Growing Combination Drug Use and The Overdose Crisis

Please be aware that this transcript may contain occasional errors or discrepancies.

0:47
Thank you all for joining us this afternoon. Today, we're here to explore new developments, and possible solutions for addressing America substance use disorder, and drug overdose crisis. Nationwide, there is an ongoing need for improved substance use disorder treatment.
In addition, nearly 74% of all overdose deaths linked to cocaine, now involve synthetic opioids such as fentanyl. This type of combination drug use is part of a new trend, driving the overdose rate along with the growing use of xylazine or tranq. The extraordinary speakers we have with us today bring a wealth of knowledge about understanding, addressing, and possibly solving many of the issues related to the overdose crisis, and ways to provide better care and more effective methods of substance use disorder prevention.

1:44
Our panelists are leaders in their fields, who will bring us the most current information and data on the policies, community based practices, and health care industry practices that will produce a positive impact.

1:57
But before we hear from them, I want to take a moment to thank NIHCM's President and CEO, Nancy and the ... team, who helped convene today's event. You can find biographical information for our speakers along with today's agenda and copies of their slides on our website.

2:15
We also invite you to join the conversation on Twitter, using the hashtag Combination drug use webinar. After our speakers have completed their presentations, we will have a brief quick Q&A if we have time.

2:29
Now, I would like to introduce our first panelist, Cecilia's Spetsnaz PHD.

2:36
Dr. Spitznas is the Senior Science Policy Advisor at the White House Office of National Drug Policy Control Policy, ONDCP, a component of the executive office of the president and acting assistant director of Translational Research, USC Merging and Continuing Threats coordinator. As senior policy advisor, she provides policy analysis and scientific advice for the ONDCP Director, Chief of Staff, and the Senior Policy Advisor for Public Health on special matters of concern.

3:08
Doctor Spitznas' extensive federal career includes a 12 year tenure at the National Institutes of Health, National Institute on Drug Abuse, NIDA.

3:18
While at NIDA, Dr. Spitznas oversaw extramural research on addiction treatment development and provider training and especially the provision of these methods on computerized and mobile platforms. Today, she is going to discuss the latest federal priorities for addressing the overdose and addiction epidemic, especially new work, addressing drugs used in combination and treatment efforts, Doctor Spitznas.

3:45
Thank you, Sheree, for inviting us, and also to the NIHCM organizers for putting this webinar together. And thank you to everyone who has turned out today. This is a really important topic. As Sheree mentioned, the Office of National Drug Control Policy, ONDCP sits within the executive office of the President and leads and co-ordinates the nation's drug policy to improve the health and lives of American, the American people.

4:11
ONDCP accomplishes this through five different main actions: developing and overseeing the implementation of the National Drug Control Strategy document. Developing and overseeing implementation of the national drug control agency budgets.

4:26
Which include: 18 different federal drug control agencies participating in regulatory decision making and federal clearance process concerning documents and rules, having to do with drug control policy, administering grant programs, including the High Intensity drug trafficking areas, grants, the drug free Community Grants programs, and the Model State Law Grant Program. And the links for these will be in my slides. The Legislative Analysis in Public Policy Association currently holds the Model State Law Grant program, and they are that link for their association. So you can see what model laws have been made through ONDCP funding is available. Next Slide, please.

5:16
I'm going to try to set the stage for the circumstances that we find ourselves in, and by going over a few data slides for you. They don't want to be overwhelming with this. But this first slide shows the breakdown of the different substances that are involved in deaths, including synthetic opioids and fentanyl. And you can see that there's been a dramatic up tick in the synthetic opioids and fentanyl category. And these different categorizations are not mutually exclusive. So, one person could be represented by psychostimulants and and the synthetic opioids. And also, this doesn't show the synthetic, I'm sorry, the natural and semi synthetic drugs that are most of the the opioid misuse, firm prescribed opioids. Next slide, please.

6:14
In terms of drug use itself, past year illicit drug use, you can see that about 24.9% of people had a past year illicit drug use problem. And again, these numbers on the right-hand side of the chart are not mutually exclusive. People could be represented in multiple of these. Media can see that two of the largest categories, hallucinogens, and pain, reliever misuse, are both rather, large. Cannabis marijuana is the largest, but we also see quite a bit.

6:48
Prescription tranquilizers, sedative misuse, Stimulant misused for prescribe stimulant like the Attention Deficit Disorder medications. And I wanted to mention, you see, down below heroin is only at one million. There's a new number from the national survey this year, and that is 680,000 past year, fentanyl users. The thing is that we think that in terms of both the heroin figure and the fentanyl figures that these are dramatic, undercounts. The National Survey on Drug Use and Health does not include people who are on housing or people who are living in institutional settings. So these numbers are most likely low.

7:31
And in addition, because fentanyl is often used in to contaminate certain substances, it's unlikely that people really, truly know if they are using heroin or if they're using fentanyl because of the contamination issue. Next slide, please.

7:53
Now, this slide looks at past year substance use disorder among people 12 and older. And you can see that 17.3% of people have a past year substance use disorder, and alcohol use disorders is largest, but that's followed by all of the drugs combined in drug use disorder. And, and they're pretty close. So, 27.2 million people having a drug use disorder and, again, these numbers, especially for heroin use disorder, we believe, are an undercount. Next slide, please.

8:32
This slide looks at people who received substance use disorder treatment in the past year. Among people who are 12 or older, who needed it. And you can see here, only 24% of people who are 12 or older, who are classified as needing treatment, received treatment at the parts on the right, break them down by age. And you can see, we're doing a little bit better, getting 12 to 17 year olds and treatment. But we're doing really poorly getting 18 to 25 year olds and treatment. And same for, I mean, across the board, we need to get more people into treatment. And we cannot, we cannot fix a disorder that we don't treat. And we're not treating nearly enough people, so treatment is a huge priority for us.

9:19
Next slide, please.

9:21
So, Saving Lives is the north star of the National Drug Control Strategy. If you look through the document, you'll see that we have both supply reduction and demand reduction sides of our drug policy. But saving lives is behind all of our goals. Next slide, please.

9:42
So, this lists all of the different National Drug Control Strategy chapters.

9:48
A lot of people just go in and read a chapter that they think pertains to their area of work. I'm gonna focus today on the harm reduction and substance use disorder treatment chapters, but you should know that there's a lot of other ones that are very relevant to public health, and there's all have a checkmark on them.

10:05
Next slide, please.

10:07
So, what do we mean when we talk about harm reduction? Harm reduction is an approach that emphasizes working directly with the people who use drugs, to prevent overdose and other harmful things that may happen as a result of drug use, including contagious disease, transmission, social well-being, of those served, and offering flexible options for accessing treatment. You might hear about low barrier to entry treatment and other health care services.

10:35
The National Drug Control Strategy includes three main topics under harm reduction, It's not to say that there aren't other harm reduction types of activities, but there's three that we are specifically trying to raise awareness about through the strategy. The first is a provision of overdose reversal medicines. Many people have heard about the medicine naloxone which reverses overdose. There's a new medicine that has been approved by FDA for treatment of overdose called nalmefene. And so, those medications are very important, and it would be really helpful if the insurance plans could elect to cover over the counter naloxone, which was recently, approved by FDA, and continue to cover the prescription formulations.

11:23
Because these different products seem to be work for different patient populations. Different patient populations prefer them. And we want to make sure as many people as possible can continue to get these these medicines. Test strips are available for fentanyl and for xylazine. Those are discussed. Those are ways of letting people take responsibility for their their drug use situation and determine whether or not the drugs they're using may be contaminated and too risky for them to use. Or if they need to use with somebody around them who could help them.

12:03
Then syringe services programs or the third part of our national drug control strategy, harm reduction emphasis. And a lot of people don't realize that syringe services programs choose to be called needle exchange programs, provide a lot of health care services, which are billable. They can provide wound care. They can provide pre-exposure prophylaxis (PrEP) for HIV, as well as PEP, pushes prevention of post exposure, HIV, testing, and vaccinations for hepatitis HIV, and syphilis. And I just want to mention that.

12:38
There is now a syphilis task force so that the office of the Secretary Assistant Secretary for Health has started up because there's a very notable increase in syphilis and congenital syphilis which crosses into the substance use disorder patient population.

12:57
OK, next slide, please: Substance use disorder treatment is a very important part of the strategy. If we were to appropriately screen, diagnose, and treat all the individuals with substance use disorders, similarly to how we treat chronic conditions like diabetes, we would be able to reduce the mortality associated with substance use by quite a bit. So, there are four areas that we have actions under in the National Drug Control Strategy on treatment. What is including access to quality treatment. One is reducing stigma associated with treatment. Another is dedicating interventions for the most vulnerable, and we've done a lot of work related to including care for people who are in prison and jails. And then making sure there's a trained workforce to meet the strategies, treatment goals, is also an important part of this.

13:49
Next slide, please. So in terms of challenges with fentanyl, in the xylazine era, many people don't know what xylazine is, the slang term for it, some people call it tranq. It is a veterinary medicine. It is not FDA approved for consumption by humans, but it is also not a controlled substance under the Controlled Substances Act. It is not scheduled.

14:13
So, cartels are sort of using a backdoor way to be able to obtain this. Because it is not on the controlled substances schedule yet. It is a sedative, it causes prolong sedation. And it does not respond to overdose reversal medicines because it is not an opioid.

14:35
However, since it's mixed with fentanyl and fentanyl does, we still recommend that fentanyl be the Naloxone or Nalmefene be reimbursed because those will help, even if there's just a little bit of fentanyl in there. They should help with with an overdose, and it closing contributes to deaths with opioids. But alone, it's generally not lethal. And one way to think about this is the Naloxone can restore breathing. And you may not have a rapid return of consciousness when there's fentanyl and xylazine together. But as long as breathing returns, that is a good thing. And that is why we're recommending to continue with Naloxone and Nalmefen, as well as calling 911, and getting emergency services available now. My boss the Director of the Office of National Drug Control Policy, Rahul Gupta, has the authority to declare an emerging threat from a drug and he declared in April 2023, that xylazine combined with Fentanyl had disseminated across enough regions in the United States to qualify as an emerging threat. So I'm going to talk a little bit about some challenges that we're seeing next slide please related to to fentanyl in the ... era. There are wounds that are contributing to negative consequences, in some cases, even amputations, And these infections seem to be distinct from other injection related wounds. And the good news is that wounds seem to be likely to respond to care. Housing and use ceases.

16:23
There are treatment challenges. We hear because of fentanyl being so high morphine equivalent that people have very high tolerance to fentanyl and in some cases, even with methadone. up to 200 milligrams of methadone may not be holding people if they are placed on methadone, may not keep their cravings at bay, and that's a really high dose of methadone. We also hear that people who are placed on buprenorphine may have difficulties and the recommended dose of 16 milligrams of buprenorphine as a limit may no longer be relevant.

17:02
NIDA, talk about that in a second, hosted a meeting this summer to develop a research agenda on treatment of patients exposed to xylazine and fentanyl. And there's a link to a paper about that, that meeting, and SAMHSA is going to hold a meeting on dose limits for buprenorphine on December 11th. Now, people dependent on xylazine may be an extreme withdrawal, even if they receive medications for opioid use disorder when they, when they go into receive treatment, and this will make treatment adherence for them very difficult. And also, wound care very difficult because they there is no medication for treating xylazine withdrawal. So, that's just something to keep in mind.
17:49
Next slide, please.

17:51
So, I promised I would talk a little bit about regulations. There is a notice of proposed rulemaking on medications for the treatment of opioid use disorder, and a supplemental NPRM on the same topic that came out last spring. And we're not 100% positive when the final rule will be out. But the unified agenda, which I encourage you all to take a look at regularly, the Unified agenda is published in the Federal Register. It suggests the final rule will be out around the first of 2024. The agencies are not held to that date, but that is the date that HHS estimates. This rule will be out. Some proposals that are in this rule include removing all the language concerning the need for a DEA registration, separate DEA registration or waiver to prescribe buprenorphine, because there was legislation that passed last fall that got rid of the waiver.

18:50
So now all providers who are eligible in their state to provide buprenorphine can provide it for opioid use disorder treatment, not just for pain medication. There's an update of the regulation of an initial dose of methadone. It remains at 30 milligrams and not to exceed 40 milligrams on the first day, but there is an incorporation of a provision for higher doses of clinically indicated. And this is very important and relates to what I talked about earlier about people needing really high doses of methadone to get started.

19:23
There were some pandemic provisions related to take home doses that have been modified slightly, but those are going to be continued if the proposal in the Notice of Proposed Rulemaking is accepted, and the requirement that opioid treatment programs maintain procedures to protect take homes from theft and version. That was continued. There's patient education on safe transport and storage of Take Home Doses, that was added. And there's also a Telemedicine Initiation of Buprenorphine. This that's discussed in there. So I just want to know let you all know that we anticipate this coming out and are very hopeful that you will be seeing an update to that soon. OK. The final thing I want to talk about is the next slide, please. ONDCP has a number of reports and products that I haven't had time to talk about, and these are all linked here, the national drug control strategy in more depth. Obviously it would be great if you could take a look at the actions there.

20:27
There is a methamphetamine plan that is out because Congress declared methamphetamine an emerging threat in 2022.

20:35
There's a really terrific recovery ready workplace toolkit that has guidance and resources for private and public sector employers. And I would encourage you, if you are an employer, even an insurance plan is technically an employer to take a look at this. Because, you know, people who go through treatment and enter into recovery, they need to have jobs, and they need to have a workplace that's friendly to their condition. And there's also a report on substance use disorder in pregnancy and how to improve outcomes for families. And finally, I mentioned a little bit about the fentanyl, adulterated or associated with Sal, is a response plan that is available to.

21:17
Next slide, please.

21:19
So that is all I have for you today. I really appreciate you listening to me. And my e-mail is cspitnas@ondcp.eop.gov. And now I'll hand it back to Sheree.

21:33
Thank you so much, Dr. Spitznas, for such an extensive overview, such critical insights and helping us to understand federal policy on the issue. We really share that.

21:44
Our next speaker is Sean Westfall. Mister Westfall is Prevention Point Philadelphia's Overdose Prevention and Harm Reduction co-ordinator. His interest in Public Health started in 2007 when he started volunteering in Philadelphia to provide free services for those experiencing homelessness. In January 2011, Sean began his journey by learning about emergency medicine, the lifesaving use of Narcan, and soon afterwards, reverse the first of many opioid overdoses in his community. Sean has been at prevention point for five years. In his current role, he is responsible for managing a team that provides education, harm reduction, counseling, and access to lifesaving tools, such as Naloxone and Fentanyl testing strips to people who use drugs.

22:32
He manages the organization's Narcan inventory, ensuring distribution to 15 prevention point teams, and ensures that the entire staff of 170 people is trained in overdose reversal. Sean is also a Certified Basic Life Support Instructor. His overdose Prevention team conducts training and Education throughout Philadelphia, with a focus on people who use drugs.

22:57
The team also provides training to providers, parents, partners, peers, and other advocates, Mister Westfall: Thank you, Sheree. I like to take this time to thank you all for attending, and thank you to the panelists and organizers.

23:17
So, what is harm reduction?

So one thing we say is any positive change, a set of practical strategies designed to reduce negative consequences of drug use or any harmful behavior? It is a person centered approach to the spectrum of different drug use. Parents, firms, people use drugs. The primary agents for improving. It also points to the right to health and safety for all people. Offering options to those most marginalized within the health system. It recognizes that poverty race class social isolation has strong gender based discrimination among others, the capacity to address drug related harms.

24:07
So, let's talk a little bit about drug supply in Philadelphia.

I want to give a shout out to the Center for Forensic Science, Research and Education, and also the Department of Public Health. Fentanyl has been the primary drug in dope since at least 2016, at least since 2018, has been the primary adulterant in dope.Fentanyl and xylazine combined make tranq dope.

24:38
So the ratios vary. Sometimes we are seeing anywhere from one part fentanyl at all to wild cards. Much it's a rarity. Usually it's about one. Tough for seven, maybe. Two are set to null up to them. 46 parts xylazine. So it varies quite a bit.

25:05
It's in all the "dope" supply that is in Kensington for the most part, spreading throughout the city in the nation. More about the drug supply in Philadelphia. So in Philadelphia, the average amount of ethanol dump samples remained relatively consistent from the third quarter 2022 to the second quarter of 2023 in content. And don't samples continue to increase quarter over quarter.

25:40
The second quarter of 2023 highest eric amount. In the first quarter, 20. And the second part of 2023 we saw examples: Jonathan Taylor, cocaine and powder cocaine samples, and methamphetamine samples really varied.

25:56
For the most part, Madeline Feldman, but there was very limited data on methods itself.

26:07
So, as we're seeing a trend the dope is mostly silencing, continues to be that way. I was thinking about overdose fatalities in Philadelphia. 2022 is the latest data that we have so far.

26:26
We saw 1413 people died from drug overdose in 2022. The second number, highest number, was in 2021, 1276 died from drug overdose. 83% of overdose fatalities involved opioids. Back in 2010, fentanyl was involved in less than 10% overdose deaths.

26:58
In 2022, xylazine was involved in 96% of all overdose deaths. So this graph here kind of goes back to 2010, goes to 2021. You see 2010, there was, and, this really represents, the medical examiners toxicology report, they find opioids.

27:27
They find stem if I haven't drugs, So, no, in 2010 opioid ants and, uh, drug overdose deaths, including opioids. What's the 297, you go back to 2021, that was 1052, so we're seeing a spike consistently increasing throughout the years. So one thing I really want people to think about in our response to suspected opioid overdoses.

28:05
Know, we've really got to change our game up a lot since 2018 or even 2016, when the market it costs. You have to be October, So no matter, know, what the person may or may not know. Or even they use drugs at all, want people to think about the basics of live support, right? So, you know, staying safe, we're calling now one person is unresponsive. We're controlling any life-threatening bleeding if necessary, in protecting the person's head that can inspire, especially if we suspect by injury. We want to make sure the person that's open airway, so they are supporting the parsonage breathing. If the person doesn't have a pulse, CPR, parents may grab A, D, if available and if we suspect overdose giving them off. So, switch a little bit into two to the wound care issue that we're seeing, there's been a lot of different wound care clinics pop up just to address that need.

29:23
This graph here goes back to 4010 or 2010, 2020. We're seeing a spike pretty much across the board, especially for skin and soft tissue infections, subsets, ah, driving. Does it have a horrible effect on people?

29:48
As far as homecare goes, we are thankful we have a wonderful little chair team here prevention point.

29:56
They recently had a paper published and The Journal of Addiction Medicine.

30:02
So, I don't really have them limited time to go too much into it, I encourage everybody to check that out.

30:10
My hat's off to all those clinicians who are doing a little care about their industry ledoux amazing job.

30:20
So, where do we go from here?

30:23
No.

30:24
As mentioned earlier, talking about test strips. At prevention point, we distribute test strips. We also distributed xylazine test scripts. Depending on the legality of that, in your locality, is going to depend on boot camp purchase or if they can purchase legally. So, we'd like to see across the board, in pennsylvania, test strips are decriminalized statewide.

30:55
We would like to see that nationwide and to also include other drug testing test strips.
I gotta mention overdose prevention, So if you yourself using a substance, if you know anybody with a substance, There's a couple of things that we like to encourage people to think about.

31:16
one, avoid using alone you know, that most people die from opioid overdose type along with everybody around them. We encourage people to use the money system and staggered their use.

31:29We encouraged people to go slow, go easy, especially if they inject more, and they can't take it out. We encourage people to avoid mixing other drugs, opioids. We want people to understand respect of times. Especially fentanyl, especially people getting out of jail for treatment. You have to understand a lot about tolerance. If a person doesn't use fentanyl, uses other substance, can we give them a hammer to test their substance with a smoke test script? Always carry narcan and know how to use it.

32:07
Prevention, while last fiscal year. We train 1300 people in how to use Narcan and distributed. Ah just over 95,000 of them came for free. Um, and a big part of how we do that is, we like to do in Canada little or no bearing whatsoever. And we've been able to do that. Because they helped us get that market out there. And really, can't say enough good things about them.

32:46
And hopefully, people in other states, ah, know, also have those type of resources where they can get them the option they need to be able to ....

32:58
Some of those services will be provided here at prevention point, 30,246 individuals served 394 HIV patient visits or ongoing medical care. 1775 HIV test administered 516 prescriptions for PrEP. 7.9 million syringes distributed. 1103 wound care visits. 10,814 social service provided. And 347 individuals, newly indoctrinated to fund it, which is up 60% over the last year.

33:46
Thank you guys so much. I appreciate your time.

33:52
Thank you so much, Sean, for helping us understand the value and power of harm reduction practices when it comes to protecting the health of people who use drugs and how the approach can improve lives. Our next speaker, our final speaker today, is Doug Henry, PHD. Doctor Henry is Vice President of Psychiatry and Behavioral Health and Allegheny Health Network doctor. Henry's professional career began at the Presley Reach Schools on Pittsburgh's North side working with children and adolescents with autism spectrum disorders in California.

34:25
He was a school counselor for Klein Bottle, Youth Services serving as an acute psychiatric inpatient clinician at Cottage Hospital in Santa Barbara, and a Counselor Services for Adolescent and Family Enrichment in Southern California, as well as a psychologist and supervising psychologist for Santa Barbara counties, alcohol, drug, and mental health services. He has more than 20 years of experience and applied psychology including inpatient outpatient and administrative assignments, Dr. Henry, rejoined Western Psychiatric Institute and Clinic as the Clinical administrator for UPC Child and Adolescent Behavioral Health Services, the UPC Center for Autism and Developmental Disorders, and the UPC Center for eating disorders. He has been at Allegheny Health Network for six years, and attracted by the emphasis on patient centered treatment at AHN. And more recently, Dr. Henry has accepted a role with Highmark Health Office of Clinical Transformation. Dr. Henry?

35:30
Thank you, Sheree. And my apologies for that long bio, obviously, you did not get the brief bio there, but appreciate it nonetheless. So, I'm a clinical psychologist by training and background and worked for Highmark Health. Which is the third largest Blue Cross Blue Shield Insurance Company in the United States and primarily in West Virginia, Western, New York, Delaware, and Pennsylvania.

36:01
My other employer, Alleghany Health Network where I serve as the vice president of Psychiatry and Behavioral health is a 14 hospital network in southwestern PA and Western New York serving roughly two point five million people.

36:16
So, to simplify my job for AHN is to plan and strategize around providing behavioral health access for a population of about 2.5 billion dollars. In my payor role, Highmark Health, I do the same function for about eight million members. Next slide, please.

36:39
So I'll talk just a little bit about both the payer and provider perspective, What can and should we be doing about the, the ongoing opioid epidemic and the emerging epidemic of combined molecules into deadly poisons that are leading to an increased frequency of overdoses? So Highmark has a three prong strategy, not surprising.

37:07
And I think the prevention point in the national government is no different. And thank you to Dr. Spitznas and Mr. Westfahl for excellent presentations by the way as well. Next slide.

37:20
Some of the things that we have done at Highmark is to partner with our local FBI offices to create videos to prevent drug use. And they're disseminated broadly. And these videos are quite high quality.

37:39
And quite engaging for young people capture their attention, a lot of FBI badges and and dramatics involved in the video. And that has been viewed by a good number of people in West Virginia, as well as a number of students in Pennsylvania, about 9000 additional students. In addition to these efforts at primary prevention, the Alleghany Health Network, also has launched a school based behavioral health program that has a mindfulness based curriculum, with lots of drug and alcohol prevention content.

38:20
And the program includes both clinical components and psycho-educational components.
In other words, we deliver psychotherapy and psychiatry on site in 50 school districts in western Pennsylvania and are looking at initiating in the state of Delaware now as well. So we provide those professional services to those top of the pyramid students who need it.

38:47
But we provide psycho-education and prevention strategies by pushing into the health classes, so that we are touching the entire student body. And actually the entire school community. So as I mentioned, where we have actual physical presence, 40 hours a week, at more than 50 school districts in Western Pennsylvania now. And so that's an additional quarter of a million students that we're reaching with our prevention efforts. Next slide.

39:19
Community support: before I get into community support, I want to talk a little bit about prevention, because this slide doesn't have a key thing that we do. And that is, that we provide prescribers data. So, we are pushing to prescribers on a daily basis.

39:38
These are physicians or advanced practice providers, or sometimes called mid levels, that are prescribing opioids and what we've pushed to them is where they're prescribing patterns fit by percentile compared to their peers across the United States and within their own region.
The point being that if you give the physicians that feedback that they're prescribing practices are out of the norm so that they're in the 70th percentile of aggressive opioid prescribing for similar clinical problems and similar CPT codes.

40:16
That information is highlighted for them very clearly, in red, in data that we pushed to them on a daily basis. And we have found that teeing, that information up for them presenting it in a very digestible, easy to understand format, then being very clear.

40:40
While not being heavy handed in respecting the sanctity of the doctor patient relationship. Just providing that information has led to a sharp decrease in the amount of opioids being prescribed, as well as the number of days' supply of opioids that is dispensed at any one time.

41:00
So, really proud of that data based effort at prevention. In terms of Community Support, we're extremely active in our community. We know that a community that is more well is good business for the payer. They're in good business for the provider, increasingly, and value based reimbursement paradigms. So, in just the past three years, Highmark has committed more than $4 million to community organizations and programs fighting the opioid epidemic in Pennsylvania, Delaware, West Virginia, and New York.

41:39
And something else that I would recommend to all of the administrators for behavioral health organizations or risk mitigation organizations that are listening in today.

41:52
And that is to harness the power of your own team.

41:58
So, at Highmark, we have 40,000 or so employees, and we have many, many people that have been touched by addiction, in their families, or personally, and are in recovery, or who otherwise are very concerned about the epidemic of drug use in the United States, and want to do something. And so, too, we've created a forum for them, that we call Learn. And, at the current date, we have more than 600 regular participants.

42:29
The anchor activity for the learn program is monthly speakers, and we invite really high quality speakers from, both within our organization and outside. And I think that the quality of that speaker series, once a month, is really that initial draw. That's what causes us to go from 200 to 600, and we'll be up to a thousand.

42:54
I have no doubt, before the end of 2004 and beyond. But people are looking for ways to impact their community, and so we have many subcommittees of the learn program that focused on philanthropic efforts, on new ideas, new ways of engaging the community, and new angles as far as new tech that might not be widely known.

43:22
So to harness and create a forum for your own staff, and the energy that already exists within them to do something positive is, has been incredibly constructive. And is the most can be the most inexpensive, the most effective and expensive intervention that you can do if you have a relatively large organization. Next slide, please.

43:52
Treatment so treatment is the second of our three prong approach, high quality, STD treatment, and then the community supports to maintain the relationship and the engagement in the treatment. Next slide, please.

44:11
So, this is probably the the most important thing that we, in the United States can do, at this point in time to combat the aids epidemic, and that's increasing access to evidence based treatment and, in particular, for today's topic, to medically assisted treatment.

44:32
So, in 2020, we launched a technology enabled opioid use disorder program in West Virginia that was really groundbreaking doing remote, M a T.

44:48
And West Virginia present certain geographical challenges and, and population density challenges. And so, digital treatment access was absolutely a priority, and a prerequisite for the approach, a population health approach that we needed to take.

45:09
And the, the participants in the program have access two multi-disciplinary staff, a variety of different supports through smartphone, tablet, or computer. And we also have kiosks and certain privacy booths, where other access can be gotten at certain points or at certain places in population centers, if people do not have their own technology.

45:39
So getting people engaged in MIT, maintaining them on MIT, is hugely, hugely important. Probably the number one thing to emphasize today. And I would would also suggest that bringing MIT access two areas and regions in the US, where they are needed. So there may be the illusion of access in certain areas, because you have 1500 providers, and that looks like enough for the cities, the size of Pittsburgh. But where those offices are where people can access those, their proximity to whole homeless camps are groups of on house people living together. That's what really matters and making sure that there is low friction access to the M a T.

46:32
Next slide, please.

46:37
In late 2020, Highmark and Axial Healthcare, Axial Healthcare, as a subsidiary of a company, that is one of our partners called Waste Spring. And Axial has gotten into the business of prevention, in terms of providing software that tracks network physicians, opioid prescribing habits very closely. And, I mentioned that earlier, that is the software that we use to create those daily feeds to primary care, and ..., and other physicians that are commonly prescribing opioids. And that data is just absolutely essential.

47:20
And other essential components are the boots on the ground, the peer support network that is cultivated across our four state areas so that people have tangible.

47:34
in three-dimensional, not two-dimensional, like we're talking right now, but people that they can relate to, and people they can have a cup of coffee, with, people that they can call, when they're having a crisis, or in the throes of cravings. These efforts have led to a reduction in opioid related overdoses as more individuals diagnosed with SUV are linked with M a T.

48:01
Next slide, please.

48:04
So this is another point of emphasis, and probably the second thing that I would really encourage providers and payers to do, and that is to monitor the data very, very carefully.
First of all, put in the the time, effort, and money to get the data, to isolate the data That is going to tell you how you're doing in your battle against the opioid epidemic.

48:35
And in the monitor, extremely, closely, to isolate the data in the way that I'm showing here, And then to pay attention to it and take action based upon it. So this is absolutely critical. And this is really looking at prescribing patterns across our four state area.

48:59
And as a network. It broadly.

49:01
And this is different than the data on individual prescribing patterns that are ranked by percentile that will tell a physician if they're in the 50th percentile, the 30th percentile or the 90th percentile for dosages and frequency of prescriptions for similar CPT codes and similar diagnoses. This is sort of, that's the prevention component.

49:24
Once somebody is on opioids, this is the monitoring, or the level of pinpoint monitoring that you need to get into answer new opioid fills per one thousand citizens. And this is the one that we're probably the proudest about right now, because we've moved the needle here so much Initial opioid prescriptions being less than a seven days supply used to be 30 days, usually at a minimum, sometimes even 90 days. And that was one of the contributing factors to the epidemic and 2016, 2017. And we've increased, we've moved the needle on this significantly. Up to above 93, 94% of all prescriptions supported by Highmark are now less than seven days supply for that initial opioid prescription.

50:23
So evidence of MIT following overdose is another opportunity for payers and providers alike. So we do induction, having the capability to offer suboxone, host MOUD, to patients that have presented at our emergency departments. This needs to be become standard care, not exceptional care.

50:54
We also have peer supports and a social worker that engage all members that have come into an ED, post, O D and that also is incredibly helpful.

51:09
The idea is to get the induction going there, the Suboxone treatment underway in the ED, and then create an appointment at a very close office to get to continue the MIT the following morning. So, anything less than that, people fall between the cracks.

51:29
But if you are there and you can induce on the spot strike while the iron is hot, so to speak, and induce on the spot and then offer next day, follow up. You have you're giving people a fighting a fighting chance at sobriety. Next slide, please.

51:50
OK, we've gone over primary prevention, safe prescribing. 51:56Our philanthropic efforts to bolster community supports, um, AHN we do things like we have a street psychiatry team that goes every day to different homeless encampments are on house encampments in the Western Pennsylvania area.

52:14
We too like prevention point Handout Narcan. No questions asked.

52:22
It's just absolutely handing out Narcan wherever we wherever we go wherever we possibly can. An interesting thing that we do, that we've gotten a lot of positive response for is we bring a mobile unit to the local county jail. And as residents are leaving, those residents that had been diagnosed while they were incarcerated with an O, you'd be, are offered the opportunity to begin medically assisted treatment before they leave the parking lot. And then, again, that next day, follow up saying, OK. We've got an office right around the corner where you can get suboxone tomorrow morning that that's the kind of thing that makes a difference. So we try to develop macro strategy strategies and population health management strategies at the high mark health enterprise level, and then really allow and encourage providers to develop their own region specific solutions, like this mobile team that we have in the parking lot of the county jail.

So that, that kind of top-down support, while allowing enough freedom for the local regions, to implement the programs tailored to their community needs, and tailored to what's happening with their population, is the right way to go. Next slide, please.

53:51
OK, questions, ill, I'll just summarize very quickly.

53:55
The, what's, what's unique, or differentiating about high marks approach to these huge societal challenges are the use of data in both prevention efforts and in prescription monitoring efforts.

54:16
And the integration of tech, such as the early adoption of remote MIT Services Service Availability in West Virginia. And we continue to spread our footprint with remote M a T, and I've found that we, we had, it works better than we had thought. And we really did learn this in the covert pandemic that this can be safe and effective.

54:44
Lastly, the emphasis on emerging technology. We're working with a company right now that has a wearable that will predict cravings. So, episodes of crisis for users, and will predict an episode of craving 4 to 6 hours ahead of the peak of the cravings so that additional support can, can reach out and engage the member.

55:13
Time for questions. Thank you so much, Dr. Henry, for that broad perspective on Highmarks, obviously, highly successful initiatives to address prevention at the community level and to provide more access to care. We have just, a few moments left for questions, I'll go back to Dr. Spitznas, she was our first speaker. We've had many questions come in.

If the speakers would like to come back on camera, Dr. Spitznas from one of our our audience members would like to know what policy changes are necessary to better match existing treatments such as: buprenorphine and methadone, with fentanyl, and polysubstance use.

55:57
Thank you, Sheree. And I'm happy to answer that. So I mentioned that SAMHSA is holding a meeting on December 11th to examine the data regarding dosing limits for Buprenorphine in light of the poly substance use, specifically style zenon, fentanyl crisis. So, that's one example of something that may be needed. And as you may be aware, there is No Medication Treatment for Simulate use Disorder currently. And that is why FDA released guidance on stimulant use disorder of Medication Development this fall. That guidance can be reached via the Federal Register, and the deadline for comment on that, actually, is today, Monday, December fourth, if people are interested in taking a look at that and commenting. So, in general, I don't know that that's necessarily as as policy, but we do need to put funding behind research on these different topics. Thank you.

56:56
Thank you. And, mister Westfall, we have a question: What do you feel is the most important action item necessary to reduce or reverse the overdose trend? What is that one powerful thing that we might be able to do?

57:11
I believe the verdict is still out. What's the one thing you know? I personally believe that we need to use, or maybe we should use every tool in the prevention toolbox that we have.
That is proven to save lives and also reduce harm in the community. With that being said, I think the move to, over again, naloxone, to moving to over the cabinet room is a huge step, as far as access.

57:46
I know we have a lot of work to do to get that price, To go down and make it more accessible, hopefully, that the insurance companies will continue covering it, But I think that a lot, accessibility is a huge part of that, also, education.

58:03
I can't stress that enough, too.

58:07
Thank you, thank you, mister Morris, for doctor Henry. From your perspective, do you see changes in our society and how we interact with each other that that might be contributing to this sudden uptick in the overdose crisis that we seem to be seeing in recent years?

58:24
Yes. Without question. Thank you for that question.

58:28
There are a number, perhaps, most salient as the epidemic of loneliness that is occurring right now. So, 61%, for example, of young people under 21 in the United States. report suffering from chronic loneliness.

58:47
And I often tell my team, or psychologists, that of training, that substance use disorders exist, and emotional spaces in people's lives, where relationships with other people should be.

59:00
And, and as we become more fragmented as a society and certainly a pandemic did not help this more separated, whether it's by political opinion, geography, or lack of social skills, then the drug problem is going to get worse.

59:23
Thank you so much. Unfortunately, we're out of time today, but I want to offer a very large thank you to our panelists, who did an extraordinary job of helping us understand this very difficult and important issue, and offer some really high impact solutions. And thank you to our audience for joining and with our discussion by sharing your questions. Your feedback is important to us, so please take a moment to complete a brief survey that will pop up on your screen right after the event.

Please also check out our other resources available on our website, including a recent infographic on this topic, combination drug use, and the overdose crisis, as well as our webinar page, which will have the presentations from our speakers, and links to some of the wonderful resources that they shared today.

Again, thank you for your time, and have a wonderful afternoon.