INDIANA DRUG PREVENTION, TREATMENT AND ENFORCEMENT PRELIMINARY ACTION STEPS MAY 18, 2017 Since January 2017, the Executive Director for Drug Prevention, Treatment, and Enforcement has undertaken an evaluation of the problems, issues and efforts surrounding Indiana’s drug epidemic. In conjunction with the Strategic Approach to Addressing Substance Abuse in Indiana, this document outlines initial action steps that align with strategic goals. It also describes programs or activities that are already underway in state agencies. This will serve as a living document to monitor priorities, implementation and new actions, and will be updated regularly. Strategy Actions 1. Reduce the incidence of substance use disorder a. Reduce the number of people who start using an addictive substance i. Encourage the use of alternative pain management treatments and therapies and hospital-driven postoperative pain management protocols. ii. Support improved, relevant education and training of prescribers and patients regarding pain medications and potential for addiction.  With providers and their professional associations, design alternative pain management protocols  Encourage schools of medicine, dentistry, and nursing to update curricula on safe and effective treatment of pain, safe prescribing practices and on recognizing patients who are at risk for becoming addicted Add continuing education requirements for opioid prescribers Educate patients about the dangers of opioid misuse The Indiana State Department of Health (ISDH) will develop a webinar for dentists on appropriate prescribing    iii. Develop and implement a multi-year public awareness and education campaign regarding stigma, addiction, and recovery.   iv. Increase awareness of high Adverse Childhood Experience (ACE) scores as a risk factor, along with other risk and protective factors.     v. Identify and support the implementation of ageappropriate evidence-based addictive substance use and misuse prevention programs for children and youth. Encourage school-based programs that support positive peer relationships and social competence and evidence-based family strengthening  The Division of Mental Health and Addiction (DMHA) will develop a public awareness, anti-stigma campaign, using funds from the recently awarded Cures Act grant. Implementation is expected by Dec. 1, 2017 Explore the use of public service announcements to create more awareness of opioid and heroin addiction dangers Department of Child Services will apply for a regional partnership grant by June 30. Grant funds (up to $600,000 annually) for up to 5 years will be awarded to regional partnerships that provide interagency collaboration and integration of programs, activities and services that are designed to increase the well-being of, improve permanency outcomes for, and enhance the safety of children who are in out-of-home placements or are at risk of entering out-of-home placements as a result of a parent's or caretaker's substance abuse Seek ways to help organizations fund staff to work with atrisk addicted pregnant women and addicted mothers and their children to build trust, monitor progress, provide life skills and education and link them to other services Encourage pregnant women with substance use disorder (SUD) to seek health care services early during pregnancy and through the birth of their children Encourage maternity care providers to identify and refer for treatment patients with substance use disorders The Division of Mental Health and Addiction will award grants to providers to implement prevention strategies designed to meet local issues and reduce substance use. Grants will be available via request for proposal by Aug. 15 2 5/18/2017 programs. Monitor rates of alcohol and drug use among persons under age 18.    vi. Encourage increased opportunities (e.g. after-school, education, training, employment) - especially for highrisk populations and in high-risk areas. vii. Promote healthy families.        b. Reduce the number of persons who become addicted to a legally prescribed substance. i. Encourage implementation across disciplines throughout the state of new evidence-informed prescribing practices that reduce the duration and number of doses of opioid pain medication.   Consider ways to expand or replicate effective programs such as Youth First, Youth Assistance Program, or others that support at-risk students and families Encourage schools, daycares and early childhood education providers to identify at-risk children and refer families for support services Explore ways to increase availability of evidence-based programs such as Life Skills Training and Family Strengthening Explore expansion of opportunities provided by or through Boys and Girls Clubs, YMCAs, other youth-serving organizations and Purdue Extension Promote maternal and early childhood health programs Prioritize pregnant women for screening and access to treatment Use Women, Infants and Children offices as touch points for addiction resources and referrals Explore expanding services provided by Purdue Extension Expand education for grandparents, other family members and foster families who are granted custody of children in drug-related DCS cases Encourage family members of persons with substance use disorder to seek support services Encourage prescribers to follow Centers for Disease Control and Prevention (CDC) and Indiana State Department of Health prescribing guidelines for opioids Enforce limits to opioid prescriptions for first-time use, prescriptions to minors, and partial filling of prescriptions 3 5/18/2017  ii. Encourage education and awareness efforts regarding safe use of legally prescribed substances. iii. Continue to make INSPECT, Indiana’s prescription monitoring program (PDMP) more user-friendly and integrate it with electronic health record (EHR) systems. Support initiatives that encourage integration with all Indiana hospital systems, health information exchanges (HIE) and pharmacy dispensing software (PDS) systems. Encourage the use of INSPECT to inform clinical decision-making and support interventions with patients who may be abusing or misusing prescription medications contributing to the overdose epidemic. iv. Encourage and support increased availability and awareness of “take back” opportunities.       c. Reduce the supply of illicit drugs i. Support and encourage targeted law enforcement work focused on the supply chain for illicit substances, including interdiction efforts, reducing the drug supply chain, reducing impaired driving and pharmacy robberies.  Ensure the Medical Licensing Board engages in rulemaking identifying limited conditions warranting exception to the seven-day limit on first prescriptions (SEA 226) Provide pharmacists with information that may assist patients who may be misusing prescription pain medication Through Cures Act grant funding and in partnership with the Professional Licensing Agency, DMHA will make funding available to support the “push” from INSPECT to office based providers. An MOU is being developed to make this funding available to the Professional Licensing Agency. Funding is anticipated to be available for providers starting July 1 Use INSPECT data to provide better metrics to providers and law enforcement Direct the Professional Licensing Agency (PLA) to begin collecting prescribing data by physician specialty State agencies will partner to offer more frequent and aggressive takeback programs in Indiana communities Consider placing permanent drop boxes in secure locations in communities so residents may dispose of needles and medication. Explore the use of state police posts as initial sites for such locations Indiana State Police (ISP) will form all crimes policing teams in 13 districts by June 1. Each team will participate in an advanced all crimes policing course by Aug. 1 and be fully engaged by Sept. 1 4 5/18/2017 ii. Support realignment of state law enforcement resources, as necessary, to better detect, disrupt, and dismantle drug trafficking organizations. iii. Assist in coordination of efforts with local, state, and federal agencies, including coordinated approaches with neighboring states.  ISP will work with PLA to better utilize INSPECT as a tool for fighting the opioid epidemic  Educate and improve the understanding of substance use disorders among ISP personnel. Ensure that education is based on evidence-based data on drug abuse, treatment and recovery options, and utilize a multi-discipline approach to combating abuse  Expand use of electronic surveillance in drug trafficking investigations  Develop protocol for responding to overdose/overdose death investigations; if illegal drug use was the cause, seek to identify supplier of illegal drug for prosecution  Empower ISP District Command personnel to mobilize troopers to respond to criminal activity in specific locations for limited periods of time to address crime surges Indiana State Police initiatives  Identify drug trafficking routes and encourage use of multiagency interdiction teams to effectively address importation of dangerous drugs  Identify and dismantle controlled substances being manufactured within the state  Use INSPECT data and other information to identify illegal prescribing or diversion of prescription medications  ISP will disseminate information to the public about drug dangers and treatment as needed  ISP will coordinate with the Drug Enforcement Administration on educational prevention programs  ISP will coordinate with the Department of Education regarding ways to educate students about drug abuse  ISP will seek to better understand Problem Solving Courts and identify individuals who may benefit from such courts 5 5/18/2017   ISP will collect and disseminate, to the fullest extent permitted by laws and regulations, all relevant data to stakeholders involved in combating drug abuse within the state Coordinate efforts with the Regional Judicial Opioid Initiative 2. Reduce additional harm that can result from substance abuse a. Increase survival rate of those who overdose i. Expand access to and training in use of naloxone.    ii. Strive to connect those who overdose with treatment as soon as possible.   b. Encourage increased accessibility for persons addicted to intravenous drug use to syringe services programs to reduce the spread of infectious diseases such as HIV and HCV and to provide treatment information. Where possible, syringe services programs should be located close to treatment centers, and it is important that those who use such programs be able to do so without stigma or fear of arrest or prosecution.   Ensure adequate access to naloxone Create a centralized state naloxone procurement and distribution system Partner with organizations such as Overdose Lifeline to ensure naloxone use training and education Peer recovery coaches will be hired in hospital emergency departments in high-risk areas of the state through Cures Act grant funding. A request for proposals will be published July 1 with hiring beginning in October Encourage local communities to implement Angel programs, which allow drug users to enter police stations to seek help getting treatment without retribution Partner with nonprofit and other organizations to provide education about safe needle use, exchanges and referrals for assistance ISDH will review best practices in counties with syringe exchange programs and offer education to those considering establishing such a program 6 5/18/2017 3. Improve treatment of persons with SUD a. Intervene as early as possible, ideally connecting individuals to treatment no later than the time of first arrest, first overdose, or first expression of a desire for help. i. When treatment is not immediately available, encourage and support services that connect persons to a counselor/coach/other caring person who will stay in close touch with the individual at least until treatment is available. ii. Encourage and support initiatives that provide counselors in emergency departments to establish a relationship with persons who have overdosed and work to get them into treatment, or, where possible, begin treatment on-site.   Implement mobile addiction treatment teams Encourage replication of crisis response teams, such as those provided by Interact for Health  Peer recovery coaches will be hired in hospital emergency departments in high-risk areas of the state with funding through the Cures Act grant. A request for proposal will be published July 1 with hiring beginning in October Identify models for emergency room intervention, such as Project Point at Eskenazi Health Work with emergency rooms to increase treatment on-site and develop hospital-based intervention programs Monitor the implementation of the pilot program “Open Beds” in central Indiana, led by the MESH Coalition. The initiative will work to create a single network of available inpatient beds, outpatient programs and social resources    b. Greatly improve access to effective, affordable treatment, with a preference for medication-assisted treatment (MAT) i. Add and/or expand treatment programs.   Identify treatment gaps throughout the state Pursue next steps for programs authorized by the General Assembly, including SEA 446, SEA 243, SEA 510 and SEA 499, 7 5/18/2017     ii. Obtain waiver to enable Medicaid to pay for residential treatment and recovery supports for SUD.  iii. Seek ways to augment the professional addiction treatment workforce, including increased use of trained paramedics, EMS workers, and peer recovery coaches. 1. Support development of a program to train paramedics to provide follow up services for persons with SUD who have been released from treatment and who live in underserved areas. 2. Explore increased training and licensure of recovery coaches.     subject to the approval of the Indiana Commission to Combat Drug Abuse. Implement programs made possible by Cures Act grant funds to expand detox/treatment programs. Take steps to increase medication-assisted SUD treatment by Community Mental Health Centers (CMHCs) 1. Ensure that CMHCs are using evidence-based practices in the treatment of opioid addiction 2. Hold CMHCs accountable for outcomes and treatment protocols Increase the number of sober living options available for persons in recovery The Family and Social Services Administration will use ECHO (Extension for Community Health Outcomes) webinars to provide training and support for Medication -Assisted Treatment (MAT) providers The state has submitted a 1115 SUD waiver through the Healthy Indiana Plan for addiction services and communitybased recovery supports. If approved, anticipated implementation is Feb. 1, 2018. The waiver could result in $60 million in additional funding Increase training of paramedics to enable them to move beyond emergency intervention and provide additional assistance for people with SUD Partner with higher education institutions to encourage behavioral health program graduates to stay in Indiana Improve training for providers who do not currently treat patients with mental illness or substance use disorder Partner with institutions of higher education to consider additional funding to create more residency or fellowship positions for addiction psychiatrists 8 5/18/2017 3. Review licensing requirements and payment policies based on licensure to determine if changes in public policy are needed.     iv. Develop one or more pilot “hub and spokes” networks to provide a full array of services for a multi-county region. Rigorously evaluate and replicate positive and promising practices that fit the assets and needs of communities and their residents. v. Encourage and support increased use of drug courts, diversion programs, and evidence-based treatment options for offenders with SUD. Identify, and seek to replicate, innovative practices being developed and used by local courts and local jails. vi. Encourage and support expansion and improvement of substance abuse treatment services within the corrections system, particularly at the time of entry.  Consider a loan forgiveness program to attract more qualified providers Enhance provider education. Develop plan for more training in addictions for health care providers. Recovery coach training through the Family and Social Services Administration is part of the training available for certified recovery specialists (peers) The Indiana Office of Medicaid Policy and Planning is building a mechanism for global reimbursement for community health workers. Anticipated implementation is early 2018 TBD  Provide opportunities for judges to learn more about SUD and treatment  Continue collaboration with the judicial branch to encourage expansion of drug courts, diversion programs, and re-entry programs Department of Correction initiatives  The Indiana Department of Correction (DOC) will participate in a National Governors Association program to develop strategies to expand access to opioid use disorder treatment for justice-involved populations  Better screen for addiction of all new DOC offenders to evaluate need for therapeutic treatment while incarcerated; improve treatment planning  Expand Therapeutic Community Program and Outpatient Treatment Program 9 5/18/2017         vii. Encourage and support stronger relationships between drug courts and corrections with community mental health centers or other addiction treatment providers to enhance the potential for successful reentry into the community and reduce recidivism and the frequency of relapses. viii. Support community-based recovery and long term wrap-around services, including recovery housing, to help persons in recovery become or return to being productive, contributing members of their communities. Seek to eliminate punitive policies that terminate services for people who relapse.      Seek to expand use of Medication-Assisted Treatment Expand access to emergency naloxone kits in DOC facilities Expand treatment and re-entry services in county jails housing offenders Better align addiction and mental illness treatment services Seek to reduce importation of illicit drugs and other substances into the Department of Correction Provide educational information on substance abuse and recovery at all facilities using multiple means of dissemination (TV, written materials, classroom/teaching) Evaluate and expand, or re-direct, if warranted, the Vivitrol pilot program Work to improve community-based treatment and resources for those re-entering society TBD The state has submitted a 1115 SUD waiver through the Healthy Indiana Plan for addiction services and communitybased recovery supports. If approved, anticipated implementation is Feb. 1, 2018. The waiver could result in $60 million in additional funding DOC will provide educational and vocational opportunities to better prepare offenders to obtain employment upon release DOC will help offenders enroll in programs necessary to sustain recovery Expand the DOC Recovery Works program 10 5/18/2017 ix. Increase the use of technology (e.g. telemedicine) to improve access to treatment services.  x. Use mobile teams to increase service availability.  As a part of ECHO (Extension for Community Healthcare Outcomes), DMHA will conduct a campaign in partnership with the Indiana State Medical Association for physicians prescribing buprenorphine for opiate addiction. This will be based upon the best practices guidelines for office-based prescribing published by DMHA in December 2016. The series will begin in summer 2017 DMHA will activate mobile teams in up to 6 communities across the state. A request for proposals is anticipated in July with startup in the fall 4. Develop and augment the ability of the Executive Director for Drug Prevention, Treatment, and Enforcement to serve its stakeholders, including persons with SUD and their families, providers of services, and units of government. 4. Develop and augment the ability of the Executive Director for Drug Prevention, Treatment, and Enforcement to serve its stakeholders, including persons with SUD and their families, providers of services, and units of government.     Partner with The Pew Charitable Trusts to determine and implement the most effective means of expanding access to quality treatment through data analysis and policy development (2017) Develop and maintain a robust, user-friendly website and provide links to well-developed sites such as Lookupindiana.org o Provide statewide data that is useful to Hoosiers to understand the scope of the state’s substance abuse problem Pursue next steps for programs authorized by the General Assembly, including SEA 446, SEA 243, SEA 510 and SEA 499, subject to the approval of the Indiana Commission to Combat Drug Abuse Facilitate working sessions between public safety and public health officials to foster better understanding and knowledge of the work of both groups 11 5/18/2017 a. Develop robust systems to gather data from disparate  sources and convert it into useful, actionable information for decision-making. Develop dashboards  that enhance the ability to track progress and quickly identify problems. Develop a capability to use predictive analytics to help reduce the incidence and severity of future substance abuse problems and to identify where  increases or shifts in resources would be advisable.   b. Utilize the Healthy Hoosiers Foundation to facilitate the development of funds for appropriate purposes aligned with the goals of this strategic approach. c. Explore potential project opportunities for graduate students in Public Health, Informatics, Social Work, and other disciplines.   Enhance plans to use additional data sources to support public health surveillance and impact assessment Encourage creation and implementation of standardized case forms for overdose deaths in hospitals, coroner and medical examiner cases. Partner with coroners to develop a pilot project for toxicological testing of overdose deaths Develop a collaboration that includes Regenstrief Center for Healthcare Engineering (RCHE) at Purdue University, Indiana University Clinical and Translational Sciences Institute and Regenstrief Institute to leverage their resources and capabilities to combat the opioid epidemic Continue the collaboration between Regenstrief Institute and the state’s Management Performance Hub to develop dashboards, complete analyses, and increase data “pushes” to hospital systems and providers. Operationalize data analyses that characterize the nature and extent of opioid abuse, inform data-driven strategies, and measure the impact of interventions Modify the state Department of Health’s ESSENCE system to enable near real time tracking of overdoses treated in emergency departments (underway) Explore relationships with philanthropic entities to supplement state appropriations to enable quicker action on selected priorities TBD 12 5/18/2017 5. Support and enhance substantial community-based collaborations aimed at prevention, treatment, and recovery. Encourage and support strengthening the infrastructure of communities (including county public health departments) to increase the capacity of communities to implement evidence-based prevention and treatment programs. a. Encourage and support community-based coalitions aimed at prevention, treatment, and recovery. Encourage significant involvement of community-based organizations, Purdue Extension, chambers of commerce and other organizations from the public, for-profit, and not-for-profit sectors.  b. Encourage improving the conditions within Indiana communities to strengthen equitable access to the social determinants of health to include, for example: improving economic and employment opportunities, improving literacy, increasing access to nutritional foods, improving access to quality education and skills training, etc. c. Encourage and support strengthening the scope and capacity of the local public health department in each Indiana county and encourage each county health department to achieve national accreditation status. Encourage and support the substantial engagement of local health departments in opioid addiction treatment and prevention services, and strongly encourage health departments and hospitals to work together collaboratively. d. Support workforce development initiatives to help ensure that communities have access to trained health professionals who engage in clinically appropriate addiction treatment and prevention services.  Utilize county Local Coordinating Councils to assist with local planning and coordination of education, treatment, social services and other programs Enhance the availability of “tool kits” and other technical assistance resources for community leaders engaged in or seeking to develop community-based coalitions aimed at prevention, treatment, recovery, and enforcement Explore the development of cross-sector collaborations  Utilize ISDH to develop a plan  Partner with the Department of Workforce Development to explore opportunities to attract or train more addiction professionals  13 5/18/2017