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OpioidAddictionandPrescribing

MitchellMutter,MDDirectorofSpecialProjects

Nashville, TN | April 12, 2018

DisclosureStatementofFinancialInterest

I,MitchellMutter,DONOThaveafinancialinterest/arrangementoraffiliationwithoneormoreorganizationsthatcouldbeperceivedasarealorapparentconflictofinterestinthecontext

ofthesubjectofthispresentation.

KeyFindingsin2017

Source: CSMD 2018 Legislative Report

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The Opioid Crisis by the Numbers

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ChronicPainGuidelinesExpertPanel

PublicChapter430

• Requires the development of the TN Chronic Pain Guidelines– 1st edition 2014

– 2nd edition 2017

– Annual review

Risk Proof Your Practice

• How many patients on greater than 120 MEDD?

• How many patients drive a far distance to practice site?

• How many patients are on combinations?

• Resources available in office– Naloxone handouts

– Education on near misses

– Education on street drugs

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PublicChapter1033

• Pain Management Clinics transitions from certificate system to licensure system– Medical director holds license – Non-transferable

– Only a pain specialist is eligible to be medical director

– > 50% of patients being treated for pain qualifies as a pain clinic and must be registered

– No pharmacy

– Clinic can be suspended based on specific violation• No new patients

• Monitored

– Went into effect on July 1, 2017

TNPainManagementClinicsperCounty,7/3/2017

AnnualNASTrends

Source: Neonatal Abstinence Surveillance System. TN Dept. of Health

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NeonatalAbstinenceSyndromeSurveillanceSummaryWeek09:February25– March03,2018

NASRateper1,000LiveBirths,2016

Source: Neonatal Abstinence Surveillance System. TN Dept. of Health

NASRatesbyRegion

Source: Neonatal Abstinence Surveillance System. TN Dept. of Health

2016 Data are provisional.

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ConsequencesofOpioidEpidemic

Source: Clinical Infectious Diseases, December 7, 2017

• Tennessee in-state variability assessment for a “Rapid Dissemination of HIV or HCV Infection Event” utilizing data about the opioid epidemic.

• More granular data improved insights into county-level HIV/HCV outbreak vulnerability compared to national models.

ScottCounty,IndianaOutbreak

• 220 U.S. counties had highest vulnerability

• 41 small counties located in TN

• 25 overlapped with more granular TN data

• CDC – acquired HIV 2016

Source: Clinical Infectious Diseases, December 7, 2017

75PredictorsUsedtoComputeeachCountyRiskScore

• MME/Capita

• Death from Heroin/Opioids

• Socioeconomic

• IV Drug Use

• Mental Health Services

• Uninsured Percentage

• Other, see December 7, 2017 Clinical Infectious Diseases

Source: Clinical Infectious Diseases, December 7, 2017

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RiskRanking

Source: Clinical Infectious Disease, December 7, 2017

PublicChapter476

• Currently, the top 50 prescribers of controlled substances in the state are annually identified and sent a letter notifying them of their inclusion on this list and asked to respond with a justification for their prescribing patterns.

• Public Chapter 476 adds the top 10 prescribers from all of the combined counties having populations of fewer than 50,000

• Effective/Signed May 18, 2015

MMEsPrescribedbyTop50PrescribersandDispensedin2013‐ 2017

Source: CSMD 2018 Legislative Report

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WhydoPrescribersandDispensersChecktheCSMD?

Source: CSMD 2018 Legislative Report

PrescriptionDrugOverdoseDashboard

Source: https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html

TennesseeDrugOverdoseData

Source: https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html

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TennesseeDrugOverdoseData

Source: https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html

Age-adjusted drug overdose death rates, by state, United States, 2016

NOTES: Deaths are classified using the International Classification of Diseases, Tenth Revision. Drug-poisoning (overdose) deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14..

SOURCE: NCHS, National Vital Statistics System, Mortality.

The Opioid Crisis by the Numbers

24.5Tennessee

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Drug overdose death rates, by selected age group: United States, 1999-2016

1Significant increasing trend from 1999 to 2016 with different rates of change over time, p < 0.05.22016 rate was significantly higher than for the rate for age groups 15–24, 55–64, and 65 and over, p < 0.05.

NOTES: Deaths are classified using the International Classification of Diseases, Tenth Revision. Drug-poisoning (overdose) deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.

SOURCE: NCHS, National Vital Statistics System, Mortality.

Age‐AdjustedRatesforAllDrugOverdoseDeathsandbySexandRaceinTNbyYear

TennesseeOverdoseDeathswherepatientdidnothaveprescriptionsinCSMD60dayspriortodeath

0%

10%

20%

30%

40%

50%

60%

2013 2014 2015 2016

 All Drug

Source: TN Dept. of Health, Office of Informatics and Analytics

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AllDrugDeathsbyAgeDistribution,2012‐2016

0

50

100

150

200

250

300

350

400

450

500

5‐14 years 15‐24 years 25‐34 years 35‐44 years 45‐54 years 55‐64 years 65‐74 years 75‐84 years 85+ years

2012

2013

2014

2015

2016

Num

ber

of D

eath

s

Source: TN Dept. of Health, Office of Informatics and Analytics

AllFentanylDeathsbyAgeDistribution,2012‐2016

0

20

40

60

80

100

120

5‐14 years 15‐24 years 25‐34 years 35‐44 years 45‐54 years 55‐64 years 65‐74 years 75‐84 years 85+ years

2012

2013

2014

2015

2016

Number

of D

eath

s

Source: TN Dept. of Health, Office of Informatics and Analytics

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OpioidsPresentinOverdoseDeathsinTNbyYear

64.768.2

71.3 72.7

4.6 5.5

12.0

18.0

5.4

11.614.1 15.9

2.0 3.7 3.4 4.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

2013 2014 2015 2016

Opioid

Fentanyl

Heroin

Buprenorphine

*  Percentages for fentanyl, heroin, buprenorphine are included in the opioid category and are broken out for clarity.

Percentage of Overdose Death

Source: TN Dept. of Health, Office of Informatics and Analytics

AccesstoDocuments

2018 CSMD Legislative Reporthttps://www.tn.gov/health/health-program-areas/health-professional-boards/csmd-

board/csmd-board/reports.html

TDH Pain Management Clinic Statutes, Rules, and Guidelineshttps://www.tn.gov/health/health-program-areas/health-professional-boards/pm-

board/pm-board/statute-rules-and-guidelines.html

Prescription Drug Overdose (PDO)https://www.tn.gov/health/health-program-areas/pdo.html

AccesstoDocuments

Tennessee’s In-State Vulnerability Assessment for a ‘Rapid Dissemination of HIV or HCV Infection’ Event Utilizing Data about the Opioid Epidemic

https://academic.oup.com/cid/advance-article/doi/10.1093/cid/cix1079/4706246

Neonatal Abstinence Syndrome (NAS)https://www.tn.gov/health/nas.html

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ContactMe

Mitchell Mutter, M.D.

Director of Special Projects

615-532-3541Mitchell.Mutter@tn.gov

Tennessee Department of Health

Health Related Boards

665 Mainstream Drive, 2nd Floor

Nashville, TN 37243

ThankYou!