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Florida’s State Targeted Response

to the Opioid Crisis Grant

Needs Assessment

Department of Children and Families

Office of Substance Abuse and Mental Health

Updated August 31, 2017

Mike Carroll Rick Scott

Secretary Governor

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TABLE OF CONTENTS

I. INTRODUCTION ................................................................................................................................... 3

II. SERVICE DELIVERY: MANAGING ENTITIES .......................................................................................... 4

III. DATA…………………………………………………………………………………………………………………………………………..5

III.A. Florida’s Prescription Drug Monitoring Program (PDMP) ..........................................................5

III.B. Opioid Associated Death Data ............................................................................................... 10

III.C. Current Availability of Medication-Assisted Treatment .......................................................... 14

III.D. Estimated Treatment Need in Florida .................................................................................... 18

III.D.(1) Population Estimates: 19,860,805 ...................................................................................... 18

III.D.(2) Estimated Number of Past-Year Nonmedical Pain Reliever Users ..................................... 19

III.D.(3) Estimated Last Year Opioid Use Disorder ........................................................................... 19

III.D.(4) Estimated Number of Life-Time Heroin Users .................................................................... 20

IV. PROGRAMMATIC CAPACITY ............................................................................................................. 20

V. PREVENTION AND RECOVERY INITIATIVES ....................................................................................... 22

V.A. Overdose Prevention ............................................................................................................ 22

V.B. Primary Prevention ............................................................................................................... 24

V.C. Recovery Initiatives ............................................................................................................... 25

VI. POLICY, LEGISLATIVE AND SOCIAL-POLITICAL ENVIRONMENT FOR THE OPIOID CRISIS AND

MEDICATION-ASSISTED TREATMENT ....................................................................................................... 26

VII. EVIDENCE-BASED AND EVIDENCE-INFORMED PREVENTION PRACTICES, AND PROMISING

PRACTICES …………………………………………………………………………………………………………………28

VIII. SPECIAL POPULATIONS ..................................................................................................................... 28

IX. ADDITIONAL FINDINGS ..................................................................................................................... 29

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I. INTRODUCTION

The mission of the Florida Department of Children and Families (Department) is to work in partnership with local communities to protect the vulnerable, promote strong and economically self-sufficient families, and advance personal and family recovery and resiliency. Within the Department, the Office of Substance Abuse and Mental Health (SAMH) serves as the single state agency for substance abuse services for the state of Florida. The office is responsible for the oversight of the statewide system for prevention, treatment, and recovery services for children and adults with substance use disorders. The Substance Abuse and Mental Health Service Administration (SAMHSA) has requested a statewide needs assessment for the State Targeted Response to the Opioid Crisis Grant (STR) following the release of SAMHSA grant money to Florida. The purpose of the assessment is to provide necessary data to help inform the Department’s strategic plan for a targeted response to the opioid epidemic in Florida and to provide SAMHSA with insight into Florida’s challenges. This report aims to provide information on the nature and extent of the opioid epidemic in the state so that the Department, its partners, and stakeholders may respond effectively to the problems identified. Data regarding the scope of the problem and current resources will provide the building blocks for coordinated regional efforts to address needs. Additionally, this report identifies gaps and opportunities to better combat the opioid crisis. Florida’s STR Project is focusing on the opioid crisis by providing evidence-based prevention, treatment (primarily through medication assisted treatment), and recovery support services. In assessing Florida’s current needs through data capture and analysis, four goals were identified as follows:

• Reducing opioid-related deaths, • Preventing prescription opioid misuse among young people, • Increasing the number of individuals trained to provide medication-assisted treatment

and recovery support services, and • Increasing access to medication-assisted treatment among individuals with opioid use

disorders.

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II. SERVICE DELIVERY: MANAGING ENTITIES

The Department contracts with seven Managing Entities (MEs) for the administration and management of regional behavioral health services and supports. MEs are private, non-profit organizations responsible for overseeing contracts with local network service providers for the provision of prevention, treatment, and recovery support services. ME contracts are managed by the Department’s regional SAMH offices with support from the headquarter SAMH office.

Map 1: Managing Entities by region in Florida

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Table 1 below identifies each ME, along with the distribution of the 67 counties they serve by urban and rural designations. The MEs play a vital role in providing insight, collecting data and managing treatment providers.

Table 1: Number of Florida Counties by Managing Entity Region and Department Region

III. DATA

III.A. Florida’s Prescription Drug Monitoring Program (PDMP)

From 2003-2009, pain clinics in Florida were prescribing large quantities of prescription medications with little medical justification, including: opioid analgesics, benzodiazepines, and muscle relaxants. In 2010, 98 out of the 100 U.S. physicians who dispensed the highest quantities of oxycodone were in Florida. In response, Florida enacted pain clinic regulations, conducted law enforcement raids, and banned dispensing of schedule II or III drugs from physician offices. Section 893.055, Florida Statutes (F.S.), created the PDMP within the Department of Health to collect controlled substance prescription dispensing information, while not infringing upon the legitimate prescribing or dispensing of controlled substances by a prescriber or dispenser acting in good faith and in the course of professional practice. Florida’s PDMP, known as E-FORCSE® (Electronic-Florida Online Reporting of Controlled Substance Evaluation Program), was implemented in 2011 with the goals to encourage safer prescribing of controlled substances and to reduce drug abuse and diversion within Florida. Prescription drug dispenser reporting to E-FORCSE was mandated, along with additional regulations on wholesale distributors. Research shows that the implementation of E-FORCSE® and “pill mill” regulations resulted in a modest

Managing Entity Department Region(s) Rural

Counties Non-Rural Counties

Total Counties

Broward Behavioral Health Coalition (BBHC)

Southeast Region 0 1 1

Central Florida Cares Health System (CFCHS)

Central Region 0 4 4

Central Florida Behavioral Health Network (CFBHN)

Suncoast & Central Regions

5 9 14

Lutheran Services Florida Health Systems (LSFHS)

Northwest & Central Regions

10 13 23

Big Bend Community Based Care (BBCBC)

Northeast & Northwest Regions

13 5 18

South Florida Behavioral Health Network (SFBHN)

Southern Region 1 1 2

Southeast Florida Behavioral Health Network (SEFBHN)

Southeast Region 1 4 5

Entire State of Florida 30 37 67

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decrease in opioid prescriptions, opioid volume, and mean morphine milligram equivalent per transaction1. Using the PDMP, Florida can review data and identify trends. PDMP data is of substantial value

not just in the fight against prescription drug misuse but also in its ability to give an early

warning in identifying other potential illicit drug use. Individuals who are addicted to prescription

opioid painkillers are 40 times more likely to be addicted to heroin2. Interviews with heroin users

who sought treatment between 2010 and 2013 support this conclusion as the vast majority

initiated use with prescription opioids and then switched to heroin because prescription opioids

were far more expensive and harder to obtain.3 Nationwide, over 77% of people using both

opioid pain relievers and heroin in the past year report using opioid pain relievers prior to heroin

initiation.4

In 2016, the opioid prescription rate was 74.62 per 100 persons in Florida with 15,080,497 prescriptions for a population of just over 20 million (See Table 2 and Figure 1). This rate was down from a high in 2015 of 82.91 per 100. Statewide rates from 2012-2016 have remained relatively stable with rates of 73.48, 70.75, 74.50, 82.91, and 74.62, respectfully (Figure 1). Upon examining the opioid prescription rate by county, we see 29 of the 67 counties (43%) in Florida with a rate above 100 per 100 persons. Of those 29 counties, 16 counties (55%) are classified as rural counties (populations less 100 persons per sq mile) and of the Top 10 counties, six (66%) were rural. When reviewing benzodiazepine prescriptions in 2016, the prescription rate was 51.73 per 100 persons in Florida with 10,455,120 prescriptions (See Table 2 and Figure 1). Statewide rates

from 2012-2016 have remained relatively stable with rates of 55.76, 55.04, 54.78, 54.91, 51.73, respectfully (Figure 1). The statewide rate for benzodiazepine prescriptions was 30% lower than opioids in 2016 and from 2012-2016 the rates have been consistently lower and more stable. When examining the county level rates compared to opioids a different picture emerges. No county is above the rate of 100 per 100 persons, compared to 29 counties for opioids. Of the top 10 counties, three counties (33%) are rural, compared to six counties for opioids.

1 Rutkow, L. C. (2015). Effect of Florida’s Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA Internal Medicine,, 175(10), 1642-1649. 2 Prevention, C. f. (2015). 1999-2014 Average Death Rates for Opioid Drug Overdose by State. 3 Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The Changing Face of Heroin Use in the United States – A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry, 71(7), 821-826. 4 Jones, C. M. (2013). Heroin Use and Heroin Use Risk Behaviors among Nonmedical Users of Prescription Opioid Pain Relievers – United States, 2002-2004 and 2008-2010. Drug and Alcohol Dependence,. Drug and Alcohol Dependence, 132, 95-100.

Figure 1.

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When compared to the opioid prescription rates, benzodiazepines are lower overall statewide and at a county level. Benzodiazepines also appear to be less prominent in rural counties than opioids.

Table 2: 2016 PDMP Data by County (alphabetical order)

County Population

Opioid Rx

Rate (per

100)

Opioid Rx

Rate (per 100)

Rank

Benzo Rx

Rate (per

100)

Benzo Rx

Rate (per 100)

Rank

Alachua 259,310 67.46 58 31.42 64

Baker 27,266 134.37 3 63.60 8

Bay 176,389 128.98 8 73.21 3

Bradford 27,380 141.27 2 51.17 31

Brevard 572,420 111.71 20 62.74 9

Broward 1,853,380 53.29 65 45.63 44

Calhoun 14,573 110.39 21 57.46 23

Charlotte 170,475 103.26 28 59.35 20

Citrus 142,948 126.37 10 74.32 2

Clay 206,339 108.06 23 50.78 32

Collier 353,238 59.80 61 41.74 52

Columbia 68,767 128.04 9 55.00 26

DeSoto 35,143 72.87 55 38.72 56

Dixie 16,650 123.69 11 40.40 53

Duval 922,006 96.95 33 46.87 42

Escambia 309,754 112.10 19 44.21 49

Flagler 105,190 99.78 30 62.29 12

Franklin 11,848 112.86 18 47.99 34

Gadsden 48,507 73.83 54 23.92 67

Gilchrist 16,939 130.08 6 45.59 45

Glades 12,871 72.04 56 32.34 63

Gulf 16,146 115.08 14 60.72 15

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County Population

Opioid Rx

Rate (per

100)

Opioid Rx

Rate (per 100)

Rank

Benzo Rx

Rate (per

100)

Benzo Rx

Rate (per 100)

Rank

Hamilton 14,923 78.72 49 34.99 58

Hardee 27,606 55.80 64 26.66 66

Hendry 38,355 75.51 52 33.22 60

Hernando 180,174 114.50 16 77.01 1

Highlands 101,966 81.95 45 59.06 21

Hillsborough 1,357,425 68.28 57 47.80 35

Holmes 19,847 112.93 17 57.37 24

Indian River 146,414 88.90 38 62.37 11

Jackson 50,723 105.57 26 51.28 30

Jefferson 14,490 81.35 46 33.13 61

Lafayette 8,676 90.01 36 44.18 50

Lake 325,753 86.91 42 46.98 41

Lee 684,668 74.95 53 47.46 37

Leon 288,481 58.13 63 31.40 65

Levy 40,647 121.01 12 47.60 36

Liberty 8,743 87.64 41 38.88 55

Madison 19,159 87.88 40 39.60 54

Manatee 360,642 86.63 43 55.25 25

Marion 347,607 101.65 29 47.25 40

Martin 152,263 81.15 47 57.53 22

Miami-Dade 2,702,890 34.52 67 59.66 18

Monroe 74,283 91.63 35 61.50 14

Nassau 78,401 131.25 4 62.13 13

Okaloosa 193,530 89.56 37 47.37 38

Okeechobee 40,400 97.78 31 52.50 29

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County Population

Opioid Rx

Rate (per

100)

Opioid Rx

Rate (per 100)

Rank

Benzo Rx

Rate (per

100)

Benzo Rx

Rate (per 100)

Rank

Orange 1,287,080 51.13 66 32.71 62

Osceola 324,717 59.08 62 34.08 59

Palm Beach 1,402,017 65.32 59 54.64 27

Pasco 499,729 105.84 25 68.09 5

Pinellas 954,629 97.55 32 70.52 4

Polk 646,783 77.94 50 46.17 43

Putnam 72,994 149.74 1 60.50 16

Saint Johns 222,416 80.49 48 53.35 28

Saint Lucie 295,743 83.95 44 47.29 39

Santa Rosa 166,994 107.13 24 44.47 48

Sarasota 398,692 88.71 39 60.41 17

Seminole 450,317 62.14 60 45.27 46

Sumter 121,359 77.40 51 43.48 51

Suwannee 44,933 114.76 15 48.24 33

Taylor 22,819 130.15 5 62.46 10

Union 16,180 94.85 34 38.62 57

Volusia 518,010 104.01 27 64.66 6

Wakulla 31,472 108.90 22 44.47 47

Walton 62,059 115.55 13 59.47 19

Washington 25,056 130.06 7 64.49 7

State 20,209,604 74.62 _______ 51.73 _______

The state law requires pharmacies to enter filled prescriptions for controlled medication into the PDMP by the end of the day business. According to the most recent E-FORCSE Quarterly Dash Board report, 93.5% of prescriptions are being entered in a timely manner. However, a gap currently exists in the lack of a mandate for prescribers to review the PDMP prior to writing a prescription. Only 28.5% of those with authority to prescribe a controlled substance have an

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account for the PDMP. If this gap were corrected, requiring prescribers to review the PDMP, there could potentially be a significant reduction in the amount of opioids prescribed. A prescriber mandate could also reduce the potential for “Doctor Shopping”. Another gap is the lack of interoperability between surrounding states. Currently, Florida can receive PDMP information from Alabama, but cannot submit and there is no exchange between Florida and Georgia. Because of the high rate of non-medical use of prescription opioids in the northern region of Florida, there could be a benefit by having nearby states communicate through interoperable PDMPs.

III.B. Opioid Associated Death Data

Drug overdose is now the leading cause of injury-related death in the United States. Since 2000, drug overdose death rates increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin). In 2015, over 52,000 deaths in the U.S. were attributed to drug poisoning, and over 33,000 (63%) of these involved an opioid (prescription or illicit). In 2015, 3,535 deaths occurred in Florida where at least one drug was identified as the cause of death5. More specifically, 2,535 deaths were caused by at least one opioid in 2015 (see Table 3). This means that seven lives per day are lost to opioids in Florida in 2015. Overall the state had a rate of opioid-caused deaths of 12.76 per 100,000. The three counties with the highest rate include: Manatee county with the highest rate of opioid-caused deaths with 36.28 per 100,000, followed by Dixie county (29.95 per 100,000) and Palm Beach (22.08 per 100,000).

Table 3: 2015 Opioid Caused* Deaths by County± (alphabetical order)

County Population Number of

Opioid-Caused Deaths

Rate of Opioid-Caused

Deaths per 100,000

Alachua 253,752 24 9.46

Baker 27,484 5 18.19

Bay 172,973 21 12.14

Bradford 27,715 6 21.65

Brevard 559,020 121 21.65

Broward 1,821,974 225 12.35

Calhoun 14,595 0 0.00

Charlotte 166,506 20 12.01

Citrus 142,942 12 8.40

Clay 202,859 36 17.75

5 Florida Medical Examiners Commission (2015). Identified Drugs in Deceased Persons

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County Population Number of

Opioid-Caused Deaths

Rate of Opioid-Caused

Deaths per 100,000

Collier 345,014 42 12.17

Columbia 68,524 7 10.22

Desoto 34,420 0 0.00

Dixie 16,697 5 29.95

Duval 901,215 143 15.87

Escambia 306,237 49 16.00

Flagler 102,738 9 8.76

Franklin 11,842 2 16.89

Gadsden 48,406 0 0.00

Gilchrest 16,906 0 0.00

Glades 12,989 1 7.70

Gulf 16,491 1 6.06

Hamilton 14,694 2 13.61

Hardee 27,694 1 3.61

Hendry 38,070 1 2.63

Hernando 178,020 12 6.74

Highlands 101,045 5 4.95

Hillsborough 1,334,793 133 9.96

Holmes 20,090 1 4.98

Indian River 143,743 12 8.35

Jackson 50,337 1 1.99

Jefferson 14,676 0 0.00

Lafayette 8,724 0 0.00

Lake 319,259 26 8.14

Lee 674,907 83 12.30

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County Population Number of

Opioid-Caused Deaths

Rate of Opioid-Caused

Deaths per 100,000

Leon 284,740 10 3.51

Levy 40,849 5 12.24

Liberty 8,719 0 0.00

Madison 19,328 1 5.17

Manatee 347,272 126 36.28

Marion 342,831 23 6.71

Martin 150,165 21 13.98

Miami-Dade 2,651,195 171 6.45

Monroe 74,094 11 14.85

Nassau 77,218 3 3.89

Okaloosa 192,676 38 19.72

Okeechobee 40,084 5 12.47

Orange 1,265,036 191 15.10

Osceola 308,780 37 11.98

Palm Beach 1,381,632 305 22.08

Pasco 492,513 86 17.46

Pinellas 942,832 137 14.53

Polk 637,493 61 9.57

Putnam 72,633 3 4.13

Saint Johns 216,670 11 5.08

Saint Lucie 287,366 38 13.22

Santa Rosa 164,206 15 9.13

Sarasota 391,451 81 20.69

Seminole 444,123 44 9.91

Sumter 118,505 10 8.44

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County Population Number of

Opioid-Caused Deaths

Rate of Opioid-Caused

Deaths per 100,000

Suwannee 44,887 4 8.91

Taylor 23,000 1 4.35

Union 15,910 0 0.00

Volusia 508,744 84 16.51

Wakulla 31,547 1 3.17

Walton 61,665 3 4.86

Washington 25,290 3 11.86

State 19,860,805 2535 12.76

* Cause = at least one opioid was identified as the cause of death

±County= County where death occurred Examination of the county level rates for opioid-caused deaths show that only three (33%) of the top 10 counties are classified as rural. Whereas the PDPM data for opioid prescription rates show six (66%) of the top 10 counties were classified as rural. This may indicate that while prescription rates may be affecting rural counties more, urban counties are experiencing a greater rate of deaths.

Examining race and sex demographics, in 2015, we see that a vast majority of the opioid-caused deaths in Florida are white (95%) and male (65%). Age grouping (Figure 2) shows that 70% of all opioid-caused deaths in 2015 in Florida occurred between the ages of 26-55, with 26-35 year olds having a slightly higher percentage of the total deaths than other age groups.

In the first half of 2016, January to June, Florida had 1628 deaths caused by at least one opioid. If this trend continued into the second half of 2016, over 3200 deaths attributed to opioids will have occurred in Florida. This is nearly a 30% increase in opioid-caused deaths from 2015 with a rate increase from 12.76 to over 16 per 100.000 statewide. Several interventions may affect the rate of opioid-caused deaths including increased access to opioid overdose reversal kits, medications-assisted treatment (MAT), opioid use disorder

Figure 2.

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prevention interventions, and challenging the stigma associated with opioid use. Observing that higher rates of opioid prescriptions are affecting more rural counties, while higher opioid-caused death rates are affecting urban counties means that there may need to be separate prevention strategies in place for urban and rural counties. Further discussion of these opportunities will occur in multiple section of this assessment.

III.C. Current Availability of Medication-Assisted Treatment

SAMHSA publishes a list of doctors in Florida who are waivered per the Drug Addiction Treatment Act of 2000 (DATA 2000) to treat opioid use disorders with buprenorphine and who have opted to be publicly listed.6 There has been an increasing trend in the number of DATA 2000 waivered and publicly listed physicians from 2002 to 2016 (Table 4.). However, of those doctors listed, only about half are accepting new patients. Therefore, this list has limited utility for individuals seeking services and analysts attempting to gauge system-wide capacity.

Table 4: Florida DATA Waivered Physicians

The total number of waivered Florida physicians listed publicly on SAMHSA’s site is half the number of physicians listed on the www.suboxone.com site maintained by Indivior, Inc. (314 vs. 626). Unfortunately, neither of these resources provides information on the number and location of individuals who are currently being prescribed buprenorphine for opioid use disorders.

6 SAMHSA, S. A. (2016). Number of DATA-Certified Physicians – Florida. Retrieved from www.samhsa.gov/medication-assisted-treatment/physician-program-data/certified-physicians?field_Bup._us_state_code_value=F

Year Certified Physicians

with 30 Patients Certified Physicians with 100 Patients

2002 43 0

2003 44 0

2004 84 0

2005 101 0

2006 157 0

2007 187 122

2008 200 48

2009 157 76

2010 146 61

2011 122 44

2012 162 48

2013 146 64

2014 138 70

2015 193 124

2016 213 101

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However, according to a recent analysis of Florida pharmacy claims for buprenorphine formulations (without an FDA indication for treatment of pain) from 2010-2013, the median monthly patient census among Florida prescribers is 11 patients. The interquartile range, which describes the range of patients treated by the middle 50% of the distribution of prescribers, is between 4 and 30 patients.7 During this period, waivered physicians were restricted to treating up to 30 patients concurrently, or, after a year, up to 100 patients upon request (the cap was recently increased to 275). This analysis reveals that Florida prescribers, similar to their counterparts in the rest of the country, tend to treat below regulatory limits. A survey of professionals in Florida Opioid Treatment Programs (OTPs) found that only 57% reported that their agency had provided focused training regarding the adoption and use of buprenorphine to clinical staff. However, 88% reported a desire for additional training on the use of buprenorphine for opioid dependence. 8

There are 52 methadone OTPs in Florida with a varying degree of services. Some clinics

provide access to buprenorphine and/or naltrexone while others provide only methadone, some

accept Medicaid while others do not, and some offer a comprehensive array of recovery

supports while others only provide the mandated counseling. Table 5 displays the county

location, corporation type and annual census of Florida’s OTPs.

Table 5: OTP Providers

County Program Name Corporation Status Annual Census

Average Per Central Registry

Palm Beach Access Recovery Solutions, LLC Florida LLC 135

Escambia Lakeview Center Inc. Century Clinic Florida Not For Profit

Corporation 78

Escambia Lakeview Center Inc. Shalimar Florida Not For Profit

Corporation 246

Escambia Lakeview Center, Inc. Pensacola Florida Not For Profit

Corporation 299

Alachua Meridian Behavioral Healthcare, Inc.

- Gainesville Florida Not For Profit

Corporation 352

Columbia Meridian Behavioral Healthcare

Lake City Florida Not For Profit

Corporation 152

Duval River Region Human Services, Inc.

JAX Florida Not For Profit

Corporation 777

Clay River Region Human Services, Inc.

JAX (Satellite) Florida Not For Profit

Corporation

Hernando Operation PAR ( MAPS) Hernando Florida Not For Profit

Corporation 404

Orange The Center for Drug Free Living

/Orlando (Aspire Health Partners) Florida Not For Profit

Corporation 147

7 Stein, D. B. (2016). Physician Capacity to Treat Opioid Use Disorder with Bup.renorphine-Assisted Treatment. . JAMA, 316(11),

1211-1212. 8 FMHI, F. M. (2012). Key Informant Survey of the Adoption of Innovation: Focus on the Use of Buprenorphine-Containing Medications in Opioid Treatment Programs in Florida. . Agency for Health Care Administration Series, 220-149.

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County Program Name Corporation Status Annual Census

Average Per Central Registry

Miami-Dade Comprehensive Psychiatric Center

(Central) Florida For Profit

Corporation 58

Miami-Dade Comprehensive Psychiatric Center

(North) Florida For Profit

Corporation 107

Miami-Dade Comprehensive Psychiatric Center

(South) Florida For Profit

Corporation 104

Manatee Operation PAR Medication Assisted

Patient Services Bradenton Florida Not For Profit

Corporation 621

Pinellas Operation PAR Medication Assisted

Patient Services Clearwater Florida Not For Profit

Corporation 819

Lee Operation PAR Medication Assisted

Patient Services FT Myers Florida Not For Profit

Corporation 1080

Pasco Operation PAR Medication Assisted

Patient Services Port Richey Florida Not For Profit

Corporation 716

Sarasota Operation PAR Medication Assisted

Patient Services Sarasota Florida Not For Profit

Corporation 415

Charlotte Operation PAR Port Charlotte MAPS

Clinic (Satellite) Florida Not For Profit

Corporation

Pinellas Operation PAR -St Petersburg Clinic

(Satellite) Florida Not For Profit

Corporation

Brevard Central Florida Treatment Center

/Cocoa Florida Profit Corporation

382

Orange Central Florida Treatment Center/

Orlando Florida Profit Corporation

319

Brevard Central Florida Treatment Center/

Palm Bay Florida Profit Corporation

267

Polk Lakeland Centers Florida Florida Profit Corporation

140

St. Lucie Central Florida Treatment Center /Ft

Pierce Florida Profit Corporation

206

Palm Beach Central Florida Treatment Center/

Lake Worth Florida Profit Corporation

243

Bay Bay County Healthcare Treatment

Center of Panama City Foreign LLC 727

Duval Parkside Clinic, LLC Foreign LLC 232

Pinellas Lakeside Clinic, LLC Foreign LLC 78

Leon Leon Metro Treatment of Florida, LP Foreign Limited

Partnership 351

Escambia Metro Treatment of Florida, LP

Pensacola Foreign Limited

Partnership 905

Duval Duval County Treatment Center Foreign Limited

Partnership 247

Duval Jacksonville Metro Treatment

Center Foreign Limited

Partnership 1376

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County Program Name Corporation Status Annual Census

Average Per Central Registry

Duval North Florida Treatment Center Foreign Limited

Partnership 131

St. Johns St Augustine Metro Treatment

Center Foreign Limited

Partnership 408

Volusia Metro Treatment of Florida, LP

Daytona Foreign Limited

Partnership 955

Osceola Mid Florida Metro Treatment Center

Kissimmee Foreign Limited

Partnership 391

Orange Orlando Methadone Treatment

Center Foreign Limited

Partnership 1114

Marion Quad County Treatment Center

Ocala Foreign Limited

Partnership 667

Broward Broward Treatment Center Foreign Limited

Partnership 429

Broward Metro Treatment of Florida, LP

Pompano Foreign Limited

Partnership 384

Palm Beach Metro Treatment of Florida, LP

West Palm Foreign Limited

Partnership 516

Broward Sunrise Treatment Center Sunrise Foreign Limited

Partnership 240

Pinellas Bay Area Treatment Center Pinellas

Park Foreign Limited

Partnership 135

Collier Naples Metro Treatment Center Foreign Limited

Partnership 292

Sarasota Sarasota Metro Treatment Center Foreign Limited

Partnership 379

Pinellas St Petersburg Metro Treatment

Center (Satellite) Foreign Limited

Partnership

Hillsborough Tampa Metro Treatment Center Foreign Limited

Partnership 576

Lee Metro Treatment of Florida, L.P. Foreign Limited

Partnership 26

Polk DACCO, Opiate Addition Treatment

Services Not for Profit Corporation

26

Hillsborough DACCO, Opiate Addiction Treatment

Services Tampa Not for Profit Corporation

729

The 52 OTPs are unevenly spread amongst Florida’s 67 counties with only 26 (39%) counties having at least one full service clinic (two additional counties have a satellite clinic). Only one OTP is located in a rural county. In the 10 counties with highest opioid-caused death rates in 2015 there are 11 OTPs, but 3 counties without an OTP. In the 10 counties with highest opioid prescription rates in 2016, only 2 OTPs exist. OTPs in Florida are largely concentrated in the southern part of the state and along the coastal regions leaving a large portion of the state without access to an OTP and methadone (Figure 3.).

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There is limited data on and connecting prescribers, treatment providers, and recovery supports. This gap makes it challenging to determine how services like medication therapy, treatment, and recovery supports are being integrated to provide a holistic recovery approach. For individuals in rural areas services and providers may not be available. An effort to increase services in these areas should be made. If there is a local treatment provider, having a connection with a distant prescriber could reduce transportation issues while providing additional treatment oversight for those considering engaging MAT.

III.D. Estimated Treatment Need in Florida

III.D.(1) Population Estimates: 19,860,805

2015 Population estimates were exported (Population by Age by County) from the Florida Health Charts website (http://www.flhealthcharts.com/FLQUERY/Population/PopulationRpt.aspx) on June 13th, 2017. These population estimates are provided by the Department of Health, Office of Health Statistics and Assessment in consultation with the Florida Legislature's Office of Economic and Demographic Research (EDR).

Figure 3.

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III.D.(2) Estimated Number of Past-Year Nonmedical Pain Reliever Users

Nonmedical prescription pain reliever users (or misusers) are a population at risk of experiencing an opioid use disorder. The National Survey on Drug Use and Health (NSDUH), an annual survey sponsored by SAMHSA, collects data from a representative sample of the non-institutionalized household population through face-to-face interviews, but age is the only demographic variable with publicly-available subgroup estimates. The table below shows the most currently available estimates of past-year prevalence of nonmedical pain reliever use, by ME region, for all age groupings, based on aggregated, combined NSDUH data from 2012-2014.

Table 7: Estimated Past-Year Prevalence of Nonmedical Prescription Pain Reliever Use, by Age Group (2012-2014)

Managing Entity

Ages 12+ Ages 12-17

Ages 18+ Ages 18-25

Ages 26+

BBHC 3.4% 4.4% 3.3% 7.6% 2.7%

CFCHS 3.6% 4.5% 3.5% 7.6% 2.7%

CFBHN 3.4% 4.4% 3.3% 7.8% 2.7%

LSFHS 3.6% 4.4% 3.5% 8.2% 2.8%

BBCBC 4.1% 4.7% 4.0% 8.5% 3.1%

SFBHN 2.9% 4.1% 2.8% 5.6% 2.4%

SEFBHN 3.4% 4.3% 3.3% 8.3% 2.6%

Entire State of Florida

3.4% 4.4% 3.3% 7.6% 2.7%

III.D.(3) Estimated Last Year Opioid Use Disorder

SAMHSA recently provided Florida-specific NSDUH estimates of the prevalence of past-year opioid abuse or dependence and the unmet need for treatment.9 Multiple years of data were pooled to increase the precision of the estimates. The table below depicts an increase in the prevalence of opioid abuse or dependence from 6.7% to 7.8% from 2003-2006 to 2011-2014. The estimated number of individuals with an opioid use disorder that did not receive treatment at a specialty facility was 92,000 for the 2003-2006 period and 101,000 for the 2011-2014 period.

Table 8: Past Year Opioid Abuse or Dependence, and Unmet Treatment Need among Floridians Ages 12 and Older (2003-2014)

2003-2006 2007-2010 2011-2014

Opioid Abuse or

Dependence

6.7% 7.7% 7.8%

Unmet Need for

Treatment

92,000 105,000 101,000

9 Substance Abuse and Mental Health Services Administration. (2017). Past Year Opioid Use and Abuse or Dependence, and Not

Received Treatment at a Specialty Facility and Opioid Abuse or Dependence in Past Year Annual Averages Based on 2003-2006, 2007-2010, and 2011-2014. Provided by Jonaki Bose (NSDUH Branch Chief) and Deepa Avula (SAMHSA).

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III.D.(4) Estimated Number of Life-Time Heroin Users

Individuals who use heroin are also at risk of experiencing an opioid use

disorder. The most recently published state-level estimates from NSDUH are

based on 2014-2015 data.10

Table 9: Estimated Past-Year Prevalence of Heroin Use

and Number of Heroin Users (2014-2015)

Age Group Prevalence of Heroin Use Number Heroin Users

12+ 0.22% 38,000

12-17 0.07% 1,000

18-25 0.60% 12,000

26+ 0.18% 25,000

18+ 0.24% 37,000

IV. PROGRAMMATIC CAPACITY

A meta-analysis of 11 randomized clinical trials involving 1,969 heroin dependent participants found that methadone is the most effective way to retain individuals in treatment and reduce heroin use (as measured by self-reports and urine/hair analysis). 11 There are 52 methadone clinic sites throughout Florida, including both full clinics and satellite clinics. Not for profit corporations operate 21 of these sites (Table 5.). According to an analysis of survey responses from 359 individuals receiving methadone from publicly-funded clinics throughout Florida, the cost of self-pay was the most frequently cited problem that interfered with treatment compliance.12 Additionally, according to an analysis of 10 years of discharge records, 3,892 methadone recipients were discharged due to inability to pay or loss of insurance coverage (or nearly 390 per year on average). Researchers from the Florida Mental Health Institute analyzed survey responses from 45 professionals who make clinical or administrative decisions regarding service delivery in publicly-funded OTPs across 12 counties in Florida. About half of the individuals served in these programs were self-pay and about half were covered by Medicaid. Most respondents (88%) reported that their clinic prescribed buprenorphine, but the vast majority (95%) reported that buprenorphine was “rarely/never” prescribed at their site. About 68% reported that when it was prescribed, it was on a case-by-case basis. Approximately 86% of respondents indicated that clients do not choose buprenorphine due to the additional personal expense. Qualitative

10 Substance Abuse and Mental Health Services Administration. (2017). National Survey on Drug Use and Health: Selected Measures in Florida Based on 2014-2015 NSDUHs. Retrieved from www.samhsa.gov/data/sites/default/files/NSDUHsaeStateTabs2015B/NSDUHsaeFlorida2015.pdf. 11 Mattick, R. P. (2009). Methadone Maintenance Therapy versus No Opioid Replacement Therapy for Opioid Dependence. . The Cochrane Library, p. Issue 3. 12 FMHI, F. M. (2012). Assessing Satisfaction in Opioid Treatment Programs in Florida. . Series 220-148: Agency for Health Care Administration.

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responses reflected the perception that the cost of the medication was the primary barrier to wider adoption by individuals served:

Qualitative responses generated by program staff communicated concern that “clients can barely pay $12 a day to dose with self-pay, $2 with Medicaid, and $8 with Medicare. Why would they be able to pay $16+ for alternative medications?” They added that “$28 more per week” adds up to “$1,400 more per year” and that this additional expense would “hinder their ability to provide food and shelter” and interfere with their ability to cover “transportation, childcare, and additional medical expenses.” Their overwhelming position is that the cost passed on to the client makes it a prohibitive option based on current reimbursement strategies.

Additionally, 26% of the individuals served reported taking buprenorphine at some time in the past, and the majority of these reported they ceased taking it (namely Suboxone) due to the price or limitations of their insurance (particularly Medicaid). Only 5.3% of buprenorphine prescriptions in Florida are funded by Medicaid, giving Florida the third lowest share of buprenorphine prescriptions funded by Medicaid out of all 50 states and the District of Columbia. Nationwide, on average, Medicaid covers about 24% of buprenorphine prescriptions.13 In a report released June 29, 2017 from Blue Cross and Blue Shield, only 29% of Florida Blue Cross Blue Shield members with an opioid use disorder received MAT in 2016.14 A recent study compared the rate of past-year opioid abuse or dependence (using combined 2009 to 2012 restricted-use NSDUH data) among Floridians ages 12 and older (7.7 per 1,000) to the maximum number of individuals who could be treated with buprenorphine in Florida (4.2 per 1,000) and found buprenorphine is potentially available to only about half of the people who might need it.15 The gap in access and available buprenorphine coverage could put those with opioid use disorder at risk for relapse or overdose. For the existing capacity for MAT, 52 methadone OTPs self-report serving approximately 19,380 individuals a year. The 19 sites that are registered as not-for-profit serve 6,861 individuals. In January 2017, a survey request made by the Department to non-profit OTP’s, the providers identified 541 individuals receiving buprenorphine. Other provider types, such as community behavioral health providers, have increased access to buprenorphine over the past several years, but are not using Department funding for the medication. This presents a data challenge for the Department and lack of certainty around treatment capacity outside of the safety net. Additional data collected through the Agency for Health Care Administration from the 13 Florida Medicaid managed care plans identified 4,307 individuals on buprenorphine or buprenorphine/naloxone and 62 through Fee for Service for 2016. From January 1, 2017

13 Informatics., I. I. (2016). Use of Opioid Recovery Medications: Recent Evidence on State Level Buprenorphine Use and Payment Types. Retrieved from Institute for Healthcare Informatics: www.imshealth.com/files/web/IMSH%20Institute/Reports/Healthcare%20Briefs/IIHI_Use_of_Opioid_Recovery_Medications.pdf. 14 BCBS, B. C. (2017). America's opioid epidemic and its effect on the nation's commercially-insured population. Retrieved from https://www.bcbs.com/the-health-of-america/reports/americas-opioid-epidemic-and-its-effect-on-the-nations-commercially-insured

15 Jones, C. M.-K. (2015). National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment. American Journal of Public Health, 105(8), e55-e63

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through June 18, 2017, data collected identified 3,083 individuals on buprenorphine or buprenorphine/naloxone. Initiating buprenorphine treatment for opioid use disorders in emergency department with primary care office-based follow-up is an effective way to expand access to treatment. Research shows that only 40% of individuals that experience an opioid-related hospitalization receive any follow-up services within 30 days. Only 10.7% of individuals receive the recommended combination of both medication and a therapeutic service.16 These findings only apply to individuals with private insurance. It is reasonable to assume that post-discharge care coordination is more challenging for individuals without insurance. Florida recently enacted a requirement for hospitals with emergency departments to develop best practice policies that focus upon the prevention of unintentional drug overdoses.

V. PREVENTION AND RECOVERY INITIATIVES

V.A. Overdose Prevention

The Department conducted a prevention system analysis during February 2016 for the Partnerships for Success (PFS) grant application. At the time, only three prevention providers reported that they are engaged in training and promotional activities related to naloxone. When surveyed about the kind of infrastructure/capacity improvements needed to more effectively respond to prescription drug abuse and heroin use, the most commonly cited need was training regarding the use of naloxone by paramedics, law enforcement officers, and other first responders, including caregivers. Florida’s STR project is designed to enhance the infrastructure and strengthen the capacity of the state’s prevention and treatment system to disseminate information regarding overdose recognition and response, conduct naloxone trainings, and implement other life-saving components of SAMHSA’s Opioid Overdose Prevention Toolkit. Florida’s Emergency Treatment and Recovery Act allows health care practitioners to prescribe and dispense naloxone to individuals at risk of experiencing an opioid overdose and bystanders/caregivers who might witness an overdose. Effective July 1, 2016, Florida pharmacies are authorized to dispense naloxone under non-patient specific standing orders to individuals without a prescription. In light of these statutory changes, coupled with the fact that Florida did not have an active network for naloxone training or distribution, the Department began implementing an Overdose Prevention Program in January of 2016. Overdose recognition and response training has been conducted for over 1,600 individuals, including drug treatment provider staff, community members, law enforcement officers, SAMH regional and ME staff, the recovery community, physicians, nurses, pharmacists, and other health care professionals. Approximately $294,000 in Substance Abuse Prevention and Treatment Block Grant funds were utilized to purchase 2,448 NARCAN® Nasal Spray kits in state fiscal year 2016-17. The NARCAN® kits were distributed to thirteen publicly-funded drug treatment providers who expressed willingness and capacity to distribute the medication to persons served at risk of witnessing or experiencing an opioid overdose. Distribution of NARCAN® to drug treatment providers began in August 2016 and stopped in December 2016 due to the depletion of supply and a lack of funds to purchase additional kits. In order to stretch limited

16 Ali, M. M., & Mutter, R. (2016). The CBHSQ Report: Patients Who Are Privately Insured Receive Limited Follow-up Services After Opioid-Related Hospitalization.

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resources, drug treatment providers submitted reduced NARCAN® orders. However, many providers did not receive kits due to the lack of supply. With regard to gaps in the data infrastructure, prevention providers most frequently cited a need for data from Emergency Medical Services on overdose calls and naloxone reversals. The next most cited needs were for data on overdoses treated in hospital emergency departments and data on physician utilization of the Prescription Drug Monitoring Program. Furthermore, the need to have a functioning local Drug Epidemiology Network (DEN) was identified. Local DENs operate within anti-drug coalitions to help community stakeholders gain a comprehensive understanding of local consumption patterns, consequences, risk and protective factors, and contributing conditions. They can serve as sentinels for detecting emerging drug threats. DENs are also supposed to help analyze and disseminate surveillance data for use in the development of local polices, practices, strategies, and programs. Gaps in the data are expected to be solved through the revitalization of the State Epidemiology Outcomes Workgroup (SEOW) via Florida’s PFS grant. The PFS grant also funds the development and implementation of DENs in each of the eight PFS-funded counties. The Department has conducted 50 overdose prevention and naloxone trainings since the first training on August 3, 2016 through the most recent training on June 9, 2017. Trainings have been conducted both in-person and via webinar, and have included 1,602 participants. Overdose prevention training participants include substance abuse treatment provider staff, mental health treatment provider staff, law enforcement officers, pharmacists, nurses, nurse practitioners, social workers, physicians, addiction counselors, peer recovery specialists, prevention providers, harm reduction organizations, medical students, SAMH regional staff, Managing Entity staff, and other health care professionals.

Purchasing and distribution resumed in April and May 2017 due to the availability of additional surplus funding. Prior to the STR Grant, NARCAN kits were only offered to substance abuse and mental health treatment providers, which represented a significant gap in Florida’s naloxone distribution network. The breakdown of surplus funding utilized to purchase NARCAN prior to Florida’s STR award is provided below (Table 6.). The number of kits purchased has varied over time due to changes in price of NARCAN Nasal Spray.

Table 6: NARCAN Purchase and Distribution

State Fiscal

Year

Funding Source Amount Date Purchased

(Month and Year)

# of Kits Purchased

15-16 Substance Abuse

Treatment Block

Grant

$224,000 April 2016 2,448 kits

15-16 General Revenue $70,000

16-17 Substance Abuse

Treatment Block

Grant

$94,234 April 2017 1,327 kits

16-17 General Revenue $120,000 May 2017 1,690 kits

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Total $508,234 5,465 kits

Overdose prevention training, along with NARCAN purchasing and distribution, is resuming

through Florida’s STR Grant, which allows for $1,732,500 per year to be utilized for these

activities. The most significant gap regarding Florida’s naloxone distribution network is a lack of

community-based naloxone distribution, especially in counties with the highest number and

rates of opioid overdose deaths. While providing NARCAN kits to patients and their caregivers

upon discharge and/or enrollment in treatment is a targeted approach, many individuals with an

opioid use disorder are not receiving treatment services, and therefore would not have access

to take-home NARCAN kits. Additionally, without organizations providing ongoing free access to

naloxone in the community, individuals who receive take-home kits from treatment providers do

not have access to follow-up kits if the original take-home kit was used. Through Florida’s STR

grant, providers eligible to receive kits from the Department for distribution will no longer be

limited to contracted substance abuse and mental health treatment providers, and will expand to

include any non-profit organization that serves individuals at risk of witnessing or experiencing

an opioid overdose. For-profit organizations that contract with one of the Department’s

Managing Entities will also be eligible to receive kits for distribution. Through a partnership with

the Florida Department of Law Enforcement, the Department will also provide $375,000 of STR

funds per year to local law enforcement agencies to equip officers with the medication to

effectively respond to opioid overdoses in the field.

V.B. Primary Prevention

Substance Abuse Prevention and Treatment Block Grant funds provide primary prevention funding allocated to local prevention coalitions and service providers. According to an analysis of survey responses recently received from 42 prevention providers, the most commonly implemented opioid misuse prevention activities are designed to reduce the supply of prescription drugs available for theft, diversion, and misuse. These activities include safe storage and disposal campaigns, participation in drug “Take-Back” events, the establishment of prescription drug drop boxes, and the provision of lock boxes and drug deactivation systems. The second most prevalent set of prevention activities are information dissemination and community education. Safe use, safe storage, and safe disposal messages are typical components of these awareness campaigns. The Department was awarded the Strategic Prevention Framework – Partnerships for Success (SPF-PFS) grant in July 2016 to reduce prescription drug misuse among Floridians ages 12-25 and the nonmedical use of opioids among Floridians ages 26 and older and strengthen prevention capacity and infrastructure at the state and community levels. Florida’s PFS subrecipient communities include five urban counties (Broward, Duval, Hillsborough, Manatee, and Palm Beach) and three rural counties (Franklin, Walton, and Washington). School- and family-based prevention programs that effectively reduce prescription drug misuse will be implemented in rural counties to prevent the initiation of prescription drug and opioid use. Local Drug Epidemiology Networks will be developed and integrated into the State Epidemiological Outcomes Workgroup (SEOW), and members of the SEOW will develop county-level reports on naloxone reversals by paramedics and EMTs, prescription drug and

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heroin exposures from Florida Poison Control Centers, and non-fatal opioid poisonings in hospital emergency departments. Florida’s PFS project also includes enhancements to the state Prescription Drug Monitoring Program (PDMP) to modify prescribing practices and increase voluntary prescriber utilization. Enhancements include customized alerts, prescriber report cards, a self-paced online training course, and a naloxone co-prescribing alert for high-risk patients. County-specific data reporting templates will also be developed to help inform community-based prevention activities and modify prescribing practices. All of these components are designed to increase the percentage of physicians that voluntarily consult the PDMP prior to writing prescriptions for controlled substances, reduce the number of patients obtaining controlled substance prescriptions from five or more prescribers and five or more dispensers, and reduce the number of patients receiving concurrent prescriptions of opioids and sedatives Based on the data presented earlier, the Department has determined a need to expand school-based prevention programs in high-need rural counties using the evidence-based prevention program LifeSkills® Training.

V.C. Recovery Initiatives

The Florida Certification Board (FCB) built the first legally defensible certification for peers in the country. The Department of Children and Families has dedicated a full-time position to champion recovery support and enhancing the peer recovery specialist workforce throughout the state. In 2016, the Department published the Florida Peer Services Handbook , authored by certified peer recovery specialists, to provide guidance for the implementation and sustainability of peer delivered services. Florida has a number organizations focusing on recovery. Statewide, Florida continues to expand their Peer Recovery Coaches/Specialists. As of June 2017, there are 418 active certifications for Certified Recovery Peer Specialists statewide. It is unknown how many of these individuals are currently employed with community providers. The Department owns the copyright to a peer training curriculum, Helping Others Heal. This comprehensive curriculum meets the 40 hour educational standards set forth by the Florida Certification Board, to obtain credentialing as a Certified Recovery Peer Specialist. There are 37 Peer Facilitators statewide, endorsed by the Department to deliver and provide the 40 hour Helping Others Heal Peer training. The Peer Support Coalition of Florida is a non-profit peer-run organization. The PSC provides wellness and recovery training and educational opportunities for peers, with over 300 individuals trained since July 2016. Membership continues to steadily grow, with over 700 active members. In July 2017, the Department contracted with the coalition to support STR Project activities, including six 2-day Introduction to WRAP for Addictions workshops targeting individuals receiving MAT services. The Department’s SAMH Leadership conducted regional site reviews in 2017 to identify care coordination strategies used in the regions. Part of the review assessed the level of integration of peer recovery specialist into systems of care. Interviews were held at multiple levels and a draft report is currently being reviewed. Based on the preliminary findings, additional training and education on use of peer recovery specialist as part of the recovery process will need to continue statewide. While some regions were more effective in the deployment of peer recovery specialists, others lacked a deeper integration into the services. Much of this could be attributed to a lack of understanding of the merits and how to operationalize these positions. A baseline has been established to address these gaps moving forward

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From September 2016 through January of 2017, the Department held a series of summits in all regions of the state to generate discussion on how to approach implementing a Recovery-Oriented System of Care (ROSC) approach throughout the state. The ROSC model leverages peer support specialist as an integral part of engaging individuals seeking recovery. Over 800 people attended 10 statewide summits. Stakeholders included; system administrators, service providers, people with behavioral health conditions and family members. Achara Consulting, Inc. developed a white paper based on the findings from the summits and next steps for addressing increase of recovery orientation throughout the state. The PFS and Opioid STR projects will implement of three care coordination pilot programs in hospital emergency departments. These pilot programs will use peer specialists to link overdose victims discharged from the hospital to drug treatment providers.

VI. POLICY, LEGISLATIVE AND SOCIAL-POLITICAL ENVIRONMENT FOR THE

OPIOID CRISIS AND MEDICATION-ASSISTED TREATMENT

Florida’s 911 Good Samaritan law became effective October 1, 2012 (s. 893.21, F.S.). The law provides limited protections for individuals experiencing an overdose, and to those who seek help during an overdose. Specifically, individuals who experience an overdose and receive emergency medical assistance, as well as individuals who seek help for someone believed in good faith to be experiencing an overdose, may not be charged, prosecuted, or otherwise penalized for possession of controlled substances (if the evidence of controlled substance possession was obtained due to the individual seeking or receiving medical assistance). Florida’s 911 Good Samaritan statute has its limitations. Individuals who seek help for an overdose or experience an overdose are not protected from arrest, and individuals on probation or parole are provided no protections under the current law. These limitations likely result in some individuals still hesitating to call 911 during an overdose due to fear of arrest or fear of police involvement. As described earlier, in 2009 s.893.055, F.S., created the PDMP within the Department of Health to encourage safer prescribing of controlled substances and to reduce drug abuse and diversion within the state of Florida. In 2016, Florida Legislature passed Senate Bill 964 authorizing direct access to controlled substance dispensing information within the E-FORCSE® database to a designee of a prescriber or dispenser. This addition to the statute allows for an additional designee for prescribers or dispensers to review prescribing histories creating greater access. The pharmacy dispensing the controlled substance and each prescriber who directly dispenses a controlled substance is required to submit to the electronic system. However, there is no mandate for prescribers to consult the PDMP for a patient’s opioid history before prescribing. Florida’s Emergency Treatment and Recovery Act became law effective July 1, 2015, and was later expanded during the 2016 legislative session (s.381.887, F.S.). The law allows for emergency opioid antagonists (naloxone hydrochloride) to be prescribed and dispensed to individuals at risk of experiencing an opioid overdose, as well as to bystanders, first responders, caregivers, and others who may witness an opioid overdose and have an opportunity to intervene and save a life. As of July 1, 2016, pharmacists are also authorized to dispense naloxone under non-patient specific standing orders to individuals at risk of witnessing or experiencing an opioid overdose but does not mandate the practice. The non-patient specific

27

standing orders are limited to naloxone in the form of auto-injectors or nasal sprays, which is concerning since generic intramuscular naloxone is the most affordable product, especially for underinsured and uninsured individuals. The statute provides civil and criminal liability protections for authorized health care practitioners and pharmacists who prescribe and dispense naloxone. Emergency responders, bystanders, patients (at risk of experiencing an overdose), and caregivers (who may witness an overdose) are authorized to possess, store, and administer naloxone to someone believed in good faith to be overdosing. Florida Governor Rick Scott issued Executive Order 17-146 on May 3, 2017, declaring the opioid epidemic a public health emergency in the state and authorizing the Florida Department of Children and Families to immediately draw down SAMHSA’s STR funding. Because of the Executive Order, Florida’s Surgeon General issued a statewide naloxone standing order, authorizing all pharmacies to dispense naloxone to law enforcement officers. Members of the public at risk of witnessing or experiencing an opioid-related overdose were not included in the Surgeon General’s statewide naloxone standing order, representing a significant barrier in naloxone access among community members. The Governor’s Executive Order was extended on June 29, 2017 for an additional 60 days. Since 2014, the Florida Legislature has appropriated several millions in general revenue funds specifically for the provision of VIVITROL®, an extended release formulation of naltrexone that is FDA-approved for the prevention of relapse of opioid dependence. VIVITROL blocks the effects of opioids, including heroin and opioid pain medications. The Florida Alcohol and Drug Abuse Association (FADAA) administers these funds allocated to the Department of Children and Families and the Office of State Courts Administrator. Since FADAA’s VIVITROL program began, over 4,000 VIVITROL injections have been administered to 1,431 individuals, and 42 providers have become enrolled participants.

A number of counties throughout Florida have formed task forces to address the opioid epidemic in the state. A list of counties with task forces focusing on prescription drug and/or opioid misuse and associated consequences is provided below: (*Indicate counties currently with active DENs via the PFS grant)

• Alachua

• Broward*

• Bradford

• Duval *

• Franklin*

• Hernando

• Hillsborough*

• Lake

• Manatee*

• Marion

• Miami-Dade

• Nassau

• Orange

• Palm Beach* (Heroin Task Force and Sober Home Task Force)

• St. Johns

• Volusia

• Walton*

• Washington*

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VII. EVIDENCE-BASED AND EVIDENCE-INFORMED PREVENTION PRACTICES,

AND PROMISING PRACTICES

As discussed earlier, Florida is currently implementing SAMHSA’s PFS grant with the goals to reduce prescription drug misuse among individuals ages 12-25, reduce the nonmedical use of opioids among individuals ages 26 and older, and increase the public’s knowledge on overdose recognition and response. LifeSkills® Training (LST) school-based prevention that effectively reduce prescription drug misuse are being implemented in each PFS county. The three rural counties are implementing two LST programs each, and the five urban counties are implementing one LST per county. Additionally, federal grant funding was used to support the STOP ACT program, providing evidenced based programs in the schools and communities statewide to strengthen resiliency. In 2016, 420,922 youth participated in these programs.

Florida’s block grant funded the promotion of statewide and community media messages,

campaigns, and fact sheets around preventing underage drinking and alcohol misuse. Youth

today are continuously using social media as an outlet to promote messages in substance

abuse prevention.

Some of the tools being used:

• FYSonline.com this tool can capture data and provide information.

• Digital story telling (Photovoice, voice thread, YouTube, and movie maker) Photovoice

and digital story telling is a process by which people can identify, represent, and

enhance their community through a specific photographic technique.

• Social media apps (snap chat, Facebook, Instagram, and YouTube)

Additionally, 2017 Florida block grant funding for evidenced base programs include Too Good

for Drugs and Violence, Alcohol Literacy and Parents Who Host Lose the Most. Primary focus

for these programs is to bring education and awareness to the students regarding alcohol,

tobacco and other drugs.

VIII. SPECIAL POPULATIONS

Florida is home to two federally recognized tribes; Seminole and Miccosukee. Phone messages

to their behavioral health services were left and letters were sent to each Tribal Chairman

explaining the goals of the STR project and a request to participate in assessing their needs if

desired. The Project Director attended a meeting with the Executive Director of the Florida

Governor’s Council of Tribal Affairs, Inc. to provide an STR project overview and ascertain

direction on how to best engage the tribes. To date, neither tribe has requested any follow up.

We recommend that the Department remain available for consultation with the tribes if they

choose to discuss further.

The Department requested from the Florida Department of Corrections (DOC) any needs they

thought fell within the STR project. To date, the Department has not received any follow up. We

recommend that the Department remain available to discuss any needs that DOC may be

considering.

Florida’s jails are primarily operated by County Sheriff Departments. Those not run by a

sheriff’s office are run by some type of county entity. The Department reached out to both

29

through the Florida Sheriffs’ Association and Florida Association of Counties to determine needs

regarding reentry. Of the sixty-seven counties, sixteen would like to offer MAT if funding came

available, nine currently have a MAT program and the reported unmet need from all programs

was 900. County jail discharges are more fluid than state correction institutes, which may

require a higher degree of planning. The BBCBC ME has engaged some of the local jails to

implement MAT programs as part of the re-entry process. The Department and MEs will

continue to work with jail entities to best identify their needs to integrate MAT into their release

process.

Currently, Florida’s child welfare system does not identify parents using opioids compared to other drugs or alcohol. Anecdotally, the field staff report that many of the families are struggling with opioid addiction. An analysis of the child welfare data system completed in December 2016 showed that 21,086 children in the child welfare system in 2015-16 had at least one parent with a substance use disorder. Of these children, 53.8% were age five and under showing a potentially devastating impact on not only the parent’s health but the child’s development as well. This gap in opioid use disorder identification may mean that many parents may not have access to effective MAT services to address their disorder. Additionally, the children could be affected by lack of an adequate intervention.

In the Southwest portion of the state where opioid use has been a very serious problem, a behavioral health program collaborated with the child welfare system and staffed behavioral health consultants within the child welfare units. The behavioral health consultants are licensed therapists and provide consultation, assistance in identification of substance use disorders including those with opioid disorders, outreach and engagement services, and linkages to treatment. Although these positions have only been in place for less than a year and adequate data has not been collected on their impact, the child protective investigative staff report that their assistance is extremely beneficial. Florida’s STR project will implement behavioral health consultants in every region of the state.

IX. ADDITIONAL FINDINGS

Development of a robust telehealth system statewide could address gaps in rural counties where transportation and driving time can be an issue. The Department of Health and the Agency for Health Care Administration conducted a survey of agencies and providers to understand the prevalence, gaps and barriers for telehealth, findings of which can be accessed through the Florida Telehealth Survey Report. Programs and providers identified barriers including concerns about reimbursement for services, lack of funding, interoperability between electronic records systems and limited buy-in from providers and leadership. By addressing these barriers, Florida could close gaps in telehealth. Reported benefits for those currently using telehealth included; patient convenience, better care coordination, better patient outcomes and filling local coverage gaps. By connecting individuals with prescribers and providers through telehealth MAT, access would increase.