In early February, Congress allocated $6 billion to combat the opioid epidemic. This represents a major step forward, as it recognizes the critical point we have reached in fighting the battle against opioid use. Without a concrete plan to spend the money, however, such progress could easy become a missed opportunity. Now, as the Senate Appropriations health care subcommittee decides how to spend the $6 billion, they should consider what has already been tried-- so as to learn from what works and what doesn't.
The plan will need to be agile, well-informed, and, above all, patient-centered. A comprehensive implementation plan will provide answers to questions such as:
- What should we do first?
- Who is accountable for each part of the plan?
- Are some parts of the plan dependent on others?
- When will results be delivered?
- What is currently working that we can support, expand, and spread to other places?
- How will we recover quickly from failures?
- How will we measure and report success to the American people?
In order to create a plan that satisfies these questions, we can turn to the tech world for guidance. When companies like Google, Amazon, and Apple face difficult problems like Congress now faces with the opioid epidemic, they use a tactical approach that focuses on “minimum viable products,” or MVPs. In essence, MVPs are the phase one of a larger plan, an in-the-moment fix that teaches them what works and doesn't work on a small scale. MVPs focus on basic features and speed to market, then quickly incorporate user feedback. If used to approach the problem of opioids, they can allow states and localities to try out many different things at once, some of which will fail and some of which will succeed. We will then have the chance to shift resources to the programs and initiatives that are working, so that they can be spread to other places.
An implementation framework for combatting the opioid crisis for 2018-2019 should have 10 workstreams:
- Leadership and Advisory
- Evidence-Based Treatment and Recovery
- Education, Training, and Prevention
- Law Enforcement, Supply, and Criminal Justice Reform
- Health Policy Modernization
- Monitoring and Surveillance
- Harm Reduction and Emergency Response
- Health IT and Interoperability Standards
- Provider and Industry Engagement
- Long-term Funding Plan
Sample workstream: Evidence-Based Treatment and Recovery
|Scope||Goals||Agency Leads||State Leads||Expert Advisors|
|- Balanced approach to reduce rate of opioid prescriptions with safe use for chronic pain|
- Medication Assisted Treatment (MAT)
- Continuum of Care
- Screening, Brief Intervention and Referral to Treatment (SBIRT)
- Evaluation research of pharmacy benefit managers (PBM) and pharmacy interventions
|- Reduce the prescription rate of opioids|
- Make VA and private provider opioid prescription data publicly accessible
- Reduce wait times for SUD treatment from weeks/months to less than 3 days
- Increase access to Narcan, bupremedine, and other MAT drugs
- Reduce the number of babies born into addiction
|- Department of Veteran Affairs|
- Department of Health and Human Services
- W. Va.
|- Bertha Madras|
- Gina Raimondo
- Richard Baum
- Tom McLellan
- Jay Unick
Luckily, each workstream has successes to build on from various states, such as:
- Vermont’s hub and spoke model integrates substance use treatment in primary care. The hub provides intensive treatment (such as daily medication), and the spokes are follow-up care.
- The U.S. Department of Veterans Affairs, the largest healthcare provider in the country, is a leader in government transparency, posting information publicly on opioids dispensed from VA pharmacies, along with the VA’s strategies to prescribe these pain medications appropriately and safely.
- St. Joseph's Hospital in New Jersey is using alternative treatments like nerve blocking injections for acute pain to decrease the use of opioids responsibly, and thus far has seen a 58% reduction in opioid prescriptions. St. Joseph's has also launched a program to help patients addicted to opioids by providing recovery coaches. 86% of participants in this program have achieved long-term recovery.
- Maryland Medicaid will begin to reimburse for residential substance use disorder treatment services, paying for up to two non-consecutive, 30-day treatments.
Education, Training, and Prevention
- Idaho has developed a toolkit that includes the CDC Opioid Prescribing Guidelines and Prescription Monitoring Program information.
Law Enforcement & Criminal Justice
- Buffalo, NY has launched the first opioid treatment court, which expedites treatment for defendants and gets them help often within hours.
- Montana is increasing access to drug treatment courts (33 courts, with 381 participants per year) and creating a pilot program to increase the number of jails and DOC facilities offering MAT.
- Colorado is considering several bills in the State House right now, one of which would limit the number of pills doctors can prescribe to patients receiving opioids for the first time.
Monitoring and Surveillance
- The Massachusetts Center for Health Information and Analysis (CHIA) is a model for interoperability between local data systems, the state, payers, and providers. The state also started the Massachusetts Prescription Awareness Tool (MassPAT) Interconnectivity Map, which has connected 29 states and the District of Columbia in order to to share patient prescription data.
Harm Reduction & Emergency Response
- South Carolina has created an Opioid Emergency Response Team that allows state officials, private partners, and law enforcement to utilize the emergency management infrastructure for combatting the epidemic.
- Denver, CO's Harm Reduction Action Center provides a safe place to exchange dirty needles for clean ones and stocks naloxone, a drug that can reverse opioid overdoses.
Provider & Industry Engagement
- Baltimore Concerted Care Group not only treats the symptoms of addiction, but also the behaviors that accompany, enable, and cause addiction. It integrates medical, psychological, vocational, economic, and social expertise to literally “wrap around” the patient and the patient’s lifestyle--all at one place.
Interoperability & Health IT
- Montana's Prescription Drug Registry is integrating their information into provider software for electronic health records and pharmacy operating systems.
- Montana is also developing a prescription drug burden document that includes analysis of all major sources of available public health and justice system data related to substance use disorder and data sharing agreements.
Long-term Funding Strategy
- West Virginia is using lawsuit settlements from drug companies to fund treatment solutions. From this, nine drug treatment programs in West Virginia will receive a combined $20.8 million in funding.