The Opioid Crisis:

Chicago Public Health Response

Elizabeth Salisbury-Afshar, MD, MPH, FAAFP, FASAM, FACPM

Medical Director of Behavioral Health
April 12, 2018
 Goals
• Chicago Framework for
Addressing Opioid Crisis
• Epidemiology of the Opioid Crisis
in Chicago
• Public Health Interventions
• Task Force on Heroin
convened in 2016
• Experts and stakeholders
gave input
• Recommendations in 6
areas:
– Data
– Community Education
– Provider Education
– Treatment
– Overdose Reversal
– Trafficking
EPIDEMIOLOGY OF THE OPIOID
CRISIS IN CHICAGO
U.S. state opioid prescribing rates,
2016

Retail opioid
prescriptions dispensed
per 100 persons

IL: 56.8
(Highest Arkansas: 114.6)
https://www.cdc.gov/drugoverdose/maps/rxstate2016.html
Retail opioid prescriptions dispensed per 100
persons, by county—U.S. 2016

Regional and hyper-local variation: some counties

have prescribing rates 7 times the national rate
https://www.cdc.gov/drugoverdose/maps/rxcounty2016.html
 Illinois opioid prescribing rates, by
county, 2016
National prescribing rate:
66.5 per 100 persons Retail opioid
prescriptions dispensed
per 100 persons
Illinois prescribing rate:
56.8 per 100 persons

Cook County prescribing

rate: 41.3 per 100 persons

https://www.cdc.gov/drugoverdose/maps/rxcounty2016.html
Rates of Drug Overdose Deaths, 2016

Age-adjust overdose death rate in US= 19.8

Age-adjusted overdose death rate in IL= 18.6
Source: CDC website
Significant Increase in OD Death Rate
from 2015-2016

IL saw a 34% increase in drug overdose deaths in one year

Source: CDC website
Overdose Deaths Involving Opioids,
by Type of Opioid 2000-2016

Source: CDC website

 Opioid Overdose Deaths
2015 and 2016
30
Age-adjusted rate per 100,000

26.7
25

20
14.7 15.5
15 13.3
10.4 10.7
10

0
2015 2016
US Illinois Chicago

Chicago saw a 74% increase in opioid overdose death

rate in one year
Epidemiology Report: Increase in overdose deaths involving opioids, Chicago 2015-2016
Chicago Opioid-Related Overdose
Deaths- 2015 and 2016
30
26.7
Age-adjusted rate per 100,000

25
2015 2016
20
17.7
15.5 15.1
15
12.4

10

5
2.7
1.4 1.8
1.1 1.0
0
i ii
All opioids Heroin Fentanyl Opioid pain Methadone
reliever

Data Source: Cook County Medical Examiner’s Office, US Census Bureau

Note: Numbers include all opioid-related overdose deaths that occurred in Chicago, regardless of decedent’s address of residence.
i The Cook County Medical Examiner’s office began routinely testing for fentanyl involvement in June 2015. For this reason, the number of fentanyl-involved overdose deaths in 2015

my be higher than reported.

ii Opioid pain reliever: buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, oxymorphone, or tramadol.

Epidemiology Report: Increase in overdose deaths involving opioids, Chicago 2015-2016

 Chicago Opioid Overdose Death
Rate by Age, 2015-2016
80

70

60

50
Rate per 100,000

40

30

20

10

0
15-24 25-34 35-44 45-54 55-64 65-74
Age range in years
2015 2016

Data reported in: Epidemiology Report: Increase in overdose deaths involving opioids, Chicago 2015-2016
 Chicago Opioid-Related Overdose
Deaths by Gender- 2016
45
40.8
40
All Opioids
35 Heroin
Fentanyl
30
Opioid Pain Relievers 27.1
24.4
25 Methadone

20

15 13.3

10 8.7
6.3
5
1.3 1.5 1.5 2

0
Female Male

Data reported in: Epidemiology Report: Increase in overdose deaths involving opioids, Chicago 2015-2016
Opioid-related overdose death rates
by race-ethnicity & opioid type, 2016

Epidemiology Report: Increase in overdose deaths involving opioids, Chicago 2015-2016

 Overdose Deaths in Chicago- 2016

Data Source: Cook County Medical Examiner. Community area overdose death rates are crude rates. Deaths are geocoded to location of incident.
Location of 12 deaths could not be accurately identified.

Epidemiology Report: Increase in overdose deaths involving opioids, Chicago 2015-2016

 Takeaways:
• Opioid overdose mortality rates continue to increase
nationally and locally
• Significant variations in prescribing practices, drug
availability, and overdose death trends
• In Chicago, illicit substances account for majority of
the mortality burden with the highest rates of
overdose among 45-64 year old African American
men
• Understanding local trends can help craft more
strategic interventions
COMMUNITY EDUCATION
OvercomeOpioids.org
 OvercomeOpioids.Org

• Understand->
– General information about opioids
– Signs of opioid use disorder
– What is an opioid overdose/risk factors
• Prevent->
– Medication disposal sites
– Overdose prevention tips
 OvercomeOpioids.Org

• Respond->
– Signs of an opioid overdose
– How/where to get naloxone
– Legal protections in Illinois around naloxone
(Good Samaritan Act)
– Handouts on how to use naloxone in English and
Spanish
• Recover->
– Explains treatment options
– Local treatment finder
Naloxone Handouts
Naloxone Posters
ChicagoConnects.org
 Dissemination of Resources

• Community Health Worker Project

• Educational Events for Providers
PROVIDER EDUCATION
 Medical Provider Education
• Areas of focus:
– Opioid stewardship in context of pain
management
• Promotion of CDC Prescribing Guidelines and the use of
IL Prescription Monitoring Program
• Co-prescribing of Naloxone
– Identification and Treatment of Opioid Use
Disorder
• Buprenorphine Waiver Trainings
• MAT Learning Collaborative
• In 2017, CDPH provided 40 trainings to over
1,700 health professionals
IL Prescription Monitoring Program

• State legislation now mandates:

– Anyone with a controlled substance license has to
obtain a login for PMP at time of renewing license
– Provider must check PMP (and document it was
checked) at time of prescribing a new Schedule II
substance
• Exemptions include oncology treatment, palliative care,
ER provider prescribing 7 days or less
Provider Education Around Opioid
Use Disorder Treatment
• Most medical providers receive little to no
education on addiction or addiction treatment
• Most medical providers report challenges in
knowing where to refer people who need
treatment
– ChicagoConnects.org
– State Help line (also new)
 Buprenorphine Waiver Trainings
• Physicians, Nurse Practitioners, and Physicians
Assistants can prescribe buprenorphine for
opioid use disorder treatment if they have
completed a mandatory training
– 10,246 licensed physicians in Chicago
• 329 providers (including NP and PA) with a
buprenorphine waiver*
• 168 (1/2) of waivered providers wrote at least one Rx in
past year*
• CDPH hosts free buprenorphine waiver
trainings every 2-3 months
*Sources: IL Dept of Financial and Professional Regulation, SAMHSA, and ILPMP, as of October 2017
 Training and Technical Assistance
Around Medication Assisted Treatment
• CDPH developed a learning collaborative to
facilitate knowledge sharing across safety net
health systems who are new to MAT
– Learning collaborative was developed based on
feedback from group of health centers who had
received grants to provide such services
– Two tracks: “decision maker track” and “provider
track”
– 13 health systems are participating and feedback
has been positive
EXPANDING ACCESS TO TREATMENT
 Addiction Treatment in Chicago
• Federal Dollars (State Targeted Response) are
awarded to the IL Single State Agency (DASA) who
distributes dollars to many treatment programs,
including many treatment programs in Chicago
• Illinois is a Medicaid expansion state and addiction
treatment services are covered by Medicaid
• City of Chicago invests additional dollars – primarily
cover costs of uninsured and underinsured clients;
some cover costs of services not reimbursable by
Medicaid (for example recovery home services)
 City Investments in Addiction
Treatment in Chicago
• 2016- City invested $1.5 million/year in prevention and
treatment services (across continuum and for all substances)
• 2017- City invested an additional $700,000/year for
Medication Assisted Treatment (MAT) for Opioid Use Disorder
(OUD)
– Reached over 1,000 individuals
– Focus on communities with highest rates of OD
• 2018-> City invested an additional $500,000/year for MAT for
OUD and recovery home services
– Anticipated to reach 500 individuals
– Focus on communities with highest rates of OD
 Training For Addiction Treatment
Providers
• Many addiction treatment providers do not
offer MAT for OUD
• We have provided and partnered with other
agencies to provide education on the
effectiveness of MAT for OUD
• All delegate agencies (agencies we fund) have
participated in mandatory trainings on MAT
and naloxone
OVERDOSE REVERSAL/NALOXONE
DISTRIBUTION
 Overdose Prevention & Naloxone
Distribution
• Starting in 2016, City has invested $250,000
annually for overdose prevention education
and naloxone distribution
• In 2018, City invested an additional $225,000
for a peer health worker project that will pay
individuals to train community members on
identifying and responding to overdose and
distributing naloxone
– Focus is on reaching communities with highest
rates of overdose
Naloxone Access and Protections in IL

• IL Drug Overdose Prevention Program (DOPP)

– Allows agencies register with state to be allowed
to train and dispense naloxone
• IL Heroin Crisis Act of 2015:
– Required that Medicaid (and all MCOs) cover
naloxone
– Allows pharmacists who have completed training
to dispense it without an Rx
Elizabeth.SalisburyAfshar@cityofchicago.org

@ChiPublicHealth /ChicagoPublicHealth

HealthyChicago@CityofChicago.org www.CityofChicago.org/Health