Clinical Advisory  Clinical Advisory on Opioid Deaths

Date:	08/16/2018
Organization:	Bureau of Health Professions Licensure Bureau of Substance Addiction Services
Referenced Sources:	105 CMR 164.00: Licensure of substance use disorder treatment programs

RE: Clinical Advisory

To: Health Care Providers
From: James G. Lavery, Director, Bureau of Health Professions Licensure
Date: August 16, 2018
Re: Clinical Advisory

Dear Providers,

Thank you for your vital role in providing quality health care to the citizens of our Commonwealth. As you are aware, Massachusetts has one of the highest rates of opioid use disorder in the country and this is having a devastating impact on our patients and communities. While your primary role may not be associated directly with this epidemic, we know that all providers have a role to play, and may at any time encounter someone seeking assistance.

We would like to share clinical advisories that were recently sent to the substance addiction providers that might also be helpful to you in your practice.

Increase in Opioid-Related Overdose Deaths with Cocaine Present:

When analyzing opioid overdose deaths, we have become aware that a significant portion of the deaths are associated with concurrent cocaine use. We believe this information is useful for you in your clinical work. Additionally, patients should be aware that polysubstance use can NOT be a reason for refusal for admission in the treatment system. Patients with SUD have specific rights and should be aware of the complaint line for issues they encounter in the treatment system. A complaint line posting is also attached.

The Massachusetts Substance Use Helpline has been improved in the last few years to allow for clinicians to gain information in new ways. Additionally, patients can access bed availability and other resources in more updated ways through the phone number or website. The helpline can be reached at [phone] or https://helplinema.org/

Re: Clinical Advisory and BSAS Complaint Line reminder

To: All BSAS Licensed and Contracted Providers
From: Allison F. Bauer, Director, Bureau of Substance Addiction Services (BSAS)
Date: June 22, 2018
Re: Clinical Advisory and BSAS Complaint Line reminder

Dear Providers:

The intent of this memo is to bring two important issues to your attention: 1) appropriate steps to take in response to the Department of Public Health (DPH) Clinical Advisory issued on June 22, 2018, and 2) a reminder of the requirement to post the BSAS Complaint Line.

Much progress has been made both in expanding services across the state and in improving timely access to treatment and we thank you for your dedication to serving the Commonwealth. As Providers it is important to remain aware of the dangers facing the individuals we serve.

1. The DPH Clinical Advisory dated June 22, 2018, reports an increase in Opioid Related Overdose Deaths with Cocaine present. The Department of Public Health Bureau of Substance Addiction Services (BSAS) is urging all BSAS licensed and contracted providers to be aware of the presence of fentanyl in other illicit drugs such as cocaine and that there is an increased risk of opioid overdose for people who use cocaine with fentanyl present.
   
   As a reminder, all licensed and contracted providers are required to appropriately assess and use all available screening tools for all individuals regardless of the substance which they are using. This is including, but not limited to opioids, cocaine and alcohol, in accordance with Department of Public Health regulations and provider contract agreements. No individual seeking treatment should be denied access based solely on the type of primary substance used. DPH BSAS may take action against programs that have a substantiated violation of this policy.
   
   Furthermore, we are asking providers to educate clients and staff regarding the presence of fentanyl in cocaine, as well as other illicit substances. Additional information and recommendations are included in the attached Clinical Advisory.
    
2. As a reminder, providers are required to post the BSAS Complaint Line Posting in all patient waiting rooms and post in a visible location within your programs. This posting highlights the regulatory and/or contractual obligation each provider has to ensure the proper assessment of all individuals seeking treatment for a substance use disorder and to ensure individuals are connected to the correct level of care if denied admission. Additionally, client records must demonstrate that the ‘Know Your Rights’ document was distributed and explained to clients at admission.
   
   DPH BSAS may take action on the status of a license and can close admissions when it determines that proper care has not been provided to a client under 105 CMR 164.019. Additionally, contractual actions, up to and including termination of the contract will be
   strictly enforced upon substantiation of violations of this policy.

As always, BSAS is committed to providing assistance to residents of the Commonwealth as well as those individuals dedicated to treating substance use disorders. For questions or concerns regarding licensing, please contact your respective Licensing Inspector, Contract Manager, or Erica Weil, Assistant Director of Quality Assurance and Licensing, Bureau of Substance Addictions Services, at [e-mail] or [phone] ext.2357 or Jim Cremer, Deputy Director, Bureau of Substance Addiction Services, at [e-mail] or (617)
624-5335.

It is through our continued work together that we will reduce the number of deaths attributed to
substance use and engage individuals on a path to long term recovery.

CC: Secretary Marylou Sudders
       Commissioner Monica Bharel

Attached: DPH Clinical Advisory
                Required Complaint Line Posting

Increase in Opioid-Related Overdose Deaths With Cocaine Present

Thank you for your partnership in addressing the current opioid epidemic. We would like to draw your attention to the most recently published quarterly opioid report. Among the findings highlighted is the increasing number of opioid overdose deaths where cocaine is present. We would like to take this opportunity to emphasize the role of polysubstance use in this current epidemic. Relatedly, DPH is aware of reports from front-line staff about the increasing presence of methamphetamine in Massachusetts.

As reported in the MA DPH Supplemental Toxicology Analysis on Opioid-Related Overdose Deaths Among Massachusetts Residents, May 2018, as well as in reports from other states^{1 2 3}, the percentage of cases of opioid-related overdose deaths with cocaine present in the toxicology screen trended up between 2014 and 2017. The reported trend of both fentanyl and cocaine present in toxicology likely includes cases of individuals who knowingly used cocaine and opioids prior to the overdose, as well as cases of individuals who used cocaine and were unknowingly exposed to fentanyl that was present in cocaine.

As you are likely aware, fentanyl is a highly potent schedule II synthetic opioid approved for treating severe pain. However, most cases of fentanyl-related harm, overdose and death in the U.S. are linked to illicitly manufactured fentanyl.^{5 6} Fentanyl has particularly rapid onset and illicit fentanyl samples have highly variable potency, both of which increase the risk of overdose death.

Therefore, people who use cocaine, who do not have tolerance to opioids and are not familiar with the risks of opioid overdose, are at exceptionally high risk of an opioid overdose when using cocaine with fentanyl present. Similar risks could emerge among people who use methamphetamine.

Recommendations

Administer Naloxone in Drug Overdoses When Non-Opioids are Suspected/Indicated

It is critical for all individuals who use illicit drugs to be aware of the risk factors, signs, and symptoms of opioid overdose and how to respond. Even though naloxone is not effective in treatment of drug overdoses caused solely by non-opioids, such as cocaine and methamphetamine, the administration of naloxone may be helpful in drug overdoses caused by a combination of stimulants and opioids like fentanyl.

Educate Individuals about Dangers of Illicit Drugs Potentially Mixed with Fentanyl

Key points to emphasize include:

• Fentanyl may be present in other drugs without the users’ knowledge.
• Fentanyl increases the risk of overdose death due to its rapid onset and high potency.
• Avoid mixing opioids with other substances, including alcohol, because they increase the risk of overdose.
• Do not use drugs alone. Anyone using drugs should be directly observed by someone else equipped with naloxone and ready to call for help in case of an overdose. Take turns using, so someone is always able to respond.
• When using, start with a small amount, so the strength is known.
• Naloxone may wear off before the opioids wear off and overdose can happen again, so stay with emergency services until they confirm you are safe for discharge.

Make sure people who use drugs and their family and friends have been trained on the signs and symptoms of a drug overdose, where to get naloxone and how to administer it, how to do rescue breathing and the importance of calling 911 immediately even when naloxone is administered.

Ensure Patients Who Access ANY Street Purchased Drugs Have Naloxone

Encourage patients/clients who use drugs, as well as their family and friends, to carry naloxone⁷. Refer them to a local DPH Overdose Education and Naloxone Distribution (OEND) program or to a local pharmacy. MassHealth and many other insurers cover naloxone prescriptions at the pharmacy. More information on how to access naloxone in MA is available here: https://www.mass.gov/overdose-prevention-and-naloxone-access.

Refer Patients with Substance Use Disorder to Treatment

Refer patients/clients who use drugs to treatment. You can direct them to treatment and recovery resources at the Massachusetts Substance Use Helpline [phone] (https://helplinema.org/).

Clinical Information about Fentanyl

• Fentanyl is an opioid analgesic. The biological effects of fentanyl are indistinguishable from those of heroin, though fentanyl acts more rapidly and therefore overdoses can develop within seconds to minutes after taking fentanyl.
• Treatment is the same as for other opioid overdoses, however, naloxone should be administered as soon as it is available and larger than usual doses of naloxone (2-10mg) might be required for reversal of the opioid effects, because fentanyl is rapid-acting and highly potent.
• Fentanyl is not detected by standard urine opioid immunoassays; therefore, opioid exposure should not be ruled out based on toxicology screen results. Consult your laboratory for preferred testing methods.
• Symptoms of overdose are characteristic of central nervous system depression: lethargy, respiratory depression, unresponsiveness, change in consciousness, seizure, and/or coma.

Know Your Rights

You have many rights under 105 CMR 164.079 related to your care. There are also ‘rules’ describing how treatment should be provided. You are encouraged to contact the Department of Public Health, Bureau of Substance Addiction Services (BSAS) to report any potential
violations of these rights or rules.

• If a provider completes an assessment and determines that this is not the right level of care for you, the provider must make a referral to the appropriate level of care and support you through the referral process.
• You cannot be denied admission based only on the results of a drug screen.
• You cannot be denied admission only because of a medication prescribed to you by a physician. This includes medications such as methadone, buprenorphine, naltrexone, and other medications prescribed for substance use disorder, mental health, or other medical conditions.
• You cannot be denied re-admission to a program based solely on one of the following happening when you were in the program:
  • you left treatment against medical advice;
  • you relapsed while in treatment; or
  • you filed a grievance or complaint either to the program or to the Bureau of Substance Addiction Services regarding any aspect of your treatment.

If you think your rights or the above rules around treatment have been violated, please call the BSAS Confidential Complaint Line at (617) 624-517

1. www.health.bcohio.gov
2. Tomassoni AJ, Hawk KF, Jubanyik K, Nogee DP, Durant T, Lynch KL, Patel R, Dinh D, Ulrich A, D'Onofrio G. Multiple Fentanyl Overdoses-New Haven, Connecticut, June 23, 2016. MMWR. Morbidity and mortality weekly report. 2017 Feb;66(4):107-11
3. www.cdc.gov/drugoverdose/opioids/fentanyl.html
4. https://www.dea.gov/sites/default/files/2018-07/DIR-040-17_2017-NDTA.pdf
5. www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html