Game Changer: Pennsylvania’s Response to the Opioid Crisis

ROBERT JOHNSON:
This is Public Health Review, I'm Robert Johnson.

On this episode: Pennsylvania takes command of its drug overdose crisis with a plan to address every aspect of the problem, including medication assisted treatment for its incarcerated populations.

DR. RACHEL LEVINE:
The disaster declaration and the formation of the opioid command center has been a game changer. I think that this has increased dramatically our ability to collaborate, and we are making progress.

STEVEN SEITCHIK:
You know, we have the momentum building, we're headed down the right path; and that's what I keep telling myself when I hit these barriers, whether it's bureaucratic or not. We're on the right path, we're going to get there very, very soon.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we're focused on Pennsylvania's fine to slow the spread of drug overdose cases due to prescription opioids, heroin, and other narcotics.

We'll examine efforts to employ medication assisted treatment for those incarcerated in the state prison system. Our conversation with Steven Seitchik, the MAT statewide coordinator for Pennsylvania's Department of Corrections, is later.

But first, our interview with Dr. Rachel Levine, Pennsylvania secretary of health, on the coordinated plan to rescue people from drug addiction in her state.

LEVINE:
As you know, the opioid crisis is really the biggest public health crisis that we faced in Pennsylvania and in the nation. In Pennsylvania in 2017, we had over 5,400 overdose deaths. So, the governor actually issued in January of 2018 a disaster declaration, which has brought us together in what we call the opioid unified command center with 17 different agencies, all collaborating to address the opioid crisis in Pennsylvania. And of course that involves our health and human service agencies, as well as law enforcement—so, the Department of Corrections is there, the Pennsylvania state police, et cetera.

And so, we have three pillars for our response. The first is prevention. The second one is rescue with a medication naloxone. And the third is treatment. And for opioid use disorder for people suffering from the disease of addiction to opioids, the standard of care is evidence-based quality medication assisted treatment—which includes medication as well as counseling and therapy, as well as the case management. And that includes patients with the disease of addiction in urban areas, suburban areas, and rural areas, and also includes our Department of Corrections.

So many people we have found in the state prison system have the disease of opioid use disorder, of opioid addiction. And it's very important for them to get appropriate standard of care treatment, which will improve their health and improve their ability to function after they're released from prison.

JOHNSON:
And you're at the tip of the spear as it relates to the overall policy regardless of where the programs are carried out, I assume?

LEVINE:
So, well, yeah, the Department of Health is lead on the command center. But I like to emphasize the collaborative nature of the response. Governor Wolf has made this an absolute priority for the administration in our second term. And so, while the Department of Health is leading, the command center really is a cooperation among 17 different agencies, which is leading to our success.

JOHNSON:
The disaster declaration obviously clears the way for all of this work to happen. I assume it might've not been possible otherwise.

LEVINE: I think the disaster declaration and the formation of the opioid command center has been a game changer because we were collaborating beforehand but not as closely, especially with law enforcement. And we have many agencies have the table—military veterans affairs, education, labor and industry, insurance, et cetera. So, I think that this has increased dramatically our ability to collaborate, and we are making progress.

So, in 2018, our preliminary data on the Pennsylvania coroners is that we have started to bend the curve in terms of the amount of overdose deaths that we are seeing, and we expect a decrease in deaths in 2018 compared to 2017—and that would be the first time in five years.

So, we're still collecting data, but every aspect of this is important: the prevention aspect, the rescue aspect with the medication naloxone—and naloxone is absolutely essential, but it's not sufficient. We have to get people into treatment, and that means evidence-based quality medication assisted treatment throughout the state, including in the state prison system.

JOHNSON:
I wanted you to break down each one of those pillars with a little more detail as they roll out in this framework that you have there in Pennsylvania. Can you start with prevention and tell the rest of us what that looks like there?

LEVINE:
There are a number of different prevention efforts. For example, the Department of Drug and Alcohol Programs work very closely with the Department of Education on evidence-based, school-based programs. In addition, there are many community-based programs for prevention.

What my work has emphasized is working with the medical community to learn to prescribe opioid pain medication more carefully and judiciously. And the term that I like to use for that is opioid stewardship, opioid stewardship. And so we have developed with the deans of all the medical schools of the state a set of core competencies for every graduating medical student on these issues. We have continuing education modules for physicians and other medical providers that are now actually required for our license.

We have developed 11 prescribing guidelines that are synergistic with the CDC 2016 guidelines. Ours include pediatric guidelines, geriatric guidelines, acute care guidelines, chronic non-cancer pain guidelines, et cetera. They all have been taken to their medical board and other professional boards for their consideration and affirmation so they establish a voluntary standard of care.

And then finally, we have a very robust prescription drug monitoring program, which was established in August 2016.

With all of those programs, we have decreased opioid prescriptions 25% in less than three years, which is very successful. But we're not stopping at all. We need to continue those efforts, to work with the medical community to limit the prescription of these very powerful medicines.

The next pillar is rescue, and that involves the medication naloxone. Naloxone is not new to medical care—we've used it in hospitals and ICUs for decades—but this community use of naloxone, also known as Narcan, is rather new. So, actually in 2015, I signed two standing order prescriptions as the state health official. I signed a standing order prescription for first responders to have naloxone, like EMS and police, as well as a standing order prescription for anyone to obtain naloxone from a pharmacy based upon my prescription—I wrote a prescription for the state.

Since we've done that, we have had tens of thousands of saves and rescues with this medication, primarily the intra-nasal naloxone. For instance, in the last 15 months, EMF has had over 18,000–19,000 rescues, police in the last four to five years have 10,000 rescues. And so, it is so important to save people's lives with this medication.

Naloxone is necessary, absolutely necessary, but it's not sufficient. We then have to get people into treatment. And so that's our, you know, enters our third pillar. And so, that would include a warm handoff to treatment. And we developed a set of warm handoff clinical pathways for emergency departments to use with the county drug and alcohol authorities to get people into treatment.

And finally, you know, the topic of the day here, we have expanded access to quality evidence-based medication assisted treatment throughout the state. That includes 45 centers of excellence for patients predominantly with Medicaid throughout the state, and then eight programs called PacMAT—PacMAT, Pennsylvania Coordinator Medication Assisted Treatment. And this is a hub-and-spokes model with the hub being addiction medicine specialist team, and then the spokes being health systems, primary care network. And we have to establish those in Philly and Pittsburgh and throughout the state. And so, the idea is to layer the state—urban areas, suburban areas, and rural areas—with the opportunity for patients to obtain medication assisted treatment with counseling, with case management. And that's what evidence suggests will lead to the best outcome.

You know, we have to get past the stigma associated with addiction. Addiction was called a chronic relapsing brain disease by the surgeon general, its a medical condition. And we have to get past the stigma about recovery with medication assisted treatment, that somehow that is not a true recovery. You know, in medicine we use lots of medicine. The recovery with medicine is exactly that—it's a recovery with medicine. Again, we also have counseling and with case management and wraparound services. And so, we're making progress, but we're staying laser focused.

JOHNSON:
On this podcast, we like to provide people in public health the opportunity to look for new approaches, to get ideas they can follow up on.

Of all of the things you're doing in Pennsylvania—and the list is long—how much of that would qualify as original thinking versus thinking that you have adopted from other places? Is there a way to quantify that?

LEVINE:
I don't know if I can quantify that. I think that we are built upon work that we have originated as well as work in other states to develop our program. And I must comment that we have had robust funding from SAMHSA, and Health and Human Services, CDC to accomplish this with the STR grants and SOAR grants as well as the CDC grant.

So, you know, I like to emphasize the collaboration. It is essential for us to work with our counties and our communities, for our state agencies to work together, for us to work with the legislature—this is a completely nonpartisan issue. But we work with other states every week we talk with—through ASTHO, through the National Governors Association, to other associations we have. We're constantly talking with other state, as well as the federal government in terms of coordinating our response.

So, I would emphasize the collaboration. I'll give you an example. So, Vermont and Rhode Island have had hub and spokes models; but Pennsylvania, it's a much bigger state than those states—we have much bigger cities and we're much more spread out. So, we are not the first state to develop a hub and spokes model, but we were the first state to expand it as we did.

JOHNSON:
Tell us what your command center looks like. Is it staffed around the clock or is it more virtual?

LEVINE:
The command center is part public health preparedness. Public health preparedness office is at the preparedness building, the Pennsylvania emergency management association building. And we have our own office for the command center, and it is staffed Monday through Friday, nine to five in the office. But then, we have staff that are watching trends all the time so we can do what's called an epi alert. If we see through syndromic surveillance that there is a cluster of overdoses in the county, then actually 24/7 we can put out in an alert that a certain county in Pennsylvania is having a cluster. And then we will automatically call the stakeholders in that community—so, that includes the police, that includes the single county authority, the drug and alcohol authority for the county, that can include the EMS for the county and the hospitals for the county. We're both staffed, you know, in an office as well as 24/7 virtually.

The 17 different agencies meet every week at the command center where we work to coordinate our care. There are many phone calls coordinating things during the week. And this is all done, you know, under the leadership of our governor, Governor Wolf, and the governor's office. So, it really has been a unique opportunity and it's such a progressive program to address the opioid crisis. And we are making progress, but we're not done. We're not declaring victory, and we're going to continue our efforts.

JOHNSON:
Is there a sunset on your disaster declaration or does it continue indefinitely?

LEVINE:
Well, they are 90 days in length—and so we're actually operating under the sixth disaster declaration—and we plan to continue those. We are working with the legislature for the secretary of health—myself—or the governor to be able to declare a public health emergency, which might be a slightly more targeted response. But that actually—that mechanism doesn't exist in Pennsylvania. So, we've gone this route of the disaster declaration and we just continue them every 90 days. I mean, we will continue to do that until it's not necessary—but, you know, it's still necessary now.

JOHNSON:
It seems you have enjoyed across the board support at every level, every juncture. Can you talk about that lift? What was involved there? What did it take? Are you satisfied with how it's all played out?

LEVINE:
Yeah, but it didn't just happen. So, Governor Wolf was elected in November of 2014. He took office in January of 2015; and after he was sworn in and we were all sworn in, the next day it was our first meeting about opioids. And so, it was really the first thing that we talked about in terms of coordinating things, but it was new at that point. And so, we knew we had to collaborate, but we had to develop those relationships. We had to develop the relationships with the counties and the communities and other important stakeholders, work on our relationships with other states, work on the relationships between public health and public safety and law enforcement.

So, it didn't just happen. That has taken, you know, time to develop those working relationships to lead to the collaboration that we have now.

JOHNSON:
Is there anything about your program that is yet to roll out? Is there something you could tease us with that might be coming that we could look forward to as you continue to do this good work?

LEVINE:
Sure. So, we are continuing, of course, to receive robust federal funding.

So, this year we have a housing initiative to try to help people suffering from the disease of opioid use disorder, of opioid addiction, in terms of their housing. We are working on workforce development in terms of substance abuse counselors and peer counselors, et cetera. We're continuing to roll out the PacMAT, that treatment program. We continue to roll out naloxone to first responders, but we've also had a naloxone day where we handed out 6,100 kits of naloxone to the public, and we plan to repeat that. We continue to develop new prevention guidelines and update our continuing education and our medical school competencies.

We are going to develop actually—which will be brand new—a patient advocacy program as part of the PDMP so that patients who feel that they are being somehow abandoned by doctors, or maybe their doctor left and they can't get their medicine. I mean, those patients are at risk of going to the black market and getting, you know, potentially heroin or even fentanyl compounds. So we're working on developing, you know, a call center for a patient advocacy program.

What we've learned in Pennsylvania—and what was actually in the news the last day or so—was the risk of other drugs. So, this is an ever changing landscape: you know, that the overdose crisis started with prescription drugs; and then the influx of cheap, powerful, and plentiful heroin; and then the last two years or three years, the influx of synthetic fentanyl analogs, which are, you know, 50 to 100 times more powerful and lead to so much overdose and death.

What we're seeing now are stimulants such as amphetamines, methamphetamine and cocaine, and—not infrequently—methamphetamine and cocaine that is laced or contaminated with fentanyl. So, you can see the risk of overdose and death with this ever changing landscape.

So, you know, as the landscape changes, our response will evolve and our opioid command center is the perfect vehicle for which to do that.

JOHNSON:
This isn't just a government initiative, though. What's been the role of PA's private sector?

LEVINE:
Well, we have very robust stakeholder involvement with the command center. So, we have brought in community stakeholders almost every meeting of the command center. We have done command center in the community where we've gone out on the road throughout Pennsylvania and worked with community stakeholders.

We actually have some specific programs—so the collaboration with the academic medicine in the University of Pittsburgh school of public health, the University of Pittsburgh pharmacy school, Penn State College of Medicine, Penn State University, as well. So, we understand the importance of working with the counties of the communities as well as our outstanding academic institutions.

We do have an excellent data dashboard. So, if go to PA opioid data dashboard to the governor's open platform website, you can see the statistics and evidence of what we were doing. And then this summer, we're going to roll out data dashboard 2.0 with a generous grant from the Aetna Foundation and collaboration of the University of Pittsburgh's school of public health.

JOHNSON:
You're a medical doctor, I think—right?

LEVINE:
I am.

JOHNSON:
Right now, how does all of this work make you feel now that you're in public health? How does it make you feel when you look at those numbers and you see them coming down?

LEVINE:
Well, it's very rewarding. You know, so my previous field was in academic medicine at the Penn State College of Medicine and Penn State Hershey Medical Center. And my field was adolescent medicine, treating troubled teens and young adults and their families.

And so, what has always interested me is that interface between medical issues and behavioral health issues. So, I was well-prepared to work and collaborate on addressing the opioid crisis, which really is a interface between medical issues and behavioral health and mental health issues. And so, you know, all, I felt that all I did at Penn State Hershey was trying to help people. I would see patients and try to help them, teach, do clinical research, develop programs to help people that we were seeing.

And so here in public health, this is the tremendous opportunity to do that with a broader public health brush, and a perfect example is our work on the opioid crisis. But it's so important to understand that, even though we're seeing progress, that we are not done in any way.

JOHNSON:
A part of this strategy involves the work Steven Seitchik is doing with people entering and leaving the Pennsylvania prison system. Himself having overcome drug addiction, Seitchik has been working since 2016 to help state inmates recover with the aid of an evidence-based treatment program.

SEITCHIK:
Well, unfortunately the prison system—whether it's the county or the state system—has turned into a situation where so many of these individuals that are dealing with addiction problems, they are going to end up many times in the ER, or they're going to end up in jail, whether that's county jail or ultimately in state prison.

And the system was never really set up to be able to do it in that manner—obviously, you want to have medical professionals dealing with medical conditions. But that's where the problem here lies, is that we do have a medical condition, a chronic relapsing brain disease.

JOHNSON:
Seitchik says his program is simple and based on science.

SEITCHIK:
I'm not making anything up, I'm just using data. People talk about data-driven management—well, it's not that hard. There's a lot of science out there and that data is what can drive your programming, and that's really what we're just doing here. I'm just taking science and then implementing the results.

JOHNSON:
The program launched three years ago, and so far Seitchik says it's been reaching more and more people ever since.

SEITCHIK:
In 2016—to give you an idea, in 2016, we ended up at the end of the year having 78 participants get vivitrol injection prior to release. Prior to me coming on board, I think we had about 20 participants between 2014 and 2016. So, I come on board in March of 2016; we're getting, you know, 78 injections. For the next year, we had 494 individuals getting an injection of vivitrol prior to release. And then in 2018, that number went up to 748 individuals. So, the trend obviously is going up and up as we've expanded to all 25 of the institutions.

So over the last three years, we've gone from vivitrol being available at one, to two, then three, and five, and 10, and now all 25 can give vivitrol. And the goal is that I have all 25 doing the other forms of MAT as well.

JOHNSON:
Overcoming stigma attached to the notion of using drugs to treat people with drug addictions hasn't been easy; but Seitchik notes the support from Pennsylvania's leadership has made the difference for his program.

SEITCHIK:
If I didn't have their support and leadership, I probably wouldn't have any programming to offer, because I wouldn't have Medicaid expansion—that, we didn't have that prior. So, I would have nothing, actually. I wouldn't be getting much anywhere.

It's amazing that that's not the case, that with new leadership comes new direction and following science, following where the evidence takes you. And we have that right now, fortunately. Hopefully it will stay that way.

JOHNSON:
Seitchik wants to be available to help others with their questions about starting their own program, noting he had support from a local law enforcement officer when he was first working to design Pennsylvania's plan.

SEITCHIK:
They can always contact me whenever they, you know, want to just shoot some ideas or just get what have we seen here in Pennsylvania. I've already dealt with a lot of other states—I enjoy that. I got help from Barnstable County—Barnstable County and the Barnstable County sheriff out there does vivitrol. They helped me out when I first started. And I remember when Barnestable was so awesome, I said to my guy, "If there anyone who needs any help, I will do anything I can to help them because Barnstable just made my life so much easier."

JOHNSON:
Links to Pennsylvania's strategy and its MAT program can be found in the show notes.

Thanks for listening to Public Health Review.

If you like the show, please share it with your colleagues. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.