Approximately 1.6 million US adults used methamphetamine each year from 2015 to 2018, many of whom had co-occurring substance use or mental illness. Higher rates of methamphetamine use were concentrated in non-urban areas, which raises concerns due to limited substance use treatment availability in outside of urban areas. Stimulant use is associated with increased risk of HIV transmission, and lower rates of viral suppression among HIV positive men who have sex with men (MSM) due to lower rates of engagement in HIV care. Successful behavioral health interventions to improve engagement in HIV care and viral suppression have often been limited to urban centers and confined to treatment settings, but mobile health (mHealth) technologies offer the opportunity to extend reach and efficacy of these interventions.
Drs. Adam Carrico, Keith Horvath, and Sabina Hirshfield recently received R01 funding from the National Institute on Drug Abuse (NIDA) to conduct a randomized clinical trial of an mHealth intervention to improve HIV treatment engagement and viral suppression among MSM who use stimulants. Dr. Carrico is a Professor of Public Health Sciences and Psychology and Director of the Division of Prevention Science and Community Health at the University of Miami Miller School of Medicine. His research largely focuses on the implications of substance use on HIV transmission and disease progression. Dr. Horvath is an Associate Professor in the Department of Psychology and San Diego State University. His primary research interests are the development and testing of mHealth interventions for sexual and gender minorities. Dr. Hirshfield is a Principal Research Scientist at SUNY Downstate Health Sciences University, where she conducts video- and message-based eHealth interventions with populations at-risk for, or living with, HIV. Her research includes home collection of dried blood spots for lab-based viral load testing. Together, the study team plans to evaluate the efficacy of the Supporting Treatment Adherence for Resilience and Thriving (START) mHealth intervention in improving and maintaining viral load suppression among MSM who use stimulants. The START intervention includes individual sessions and medication self-monitoring.
With input from the CHERISH Consultation Service, the START study team was able to include an economic evaluation for the mHealth intervention in his research plan. CHERISH Methodology Core Co-director Kathryn McCollister provided input for the grant application on how to best capture intervention costs and potential economic benefits of the START intervention. Dr. McCollister will also serve as a co-investigator to lead the economic evaluation for the intervention. Dr. Carrico reported that he was very satisfied with the consultation and would recommend the service to other investigators. “Dr. McCollister’s input strengthened our application and we look forward to collaborating on this important and timely project that will provide valuable information on both the effectiveness and cost of this mHealth intervention,” said Dr. Carrico.
Dr. Ali Jalali is a Postdoctoral Associate in the Department of Population Health Sciences at Weill Cornell Medical College. He completed his doctorate in economics at the University of Utah. His current research focuses on economic evaluations of interventions for substance use disorders and related conditions. His pilot grant will examine healthcare resource utilization patterns and Medicaid costs for pregnant women with opioid use disorder, infants with and without exposure to opioids in utero, and infants with and without neonatal opioid withdrawal syndrome (NOWS). He will use data from the Medicaid and Children’s Health Insurance Program (CHIP) Transformed Medicaid Statistical Information System (T-MSIS), which will provide the opportunity to generate nationally representative Medicaid unit costs for healthcare services. This study will address knowledge gaps regarding pregnant women with opioid use disorder and their infants, and will be the first study to provide Medicaid healthcare resource unit cost estimates for these women and infants for future economic evaluations.
Dr. Hao Zhang is a Postdoctoral Associate in the Department of Population Health Sciences at Weill Cornell Medical College. He completed his doctorate in health services research at Texas A &M University focusing on econometric models and policy analysis. His current research centers on evaluating opioid-related policies and his pilot grant will examine the effect of changes in opioid prescribing practices on patients with metastatic bone cancer and patients with sickle cell disease who may be undertreated for pain. His study will assess trends in rates of emergency department visits, emergency department initiated opioid prescriptions, and costs among these populations using the Health Care Cost Institute (HCCI) claims database, a national dataset of commercially insured and Medicare Advantage individuals. This study will generate new knowledge regarding pain management, access to opioid therapies, and costs among patient populations at risk for under treated pain.
Dr. Austin Kilaru is a Fellow in the National Clinicians Scholars Program and Attending Physician in the Department of Emergency Medicine at the University of Pennsylvania, and an Associate Fellow at the Leonard Davis Institute of Health Economics. As part of his fellowship he has received training in health services research and his research has focused on financial incentives to improve on opioid use disorder treatment systems within hospitals. His pilot grant will examine adherence to medications for opioid use disorder (buprenorphine and methadone) following an opioid related emergency department visit. He will explore the association between adherence and co-payment or out-of-pocket costs and the association between treatment discontinuation and repeated opioid-related emergency department use. He will use the Optum Clinformatics Datamart, a national commercial claims dataset. This study will have policy implications for payers and providers that seek to expand access to opioid use disorder treatment.
The Coronavirus (COVID-19) pandemic has brought unprecedented challenges in healthcare delivery to people who use drugs. However, it may also have provided impetus to precipitate innovative changes in providing opioid overdose prevention, syringe services, and medication for opioid use disorder (MOUD) to this vulnerable population. In a new Viewpoint in Psychiatric Services, CHERISH Research Affiliate Yuhua Bao from Weill Cornell Medicine, Arthur Robin Williams from Columbia University, and CHERISH Director Bruce Schackman outline changes in policies addressing the opioid crisis during COVID-19 and highlight the opportunity to continue them after the pandemic subsides.
Social distancing measures and resulting social isolation may exacerbate the risk of fatal overdose due to reduced access to in-person naloxone distribution through harm reduction services and more injection drug use in isolation. In order to adapt to social distancing measures, some syringe service programs have begun or increased delivering naloxone kits and sterile syringes to clients’ homes and have relaxed policies that limit the number of syringes that can be exchanged. Community pharmacies that can distribute naloxone under state-specific standing order policies are also potential resources for naloxone and syringe distribution in areas where syringe service programs are no longer operating in-person services.
COVID-19 also presents unique opportunities to expand MOUD through telehealth and to reduce the burden of frequent visits to opioid treatment programs for medication dispensing. There are three pharmacotherapies approved by the Food and Drug Administration for OUD treatment: buprenorphine, methadone, and naltrexone. Due to COVID-19 and social distancing measures, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued guidance that permits patients to be initiated on buprenorphine through a telemedicine visit (by telephone if necessary) without an in-person exam. SAMHSA has also provided blanket exceptions for extended take home for methadone and buprenorphine dispensed by opioid treatment programs, although adoption and implementation of these measures likely varies at the state and treatment program level.
The Viewpoint authors suggest that payment reforms must accompany the expansion of telemedicine and take-home dosing in order to ensure sustainability. For example, New York State Medicaid moved from fee-for-service payment for opioid treatment program services prior to COVID-19, to adopting the Medicare weekly bundled payment codes and rates for MOUD during the emergency. Adoption of payment changes are also likely to vary by state and treatment program.
While the COVID-19 has pushed the limits of the healthcare system, it has also presented opportunities to implement innovative models of care delivery for people who use drugs. The natural experiments created by COVID-19 will enable researchers to evaluate adoption and health outcomes in order to determine which of these policy changes should be sustained long-term.
Although there are several evidence-based cost-effective interventions for people with opioid use disorder (OUD), they are underutilized. Questions remain regarding intervention selection, and cost of service delivery. Simulation modeling offers an opportunity to support decision making to address the syndemic of opioid overdose, HIV, and hepatitis C (HCV). In an article recently published in the International Journal of Drug Policy, the OUD Modeling writing group described the benefits of using simulation models for OUD-related clinical and public health decision making and the different types of simulation models available. They also identified the need to collect and synthesize local data to model sub-epidemics and calibrate models to support local decision making.
The authors outlined several benefits of simulation modeling that allow researchers to study scenarios that would not be possible to study in the real world at the necessary pace required for decision making. Simulation models can translate results from small-scale trials to the population level. They can also be used to explore uncertainty regarding current knowledge in order to highlight important individual-level, and system-level factors that drive outcomes. In doing so, they can explore the health effect and costs of different intervention combinations over long periods of time that exceed what would be feasible during a clinical trial. Additionally, models can examine benefits and costs from multiple perspectives such as the healthcare system, the criminal justice system, or the broader societal perspective. This can help inform the priorities of future research and provide real-time estimates for policymakers to make decisions.
Model selection depends on the research question, whether the model needs to account for interactions between individuals, the time horizon, and the granularity of the data available. Various types of models can be used to address these questions, including Markov models, micro-simulation models, population-based compartmental models, and agent-based models. The authors provide examples of how model selection can be “fit to purpose.” CHERISH currently offers consultation services to provide guidance for building the appropriate model.
Ultimately, model selection also depends data availability. The opioid crisis in North America is made up of several local epidemics that vary regarding drug supply, demographic characteristics and treatment capacity. These factors affect intervention selection, the effectiveness of the intervention and the financial capacity for implementation and scale up. In order to inform policymakers at a local level, the authors identify the need for local context-specific data. For example, a recent study by CHERISH Research Affiliate Bohdan Nosyk and colleagues modeled local HIV epidemics in six US cities to recommend cost-effective intervention combinations that met local needs.
To maximize the impact of opioid models, the authors emphasize that substantial efforts will be required to collect, analyze, and synthesize the data needed to support model development. The authors encourage the modeling community to collaborate to share model code and pool resources to generate critical inferences; produce, adapt and cross-validate models; and effectively disseminate findings. They argue that the opioid crisis is unprecedented and the modeling community should recognize the need for a collaborative approach in order to respond as effectively as possible, while acknowledging the challenge to manage collaborations so that they produce timely results and address the questions of greatest relevance to policymakers at the local and regional level.
When it comes to substance use disorder-related policies and funding, evidence is absolutely necessary though not sufficient. In a recent webinar with CHERISH Research Affiliates, Dr. Jules Netherland, Managing Director of the Drug Policy Alliance Department of Research and Academic Engagement, and Daniel Raymond, Deputy Director of Planning and Policy at the Harm Reduction Coalition, discussed the potential roles of health economics and health services researchers in harm reduction policymaking and advocacy, and opportunities and challenges for researcher engagement.
Dr. Netherland and Mr. Raymond agreed that academic engagement is critical to inform evidenced-based policy for substance use disorder. Academic researchers produce knowledge that advocates rely on when presenting their positions to policy makers, but it is important to understand how that information is used with policymakers. As Netherland explained, researchers are “experts with credentials and influential power in the halls of statehouses.”
Health economics research in particular offers the opportunity to go beyond discussing the public health benefits of a particular policy by describing the cost-effectiveness of proposed strategies for addressing substance use and promoting harm reduction. Mr. Raymond pointed out that health economics research can also address, “What targets are we setting for more funding? Who should pay for that depending on the kinds of outcomes? What is the return on investment and what is the cost of scaling up these interventions?” Answers to these questions can help advocates and policymakers make the case for increasing resources for medications for opioid use disorder and harm reduction. Health economics and health services researchers can model the impact of potential policy changes and describe the consequences and costs to society. One way to examine this question is by evaluating the “cost of doing business as usual.” Quantifying the cost of existing failed policies could lend support for policy change.
Health economics and health services researchers should engage with policy audiences – including policymakers, people with lived experience, and advocacy groups – during the study design process in order to increase the real-world impact of their research. This relationship should continue throughout the study in order to guide the research, engage with the affected communities in a meaningful way and interpret the findings. Both Netherland and Raymond stressed the importance of working with these communities in a respectful way, by valuing their time and budgeting financial support for their engagement. Otherwise, “it may feel tokenizing to ask people to lend their time and their name for the veneer of community engagement without meaningful involvement in the research design or questions.”
Both Netherland and Raymond recognize that there are challenges to engaging with advocacy groups and policymakers, such as policy outpacing the research, the relatively narrow scope of research, and translating findings for dissemination. Policy needs outpace grant deadlines and manuscripts, and both Netherland and Raymond explained that the key is to engage with policymakers in a timely manner. They often receive requests for information within days and hours. To respond, academic researchers should rely on the body of literature write large and speak as experts in the field when responding to policymakers or the media, rather than relying solely on their own individual research. It is also valuable to go beyond any single study by grounding the issue in history, discussing the thought process behind the research, and weaving real life stories to make the findings more personal. When disseminating findings of a specific study, it is critical to keep the audience in mind and translate the research into plain language. This can be done through concept sheets, twitter threads, blogs, and visual abstracts.
The Department of Healthcare Policy & Research at Weill Cornell Medicine is seeking a Postdoctoral Associate with an interest in conducting comparative economic evaluations of substance use disorder interventions alongside clinical trials and cohort studies in multiple settings. We are seeking an economic researcher who will work on multiple projects aimed at addressing the opioid crisis and improving substance use disorder treatment under the direction of CHERISH Investigators Sean Murphy, PhD, and Bruce Schackman, PhD, MBA.
In 2019, the United States launched the effort to End the HIV Epidemic by reducing new infections by 75% within 5 years and by 90% within 10 years. This national strategy comes with some new funding for the Centers of Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the Ryan White HIV/AIDS Program focused on 48 affected counties, Washington DC, San Juan Puurto Rico, and 7 southern states. To help cities spend HIV funds wisely, CHERISH Research Affiliate Bohdan Nosyk and colleagues developed an economic model that identified the combinations of evidence-based interventions with the greatest likelihood of reducing HIV transmission over 10 years in six cities. The study, published in Lancet HIV, examined the level of scale-up and implementation of 16 evidence-based strategies required to address these local micro-epidemics, and ultimately reduce HIV-related disparities.
Nosyk and colleagues used a dynamic model that reflected HIV micro-epidemics in Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, which together have almost one quarter of all people living with HIV in the US. Data for the model were largely city-specific, producing results that reflected local economic resources, HIV transmission patterns, and service levels that would affect cost-effectiveness of different interventions (Figure 1). These interventions were modeled at both conventional and optimal levels of scale-up and implementation. They then compared the costs and effects of these interventions on HIV prevention to the status quo over a 10-year time horizon.
Depending on the city, intervention combinations included 9-13 strategies that produced the greatest health benefits while remaining cost-effective. Access to medication for opioid use disorder (MOUD), electronic medical record testing offer reminders, nurse-initiated rapid HIV testing, rapid testing in MOUD and ART engagement or re-engagement interventions were included in intervention packages across all cities; opt-out testing in the emergency department and primary care setting, and non-targeted care coordination to improve ART were not included in any city. These results give local policymakers insight into the best use for that additional dollar of HIV spending; for example, expansion of syringe service programs to prevent HIV was only recommended for cities that did not have high levels of existing syringe-exchange services, including Atlanta, Los Angeles, and Miami. Expansion of PrEP for high-risk men who have sex with men was only included for Atlanta, Baltimore, Los Angeles, and Miami. Expanded PrEP became an optimal strategy elsewhere if the medications were donated by the manufacturer.
Optimal strategy combinations were cost saving in Atlanta, Baltimore, and Miami, meaning the health care gains outweighed the costs of implementing and delivering the health services at a conventional level. These strategies were cost-effective in the remaining cities at a threshold of $100,000 per quality-adjusted life year (QALY).
But even the optimal strategy implemented at conventional levels would not achieve national HIV goals: the model suggests that HIV incidence would decrease by about 38% by 2030, which is less than half the national goal. Significant additional investment and unprecedented scale-up of service delivery would be required to meet national goals. In an invited commentary, Drs. Brooke Nichols and Stephen Kissler point out that these strategies still require a large initial investment in order to achieve long-term benefits, and emphasize the need for similar modeling in rural settings that may face additional barriers to service access.
In March 2020, Dr. Nosyk was awarded supplemental funding from the National Institute on Drug Abuse (NIDA) that will support a collaboration with CHERISH Dissemination & Policy Core leaders Dr. Zachary Meisel and Dr. Janet Weiner at the University of Pennsylvania’s Leonard Davis Institute of Health Economics. Together, they will communicate the findings to local decision makers in each city and identify opportunities to support local decision making. “In our discussions with stakeholders and policymakers, they have expressed the need for data that addresses local circumstances. This supplemental study provides us with the opportunity have those meaningful and productive conversations,” said Janet Weiner.
The proportion of hospital admissions for endocarditis attributable to injection drug use increased from 7% in 2000 to 12% in 2013. Endocarditis is an infection in the lining of the heart chambers and valves that can be contracted through shared injection equipment. Rates of endocarditis are disproportionately affecting young people who inject drugs (PWID), which has long term health consequences and affects future healthcare utilization. Endocarditis treatment often includes valve replacement and a lengthy course of antibiotics, which lead to costly long-term hospitalizations and may lead to prosthetic valve infections that require re-treatment. Among those who have been treated for endocarditis, estimates of reinfection range from 13% to 44% due to continued injection drug use. Treatment with medication for opioid use disorder (MOUD) such as methadone, buprenorphine or naltrexone can decrease the likelihood of continued injection drug use and reinfection. The treatment episode for endocarditis offers an opportunity to initiate MOUD prior to discharge to reduce the likelihood of reinfection and overdose.
A recent study by CHERISH Research Affiliate Joshua Barocas, MD and colleagues at Boston Medical Center, Boston University, and Tufts Medical Center examined the rates of MOUD initiation among PWID following endocarditis treatment, and compared overdose and health outcomes among those who initiated MOUD and those who did not. This study examined treatment and health outcomes for 768 adults 18 years or older with opioid use disorder (OUD) who underwent endocarditis treatment between 2010- 2016 in the Marketscan commercial claims and encounters database. The study found that only approximately 6% of the individuals treated for endocarditis (44/768) initiated MOUD during the peri-hospitalization period or within 30 days of the index endocarditis hospitalization. Those who initiated MOUD were significantly younger than those who did not (average age of 25 and 40 years, respectively) and experienced fewer overdoses compared to those who did not (5.8 per 100 person years [PY] and 7.3 per 100 PY, respectively). They also experienced fewer episodes of opioid related re-hospitalizations during the one-year follow up (162.0 per 100 PY and 255.4 per 100 PY, respectively). In adjusted Cox proportional hazard models, however, the receipt of MOUD was not associated with either outcome. This may be attributed to low overall event occurrences or the lack of methadone treatment information in the claims database. Methadone was not reliably included in the data set and was not included in the analysis, because it was not covered by commercial insurance until late 2017. The study highlights a missed opportunity to engage PWID with endocarditis in MOUD care in order to reduce the risk of overdose, improve health outcomes, and reduce costly re-hospitalizations.
Dr. Barocas and colleagues conclude that there is a crucial need to improve low barrier access to MOUD, and early initiation of MOUD should be the standard of care for persons with OUD-related infections. An invited commentary by Ellen Eaton, MD, MSPH at the University of Alabama contextualizes these findings within the U.S. treatment system and insurance reimbursement structure. Dr. Eaton compares the financial support for the continuum of OUD care to that of HIV to illustrate how government funding influences treatment uptake and availability. People with OUD face several financial and physical barriers to accessing MOUD, such as waiting lists for treatment that are upwards of one year long and the low number of waivered physicians that is not distributed across the country in a pattern consistent with the greatest need. In contrast, people living with HIV can be initiated on ART on the day of diagnosis and connected to additional services due to continued government support through Ryan White funding and other avenues. In order to implement same day MOUD to improve long term health outcomes and address the opioid overdose epidemic, Dr. Eaton emphasizes the need for comprehensive funding and support for MOUD.