State of Maryland Update

Substance-related and Addictive

Services

Barbara J. Bazron, Ph.D., Deputy Secretary

Behavioral HealthDate: November 11, 2017

Presenter Disclosure: Barbara J. Bazron, Ph. D.

has no relevant financial relationships which

would require disclosure.”

Disclosure

Increase knowledge of Substance-related disorders and Maryland’s Overdose Prevention efforts:

1. Increase knowledge of Prescription Drug Monitoring Program by:

a. Identifying legislative mandates on registration/enrollment,

b. Highlighting prescriber responsibility, and

c. Underscoring the PDMP’s overall correlation in overdose prevention.

2. Broaden understanding of Medication Assisted Treatment services in helping individuals with substance-related

disorders recover, by

1. Highlighting the number of individuals currently being served/receiving services,

2. Emphasizing its efficacy in recovery, and

3. Featuring Maryland’s expansion efforts, which includes the use of Vivitrol

4. https://www.samhsa.gov/medication-assisted-treatment

3. Clarify the relationship between the Opioid Operations Command Center and the Behavioral Health

Administration, and its partnership in overdose prevention efforts.

4. Increase understanding of gambling disorder/addiction and identify awareness/prevention efforts.

Learning Objective

VISION

Improved health, wellness, and quality of life for individuals across the life

span through a seamless and integrated behavioral health system of care.

MISSION

The BHA will, through publicly-funded services and support, promote

recovery, resiliency, health and wellness for individuals who have or are at

risk of emotional, substance related, addictive and/or psychiatric disorders

to improve their ability to function effectively in their communities.

Our Mission and Vision

MENTAL HEALTH• Inpatient Services• Health Services

• Targeted Case Management• Psychiatric Rehabilitation Services• Residential Rehabilitation Services

• Residential Treatment Services (RTCs)

• Mobile Treatment

• Assertive Community Treatment• Traumatic Brain Injury• Respite Services

• Supported Employment• Crisis Services• Permanent Supported Housing

• Data Link

SUBSTANCE USE DISORDERS

• Recovery Housing and Supports

• Residential Treatment Facilities

• Withdrawal Management

• Medication Assisted Treatment

BOTH Mental Health and Substance

Use Disorders• Individual Practitioners

• Outpatient Services

• Intensive Outpatient Services

• Partial Hospitalization

• Lab Services (behavioral health related

disorders)

• Health Homes

• Care Coordination

Services Provided

Note: Based on claims data through 08/31/2017

Total Individuals is an unduplicated count of individuals receiving mental health or substance use disorder services in the PBHS.

Dually Diagnosed are those individuals receiving services in the PBHS with MH and SUD diagnoses during the year.

Claims can be submitted up to 12 months from the service date and therefore data regarding FY 2017 are incomplete now.

Total Number of Individuals Served in Public Behavioral

Health System FY ‘16 and FY ‘17

243,820 259,489

69,375 75,954

-

50,000

100,000

150,000

200,000

250,000

300,000

Total Number

of Individuals

Served in

PBHS (MH +

SUD)

FY 16 FY 17 Dually

Diagnosed

FY 16 FY 17

Note: Based on claims data through 08/31/2017

FY 2015 data for substance use disorder services is for only six months January through June 2015.

Claims can be submitted up to 12 months from the service date and therefore data regarding FY 2017 are incomplete now.

Individuals Receiving Substance Use Disorder Services in

Maryland’s Public Behavioral Health System

56,406

90,864

102,634

-

20,000

40,000

60,000

80,000

100,000

120,000

SUD Individuals Served FY 15 FY 16 FY 17

Number of Opioid-Related Deaths Occurring inMaryland from January through June of Each Year.*

285

8*2017 counts are preliminary.

261 246 244268

310336

508458

873

1029

0

200

400

600

800

1000

1200

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017*

Nu

mb

er

of

de

ath

s

Number of Heroin-Related Deaths Occurring inMaryland from January through June of Each Year.*

184

9*2017 counts are preliminary.

151 155

119 115

176202

293

336

579 586

100

0

200

300

500

400

600

700

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017*

Nu

mb

er

of

de

ath

s

Number of Fentanyl-Related Deaths Occurring inMaryland from January through June of Each Year.*

11

10

*2017 counts are preliminary.

13 16 21 18 18 15

114 121

469

799

0

100

400

300

200

500

800

700

600

900

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017*

Nu

mb

er

of

de

ath

s

Number of Carfentanil-Related Deaths Occurring inMaryland from January through June of Each Year.*

0

46

0

45

40

35

30

25

20

15

10

5

50

2012 2013 2014 2015 2016 2017*

Nu

mb

er

of

de

ath

s

2007 2008 2009 2010 2011

*2017 counts are preliminary.** Screening for Carfentanil began in 2016, first detected in 2017 6

Number of Prescription Opioid-Related Deaths Occurring inMaryland from January through June of Each Year.*

140 136

114

144

183

163158

172

190

218211

0

50

100

150

200

250

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017*

Nu

mb

er

of

de

ath

s

12

*2017 counts are preliminary.

MDH / BHA Priorities

Prevent Opioid Misuse and Abuse through

Enhanced Prescriber Practices and Public

Awareness

Treat Opioid Dependence by Expanding Treatment and Increasing Quality

Prevent Overdose Fatalities through

Naloxone Expansion

Expand Recovery Supports in the

Community

Mission: Curb the Rate of Growth in Overdose Deaths over the Next Two Years

PDMP Mission and Description

1

Mission: The Maryland PDMP collects controlled dangerous substance (CDS) prescription dispensing information and enables authorized users’ access to these data for the purpose of improving the health and safety of Maryland patients and the public.

Basic Description of the Maryland PDMP:– Secure, state-wide, electronic database

– Contains Schedule II-V pharmaceutical controlled dangerous substance (CDS) Rx dispensed in Maryland

– Rx data can be disclosed for clinical, investigative and research/public education purposes as allowed by law

• Mandated Registration-July 1, 2017

• Mandated Use-July 1, 2018

PDMP Registration Mandate Achievements

1

Registrant Type % Registered

Nursing (CNM, CRNP) 77.00%

Dental (DMD, DDS) 71.45%

Physician (DO, MD, PA) 73.01%

Veterinary (DVM, VMD) 78.10%

Podiatry (DPM) 82.29%

TOTAL PRESCRIBERS 73.64%

Pharmacist 59.97%

TOTAL PROVIDERS 70.27%* Removed from this l ist are CDS permitholders

known through individual outreach to have moved

out of state or who intend to allow their CDS

Data Current as of 9/6/2017

Major PDMP Stakeholders

PDMP means different things to different people based on their

unique role in combating the epidemic

Raw Data End User

Data Analytics

Aggregate Data User

Data Reporter

Many different stakeholders trying to bend the opioid curve

*Total Opioids include all prescriptions containing a medication in the opioid class of drugs, with the exception of medication

containing an opioid in a formulation indicated for the treatment of opioid use disorder

Goal: Enhance Clinical Utility of PDMP

CRISP/PDMP Integrations: “One Click” Access

1

Single Sign-on (SSO) Facilities: >30 are LIVE!• Medstar – all 7 hospitals + ambulatory• Lifebridge – Northwest, Sinai• Doctors Hospital• Holy Cross Health• Calvert Memorial Hospital• Mercy Medical Center• UMMS – Medical Center, St. Joe, R&O, Midtown,

Harford + ambulatory• Union Hospital of Cecil County• St. Agnes Hospital• Peninsula Regional Medical Center• Kaiser Permanente• Western Maryland• Meritus Health System• Johns Hopkins Health System • Greater Baltimore Medical Center (GBMC)• Upper Chesapeake Medical Center (UCMC)• Mount Washington Pediatric Hospital• Atlantic General Hospital• Frederick Memorial Hospital• Garrett County Memorial Hospital

Unsolicited Reporting – ‘Indicators of Misuse/ Abuse’ Notifications

1

Total Notification Letters sent to PRESCRIBERS in last year: 661

Unsolicited Reporting Notifications: Change in ‘Doctor / Pharmacy Shopping’

1

Change in Number of Individuals Meeting Multiple Provider Episode Criteria, 1/1/2015 - 8/31/2017: 64.74% Decrease

* Multiple Provider Episodes = > 5 pharmacies and > 5 prescribers seen in 3 month period of time, common proxy for ‘Doctor / Pharmacy Shopping’

PDMP Dashboard

22

Overdose Hospital Events

Dashboard

23

Prescription Drug Monitoring Program-Mandatory Registration: July 1, 2017

• Goal: reduce Rx drug misuse & diversion

• Integrated with CRISP, the state-designated health information exchange

• Secure, electronic database with information on the prescribing and dispensing of Rx controlled substances

• Data is reported by drug dispensers, including pharmacies and dispensing practitioners

• Access granted to healthcare practitioners, licensing boards, law enforcement & specific DHMH agencies

• In January 2017, clinical users generated over 189,000 queries in portal and integrations

• Progress continually being made toward registering all CDS prescribers and pharmacists in Maryland in advance of 2018 Use Mandate:

* Number of prescribers (33,807) obtained from roster of licensees who have an active CDS registration with Office of Controlled Substance Administration (OCSA, formerly Division of Drug Control), the State CDS permit authority.** Number of pharmacists (11,296) obtained from communication with Board of Pharmacy staff October 26, 2016 about total licensees in possession of an active Maryland pharmacy license.

Registrant Type % Registered (9/6/2017)

CDS Prescribers 74.64%

Pharmacists 59.97%

All Providers 70.27%

PDMP Registration Mandate Achievements

Registrant Type % Registered

Nursing (CNM, CRNP) 77.00%

Dental (DMD, DDS) 71.45%

Physician (DO, MD, PA) 73.01%

Veterinary (DVM, VMD) 78.10%

Podiatry (DPM) 82.29%

TOTAL PRESCRIBERS 73.64%

Pharmacist 59.97%

TOTAL PROVIDERS 70.27%* Removed from this l ist are CDS permitholders

known through individual outreach to have moved

out of state or who intend to allow their CDS

Data Current as of 9/6/2017

Prescription Drug Monitoring Program

Change in Percent of All CDS Permit Holders Registered By Profession

Change over time April 5, 2017 to September 6, 2017

Breaking the Cycle

Department of Public

Safety and Correctional

Services

Maryland State Police

Maryland State

Department of Education

Department of Health and

Mental Hygiene

Department of Human

Resources

Maryland Insurance

Administration Department of Juvenile Services

Maryland Institute for Emergency

Medical Services Systems

Governor’s Office of Crime Control and

Prevention

Local and County Governments

OPIOID OPERATIONAL

COMMAND CENTER

Opioid Operational Command CenterFACING THE PROBLEM TOGETHER

Opioid Operations Command Center Goals & Priorities

The OOCC’s goals include, but are not limited to, the following:

• Facilitate operational collaboration and coordination among state agencies and

local partners working on heroin and opioid-related response initiatives.

• Strengthen information management and sharing to partners and the public.

• Coordinate the development of stakeholder reports to document system-wide

progress.

• Develop cross-cutting, multi-disciplinary Opioid Intervention Teams (OITs) based

on local needs, to include training and subject matter expertise.

• Coordinate training and resources available to state and local agencies.

700% Increase in Substance Use Funding

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

FY14 FY15 FY16 FY17

Diversion

Heroin Coordinator

Law Enforcement Enhancement

Medication Assisted Treatment(MAT)PDMP

Prevention

Problem Solving Court

Prosecution and TreatmentInitiativeReentry Services

Peer Recovery Specialists

Treatment Services

Funding to Address the Opioid Crisis

• Behavioral Health Administration was awarded a $20 million 2-year grant under

the 21st Century Cures Act from the U.S. Department of Health and Human

Services, administered by the Substance Abuse and Mental Health Services

Administration (SAMHSA), to be used for the prevention and treatment of opioid

abuse over a two-year period.

• The funding for Fiscal Year 2018 includes the first $10 million of Governor Larry

Hogan’s $50 million commitment to address the crisis announced in March 2017.

• $2.1 million from the Governor’s Office of Crime Control & Prevention.

Eighty percent will go to Maryland’s 24 local jurisdictions and

service providers to fund prevention, enforcement, and treatment

efforts throughout the state.

Opioid intervention teams

• Opioid Intervention Teams (OITs) have been established at the local jurisdiction level. These multi-agency coordination bodies integrated strategies at the local level consistent with the statewide opioid response.

• 24 local jurisdiction Opioid Intervention Teams (OITs)

• 154 OIT Coordination Meetings since March 1st

Initiatives to Address Opioid Crisis

Social Marketing Campaign

Naloxone Saturation Project

Harm Reduction Outreach

Consultation Helpline

Crisis Stabilization Center

Expansion of crisis beds within a

3.7 residential facility

Expansion of level 3.1 residential

services

Client Transportation

Workforce Training

Peer Recovery Services

Student Assistance Program (SAP)

Teams

Bed Tracking System

IT Support

Prevention activities database

Social Marketing/Media Campaign

OCSA Regulatory Compliance

Obtain Mobile Forensic Devices

Drug Trafficking Organizations

Opioid Use Disorder Information

Distribution

Screening, Brief Intervention and

Referral to Treatment (SBIRT)

Peer Recovery Support Specialists

Medication Assisted Treatment

Behavioral Health Crisis Hotline

Recovery High Schools

Naloxone Stockpile

Opioid Intervention Teams

Rate Setting Study

Medication Assistant Treatment Programs (MAT)

Maryland unbundled dosing and treatment in 2017. Research shows that a

combination of medication and behavioral therapies is the most effective.

• BHA has 84 Opioid Treatment Programs throughout the state

• 32,210 individuals received services in FY 17 based on claims paid through September 30, 2017

Medication Assistant Treatment Programs (MAT)

o Targeting Opioid-related Recidivism: Combining evidence-based treatment with best practices for reentry.

o Justice Reinvestment Act: Expansion of intensive reentry programming at the local detention centers.

o 11 county programs initiated since the beginning of the Hogan Administration.

o Promoting Data Access: Producing a formal evaluation in Dec 2017 to measure efficacy and support MAT integration in corrections.

Medication Assistant Treatment Programs (MAT) for Young

Adults (18-26)

The number of young adults accessing Medication Assisted Treatment (MAT) statewide is

3,437for FY ’17

There has been no significant change in the number of young adults accessing MAT over

the past two years, with only 3,431 young adults receiving MAT in 2016.

(Based on claims data through September 2017.)

• BHA in partnership with Dr. Mark Fishman from Hopkins University, is developing a strategy to pilot a

comprehensive MAT Program specifically designed for young adults ages 18 – 25.

• Dr. Fishman will be establishing a 15-20 bed residential facility to provide MAT that will include: use

of Vitriol as a long acting relapse prevention medication, Buprenorphine, multi-component recovery-

oriented treatment, outpatient substance use and mental health treatment.

• The MAT pilot program for young adults will be established in Baltimore City at the William Donald

Schaeffer House, a facility with 20-bed capacity, that served as a group home for males 18 – 24 with

substance use disorders and was operated by the DJS.

Buprenorphine Expansion…..

• Key strategies:

–Support Federal expansion of the pool of prescribers to include Nurse

Practitioners and Physician Assistants in addition to physicians

–Expand use of buprenorphine in Opioid Treatment Programs and

Outpatient Mental Health Clinics

–Emergency Department(ED) initiative: prescribe buprenorphine in ED and

use peers to link to community based providers (N=4 hospitals; Bon Secours,

Harbor, Mercy and Franklin Square)

–Buprenorphine induction in SUD crisis beds to be funded by Opioid STR

Grant

–Creating statewide consultation service to support prescribers to be funded

by Opioid STR Grant

• Buprenorphine warm line for prescribers of buprenorphine to

support clinical care of patients.

• Prescribers not associated with treatment programs lack support

with unstable or early recovery patients. Prescribers can receive

consultation with a waivered prescriber to guide clinical care.

• Executed contract with University of MD to create consultation

service for community-based prescribers of buprenorphine. This

will eventually expand to additional addictions issues.

• Service began October, 2017.

Buprenorphine Expansion

Maryland’s Overdose Response Program

Established in 2014 as a public health outreach model through which to provide overdose education and

naloxone to people at risk for overdose, their friends and family, law enforcement, and providers.

As of January 2017:

• 57 authorized local training programs

• Total 40,316 individuals trained and 44,932 doses of naloxone provided at time of training

• Total 1,445 reports of naloxone use in the community

• Extraordinary program growth with 188% more people trained in FY16 than FY15

• 45% of people received training in FY16 because of social experience

• Online training anticipated 2017

Program expansion:

• Over the counter access to naloxone

without a prescription

• 8 local health departments are

partnering with detention centers to

provide naloxone to inmates upon

release

• ORP Workshops on how to do street-based

training

• Training of trainers provided to Peer

Recovery Specialists

SAMHSA MAT-PODA (Medication Assisted Treatment-Prescription Opioid Drug

Addiction): Three-year $ 2.4 M Grant

Goals:

• Increase utilization of Medication Assisted Treatment (MAT)

• Targeted enrollment: 813 people over 3 years

• Pilot Buprenorphine induction in 3.7 residential treatment setting

• Provide specialized training to peers for engagement of overdose survivors

seen in the ED and community outreach

• Care Coordination for all service recipients

Local Implementation Partners:

• Anne Arundel County Health Department

• Behavioral Health Systems Baltimore

• Medmark/Daybreak Treatment (Methadone) Center

• Reflective Treatment (Methadone) Center

• Tuerk House Residential Treatment (Buprenorphine induction)

• FQHC Total Health Care (Buprenorphine,Vivitrol)

aryland MATRS

project

Expand Recovery Supports -

Certified Peer Recovery Specialists (CPRS) Program: Maryland’s Certified Peer Recovery Specialist

program, in conjunction with the Maryland Addiction and Behavioral-health Professional Certification

Board (MABPCB), provides State certification for individuals who provide direct peer-to-peer support

services to others who have mental health, substance use, or co-occurring disorders. CPRS’s can, with

specialized training and guidance, draw from their own lived experiences of recovery inspire hope and

provide support to others who are facing similar situations.

Peer Recovery Support Services

✓ accompanying individuals to appointments/12-step meetings and leisure activities

✓ providing assistance with completing paperwork for social services and other support services

✓ providing assistance/preparation for employment such as shopping for work related clothing coaching to prepare for an interview

Certified Peers (N=121) perform activities aligned with four domains:

✓ Advocacy

✓ Recovery & Wellness

✓Mentoring & Education

✓ Ethical Responsibility

Expand Recovery Supports – Peer Support Services

Drug Courts

• In collaboration with the Office of Problem Solving Courts, BHA provides

funding and oversite to establish drug treatment courts or Drug Courts.

• These courts are specialized court dockets that target criminal defendants and

offenders, juvenile offenders, and parents with pending child welfare cases who

have alcohol and other drug dependency problems who may be better served

outside of incarceration.

• Justice involved individuals agree to participate in structured, intensive

treatment programs.

• Participating health authorities agree to participate in team meetings, attend

court status hearings, collect data (i.e., case notes, drug tests), and work with

case managers and coordinators for consultation on participants progress,

issues.

Team Structure

What have we done recently (1 of 2)?

- 44 -

Shared-services model actively being rolled out in Oct and Nov

All seven BHA facilities now managed by an empowered and proven Director

Internal consulting team deployed to BHA Forensics for transforming processes, tools, and performance

Centralized Admissions Office

What have we done recently (2 of 2)?

- 45 -

BHA formally launched and announced its Centralized Admissions Office on October 13. The above information card has been sent via email to the courts, the detention-center administrators, and other key stakeholders

Number of Forensically-Involved Individuals Served

• Individuals Receiving Health-General §8-505 Assessments – 782

(July 1, 2017 – October 31, 2017)

• Individuals Receiving Health-General §8-507 Orders - 543

(July 1, 2017 – October 31, 2017)

Service Delivery Status:

• Evaluations are conducted within 7 days.• Wait time for placement has been significantly reduced. It is

now within the 21-day mandate by the Justice Reinvestment Act.

• Inpatient detoxification

• Alcohol and/or drug assessment

• Individual therapy

• Group therapy

• Intensive outpatient program services

• Partial hospitalization

• Ambulatory detoxification

• Opioid maintenance therapy for individuals 18 and over

• Laboratory services

• Residential rehabilitation programs (SUD service if w/ dual dx)

• Supported employment (SUD service if dual dx)

• Respite care (SUD service if dual dx)

• Crisis services

• Peer support

• Recovery services

Medicaid-

eligible

Services

Non-

Medicaid-

eligible

Services

BHA Substance Use Disorder Services Available to Defendants

Receiving a Court-ordered 8-505 Assessment and/or 8-507 Placement

Dual dx means: mental illness and substance related disorder

Strategic Approach

• Individuals with gambling disorders present to the behavioral health system for treatment.

– Up to 50% of those with a substance use disorder also have a gambling disorder. – The rates of gambling disorders in the mental health population are double the

general population.

• Approach has been to train up the substance use and mental health workforce to identify and treat gambling disorders.

• Counselor training has occurred in treatment programs throughout the state.

• Payment for services is either through Medicaid, if the individual has a substance use disorder or mental health diagnosis. Grant funds are available to provide services to those without a behavioral health diagnosis.

BHA has established the Center of Excellence on Problem Gambling in partnership

with the University of Maryland

Maryland Center of Excellence on Problem Gambling

Services provided include:

• Maintaining a free and Confidential 24-hour helpline

• Developing and conducting training for behavioral health providers

• Clinical Case Consultation calls designed to enhance the skills and competence of treatment providers

• Treatment services—Funding moves to the fee-for-service system January 1, 2018

Maryland Center of Excellence on Problem Gambling

The Center serves to:

Centralize the specialized knowledge and expertise needed by treatment and prevention

professionals, researchers, somatic care practitioners, problem gamblers and their families,

general public and other stakeholders to address this issue.

Continue to support and enhance the existing behavioral health treatment system to

provide effective problem gambling services- In FY 2017, over 1,700 participates

were trained in 51 educational events, including specialized training to the faith

community for clergy and lay ministers.

Continue the helpline for information and referral to treatment

Implement training curriculums to increase behavioral health workforce competence -

809 unique individual clinicians attended problem gambling clinical training, with

261 achieving 30 or more hours .

Maryland Center of Excellence on Problem Gambling

Provide prevalence and community impact data to determine future interventions and to evaluate effectiveness of strategies-2nd Problem Gambling Prevalence Study to be completed January 1, 2018.

Continue to collaborate with the MD Lottery and Gaming Control Agency to assist individuals in the Voluntary Exclusion Program (VEP).

Maintaining partnerships with the Local Health Departments, agencies, community organizations and the 6 Maryland Casinos to educate and form alliances for treatment best practices and responsible gaming practices.

Maryland Center of Excellence on Gambling

Provide prevention and public awareness campaigns - In FY2017, overall website traffic increased 48% over the previous year.

Marketing efforts that focused on directing help seekers to helpmygamblingproblem.org continued in FY 2017 as evidenced by the growth in use of this site (see figure above)

0

50,000

100,000

150,000

200,000

helpmygamblingproblem.org

FY15

FY16

FY17

Maryland Center of Excellence on Gambling

Over 80,000 awareness materials on gambling, problem gambling and gambling addiction were distributed in FY 2017.

In partnership with key stakeholders and community advocates, The Center participated in 33 community events with over 39,000 Maryland residents in attendance.

Planning began in FY 2017 to launch a multimedia public awareness campaign including billboards, radio and TV public service announcements, social media and movie theater announcements –This FY 2018 multimedia campaign is the first statewide, year long campaign to be conducted.

• Marylanders who need help finding substance related disorder treatment resources

should visit MdDestinationRecovery.org or call the Maryland Crisis Hotline, which

provides 24/7 support, at 1-800- 422-0009.

• For information on many of the policies currently implemented to fight substance

related disorders and overdose in Maryland, see http://goo.gl/KvEzQw.

• If you know of someone who could use treatment for substance related disorders

treatment facilities can be located by location and program characteristics on our

page at http://goo.gl/rbGF6S.

• Helpmygamblingproblem.org

Resources

bha.health.maryland.gov/OVERDOSE_PREVENTION/Pages/Index.aspx

beforeitstoolate.maryland.gov/about-the-opioid-operational-command-center

Thank you, and Enjoy your day!

Let’s Continue to Support Pathways to Recovery

Thank You, and Enjoy your Day!