To help tackle the issue of opioid misuse in older adults, the at the University of Louisville has been working with individuals in rural Kentucky who are involved in the institute’s , which is designed to deliver interdisciplinary care coordination to those with chronic conditions.

Of the 154 patients who have received services, medication management issues related to opioid prescriptions and interactions with other medications were a factor with more than 90 patients. Medication safety also proved to be a problem, with family members or caregivers taking opioids from patients in at least 10 percent of cases.

The institute recently received supplemental federal funding to their Geriatrics Workforce Enhancement Program grant, specifically to expand work in Bullitt, Henry, Oldham, Shelby, Spencer and Trimble counties related to opioids and older adults. This effort also will be offered in Jefferson, Barren, Metcalf and Hart counties.

“This additional funding will allow us to dramatically increase our ability to screen for potential opioid misuse and to educate patients, students and practitioners on best practices for pain management for older adults,” said Anna Faul, PhD, the institute’s executive director.

Joe D’Ambrosio, PhD, the institute’s director of health innovation & sustainability and assistant professor at the UofL School of Medicine, will lead an interdisciplinary clinical team of faculty from nursing, social work and counseling psychology to serve as mental health clinicians for the project.

He said the institute is developing a new program to train students and clinicians on how to identify and treat opioid-related substance abuse among older adults. The programming also will be offered to community mental health partners including , the region’s largest mental health care provider.

The LEAD program, which first launched in Seattle in 2011, is an innovative pre-booking, community-based program focused on routing individuals suspected of committing low-level drug-related offenses away from jail and prosecution into treatment.

Louisville has been awarded a $400,000 federal grant to fund a pilot project, serving 50 qualifying individuals who come into contact with police in the Portland and Russell neighborhoods over the next 18 months.

“The Opioid crisis remains a vital concern to public safety in this community,” said Mayor Greg Fischer. “But incarceration cannot be the only option for those struggling with addiction. We must find ways to divert people to treatment and stem the tide of drug-related crime. This program is one more option for our community.”

Commonwealth Institute research scholars Liza Creel, PhD, and Susan Buchino, PhD, will conduct the evaluation, ensuring the program is working as it should.

“By following an evidence-based intervention that has shown success in other communities and designing it to meet Louisville’s needs, the Louisville LEAD pilot has great potential to positively impact participant lives and our community,” Creel said.

The research team will look specifically at the impact of LEAD on:

• Recidivism, including arrests and charges
• Use of publically-funded legal and criminal justice services
• Costs to the local criminal justice system
• Use of treatment and other services after LEAD enrollment
• And fidelity to the Seattle-model (the extent to which the Louisville LEAD pilot aligns with the model implemented in Seattle)

“UofL is committed to enhancing the well-being of our city through research and collaboration. We look forward to sharing our evaluation findings over the next two years,” she said.

The program is expected to fully launch by Oct. 1.

Here’s how it will work:

• LMPD officers working in the targeted beats in the Russell and Portland neighborhoods will use discretionary authority at the point of contact to divert eligible candidates into intervention for offenses driven by substance use disorder.
• The LMPD officer will determine eligibility for the LEAD program based on established offense criteria and criminal history exclusions. Eligible crimes will include felony possession of an opiate and possession of heroin under two grams, as well as low-level property crime stemming from opiate addiction.
• Instead of taking them to jail, officers will take those volunteering to participate to the Volunteers of America Mid-States triage location on West Broadway to be connected with a case manager.
• Within 72-hours a potential participant must complete an in-depth assessment before becoming one of the 50 pilot project participants to receive treatment and wrap-around services.
• Volunteers of America Mid-States will assume responsibility for the case management of the individuals.
• UofL’s Commonwealth Institute of Kentucky will conduct the evaluation of the program.

“So often, officers come into contact with members of our community who are committing crime as part of their addiction to opioids and other drugs,” said Col. Michael Sullivan, deputy chief for Louisville Metro Police. “This gives officers a tool to divert people into treatment, rather than taking them to jail, where they may or may not get to address the underlying issue leading them to crime.”

Volunteers of America Mid-States will work with pilot program participants to coordinate services they need to get themselves back to a healthy and productive lifestyle.

“We know that we can change people’s lives when we surround them with professional care and treatment and access to comprehensive support and services,” said Jennifer Hancock, President and CEO of Volunteers of America Mid-States. “Opioid use and addiction is a public health crisis and LEAD will be successful because it offers a public health solution.” 

Under the agreement, the Justice Cabinet will contract with the universities for forensic pathology services, combining resources for both autopsies and medical education. The move is expected to boost salaries for doctors, helping improve recruitment and retention, and it will help the cabinet avoid charging counties a fee for autopsies.

“The opioid crisis has placed tremendous strains on our state, and we must take every opportunity to innovate and find efficiencies,” Secretary Tilley said. “By partnering with universities, we can improve the pay and size of our forensics team while also ensuring that families, coroners and police get the answers they need when tragedy strikes.”

The agreement also will help UK and UofL maximize training opportunities for medical students and residents in pathology.

“Our collaboration with the Justice Cabinet and their Medical Examiner’s Office illustrates the University of Kentucky’s desire to take a comprehensive, ‘all hands on deck’ approach to addressing Kentucky’s opioid crisis,” said Dr. Darrell Jennings, chair of the UK Department of Pathology and Laboratory Medicine. “This opportunity will provide our medical students in Lexington, Bowling Green and Northern Kentucky, along with our residents and fellows, with unparalleled training on the front lines, harnessing the power of compassion and commitment to transform the future.”

“Through this strengthened relationship with the state Medical Examiner’s Office, we will broaden the educational and training opportunities for our students, residents and fellows,” said Dr. Eyas Hattab, chair of the Department of Pathology and Laboratory Sciences at UofL. “Our trainees will have access to the number and variety of cases that are invaluable as they prepare for the next steps in their careers.”

UofL will provide up to six pathologists in state medical examiner offices; UK will provide up to four. The cabinet will pay the universities for any services performed by these doctors on a scale similar to current costs. The cabinet and universities will also collaborate on strategies that could possibly lower the overall cost of the program in the long run.

The Medical Examiner’s Office currently employs nine doctors – six in Louisville, two in Frankfort and one in Madisonville. The partnership is expected to provide a net increase of one forensic pathologist immediately with opportunities to add an additional doctor, possibly within two years, thanks to recruitment assistance from the universities.

All doctors have an opportunity to transition into university positions, and those who do are expected to receive a salary increase depending on the individual contracts between doctors and universities. Added salary will compensate for additional responsibilities such as teaching, researching, writing, consulting or other contributions that doctors are interested in pursuing.

While the exact terms of employment will depend on the individual contracts, the higher pay scale is expected to make Kentucky more effective at hiring and keeping new doctors.
Kentucky, like many other states, has struggled to recruit forensic pathologists in recent years due to a national shortage. Only about 500 forensic doctors are currently practicing across the country. At the same time, overdose deaths have continued to climb over the past decade, driving up demand for autopsies and toxicology tests. More than 1,400 Kentuckians died from an overdose in 2016.

In response, enhancing the Medical Examiners’ Office has remained a high priority under the current administration.

In 2016, the office resumed services in Madisonville (following a two-year hiatus), helping coroners and law enforcement agencies across Western Kentucky reduce travel costs and obtain evidence at a faster pace.

Secretary Tilley said he plans to continue looking for ways to improve the office. For instance, the cabinet is aggressively seeking grant funds to expand capacity, reduce caseloads, expand toxicology analysis and enhance data collection.

“We want to consider every option to enhance services while avoiding fees for counties,” he said. “UK and UofL have been excellent partners in this process, and we look forward to continuing our work with coroners to ensure their needs are met.”

Gabapentin, a nerve pain medication and anticonvulsant sold under the brand name Neurontin and others, increasingly is being misused, necessitating prescribers to understand its abuse potential and risk profile, said Rachel Vickers Smith, PhD, MPH, assistant professor in the University of Louisville School of Nursing.

She has found that abusers typically mix gabapentin with opioids, marijuana, cocaine and opioid treatment medication, compounding side effects to the central nervous system that include euphoria and sedation.

Some people who have primarily abused opioid pain medication have turned to gabapentin after crackdowns made it more difficult to obtain opioid prescriptions or purchase the drug on the street because of its expense.

“People are looking for other drugs to substitute for opioids, and gabapentin has filled that place for some,” Vickers Smith said. “Some have said it gives them a high similar to opioids. It had been easy to get a prescription for gabapentin and it’s very cheap.”

Vickers Smith and other researchers authored a  recently published in Psychology of Addictive Behaviors that explores recreational gabapentin use by a cohort of study participants in Appalachian Kentucky. Thirty-three people who reported recent recreational use of gabapentin were recruited from two ongoing longitudinal studies of drug users to participate in focus groups.

Overall, participants reported having started taking gabapentin more than 10 years ago after it was prescribed for a legitimate, though generally off-label reason, including pain, anxiety and opioid detoxification.

The findings highlight the low cost of gabapentin and its increasing recreational popularity, particularly over the past two years.

In July, Kentucky became the first state to classify gabapentin as a controlled substance, making it more difficult for the medication to be prescribed. State lawmakers relied on research findings of Vickers Smith and others as evidence during senate hearings.

Despite its abuse risk, the Centers for Disease Control and Prevention two years ago released  recommending gabapentin as an alternative to opioids for pain treatment.

Since gabapentin’s release in 1993, there have been no human laboratory studies done on the drug, Vickers Smith said.

“Early on, it was assumed to have no abuse potential,” she said. “There’s a need to examine it in further detail, especially if prescribing it is going to be encouraged.”