FDA Approved?, Zachary Brennan, 2/24/16,
http://www.raps.org/Regulatory-Focus/News/2016/02/24/24400/OTC-Opioid-Overdose-Antidote-Why-is-it-
not-FDA-Approved/

34. Opportunities for Advocacy
• Individual doctors have been instrumental in
supporting growth of community-based
OENDs
• State medical societies provide valuable
support for state legislation
• Doctors can education patients & partners on
naloxone, champion naloxone prescribing
• Partner with community groups for increased
impact on awareness, access, advocacy

35. Advocacy Track:
Physicians Engaged
in Prevention

36. Angela Conover, has disclosed no relevant,
real or apparent personal or professional
financial relationships with proprietary
entities that produce health care goods and
services.

37. Learning Objectives:
1. Specify roles for physicians and medical professionals in
responding to the nation’s Rx drug abuse epidemic.
2. Explain how policies supporting PDMP, MAT and
naloxone access can work together to reduce opioid
abuse.
3. Describe a state program that educates physicians
about Rx drug abuse and its link to heroin abuse and
engages them in prevention efforts.
4. Provide accurate and appropriate counsel as part of the
treatment team.

38. Who We Are

39. Opiate Abuse In New Jersey
Current Drug Trends

40. Engaging Stakeholders
• Law Enforcement
• Physicians
• Faith Based Leaders
• Community Prevention Agencies
Accessing the Need and Building Capacity

41. Provide
Information
Build Skills Provide Support
Reduce Barriers
and Enhance
Access
Change
Consequences
Change Physical
Design
Modify Policy
CADCA’s Seven Strategies to Effect
Community-Level Change
CADCA: Community Anti-Drug Coalitions of America
Utilizing Prevention Science

42. Do No Harm Overview
Hackensack University Medical Center
Hackensack, Bergen County, NJ
October 30, 2013
Morristown Medical Center
Morristown, Morris County, NJ
June 10, 2014
Community Medical Center
Toms River, Ocean County, NJ
June 11, 2014
Cooper University Hospital
Camden, Camden County, NJ
June 12, 2014
Robert Wood Johnson University Hospital
New Brunswick, Middlesex County, NJ
October 1, 2014
Morris County Correctional Facility
Morristown, Morris County, NJ
April 30, 2015
Jersey Shore University Medical Center
Neptune, Monmouth County, NJ
June 10, 2015
Capital Health
Hopewell, Mercer County, NJ
November 7, 2015
New Jersey Dental Association
Livingston, Essex County, NJ
November 13, 2015

44. 0
50
100
150
200
250
300
Total Do No Harm Medical/Dental
Attendance: 1,578

45. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentages of prescribers who intend to make opioid prescribing
changes or apply learnings to their practice as a result of attending
the Do No Harm Symposium

46. Earned Media

47. Recognition:
National Association of Government Communicators
White House Office of National Drug Control Strategy

48. Provide
Information
Build Skills Provide Support
Reduce Barriers
and Enhance
Access
Change
Consequences
Change Physical
Design
Modify Policy
CADCA’s Seven Strategies to Effect
Community-Level Change
CADCA: Community Anti-Drug Coalitions of America
Utilizing Prevention Science

49. Physicians Engaged
in Prevention
Presenters:
• Yngvild Olsen, MD, MPH, Medical Director, Institutes for Behavior
Resources, Inc.
• Daniel Raymond, Policy Director, Government Relations Manager, Harm
Reduction Coalition
• Angela Conover, Director, Media and Community Relations, Partnership
for a Drug-Free New Jersey
Advocacy Track
Moderator: Daniel Blaney-Koen, JD, Senior Legislative Attorney,
American Medical Association Advocacy Resource Center, and
Member, Rx and Heroin Summit National Advisory Board