December 17, 2015
Dear Colleague:
This holiday season for so many Virginians will be anything but happy and healthy as a result of the significant impact of drug abuse and addiction in the Commonwealth. Preliminary data for the first nine months of 2015 show a 36% increase in the number of fatal heroin overdoses (n=235) compared to the first nine months of 2014 (n=173). Fatal prescription opioid overdoses, however, remain the number one drug category causing or contributing to death in Virginia. Benzodiazepines and cocaine also remain significant causes of overdose deaths. Finally, there has been a 45% increase in overdose deaths involving fentanyl in 2015 compared to 2014 year-to-date. More details, including information on overdose deaths by city/county, are available.
We are issuing this urgent communication today to continue to highlight key approaches related to our collective efforts to address the epidemic of opioid abuse and overdose, and to reduce the broad health impacts of drug abuse and addiction on the communities of Virginia. Specifically this correspondence focuses on:
- Virginia’s Prescription Monitoring Program (PMP)
- Screening, Brief Intervention, and Referral to Treatment (SBIRT)
- REVIVE! and Expanded Access to Naloxone
- Comprehensive Harm Reduction: Reducing the Risk of HIV and Hepatitis C Infections
Virginia’s Prescription Monitoring Program (PMP)
Virginia’s Prescription Monitoring Program is a valuable tool to fight this public health and safety emergency. The PMP is available to all prescribers and pharmacists to assist them in making treatment, prescribing and dispensing decisions. A PMP report can:
- Confirm a patient’s prescription history for controlled substances
- Assist in monitoring the patient’s compliance with the treatment plan
- Alert the healthcare practitioner to overlaps in drug therapy or high-risk combinations of medications such as opioids and benzodiazepines
- Alert the healthcare practitioner to behavior that may indicate “doctor-shopping”
- A PMP report defaults to a one-year period of prescription history for a patient and has several features:
- Cumulative Morphine Equivalent Dose score for a patient with an active opioid prescription, which can assist the healthcare practitioner in evaluating the patient’s overdose risk
- Indicator of whether a specific prescription is inactive (completed) or active for all prescriptions on the report
- Daily Morphine Equivalent Dose score for each opioid prescription
- For each prescription, the prescriber, pharmacy, name of the drug, quantity, date filled and written, method of payment and other information
Prescribers also may request a report for prescriptions dispensed under their DEA number for the past 90 days. Prescribers and pharmacists may both authorize delegates to request information on their behalf by submitting the form at PMP Delegate Authorization Form.
The Department of Health Professions is required to register all prescribers and pharmacists with the PMP prior to January 1, 2016 per § 54.1-2522.1 and 2522.2 of the Code of Virginia. If you are not already registered with the PMP, you should expect future communication about this requirement.
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with and at risk of developing substance use disorders.
- Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.
- Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
- Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.
We encourage you to incorporate SBIRT into your clinical practice. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur. SBIRT resources include:
- Virginia Department of Behavioral Health and Developmental Services (DBHDS) website with DBHDS-vetted SBIRT guidelines and screening instruments
- SAMHSA-supported Addiction Technology Transfer Center Network, which provides a SBIRT Toolkit
- SAMHSA-HRSA Center for Integrated Health Solutions (SBIRT), which offers guidelines, tools and other resources for integrating SBIRT into practice
If you do not know all of the substance abuse treatment services in your community, one place to start is the SAMHSA Behavioral Health Treatment Services Locator.
REVIVE! and Expanded Access to Naloxone
As a reminder, the DBHDS Office of Substance Abuse Services has established REVIVE! as the Opioid Overdose and Naloxone Education (ONE) program for the Commonwealth of Virginia. REVIVE! provides training to professionals, stakeholders, and others on how to recognize and respond to an opioid overdose emergency with the administration of naloxone. The Board of Pharmacy also has approved a Protocol for the Prescribing and Dispensing of Naloxone. Both sources include guidance on prescribing and dispensing naloxone for intranasal administration, as well as by auto-injector.
Comprehensive Harm Reduction: Reducing the Risk of HIV and Hepatitis C Infections
Individuals who are injecting drugs are at increased risk for bloodborne infections, including HIV and hepatitis C (HCV). The number of individuals claiming injection drug use as a risk factor during HIV counseling sessions in VDH-supported test sites increased from 840 in 2010 to 1282 in 2014. Reports of acute HCV infection vary from year to year in Virginia with a significant increase in cases reported since 2006.
In 2015, rural Scott County, Indiana experienced an unprecedented outbreak of HIV infection. In a county with fewer than five cases of HIV a year, public health officials diagnosed over 175 cases of HIV. Over 80% of those newly infected reported injection drug use: over 80% were co-infected with HCV. In a study expected to be published in early 2016, the Centers for Disease Control and Prevention (CDC) will identify, using predictive modeling, other communities across the nation, including several counties in Virginia, that are at risk for a similar outbreak among injecting drug users.
In addition to referring patients with suspected injecting drug use to addiction treatment, hepatitis testing is recommended for any person who is currently injecting or has ever injected drugs. CDC also recommends that all people between the ages of 13 and 65 get tested for HIV. Annual testing is recommended for populations at increased risk, including people who inject drugs. Clinicians are encouraged to incorporate routine screening services in their practice. The Virginia Department of Health provides or supports screening services at many locations in Virginia. VDH’s Disease Prevention Hotline at 800-533-4148 (Monday-Friday, 8:00 am – 5:00 pm) also provides assistance in finding screening services.
We thank you for your efforts as clinicians to prevent or reduce the risk of opioid abuse by the patients under your care. In addition, your actions, as members of your community, to support efforts to stem the epidemic of substance abuse and addiction, injection drug use, and the related health impact on all Virginians are critically needed at this time. By doing so, perhaps next year’s holiday season will be joyous for more Virginians.
Sincerely,
| Marissa J. Levine, MD, MPH, FAAFP
State Health Commissioner Department of Health |
David Brown, DC
Director Department of Health Professions |
Jack Barber, MD
Interim Commissioner Department of Behavioral Health & Developmental Services |