فیلم پاسخگویی به اپیودمی اپیودیوم (بخش دوم از ۳)

Title:Responding to the Opioid Epidemic (Part 2 of 3)

امسال، مرکز برنامه‌ریزی و سلامت جامعه APA و انجمن‌های سالم، میزبان مجموعه‌ای از وبینارها برای بررسی تلاقی برنامه‌ریزی و اپیدمی مواد افیونی بودند. این مجموعه که برای به اشتراک گذاشتن تجربیات محلی و منابع ملی طراحی شده است، همچنین به منظور راه اندازی شبکه ای از اعضا و متخصصان همتا است که برای درک بحران و نقش ما در آن تلاش می کنند. این جلسه دوم، پاسخ به اپیدمی مواد افیونی، به چگونگی واکنش جوامع به بحران مواد افیونی می پردازد. بینندگان می توانند انتظار داشته باشند که درباره بهترین یا در حال ظهور شیوه ها و تجربیات جامعه بیاموزند. دکتر براندون مارشال از دانشکده بهداشت عمومی دانشگاه براون تجربیات خود را با Prevent Overdose RI، نظارت بر مصرف بیش از حد دارو در رود آیلند و داشبورد اطلاعاتی ارائه می دهد. دکتر رابرت پارک از دانشگاه ایالتی تنسی شرقی کار خود را در مورد واکنش به مواد افیونی در تنسی به اشتراک می گذارد. قسمت ۱ مجموعه وبینار را تماشا کنید: https://youtu.be/IoCL2r81VgQ
قسمت ۳ مجموعه وبینار را تماشا کنید: https://youtu.be/qweX8iQVHDk

درباره بحران مواد افیونی بیشتر بدانید: https://www.planning.org/blog/blogpost/9141430/

درباره کار مرکز برنامه ریزی و سلامت جامعه APA بیشتر بدانید: https://www.planning.org/nationalcenters/health/ (برچسب‌ها برای ترجمه برنامه ریزی شهری

قسمتی از متن فیلم: Hello everybody thanks for joining us on today’s webinar going to just wait a minute or so to to let people sign off wanted to handle some some general housekeeping first though this webinar is available for 1 cm credit it is being recorded and everyone will get a copy of

The recording in the next couple of days and it will be available on APA website as well and if you have questions please include them in the box on the right hand side on the chat box throughout the presentation there’s no need to wait for the Q&A session at the

End to write down the question where else we’ll collect them throughout the presentation ok let’s get started thanks everyone for joining responding to the opioid epidemic we’ll just a reminder again that this is being recorded and so you will get the slides afterwards and submit questions if you

Have them throughout the throughout the presentation so this is part of a series planning in the opioid epidemic of being expected the first one was on January 25th and is available on the APS website and the final one will be coming up next month in March the first webinar focused

On some of the background related to the introducing planners to the opioid epidemic and planning it’s available for continuing education CM credits and it’s also available on YouTube for those who don’t need CM credits it laid out the common terms of healthy community design a piays efforts in some more detail

Looks at the opioid epidemic through a public health framework and highlights some efforts underway from the National Association of counties to pit opioid epidemic this session is focusing on the public health response to the opioid epidemic I’m going to do a brief introduction just to bring people who were not part of

First webinar up to speed quickly and then we’ll discuss strategies to address the opioid crisis with examples from Rhode Island and a community University partnership to address the epidemic and opioid use disorder and APA has long been involved in healthy communities and has a lot of great resources health and

Community Design in general through their planning and Community Health Center and there’s also a healthy communities collaborative through APA linking planners and other allied professions to focus on healthy communities design as an interest group you do not have to be an APA member to participate in the healthy communities

Collaborative and there are three subcommittees so you can get involved in an area of your particular interest here is short some how you get in touch with the healthy communities collaborative through email or Facebook and again the presentation will be shared afterwards so healthy communities design in general

Focuses on making the Healthy Choice the easy choice for our residents and I think when you look at it the work we do as planners we can see a lot of ways that healthy communities are affected by the work we do in our individual fields in planning from transportation to air

Quality to access to healthy foods and social equity is another key element for healthy community design and is particularly pertinent to the when discussing substance abuse and the opioid epidemic it’s important to remember that equality is not the same thing as equity equality treats everyone equally regardless of differences so

Some people still fall short of the goals of healthy communities design of the programs we’re working on equity provides resources to achieve those same results for everyone taking into account the differences of people in their age or population APA has also been involved in a plan for health

Project with the American Public Health Association which was a multi-year effort to further healthy communities I I was involved in the healthy communities in PA which was the planners for health project in Pennsylvania and through that we did a survey of every planning county planning director in Pennsylvania to help identify what tools

Planners needed what issues were and how they believe they could affect change so this slide shows in red issue pressing issues that planners around Pennsylvania were facing and blue shows planning issues that planners spell fate they have the proper tools to address so you can see substance abuse shows the

Greatest disparity between planners seeing issues in their communities but not really knowing how to help address the issue and that helps lead to this webinar series and we can see that this is an issue in Pennsylvania but it’s an issue all over the country it isn’t geographically based and I

Think we can they also look further and see that this is also an issue that’s on a ride on the rise so for example motor vehicle traffic deaths in the u.s. we’re ten point nine per 100,000 population in 2015 and on the decline while drug overdoses rates are nineteen point eight

And that’s all on the rise and so I think this issue is something that we’re definitely going to want to address in the future and figure out how planning can address this issue so just briefly to introduce today’s speakers we’ve already got to know me I’m a local planner with Delaware County in

Pennsylvania focusing on the statewide healthy communities in PA task force dr. Brandon Marshall is an associate professor of epidemiology at Brown University School of Public Health he works closely with the Rhode Island Department of Health on the state’s overdose epidemic efforts and directs the prevent overdose our eyes org

Website a CDC funded statewide online surveillance system and dr. Robert pack is a professor of community and behavioral health as so Dean for academic affairs in the College of Public Health at East Tennessee State University and director of the ETSU Center for prescription drug abuse prevention and treatment and as they’re

Speaking please do submit questions that you have in in the chat box on the side and we’ll have a moderated QA session at the end so I’m going to hand it over to Brandon great Thank You Justin all right it’s a pleasure to present him the webinar today thanks for the

Introduction Justin I’m going to spend 15 minutes or so talking about the overdose crisis and what we’re doing to address it here in Rhode Island I’ll start by looking just at the state of the epidemic mostly nationally drawing on what Justin has already presented and then focusing down in on Rhode Island

Spend most of the time discussing our strategic response which was implemented in 2015 and then just finished with how we’re communicating that progress through the surveillance website prevent overdose RI org that Justin mentioned so what is the save at the epidemic nationally and here in Rhode Island this

Is a figure from the New York Times that I think does a very nice job visually showing how the epidemic has grown exponentially really over the last several couple of decades this is the number of drug overdose deaths in the United States and when this was published the 2016 data were preliminary

The numbers now have come in at over 63,000 in 2016 so actually at the top of those estimates that are shown in red and this is well in excess of the number of gun deaths at their peak in 1993 and also the peak number of deaths due to

HIV and AIDS in 1995 so for many of my students here at Brown I tell them that this could very well be the epidemic of their generation much like HIV was for earlier public researchers and activists just visually another way to look at this is spatially

This is from the same article in The New York Times that looks at the rate of drug overdose deaths by county in the United States in 1999 showing really some hotspots in West Virginia and Appalachia parts of New Mexico in the West Coast this is what the epidemic looked like last year

So as you can see in this slide essentially high rates of overdose across the country rural areas urban areas red states blue states really many ways you look at it overdose is an issue now that affects every community across the nation when we look drill down now

By States this is a most recent data from the CDC showing the increases in drug overdose death rate from 2015 to 2016 and the top ten states I’ve shown here for you you can see dramatic increases in drug overdose deaths in some regions particularly the District

Of Columbia had a doubling in only one year which is just shocking Rhode Island was fifth highest in 2015 you can see here in 2016 we dropped down to ten and that’s simply of a function of the fact that we increased more slowly than some other states like Pennsylvania which

Actually jumped ahead of us so we’re still a very very highly affected state but our epidemic as you’ll see is looking like it may be stabilizing and perhaps declining hopefully for reasons which I’ll talk about in a little bit going down now looking by age overdose used to be an issue that primarily

Affected people in middle age in the early 2000s the highest rates were in the late 30s and early 40s over the last decade or two the number has or the ages most highly affected has shifted and you can see here in the slide that concerning lis in 2016 was the first

Year that the rates were actually highest in younger people 25 to 34 commensurate with a dramatic increase in overdose rates in older people as well aged 55 to 64 and that’s largely due to an intertwined epidemic of illicit drug use we’ll talk about how fentanyl is affecting the illicit drug use overdose

Epidemic and an ongoing epidemic of prescription opioids which tends to affect older populations more heavily the vast majority of drug overdoses in Rhode Island over 85% and the majority of overdoses and the us are due to a class of drugs called opioids so what are opioids these are substances which interact with

Opioid receptors which are found throughout the brain this is a broad class of drugs that includes illicit drugs such as heroin and then other drugs used often in medical both acute chronic and surgical settings these drugs when they bind with opioid receptors create feelings of pleasure euphoria and also very effective at

Reducing feelings of pain so that’s why they’re used in medical settings and also can be misused or used recreationally when opioids bind to opioid receptors they also affect the respiratory system and that’s essentially what causes an overdose as opioids bind more and more to the receptor that basically slows

Down someone’s breathing and an overdose essentially respiratory depression that happens often sometimes quite slowly an overdose can occur over a period of one to two hours classically we see what’s called the overdose triad which are three symptoms that are all do really – respiratory depression breathing slowly

Having trouble waking the person up and turning blue or having the skin to look very pale and so I just like to highlight these symptoms of overdose in case you’re in a very unfortunate circumstance of witnessing one the real key thing here is to call 9-1-1 immediately and if naloxone is on hand

Administer that naloxone which is an effective opioid overdose antidote for those who are trained in CPR also to initiate rescue breathing again because an overdose is essentially a severe respiratory depression so I want to talk a little bit about fentanyl this is a highly potent opioid which used to be

Which is still used in often surgical settings in the US and is up to a hundred times more potent than morphine this figure shows here a lethal dose of heroin 30 milligrams compared to a lethal dose of fentanyl about three milligrams fentanyl is increasingly be cut in being cut in the illicit drug

Supply in the US for nominally in heroin but has also been found in cocaine and other illicit drugs and counterfeit prescription pills as well it’s put in there because it is very potent and it’s very easy to traffic because such small quantities small quantities are required and this

Is what is really driving the overdose rates in Rhode Island and in many other states at this point our deaths due to illicit fentanyl and this is another reason why we’re seeing such rapid increases in deaths among young people because the fentanyl is so potent it essentially makes the risk of overdose

For every youth event much much higher than it used to be so where sometimes it would take decades of heroin use to result in a fatality we’re now seeing fatalities much much earlier in someone’s drug using trajectory largely due to fentanyl we’ve been doing some work with the Rhode Island Department of Health

Understanding what fentanyl overdose looks like in Rhode Island this was a study we published recently in the International Journal of drug policy we collect with the state information at the address level on where every single overdose fatality event occurs we’re doing a lot of interesting research on

That geospatial data right now I’m happy to talk about some of our other findings one thing that might be interesting to this group is that over ninety percent of fatal overdoses in Rhode Island happen in private residences which is quite a bit different than what you

Might hear in the news as coming out of Philadelphia or San Francisco or large urban centers such as Boston here we predominantly have an epidemic people using drugs alone in their homes and that is difficult and challenging for intervention these figures are hot spot analysis where we compared the hot spots of

Fentanyl and non fentanyl overdoses and we hypothesize that the geospatial distributions would be different in some way but as you can see the geospatial clustering is actually strikingly similar and this suggests that fentanyl is broadly contaminating the illicit drug supply in Rhode Island it’s not being pushed by say one or two drug

Dealers operating in a community in Rhode Island rather it’s sort of infiltrating the illicit drug supply very broadly and is resulting in a and that is very similar to non fentanyl overdoses just much much greater numbers and you can see here primarily in Rhode Island we’re dealing with an urban

Overdose epidemic those pounds that are urban are highlighted in dark black in other areas such as West Virginia and Pennsylvania you have more of a mixed epidemic or higher rates in rural settings which is not as much what we see in the state so I wanted to spend

The bulk of the time talking about our plan in Rhode Island the governor in 2014 charged academics including myself to write a strategic plan that would help us reach this goal which was to reduce overdose deaths by one-third and three years from 2015 and 2018 unfortunately largely due to fentanyl

Were not at that goal but we have been seeing progress and I’m happy to talk about that today and and discuss some of the interventions that have have been implemented and are leading to some indications of success so I won’t get into the plan in great detail today but

Essentially it’s a four pillars approach where we’re dedicating resources and interventions into four domains where we think we can have the biggest impact on reducing overdose death in our state the four domains are prevention rescue treatment and recovery prevention really refers to the prevention of high-risk prescribing reducing the number of

People who are receiving high-dose opioid prescriptions from their doctors or dangerous Co prescriptions of opioids with other medications that increase the risk of overdose such as benzodiazepines which was a major issue in Rhode Island specifically I’m not going to talk too much about those strategies today rescue refers to increasing access to naloxone

That overdose antidote that I mentioned earlier our goal is essentially to sure that that is available in every community and is being distributed through many different mechanisms through outreach through pharmacies and by community-based organizations is also carried by all of our first responders and police and the thing and we

Dramatically increase the rate of No zone distribution in Rhode Island as a result of those increased resources and not plan I’m going to focus a little bit more today on our two colors treatment and recovery treatment in our case is really focusing on expanding and building capacity for what’s called

Medication assisted treatment or m18 there are three medications that are fda-approved to treat people with opioid use disorder two that we’re really focusing on in Rhode Island during expanding access to people nor fein and methadone so I’ll talk about each of those and there were three general strategies we’re using to increase

Access as evidence-based set of medications the first is expanding access to people morphine the second is the Centers of Excellence program for both types of treatment and the third is expanding access and maytee at our Department of Corrections so just to talk a little bit about buprenorphine for a minute this is

A medication that can be prescribed by providers with training from the federal government it’s about a 10-hour training that providers have to complete as you can see here we’ve dramatically increased the number of providers in Rhode Island who are able to prescribe you an or Fein and that’s great these

Are often primary care physicians who are working in communities who now can be screening for opioid use disorder and prescribing buprenorphine to people who are struggling so this is an office based program largely that should be done in primary care settings the second is the center of excellence programs so

The idea is to broadly increase buprenorphine access for all people in the community for patients that need a little bit more support and who might not be entirely stable or have comorbidities we’ve also instituted centers of excellence program which are specialized treatment centers in Rhode Island that provide basically additional

Programs for patients who need a little bit more services and they work with those providers to try to overcome some other issues that the patient might be facing or other comorbidities so these can be both for people nor Fein and also with methadone methadone is provided by federally regulated

Opioid treatment programs which are specific facilities and they in this case often are centers of excellence or work with centers of excellence to try to improve patient care for these treatment modalities and the final program I wanted to highlight today is our work in the Department of Corrections through some analyses we

Conducted at Brown we learned that around 12 to 15 percent of people who died from an overdose in Rhode Island had been released from our Department of Corrections within one year of their death those figures are shown here in green so that’s a significant amount of people who are going through the

Correctional system and are then being released and are dying at are a very very high risk of overdose once they’re released and that’s because their tolerance is down and they’ve not been using opioids in the prison setting and then we’re there when they’re released without appropriate social and health

Supports they’re very high risk for relapse and because their tolerance is down risk for overdose and death so what do we do to address those in Rhode Island well we started implementing a program wide screening and treatment program for all inmates in our correctional system everyone in our

Integrated prison and jail system is now screened for opioid use disorder and is offered one of those medications that I mentioned earlier this is a first in the nation program in a statewide correctional system these folks are then provided with services after they’re released in our link to community-based

Treatment we just published a study last week actually showing a 61 percent reduction in the number of people who have been died of an overdose and had been recently released from our prison system you can see there were 26 people who were recently released and died in

The first six months of 2016 only nine in the first six months 2017 that 65 percent decrease in that population compared to only a three percent decrease in the overall and the other drug overdose deaths so this program alone has actually led to a 12% decrease in over

All drug overdose fatality in Rhode Island and it’s at least a glimmer of hope that one of our programs seems to be working at having population level impact we received some media on this program including this news article in stat which I can refer you to it was published last Wednesday that describes

This program and our work in a little bit more detail I wanted to close with another intervention that we’re putting a lot of resources in in Rhode Island which is pure based recovery these are folks who are experienced addiction themselves in their own lives and go through a pretty rigorous

Certification and training program and then work in the community to interact with people who are struggling with addiction they work in our jail system they work in our emergency department across Rhode Island they work on the street and do outreach and try to interact with people who are struggling

With addiction and provide really anything that might be needed referrals to social services housing supports and also linkages into some of those treatment programs which I mentioned earlier so they’re really the ones on the front line and we’re trying to provide those referrals into treatment for people at risk for overdose who may

Who may have opioid use disorder so we’re getting a lot of attention for this Rhode Island model and we’re just starting to evaluate these programs more rigorously now so stay tuned for more data as we evaluate these programs more comprehensively I’ll just finish with a in a couple of minutes here with some

Information on our surveillance website basically just highlight it for you let me try to move to the next slide so as part of our strategic plan we thought it was important to show the progress and people really wanted to see the data to see quantitatively what the epidemic

Looks like in Rhode Island and how we’re doing so I direct our information and surveillance dashboard prevent overdose or i.org I’m just at my time so I won’t really go into it but I encourage you to check it out after the webinar we have a lot of

Data that we have visualized and present on the site and a bunch of other resources as well for anyone who might be affected by overdose family and friends first responders or providers there’s interactive maps on the website that provide community specific resources for where to find the

Lock zone for example and where to access treatment we’re evaluating this program now we hear a lot that people like community specific resources where in my city and town can I go and what are the you know what’s the information and what does that look like so we

Really try to make this as communities focused in specific as possible and I think you’ll see that if you click on some of the resources so I think with that so it’s not to take up too much time Justin I’ll turn it over to my subsequent presenter and then I’m happy

To answer additional questions at the end of the session great thank you turn it over to Robert to artistic okay thank you very much I just want to echo my colleagues thanks for just reaching out to offer this opportunity to he and I you know so vitally important that we work between sectors

You know the planning sector in the in the public health sector I think can work well together and I have a lot to learn from each other as was certainly the case in our situation here in East Tennessee and I’ll share more details about that in a few minutes just to give

You a bit of context I just want to mention that that the opioid use disorders really fought to be present about one percent of the population and it may be an under estimate at this point but this is from the National Survey of drug use and health which takes participants respondents rather

Through a series of questions on you know sort of diagnostic criteria and so about 2 million folks in the 2015 news the survey had substitutes or involving prescription pain reliever about 600,000 less at a substance use disorder involving heroin heroin is pretty dangerous as you as everyone

Likely knows about 25 23 to 25 percent of individuals who use it go on to develop an addiction historically prescription pain killers were not thought to be quite so risky and there was a massive amount of prescribing that think most people are probably pretty aware of at this point and the last

Bullet point on this slide illustrates that that about 80 percent of new heroin users actually started out misusing prescription painkillers and as the supply of those begin to really diminish the the demand for other opiates really became prompt more prominent and that’s where the heroin market began to grow so

That’s that’s kind of where we are at this point so the next slide I know it’s pretty similar to one that dr. Marshall showed but I put it on here for a reason even after I had a glimpse at his slides yesterday because I will point out that

That on the on the map on the left there were two counties in 2003 they actually had overdose death rates or drug poisoning death rates rather greater than thirty four hundred thousand one was McDowell County West Virginia is that one right there and the other one was Rio Arriba County New Mexico really

Poor counties these are you know at the bottom of the list in terms of all of the indicators for socioeconomic status and that’s fairly that’s part of the story here what is interesting about this this one in Central Appalachia is one that we watched closely being in

This area and begin to grow quickly out from there to this area of Southwest Virginia southeastern Kentucky and then up into Ohio and West Virginia rather quickly after 2003 and and now as everyone knows where we’re dealing with a nationwide phenomenon in Tennessee where actually I guess probably five or six counties away

From this county in McDowell County south southern West Virginia we’re right here in Northeast Tennessee about four hours from Nashville and about 8 hours from Memphis we’re as far away from Memphis as you pretty much can get in the state of Tennessee fairly large state about 500 plus miles across we

Have in 2016 we had 16 hundred and thirty one drug poisoning deaths in the state at a rate that’s about 24 and a half and that’s significantly less than then the numbers that dr. Marshall was showing earlier it has been a place where we have taken this this problem

Very seriously and it’s interesting over time you can see certain you can see different counties making progress in other counties beginning to slip in a very troubling way the ones with that are making progress in that better infrastructure better planning better connection to the governmental priorities etc our local effort really

Began in about 2012 to address this and really they really grew out of a an effort on campus to to begin to take the problem more seriously many of us are paying attention to it and you know having seen what was happening in southern West Virginia and southeast

Kentucky and and so we formed this interprofessional working group and 2012 will focus on being able to do some research and outreach education but probably more importantly you began to think about systems level interventions that we might be able to to to tackle in order to have some

Impact we actually have about 240 people in the email list at this point we kind of each meeting really starts with introductions and sort of ask you know who else needs to be here and what else is what’s going on in the community about twenty to forty highly engaged

Stakeholders out of that larger email list show up every month and it’s really a different group every month but we all learn from each other and it’s really more of an opportunity to listen to each other more than more than anything we we do meet on campus in off-campus in order

To facilitate learning from from the community okay so this just this slide illustrates the diversity of different professions that are represented there and you can just tell that we’re actively seeking out different different perspectives so that we can so we can learn more about what’s happening the I

Love you this working group is very fertile ground for new projects and new initiatives and one of them I guess early on in 2013 we’re awarded Knight a grant to develop research infrastructure and and to conduct research on the problem and and we’ve used that in that research infrastructure development

Opportunity to we’ve leveraged all that and into the larger impact in the region what it really does I guess the working group more than anything helps us get a lot of different perspectives on the problem and and out of that grew the vision to create a center for prescription drug abuse prevention

Treatment kind of based on a Cancer Center model where you might have a patient care core research and evaluation core education outreach an admin core and the patient care core is something them will talk about in in detail here in in a few moments I the framework that we developed to

Really talk about the problem is one of the continuum of addiction this kind of a big picture note I’ll take you through it sort of piece by piece continuum addiction from non use to potential overdose deaths it is just represented along this line and it’s greatly simplified obviously but the

Further you go down that continuum the harder it is to sort of get back out of it and this just represented here by the by the red band and then sort of in that danger zone that sort of red oval there that’s that’s the space of dependence and if you will

Development of opioid use disorder like it’s formerly known as addiction we’re trying to move away from that vernacular in the field at this point obviously it’s easier to move back out over into non-use if you just begun initiating misuse and that that purple space of dependence is really the space of

Physical dependence where you know you’re growing in tolerance for the for the opioid and we say that there’s this is a complex problem but we have a lot of effective tools and and and it’s just to illustrate the fact that different things work it work differently in terms

Of their they have different impacts along this continuum and really you’re going to have much greater impact with prevention programs that you know in terms of return on investment they’ll share some that that data airs the I guess at the end but development or rather the dissemination implementation

Of prevention programs is really a priority prevention programming can take the form of Health Professions training continuing education it can take the form of early interventions with high-risk groups but really you know you’re going to have the best impact with primary prevention programming some of the work that we’ve done in this area

We’ve partnered with our elected officials to really prioritize prevention program for people in the workforce so that they can access employee assistant programs earlier we’ve learned that folks that the elected officials rather are very very interested and anything that can harm a workforce in a state a particular

State like Tennessee where we have a lot of different manufacturing sites and and culture sites and so on it can be very problematic if you have a group in population that that doesn’t access employment opportunities or and/or is disabled due to opioid use disorder or other substance use disorder we’ve

Engaged with other types of prevention programming including evidence-based parenting and have had a good success in that arena in terms of training and promotion through a coalition that was developed out of the working group for a local rural County second area I think you know the spent every state I think

Every state now has mandated or or voluntary use of prescription drug monitoring programs and diversion control programs and that is going a long way toward helping to control some of the supply side but also you know helping people in primary care if they present with some sort of substance use

Disorder by engaging a screening brief intervention referral treatment in Tennessee we’ve had some success in and basically moving people into early intervention through this screening brief intervention referral treatment trying to implement that statewide that’s a statewide initiative out of the Tennessee Department of Mental Health and substance use services who has taken

This problem very seriously so we’ve got about order of magnitude more more screenings at this point so on down the continuum you know it’s more appropriate I guess for folks that are suffering from a proper opioid use disorder to engage in medication assisted treatment or abstinence based treatment typically

Medication assisted treatment has been met with some resistance both by the provider community as well as the recovery community there’s all kinds of different stigmas associated with about discuss shortly but I guess one of the things that that that we felt was a real need in our area was there were only 12

Methadone clinics in the entire state there were 12 and there were the closest one in Tennessee was about a hundred miles from here that in Knoxville and there’s there some across the border in North Carolina over Nashville but but Tennessee residents in Northeast Tennessee didn’t have access to

Methadone and so we said the partner with Mountain States Health Alliance our largest regional health care system and our largest community mental health services for Frontier health to open a methadone treatment facility called an outpatient or an opioid treatment program highly regulated these are places where folks go in and they gain

Access to methadone that will then subsequently relieve their cravings for about 22 to 24 hours they come back the next day they get some more they have to have regimented sequence of counseling you have to go to the program in a way that is come demonstrates compliance

With standards for some period of time before you can even have any take-home doses and so the idea is that you control diversion methadone while also allowing folks that gain access to counseling as well as other services that can help them you know get their life back back in

You know back in order and it is a it’s been a an interesting an interesting Road I guess the first first thing I’ll discuss relative to this is sort of the pathway to get methadone approved here we had to do a certificate in need we had to do multiple hearings related to

The zoning for the facility and that’s directly relevant to the Planning Organization so it’s a it’s we had the plan initially initiated the plan in May of 2016 and it took until September 2017 to get the doors open when I say that that we initiated the plan this is

Really the press conference where we we first talked about it and everyone looks like they’re in pretty good spirits here this I’m on the right the president health system is in the center and the university presidents on the left and shortly thereafter there was a group of

Folks in the community where we wanted to cite the the clinic that organized and basically began to fight having the methadone clinic in the in the community these are very good people we think that they’re you know I mean these are our neighbors and so on this is but it is

Very much a not in my backyard sort of thing when it comes to methadone I think some others related to to the stigma associated with it some of us religious misunderstanding for example we saw a fair amount of you know no mess and in my community and that’s sort of a

Pushing together of the concepts of methamphetamine and methadone which are two completely different drugs this is one of the community hearings about the about the clinic several hundred people were there and everyone that wanted to get a chance to speak and we have there’s much signs and and so on in the community

Including protesters that our zoning appeal hearings as well as our City Council hearings that had to approve the zoning for for the for the clinic and you know was was actually we actually put it into a place where there was formally an urgent care and it was just

An artifact that it wasn’t zoned for this particular type of clinic at the time which was an MS one it’s a fair amount of fair amount of difficulty for some period of time but it did lead to a lot of excellent conversation in the community and when we really got a

Chance to discuss things like stigma and we got a chance to discuss you know the efficacy of medication assisted treatment and and got to lay out from some of those things as as we went through the whole process it did take quite a long time to go through the

Different hearings and I will say that I don’t think that any any one that is starting and clinic like this one would necessarily I think each one is going to be unique try there’s going to be more and more resistance in different in different areas this is a largely

Conservative region and it is it’s an area that historically you know has actively tried to keep for-profit methadone clinic out we’re a nonprofit that’s a wholly owned corporation between actually two institutions East Tennessee State University Research Foundation and what was formerly Mountain States Health Alliance but is

Now ballot out so straight amount of stigma as you can see here and you should probably read through on this slide and it’s not only stigma among the community was also in health care professionals a lot of a lot is made about methadone being a crutch named stripper buprenorphine actually and and

Even one headline and in the paper nearly verbatim stated replaces one drug addiction for another so you know it did give us an opportunity to educate and to have this community level conversation so these are two slides back-to-back that this point point to met you know the effectiveness of methadone in terms of

Keeping people retained into treatment and what their long-term effects are with respect to illicit opioid use these are basically reviews of review articles sort of a very high level of demonstration that the that the treatment is is good for keeping people people engaged in treatment and preventing further illicit use this is

Just review plan orphan maintenance therapy which dr. Marshall I think discussed well and and this just and then the next slide actually just talk about the broad impacts of stigma and how you know stigma in a community can actually prevent people from gaining access to care and then we really want

To turn up access to care if we’re going to be able to keep people alive with it the clinic actually is now open and that was a picture of it we’ve also been engaging in this problem of neonatal abstinence syndrome and trying to help different clinics understand what their

Role is and that and help different families understand you know how to best best approach that that potential outcome and I say it’s a complex problem for which we have many effective tools naloxone is another one and this person is dr. Sara Melton it was just a real public health hero she’s

She’s a pharmacy professor but she and so my other colleagues have designed some naloxone training that’s been access to more than 38,000 times at this point it’s actually train-the-trainer kind of program and so these the 38,000 people that have gone through it are now all also equipped to train others to use naloxone

And we’re also how engaged and trying to improve the status of recovery courts and also you know this one’s a little tougher because you don’t necessarily flip a switch and no recovery cord that complies with national drug court Institute standards that those two things don’t necessarily go one-to-one

Because the local courts have a lot of control over what they choose to do but the good news is that the recovery courts are increasing dramatically in the state when I fit the problem for which we have many effective tools the tools are basically significantly you have grave much greater return on

Investment to the left of the continuum than you do on the right and this slide just illustrates how much more in fact we’ve learned some key lessons here problems very large and growing faster than we anticipated there’s a lot of people making money on this that’s what

Supply-side drivers make there’s a lot a lot of people making money on this problem and that has led to some real difficulties efforts to address the problem have historically been fragmented another problem I think that is true for a lot of public health issues is that when programs are reliant

On grant funding not only are the program’s fragmented they’re not very sustainable and so what we try to do with the clinic is we set up a partnership with Mountain States Health Alliance where the revenues after the the costs are reinvested back into the center so that we can expand our

Prevention and other outreach efforts I think it’s also imperative that there’s a conversation with planners and people that are in the communities that can that can influence policy related to siding and that’s most important particularly to this audience elected officials are very much concerned about the work force you have

To engage with the affected community including I have to applaud dr. Marshalls emphasis on peer recovery specialist which is a very important group to to be working with and I would encourage all listeners that they can to begin to be engaged in that concept as well in their local communities and the

Stigma and addiction stigma about addiction and mental health is still very very common on the last slide last slide for which have any any advice is that if you’re going to fully respond you have to have some coordinated effort between the government and the communities the guy

Case you have to stay current on data and and the data needs to be released and consumed quickly one of the issues of public health informatics is that often the data is is far too old to be useful you know when when it’s held too closely by different entities needs to

Be good community engagement and conversations the concept of public-private partnerships is under explored and I feel like you know there are some unique potential opportunities here with imparting with different treatment services and Public Health that that can be that can be evaluated and then disseminated later on to may be

Able to inform policies in other places we need to be adherent to evidence-based practices and then take them out to scale and we need to support evaluate and expand local efforts if they’re good novel efforts that are working last thing is I would like to acknowledge a

Large group of folks that work with that that have been so instrumental in and moving things forward here in Northeast Tennessee happy to answer questions at this point great thank you and again the presentation is going to be available afterwards but look we’ve had a lot of great questions come in I

Guess one to start for both of you is how did your states develop your strategic plan around opioids what was the process how are the states ensuring implementation and how are they funding some of some of this work that you’re doing is it state or federal funding

Sure I can take that justin from rhode island’s perspective the strategic plan that I mentioned was drafted by an academic research team including experts from Brown and other institutions and community stakeholders it was then endorsed and is being implemented by a taskforce that our governor convened with a number of

High-level leaders from different stakeholder groups state agencies and other places so they are the central coordinating group and then also are working to ensuring that it’s being implemented with high fidelity so every month we have a taskforce meeting people come and present on their progress they troubleshoot any sort of barriers

That the program might be encountering to implementing that part of the strategic plan and so forth the funding is from a number of different sources we’re lucky to be one of the states that has received quite a bit of funding from Samsa as part of their targeted opioid

Response initiative we my work on the dash board is funded from a separate drug overdose prevention grant from the CDC which other states also receive we decided to invest some of those funds in the surveillance program and that the website takes sort of the public face of

And then also the m80 program in the Department of Corrections is actually funded by out of the governor’s general fund and so that is sort of an additional add-on to the do-si budget and involves a community-based provider of m80 being the primary contractor for the treatment on the inside and providing that

Community treatment on the outside so it’s sort of a mixed bag of funding at this point in Tennessee we have not had as high-level engagement with academic institutions the state departments of health and mental health and substance abuse services those two departments have largely been responding to the

Problem using strategic plans that were developed for the most part in-house they have expanded a lot of their programs that they were doing already and they’ve done that with samjoe money and you know we do have some connection to the state related to the different coalition’s different grants to do

Different project activities but we haven’t enjoyed the same level of connection with the state as my colleague from Rhode Island there were also a couple of questions related to the siting of the facility in gray county you’ve mentioned some of the NIMBYism and difficulties in locating a

Methadone clinic in a suburban part of the county I guess what are the responses now that it is up and running has anything changed do you have anything specific to to add about difficulties or ways the planners could help with the siting we’ve had no problems at the facility

And and you know one of the things that we learned through this process is the lot of folks are concerned about crimes and particularly you know a new crime coming on when there’s a new methadone facility turns out that there was a nice study done at hopkins i

Thinkin maybe twenty twelve or thirteen that i demonstrated that there was more crime associated with the opening of a new convenience store than there than there was with the opening of a new methadone clinic in fact there are a lot of controls around methadone it sits in

A situation where Sam both Sam so regulates dispensing practices as well as the State Department of Mental Health and substance abuse services and there’s really good controls inside the clinic on diversion as well as you know we can do callbacks random callbacks to make sure that if anyone does have take home

Doses and they have been in the program for a while and they have sort of ramped up to that take-home level then they can you know have to demonstrate that they haven’t sold it anyone on the street we’ve had no incident in the community the the group that was called citizens

To maintain gray to my knowledge still exists but doesn’t I doesn’t create any kind of protests or anything like that the all of four has died down and that happened shortly after our final approval which was in November of 2016 yeah on the topic of stigma I also

Wanted to point people towards the first webinar live blackwell more did a great presentation that she got from the framework Institute that we can also use when discussing stigma associated with addiction and an opioid epidemic it seems like we are out of time I know there are a few questions we didn’t get

To are there anything from that that you’d like to to say for closing something you didn’t get to I would go ahead brron I would close by highlight one thing that I think relates to the issues that you were discussing Robert and then I didn’t get a chance to

Mention is that you know we’re putting a lot of resources into expanding access to MIT both on the buprenorphine vitae and methadone and there have been instances you know I think we have to regulate expanded access we have to improve access but also regulate these opportunities and make sure that it’s

Quality care we have seen in other statement instances where you see very very poor quality buprenorphine clinics pop up especially because they can be it provide an office based setting and so we haven’t seen that as much in Rhode Island but there are some there could be also some planning issues or state

Regulations around ensuring that the treatment that is provided is of sufficient quality and I think that’s going to be a focus for a lot of research and Public Health practice now that we now that we’re trying to scale up treatment making sure that it is of

High quality for for folks and so I think that’s the next thing that we need to start tackling this is an excellent point and that there are some very large buprenorphine practices called office based outpatient treatment programs oh bots and our state has designed some rules for how they operate in terms of

Making sure that there’s good access to care good access to counseling you know really good patient records that if you’re going to be and if you have a license to be a no bot and they are being licensed at this point on our state then then you need to have a

Diction American side for addiction medicine level credentials for prescribers you need to have many other quality metrics in place and you also need to be able to take insurance and that’s one of the things that’s that’s really been driving this is is some of these office based treatment programs

Have been cash cows and a lot of scale a lot of providers have moved into that arena you know sort of on the side and begin to also be a supply-side driver for diversion Oh buprenorphine on the street yeah and I think some of those credentialing and regulatory issues may help to reduce

NIMBYism as well for folks in the community to know that these office based programs are of high quality and and do meet certain standards I think that will be important as they continue to be expanded yeah okay great well thank you for offering to speak and and joining us on this and

Everyone else please look for the next and final and installment on March thing in the week of March 19th we’re still setting a date thank you thank you thanks everybody

ID: Ck8buwhdEco
Time: 1519246812
Date: 2018-02-22 00:30:12
Duration: 01:01:09

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