Tackling the Opioids Epidemic:

Evidence on Approaches that Work

Jay C. Butler, MD, FAAP, MACP, FIDSA

Chief Medical Officer,
Alaska Dept of Heath & Social Services
Director, Division of Public Health
 Age-adjusted Drug Overdose Death Rates,
US, 1999-2016

Hedegaard H, et al. NCHS Data Brief no. 294, 2017

 Drivers of Changes in Life Expectancy, US,
From 2000 to 2015

Dowell D, et al. JAMA 2017; 318:1065-1067

 Opioid-Related Overdose Deaths,
Alaska, 2012-17
120

100 Death Involving**

Any Opioid
No. of Deaths

80 Prescription Pain Reliever

Heroin
60 Fentanyl(s)
Methadone
40
2016 rate: 12.9/100,000
20

* Preliminary (through Jan 3, 2018)

0 ** Many deaths involve >1 substance
2012 2013 2014 2015 2016 2017
Alaska News Dispatch, Aug 26, 2016
 Voices of Alaskans

“We never used to see ambulances going down to the

docks. Happens all the time now. We all know what is
happening, but nobody is talking about it.” -Sitka
“[my daughter] told me a couple of months before she died,
‘Dad, they tell you in school that you can get addicted, but
they don't tell you what addiction is.’”
“I never locked my door. I never owned a handgun.
I do both now.” -Petersburg

“[my daughter] told me a couple of months

before she died, ‘Dad, they tell you in school
that you can get addicted, but they don't tell
you what addiction is.’”
“This sickness has come to our island, to our State. We have
got to figure out how to stop this. We have got to
communicate with each other. Because if we don’t, our
people will die.” -Klawok
Conceptual Framework
Public Health Approaches to Preventing Opioid Misuse and Addiction
Public Health
3⁰ Prevention Practice Paradigms
Prevent life-threatening Naloxone
Acute health event
adverse outcomes control and prevention
Syringe/Needle
Exchange

2⁰ Prevention Screening and Treatment

Diagnose and treat addictions Remove Stigma Chronic disease screening
and substance use disorders Understand Addiction as a Chronic and management
Condition of the Brain

1⁰ Prevention Withdrawal Management and MAT

 Reduce the need to Effective PDMPs and Use of Data Environmental

self-medicate Rational Pain Management Judicious Prescribing controls and
 Control access to
Drug Take-Back Integrated Behavioral Health Services social
addictive substances
Prevent and Mitigate ACEs Adolescent Risk Reduction determinants
 Promote protective
factors Personal and Community Resiliency

Foundation: Effective, Evidence-Based Education and Communication

Adapted from: Butler JC. J Public Health Pract Manag 2017; 23:531-536
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 Phylodynamic Analysis of Viral Genetic and
Epidemiological Data, HIV Cases (n=183) Scott Co., IN
HIV Cases Simulated
Transmission
Diagnosed Incidence
began in 2011
(sexual Tx)

Exponential
spread began in
mid-2014 (sexual
and needle
sharing)

Campbell EM, et al. J Infect Dis 2017; 216:1053-62

 Addiction: A Chronic, Relapsing Health
Condition Involving the Brain

McLellan AT, et al. JAMA 2000; 284:1689-95

Conceptual Framework of Opioid Tolerance
and the Role of MAT in Management
 Benefits of Medication-Assisted
Treatment for Opioid Use Disorders
• Lower relapse
• Decreased overdose and all-cause mortality
• Reduced acquisition of HIV and HCV
• Improved social functioning
• Greater retention in rehabilitation programs

Schuckit MA. N Engl J Med 2017; 375(4):357-368

Sordo L, et al. BMJ 2017; 357:j1550
 National Principles of Care
• Routine screenings for SUD in every medical setting
• A personal treatment plan for every patient
• Fast access to treatment
• Disease management, as with other chronic
conditions
• Coordinated care for all illnesses
• Behavioral health care from legitimate providers
• Access to medication-assisted treatment
• Support for recovery in the community
https://www.shatterproof.org/national-principles-care
 Past Year Substance Use Disorder and
Mental Illness, US Adults Aged ≥18 Years,
2015
“We should not consider people who hold jobs,
reengage with their families, and regain control
over their lives through treatment that uses
medications to be addicted. Rather, we should
consider them to be role models in the fight
against the opioid epidemic.”

FDA Commissioner Scott Gottlieb, MD

Oct 25, 2017 Testimony to
House Committee on Energy and Commerce
https://vimeo.com/235831149
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 Judicious Use of Opioids:
Lessons Learned From Antimicrobial
Stewardship
• Accountable Justification
– Use of drug and manner of
administration
• Peer Comparison
– “Report cards”
• Suggested Alternatives
 Stewardship and Infection Control

– PDF of Jeffrey Linder presentation

Huffington Post
 Opioid Prescribing Rates by County Vary
By Up to Six-Fold

Guy GP, et al. MMWR 2017; 66(26):697-704

 RCT of 410 Pts: Management of Extremity
Pain (Sprain, Fracture, MS Pain) in the ED
10 Ibuprofen 400mg +
9 Acetaminophen 1000mg
8 Oxycodone 5mg +
Acetaminophen 325mg
Subjective Pain Score

7
Hydrocodone 5mg +
6 Acetaminophen 325mg
5 Codeine 30mg +
4 Acetaminophen 300mg
3
2 1° Endpoint:
1 Decline in score at
0
2 hours (p=0.053)
Baseline 1 hour 2 hour

Chang AK, et al. JAMA 2017; 318(17):1661-67

 Effect of Prescribing Guidelines on Post-
Surgical Opioid Prescribing

No increase
in refill
requests

Howard R, et al. JAMA Surg 2017; published ahead of print Dec 6, 2017
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 Percentage of 10th grade students in Reykjavik schools, smoking daily (dark blue line) , being
drunk (green line) the last 30 days, used narcotics once or more in their lifetime (red line), and
mariuana/kanabish (light blue line)- 1997-2017
Iceland Model for Youth Substance Misuse
Prevention: Actions
• Youth engagement: sports, other extracurricular activities,
community involvement (Leisure card, transportation)
• School-based and after-school programs: positive peer influence
• Media: discouraging alcohol and tobacco use
• Parental education: “quantity time”; “vitamin NO”, emotional
support
• Strengthened networks: community agencies and schools
• Supportive legislation:
– Age of majority increased from 16 to 18
– National curfew with enforcement
– Ban on alcohol and tobacco advertising; limited visibility
• Ongoing data collection and analysis; local ownership
Cross-Sectoral Collaboration is Key
Public Health Attorneys General Justice and Medical Boards
Agencies Offices Corrections

Healthcare Providers Hospitals and Clinics Community Coalitions Businesses and Labor

Media Emergency Medical Social Services Faith Communities

Services Agencies

Pharmaceutical Educators Third-Party Payers Others

Industry
 Governor

Opioid Response Multi-Agency Coordination Opioid Response Alaska Criminal Information

(MAC) Group: Possible Participants Incident Commander & Analysis Center

Alaska Opioid Response Governor’s DHSS DOC

Office

Incident Command System DCCED DEED DPS

Opioid Response
Deputy IC

• State Disaster Declaration DOL Local/Tribal Federal Public Information

Entities Entities Officer
• February 14, 2017
Liaison Officer
• Administrative Order 287
• Multi-agency approach
• Local, Tribal, State, Federal, and
Non-Governmental Agencies Opioid Response Opioid Response Opioid Response
Planning Section
Opioid Response
Operations Section Logistics Section Finance Section

• Multi-Agency Coordination (MAC)

Group Law Enforcement Procurement and Situation Unit SOA Grants
Transportation
• Incident Command System
• Alaska Criminal Information and Community–Based Documentation Unit
Prevention
Analysis Center
• Joint Information System Provider and Public Federal Grant
Education Tracking

Opioid Use Disorder

Treatment Opioid Response Joint
Information Team

Governor’s Office / DHSS /

Criminal Justice
DPS / DOC / DCCED / DEED /
Populations
DOL

Prescription Drug
Monitoring Prog

School Based
Prevention/Education
 Emergency and Disaster Declarations:
Purposes
• Personnel: deployment, intra-agency reassignment,
cross-agency embedding
• Pay: access to emergency funds, appropriation of
additional funds
• Procedures: streamlining of bureaucratic functions
• Procurement: fast-tracking and use of non-traditional
methods
• Policy: new laws and regulations to support long-term
response and recovery
• Priority: statement of importance, rhetorical tool
• Play together well
Scope of Substance Misuse and Addictions

Legal
Substances Alcohol, Marijuana

Illicit
Substances Heroin, Methamphetamines, Synthetic Cannabinoids, Cathinones

Therapeutic
Substances and
Opioids, Amphetamines, Benzodiazepines
Prescription Drugs

Emerging
Technologies Powdered Alcohol, Vaping Devices, Designer Psychoactives
What Will Success Look Like?
Near horizon (next 3 years)
• Reduced deaths from drug overdose; less NAS
• Declines in motor vehicle crashes from impaired driving
• Fewer self-injection related HIV and HCV infections
• Less unintentional injuries and self-harm related to drugs and alcohol
Further horizons
• Lower rates of drug misuse and addiction, including underage use
• Reduced drug- and alcohol-related incarceration and re-incarceration of
persons with addictions
• Lower rates of crime and referrals to child protective services
• Less interpersonal violence, self-harm, and child neglect
• Prevention of excessive prescriptions for controlled substances while
improving wellness and function

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