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State Approaches to Cross-Agency Organization and Funding for Substance Use Disorder: Spotlight on Kansas, Maine, and Pennsylvania

August 3, 2022/in Behavioral/Mental Health and SUD Kansas, Maine, Pennsylvania Featured News Home, Reports Opioid Center Funding Options /by Jodi Manz, Eliza Mette and Mia Antezzo

How States Are Leveraging Payment to Improve the Delivery of SUD Services

March 15, 2022/in Opioid Center Featured News Home Behavioral/Mental Health and SUD, Relief and Recovery /by Neva Kaye

Confronted with Overdoses, Rhode Island’s Emergency Departments Employ Peer Services to Promote Treatment

April 12, 2021/in Policy Featured News Home, Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration /by Jodi Manz and Kitty Purington

Drug overdose deaths nationwide have continued to rise during the COVID-19 pandemic, exceeding 88,000 between August 2019 and August 2020, signaling a critical need for substance use disorder (SUD) treatment services and the workforce to provide them. Non-fatal overdoses, which are a predictor of future fatal overdoses, also rose, leading to an increase in opioid-related emergency department (ED) visits even as overall ED visits declined during the pandemic.

While overdose-related ED incidents are traumatizing to individuals and costly to payers – especially state Medicaid programs – Rhode Island has found that hospital emergency rooms can be low-barrier and successful access points to SUD treatment with the right crisis response – including peer services – in place.

Background

Peer recovery services for substance use disorder (SUD) have been demonstrated to help individuals stay in treatment, increase satisfaction with treatment experiences, and reduce rates of return to use.

Responding to existing and projected behavioral health workforce shortages, states are building capacity for SUD treatment by developing certification pathways and reimbursement structures for peers as a non-licensed, supportive workforce.

Rhode Island, and 38 other states, have integrated the use of peers as care team members who can provide Medicaid-reimbursable, non-clinical treatment and recovery support services. In 2014, the state developed an innovative model, AnchorED, that introduced peers into hospital EDs to link patients who experienced overdoses with treatment and recovery. This program is the result of cross-agency collaboration among Rhode Island’s Department of Health (RIDOH), Department of Behavioral Health, Developmental Disabilities and Hospitals (BHDDH), the Providence Center (a community behavioral health provider), and Anchor Recovery Community Centers.

Currently, post-overdose peer services are accessible at all hospitals in the state – with the exception of a Veterans’ Affairs hospital – and peers who provide services are available 24 hours a day, seven days a week. Early evaluation of AnchorED showed that in the program’s first year, peers had contact with 1,329 patients. Among those patients, 88.7 percent were trained to use naloxone and 86.8 percent agreed to engage with a peer after hospital discharge. Further evaluation showed that ED providers consulted with peers in over 85 percent of overdose cases, and referral to treatment upon discharge increased from 9 to nearly 21 percent.

Building Blocks for Rhode Island’s AnchorED Program

State Leadership

State leadership ensures that peer services are recognized as a valuable component of opioid/substance use disorder (OUD/SUD) systems in Rhode Island. The Rhode Island Governor’s Overdose Prevention and Intervention Task Force, established through an Executive Order in 2015, provides a forum for consistent communication related to all SUD-related initiatives and has been important in promoting the peer workforce. This group, composed of stakeholders as well as state policy leaders, is co-chaired by the directors of the RIDOH and BHDDH, the two agencies that were instrumental in implementing policy for peer services in hospital EDs. In 2017, the governor signed another Executive Order making additional policy actions in response to the needs of the state emerging from the task force, including several initiatives supporting peer services that align to the task force’s Action Plan. Outcomes, including data on the number of peer recovery specialists (PRS) in the state and the number of services they provide, are reported on regularly updated public dashboards.

Data for 2020 showed an increase in the number of newly trained PRS, which reached 958 by September, and new client enrollments in services, which has increased steadily from a low point in April, 2020, likely related to the COVID-19 pandemic. The task force, which continues to hold open monthly meetings, recently issued an updated strategic plan that includes goals to further expand and enhance the peer recovery workforce. Task force meeting notes and presentation archives are also publicly posted.

Rhode Island state leaders were also engaged in concurrent efforts on workforce development as a component of their State Innovation Model (SIM) project. The state’s Health System Transformation Program published a Healthcare Workforce Transformation report that advocated expanding the role of peers as members of integrated behavioral health teams. The report recommended providing a pathway for state certification for peers as a strategy to build behavioral health workforce capacity with non-clinical team members in supportive roles.

Infrastructure

Rhode Island, through a number of policy actions, has created a regulatory framework that supports delivery of peer services in hospital EDs. In 2016, the state passed legislation that requires hospitals to submit comprehensive discharge plans to its health department director and outlines specific requirements for post-overdose patient care. Aligning with this statute, RIDOH and BHDDH developed standards for hospital EDs, requiring integration of peer services into ED overdose response across all state hospitals, as well as Freestanding Emergency Care Facilities (FECF) that provide emergency services outside of a hospital’s structure. The agencies delineated these standards in the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder, creating three levels of certification for EDs across the state. In order to gain certification at any of these levels, hospitals and EDs are required to complete and submit a self-assessment that reviews where each facility falls on the continuum of services identified in the standards.

Rhode Island Hospital Levels of Care Standards

Level 3: Minimum standards – indicating readiness and capacity to:

Level 2: These certified facilities must meet Level 3 criteria, and also show capacity to:

Level 1 In addition to meeting levels 1 and 2 criteria, these certified facilities must:

1. Offer peer recovery support services in their emergency departments.

2. Follow the discharge planning standards as stated in current law.

3. Administer standardized substance use disorder screening to all patients.

4. Educate all patients who are prescribed opioids on safe storage and disposal.

5. Dispense naloxone for patients who are at risk, according to a clear protocol.

6. Provide active referral to appropriate community provider(s).

7. Comply with requirements to report overdoses within 48 hours to RIDOH.

8. Perform laboratory drug screening that includes fentanyl on patients who overdose.

1. Conduct comprehensive standardized substance use assessments.

2. Maintain capacity for evaluation and treatment of opioid use disorder using support from addiction specialty services.

1. Maintain a Center of Excellence or comparable arrangement for initiating, stabilizing, and re-stabilizing patients on medication-assisted treatment:

· Evaluate and manage medication assisted treatment, and

· Ensure transitioning to/from community care to facilitate recovery.

These standards for EDs also inform licensing regulations for both hospitals and Freestanding Emergency Care Facilities (FECF) in Rhode Island. Those regulations require that overdose patients and/or patients who are evaluated and found to have SUD are informed of available treatment services and that those patients are offered an opportunity to speak with a PRS. RIDOH also encourages hospitals in Rhode Island to use the BHDDS model consent form language for peer services, facilitating patient consent to both peer and medical services simultaneously. This approach to incorporating peer services into hospital consent forms was mandated by the legislature in 2018.

At this time, the standards are currently under revision by a workgroup of state leaders and stakeholders to identify and address gaps in alignment between the standards and the provider experience. These revisions, however, are not expected to lead to changes in the regulations.

Workforce Development

As officials developed certification requirements for peers, members of the peer community and people in recovery from SUD explained that being paid to help others conflicted with an important tenet of their personal journeys, which is to give freely of their time helping others with SUD and “pay it forward.”

The state began laying the groundwork for peer certification in 2012 when BHDDH began trainings for mental health peer recovery specialists through certification planning developed as part of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Transformation Transfer Initiative (TTI). In 2014, the Rhode Island Certification Board (RICB) – not a state entity – began certifying SUD peer recovery specialists as well, this led to BHDDH ultimately integrating mental health and SUD peer recovery trainings after the state brought together stakeholders through SAMHSA’s Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS) program.

Peer certification in Rhode Island begins with the state’s integrated peer recovery and mental health training provided through Anchor Recovery. Requirements include:

46 hours of didactic learning across four domains (advocacy, mentoring/education, recovery/wellness support, and ethical responsibility)
500 internship hours, including or in addition to 25 supervised hours.
Evidence of passing the International Certification and Reciprocity Consortium (IC&RC) peer recovery certification exam. To prepare for the exam, IC&RC provides a Candidate Guide, and BHDDH contracted with JSI International to develop the Rhode Island Peer Recovery Specialist Certification Study Guide.

Peers delivering services in Rhode Island must receive ongoing supervision from either licensed health care practitioners or certified peers who provided peer services for at least two years. Supervisors must also complete BHDDH-approved core competency training provided through a contract with Anchor Recovery. Agencies providing peer services must maintain a ratio of 1 supervisor for every 10 peer full-time-equivalents, and document provision of supervision totaling at least two hours per month or 30 minutes per week. Agencies must also provide at least a monthly opportunity for group meetings for working peers. In order to deliver services, these agencies must also be certified by BHDDH as Peer Based Recovery Support Services (PBRSS) providers and can use the PBRSS Provider Billing Manual to bill for services.

State Investment and Resources

Initial grant funding. Peers initially began meeting with overdose patients in hospital EDs as a volunteer engagement opportunity supported by Providence Center’s Anchor Recovery, a community recovery organization established in 2010 and funded through the state’s Substance Abuse Prevention and Treatment (SAPT) block grant.

Direct patient crisis response in partnership with a community organization was a familiar approach for the first Rhode Island hospital site to provide SUD peer services. The hospital already had an agreement with a local intimate partner violence organization that allowed volunteers to connect with patients in the ED. The hospital also maintained an agreement with the Providence Center to provide a clinician to triage and assess patients who came into the ED indicating mental health and SUD-related needs. Initial grant funding and existing relationships helped to facilitate development of peer integration.

Medicaid reimbursement. In the long term, paying for peers meant developing a source of sustainable funding for the program, and Rhode Island’s health policy leaders saw an opportunity to reimburse for peer services in Medicaid. While states have a variety of authority options to cover recovery support services in Medicaid, including health home models and 1915(b) and 1915(c) waivers, Rhode Island is one of nine states to provide these services under an 1115 demonstration waiver, submitted to the Centers for Medicare & Medicaid Services (CMS) in 2016 and approved in 2018. The waiver specifies that reimbursable services under the authorized Recovery Navigation Program (RNP) and Peer Recovery Specialist (PRS) Program include “an array of interventions that promote socialization, long-term recovery, wellness, self-advocacy, and connections in the community,” delivered as part of a care team.

Rhode Island’s waiver requires the state to credential peers using the International Certification & Reciprocity Consortium (IC&RC) exam and to develop standards for peer supervisors, as outlined in the previous section. The Rhode Island waiver created a bundled payment, which incorporates services provided by peer recovery specialists as part of the Recovery Navigation Programs. Services outside of such programs, which include those provided in EDs, are billed by the Medicaid-enrolled provider organization employing the PRS and are paid as a flat fee – peer services are reimbursed by Medicaid at rates of $13.50/15 minute unit for one-on-one services and $4/15 minute unit for up to 10 participants for group services.

Reporting and Outcomes

State regulations require that hospitals must report all opioid overdoses to RIDOH within 48 hours through a case report form that captures information about the patient and the overdose event. Additionally, AnchorED captures and reports on each unique patient contact, including data describing whether peer or other counseling services were accepted by the patient. Patients may also be referred to outpatient MOUD treatment, admitted to detox, or refuse engagement altoghter. This data is reported to the state by each hospital as de-identified, aggregate demographic and incident data. This is used to inform state leaders about who is seeking services and what factors may be leading to overdose, and how services are being initiated by PRS.

Anchor Recovery peer specialist services include:

Linking individuals to treatment and recovery resources;
Educating about overdose, prevention, and how to obtain naloxone, a drug that reverses the effects of an opioid overdose when administered quickly;
Providing additional resources to individuals and family members; and
Contacting the individual after release from the ED with a follow-up phone call.

Source: Anchor Recovery

AnchorED reports:

Average minutes between contact and team connection to a patient;
Whether naloxone training was done;
Whether an individual agreed to see a PRS;
Whether an individual agrees to a treatment referral; and
Whether an individual agrees to initiating MOUD that day.

State agencies use these data sets to track outcomes and understand how hospitals are engaging individuals after an overdose to ensure connections to treatment are made. Rhode Island’s overall SUD response strategy includes collection and analysis of treatment and recovery data, and the state uses its Prevent Overdose RI website as a platform to publicly report on measures. ED overdose visits are reported publicly on a monthly basis, along with location and naloxone provision data, and the AnchorED outcomes of patient engagement. Reports include quarterly numbers showing total ED visits, as well as post-overdose counseling, which was accepted by 26 percent of overdose patients in the most recent data reported for the fourth quarter of 2020. Data for that time period also shows that of a total 267 overdose patients, with 45 percent receiving naloxone before being discharged from the hospital.

Challenges and Considerations in Maximizing Peer Workforce

Engage stakeholders. Peer stakeholders have been engaged with policymakers since the inception of the AnchorED program. These relationships helped to develop the policies that support the program, particularly for peer certification requirements. Stakeholder and cross-agency communication continues to drive policy in Rhode Island; regular informal communication through weekly calls among PRS contractors/peer recovery organizations, ED providers, law enforcement, detox centers, and state agencies has been key to identifying emerging trends and resulting needs.

Build workforce diversity. Several state leaders and stakeholders noted that diversity is lacking in the existing peer workforce and suggested that targeted recruitment of peers who are people of color, are bilingual, and/or identify as LGBTQ may help better meet the state population’s needs. A February 2021 update to the Governor’s Task Force – which has recently created a Racial Equity Workgroup – prioritizes this as a goal for the state’s recovery work, listing recruitment and training of people of color and those who speak languages other than English as a short-term recommendation.

Delineate peer roles. While the goals of peer engagement include patient retention and continuity of care, ED providers and stakeholders repeatedly stressed that connecting overdose patients to medications to treat opioid use disorder (MOUD) was the most important intervention to reduce overdose death. Providers noted concern regarding peers advocating for patients to choose either MOUD or abstinence-based recovery, a clinical decision that may test role definition and boundaries. While they emphasized that most peer-to-patient interactions are not clinical in nature and do not include discussions of medical interventions, there have been occasions when providers felt that peers may be overstepping in their roles by dissuading overdose patients from initiating MOUD. Providers and peers alike are mindful of existing tension in the recovery community regarding the use of medications. Abstinence-based recovery programming sometimes discourages medications, though this perspective is far from universal. In the most recent Governor’s Task Force strategic plan update, Rhode Island included a goal to develop PRS who focus on supporting patients in MOUD treatment, and to integrate these specialty PRS into services across the SUD continuum of care.

Identify hiring barriers. When Rhode Island first shifted toward employing peers to work within the hospital, leaders within the recovery organization and the hospital system had to decide whether peers would need to go through hospital system human resources checks and procedures, which may have posed barriers to peers being able to work in the hospital environment due to felony backgrounds or other prior issues. Rhode Island determined that the best course of action was to have peer candidates evaluated as part of the the recovery organization’s human resources to avoid this. Within some health systems, internal hospital policies can prevent the hiring of individuals with felony records, a challenge for some people in recovery who had past convictions. To mitigate this, states can consider approaches in which peers are hired by the organizations that bill for peer services rather than directly by hospitals.

Conclusion

The importance of relationships across systems and among team members in developing and integrating peer services in EDs was a dominant theme in interviews with state leaders and stakeholders. Relationships between the recovery community and hospital clinicians were already in place before AnchorED became a Medicaid-reimbursable model, and leaning on those relationships was key to licensure and Medicaid policy creation. Further, the relationships that develop between team members when providing peer services in the ED help to reduce stigma. As one peer leader said, integrating “education along the way” by talking with providers about the realities of active use and the fears that emerge from it helped humanize recovery for ED providers. Rhode Island’s leaders routinely pointed to the small size of the state and the opportunity that affords them to develop such relationships across systems. While the state’s small size is a unique factor that cannot be replicated, it suggests that states can support regional relationships among community behavioral health, community recovery organizations, and hospital systems through formal regional networks and activities.

Acknowledgements: This brief was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials cooperative agreement. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA/HHS, or the US government. The authors would like to thank HRSA project officer Diba Rab for her support and guidance. Further, the authors would like to acknowledge the dedication, leadership, and input of Rhode Island state agency leaders and staff, as well as providers, stakeholders, and peers who contributed to this brief.

Medications for Opioid Use Disorder (MOUD) Provided in State Prisons, March 2021

March 4, 2021/in Opioid Center Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by NASHP Staff

How States Access and Deploy Data to Improve SUD Prevention, Treatment, and Recovery

January 29, 2021/in Policy Behavioral/Mental Health and SUD, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Quality and Measurement /by Kitty Purington and Jodi Manz

As state policymakers confront the substance use disorder (SUD) epidemic, they require a wide range of data – often found in disparate systems – to understand its impact and craft more effective treatment programs and interventions. This report explores best practices and sources for data gathering and describes how states can help communities access and use data to support local efforts.

Introduction

The nation’s substance use disorder (SUD) epidemic poses unique challenges for policymakers working to understand and apply data – which often exists in disparate systems – to guide their treatment and interventions. States, localities, and organizations need to access and generate reliable data, not just in health and behavioral health care, but in workforce, criminal justice, social services, and other systems to design successful SUD interventions.

This report describes the uses and limitations of commonly available data sets that can stand alone or be used in conjunction with other data to answer common questions posed by state and local leaders. The report reviews common data sources that can help state leaders address key issues, such as preventing SUD and diversion of controlled substances, supporting harm reduction, increasing treatment capacity and service delivery, and understanding the needs of vulnerable populations. The report also highlights best practices at the state level, and notes where state strategies can also assist communities in accessing and using data to support local efforts.

The State SUD Data Landscape

Policymakers have access to data sets that are collected, compiled, analyzed, and maintained by state and federal agencies and other entities responsible for providing or overseeing services related to the prevention, reduction, or treatment of SUD. The following highlights data sets that are commonly used by state policymakers in their efforts to analyze key SUD indicators.

Individual claims and administrative and programmatic data collected by states: Individual-level data sets that tie to the unique experiences of one person through a system can help illuminate the ways that individuals and populations seek and use services. This data is often personally identifiable, which requires either consent, legally authorized use, or systematic anonymization that removes identifying characteristics.

Data	Ownership/Maintenance	Content
Medicaid claims and encounter data	State Medicaid agency Medicaid managed care organization	· Patient demographic data · Diagnostic/service codes · Service utilization data
Prescription drug monitoring programs (PDMPs)	State licensing boards, public health agencies, or free-standing PDMP agency	Patient and prescriber data related to scheduled prescription drugs
Vital statistics, forensic epidemiology, or medical examiner/coroner reports	State public health or vital statistics agencies	· Deceased demographic data · International Classification of Diseases 9-10 codes identifying causes of death · Toxicology reports
Homeless management information systems	State housing or social service agencies	Housing program services and client data, including self-reported diagnoses
Infectious disease data	State public health agencies	Surveillance data on hepatitis B/C and HIV infections
Behavioral health services data	State behavioral health agencies	· Non-Medicaid-funded services for SUD delivered by community behavioral health systems or state hospitals · Provider licensure information
Emergency medical systems data	State public health agencies	Overdose response data, including naloxone deployment
Hospital admissions and discharge data	State public health agencies	Overdoses treated in hospital settings and/or discharges coded as overdose-related
Corrections	State and local corrections agencies	Health and behavioral health assessment and treatment data for incarcerated individuals

De-identified state/federal data sets available to researchers, organizations, and the public: Aggregate data sets can also be helpful to understand system interactions and population trends. These kinds of data are valuable in gauging systemwide behaviors as well as shifts in services, demographics, or activities that indicate the needs of a given region or population.

Data Set	Ownership/Maintenance	Content
All-payer claims databases (APCD)	Independent state or quasi-governmental organizations	Insurance claims from across payer sources
Behavioral Risk Factor Surveillance System (BRFSS)	Centers for Disease Control and Prevention (CDC)	Self-reported health risk factor and health condition data
Census data	US Census Bureau	Self-reported demographic data
National Overdose Report	CDC	Overdose deaths by demographics, states/regions, and substances present
Annual HIV Surveillance Report	CDC	HIV infections by demographics, states/regions, and transmission factors
National Survey on Drug use and Health (NDSUH)	Substance Abuse and Mental Health Services Administration (SAMHSA)	Self-reported substance use, mental health, and treatment services by demographics and state/region

SUD Data Use Cases for State and Community Leaders

The following data use cases and strategies describe how available data can be used, often in innovative ways, to inform and guide state and local policy decisions.

Limit Diversion and Promoting Prevention Use Cases

Prescription opioids are often described as the substances behind the “first wave” of an overdose epidemic that has evolved to now be driven by illicit forms of opioids, such as heroin and fentanyl. In one study, over 80 percent of current heroin users reported that their first experiences with opioids involved diverted prescription pills, suggesting that policy interventions to reduce this diversion should be among state and local leaders’ top priorities. Analyzing available data can help to structure strategies that limit opioid diversion and prevent inappropriate prescribing.

Identify risky prescribing: Forty-nine states and Washington, DC support Prescription Drug Monitoring Programs (PDMPs) that contain prescriber, dispenser, and patient-level data about controlled substances. Policymakers can use PDMP data to develop baselines that help show geographic and individual prescriber averages, as well as aberrations in prescribing and dispensing patterns. Pennsylvania maintains public-facing aggregate PDMP data that can be searched at the county level for a range of measures that indicate risky prescribing patterns, such as:

Number/rate of individuals seeing five-plus prescribers and five-plus dispensers;
Number/rate of individuals seeing four-plus prescribers and four-plus dispensers;
Number/rate of individuals seeing three-plus prescribers and three-plus dispensers;
Morphine milligram equivalents (MMEs);
Number/rate of individuals with an average daily MME of more than 50, 90 or 120;
Number/rate of individuals with overlapping opioid/benzodiazepine prescriptions; and
Number/rate of individuals with more than 30 days of overlapping opioid/benzodiazepine prescriptions.

Similarly, Illinois tracks a “high-risk patient” population using data from its PDMP to better understand trends among individuals who have been:

Prescribed both opioids and benzodiazepines;
Individuals prescribed greater than 90 MME; and
By number of total prescriptions.

Refine prescribing guidelines: States have significant leverage to implement opioid prescribing guidelines in their Medicaid programs and can then use this claims data to support these interventions. Using PDMP and Medicaid service utilization data, state Medicaid agencies can enact and support policies that reduce opioid prescribing and incentivize non-narcotic pain management. Policymakers in Virginia reviewed both opioid and non-opioid prescribing claims in Medicaid, and found the data suggested opioid prescriptions were the default for pain management. Working with stakeholders, including managed care pharmacy directors, the state removed prior authorization for non-opioid pain management and implemented limitations on opioid prescribing among Medicaid providers. Other states, including Ohio, have similarly used PDMP data to track and manage opioid prescribing limits that reduce the availability of pills for potential diversion. Ohio experienced a 41 percent decrease in opioid doses and a 37 percent decrease in prescriptions between 2012 and 2018 as a result of adopting these kinds of regulations.

Understand substance use trends: Massachusetts analyzed death records, state toxicology reports, and prescribing data from its PDMP to better understand substances involved in the state’s overdose deaths. Matching and analyzing these data sets revealed that people dying from overdose were much more likely to have an illegal substance in their system at the time of death, which resulted in a state review of its harm reduction strategy. The report noted that “(a)s a result of these findings, increasing the availability of harm reduction strategies and interventions that target heroin, fentanyl, and polysubstance use (especially benzodiazepine and cocaine use) could significantly reduce the opioid-related death rate.”

Preventing Overdose and SUD-Related Comorbidities Use Cases

Harm reduction interventions can lower the likelihood of both overdose and infectious disease by engaging individuals in active use to mitigate their risks. State-level data sets can help illuminate state- and community-specific needs related to reducing harm from opioid use, and can identify areas for policy intervention that can both improve outcomes for people using drugs and avoid costs related to chronic, comorbid illnesses.

Target resources where most needed: Targeted deployment of key harm reduction resources, such as naloxone, can be difficult to pinpoint:

Lay use of naloxone goes unreported, and
Emergency medical services (EMS) may use multiple doses for one overdose or may use naloxone when overdose is suspected but not present.

Wisconsin took a comprehensive approach in its harm reduction analysis. Policymakers analyzed four indicators across the state to identify areas of greatest need of harm reduction interventions: Incidents of opioid overdose deaths;

Opioid overdose hospitalizations;
Suspected opioid overdose ambulance runs; and
Newly reported cases of hepatitis C in people age 15 to 29.

The state then used data on available resources, such as syringe services programs, naloxone availability at pharmacies through a standing order, medication-assisted treatment, HIV prevention, hepatitis C treatment, and SUD treatment providers to identify areas experiencing acute gaps in harm reduction resources.

To further support harm reduction efforts, Wisconsin also tracks suspected overdose deaths on a monthly basis, enabling the state to provide more timely and actionable data to state and local officials. The state reviews 911 ambulance runs and uses word searches in free-text fields to identify additional details. Data is presented as unconfirmed.

Push out actionable data to clinicians to treat common comorbidities: The Louisiana Public Health Information Exchange (LaPHIE) was first implemented in 2008 as a partnership between its Office of Public Health and Louisiana State University Health Care Services Division. The OPH maintains comprehensive HIV surveillance data that is updated daily through lab reporting. If a patient enters a participating hospital and a provider opens that patient’s electronic medical record to provide services, the provider will be notified if the patient has not received timely HIV care and prompted to take appropriate action. LaPHIE is bi-directional, any action taken by the provider with respect to the patient, whether it be a referral or a link back into care, is incorporated into the patient’s electronic medical record (EMR) and returned to the OPH, which then updates the state’s HIV surveillance data.

Identify critical intervention points: Several states have used comprehensive, cross-agency strategies to identify patterns and opportunities for intervention, and the Delaware Drug Overdose Mortality Surveillance report is one such example. This report uses data to illuminate the experiences of individuals in the months prior to their deaths and includes information from a broad scope of data sets, including hospital and health system interactions (including EMS and emergency department visits for overdoses), corrections engagement, and interface with the behavioral health system. By looking at non-fatal overdoses and interactions with EMS, officials can understand the systemic interplay and individual experiences of individuals who fatally overdose in order to better target opportunities for intervention, including treatment in emergency departments.

Similarly, in Massachusetts, the state linked ambulance data with state hospital data to identify individuals who had experienced a non-fatal overdose. By leveraging access to data afforded by the state’s opioid data-sharing initiative, Chapter 55, analysts were able to:

Link information about this subset of individuals to other state data systems;
Identify individuals’ prescription drug patterns through the state PDMP;
Chart their contact with the health care and behavioral health systems through the state’s APCD; and
Document their involvement with corrections.

The state used this information to identify opportunities for intervention and outreach on SUD treatment. A similar data exercise in West Virginia identified that 81percent of those who died from overdoses had interacted with at least one of the state’s health care systems.

Improving Treatment and Recovery Supports Data Use Cases

Ensuring an adequate treatment infrastructure is a high priority as states work to develop access to evidence-based services in the face of this epidemic. By investigating the current treatment landscape in a given state or region, policymakers can analyze unmet need and address gaps in care. Understanding the actual inventory of existing treatment providers through various data sources can help states develop gap analyses and understand workforce needs.

Quantify and optimize current capacity: The Substance Abuse and Mental Health Services Administration (SAMHSA) established a public list of buprenorphine-waivered providers by state and a list of opioid treatment programs (OTP) that provide methadone, also searchable by state. These are helpful starting points when assessing state and local needs, but can be misleading as only a small percentage of waivered providers deliver care to the full extent enabled by the waiver process, and providers can choose to opt out of the listing. Policymakers can compare state-level claims data (Medicaid, APCD) to identify waivered providers who are not providing treatment or maximizing waiver treatment capacity limits. Through this additional step in analysis, state and local policymakers can drill down to better understand which providers may need support in engaging in the medication for opioid use disorder (OUD) provision. Referring these prescribers to tools such as the SAMHSA Provider Clinical Support System can provide additional tools and supports for those providers who are reluctant to maximize their capacity.

Indiana used state workforce survey data to identify which regions of the state lacked a sufficient amount of SUD treatment providers. The Indiana State Department of Health was one of several funders that supported the development of a user-friendly Health Workforce Information Portal that allows members of the public to create maps and reports to review both current workforce and educational pipelines for emerging professionals. Based on survey data, state, county, and local leaders could identify the number of full-time equivalents across areas of the state for a range of professionals, including psychiatrists, clinical social workers, and addiction counselors.

Understand cost and utilization patterns within Medicaid: Looking at existing cost drivers of SUD in Medicaid claims and encounter data within a state’s Medicaid Management Information System (MMIS) can be a helpful starting point for states seeking opportunities to both reduce costs and realign reimbursement structures with service needs. Creating service delivery systems that prioritize a continuum of care in which services can be provided in community clinical settings presents an opportunity for Medicaid programs to reduce costs. In order to better coordinate care and potentially realize cost savings, states can use their Medicaid cost data to develop a range of options that support behavioral and physical health integration and promote team-based care. Virginia’s Addiction and Recovery Treatment Services (ARTS) waiver aligned SUD services to the American Society of Addiction Medicine’s (ASAM) criteria, and encouraged those services to be provided in primary care settings and office-based outpatient treatment facilities. In doing so, Virginia Medicaid experienced a 32 percent reduction in emergency department visits related to OUD during the second year of the program.

Support real-time access to treatment: In addition to the SAMHSA provider locator mentioned above, states can use self-reported provider data to maintain their own state-level treatment locators, and those can include a range of filters to identify particular information, similar to the tool developed by Kentucky using federal grant funding. Through a diverse partnership, the Kentucky Department for Public Health (via the Kentucky Injury Prevention and Research Center) engaged with the Kentucky Office of Drug Control Policy, the Kentucky Department for Behavioral Health, Intellectual, and Developmental Disabilities, and Operation Unite to pull together provider data and develop a short screening that could connect the user to an available treatment provider. Providers have the necessary access and ability to update their facilities’ information daily, and are encouraged to do so. Some states are also employing “bed registries,” tools that track availability of inpatient hospital services, many of which are specific to detox and/or treatment and may serve to help providers in accessing real-time data about available treatment space.

Data Use Cases for At-risk and Underserved Populations

States can also analyze Medicaid service utilization data for specific populations or eligibility categories in order to tailor policy approaches to support vulnerable or underserved populations.

Racial and ethnic disparities: West Virginia, Minnesota, and other states that have analyzed overdose deaths through a racial/ethnic disparity lens have found higher rates of death from overdose among these populations. Minnesota released data analysis focused on the racial disparities it found by reviewing state death certificates and coroners’ reports. The state concluded that the overall low drug mortality rate masked significant racial disparities: Blacks were twiingce as likely to die from a drug overdose than Whites and American Indians were almost six-times more likely to die of a drug overdose than Whites. While drug overdose mortality rates increased for all groups, racial disparities in overdose mortality also increased.

Pregnant women: Through collaborative efforts across state and private agencies, West Virginia identified and addressed a surge in neonatal abstinence syndrome (NAS) and developed a programmatic response. The effort began by standardizing definitions for neonatal withdrawal and providing guidance to clinicians explaining how to use and track diagnostic criteria. The data informed the development of DrugFree Moms and Babies, a program that provides early intervention, treatment, and recovery supports to women and their newborns. The program has improved identification of families at risk and created a structure to support them.

Individuals with corrections involvement: The SUD crisis has highlighted the need for cross-system collaboration between health, behavioral health, and criminal justice systems. A 2017 Special Report from the Bureau of Justice Statistics detailed substance use patterns among individuals incarcerated in state prisons and jails between 2007-2009 and indicated that more than half of incarcerated individuals meet criteria for SUD. Kentucky’s Office of Drug Control Policy, in conjunction with the Kentucky Agency for Substance Abuse Policy, publishes a combined annual report that helps policy makers drill down to specific trends or patterns in charges that may indicate SUD, which can then be used to target the development of incarceration-based treatment programs and pre-arrest diversion programs such as the Law Enforcement Assisted Diversion (LEAD) initiative in Louisville. In Massachusetts, the state Department of Corrections and county-level corrections agencies provided a complete list of people who had been released during one analysis period. The state found that people recently released from corrections facilities were 56-times more likely to die of an opioid overdose than the general public. Moreover, data indicated that those who had received treatment while incarcerated did not have a significant reduction in their risk of overdose. The analysis noted that additional attention should be paid to be individuals leaving corrections facilities, and that treatment should be standardized, regardless of setting.

Individuals without stable housing: Data on housing and homelessness is collected and maintained in Homeless Management Information Systems (HMIS) and can often be accessed directly from the Communities of Care (CoC) that operate regionally to provide a host of services that support housing. CoCs collect and report both housing inventory count (HIC) and point-in-time (PIT) counts of individuals who are homeless, information that can also be accessed at the CoC and state levels through the federal Housing and Urban Development Exchange website. Matching HMIS data with Medicaid utilization data through a state’s MMIS can provide opportunities to develop specific interventions for individuals who are homeless and have received services related to SUD. In Connecticut, the state matched HMIS and Medicaid data and identified a subset of Medicaid enrollees with complex and high-cost health care needs. The state used this data to develop program strategies to better support these individuals, and has since documented improved housing retention, decreased use of emergency departments, and improved connection to preventative services.

Supporting recovery: States are increasingly building peer supports into the continuum of care for SUD. While definitions and services provided vary, 39 states currently reimburse for peers in some capacity through their state Medicaid programs. North Carolina, in addition to tracking access data such as buprenorphine prescriptions and enrollment in opioid treatment programs, also includes access to peer recovery as a key metric on that state’s opioid dashboard. The state has demonstrated a significant increase in the number of certified peer support providers in the state, and provides the data by county.

Best Practices in Using Data to Support State and Local Policy Development

Comprehensive data – often gathered from across state, local, and federal resources – enables state and local leaders to tailor their prevention, treatment, and recovery responses and make the most of scarce resources. However, effectively using available data, matching or comparing complementary data sets, and identifying what should be the focus of analyses can be complicated. The following are key considerations for states seeking to improve data quality, explore data-sharing opportunities, and analyze existing data sets across systems.

Leadership is critical: Sharing data across state silos is challenging – many agencies generally prefer not to release data. Encouraging the sharing of health care and related data sets requires unifying leadership and a vision that can maintain momentum through many programmatic, legal, and technical hurdles. In some states, such as Pennsylvania, the governor used a disaster declaration to bring agencies to the table to create and sustain that state’s multi-agency data capacity. Other states, such as Massachusetts, made significant progress in cross-agency data sharing through legislation. That state’s Chapter 55 public law, passed in 2015, provided the impetus and structure needed for that state’s many SUD data innovations.

Engage both technical and policy expertise to make the most of existing data: While technical expertise in essential, policy and programmatic expertise is also a critical factor in successfully using data to support SUD prevention, treatment, and recovery. Data insights help state policymakers understand and explain variances in eligibility groups, interactions between specialty programs, and flag anomalies in the data due to program idiosyncrasies. Data also helps guide analysts in shaping metrics that will have value for policy decision-making.

Allow time and resources to address data governance: How substance use data is stored and shared is covered by both the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2 – the latter is specific to SUD data and imposes privacy standards that are often more stringent than those found in HIPAA. With few exceptions, providers and stewards of SUD data must obtain consent before sharing personally identifiable information that is protected by 42 CR Part 2. States can make the most of sharing data across agencies by building in time and resources to manage data governance issues:

Data use agreements help to clearly articulate how organizations will use data, and specifically how it supports policy development. This Centers for Medicare & Medicaid Services fact sheet on DUAs outlines necessary components, helpful tips, and includes state example documents. Recognizing the limitations of all data sets included in a DUA also helps to expedite work. Confidentiality issues can be addressed clearly and completely, eliminating onerous approaches to de-identification or aggregation that may not ultimately be necessary. State agencies may have existing DUAs in place that can support new/emerging uses.
Massachusetts was able to combine protected data from across ten disparate state agencies through a project-specific de-identification process that assigned random identifiers to each record. The state also developed a series of legal agreements that covered how data would be linked, shared, hosted, and accessed.

Expect challenges:

Timeliness of data in a rapidly shifting substance use epidemic can be a challenge for virtually all data sets, as very few reporting systems offer real-time data. Longer lags, however, particularly those that pass more than a year from collecting data to reporting, make some data sets better used for understanding the landscape in retrospect rather than as a planning tool. Some states use unconfirmed data when necessary to track particularly urgent indicators, such as drug overdose deaths.
Completeness of data sets – and the lack thereof – can also pose limitations for policymakers and is a major factor in data quality. State Medicaid enrollees, for instance, may move on and off the program as individual eligibility fluctuates, creating gaps in coverage and in key data points, such as current addresses. Encounter data from Medicaid managed care plans can also be problematic – states can improve encounter data quality through contract incentives, regular communication, and guidance. State-level guidance to providers and/or managed care organizations may be required to improve completeness of data

Conclusion

Many data sets produced by state and federal agencies have value when used individually, but when data can be shared and presented in new ways, it begins to tell a more comprehensive story of the particular and highly localized impact of SUD across systems and populations. There has been unprecedented activity at the state level in recent years to identify and use data sources to better understand and address state and local needs to prevent SUD, reduce the harms caused by SUD, and promote treatment and recovery. While states adopt indicators and metrics that meet specific state needs, there is an increasingly innovative menu of options to support their efforts.

Acknowledgements: The National Academy for State Health Policy provided this report with the ongoing support of JBS International and the federal Health Resources and Services Administration (HRSA). The authors would like to thank Lisa Patton, PhD, Vice President of Health Optimization Program and RCORP-TA Project Director at JBS International, and Marcia Colburn, MSW, Program Analyst in the Federal Office of Rural Health Policy at HRSA, for their continued guidance and expertise in supporting this work.

Government Eliminates Waiver Requirement for Doctors Prescribing the Addiction Treatment Medication Buprenorphine

January 18, 2021/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Jodi Manz and Kitty Purington

Update: On Jan. 27, 2021, the Office of National Drug Control Policy (ONDCP) notified stakeholders that the earlier announcement from the Department of Health and Human Services (HHS) that physicians will no longer have to obtain a federal waiver to prescribe the opioid use disorder treatment buprenorphine to patients – as described in this blog – will not be issued at this time. ONDCP noted that it will continue to work with HHS to “examine ways to increase access to buprenorphine, reduce overdose rates, and save lives.” NASHP will continue to update state policy leaders as these federal actions evolve.

Under new US Department of Health and Human Services practice guidelines, physicians will no longer have to go through the cumbersome process of obtaining a federal waiver to prescribe the opioid use disorder (OUD) treatment buprenorphine to patients.

Eliminating the Drug and Alcohol Enforcement (DEA) waiver regulation requirement – long viewed as a significant hurdle to increasing access to OUD treatment medications – is expected to help promote the use of medications for OUD across a range of settings. Providers and policymakers have described the waiver process as antiquated and burdensome, hindering their ability to adequately address the ever-burgeoning opioid crisis.

This change was made under the Secretary’s authority to issue practice guidelines and exemptions to the regulatory requirements for buprenorphine prescribing. It does not change existing federal law, though this may signal that such legal change is on the horizon.

A bill introduced in 2019 by US Rep. Paul Tonko of New York to remove the waiver requirement language for all eligible prescribers remains alive in the House of Representatives, awaiting action. The incoming Biden Administration could swiftly retract this new guidance, but given the momentum toward removing barriers to OUD treatment, it is not expected to be repealed. The new administration is more likely, in alignment the campaign’s opioid epidemic plan’s emphasis on access to treatment, to codify such an expansion in providers’ ability to treat.

Before the waiver was eliminated, doctors had to:

Complete eight hours of training and complete an application to the Substance Abuse and Mental Health Services Administration.

Once granted a waiver, they could prescribe to a maximum of 30 patients for the first year.

After a year, they could submit another application to increase their patients to 100, and eventually serve up to 275 patients.

Providers have described the waiver process as antiquated and that ability to prescribe to only 30 people in the first year hindered their ability to adequately address the opioid crisis.

Because the waiver requirement was previously required for physicians in order to prescribe the medication component of OUD treatment services according to federal law, states similarly imposed this requirement in their own approaches and may need to take steps to re-align policy with the new federal guideline:

States that integrated buprenorphine prescribing practices into their licensing regulations for prescribers may need to amend regulations to reflect changes to physician requirements. In some states, such regulations are also intended to promote prescribing safety, requiring that providers document connections to counseling and other supports, an effort designed to minimize potential diversion of buprenorphine. States could take steps to maintain – or even strengthen – these requirements, as diverted buprenorphine remains a concern to public safety policymakers.
As states have worked to build treatment capacity for OUD, they have integrated the required training for the waiver into their efforts, often partnering with professional associations to provide the in-person training hours. States have also dedicated funding to these trainings in both state budgets and via State Opioid Response (SOR) grant dollars. Because waiver trainings will now only be required for non-physician prescribers, states may need to quickly shift training plans and provider association partners.
Reimbursement for these services may be administratively tied to the requirement to have a waivered prescriber among OUD care team members. As states have developed Medicaid waiver demonstrations and amended state plans to include OUD treatment services, language requiring waivered prescribers was incorporated to align with the federal policy. All of these documents, directives, and billing practices will need to be amended by states to ensure that physicians – now without the waiver – can seek reimbursement.

States can leverage this policy change to address many of the challenges that were previously posed by the waiver requirement in expanding access to this life-saving treatment:

By allowing all licensed physicians to prescribe buprenorphine to a maximum of 30 patients in their first year, this policy change helps to normalize OUD treatment as part of health care, reflecting a long trend of integrating behavioral health and primary care practices. This helps to create administrative ease for providers and payers and reduces logistical barriers for patients.
Stigma regarding OUD has long posed a challenge for states in their efforts to expand treatment capacity, and this change at the federal level represents a sanctioning and approval of this component of treatment that may help to alleviate that stigma.
Emergency departments have been increasing their efforts to transition individuals who use opioids and have overdosed to buprenorphine, though this approach previously required that a waivered prescriber be present at all times in the hospital setting. All emergency department physicians will now be able to administer buprenorphine onsite if necessary.

While this change opens up opportunities for physicians to expand their OUD treatment services, it also leaves many practical questions unanswered. Non-waivered physicians who previously did not obtain the waiver and who decide to begin prescribing buprenorphine in light of this new policy may want additional guidance from their states to feel comfortable prescribing, particularly for non-waiver education and billing practices.

The National Academy for State Health Policy (NASHP) will continue to follow policy changes in the treatment of OUD as they emerge from Congress and the incoming Biden Administration.

Q&A: How Louisiana Has Retooled its Harm Reduction Services for Vulnerable Populations during COVID-19

November 23, 2020/in Policy Louisiana Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Health Equity, HIV/AIDS, Physical and Behavioral Health Integration, Population Health, Safety Net Providers and Rural Health, Social Determinants of Health /by Eliza Mette, Mia Antezzo and Jodi Manz

As drug overdose deaths accelerate during the COVID-19 pandemic, states are working to ensure that a continuum of services, including access to harm reduction programs, remain available to people with substance use disorder (SUD). The National Academy for State Health Policy (NASHP) recently spoke to Louisiana’s Viral Hepatitis Coordinator Emilia Myers and STD/HIV/Hepatitis Program Deputy Director Anthony James to learn how the state is continuing to provide harm reduction services during the pandemic.

Louisiana authorizes cities, including New Orleans, Baton Rouge, Shreveport, and Alexandria, to operate syringe services programs (SSP). The state has helped maintain these programs by targeting federal grants and through close cooperation between state and community partners.

How have the challenges posed by COVID-19 impacted the day-to day operation of harm reduction services in Louisiana?

Louisiana has six active SSPs across the state. They have stepped up to the challenges of this pandemic and have continued to provide their services, essentially without interruption. They’ve been able to do so through some very innovative approaches, such as hotlines and mail-based naloxone services, and by moving away from brick-and-mortar SSPs. The Louisiana Department of Health (LDH) has worked to improve its relationships with SSPs and link them with their respective local health departments. One result of this manifested in New Orleans where, right when COVID-19 started to ramp up, the city started providing residences for folks who were experiencing homelessness. SSPs went out to the hotels that were housing people to bring harm reduction services to them.

We are also using federal State Opioid Response (SOR) grant dollars in collaboration with the Office of Behavioral Health to fund SSP navigators and federal Opioid Overdose Data to Action (OD2A) dollars in collaboration with the Bureau of Community Preparedness to fund Linkage to Treatment Coordinators (LTCs), who prioritize people who inject drugs (PWID) who have fallen out of hepatitis C treatment. If they are also willing to talk about their drug use, the LTC will conduct a Screening, Brief Intervention and Referral to Treatment (SBIRT). We’ve also been using OD2A funds for our marketing campaign to raise awareness of integrated and co-located care for OUD (opioid use disorder), hepatitis C, HIV, and SSPs to reduce harms associated with substance use disorder, which we hope to continue.

Luckily, there is buy-in to this work. About a year ago, together with the Office of Behavioral Health and Bureau of Community Preparedness, we developed a state health department-wide, harm-reduction crosswalk, which was an environmental landscape analysis of who’s doing what in infectious disease, who’s doing what in OUD, and how we can create no-wrong-door systems of care. We’ve had some modest gains as a result, including braiding select government funds, scaling up SSP-based OEND (overdose education and naloxone delivery), increasing opt-out hepatitis C testing at select human service district agencies and cross-training OBOT (office-based opioid treatment) providers statewide to deliver both medication-assisted treatment for OUD and treatment for hepatitis C and we are looking to build on our momentum. Our state agencies have innovative leaders that make connections for more effective public health and behavioral health collaboration and care touch points, and we’re fortunate to have trailblazers that keep this work moving along.

How have people with comorbid HIV and hepatitis C diagnoses been affected by COVID-19, and how has the state responded?

We know folks who are coinfected are one of the populations most vulnerable to unemployment, poverty, lack of access to health care, and they generally have a lot of competing priorities between trying to take their medications and live their lives. Anecdotally, we are seeing more people accessing SSPs and needing supplies, and SSPs are trying to accommodate that increased demand. With an increase in utilization of SSP services, we hope there will not be an increase in overdoses and or increases in HIV and hepatitis C transmission. I think COVID-19 has really turned access into a challenge and created additional burdens for vulnerable populations, so we have to look at the issue through a health equity lens. There are a lot of systemic challenges and barriers that have been exacerbated by the pandemic, and people’s health has become a lesser priority because they’re trying to survive day to day.

Within our Hepatitis C Elimination Plan activities [featured in an April 2020 NASHP case study], we have seen decreases in testing and treatment as a result of the pandemic. Before we launched our program, 61 people per month were starting curative treatment. After implementation, we were seeing on average 478 people per month starting treatment. At the start of the COVID-19, that number dropped back down to an average of 155 people per month, but since September 2020, testing and treatment utilization has picked back up. This has forced us to learn how to get testing and treatment outside of brick and mortar treatment facilities, because people are anxious of going into health care systems. Because of funding reductions and other impacts of COVID-19, we revisited our hepatitis C strategy to ensure we were focused on realistic and achievable objectives for the second year of the plan, and reassess what Years 3 through 5 will look like. COVID-19 has forced us to pivot and continuously innovate hepatitis C service delivery. We will use this as an opportunity to leverage our response and facilitate a larger push in harm reduction.

How does Louisiana’s harm reduction approach support health equity and reduce disparities?

In both the LDH and STD/HIV/Hepatitis Program mission statements, we focus on addressing health equity and racial disparities across the board. Disparities in health care exist and are associated with worse health outcomes, for example the HIV/HCV coinfection diagnosis and prevalence rates are disproportionally higher among Black males primarily in the Baton Rouge and New Orleans areas. Looking at the mono-hepatitis C surveillance data, there hasn’t been a lot of variability in who’s being diagnosed by race. We see disparities in rates of infection by age – we have baby boomers and people who inject drugs getting infected, so we have this bimodal distribution. In an effort to address these disparities in the context of the current hepatitis C/OUD syndemic, we have to pinpoint shortcomings in hepatitis action towards people who actively use drugs and expand primary prevention through harm reduction because treating your way out of a hepatitis C epidemic isn’t feasible. PWID are increasingly researched, but their ability to tell their own stories and provide input into the programs and services they utilize has been historically limited due to stigma. Louisiana is changing that by leveraging community wisdom through community advisory boards to inform evidence-based service delivery. We move this work forward through a core set of values to help us ensure that the services that we and our community partners provide are moving in an equitable direction.

How has the pandemic necessitated or encouraged new strategies or partnerships?

One of our strategies has been offering provider training. We’ve leveraged Project ECHO to train providers how to leverage telemedicine to treat and manage hepatitis C virtually, revamping remote care. There has been a lot of engagement from clinicians.

There was also a decline in hepatitis C and HIV testing at the start of COVID-19. Our community-based partners have conducted risk mitigation strategies to safely re-engage people in testing. Now that they’ve been able to get PPE, they are able to conduct testing in community settings again.

We are also prioritizing data sharing and maximizing opportunities to form strong partnerships, because the syndemic of hepatitis C, HIV, and drug overdose is really intertwined, and COVID-19 has only made things more challenging. Reinforcing our partnerships and leveraging data sharing, in addition to amplifying the voices and wisdom of community members, is helping us make these programs work for the people who rely on them.

What would you say are your greatest lessons learned from COVID-19?

We really need to lean into interdisciplinary telemedicine for comprehensive care, especially for the hard-to-reach communities in high-burden regions of the state. COVID-19 has caused so much slow down, but also additional time to re-assess what we’re doing. In this context, developing robust telemedicine programs will be critical. The next challenge will be how to integrate offerings into clinical care beyond the COVID-19 pandemic so that a “one-stop-shop” PWID service bundle will become an increasingly ordinary part of care with movement towards the goal of reducing disparities in infectious diseases and opioid use disorder treatment access.

Harm Reduction in the COVID-19 Era: States Respond with Innovations

October 19, 2020/in COVID-19 State Action Center Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Population Health /by Mia Antezzo, Eliza Mette and Jodi Manz

Despite COVID-19 workarounds, such as telehealth and virtual recovery programs enabled by flexible federal guidelines, more than 40 states have reported increases in drug overdoses during the pandemic, underscoring the importance of keeping state harm reduction programs as accessible as possible.

As COVID-19 upends the nation’s health care systems, treatment for substance use disorder (SUD) has shifted to telehealth environments and recovery programs have gone virtual as state and federal policymakers adjust regulations and guidance to maintain access to services. But the unique risks facing people with SUD during this time of isolation and mandatory social distancing are also becoming more clear.

State-authorized harm reduction programs that provide syringe exchange services, testing for infectious diseases and referral to treatment, and connections to treatment for opioid use disorder and other SUDs provide a critical intervention. Despite the challenges of implementing COVID-19 protocols for what have traditionally been in-person services, states have developed flexibilities and innovative approaches to ensuring that these programs continue to provide critical, ongoing support to people with SUD until they are ready for treatment.

State guidance for harm reduction providers in response to COVID-19:

The guidance that state officials and agencies have developed recognize the unique challenges that face harm reduction providers during the COVID-19 pandemic. Many states acknowledge harm reduction as an essential service and some have temporarily loosened program restrictions to ensure the continuity of services during the pandemic.

The Oregon Health Authority (OHA) authorized its Syringe Service Programs (SSP) to provide curbside services and phone orders for syringes, naloxone, and other supplies. OHA also suggested operational shifts in staffing, distancing protocols, and volunteer management to mitigate COVID-19 transmission among staff, volunteers, and clients. OHA included messaging in support of people who use drugs (PWUD) in order to maintain their safety during the pandemic. The messaging emphasized the increased respiratory risks associated with drug use and COVID-19 and provided guidance on how to reduce the risk of COVID-19 infection as well as the risk of overdose during the pandemic.
In Maine, Gov. Janet Mills issued an Executive Order on March 30, 2020, suspending an existing one-to-one syringe exchange rule, thereby increasing the number of syringes individuals can take home at once. The order also allows flexibility in mail delivery services, needle exchange site locations and operational hours and provided on-site social distancing protocols.
The Missouri Department of Mental Health issued comprehensive COVID-19 guidance in mid-March, which featured published resources from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Harm Reduction Coalition, and the National Health Care for the Homeless Council (NHCHC), as well as best practices from other states and programs. Missouri’s guidance includes operational directives for treatment and harm reduction providers, as well as practical harm reduction guidance for PWUD, particularly individuals who use drugs alone.

Adaptations in harm reduction services:

Harm reduction programs are making policy shifts to develop practices that respond to the specific needs of their communities. As states and municipalities have responded to the COVID-19 pandemic at varying degrees of restrictiveness, harm reduction programs have also tailored their programs to respond to the pandemic.

Operational changes. Programs in Washington and other states have shifted services outdoors. They now provide curbside or mobile services and have closed their fixed sites entirely and instead rely on delivery services. Many Washington State SSP programs have limited hours and scope of services. In New York, SSPs have been operating with skeletal staff and reduced resources. In response to the new limitations on in-person service, 22 of 23 of New York’s SSPs now rely on some form of peer-delivered syringe services.
Shifts in testing priorities. In addition to continuing to provide harm reduction services, some SSPs in Washington now provide COVID-19 screening and testing at their program sites. West Virginia’s harm reduction programs have reduced the amount of non-COVID-19 infectious disease testing they’re conducting and the amount of hepatitis A and B immunizations they administer, in order to focus on COVID-19 and the immediate needs of individuals with SUD.
Emphasizing naloxone distribution. As overdose rates continue to rise during the pandemic, states are increasing access to the overdose-reversal drug naloxone. Pennsylvania’s Secretary of Health signed an updated standing order that allows community organizations to distribute naloxone through mail. Ohio’s Department of Mental Health and Addiction Services has provided official guidance to all community programs through its statewide Project DAWN overdose reversal initiative to maintain minimal contact with individuals who need services while maximizing naloxone distribution as a strategy to mitigate overdoses. Additionally, the US Department of Health and Human Services has published guidance for first responders to safely administer naloxone during the pandemic.

Looking Ahead

As states begin to consider the impact of COVID-19 on their budgets, programming, and future planning, maintaining harm reduction programs may become more challenging. Harm reduction programs are often supported by multiple funding streams, and program administrators and policymakers may consider leveraging federal grants and other non-state funds to maintain these services. In addition to ensuring access to infectious disease prevention and life-saving treatment and recovery services, harm reduction programs offer a mechanism to maintain engagement with people who have SUD and reduce their risk of overdose, which results from isolation.

This work was funded by the Foundation for Opioid Response Efforts (FORE). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies or stance, either expressed or implied, of FORE. FORE is authorized to reproduce and distribute reprints for foundation purposes notwithstanding any copyright notation hereon.

Three Approaches to Opioid Use Disorder Treatment in State Departments of Corrections

September 2, 2020/in Policy Kentucky, Maine, Pennsylvania Featured News Home, Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Coverage and Access, Medicaid Expansion, Population Health, Social Determinants of Health /by Jodi Manz and Eliza Mette

As drug overdose fatalities continue to rise and incarceration rates remain high nationwide despite recent declines, states are increasingly developing opportunities for incarcerated individuals to access evidence-based opioid use disorder (OUD) treatment in state prison facilities.

While the forced abstinence during incarceration can temporarily pause substance use itself, providing comprehensive treatment that includes medications for opioid use disorder (MOUD) during incarceration is shown to result in better treatment engagement as well as long-term recovery upon re-entry. Providing this kind of treatment during incarceration represents a shift in criminal justice approaches to substance use disorders (SUD), one that relies on partnerships between state agencies and providers, as well as the adoption of an understanding of OUD as a chronic-yet-treatable disorder with effective medical interventions.

Any discussion of this shift toward reframing people with OUD as individuals in need of Treatment – including those incarcerated as a result of their substance use – must also recognize that racial bias across systems affects sentencing policies. While Black people use illicit drugs at similar or lower rates than the rest of the population, they are incarcerated at over five times the rate of White people. Black Americans have also been disproportionately affected by recent increases in overdose fatality due to synthetic opioids, underscoring inequitable systemic responses to prevention, treatment, and recovery for Black individuals with OUD. The incarceration-based treatment approaches emerging today stand in stark contrast to the policy response to the crack-cocaine epidemic and subsequent sentencing guidelines of the previous generation that saw millions of Americans, approximately 80 percent of whom were Black men, incarcerated without a similar focus on treatment.

Policymakers are currently charting a different course by offering evidence-based treatment that is initiated alongside incarceration, recognizing that systems can work together to support people with SUD. These programs represent an opportunity to address both the SUD that may be at the root of criminalized behavior, and the racial disparities in sentencing that foster health disparities.

Developing programs that emphasize treatment instead of incarceration ultimately requires not just a shift in perspective about the nature of SUD, but also the will of leadership to implement new policies and clinical practices – and the funding to do so. The National Academy for State Health Policy (NASHP) talked to leaders from three states – Kentucky, Maine, and Pennsylvania – about their approaches to SUD treatment within their state prison populations and how these approaches are evolving.

Maine

In early 2019, the Maine Department of Corrections (ME DOC) developed a pilot program to begin providing MOUD, starting in one secure state facility and two pre-release state facilities. Part of the impetus for this program was a 2018 lawsuit filed by the American Civil Liberties Union (ACLU) on behalf of an individual with OUD who was entering a Maine state prison and was going to be denied treatment, despite having been in recovery for five years with the assistance of prescribed medication.* ME DOC ultimately settled the case, agreeing to continue providing the individual with necessary medication. Prior to this, the state’s correctional facilities focused on providing residential and out-patient level of substance use treatment and continuity of care in the community upon release, but had no internal, evidence-based program that provided MOUD. In 2019, a new governor and administration initiated different priorities, including new approaches to address Maine’s opioid epidemic. Additionally, the state had just expanded Medicaid, which helped ME DOC to develop protocols that would ensure continuity of care upon release by enrolling participants in Medicaid coverage immediately upon re-entry.

To inform its planning process and learn about successful incarceration-based MOUD programming, Maine’s corrections leadership visited Rhode Island, a leading state in SUD treatment with incarcerated populations. ME DOC launched its buprenorphine pilot in July 2019 by engaging 50 individuals in the program, each of whom was three months from release. The size and scope of the initial pilot phase were intentional, as the state was limited to operating within its existing budget, staffing, and medical services contract. By November, with additional funding, a second facility was added, expanding the program to 75 to 90 participants, and by the end of that year, 115 individuals had successfully initiated treatment while incarcerated and transitioned back into the community.

In 2020, ME DOC expanded the program to all secure and pre-release state facilities and has nearly 200 participants enrolled in the program on average. ME DOC continued to expand eligibility policy over time. Currently, if a behavioral health or medical provider refers an individual for induction, regardless of entry or release date, ME DOC is able to provide MOUD. All program participants are released with a naloxone kit and a continuity of care plan in place, and internal data has shown that 84 percent of program participants attended their initial treatment appointment post-release.

Pennsylvania

Pennsylvania’s Department of Corrections (PA DOC) began offering injectable naltrexone in 2014 through a small pilot with women who were re-entering the community from one state correctional facility. Within two years, PA DOC had expanded this program to other facilities, identifying individuals at risk of overdose and providing injectable naltrexone prior to re-entry, as well as connections to Medicaid enrollment to support continued treatment in the community.

On June 1, 2019, PA DOC continued this development of treatment services through a formal policy change that supports provision of buprenorphine to anyone coming into state custody who was on a verified prescription upon entry, though not yet to other incarcerated individuals with OUD. While this did not replace the naltrexone program, it did introduce a second form of MOUD into the state corrections system, creating entirely new protocols and challenges and with them, opportunities. PA DOC also began inducting those individuals who entered prison due to technical parole violations on injectable buprenorphine before they returned to the community as an alternative to detoxing onsite. Buprenorphine provision, however, experienced serious disruption with the temporary loss of a provider to prescribe the drug, followed by the emergence of COVID-19, which has affected clinical and procedural protocols across the board for PA DOC.

Pennsylvania also brought on a full time medication-assisted treatment (MAT) coordinator for corrections in 2016, a move that led to planning and exploration of expanded treatment provision development, bringing significant growth to the program. In the first year, the state had fewer than 80 individuals receiving MOUD, but participation has grown annually and is on track to include over 1,000 people in all 24 state prisons in 2020.

Kentucky

Kentucky’s Department of Corrections (KY DOC) currently maintains about 6,000 SUD treatment beds within the state’s correctional facilities, though most of those do not include the provision of MOUD and instead promote an abstinence-only approach. In 2018, the state developed the Substance Abuse Medication Assisted Treatment (SAMAT) project in which at-risk individuals are identified pre-release and provided injectable naltrexone or buprenorphine. While still incarcerated, they are connected to Kentucky Medicaid and enrolled in a managed care plan, and prior authorization is completed for necessary continuity of medication upon re-entry.

In 2020, looking for ways to further support and sustain comprehensive treatment in state prisons, the Kentucky legislature passed a budget that included language directing the state Medicaid agency to develop and submit an 1115 demonstration waiver to the Centers for Medicare & Medicaid Services (CMS). This waiver is intended to create a mechanism for Medicaid coverage of SUD treatment while an individual is incarcerated, an approach that is currently prohibited by language known as the “inmate exclusion” in the Social Security Act.

This means that policymakers in Kentucky are simultaneously designing a DOC treatment program and the mechanism to administer and fund it. State leaders are currently exploring proposals to amend the current 1115 waiver to address anticipated clinical and policy challenges to providing MOUD, especially buprenorphine, to people who are incarcerated. All of this must be done while maintaining the budget neutrality required by 1115 waivers. This process also raises questions about when Medicaid coverage would begin, and what services would be absorbed by the DOC budget as opposed to those that would be reimbursable by Medicaid. A mechanism to provide Medicaid coverage to individuals within a 30- to 60-day window prior to release may mitigate some of these concerns. This approach would ultimately increase resources for KY DOC to improve its quality of services by moving toward a more evidence-based approach that includes MOUD.

Considerations for States

All three of the featured states started small, beginning their DOC-based MOUD provision in pilot programs, and with initial success and additional funding, scaled those programs up to meet demand. States had to account for multiple factors in deciding which forms of MOUD to use in their programs, including the expectations of DOC clinical providers, security within facilities, and community treatment supports upon re-entry.

Widespread concerns among corrections officials about potential diversion, as well as stigma about using agonists and partial agonists for treatment, has resulted in a slower adoption of their use in incarceration-based treatment. Though naltrexone has been more widely embraced by correctional facilities than agonists and partial agonists like buprenorphine and methadone, each state has included or is working to include at least two forms of MOUD. Beyond this, state officials also developed clinical protocols and program components based on state resources and needs, and certain experiences and design elements were common across the states.

Decisions around specific forms of MOUD. Maine’s program currently primarily utilizes buprenorphine, recognizing that methadone provision would require significant administrative and clinical policy change. Federal methadone treatment regulations require accreditations and standards that are challenging to meet for an existing correctional facility. ME DOC is, however, exploring opportunities to expand the program to include methadone over time. Additionally, because naltrexone has limited availability in the community for individuals upon release, policymakers were concerned that a program utilizing naltrexone may make connections to ongoing treatment challenging.

While Maine has had success with buprenorphine, current PA DOC policy does not provide for induction on buprenorphine to most incarcerated individuals with OUD – a challenge that is both clinical and administratively-based. Like many states, Pennsylvania contracts for medical care in state prisons, and the current contract was not written to include the provision of MOUD, particularly buprenorphine, which can be clinically intensive and comes with provider waiver requirements.

Per the Request for Applications (RFA) issued by PA DOC, the next iteration of the contract will include a requirement that the state’s corrections medical provider provide MOUD. The RFA stipulates that:

An Addiction Specialist, certified through the American Board of Preventative Medicine, be identified among the contractor’s leadership to support SUD treatment needs;
All providers are educated in SUD treatment;
The contractor must register each correctional institution in the Risk Evaluation and Mitigation Strategies (REMS) program in order to safely order, store, and administer buprenorphine.
Subcontracts are developed with opioid treatment programs to provide methadone at certain facilities; and
A sufficient number of provider staff hold a waiver to prescribe buprenorphine.

Regardless of current challenges, Pennsylvania is prioritizing buprenorphine induction for individuals with OUD who are re-entering communities, similar to the way in which they are currently providing naltrexone. Further, there is a push to be able to induct those who are using contraband opioids, often as a means of harm reduction, while incarcerated. While the state uses injectable buprenorphine for a small minority of program participants, state leaders are awaiting the late 2020 release of a shorter-acting, non-refrigerated formulation that may be less cumbersome to administer.

Attention to correctional workforce needs. Recognizing that addressing staff concerns about the provision of MOUD, including issues of security and diversion, would be necessary for the program to succeed, ME DOC leadership arranged a second site visit specifically for security staff to meet with their counterparts in Rhode Island. To gauge staff culture, ME DOC leadership also conducted an internal survey among staff to assess the general understanding of MOUD, the results of which were used to tailor subsequent staff training and education prior to program implementation.

Kentucky is contemplating the development of new workforce protocols to provide these services as part of the state’s proposed Medicaid waiver. The current approach uses KY DOC counseling staff who are not licensed as behavioral health professionals. The state may consider developing a new provider type of DOC-based professionals, requiring new or amended professional licensing regulations, reimbursement policy changes, and facility licensure changes if needed. The state is also deliberating what utilization of peers may look like in such a program, as well as what supervision for unlicensed staff would include.

Ensuring continuity of care upon re-entry. Individuals leaving incarceration face a host of risk factors for return to substance use and potential overdose, including lack of access to treatment and limited financial resources. In recognition of this, all three states ensure that program participants are enrolled in Medicaid coverage, safeguarding their access to continued treatment in the community. The ME DOC also contracts with Groups Recover Together, a community recovery organization that helps to ensure that individuals are connected to and engaged in recovery services upon re-entry.

Pennsylvania is also considering how individuals progress with treatment upon re-entry based on the treatment provided to them while still incarcerated. Currently, PA DOC is providing up to three naltrexone doses prior to release and is reviewing state Medicaid treatment data to understand the impact of multiple doses versus one dose on treatment outcomes in the community.

Coordination between state leadership. Because these programs often emerge from previously existing social or abstinence-based approaches, the development of protocols and resources must be coordinated under the direction of high-level state leadership. Officials in all three states indicated they had leaders who not only authorized but championed treatment in incarceration settings. These leaders were critical to developing treatment policy, and their continued focus on OUD-related initiatives was a key component to maintaining services. In 2018, Pennsylvania’s governor declared the overdose epidemic a statewide disaster, and he continues to renew that declaration to ensure that initiatives it supports – including treatment within PA DOC – are maintained. The declaration established a cross-agency Opioid Unified Coordination Group composed of cabinet-level health and public safety officials that meets weekly.

Kentucky is one of few states to have a dedicated Office of Drug Control Policy, which led the charge for them to be among the first states to fund and implement an incarceration-based naltrexone program in corrections. The state legislature is unique in the nation in its decision to direct the state Medicaid agency to explore and submit a Medicaid waiver to provide SUD treatment to incarcerated individuals.

Maine’s current governor appointed a cabinet-level State Opioid Response Director, and she included incarceration-based treatment among her top priorities for the state upon assuming office. The governor’s second Executive Order, signed less than a month into her term, directed the development of OUD treatment in criminal justice settings, and the state’s DOC commissioner was working to implement this within the first few weeks of her administration.

Funding and Support for Incarceration-Based Treatment Sustainability

Because of the inmate exclusion that prevents correctional facilities from receiving Medicaid reimbursement for services in incarceration settings, states are relying primarily on federal grant funding to support these programs.

Maine launched its pilot program without using any additional funds beyond its internal budget, receiving an additional $1 million in funding from the Maine Office of Behavioral Health’s federal substance abuse block grant to support the program later in 2019. Concurrently, ME DOC realized savings in its health care budget as a result of the state’s recent Medicaid expansion. With these additional funding streams, Maine was able to make its final program expansion by adding its last remaining correctional facility to the program and expanding program eligibility to allow individuals who entered a facility from a local jail to continue on a course of MOUD that had been established previously. This also allowed Maine to expand treatment to individuals who are 180 days pre-release.

Kentucky’s initial provision of naltrexone was supported through state legislation that allocated $3 million to the program, and the current program is supplemented through federal State Opioid Response funds provided via the Kentucky Opioid Response Effort (KORE). Pennsylvania similarly uses their SOR funding to support current programming.

Looking Ahead

States are looking to the future as they plan what OUD treatment services for incarcerated populations will look like, as well as how to fund such services with increasingly limited resources and current reliance on federal grants. There may be an emerging appetite to address the inmate exclusion and develop new approaches through Medicaid, though as the COVID-19 pandemic increases Medicaid enrollment and drives state revenues down, any new Medicaid-funded services will be challenging to state budgets.

Even in successful corrections treatment programs, lack of insurance coverage upon re-entry is a barrier to long-term treatment and recovery outcomes. A House bill introduced in 2019, known as the Re-entry Act, was written to allow states to reinstate eligibility for Medicaid for incarcerated individuals in jails and state prisons up to 30 days prior to re-entry. Recognizing that the COVID-19 pandemic has disrupted, if not altogether halted, re-entry services across the country, the bill’s language was integrated into pandemic response legislation as a part of the Heroes Act, which has yet to be passed.

Treatment programs in incarceration settings are helpful tools that states are using in hopes of reducing opioid overdoses, but also in reducing the stigma around SUD and the racial disparities in health outcomes for people with OUD. As states continue to take steps to tackle the opioid epidemic, state corrections settings are proving to be an innovative access point for evidence-based treatment.

*See Smith V. Fitzpatrick, et al. The lawsuit argued that the DOC was violating the Constitution and the Americans with Disabilities Act by denying treatment to prisoners with OUD. At the time, the Maine DOC had a policy generally prohibiting medication-assisted treatment, under which Smith would have been prevented from taking his medication and forced into acute withdrawal.

Acknowledgements: The National Academy for State Health Policy is providing this case study with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. Further, the authors would like to thank Allen Brenzel, medical director of the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities; Steven Seitchik, Statewide Medication Assisted Treatment Coordinator for the Pennsylvania Department of Corrections, and Ryan Thornell, Deputy Commissioner of the Maine Department of Corrections for contributing their expertise and state experiences to this brief.

Federal Rule Change Allowing Providers to Share Data Poised to Improve Substance Use Disorder Treatment

August 24, 2020/in Policy Behavioral/Mental Health and SUD, Chronic and Complex Populations, Health Coverage and Access, Health IT/Data /by Eliza Mette

Last month, the Substance Abuse and Mental Health Services Administration (SAMHSA) revised its rules and gave providers at substance abuse treatment centers increased access to patient information, including prescribing information, to help them make more informed decisions and avoid duplicative treatment.

SAMHSA changed its Part 2 Rule, first published in 1975, that originally limited the sharing of data about individuals receiving substance use disorder (SUD) treatment at federally-assisted programs. State policymakers have long argued the rule did not align with the Health Insurance Portability and Accountability Act (HIPAA) regulations, creating hurdles to care and, for some systems, restricting care coordination and integration.

The revised rule will especially benefit states’ opioid treatment programs (OTPs) and prescription drug monitoring programs (PDMPs) as they confront mounting overdoses resulting from the COVID-19 pandemic.

Increasing Disclosures to Prescription Drug Monitoring Programs

Nearly every state maintains a PDMP, a secure database that collects and maintains controlled substance prescription data on a statewide platform. Prescribers and pharmacists and, in some states, law enforcement and regulatory boards, may access these databases in order to prevent duplicative or harmful prescriptions and ensure appropriate prescribing practices.

PDMPs have been critical tools for states’ opioid responses, providing policymakers with data to help reduce opioid prescribing and decrease prescription opioid-related overdose deaths.

Until now, Part 2 has prevented states from including prescribing data from Part 2 providers, such OTPs, in PDMP information. In a 2011 guidance letter, SAMHSA indicated that while OTPs may access PDMPs, they may not disclose patient identifying information to them. PDMPs are designed to make patient information more readily available to authorized users, which necessarily involves the re-disclosure of patient-identifying information. This re-disclosure of patient-identifying information from a Part 2 program is generally prohibited by the Part 2 Rule.

Other major changes under the new Part 2 Rule:

Part 2 program employees may now “sanitize” their personal phones or computers by simply deleting a message that an SUD patient accidentally sends them.
Declared emergencies (e.g., natural disasters) qualify as “bona fide medical emergencies” for purposes of disclosing SUD records without patient consent.
Disclosures for research under Part 2 are permitted under certain circumstances.
It also clarifies scope of permissible disclosures for audits and/or program evaluation purposes.
The changes extends court-ordered placement of an undercover agent or informant within a Part 2 program to 12 months.
An SUD patient may now identify an entity (instead of an individual) when consenting to the disclosure of his or her Part 2 treatment records.
It clarifies what qualifies as a disclosure for the purpose of “payment and health care operations” and expands the list to include care coordination and case management.

Under the revised rule, OTPs are now permitted to enroll in a state PDMP and report data to it when prescribing or dispensing Schedule II to V controlled substances, so long as they have patients’ consent. SAMHSA explained, in its response to public comments, that excluding OTP data from PDMPs can result in providers inadvertently prescribing duplicative or contraindicated prescriptions, and that allowing Part 2 programs to enroll in PDMPs will improve treatment and promote more efficient care coordination among providers. SAMHSA also indicated that permitting OTP enrollment in PDMPs will strengthen the ability of PDMPs to achieve their core function of preventing misuse and potential overdose by including the most complete patient data available.

Disclosures to Central Registries

Central registries – used in some states – are defined by Part 2 rule as entities that maintain patient-identifying information about individuals who apply for withdrawal management or maintenance treatment, with the goal of avoiding enrollment in multiple treatment programs. Prior to the recent , only member organizations (i.e., other OTP providers) could access patient-identifying information through central registries.

Under the revised rule, any treating provider may now access central registries to review patient information, with the goal of preventing duplicative prescriptions and better coordinating care. In its comments, SAMHSA noted that all providers who work with patients with SUDs should have access to information that may aid in preventing duplicative treatment, and that non-OTP providers need to have the complete medical history of their patients in order to provide effective and safe care.

Applicability to Non-Part 2 Providers

With an increased focus on integrated and coordinated care, providers across a range of settings, including primary care, have experienced challenges in sharing, receiving, and segregating patient information related to SUD treatment. While SUD records sent by a Part 2 program to a non-Part 2 program remain protected and may not be re-disclosed without patient consent, recent rule changes do remove some burdens. The new rule clarifies that treatment records created by non-Part 2 providers based on their own patient encounters are not subject to Part 2. SAMHSA is encouraging non-Part 2 providers to segregate their patient records from any records received from Part 2 programs in order to ensure that their records do not become subject to Part 2.

Implications for States

States can use these new flexibilities to bolster their PDMPs and improve the tracking and analysis of prescribing data. Adding OTP data to the equation will help complete the picture of prescribed drugs at both state and clinical levels, supplying health officials with better data to drive program and policy decisions. Critically, improved access to prescribing information will give providers the clinical data they need to make informed decisions and avoid duplicative treatment. By implementing these changes, states can work toward coordinating and improving patient care and ensuring better patient outcomes.

Posts

State Approaches to Cross-Agency Organization and Funding for Substance Use Disorder: Spotlight on Kansas, Maine, and Pennsylvania

How States Are Leveraging Payment to Improve the Delivery of SUD Services

Confronted with Overdoses, Rhode Island’s Emergency Departments Employ Peer Services to Promote Treatment

How States Access and Deploy Data to Improve SUD Prevention, Treatment, and Recovery

Conclusion

Harm Reduction in the COVID-19 Era: States Respond with Innovations

Federal Rule Change Allowing Providers to Share Data Poised to Improve Substance Use Disorder Treatment

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