FATALITIES ACROSS TIME
PREVENTION OF OPIOID MISUSE AND OVERDOSE
ENSURING ACCESS TO CARE
PROVIDING RECOVERY AND SUPPORT
40 percent of all opioid overdose deaths involve a prescription opioid. The best ways to prevent opioid overdose deaths are to improve opioid prescribing, reduce exposure to opioids and prevent misuse.
Measuring the extent of prescription drug misuse and doctor shopping
We conducted several epidemiological studies of controlled drugs to better understand prescribing behavior and the prevalence of "doctor shopping"—patients visiting multiple prescribers to obtain multiple prescriptions for opioids and other drugs.
Analyzing more than 250 million prescriptions of 25 different controlled substances dispensed by retail pharmacies in the U.S., we found an extreme lack of uniformity in prescribing practices for controlled opioid pain relievers, sedatives and stimulants—suggesting a need for better guidance.
We also found widespread geographic variation in the prevalence of doctor shopping for these same drugs, indicative of the need for more accessible information so that prescribers have a more complete view of patients’ care by other providers.
Documenting widespread differences in opioid prescribing indicated the need for guidelines from a trusted source.
Documenting the prevalence of doctor shopping supported the case for investing in improved drug monitoring systems.
Informing safer and consistent prescribing practices: CDC Guideline for Prescribing Opioids for Chronic Pain
Widespread inconsistencies in opioid prescribing practices resulted in part from a lack of trusted guidance. To remedy this, the U.S. Centers for Disease Control and Prevention (CDC) issued its Guideline for Prescribing Opioids for Chronic Pain in early 2017. We supported the CDC’s development of the Guideline by assessing the evidence base for all of the recommendations.
The Guideline and its recommendations are being adopted by clinicians. Following the release of the CDC Guideline, U.S. providers’ opioid prescribing practices changed.
CDC Guidelines have been one of the greatest tools we have to combat the rising tide of opioid overdoses in America.
Scott Gottlieb, M.D. Commissioner of the Food and Drug Administration
Lessons learned from the pilot have been incorporated into a forthcoming resource from the CDC for clinicians and health systems leaders.
Improving Care Coordination for Safer Opioid Prescribing
Abt and the CDC collaborated to develop and pilot test a coordinated care plan for safer opioid prescribing to patients on long-term opioid therapy for chronic pain. This is designed to support physicians and other clinicians in putting the CDC’s prescribing guidelines into practice. The plan includes upper limit dosing thresholds, cautions for co-prescribing certain medications, attention to drug-drug and drug-disease interactions, use of urine drug testing, among others.
We then partnered with MedStar Health to pilot test the plan in nine primary care practice sites in Maryland, with nine other control sites for comparison, assessing the extent to which the primary care practices were able to implement these safe prescribing practices. This test identified ways to improve clinician’s adoption of guideline-concordant practices—approaches that Abt is currently developing and testing.
Supporting Quality Improvement Efforts on Opioid Prescribing
Although the CDC Guideline for Prescribing Opioids for Chronic Pain provides authoritative recommendations for clinicians, effective implementation of the guideline recommendations in primary care is key to ensuring safer opioid prescribing and reducing the risk of overdose.
We are supporting the implementation of the guideline in primary care practices by developing and testing clinical quality improvement (QI) measures that align with guideline recommendations. We are creating an implementation package for health care systems and supporting a QI collaborative of six health care systems consisting of just over a hundred practices, covering eight states.
Some of these practices also serve underserved and tribal communities, as well as rural and frontier areas of the U.S. The QI measures, implementation guide and coordinated care plan mentioned above will be released as part of a forthcoming resource from the CDC titled, “Quality Improvement and Care Coordination: Implementing CDC's Prescribing Guideline.”
Our work provides health care systems and practices a way to implement and measure improvements in their opioid prescribing practices.
Evaluating Effectiveness of Prescription Drug Monitoring Programs and State Prescription Drug Laws
Absent universally available patient medical histories, physicians may not know if other physicians are also prescribing controlled drugs to their patients. This puts patients at risk of uncoordinated care and misuse of dangerous prescription drugs. States have therefore created Prescription Drug Monitoring Programs (PDMPs) to collect information from pharmacies about all sales of controlled drugs in their states. These have the potential of assisting prescribers in making informed choices, but use of PDMPs varies widely.
Using national survey data spanning 24 states and 10 years, Abt researchers collaborated to assess the effects of PDMPs on the prescribing of opioid analgesics and other pain medications in ambulatory care settings at the point of care.
Implementation of a PDMP was associated with more than a 30% reduction in the rate of prescribing of Schedule II opioids.
Requiring prescribers to check PDMP data, and using PDMPs in ambulatory care settings reduces rate of opioid prescribing.
Requiring prescribers to routinely check PDMP data is more effective in preventing misuse than proactive notification.
Instead of relying on clinicians to access PDMP data on their patients, many PDMPs have used algorithms to search their prescription datasets and flag patients whose purchasing patterns suggest misuse of controlled drugs. Abt researchers conducted a random-assignment experiment in Nevada to determine if searches and proactively notifying these patients’ providers were effective in curbing patients’ obtaining suspiciously large amounts of prescription opioids.
We found that proactive notification was not cost-effective and concluded that requiring prescribers to check their patients’ PDMP data routinely is likely to be more effective in preventing misuse.
Abt researchers also collaborated in a study to examine the effect of two state laws specifically designed to curtail access to prescription opioids to non-medical users: pain management clinic and doctor shopping laws.
They used administrative data on overdose deaths and admissions to specialty substance use disorder treatment. The study found that both pain management clinic and doctor shopping laws have the potential to reduce prescription opioid overdose deaths. Moreover, doctor shopping laws appear to reduce prescription opioid treatment admissions.
Advancing knowledge to inform strategies that prevent and fight opioid misuse
We supported the development of the first-ever Surgeon General’s Report on Alcohol, Drugs, and Health, which discusses the growing relationship between prescription drug misuse and heroin use, and provides evidence-based strategies for addressing the growing opioid epidemic. Released in November 2016, the report received significant national media attention.
In the first 3.5 weeks following the report’s release, print, broadcast and online media outlets published more than 1,000 stories that reached an audience of more than 1.9 billion. The report currently has over 150 citations on Google Scholar, and at least five peer-reviewed articles focused entirely on this report have been published since it was released. There have also been news articles about communities and organizations implementing the recommendations in the report to improve public health.
In 2015, 21.7 million Americans needed treatment for an alcohol and drug problem, but only approximately 2.3 million received it. With more Americans dying from opioid overdose and fighting opioid addiction, the urgency to address access to care barriers is increasing. We have focused on both removing these barriers and improving the quality of care across the US.
Improving the Quality of Medication Assisted Treatment Financed by State Medicaid Systems
We have conducted an array of activities to educate Medicaid directors and staff about mental health and substance use disorder services.
Our report, “Implementing Evidence-Based Practices in State Medicaid Systems: Medication Assisted Treatment,” describes how successful implementation of Medication Assisted Teatment (MAT) requires collaborations across general health, substance use disorder and other social service systems. The report also identifies Medicaid State plan options and Medicaid waivers authorities that can be used to support access to MAT.
Expanding Awareness of Medication Assisted Treatment in the Medical Community
To expand the medical community’s awareness of buprenorphine as an effective treatment option for opioid addiction, we conducted eight forums for SAMHSA. Medical societies, pharmacists and substance use disorder counselors from rural and urban communities with high opiate use participated in the forums. In addition, we developed a publication on the issue targeted to nurses.
Helping States Take Action against the Opioid Crisis
We partnered with the Massachusetts Health Policy Commission (HPC) to examine the opioid addiction crisis in the Commonwealth and provide recommendations to address it. By synthesizing findings studies and reports from legislative committees, the Bureau of Substance Abuse, and MassHealth, we developed recommendations covering financing and return on investment, provider capabilities, quality metrics and workforce development. We informed action plans for the Commonwealth by conducting a gap analysis between system specifications and current capabilities.
Advancing Knowledge of Effectiveness and Availability of Recovery Services
Collaborating with the Legal Action Center and Partners for Recovery, we developed the “Know Your Rights” brochure and webinars to train and educate the general public and those in recovery about the rights of individuals in recovery from alcohol or drug problems under federal and state laws. The information covers laws prohibiting discrimination against people with disabilities in the areas of employment, housing, public accommodation, and government benefits and services. It also covered the rights of individuals with criminal conviction histories and individuals in medication-assisted treatment.
Increasing understanding of medically assisted recovery availability, quality and effectiveness.
We developed a situational analysis that assessed availability of mental and substance use disorder peer-run recovery supports across the U.S..
To increase understanding of medication-assisted-recovery (MAR), we developed a background paper for the Substance Abuse and Mental Health Services Administration (SAMHSA) expert panel. It detailed key aspects of MAR, including the available medications and service settings, the effectiveness of medications used in MAR, the need for MAR, and the barriers in accessing MAR. This paper guided the panelists as they developed recommendations to expand services and quality of care for people with substance use disorders.
Informing Housing Strategies to Aid in Recovery
To better inform both housing and medication-assisted treatment providers of the housing and support needs of individuals with Opioid Use Disorder (OUD), we are developing a housing typology with descriptions of housing models best suited to a variety of populations affected by both OUD and the experience of homelessness.
We implemented a webinar series on behavioral health crisis and homelessness that included presentations on the risk of opioid overdose in the aftermath of natural disasters, use of crisis diversion services for individuals without housing who face crises related to substance use disorders, and use of peer supports to assist people without housing who are facing an OUD-related crisis.
Continuity of Care
Facilitating Technology-based Solutions
Opioid treatment is vulnerable to both unplanned service disruptions (e.g., natural disasters) and planned service disruptions (e.g., patient travel to another state). We evaluated a SAMHSA health pilot project that enabled patients to control the sharing of their opioid treatment information with other providers via a Health Information Exchange and a patient portal to support continuity of care.
Our analysis detailed the challenges associated with developing the solution, the extent to which SAMHSA’s goals for this pilot were met, lessons learned, and recommendations for future applications of these findings.
We assisted SAMHSA in launching three technology-based innovation challenge grants. These grants encouraged web developers to design and develop novel technology solutions to address behavioral health issues related to opioid use.
The first challenge focused on providing overdose prevention information to first responders through simple, easy-to access applications. The second challenge sought to support successful reentry into the community after incarceration by using resources that included treatment, recovery and overdose prevention support. And the third challenge looked to create tools to assist individuals in medication-assisted treatment. The challenges generated national interest from developers, public health professionals and even students.
Winning entries ranged from websites to smartphone apps and were available, for free, to all audiences. We provided recaps of all challenges, including lessons learned and best practices to make the most of these challenges.
Facilitating innovative solutions for first responders, post incarceration community re-entry and MAT
Our deepest gratitude to our clients, funders and local partners, whose support and collaboration is critical in enabling us to achieve our mission.
United States Department of Health and Human Services
United States Substance Abuse and Mental Health Services Administration