CHERISH Appoints Margaret Lowenstein as the Dissemination and Policy Core Co-director

Profile image of Margaret Lowenstein

Margaret Lowenstein, MD, MSHP, is a former pilot grant recipient and CHERISH Research Affiliate. Follow her on Twitter @m_lowenstein.

The Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH) is proud to welcome Margaret Lowenstein, assistant professor at the Perelman School of Medicine and senior fellow at the Leonard Davis Institute of Health Economics (LDI) at the University of Pennsylvania, as the new co-director of the Dissemination and Policy Core. Lowenstein succeeds Janet Weiner who retired earlier this year.

“I appreciate the opportunity to amplify the important research at CHERISH and work alongside colleagues with diverse and complementary expertise in substance use disorder research. I’m going to miss Dr. Weiner because her work is incredible. The latest CHERISH and Penn LDI brief distilling complicated research and policy questions is a great example of Janet’s contributions,” Lowenstein said.

Lowenstein’s interest in substance use disorder care took off during her Internal Medicine residency training at the University of California, San Francisco. “I really loved caring for patients with substance use disorders. Working as a primary care doctor, I’m excited that people get their blood pressure or their diabetes under control. That’s important, but when you get somebody’s substance use disorder under control, their life is immediately changed. I find the clinical work incredibly gratifying.”

Drawing from her experience as a general internist and addiction care physician, Lowenstein’s research focuses on expanding evidence-based treatment and harm reduction strategies for patients with substance use disorders, and particularly on leveraging ‘reachable moments’ to engage patients in care.

“I’m excited about low threshold treatment strategies in non-traditional settings,” she says. “It goes back to how I got interested in this work. Many patients who are struggling with substance use never made it to my primary care clinic. But there are reachable moments in the emergency department or community settings like libraries where patients may go to address immediate needs or access resources. These are important opportunities to meet patients where they are and offer treatment and harm reduction.”

Her latest work with colleagues at the University of Pennsylvania appeared in JAMA Open Network and highlights an opportunity to support emergency department-based naloxone distribution efforts. Lowenstein also received a 2022 Junior Faculty Scientific Presentation Award from the Society of General Internal Medicine for her paper, “Exploring Patient Perspectives on Low-Threshold Treatment for Opioid Use Disorder.”

Working alongside Dissemination and Policy Core Director Zachary Meisel, Lowenstein will continue to increase the visibility and impact of health economics research on substance use treatment policy. Outside research, Lowenstein enjoys indulging in Philadelphia’s diverse cuisines and embracing the growth of her two-year-old daughter.

Providing Naloxone in the Emergency Department Can Save Lives

This article originally appeared and was produced in conjunction with the University of Pennsylvania Leonard Davis Institute.

an emergency sign in red text is centered

New study suggests that text messaging can be used to interact with individuals at high risk for opioid use and overdose, and this automated system offers an opportunity to augment and support ED-based naloxone distribution efforts.

thumbnail of margaret lowenstein

Senior author and former CHERISH pilot grant recipient Margaret (Maggie) Lowenstein, MD, MPhil, is the CHERISH Dissemination and Policy Core co-director.

Overdose deaths continue to be a national tragedy. More than 800,000 Americans died from an overdose between 1999-2019, and the annual rate of overdoses has increased dramatically during the pandemic, according to the latest data from the Centers for Disease Control and Prevention.

Roughly 7 in 10 current overdose deaths involve opioids, which means that many of them could be prevented with naloxone. Naloxone, also known by its brand name Narcan, acts to reverse opioid overdoses and save lives when used in time. It is easy to carry and use, and studies have demonstrated that laypeople can administer it safely and effectively to reverse overdoses.

But many of the people who are most likely to witness an overdose, including individuals who use opioids and their friends and family members, may not have easy access to naloxone. Strategies are needed to increase uptake, carrying, and administration of naloxone, especially among at-risk individuals in the community who may not be engaged in routine health care or with community naloxone distribution efforts.

However, many at-risk individuals find themselves in the emergency departments (ED), either because of an overdose or other complication of substance use. For this reason, we recently examined the potential for ED visits as a critical, reachable moment to engage high-risk individuals in overdose prevention. As we reported recently in JAMA Network Open, we reached out to at-risk patients prescribed naloxone in the ED to understand whether they had obtained their naloxone during or after their ED visit, whether they were carrying it, and their plans to carry it in the future.

To collect data, we sent the patients a text messaging-based survey following their ED encounter. Of the 205 patients sent the survey, 41 (20%) completed it, a promising response rate for a historically difficult-to-reach population. The novel survey approach created a space for patients to provide input and feedback, a component important for future interventions to motivate behavior change.

The survey asked patients about their experiences and perceptions following the ED encounter related to accessing, using, and carrying naloxone. Findings included:

  • Most of the patients did not carry naloxone prior to their ED, but over a third reported having a personal history of an overdose requiring naloxone and more than a quarter had used naloxone to reverse an overdose for another person in the past.
  • Approximately half of the patients said that they were carrying naloxone after their ED visit and two-thirds planned to continue carrying.
  • Of patients not carrying naloxone prior to their ED visit, 54% reported a plan to continue carrying in the future.

These findings on patient perspectives and experiences using naloxone indicate that EDs represent an opportunity to improve naloxone carrying. These early insights are key in helping quality improvement, operational, and administrative efforts to support addiction-based care and to save lives within the community.

The Biden Administration recently announced that for the first time, harm reduction services are a federal drug policy priority, and specifically highlighted EDs and hospitals as key settings for naloxone distribution. Although the plan included few specifics, our work suggests that bolstering funding to provide naloxone directly to patients in the ED may be an effective strategy to promote naloxone carrying and use among people who are highly likely to witness an overdose.

Increasing naloxone distribution should include not only EDs, but also extend into health centers, outpatient and inpatient settings, and nontraditional venues (e.g. libraries or public vending machines). Our work reinforces the need to focus on harm reduction methods across the spectrum of public health. This should include efforts at the local and federally level to sponsor widespread and low-cost access to naloxone, especially within high-risk communities. Similar to historical efforts to increase access to defibrillators (also called AEDs) within public spaces for cardiac arrest, a synergistic approach to make naloxone easy and simple to access is paramount to preventing overdose deaths.

The study, Assessment of Patient-Reported Naloxone Acquisition and Carrying With an Automated Text Messaging System After Emergency Department Discharge in Philadelphia, was published in JAMA Network Open, March 24, 2022. Authors include Anish K. Agarwal, Hareena Sangha, Anthony Spadaro, Rachel Gonzales, Jeanmarie PerroneM. Kit Delgado, and Margaret Lowenstein.

Why Does the Opioid Mortality Rate Continue to Rise?

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The University of Pennsylvania’s Leonard Davis Institute of Health Economics’ event was co-sponsored with the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH).

From April 2020 through April 2021, there were 100,300 drug overdose deaths across the country according to the CDC — a 28.5% increase over the previous year. Some 75% of these were opioid-related overdoses that killed an average of nine users an hour around the clock throughout the year. Looking forward, the just-published Stanford-Lancet Commission on the North American Opioid Crisis predicts that 1.2 million more opioid users will die of overdoses by 2029.

Against this background, the University of Pennsylvania’s Leonard Davis Institute of Health Economics (Penn LDI) convened a March 4, 2022, panel of four top experts to discuss the current efforts to address this rapidly growing public health crisis. The panel included the head of the Stanford-Lancet Commission as well as the former Acting Director of the Office of National Drug Control Policy, the Associate Dean for Social Justice at the University of Southern California’s School of Medicine, and moderator Shoshana Aronowitz, PhD, MSHP, LDI Senior Fellow, and Penn School of Nursing researcher whose work is focused on equitable access to substance use treatment and harm reduction services.

The virtual event was co-sponsored with the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH).

Synopsizing the bottom line of the national challenge to reduce this overdose epidemic, panelist and USC Professor Ricky Bluthenthal, PhD — who has been researching substance use interventions for 30 years — pointed to the lack of coherent government action and policies.

Ricky Bluthenthal, PhD
Ricky Bluthenthal, PhD
Professor of Populations and Public Health Sciences at the University of Southern California

Step Up Our Game

“We haven’t had the kind of local, state, and national response to this crisis that we need to,” Bluthenthal said. “We actually have many effective solutions, most of which involve engagement with people with lived experience, and the distribution of things like naloxonesafe injection suppliesdrug consumption sites, and the like. There are a lot of things we could be doing if we were willing to take them to scale, but we now need to step up our game in terms of things that we can do right now that would facilitate access to medications for opioid use disorder and provide delivery systems that actually get those services to the people who need them.”

Regina LaBelle, JD, Director of the Addiction and Public Policy Initiative at Georgetown University’s O’Neill Institute for National and Global Health Law, noted: “When the April 2021, numbers were announced, there was a lot of shock, but anyone who had been paying attention could see this building in the various models being done. Some policy improvements were made in the Obama and Biden administrations, but some of the basic conditions remain. We have a lack of evidenced-based treatment availability. We have huge amounts of stigma associated with both people who may use drugs as well as stigma about even seeking treatment.”

Regina LaBelle, JD
Regina Labelle, JD
Director of the Addiction and Public Policy Initiative at Georgetown University’s O’Neill Institute for National and Global Health Law

Aronowitz noted that, although alarming, the latest mortality statistics fail to convey the full scope of the problem because they don’t count near-fatal overdoses. “Emergency department numbers for overdoses are five times those of deaths — and half of overdoses are self managed,” she said. “Non-fatal overdoses strongly predict eventual overdose death. Are we using this information to agitate for change?”

LaBelle acknowledged the enormity of that data collection challenge. “Traditionally, we measure how well we’re doing based on the rate of overdose deaths, when that’s only the tip of the iceberg,” she said. “We just don’t have great data on overdoses that don’t end in death. That underscores for me why naloxone should be more widely available. I don’t see the reason why it has to be prescribed rather than made readily available over the counter to substance users at great risk.”

The Number One Thing

Stanford Professor of Psychiatry and Behavioral Sciences Keith Humphreys, PhD, pointed out that “naloxone distribution is the number one thing the Stanford-Lancet Commission model found to save lives — we need a dramatic expansion of naloxone distribution,” he said. “If we could boost current levels of availability by a third, we would reduce hundreds of thousands of deaths over this next decade.”

At the same time, Humphreys emphasized that the overall policy focus has to be greatly broadened because overdose deaths and near deaths occur in the extreme downstream of the crisis.

Keith Humphreys, PhD
Keith Humphreys, PhD
Esther Ting Memorial Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University

“We have to understand that much the same as monoclonal antibodies are great for people who are intubated with serious cases of COVID-19, naloxone serves only the immediate condition of overdose. But you will never solve either epidemic by just taking care of people at that extreme downstream end,” Humphreys said. “You have to go upstream. In COVID, that means preventive measures like vaccines, masks, social distancing, and such. In substance use disorder, that means investing in kids — I’m not talking about ‘just say no’ programs, but rather things like nurse-family partnerships, Head Start, pre-K. We need interventions that set kids off on a good start in life, particularly kids in low-income neighborhoods and places that have already gone through a generation of addiction. It has been very hard to persuade politicians and the public to make 20-year investments, but we really need to think that way.”

“It also means we need to make sure we separate our health care institutions, our regulators, and our educational institutions from corporate interests that profit from the spread of addiction,” Humphreys continued. “We need to tighten up the regulatory system. There is no reason why 10 years from now we couldn’t have another epidemic like this one started in the health care system with a different drug, like stimulant medications or benzodiazepines, or we would not have approved ketamine that’s now out there. We may soon approve MDMA. And the holes that companies like Purdue Pharma walked through largely remain. The political influence of the industry and their ability to advertise beyond any sane amount needs to be fixed on the preventive side. I know it’s hard to think long term when we’ve got a crisis on our hands, but we have to do both things. We have to manage those people who have the problem, and we have to stop future generations from going through the same thing.”

Medicaid and Prisons

Along with much wider naloxone availability, evidence-based MOUD treatments, Emergency Department engagement programs, and retaining the new pandemic-driven flexibilities in telehealth and other treatment modalities, the panelists emphasized two other areas of policy reform that could have potentially outsize impact. The first is expanding Medicaid in those states that haven’t yet done so to provide coverage for in-patient and out-patient substance use treatment. The second is overhauling the addiction-related regulations and practices in correctional facilities that house such large populations of drug users.

LaBelle noted, “We know that you’ve got up to a 40 percent greater chance of overdosing if you are not treated with a Medication for Opioid Use Disorder (MOUD) while you are incarcerated. First of all, it’s against the law to force someone on methadone or buprenorphine to stop and go into withdrawal when they enter corrections. From federal court cases we know that’s a violation of the Americans with Disabilities Act. It’s also a violation of the Eighth Amendment.”

“At Georgetown,” LaBelle continued, “we worked with the Sheriffs’ Association and the Bureau of Prisons on this issue, and there is a great interest in expanding access to treatment and corrections to evidence-based treatment. Groups like the National Sheriffs’ Association and others are calling for the elimination of the Medicaid Exception (that bars the use of Medicaid funds to cover inmate health care services). So the proposed Medicaid Reentry Act would allow incarcerated individuals to get Medicaid coverage for addiction treatment starting 30 days before their release.” Once released, the former inmates are again eligible for ongoing Medicaid coverage of their continuing treatment.

“We know from Rhode Island’s experience how they decreased overdose deaths in the reentry population by 60 percent and six percent overall in the state by implementing Medicaid-based treatment in corrections,” LaBelle said.

“Like Being in Combat”

Humphreys, who has visited that Rhode Island Department of Corrections prison in Cranston, agreed. “It’s really a terrific model of continuity of care,” he said. “You have the same provider when people are incarcerated and when they go back out into the community. This is so important because we lose a lot of people in that first two weeks after prison — the death rate is just appalling. It’s like being in combat. It’s not enough to say, ‘Well, there’s a clinic out there somewhere. Good luck finding it.’ Instead, they have someone they know meeting them at the exit gate and taking them to treatment somewhere they already know. It’s remarkable how lifesaving this is.”

While that Rhode Island program works well, Bluthenthal pointed out that not-in-my-backyard (NIMBY) political resistance frequently preventing the siting of treatment facilities is a major reason easily accessible treatment sites are in critically short supply.

“Currently, the kinds of treatment and harm reduction services available to people are better understood by politics rather than need,” Bluthenthal said. “It has a devastating consequence for people of color and other minority populations because they end up not getting the service they need or they get the negative intervention — mass incarceration. It’s a problem with our politics — these NIMBY-driven decisions are very narrow minded.”

Shoshana Aronowitz, PhD
Shoshana Aronowitz, PhD, MSHP, FNP-BC
Moderator and Assistant Professor in the Department of Family and Community Health at Penn Nursing

As the session ended, Aronowitz asked the three panelists their thoughts on the most important thing that needs to be done more or differently to better address the opioid crisis. Their answers:

Humphreys: “We need the criminal justice system to stop punishing and start engaging in rehabilitation, and the health care system to take on substance use disorder permanently as an enduring condition of life like heart disease or cancer, so that every single health care system is competent to provide treatment. And we need to fix the holes in the pharmaceutical regulatory framework.”

Bluthenthal: “To make all the things we’ve been talking about work, we need to have an infrastructure that reaches these populations. We have to invest in community-based organizations and people with lived experience to staff them so they have the jobs and can connect the effective treatment services to the people who need them.”

LaBelle: “At Georgetown, I’ve started a year-long Master’s of Science in Addiction Policy and Practice program to marry science research with policy. We have a class of 10 people now; and every year, I’m going to have more coming through this program so we can have an addiction policy that’s based on science, evidence, and compassion.”

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Reducing Opioid Overdose Deaths

Watch the full video at PennLDI.

Meet Ane-Kristine Finbraten: Harkness/Norwegian Institute of Public Health Fellow, Physician, and Researcher on Hepatitis C Elimination

Ane-Kristine Finbraten and husband atop the Empire State Building

Commonwealth Fund Harkness Fellows can be placed anywhere in the United States. Ane-Kristine Finbraten, MD, PhD, photographed with her husband, chose New York City and CHERISH as her preferred placement.

Coming to New York City was an easy decision for Harkness Fellow Ane-Kristine Finbraten. The city has one of the most robust hepatitis C elimination efforts to learn from. A founding member of the Centre for Elimination of Hepatitis C in Norway and an infectious diseases provider, Finbraten was elected as a 2021-2022 Commonwealth Fund Harkness/Norwegian Institute of Public Health Fellow to conduct original research and gain exposure to policy development in the United States.

“I wanted to understand more about policy work and learn how I can help more people by working at the health systems level,” Finbraten said. At the Centre for Elimination of Hepatitis C, Finbraten and her team document the hepatitis C elimination processes in Norway and develop treatment models to further the World Health Organization’s global initiative to eradicate viral hepatitis C. One treatment model in development is Opportuni-C, in which her team studies the effect of initiating rapid hepatitis C treatment for people who inject drugs and are hospitalized.

Through the Commonwealth Fund, Finbraten connected with Bruce Schackman, CHERISH director and Saul P. Steinberg Distinguished Professor at Weill Cornell Medicine; Shashi Kapadia, CHERISH Research Affiliate and infectious diseases physician at Weill Cornell Medicine; and Benjamin Eckhardt, infectious diseases clinician researcher and assistant professor at New York University. During Finbraten’s one-year placement at the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH) in New York City, Schackman, Kapadia, and Eckhardt serve as collaborators and advisors on her research and provide health economics, epidemiological, and policy perspectives.

“Choosing these advisors was not difficult after understanding what CHERISH does and offers. I have the best team supporting me to make my project and learning experience successful and meaningful,” she said. Finbraten’s primary research compares low-threshold hepatitis C treatment models in New York City and Norway. Additional studies Finbraten is working on address barriers to care for people who inject drugs and are co-infected with HIV and hepatitis C.

Ane-Kristine Finbraten atop a hike in Northern Norway

Finbraten enjoys calm summer hikes back at home in Norway.

Finbraten is also eager to learn how to conduct qualitative research and design treatment models with patients in mind. “I am a fan of developing research questions that ask about the outcomes that matter to the patient. When developing treatment models, we need to know how the patient feels. A model cannot be useful unless it is accepted by the people who are receiving the care,” she said. As her team in Norway is expanding to incorporate more qualitative research, Finbraten looks forward to bringing home new research methods and treatment strategies that integrate the voices of people who inject drugs.

Cost of Hepatitis C Care Facilitation for HIV/Hepatitis C Co-infected People Who Use Drugs

Text on image shows takeaway of study.

The development of direct-acting antivirals transformed hepatitis C virus (HCV) therapy, allowing patients to experience fewer side effects and non-specialist providers to prescribe HCV treatment with more ease. Despite these advances, existing social and structural barriers, such as stigma and accessibility of medical care, restrict access to effective HCV treatment for people who use drugs who are co-infected with HIV and HCV. To improve access to care for HIV and HCV co-infected people who use drugs, researchers are looking at models that borrow from successful HIV linkage to care interventions.

Results from CTN-0064, a national clinical trial funded by the National Institute on Drug Abuse, showed that a care facilitator intervention helped HIV and HCV co-infected people who inject drugs advance further in their HCV treatment. To help healthcare organizations understand the cost of care facilitation interventions, lead author Sarah Gutkind, CHERISH Research Affiliates Laura Starbird and Daniel Feaster, CHERISH Methodology Co-director Sean Murphy, and CHERISH Director Bruce Schackman used data from CTN-0064 to estimate the costs of implementing and managing this model of care across eight sites in the United States.

Sarah Gutkind, MSPH

Lead author Sarah Gutkind, MSPH, is a pre-doctoral fellow in the Substance Abuse Epidemiology Training Program at Columbia University Mailman School of Public Health.

In this study, Gutkind and colleagues found that the cost per participant decreases with higher caseloads in real-world settings compared to costs incurred in the intervention trial. In a sensitivity analysis, maintaining a site’s peak caseload during the trial (approximately 5 participants per week on average) was found to lower the cost per participant by a half, from $450 to $220 in 2017 USD. When adapting to a real-world setting with a maximum of 10 cases per week, the cost each week per participant lowered by three quarters, from $450 to $110 in 2017 USD. Co-authors also found the average start-up cost for HCV care facilitation to be approximately $6,320 per trial site. Costs could be further reduced by adapting administrative and recruitment processes for real-world settings, such as maximizing outreach activities through site visitations and database search records, reducing the number of supervision meetings, and leveraging local staff and webinars to conduct start-up trainings.

Advancing Evidence-Based Substance Use Disorder Treatment Policies

This article is cross-posted at the University of Pennsylvania Leonard Davis Institute.

Rebekah Gee, MD, MPH

Penn aluma and former Louisiana Secretary of Health Rebekah Gee detailed some of the strategies her team used to get a Medications for Opioid Use Disorder law passed in one of the country’s most conservative states.

If you want to reform state laws to require detox facilities to include medications like buprenorphine and methadone in their treatments, you should start by changing the “hearts and minds” of those who oppose it, Rebekah Gee, MD, MPH, MHSPR, told the January 14, 2022 Penn LDI/CHERISH Virtual Conference at the University of Pennsylvania.

Keynoting a gathering organized by Penn’s Leonard Davis Institute of Health Economics (LDI) and the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV and HIV (CHERISH), the former Louisiana Secretary of Health detailed how that approach helped to pass a state law requiring that residential treatment facilities offer medications for opioid use disorder (MOUDs) in one of the country’s most conservative states.

Now CEO of Health Care Services for the Louisiana State University Health System, Gee has been something of a wunderkind in the last decade in achieving progressive reforms in some of health care’s most politically divisive areas, like Medicaid expansion and the MOUD issue. Evidence shows MOUDs are effective in reducing overdoses and mortality rates. But they are widely underutilized because of the misconception that medication treatment merely substitutes one drug for another. (Continues below conference videos)

Welcome and Keynote Session of the 2022 Penn LDI/CHERISH Virtual Conference

Session 2: Progress Toward Model State Licensing Standards for Access to Medications for Opioid Use Disorder (MOUDs)

Session 3: Evaluating Impact: Using Data and Modeling to Inform Implementation of State Licensure Changes

Zachary Meisel, MD, MPH

The conference was hosted by Zachary Meisel, MD, MPH, MSHP, LDI Senior Fellow and Director of the CHERISH Policy and Dissemination Core.

Before becoming Louisiana Secretary of Health, Gee was Chief Medical Officer of the state’s Medicaid program at a time when deep south states from Virginia to Texas refused to expand their Medicaid programs under the Affordable Care Act. Nevertheless, working with two Democratic governors, she and her team helped pass a new law expanding Medicaid in Louisiana, which provided health insurance to 600,000 more low-income residents. Likewise, her team worked to make syringe services programs legal as well as require that residential treatment facilities offer MOUDs.

How did she accomplish this?

“I had to learn to speak Republican,” said Gee, acknowledging she is a liberal-leaning Democrat. “My heart is with social justice and the idea that health care is a right. But that’s not the approach of every policymaker, especially in conservative states,” she said. “Right now in this country there’s a lot of ‘talking past,’ not ‘talking with’ going on in the policy space. That’s why it’s so important to focus on ‘hearts and minds’ first. If you want to solve a problem, you really have to convince people that there is a problem and you have to figure out what’s in it for them.”

Making It Personal

“One of the things that made it easier,” Gee continued, “was that the hardest hit parts of Louisiana with opioid overdose deaths tended to be the most conservative. And so, it became easier to talk to legislators, policymakers, and local leaders there because they might have had a cousin, a brother, or sister who had been involved in an addiction journey and needed help. And so I think changing hearts and minds was easier. But it was important to talk about it as a disease and really deal with stigma reduction.”

“We got creative about how we framed the need for change,” Gee said. “For instance, my team felt it was important to allow needle exchange so we could reduce the risk of transmission of infectious viruses for individuals who were using drugs with a needle. We were able to get a law passed because we went to the Sheriffs’ Association, a very conservative group, and said, ‘Look, the folks who are working with you may be in a situation where they might be exposed to a needle and might get infected. Isn’t it in all of our best interests that our first responders, as well as individuals in society, have less of this disease?’ Then, we had a sheriff introduce the bill and it was passed.”

Gee also pointed out that two other elements of her Department’s ‘secret sauce’ were data gathering and effective storytelling.

“Ironically, it is somewhat unusual for policymakers to focus on a data-driven approach to problem solving,” said Gee. “It really matters to have data first and then change later. You need to first get answers for where is the problem? Where do we focus on solving it? Are we getting better or are we getting worse? Where are the deaths? What kinds of drugs are being used? What are the prescribing patterns? If we don’t know where we are, we can’t improve it. In Medicaid expansion, for instance, we showed that it wasn’t just about getting a Medicaid card, because we were able to show the numbers of people being treated for addiction disorder who needed the coverage. We created the Louisiana Opioid Data and Surveillance System (LODDS) that provided the data we were able to use for grant funding, policymakers, advocates, and clinicians practicing across the state.”

“Another very effective tool was storytelling,” said Gee. “We told stories of those who benefited from the Medicaid expansion so that they were real. They were musicians, they were waiters in the restaurant you might have gone to. They had breast cancer. I think bringing in storytelling is really important in terms of changing hearts and minds.”

Equity and MOUDs

Equity within both the policy and practice of substance use disorder treatment was another discussion point in the conference’s first panel entitled, “Progress Toward Model State Licensing Standards for Access to Medications for Opioid Use Disorder.”

“We hear people frequently saying ‘disparities’ or ‘inequities,’ but I would say ‘racism’,” said panelist Chinazo O. Cunningham, MD, MS, Commissioner of the New York State Office of Addiction Services and Supports. “This country has a history of racism when it comes to policies around substance use. And I think we have to say that out loud and then bring an equity lens to everything we do.”

Chinazo O. Cunningham, MD, MS
Chinazo O. Cunningham, MD, MS
Commissioner of New York State’s Office of Addiction Services and Supports.

“Can we address this from a licensing or regulatory aspect? I think that certainly could be an effective tool,” Cunningham continued. “I think the discussion should also include widening access to medication through pharmacies. Pharmacies are much more available than treatment services and medical providers. Can we leverage pharmacies to make sure they have naloxone available along with medications to treat substance use disorders, like buprenorphine? We have to find ways to potentially expand access for populations that have not been able to access substance use disorder treatment.”

“In another area,” said Cunningham, “our Governor recently signed into law a bill that mandates substance use disorder medication treatment in jails and prisons throughout the state. I think this is a game changer. It really targets some of the people who were at the highest risk of overdose death — particularly people of color. As you know, we have historically had racist policies about who ends up in jail for drug-related offenses. We’re in the process of figuring out how to implement this law that requires all three types of SUD medication treatment in jails and prisons across New York State.”

Panelist Yngvild Olsen, MD, MPH, Acting Director of the Center for Substance Abuse Treatment in the Substance Abuse and Mental Health Services Administration (SAMHSA), emphasized the need for equity surveillance in all levels of SUD treatment and policy.

Yngvild Olsen, MD, MPH
Yngvild Olsen, MD, MPH
Acting Director of the Center for Substance Abuse Treatment in the Substance Abuse and Mental Health Services Administration (SAMHSA)

“Dr. (Miriam) Delfin-Rittmon, the Assistant Secretary for Mental Health and Substance Use has really baked in equity as one of her cross-cutting principles across all the work that SAMHSA is doing. That is now a very big priority,” said Olsen. “It is important to be very intentional about what we measure and pay attention to those elements through an equity lens.”

“When you look at survey after survey, whether it’s among the public or health care professionals, you see that stigma is a huge barrier in all of this. We need to end stigma as an operationalized kind of discrimination. We need to be measuring and understanding where those inequities are playing out, whether that’s in regulatory policies or even local zoning policies.”

Inside the Licensure Process

In an effort to provide a real-world sense of how MOUD licensing requirements work in five states (LA, MO, NY, MA, MD) that have passed such laws, a Johns Hopkins Bloomberg School of Public Health team led by Brendan Saloner, PhD, interviewed government officials, providers and advocates there.

Saloner presented the three main findings:

1. Licensing is a very effective stick, but there are a lot of carrots that also matter.

“A lot of our interviewees believed there was still an important role for persuasion, but some of them really did lean into the idea that mandates are sometimes necessary. One treatment advocate said ‘The soft approach is nice, but the only real way to make change is when there’s a consequence associated with it.’”

2. To work, a MOUD licensing requirement needs to be backed up by robust monitoring and technical assistance.

“It’s one thing to tell providers they have to provide access to medications, but the state has to be able to have good auditing, oversight, and outreach practices to help providers understand how to be in compliance with the law.”

3. It’s important to understand that there is both real stigma against medication as well as other nuanced issues at work for some reluctant providers.

“Some people said, ‘How could you offer medication-assisted treatment to people who are unable or unwilling to participate in psychosocial treatment at the same time?’ That was seen as devaluing psychosocial treatment or not holding people accountable.”

Brendan Saloner, PhD
Brendan Saloner, PhD
Associate Professor at Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health

Another point of the interviewees was that some reluctant facilities may be forced by law to comply, but then do a bare minimum to demonstrate their compliance. “So, getting providers in formal compliance may not totally shift the reality of the kinds of services they provide to patients or how they counsel those patients with the subtle and not so subtle things they say.”

Inconsistent Regulations

Beyond the reluctance of such providers, and perhaps one of the MOUD movement’s greatest challenge is the organizational tangle of how 50 states and federal government agencies inconsistently regulate the provision of opioid use disorder treatment and the use of heavily stigmatized and politicized drugs like buprenorphine and methadone.

In a presentation titled “State Laws That Might Influence Access to Medication for Opioid Use Disorder,” panelist Rosalie Pacula, PhD, from the University of Southern California, reviewed the policies and restrictions that have traditionally presented formidable access barriers to MOUDs. She referenced the online interactive maps of Temple University’s Prescription Drug Abuse Policy System that provides vivid visuals of the heavily balkanized and often contradictory policies that now define the choke points of this national health emergency.

Rosalie Pacula, PhD
Rosalie Pacula, PhD
Elizabeth Garrett Chair in Health Policy, Economics & Law in the Sol Price School of Public Policy and the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California

“In pulling all of this together,” Pacula said, “it creates a very complex regulatory environment in which doctors and facilities are trying to operate and provide evidence-based treatment practices.

“It’s really important to consider that whole environment when evaluating the effect of any particular strategy or approach,” Pacula continued. “Most researchers tend to get excited about one particular policy that gets adopted even as they forget the overall environment in which that policy is being implemented that might facilitate or reduce its effectiveness. And so, in thinking about this as a policymaker as well as a researcher, my work is just trying to expand how people think about the entire environment for improving access to evidence-based OUD therapies.”