Burlington confronts opioid crisis

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Burlington confronts opioid crisis

Thu, 02/16/2017 - 3:59pm -- tim

Vermont Business Magazine Mayor Miro Weinberger today released new principles and announced the pursuit of new initiatives to address the deepening opioid crisis in the region that has resulted in a significant 38 percent increase in opioid-related deaths in Vermont from 76 in 2015 to an estimated 105 in 2016. In Chittenden County, indicators such as retail theft and opioid-related arrests also show a growing crisis. The City is moving on numerous fronts to organize a sustained local effort to turn the crisis around, and announced today new partnerships with the University of Vermont Medical Center, the Chittenden County State’s Attorney, and metro area police departments.

“Despite the hard work of many state and local agencies and individuals that undoubtedly has saved lives, we face a deepening opioid crisis that is taking lives and ravaging our community,” said Mayor Miro Weinberger. “The City is using its new analytical and coordinating capacity to take stock of our collective efforts, create new partnerships, and launch new opioid initiatives.  All of us – government officials, doctors, police, parents and patients – must take responsibility, be fully aware of the risks of opioids, and act with urgency to turn this crisis around.”

“The goal of the Burlington Police is to reduce the number of Vermonters who die from opioid overdoses,” said Burlington Police Department (BPD) Chief Brandon del Pozo. “Achieving this goal will yield many collateral community benefits, such as fewer overdoses and overall fewer fractured families and social networks. We appreciate that medical professionals, business and community leaders, and people from all government sectors will stand with our mayor on a set of guiding principles that will keep our collective work focused. The work ahead will involve the police taking novel approaches to saving lives, and we are ready to innovate. All we request is that our partners be as relentless as we will be.”

New Opioid Principles

The City of Burlington is redoubling its efforts with new initiatives on numerous fronts of the opioid crisis. The City has drafted 11 new Opioid Principles to explain its approach to the public, to encourage community debate about and engagement with these efforts, and to guide City employees and officials working on this urgent challenge (each principle is expanded upon and explained in the attached document):

1.       Prescription opioids can be as dangerous as heroin – and should be treated as such.

2.       Opioid addiction is a public health crisis with a law enforcement component.

3.       City governments play a unique and vital role in addressing the opioid challenge.

4.       People struggling with opioid addiction need access to treatment without delay.

5.       Police should give amnesty to users seeking help for their addictions and send them to treatment.

6.       Heroin dealers who knowingly destroy communities should receive the full penalties they deserve.

7.       The community needs the medical profession to fully embrace its role as one of the most important partners in solving the opioid crisis.

8.       All institutions engaged in resolving the opioid crisis should embrace data collection, data-sharing, analysis, and transparency.

9.       The pharmaceutical industry has a role in resolving the crisis it helped create.

  1. Treatment for opioid addiction should not end upon arrest.

11.   Naloxone must be available to the people abusing opioids, their friends and family, and their emergency service providers.

To share its approach with the public, and to gather public input through community debate and engagement, the City will hold an Opioid Town Hall meeting in Contois Auditorium on March 16 at 6 p.m. before presenting these principles to the City Council for final approval.

There will be an additional Burlington public event regarding the opioid crisis on April in Contois Auditorium at the Mayor’s Book Group discussion of Dreamland: The True Tale of America’s Opioid Epidemic.  Author Sam Quinones will speak at the event and participate in a panel discussion. Dreamland reveals the origins of the nation’s opioid epidemic in the 1980s and 1990s – a narrative that is critical to understand as we seek to resolve this corrosive crisis.

New initiatives flowing from these principles

The City has taken the following steps in accordance with its principles:

1.      CommunityStat effort expands to include South Burlington and Winooski police departments

As of February 2017, the CommunityStat group has expanded to include representation from the South Burlington and Winooski police departments. The CommunityStat group was originally formed in November 2016 to provide coordination of data gathering and analysis efforts among the police, public health and safety professionals, and social service providers as part of the effort to more effectively reduce the impact of opioid addiction in Burlington. The South Burlington and Winooski police departments have agreed to meet with the BPD on a bi-weekly basis to discuss identified cases and concerns.

Through these conversations, the three departments will identify individuals who are engaged in risky behavior, need treatment, housing, or other social services, or may cause imminent harm to themselves or their community. The police departments will track these cases, including the time it takes to get an individual into various levels of care, and will share the data findings at the monthly CommunityStat meeting.

“The Winooski Police Department is looking forward to collaborating on this project,” said Winooski Police Department Chief Rick Hebert. “Joining data sets from our three cities will enable the team to more quickly identify and provide services to people caught in this public health epidemic.”

“The South Burlington Police Department is pleased and proud to be involved with CommunityStat,” said South Burlington Police Chief Trevor Whipple. “Individuals struggling with opioid addiction travel from community to community, making this collaborative effort even more important. This common sense approach to fighting addiction and working toward saving lives is beneficial to all our communities and those we serve. We are appreciative of Burlington taking the lead and inviting our department to join the fight against this public health crisis.  We are fully committed to working together to help those in crisis.”

2.      First regular CommunityStat data report

One of the key Opioid Principles is a commitment to data and transparency, an effort that already has yielded valuable insights into the many effects of the crisis at the local level. Slides compiled through the City’s CommunityStat meetings (see attached) show worsening trends.

·         In 2015, more children under six years old came into Department of Children and Families custody due to guardian opioid use issues than any other issue (51 percent, or 276 cases total).

·         More individuals are seeking treatment for opioid substance abuse than ever before in both Chittenden County (1,390) and the State of Vermont (6,084). Statewide, in 2015 more people received treatment for opioid substance abuse than all other substances combined.

·         Opioid-related overdose deaths statewide and in Chittenden County continue to rise. Chittenden County reported 20 deaths in 2015, up from 19 in 2014 and 18 in 2013.

·         There is increased demand for Narcan year over year. In 2015, Safe Recovery dispensed 5,872 doses of Narcan to the public, up from 2,893 doses in 2014.

·         Anecdotally, many social service agencies, including those focused on housing, economic support, and treatment, are reporting increased stress on their agencies as a result of the crisis.

3.      UVM Medical Center agrees to reduce opioid prescriptions and increase public transparency around opioids

In January 2017, Centers for Medicare & Medicaid Services released a national Medicare Part D Opioid Prescribing Mapping Tool based on prescription data from 2013-2014.  This mapping tool suggests that of all New England states in those years, Vermont was an outlier in its prescribing practices. The BPD has completed a thorough analysis of the data provided by the map (see the BPD analysis and Executive Summary attached), which includes individual physicians’ prescribing practices, and found the following:

  • At 3.2 scripts per patient, Vermont opioid prescriber’s rates in 2014 were 13 percent higher than the next highest state (Maine), and 17 percent higher than the average rate for New England not including Vermont.
  • Vermont also led the region in drug supply days per beneficiary. On average, individual recipients were suppled opioids for 69 days of the year in 2014. That is 10 days longer on average than for the region not including Vermont.
  • At 6.34 percent of all drugs, Vermont prescribed opioids at a 22 percent higher rate than the average for the region not including Vermont in 2014 (note: VT was not the state with the highest rate in the region).
  • In 2014, doctors in Vermont wrote 11,000 more opioid scripts (82 percent of which were for the most abused opioids) to patients than the previous year – a 9 percent increase. The number of days for which doctors supplied patients with opioids increased an average of approximately one and a half days.

This analysis, along with the information already publicly available on Vermont Prescription Monitoring System (VPMS), gave the City concern that prescribing practices may remain an issue. UVM Medical Center agrees with the City that it is important to continue to focus on prescribing practices, and this is an area where continued work is needed. The UVM Medical Center has agreed to spend 90 days to create a new system in which there would greater public transparency and accountability about the hospital’s prescribing practices. The release of UVM Medical Center prescription data will allow an important public conversation about optimal prescription practices. The City and the UVM Medical Center will also work with other stakeholders to translate this progress into a new, statewide system.

“The University of Vermont Medical Center is committed to stemming the opioid addiction epidemic in Vermont,” said Stephen Leffler, MD, Chief Medical Officer, University of Vermont Medical Center. “We are engaged in both the Chittenden County Opioid Alliance and the City of Burlington’s CommStat effort. The UVM Medical Center has increased the number of providers who are prescribing Medication Assisted Treatment by nearly 50 physicians over the last year and a half, while reducing the amount of opioids we prescribe, but there is much more work to be done. Transparency is important when we are reforming complex systems, and we look forward to partnering with the City of Burlington on developing a process for reporting on our progress.”

4.      State agrees to release frequent reports of opioid-related deaths

As mentioned earlier, recently released Vermont Department of Health data revealed that opioid-related deaths rose from 76 in 2015 to an estimated 105 in 2016 – a 38 percent increase. At present, the Health Department releases statewide opioid death numbers quarterly, and county-level numbers annually. The Health Department soon will begin updating county-level data monthly.

“Supplying this county-level information more often may help everyone engaged in responding to the opioid crisis have a more complete picture of what’s happening on the ground,” said Vermont Health Commissioner Harry Chen, MD. “We stand with Burlington and the Chittenden County Opioid Alliance and will do whatever we can to strengthen our collective efforts.”

In addition, the City has a new agreement with the State’s Attorney’s Office regarding the weekly reporting of untimely deaths.

“I want to continue to grow and strengthen the programs the State’s Attorney’s Office currently has in place to address opioid addiction as a public health issue, and also to address public safety and reduce recidivism rates,” said Chittenden County State’s Attorney Sarah George. “My office can be helpful at an even earlier stage in the process. I have directed our deputies to track every overdose death we are called on so that I can review and analyze that data. This process will allow us to have weekly numbers on the likely number of overdose deaths in our county.”

Summary of recent, previously announced City of Burlington initiatives to address the opioid epidemic

In the fall of 2016, the City reorganized the BPD to treat the opioid epidemic as a public health crisis, hiring former social worker Jackie Corbally as the new BPD Opioid Policy Manager, and sharing the cost with the Chittenden County Opioid Alliance (CCOA) of a new Data Manager, Sam Francis-Fath, to help analyze and track opioid-related data. The BPD also has contributed significantly to the effort with its own analyst, Eric Fowler.

In November 2016, the City launched its CommunityStat effort to reverse the opioid crisis by approaching it as a public health challenge that requires collaboration and coordination of efforts among all the community stakeholders engaged in responding. Stakeholders include the Vermont Department of Health, Vermont Department of Children and Families, Vermont Department of Corrections, University of Vermont Medical Center, Community Health Centers of Burlington, the Chittenden County State’s Attorney’s Office, State Attorney General, the Community Justice Center, Howard Center, United Way, Turning Point Center, Steps to End Domestic Violence, Champlain Housing Trust, Burlington Housing Authority, King Street Center, Outright Vermont, Spectrum Youth & Family Services, and many more.

“I applaud the City of Burlington for developing a comprehensive approach to finding solutions for the opioid crisis that includes education, treatment, and law enforcement,” said St. Albans Mayor Liz Gamache, who has been facing similar opioid challenges in St. Albans. “Progress can be made by engaging both stakeholders and the community at large.”

BPD Medicare Prescription Data 2013-2014 Analysis

Executive Summary

Data

The Centers for Medicare and Medicaid Services’ ”Medicare provider utilization and payment data public use” file tracks prescriber practices for drug events incurred by individuals on Medicare Part D drug plans in calendar years 2013 and 2014, the most recent years this data is currently available. Those eligible for Medicare Part D include individuals over the age of 65, individuals under the age of 65 who have certain permanent disabilities, and individuals with end-stage renal disease.

Findings

The analysis of the Medicare data from 2013 and 2014 included the following major findings about opioid prescribing practices in Vermont:

1) In 2014, Vermont was an outlier when compared to the other five New England states in terms of unique opioid prescriptions per beneficiary (i.e. patient) and well above average for number of days an opioid was prescribed per beneficiary

a. At 3.2 scripts per patient, Vermont prescriber’s rates were 17% higher than the average rate for New England outside of Vermont (18% for most abused or diverted opioids)

b. At 69 days per beneficiary, Vermont doctors prescribed opioids 10 days longer on average than the rest of New England doctors

2) From 2013 to 2014, doctors increased the rate of opioids prescribed and the number of days they were supplied

a. Specifically, doctors prescribed 11,000 (9%) more opioid scripts in 2014 than 2013, 82% of which were for opioids identified as being the most abused1

b. Doctors also prescribed opioids for a day and a half longer on average in 2014

1 77% of the overall opioid sample were drugs identified as most abused opioids

3) A number of Vermont specialties prescribed opioids at statistically significantly higher rates than their New England peers in 2014. Some of those include:

a. Family Practice doctors in Vermont prescribed opioids at a rate per beneficiary that was 5% higher than their New England peers. They supplied the most abused opioids 4 days longer per patient on average than other New England doctors (a 6% higher rate)

b. Internal Medicine doctors in Vermont prescribed opioids at a rate per beneficiary that was 16% higher than their New England peers. They supplied opioids 4 days longer per patient on average than other New England doctors (an 11% higher rate)

c. Nurse Practitioners in Vermont prescribed opioids at a rate per beneficiary that was 13% higher than their New England peers. They supplied opioids 4 days longer per patient on average than other New England doctors (an 13% higher rate)

For several other specialties, the disparity in opioid prescriptions were much larger in terms of percent difference between Vermont’s rates and the average rate for the rest of New England. However, in

these cases, one or a very small number of outlying prescribers skewed the rate within their specialty, and therefore those results were not included here.

4) There are a number of doctors that fall at least 3 standard deviations above the mean for opioid prescription rate per beneficiary and are, by definition, statistical outliers. It will be important to take a closer look at these prescribers and to track their rates over time to determine if there is a reasonable explanation for why they prescribe opioids at such higher rates than their peers

Limitations & Implications of the Analysis

About 14% of insured individuals in Vermont have Medicare Part D plans. We cannot say for sure that the prescribing trends apparent in the federal Medicare data, which covers Medicare Part D beneficiaries, is representative of the prescribing practices to patients in Vermont overall. Regardless of this limitation, the findings of the analysis are important for two reasons: First, we find doctors in Vermont are over-prescribing opioids to Medicare Part D beneficiaries, the same concerning practices could be occurring within the larger universe of drug prescription. Second, regardless of the generalizability of the prescribing practices to Medicare Part D beneficiaries, if it is apparent that doctors in Vermont are over-prescribing opioids to people over the age of 65 and to those with permanent disabilities, these could be populations at a heightened risk for opioid addiction. Additionally, this finding would highlight the importance of transparency in public health care operations and would demand a deeper dive into prescribing practices to include other public insurance programs, such as Medicaid.

An additional limitation of the data is that it is only available through 2014. That we only have data as recent as 2014 when it is now 2017 demonstrates the need for the more timely collection and dissemination of information crucial to tracking trends in prescription practices that should have direct implications for public policy.

These two limitations underscore the importance of more inclusive and timely public health data releases. Providing more comprehensive public health prescribing practice data and at more frequent iterations while maintaining individual beneficiaries’ privacies is crucial. Beyond offering the public the level of transparency they deserve from the public health sector, such an effort would:

1) Generate public discourse about opioid prescribing practices in the state of Vermont and how such consequential public services are affecting community health, safety and quality of life

2) Give individual doctors and prescribers the opportunity to compare their practices to those of their peers and to make adjustments, if appropriate

3) Allow for the monitoring of progresses in prescribing practices over the course of months and years and encourage the examination of areas in need of attention and reform

Source: City of Burlington 2.16.2017