Opioid Misuse, Substance Use Disorder, and Overdose Prevention
The Three Sisters
A prevention parable tells the story of three sisters who were taking a walk along a river. As they turned a corner, they saw babies in the river. One sister swooped the babies out of the water. The second sister jumped into the river and showed the babies how to swim. The third sister ran upstream to see why the babies were falling into the river.
We need all three sisters. If we only respond to emergencies, we never address the root causes of the problem. If we only address the root causes, we are missing the emergencies that are currently happening. All the sisters must work together, simultaneously.
- The first sister is emergency response – she saves lives.
- The second sister is intervention and treatment – she addresses harms that have already happened.
- The third sister is primary prevention and public health – she looks at the conditions that create health
Emergency Response (Tertiary Prevention) e.g. Naloxone, Good Samaritan Laws, Syringe Exchange, transitions of care, discharge planning, fentanyl alerts, infectious disease control
Intervention & Treatment (Secondary Prevention) e.g. Screening, early identification, SBIRT Services, Medication Assisted Therapy, chemical health treatment, OB and infant care for NAS, safe storage, safe disposalPrimary Prevention & Public Health (Primary Prevention) e.g. Prescribing practices, safe use of prescriptions, control supply, prevent diversion, reduce marketing, enrollment and use of PMP, prevention of ACEs, adolescent risk reduction, pain management, addressing trauma, integrating care, protective factors, community resiliency, culture as prevention
Prescription & Heroin Overdose Prevention
Preventing opioid overdose death in Minnesota requires multi-sector collaboration with action along the drug pathway from manufacturing, marketing, prescribing, dispensing, using, disposing, treatment, and recovery.
The overarching, long terms goals are to:
- Reduce opioid overdose death
- Reduce non-fatal opioid overdose
- Reduce disparity in opioid use and overdose death within Native American, African American, and LGBTQ communities
- Improve prescribing practices
- Diagnose and treat substance use disorder
- Increase investment, intention and financial support for identified high-need communities
- Increase the conditions that support health (e.g. mental, medical, dental, sexual, chemical)
The Association of State and Territorial Health Officials (ASTHO) identified five key strategies to prevent substance misuse and addiction:
- Reduce stigma and change social norms
- Increase protective factors and reduce risk factors in communities
- Strengthen multi-sectoral collaboration
- Improve prevention infrastructure
- Optimize the use of cross-sector data for decision making
Minnesota has a number of workgroups addressing opioid use, misuse, substance use disorder, and overdose prevention, including, but not limited to:
- State Opioid Oversight Project (SOOP): a collaborative effort of 12 MN state agencies to initiate and implement initiatives to reduce opioid use, misuse, opioid use disorder, and opioid overdose death
- State Epidemiological Outcomes Workgroup (SEOW): a collaborative effort of MN state agencies that builds the capacity of alcohol, tobacco, and other drug prevention practitioners through the development of community epidemiological profiles, disseminating data products and expert guidance on the use of data to prevent substance misuse and substance use disorders
- State Targeted Response (STR) Advisory Committee: an advisory committee to help direct the efforts of the Minnesota State Targeted Response to the Opioid Crisis (MN Opioid STR)
- State Prevention Framework for Prescription Drugs (SPF Rx) Advisory Committee: an advisory committee to help direct the efforts of the State Prevention Framework for Prescription Drugs (SPF Rx) using the SPF five-step planning process to guide the selection, implementation, and evaluation of effective, culturally appropriate, and sustainable prevention activities
- Opioid Prescribing Improvement Project (OPIP): established by the MN legislature in 2015, the aim of OPIP is to reduce opioid dependency and substance use due to the prescribing of opioids by health care providers
- Opioid Prescribing Workgroup (OPWG): advisory group of experts convened by OPIP that recommends statewide opioid prescribing protocols for acute, post-acute, and chronic pain
Minnesota has a number of existing publications to build on in developing the state strategic plan including, but not limited to:
- Minnesota Opioid Action Plan: an overview of state government’s actions to address the opioid epidemic, released from the Governor’s Office 2/14/18
- President’s Commission on Combating Drug Addiction and the Opioid Crisis final report.
- State Substance Abuse Strategy (SSAS): a multi-agency, multi-faceted plan to tackle substance use, misuse, and substance use disorder in Minnesota
- Tribal-State Opioid Summit: a compilation of strategies and solutions to address the opioid crisis in Indian Country
- National Governor’s Association (NGA) Roadmap: public health and public safety strategies to end the opioid epidemic from prevention and early identification to treatment and recovery
- Surgeon General Report: the first-ever Surgeon General’s Report on Alcohol, Drugs, and Health reviews how to address substance misuse and related consequences
State Strategic Plan
In 2014, Minnesota was chosen to be one of six states to participate in the National Governors Association (NGA) prescription drug abuse academy. A Minnesota State Substance Abuse Strategy (SSAS) frame was proposed to develop a robust approach to prevent opioid use disorder and reduce access to prescription pain medications throughout Minnesota. To make this a reality, the State Opioid Oversight Project (SOOP) was formed.
At the request of the Office of Governor Mark Dayton, SOOP has participation from 12 state agencies.
- Department of Health
- Department of Human Services
- Department of Corrections
- Department of Education
- Department of Labor and Industry
- Department of Public Safety
- Minnesota State Judicial Branch
- Minnesota Board of Pharmacy
- Minnesota Board of Medical Practice
- Minnesota Board of Dentistry
- Minnesota Board of Nursing
- Minnesota Board of Podiatric Medicine
SOOP has focused on decreasing excessive opioid prescribing, providing naloxone to reverse overdoses, and improving access to treatment for substance use disorder. The eight focus areas with updates are below.
The Opioid Prescribing Workgroup (OPWG) has released Minnesota's opioid prescribing guidelines (PDF) to provide a framework for safe and thoughtful opioid prescribing for pain management. The guidelines are available for use by all providers and payers.
There is a marketing company working with providers to develop a provider campaign that addresses opioid prescribing, pain management, discussing tapering, and assessing for substance use disorder. In addition, a Continuing Medical Education (CME) credit will be offered to review this guidance.
The Opioid Prescribing Improvement Project (OPIP) submitted their annual Legislative Report. Included were the three key principals underlying the opioid prescribing guidelines that the Opioid Prescribing Workgroup (OPWG) will publish in October 2017. They include:
- Prescribe the lowest effective dose and duration of opioid analgesia when indicated for acute pain. Clinicians should reduce variation in opioid prescribing for acute pain.
- The post-acute pain period is the critical timeframe to halt the progression to chronic opioid use. Clinicians should increase assessment of the biopsychosocial factors associated with opioid-related harm and chronic opioid use during the post-acute pain period.
- The evidence to support chronic opioid analgesic therapy for chronic pain is insufficient at this time, but the evidence of harm is clear. Providers should avoid initiating chronic opioid therapy for new chronic pain patients, and carefully manage those who remain on opioid medications.
Governor Mark Dayton requested the Minnesota e-Health Advisory Committee provide a set of recommendations for e-health strategies to address the current epidemic of opioid abuse and overdose. Final Opioid and e-Health Recommendations (December 2017) (PDF) are available on the Minnesota e-Health Initiative Advisory Committee page.
This means people who are in jail, prison or involved with the justice system in some way. Some of the topics related to justice-involved populations and opioids are the criminalization of substance use disorders, lack of access to chemical health treatment while incarcerated, high risk of overdose upon departure from jail or prison when tolerance is reduced, and race disparity in drug offense sentencing.
SOOP is looking at the transition of care from community, to prison or jail, and back to community, especially emphasizing continuation or initiation of Medication for Addiction Treatment (MAT).
By June 2018 SOOP will create a state strategic plan that includes:
- Prescription drug overdose (PDO) and heroin overdose death (HOD) prevention
- Emergency response
- Intervention & treatment
- Primary prevention & public health
- An interagency grant matrix
- Integration of statewide efforts, including established workgroups and publications
Updates about the statewide strategic plan for prevention of opioid use, misuse, opioid use disorder, and overdose will be posted here.
For questions or to get involved in SOOP, contact Tara Holt, State Substance Abuse Strategy Coordinator at firstname.lastname@example.org
Please visit the Opioid Dashboard for more information on opioid overdose death, nonfatal overdose, use, misuse, substance use disorder, prescribing practices, supply, diversion, harm reduction, so-occurring conditions and social determinants of health.