The plan

 The Hawaii Opioid Initiative action plan is a comprehensive strategy to aggressively counteract the increased abuse and misuse of opioids in Hawaii. The plan is designed to sustain a system-wide, coordinated and proactive response to not only opioids, but also methamphetamine and other prevalent drugs. The collaborative effort is led by the Department of Health, together with the Department of the Attorney General, Department of Human Services Med-QUEST Division, Department of Public Safety Narcotics Enforcement Division and a wide range of community groups.

To halt the looming opioid threat, the state is moving forward with the Statewide Action Plan on opioids, portions of which have already been implemented. The plan identifies six key focus areas:

 

Click below to learn more about each focus group's objectives and accomplishments. 


TREATMENT ACCESS

Improve and modernize healthcare strategies and access for opioid and other substance misuse treatment and recovery services.

Objective: Establish a pilot coordinated entry system to process and coordinate substance use disorder (SUD) treatment referrals.

A coordinated entry system for SUD provides a single point of contact for any community based substance misuse referral. This means that medical providers, law enforcement, community organizations and others will be able to make referrals through one entry point utilizing universal procedures. A coordinated entry system is a unified and universal referral system for the community and helps to integrate primary and behavioral healthcare systems by providing a more streamlined access point for referrals by primary care providers. It also enhances a balanced public health/public safety approach by providing opportunities for entities from both fields to work together toward overlapping objectives.

Accomplishments:

  • Piloting coordinated entry system to allow people to go to one source for addiction and treatment help or access.

  • Includes medically assisted treatment such as MAT and residential treatment facilities.

  • Facilities to have standardized protocols

  • Working to fix prior authorization problems that providers face with insurance companies.

  • Still working on processes surrounding Suboxone/buprenorphine

PRESCRIBER EDUCATION

Objective: Increase primary care provider pain management practice (PMP) registration rates by 25% by providing training to prescribers; increase PMP utilization rates by 10%.

The use of a PMP is nationally and universally recognized as a cornerstone activity for reducing over-prescribing of opioid pain medications, as well as for decreasing diversion and "script shopping". Universal use of the PMP in other states have been attributed to reduction of duplicated opioid prescriptions as well as increased awareness of medications patients are prescribed by various providers.

The Department of Public Safety, Narcotic Enforcement Division (NED) and the Department of Health (DOH) will partner and coordinate resources to develop and implement a statewide training and education campaign to increase prescribers use of PMP.

Objective: Assure universal screening for substance misuse in hospital and primary care settings Statewide.

Provide training for providers on implementation of universal screening, brief intervention and referral to treatment (SBIRT) screening into provider practice workflows will increase prevalence and normalcy of low level opioid use disorder (OUD) and substance use disorder (SUD) screening in primary care settings.

One of the primary barriers to effectively intervening with persons at risk for OUD and other SUDs is the lack of universal screening. Often, the emergence of opioid or other substance use problems are a result of critical and acute symptomology such as involvement with law enforcement. Interventions at this point in the progression of the disease, while necessary, requires more resources than if the risk had been identified early on.

Accomplishments:

  • Developed prescriber guidelines for physicians and APRNs, endorsed by various hospital systems.

  • Emergency Departments has standardized procedures for opioid prescribing to limit “doctor shopping”

  • Collaborating with Project Echo at John A. Burns School of medicine to allow rural communities to collaborate with their peers regarding opioid best practices.

  • SBIRT Training with Project Echo to take place on August 9

DATA INFORMED DECISION MAKING

Implement system-wide routine data collection, sharing and dissemination to increase knowledge and inform practice.

Objective: Amend HRS 329-104 to allow limited release of data by the NED to the DOH for purposes of public health surveillance.

The statute in its current form limits NED's statutory authority to allow access to PMP data. A change in the language to provide extended authority of NED to provide data for select public health use would significantly support advancement in this area.

Objective: Develop a standardized framework for the collection, synthesis, and dissemination of data.

Much of the discussion in the various groups centered around the "need for data" to make decisions. However, the data workgroup have recognized that while more data is needed, a more pertinent need is for a standard way of collecting, synthesizing and disseminating data. The act of gathering more data, while helpful, does not benefit decision making if it is not processed in a way that informs policy makers.

To assure that opioid prevention and treatment efforts are data driven and measurable, DOH, Emergency Medical Services, Injury Prevention Services Branch (EMS/IPSB) will develop a data framework to analyze and report existing data and identify unmet data needs of the workgroups. A data framework supports and informs system level coordination and policy making by providing clear information on where resources and efforts are most effective. It can be leveraged by both public health and public safety entities to assist with informed decision making that considers the objective of both and promotes balanced policy. A data plan is a framework that not only collects data but collectively processes it in a way that programs can utilize to focus limited resources is self-explanatory.

Components of the plan will support: 1) Public health surveillance; 2) Dissemination of data for informing practice and decision making; 3) Outcomes measurement of interventions and program; and 4) Availability of data: a) in near real time form for use by first responders and others; and b) in periodical format for policy decision making.

Accomplishments:

  • Looking forward to integrating Electronic Medical Records by 2020

  • Mandated use of the Prescription Drug Monitoring Program via Act 153, Relating to Prescription Drugs

  • Data dashboard: contract in process; group is working on formalizing a framework.

PREVENTION AND PUBLIC EDUCATION

Objective: Implement year-round drop off/"take back" sites at a minimum of 2 county police stations within the State to include protocols for disposal of unused medications in a safe and secured manner.

The Drug Enforcement Agency (DEA) coordinates 2 annual "take back" initiatives through coordination between the Attorney General (AG) and NED. Standing "take-back" sites is a cornerstone recommendation and many states as well as corporate entities such as CVS have developed year-round take back initiatives.

This objective seeks to work with county law enforcement to house approved medication drop boxes at county police stations. On October 16, 2017 the AG hosted a meeting with DEA, NED and key law enforcement representatives to discuss the viability of implementing these sites at county police stations. All county police departments voiced their support of exploring the objective further. Implementation will include a review of best practices. DOH will work with law enforcement and other partners to promote awareness of the drop boxes and encourage the public to use this option when medications are no longer used. Safe handling and disposal of unused opioids will be covered in provider training.

Implementation of standing take back sites requires coordination on the federal state, county and community level. Take back initiatives provide the opportunity for law enforcement entities in Hawaii to assist with prevention efforts and to increase community partnerships. Standing take back sites also provide an important opportunity to collect data related to the volume of medications disposed in comparison with those dispensed.

Objective: Develop and disseminate an evidence-based training module on opioid use, misuse, overdose and related harms for non-prescribers.

To reduce opioid misuse and related harms, DOH and community partners will develop and implement a training module to be integrated into existing trainings for Certified Substance Abuse Counselors, Certified Prevention Specialists, adolescents and school-age youth, teachers, home healthcare providers and others who work with populations at-risk for opioid misuse and related harms. There will also be a module for training of trainers to maximize existing training infrastructure and enhance dissemination. Not only will this increase awareness and capacity but will also provide additional opportunities for community engagement around these issues.

The training curricula will be based on research and evidence-based practices from the Center for Disease Control (CDC) and the Substance Abuse Mental Health Services Administration (SAMHSA) and content will be aligned with the Prescriber Education training yet will be targeted for non-prescribers. Content will include the risks associated with long-term use or misuse of opioids, data on prevalence of opioid use and overdose in Hawaii, strategies for prevention of opioid misuse and related harms such as overdose, and an overview of OUD and treatment and local resources.

Accomplishments:

  • Website is up and running, each stakeholder group will have a section where they can go for information pertaining to their field.

  • Hawaii Health and Harm Reduction Center managing website with designated staff.

  • They are working on an interactive map that will identify pharmacies that carry naloxone.

  • Interested in adding take-back boxes to the map as well. Currently, all available take-back boxes are listed on website.

  • Social Media campaign to kick off in 2019 to raise awareness.

  • Interested in translation services for website and information sheets.

PHARMACY-BASED INTERVENTIONS

Increase consumer education and prescription harm management through pharmacy-based strategies.

Objective: Establish a standing order through the DOH to allow pharmacists to dispense Naloxone to patients and community members to increase access to life-saving medication; modify Hawaii Revised Statutes to allow pharmacists prescriptive authority to prescribe Naloxone to patients and community members to increase access to life-saving medication.

Access to Naloxone is a nationally and universally recommended cornerstone practice and has been shown to reduce the incidence of opioid deaths due to overdose. Many states have instituted a standing order that allows pharmacists to dispense the life-saving medication. This objective is specifically targeted for patients who are filling an opioid prescription.

This action is a key system level policy that requires collaborative effort by a number of state and community entities. It provides a foundation for integrated care by normalizing the conversation around opioid overdose and by providing an opportunity for education at the pharmacy level which is a significant point of contact.

Objective: Provide continuing education presentation on pharmacist role in screening for risk for patients with opioid prescriptions.

Pharmacists play an important role in the strategy to address opioid issues in the State. As a primary point of contact for persons with opioid and other narcotic prescriptions, they represent a significant component for moving the State toward improved integration of healthcare. Pharmacists can provide key screening and education for patients while filling prescriptions and are well positioned to support public awareness efforts.

Objective: Develop Naloxone training program for pharmacists.

Pharmacists play an important role in the strategy to address opioid issues in the State. As a primary point of contact for persons with opioid and other narcotic prescriptions, they represent a significant component for moving the State toward improved integration of healthcare. Pharmacists can provide key screening and education for patients while filling prescriptions and are well positioned to support public awareness efforts.

Accomplishments:

  • Act 154, Relating to Opioid Antagonists put into law, allowing pharmacists to prescribe naloxone.

  • Medicaid to cover the prescription

  • Information sheet to accompany prescription has been developed. Details how to administer opioid antagonists and lists additional resources.

  • Working on getting a training module approved for Continuing Education credits for all pharmacists who complete the program. The training includes information about SBIRT and how it relates to pharmacist.

  • Program to roll out within the next two months.

  • Local pharmacies in each county have expressed interest in participating, however still waiting to hear back from the “Big Box” stores (Walgreens, CVS, etc.)

SUPPORT LAW ENFORCEMENT AND FIRST RESPONDERS

Coordinate operations and services, support specialized training for first responders and assure effective laws and policies.

Objective: Develop a recommended course of action to be taken by first responders when encountering opioid overdose victims using a clearly defined recommended protocol; train 30% of law enforcement/first responders in all four counties on the training program that is developed by this group.

The intent of this goal is to research national evidence-based multi-disciplinary approaches for law enforcement/first responders and develop a training curriculum that meets the needs of Hawaii's law enforcement/first responders. The intended result is a better understanding by first responders (to include Emergency Medical System (EMS), Fire, and Police) of drug trends, protection and exposure protocols to ensure the safety for themselves and the community.

Objective: Develop and recommend standard procedures for first responders on treatment referral at initial contact by law enforcement/first responders; coordinate with other working groups and stakeholders to create a list of diversion programs for law enforcement/first responders to use as a reference when referring overdose victims.

At the center of these goals is the belief that law enforcement and other first responders can help those in need of substance misuse and other behavioral health services even if no immediate crime has occurred.

Diversion efforts such as Law Enforcement Assisted Diversion (LEAD) and Help Honolulu are currently in development in Hawaii. These efforts are based on successful and evidence-based programs implemented in other parts of the country. The common theme of these programs is the beneficial partnership between first responders and public health personnel.

The result of successful achievement of these objectives will be a set standard procedures and protocol recommended for first responders.

Accomplishments:

  • Hawaii Health and Harm Reduction Center has provided training on using Narcan.

  • Each district or “beat” has a “save kit”, equipped with opioid antagonists.

  • Workgroup to develop a standardized training for all first responders.

  • Incorporating SBIRT and diversion programs when responding to overdose cases.

  • Take-back boxes are currently in all four counties.

  • Maui utilizing innovative data collection system, ODOM.


Download a copy of the complete, 60-page report, including a comprehensive look at the problem of opioids and substance misuse, the opportunities present in the current crisis, and complete detail for the six focus domains. The action plan also includes more information on next steps, project collaboration partners, and statements from Governor David Ige and Dr. Ginny Pressler (Director, Department of Health).


SEPTEMBER 2018 UPDATE: surgeon general’s spotlight on opioids

The Surgeon General of the United States Department of Health & Human Services recently released the newest edition of Facing Addiction in America. The Surgeon General’s Spotlight on Opioids calls for a cultural shift in the way Americans talk about the opioid crisis and recommends actions that can prevent and treat opioid misuse and promote recovery.

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