Reducing Opioid Use Disorder and Overdose in the United States: Model Development and Policy Analysis

Mohammad Jalali, PhD
Harvard University

Wayne Wakeland, PhD
Portland State University

ABSTRACT:
The opioid crisis is one of the most pressing public health issues in the U.S. today. Opioid overdoses are the proverbial “tip of the iceberg,” arising within a complex adaptive system characterized by rapidly changing dynamics combined with significant time lags and large uncertainties in the data. System dynamics modeling is a critical tool to guide policymaking and avoid unintended consequences. We developed a simulation model of the opioid system, spanning from medical use of prescription opioids to opioid misuse and heroin use, use disorder, treatment, and remission. The model aims to help policymakers address the crisis by aiding in policy analysis and decision-making under uncertainty. We project the effects of several policies to reduce opioid use disorder and overdose, and analyze intended and unintended effects of the policies over the next 10 years. Model simulations suggest most policies implemented on their own will achieve only modest reduction in either fatal overdoses or prevalence of OUD.

Alliances to Disseminate Addiction Prevention and Treatment (ADAPT)

Matthew Aalsma, PhD
Indiana University

ABSTRACT:
Data science and informatics are increasingly driving public health efforts. This had led to medical systems utilizing electronic health record information to drive care improvement. Change mechanisms, such as Learning Health Systems, have been applied less often within community based systems, such as court and treatment settings. Dr. Aalsma will discuss efforts to improve addiction screening and treatment for justice involved youth through community-based collaboration in Indiana communities.

Treatment for opioid use disorder in the Florida Medicaid population: A cascade of care approach to assessing quality.

Kimberly Johnson, Ph.D.
University of South Florida

ABSTRACT:
Despite increased funding, opioid overdose rates remain high. Understanding at what stage of the process and for whom the system is failing is critical to improving care. A cascade of care (CoC) model may improve understanding of gaps in addiction treatment availability and quality over current single measure methods. Using a CoC framework, we assessed treatment quality and outcomes for opioid use disorder for the Florida Medicaid population in 2017/2018 by demographics.

Methods: Data from Florida Medicaid claims for 2017 and 2018 were used to calculate the number of enrollees who were diagnosed, began medication, were retained on medication for a minimum of 180 days, and who died.

Results: Only 28% of those newly diagnosed with OUD in 2017 began treatment with an FDA approved medication. Once on medication, 38% of newly diagnosed enrollees were retained in treatment for at least 180 days. Those who remained in treatment for 180 days had a hazard ratio of death of 0.226 (95% CI = 0.174 to 0.294) compared to those that did not initiate treatment, a reduction in mortality from 10% without care to 2% with care.

Conclusions: Initiating medication after diagnosis is the process most in need of improvement, though there is much room for improvement in treatment retention as well. The CoC is an appropriate method of measuring the quality of the functioning of the treatment system at the state level.

Agent-based models for understanding the impact of transitions between community and criminal justice settings on HIV transmission and opioid mortality: implications for intervention development

Anna Hotton, PhD, MPH
John Schneider, MD, MPH
University of Chicago Medicine

ABSTRACT:
Criminal justice involvement (CJI) has important public health and social consequences, affecting social and sexual network stability, employment and housing opportunities, and access to medical care, all of which can lead to cycles of socioeconomic marginalization and adverse health outcomes. CJI populations are disproportionately impacted by HIV and substance use disorders, which can be exacerbated by frequent cycling between communities and criminal justice settings. However, such settings also offer opportunities for delivery of treatment and prevention interventions, such as PrEP, ART, and medication assisted therapy to populations who may not otherwise access these services. Guidance is needed to determine how interventions for CJI populations can be most effectively deployed, but logistical and ethnical challenges make empirical research difficult in contexts that often include marginalized communities that are highly mobile, have significant loss to follow-up, and cycle frequently between criminal justice and community settings. Agent-based models (ABMs) can generate insights about the processes that drive HIV transmission and opioid related mortality and provide a platform for virtually evaluating potential candidate interventions, thus facilitating more efficient and focused intervention development. By illuminating mechanisms associated with intervention success and providing the ability to parameterize the relevant individual-level heterogeneity via detailed, local data, ABMs allow for exploration of complex interventions, enabling the investigation of specific intervention ingredients and mechanisms likely to have the most impact on the HIV and opioid epidemics in the US. We present early applications of ABMs for evaluating interventions for CJI populations with nascent examples in HIV and opioid mortality, and discuss implications for structural, policy, and network-based interventions.

Using Systems Consultation to Improve Opioid Prescribing in Primary Care: Protocol for a Sequential, Multiple-Assignment Randomized Trial (SMART)

Andrew Quanbeck, PhD
Department of Family Medicine and Community Health
University of Wisconsin
School of Medicine and Public Health

ABSTRACT:
Background (context and purpose of the study) Health care systems are notoriously slow to adopt clinical guidelines and other evidence-based practices, in part because the literature offers little help about which implementation strategies work best in different clinical settings and how strategies could be tailored to maximize their effectiveness in different contexts. This study tests a blended implementation strategy called systems consultation to improve concordance with clinical guideline for opioid prescribing in primary care. Systems consultation consists of the following theoretically and empirically proven strategies: (1) an educational meeting followed by audit and feedback, (2) practice facilitation, and (3) physician peer consulting. The study aims to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.

Methods (how the study will be performed) The study is a hybrid type 3 cluster-randomized sequential multiple-assignment randomized trial (SMART) that randomizes clinics at two timepoints, months 3 and 6 of an 18-month intervention period. The study will compare the effect on morphine-milligram equivalent dose of the elements of systems consultation. Four combinations of implementation strategies will be assessed: an educational meeting and audit and feedback alone (AF), AF plus practice facilitation (PF), AF + PF plus physician peer consulting (PPC), and AF + PPC. In addition, an assessment of system-, clinic-, and prescriber-level contextual factors will be developed and tested to build a tool for tailoring strategies to different clinics, and a cost estimate will be conducted of the strategies that make up systems consultation. The study aims to enroll up to 38 clinics from three health systems. Mixed methods will be used to evaluate systems consultation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Clinics will be the primary unit of analysis.

Discussion (summary and potential implications) Systems consultation is a practical blend of evidence-based strategies, in this case used to improve opioid prescribing practices in primary care. The blend offers a range of strategies from minimally to substantially intensive to make available the most cost-effective strategy(ies) for specific clinical contexts. Systems consultation and the adaptive approach used to deliver the strategy may generalize to the adoption of other evidence-based practices as well.

The SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) center to increase identification and treatment of opioid use disorder in VA primary care: An operationally-partnered internal facilitation implementation effort

Emily C. Williams, PhD, MPH
Department of Health Services
University of Washington

Eric J. Hawkins, PhD
Addiction Medicine
VA Puget Sound Health Care System

ABSTRACT:
Opioid use disorders (OUD) are increasingly common and dangerous. Though medication treatment of OUD is effective, recommended, and can be offered in primary care settings where patients with OUD are frequently seen, it is substantially underused with multiple barriers to its provision. The SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center is a partnership between researchers and clinical leaders to assist VA primary care clinics in identifying and treating OUD. We will describe our operationally-partnered implementation efforts using internal facilitation and use of rapid mixed-methods formative evaluation to refine our implementation strategies, and we will present up-to-date evaluation results.

Applying lessons learned from global mental health to the opioid crisis

Jessica Magidson, Phd
Department of Psychology
University of Maryland

ABSTRACT:
The current opioid crisis in the United States has been considered an “epidemic of poor access to care”. Similar to the shortage of trained providers to prescribe medications to treat opioid use disorder (OUD), there is a severe shortage of trained providers to meet the behavioral health needs of patients with OUD. This talk will draw from global mental health models of “task sharing” to discuss how lessons learned from scaling up evidence-based interventions with lay health workers in low and middle-income countries can inform efforts to increase access to behavioral health care for patients with OUD in the US. Research will be presented using peer recovery coach models to integrate substance use treatment into HIV care in South Africa and to promote linkage and retention in OUD care locally.

The Emergency Department as an Implementation Science Laboratory: Evidence Based Treatment for Opioid Use Disorder

Lauren Whiteside MD MS
Assistant Professor
Department of Emergency Medicine
University of Washington

ABSTRACT:
The Emergency Department (ED) is at the forefront of opioid public health crisis with increasing ED visits for overdose and opioid.  Additionally, deaths related to opioids are increasing despite work that is ongoing around harm reduction and access to treatment.  There is a growing body of evidence that patients with OUD initiated on buprenorphine in the ED are more likely to be engaged in substance use treatment at 30-days compared to patients who are referred to outpatient treatment only.  Additionally, there is an increasing evidence-base for other ED-based interventions such as take-home naloxone and care navigation to improve care transitions.

This talk will discuss some unique challenges related to implementation of evidence-based treatment in the ED.  Next, I will share results from a qualitative study of Emergency physicians highlighting the barriers and facilitators of ED-initiated buprenorphine using the Consolidated Framework for Implementation Science.  Lastly, I will describe a pilot pragmatic randomized clinical trial of a care coordination intervention called ‘Emergency Department Integrated Care’ or ED-LINC and discuss innovative ways to improve provision of evidence-based treatment for patients with OUD from the ED.

Health Economic Research Supporting the U.S. Response to the Opioid Crisis: Defining Cost Effective Interventions and Implementation Strategies

Kathryn McCollister, Phd
University of Miami, Miller School of Medicine

ABSTRACT:
As the U.S. continues to grapple with the opioid epidemic, the National Institutes of Health, in collaboration with the Substance Abuse and Mental Health Services Administration, has recently launched several funding initiatives tasked with identifying, testing, and implementing evidence-based strategies to significantly reduce overdose fatalities and other negative consequences associated with opioid use disorders (OUD). Health economics research is highlighted as an important component to these new studies; specifically, the need for economic data informing resource allocation, cost effectiveness, and financing mechanisms that support the feasibility and sustainability of recommended strategies. This talk will describe the current state of knowledge on the cost effectiveness of treatment interventions and other strategies for OUD as well as relatively new questions relating to the economics of implementation at a broader community- or systems-level.

Title: Cost-Effectiveness of Care Models to Support HCV and HIV Elimination in People Who Inject Drugs

Bruce Schackman, Phd
Weill Cornell Medical College

ABSTRACT:
The United States has set ambitious goals to eliminate Hepatitis C Virus (HCV) and HIV infections nationally, but the current opioid crisis has resulted in increased incidence of HCV as well as outbreaks of HIV among people who inject drugs (PWID). PWID may not access healthcare services because of stigma, abstinence requirements, and lack of available providers. This presentation will describe recent and ongoing work evaluating the effectiveness, cost-effectiveness, and implementation of different healthcare models designed to bring HCV/HIV testing and HCV care to PWID in a variety of settings including methadone maintenance programs, syringe service programs, and clinical settings.

House on Fire: Addressing Opioid Overdose as an Epidemic

Kimberly Johnson, PhD, MBA
Research Associate Professor, University of South Florida

ABSTRACT:
There are standard public health models of addressing epidemics of contagious disease. This presentation will argue that if we use standard protocols that have been developed to address other epidemics, we would make greater progress in reducing the rate of drug overdose deaths in the United States. The presentation will remind participants of how smallpox was eradicated and what was learned about epidemic control in that effort as well as what is being learned in international efforts to eradicate the spread of HIV. The presentation will conclude with a discussion of the strengths and weaknesses of the current response to the opioid epidemic from a public health epidemic control perspective.

Approaches for implementing digital treatments for drug use disorders into primary care: A qualitative study of patient perspectives

Joseph E. Glass, PhD, MSW
Kaiser Permanente Washington Health Research Institute

ABSTRACT:
Researchers and health systems do not know how to care for large numbers of primary care patients with opioid and other substance use disorders, even though these conditions are increasingly deadly and costly. Digital treatments, or software-based care delivered via apps and websites, could be used to reach large numbers of patients with effective treatments. However, there is inadequate knowledge about how to support the delivery of digital treatments in primary care. This presentation will describe findings from research that engaged patient stakeholders to develop a user-centered approach for offering digital treatments to patients with opioid, stimulant, and cannabis use disorders.

Long-term buprenorphine treatment for OUD and adverse events following discontinuation among Medicaid beneficiaries

Arthur Robin Williams, M.D.
Department of Psychiatry, Columbia University

ABSTRACT:
Background: Buprenorphine reduces the risk of overdose and death among patients with opioid use disorder, yet to date, an empiric basis for the optimal length of treatment is lacking. Adverse health outcomes following buprenorphine discontinuation were compared among patients who were successfully retained beyond six months of continuous treatment akin to the "Retention" stage of the OUD Cascade of Care.

Methods: Retrospective longitudinal cohort within MarketScan multi-state US Medicaid claims (2013-2017) covering 12 million beneficiaries annually. The sample included adults 18-64 years old who received buprenorphine continuously for ≥180 days by cohorts retained for 6-9 months (n=4,126), 9-12 months (n=2,440), 12-15 months (n=1,499), and 15-18 months (n=931) with claims extending 6 months following discontinuation to assess outcome events. Primary adverse outcomes included all-cause emergency department visits, inpatient hospital admissions, filled opioid prescriptions, and overdose, controlling for demographic characteristics and comorbid mental health and substance use diagnoses.

Results: Rates of adverse events were high across all cohorts following buprenorphine discontinuation with approximately half of patients (42-50%) seen in the emergency department at least once during the 6 months following discontinuation. Compared to those retained for 6-9 months, patients retained for 15-18 months had lower odds of all-cause emergency department visits (OR 0.70, 95%CI 0.60-0.90, p<0.001), all-cause inpatient hospitalizations (OR 0.80, 95% CI 0.6-1.0, p<0.05), and filling opioid prescriptions (OR 0.70, 95%CI 0.60-0.80, p<0.001) in the six months following discontinuation. Approximately 5% of persons across all cohorts experienced one or more medically treated overdoses in the 6 months following buprenorphine discontinuation. Analysis was limited to beneficiaries in multiple unidentified states and could not account for mortality outcomes.

Conclusion: Risk of acute care service use and overdose were high following buprenorphine discontinuation irrespective of treatment duration. Superior outcomes became significant with treatment duration beyond 15 months but remained concerning suggesting a minimum of 6 months is insufficient. Improvements at all levels of care are needed to increase retention of patients on buprenorphine.

Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A type 3 effectiveness-implementation hybrid trial

Bryan Garner, Ph.D.
Research Triangle Institute (RTI)

Sara Becker, Ph.D.
Department for Behavioral and Social Sciences, Brown University School of Public Health

ABSTRACT:
There is an urgent public health need to improve the outcomes of individuals with opioid use disorders (OUDs). There are currently five approved medication formulations, which relative to placebo have demonstrated effectiveness in helping patients attain abstinence from opioids. Nonetheless, patients’ opioid abstinence rates are sub-optimal: even when treated with the newest extended-release formulations only about 40% of patients maintain abstinence during the first 6-months of treatment. Contingency Management (CM) is one of the only behavioral treatment shown to improve OUD pharmacotherapy outcomes, yet implementation of CM within OUD treatment centers remains quite low. Project MIMIC is a type 3 effectiveness-implementation hybrid trial to test the effectiveness of an enhanced-version of the Addiction Technology Transfer Center’s current multifaceted implementation strategy on both implementation outcomes (primary aim) and patient outcomes (secondary aim). For this PSMG web-presentation, Drs. Becker and Garner (Project MIMIC’s principal investigators) will teach others about the project and its protocol, with special emphasis on helping the audience learn more about the project’s two implementation conditions, key challenges, and key lessons learned.

Stimulant Use Disorders: Epidemiology, Clinical Challenges, and Review of Treatments

Richard Rawson, PhD
Department of Psychiarty, UCLA

ABSTRACT:
Methamphetamine and cocaine use rates and overdose deaths are rapidly increasing in much of the US.  The presentation will review the clinical challenges presented by individuals who use stimulants and current protocols for addressing acute medical/psychiatric conditions.  Evidence-based behavioral/psychosocial strategies are presented, along with pharmacotherapies currently considered promising.

The US opioid epidemic: A public health crisis and opportunity for implementation research

Mark A. McGovern, PhD
Stanford University

Abstract: The US opioid epidemic has exposed a significant gap in access to evidence-based care for persons who suffer from opioid use disorders. Although effective medications exist for opioid addiction, they are not widely available. This presentation describes several system level initiatives to increase reach and adoption, in efforts close the implementation gap. An emphasis will be on lessons learned, and how more rigorous implementation research methods may be brought to bear to address this major public health problem.

Leveraging Treatment & Recovery Services to Address the Opioid Crisis

Todd Molfenter, PhD
University of Wisconsin - Madison, Center for Health Enhancement Systems Studies

Abstract: Dr. Molfenter will provide an overview of the “Opioid Crisis” in the United States and how it is impacting research opportunities in the addiction treatment and Implementation Science fields.  Causes and impact of the epidemic will initially be discussed. Then, opioid use disorder treatment evidence-based practices will be described. Followed by the gaps and challenges being experience in getting these practices implemented and research we have conducted to better understand how to get these practices implemented (or scaled-up) into broader practice.