Addressing the Growing Overdose and Addiction Epidemic

Kathryn Santoro (00:00:01):

Thank you, and good afternoon. I am Kathryn Santoro, director of programming at the National Institute for Health Care Management Foundation. On behalf of NIHCM, thank you for joining us today for this important discussion on Addressing the Growing Overdose and Addiction Epidemic. Over the past 10 years, we have seen drug overdose deaths nearly double. And overdose deaths involving synthetic opioids and stimulants have risen rapidly in recent years. Provisional CDC data suggest these increases have continued well into the pandemic. So, many Americans experienced isolation and economic upheaval over the past year, as well as hindered access to treatment options and support systems, all of which increase the risk of addiction and relapse.

Kathryn Santoro (00:00:54):

These new pressures exist along with the stigma that often prevents people from receiving care for substance use disorder. Today, we will hear from a prestigious panel of experts to explore strategies and solutions to reduce overdose rates with the focus on efforts to expand access to evidence-based recovery programs. Before we hear from them, I want to thank NIHCM's president and CEO, Nancy Chockley, and the NIHCM team who helped to convene today's event. You can find biographical information for all of our speakers along with today's agenda and copies of slides on our website.

Kathryn Santoro (00:01:36):

We also invite you to join the conversation today on Twitter using the hashtag SUDCOVID-19. First, we will hear from Dr. Jan Losby, the branch chief for the health systems and research branch and the division of overdose prevention at the Centers for Disease Control and Prevention. Dr. Losby is responsible for evaluating and advancing the implementation of CDC guidelines for prescribing opioids for chronic pain and building scientific evidence to support state community and tribal efforts to address the opioid overdose epidemic. We're so grateful she is with us today to share CDC's comprehensive overdose prevention efforts.

Jan Losby (00:02:24):

Thanks so much, Kathryn. It is an honor and privilege to be with you and to serve on this panel. In our time together, I will discuss the drug overdose burden, trends over time, and its evolving nature. Next slide, please. I will then walk through the key aspects of CDC prevention and our portfolio related to data, prevention, collaboration between public health and public safety and community efforts. Lastly, I will share some relevant resources. So, let's look at the next eight slides that describe the evolving nature of drug overdose in the United States.

Jan Losby (00:03:05):

Next slide, please. You've already seen this slide, so, I'll just highlight a couple of points here, that it can be helpful when trying to understand the opioid overdose epidemic to think of it as three overlapping and reinforcing waves. Beginning in 1999 with prescription opioids, this increased as you see here in the purple line, the heroin surge beginning in 2010, seen in the orange line, and largely the illicitly manufactured fentanyl or IMF and fentanyl analogs skyrocketing in 2013, the black line.

Jan Losby (00:03:43):

Next slide please. And opioids are now nested in a broadening poly drug crisis driven by stimulants, such as cocaine and methamphetamine. From 2013 to 2019, the cocaine involved death rate tripled the red line and the death rate for psychostimulants quadrupled, the green line. Opioids were involved in over 70% of cocaine involved deaths and 50% of psychostimulants involved deaths. Next slide. And looking, excuse me, holistically at all drugs involved in overdose deaths in the first six months of 2018 for 25 states reporting data to CDC, two thirds of all opioid deaths highlighted by the arrow involve fentanyl. Also, a third of deaths only involve fentanyl with no other illicit opioids on board.

Jan Losby (00:04:43):

Next slide, please. In the same study using 2018 data, we reported that 63% of all opioid deaths involve some combination of cocaine, benzodiazepines or methamphetamine. Next slide. How has polysubstance use changed over time? Using a national study of people entering treatment of opioid use disorder, researchers found that past month illicit opioid use increased from about 45% in 2011 to 70% in 2018. At the same time, the use of prescription opioids remained high, but decreased slightly from 95% to 85%. And the use of prescription opioids alone dropped from 55% to 30% as shown on this graph past month use of at least one non opioid drug occurred in nearly all participants over 90% with significant increases in methamphetamine.

Jan Losby (00:05:48):

Next slide, please. CBC released a health alert network last December. And in it, we looked at provisional estimate and drug overdose deaths from the 12 months ending in May, 2020, revealing a concerning acceleration of drug overdose deaths during the COVID pandemic. Here, there are many potential reasons for these trends that we are seeing, including persons struggling to maintain access to essential harm reduction treatment and recovery support services initiating or increasing substance use to cope with the stressors and social isolization created and using illicit drugs while alone more frequently.

Jan Losby (00:06:33):

Next slide, please. On the left, this map shows the percentage change in the 12 month provisional count of all fatal overdoses from June, 2019 to May, 2020, with red indicating greater increases drug overdose deaths during this time increased more than 20% in 25 states, including D.C. The map on the right, we see the percentage change of fatal overdoses involving synthetic opioids. The dark burgundies showing increases of 50% or more. Of the 38 jurisdictions with available synthetic opioid data, 37 jurisdictions reported increases in synthetic opioid overdose deaths. 18 reporting increases greater than 50% and 11% reporting increases 25 to 49%.

Jan Losby (00:07:28):

Next slide, please. If we turn to CDC efforts related to data and surveillance and prevention... Next slide. The division of overdose prevention has its goal and vision and mission of ending drug overdose and related harms with a specific mission to monitor, prevent, reduce harms associated with drug use, misuse and overdose. Within the division, we have six key strategies that address these overarching goals, mission and vision. And I'll touch on some of these during the remainder of my time with you. Next slide, please. CDC is funding 66 jurisdictions, including states, territory, cities and counties, who are part of the overdose data to action program. The program combines data and prevention efforts.

Jan Losby (00:08:24):

The seamless integration of data informing action is essential because of the potency and the rapidly shifting illicit drug markets. And I'll give some examples of the work here. Next slide, please. Data guide what we do, where we do it and allow us to know if our actions are making a difference. We need more timely, high quality, comprehensive, localized, and actionable data. And we need to create data that are easily accessible and readily used. We do this both for morbidity and mortality data. For morbidity or non-fatal overdoses, we leverage existing data systems such as syndromic data within 24 to 48 hours and hospital billing and claims data. Sometimes within three to four weeks. This allows us to report drug overdose, emergency department visits as quickly as every two weeks. Now, a total of 75% of emergency department related drug overdoses are captured.

Jan Losby (00:09:28):

Next slide, please. Through OD2A, states are incentivized to share data quarterly with deaths that occurred six to 11 months ago, detail information about deaths and their circumstances from death certificates, medical examiner, and coroner reports and toxicology results. Next slide, please. More detail data can help us inform future prevention activities or help us refine current prevention activities. It'll allow us to know, not only that someone died from a drug overdose, but also the details about all drugs at the time of death and the route of administration, but also tells us the circumstances leading up to an overdose such as someone's prescription and substance use history, if they were in recovery or had a relapse, if they were recently incarcerated or if they had any co-occurring mental health diagnosis.

Jan Losby (00:10:31):

Next slide, please. OD2A also encompasses a range of prevention strategies. And I'll just note a few here. So, better use of prescription drug monitoring program or PDMP data, to inform prescribing practices and prevention interventions, supporting healthcare providers and health systems with drug overdose prevention and response, including expanding the use of evidence-based prescribing and treatment practices related to linkage to care. Ensuring people are connected to the care they need by leveraging systems and upstream prevention efforts. Improving state and local prevention efforts to build more effective and sustainable surveillance and implement community level interventions in high burden areas.

Jan Losby (00:11:19):

Next slide, please. CDC is also funding tribes to address drug overdose. We are funding 11 tribal epi-centers and those that you see listed on the slide, to provide technical support to tribes and key partners for data collection use and for sharing. Equally important, we are funding 15 tribes from across the country to implement prevention and response activities similar to those I outlined earlier supported in OD2A. Next slide, please. I'd like to highlight a few public health and public safety collaborations. Next slide. One of the ways CDC is broadening our work is by strengthening the partnership between public health and public safety. One program involves CDC collaboration with High Intensity Drug Trafficking Areas or HIDTA, in 30 states around the overdose response strategy for ORS.

Jan Losby (00:12:16):

We support both a public health analyst and a drug intelligence officer in each of these HIDTA in the light blue states on the slide and a DIO in the dark blue states. The program works to coordinate data sharing between public health and law enforcement, developing and supporting the implementation of evidence-based programs and strengthening engagement of local communities to promote the inclusion of those most impacted by the drug crisis when designing planning and implementing activities. Next slide. CDC is co-sponsoring with the University of Baltimore and ONDCP to combat opioid overdose through community level intervention initiatives.

Jan Losby (00:12:58):

These are innovative evidence-based community interventions, and I've listed a few examples here. So for example, emergency department initiated referrals to MOUD. On-call recovery coaches and referral to treatment for opioid use disorder in fire departments. Expanding access to medication opiod use disorder, MOUD in jails, and all of these have the goal of moving forward to expand, reach and scale. Next slide, please. With funding from Bloomberg Philanthropies, these and in collaboration with the CDC foundation and NACCHO, CDC developed a toolkit to guide localities and initiating and maintaining partnerships to reduce overdose deaths. And this toolkit that's listed here, illustrate information to help target response efforts through accountable accountability, collaborative and coordinated teams.

Jan Losby (00:13:59):

The org chart, which I know is quite small here, shows the makeup of these fast teams. And as you can see, the teams are inherently multi-sectoral and community-based. The teams focus on collaboration and learning coordinated response activities as well as continuous quality improvement for the purpose of reducing overdose deaths. Next slide, please. If we transition and look at the efforts that are happening at the community level... Next slide, please. Implementing overdose prevention strategies at the local level is a cooperative agreement between CDC and NACCHO show that began in 2019. The program was designed to mirror OD2A that I mentioned a little bit earlier and local communities by providing funding to conduct overdose, surveillance prevention and response work. This is a comprehensive, interdisciplinary and integrated public health approach. You can see here, the sites that were funded in round one and round two.

Jan Losby (00:15:02):

Next slide, please. In 2020, CDC is collaborating with ONDCP to administer the program working closely with CADCA to support it. And this is the Drug-Free Communities program. The central aim of the Drug-Free Communities program or DFC is to use community-based coalitions across the many different sectors as shown on the slide to organize, to prevent substance use. The DSD program includes a community match requirement to further enrich commitment and buy-in and a community can be funded for up to 10 years. It was launched in 1998 and has grown substantially. There are over 700 coalitions last fiscal year. And right now one in five Americans now live in a DFC community.

Jan Losby (00:15:57):

Next slide, please. I wish to close by sharing a few resources that might be relevant to your work. Next slide. On the left, CDC developed an evidence-based menu and published the summary report on 10 best practices. This is based on the efforts happening in communities that I've highlighted earlier. It includes detailed explanations of harm reduction strategies, such as targeted Naloxone distribution, good Samaritan laws, syringe services programs, MOUD and criminal justice settings and emergency department buprenorphine initiation. On the right, I pulled this earlier from the earlier slide just to have it here as a resource. So, this is the one that guides partners in their use of information to target response efforts through collaborative and coordinated team efforts with the goal of reducing drug overdose deaths.

Jan Losby (00:16:54):

Next slide, please. In 2017, we launched the RX awareness campaign, and this was the first federal health effort to raise awareness about the dangers of prescription opioids. And the campaign tells the stories of real people whose lives were affected by prescription opioids. In July of 2020, we launched some additional stories featuring audiences heavily impacted, including pregnant women, veterans, younger adults, older adults, and American Indian [inaudible 00:17:24]. A new campaign messages evolve in a more positive, empowering and hopeful approach emphasizing that recovery is possible and emphasizing that where there is hope that recovery is possible.

Jan Losby (00:17:42):

Next slide, please. Resources for providers. Many of you are probably familiar with these. So, I just included the link to interactive trainings on the topic of communicating with patients and dosing and titration and assessing and addressing SUD. And many of the interactive trainings are really tied to the CDC prescribing guideline that was released in March of 2016. These two additional resources, one looks at quality improvements and the other provides advice and insights from healthcare and executives.

Jan Losby (00:18:16):

I will close here. I think we'll have time for some questions at the end, but just in terms of where do we go from here on the next slide, continuing prevention efforts at the state and community level, continuing to address areas around the evolving drug trends that we're seeing now with IMF and other illicit opioids, it requires enhanced coordination and collaboration. It also is important to expand access to and training for administering naloxone, which is essential, including those who are knowingly using opioids, their friends and others or who are responding to an overdose, expanding the provision of overdose prevention education. And I'll just note here in reference to time expanding access to, and the provision of treatment for substance use disorder and addressing barriers such as stigma. So Kathryn, I will turn it back over to you. Thank you so very much.

Kathryn Santoro (00:19:13):

Thank you so much, Jan, for the CDCs leadership and data collection that informs action and your support for partnerships with the states and local communities to foster evidence-based strategies and solutions. So, I am now pleased to introduce our next speakers, Tom Hill and Cece Spitznas. Tom is a senior policy advisor in the office of National Drug Control Policy, a component of the executive office of the president. He joined the national council for mental wellbeing in March 2017 as vice-president of practice improvement and previously served as a presidential appointee in the position of senior advisor on addiction and recovery to the SAMHSA administrator.

Kathryn Santoro (00:20:01):

Cece Spitznas is senior science policy advisor, and ONDCP. She provides policy analysis and scientific advice to the director and chief of staff on special matters of concern, such as emerging job trends and demand reduction, and helps to develop legislative responses to problems of national scope, particularly on prescription drugs, heroin and fentanyl. We're so honored to have them with us today to share the administration's drug policy priorities.

Tom Hill (00:20:37):

Good afternoon. And thank you so much, Kathryn. My name is Tom Hill. I'm going to be co-presenting with my colleague, Dr. Cecelia Spitznas, and I will get us started. So, let's go to the next slide, please. So, we're going to talk today about our high level policy priorities, and then we're going to drill down on some of them, but just a little primers that through our National Drug Control Policy Authorization Act of 1998, it states that the director shall release a statement of drug control policy priority in the calendar year of a presidential inauguration, following the inauguration, but not later than April 1st. So, that's a long way of saying that right after the inauguration, we got busy on our priorities. And [inaudible 00:21:32] finished in time to deliver them to Congress at the deadline April 1st.

Tom Hill (00:21:37):

And if you move to the next slide, please. A little bit of background is that our policy priorities, they're really focused on the urgency of the overdose epidemic, which we all know is rising at alarming rates and something that we chose to address in our priority. And the second part is really what's achievable in the first year of this administration? So, we designed them in a way that additional items can be folded into our 2022 national drug control strategy that is due in February of 22, and that we're also currently working on. We also do not have a Senate-confirmed ONDCP director. We have an acting director, Regina Lavelle, who is guiding us on. And we're working with a lot of federal partners agencies who also do not yet have Senate-confirmed leadership and that will change things considerably and we're acting in good faith until then.

Tom Hill (00:22:44):

So, I'm going to go to the next slide and then the one after that, and we view the high level priorities, and you can see the four of them are in red, and those are the ones that we're going to drill down on. So, just around the block, look at them as the first one expanding access to evidence-based treatment. The second is advancing racial equity issues related to drug policy. The third is enhancing evidence-based harm reduction efforts. The fourth, supporting evidence-based prevention efforts to reduce youth substance use. The fifth is reducing the supply of illicit substances. Six is advancing recovery-ready workplaces and expanding the addiction workforce. And the seventh is expanding access to recovery support services. So, we decided to do one, two, three, and six and reviewed them in greater depth on just so you get a deeper taste of what we're talking about here.

Tom Hill (00:23:52):

We can go to the next slide. One of the things that we in our past policy priorities document that we highlight is that in each of those seven sections, we have introductory chapters. And we talk about that we create the policy and have budget oversight authority. So, we typically rely on agencies to fund programs and implement policies. And there are a couple of exceptions there. We have grants featuring coordination of high intensity drug trafficking areas, we call them our HIDTA grants and the Drug-Free Communities, which's the DFC. So, those are our grant making capacity. I'm going to turn it over to Dr. Cece Spitznas to talk about expanding access to evidence-based treatment. And she'll go into some greater depth to that.

Cece Spitznas (00:24:51):

Thank you. And I just wanted to say that we selected the items that we're talking about today here, because we thought that they would be of great interest to the NIHCM community and plans in particular. So, obviously expanding access to evidence-based treatment is incredibly important, and I'm going to go over these in depth just so that people will have a real flavor for what we're interested in doing. First one has to do with removing unnecessary barriers to prescribing buprenorphine and identifying opportunities to expand low barrier services. So really meeting people where they are. And in some cases that's quite literally where they are is they might be on the streets making it very easy for them to obtain treatment. For example, they might come to certain services programs to get buprenorphine.

Cece Spitznas (00:25:48):

And we've already done a little bit of this in that you may have read that HHS issued a guideline on prescribing buprenorphine. So, providers could prescribe without going through the regular training that is necessary and paperwork that is necessary. They simply need to notify HHS and DEA of their intent to prescribe to up to a 30 per patient. And they can start prescribing buprenorphine right away. Our next one, review methadone treatment policies and develop recommendations to modernize. This is something that we feel very strongly needs to happen. Right now there's a number of barriers in a methadone treatment policy that keeps people from being able to access care. And an example of that, one thing that we were able to do during the pandemic was to offer people, other options for take home than they normally would be able to get for their doses to help improve access.

Cece Spitznas (00:26:50):

Expanding access to evidence-based treatment for incarcerated individuals, by working with Congress and the NRA agency is something that's very important, especially considering how many people overdosed when they leave prison or jail. Publish final rules this year concerning the telemedicine special registration and methadone vans or mobile narcotic treatment units is what they're called in the regulation. Evaluate progress that's been made since 2016, mental health and substance use parity task force recommendations, and identify next steps. We know a lot has already been done on that, but we need to really clarify what has the done.

Cece Spitznas (00:27:30):

Develop and establish a working relationship with payers and employers to promote full implementation of the, sorry, mental health parity and equity act to eliminate discriminatory barriers. I hope I got the MPHEA right. I should just say MPHEA. Identifying and addressing policy barriers related to motivational incentives for stimulant use disorder. As many of you may know that's one of the most applications treatments available, and we need to work on eliminating policy barriers related to that.

Cece Spitznas (00:28:11):

Next slide, please. Sorry. Exploring reimbursement for motivational incentives, as well as digital treatments. We've already gotten an extension on the opioid public health emergency declaration, and we're also going to be exploring and making permanent exploring and trying to determine what we can make permanent related to the emergency provisions implemented during COVID. Especially, we're concerned about telehealth and methadone policies that I mentioned before, and exploring and identifying barriers and establishing policies to help pregnant women with substance use disorder, access prenatal care and addiction treatment without fear of child removal. So, these are some things that we will be working moving forward, Tom.

Tom Hill (00:29:02):

[inaudible 00:29:02].

Cece Spitznas (00:29:03):

Oh, am I doing equity? Okay, I'm doing equity too. So advancing racial equity issues is something that woven through out the policy priorities document. But we have some real data needs that are in here in a standalone policy priority. So identifying gaps related to drug policy to target unmet needs in diverse communities. The first executive order that president Biden signed of this administration had to do with equity. And we are working closely with the equitable data working group on this. Establishing a research agenda to meet the needs of historically underserved communities. Establishing an inter-agency working group to agree on specific policy priorities for criminal justice reform, very important issue right there. Identifying culturally competent and evidence-based practices for black indigenous populations and people of color across the continuum of care.

Cece Spitznas (00:30:04):

We are also going to be working on reforming how we do our drug budgeting so that we include an analysis help federal dollars needs to needs. And next slide, sorry, I keep forgetting the next slide. There we go. Directing agencies to begin collecting budget data, this aggregated by demographic category that is so that we can see how the money is being spent and ensure that the money is going to the people who are most in need of the money. And then finally, promoting integration of the standards of culturally and linguistically appropriate services in health and healthcare for providers of treatment prevention and recovery support services, starting with a review of the standards by executive departments and agencies with healthcare roles.

Cece Spitznas (00:30:51):

So, that really has to do with making sure that people who are providing care in a manner that is culturally appropriate. And people can actually speak to the people that they're serving. So, these are some issues that we think are unique. We've never had advancing racial equity as part of the ONDCP priorities before. And we're really excited about this part. Okay. Now I'm going to turn it back over to Tom. Yes. There we go.

Tom Hill (00:31:25):

Thank you, Cece. So I'm going to go to the next slide and we're going to talk about enhancing evidence-based harm reduction efforts. So, this is a first time for policy, for the ONDCP to highlight harm reduction. And when we talk about harm reduction, we're basically talking about Syringe Service Programs or SSP. We're talking about Sentinel Test Strips, or STSs. We're talking about naloxone availability. One of the main reasons we were looking at harm reduction as a policy is because it is a way of engaging many people who would not ordinarily be coming through on the portals of the healthcare system or the treatment system. And so, it's a way of engaging people into healthcare and treatment often for the first time. And often to a very low threshold manner of entry, not a lot of requirements and a way to treat people without judgment, without shame, that's when it comes to the door and get them, help them with what they need.

Tom Hill (00:32:44):

So, the first one is integrated and build linkages, which is between funding streams to support syringe service programs. That's really on a federal level across programs, CDC, SAMHSA and other agencies to just start connecting the dots that exists in a way that makes sense programmatically and on policy level. Second is to explore opportunities to lift barriers for federal funding for SSP, particularly, for the barriers against being able to not spend federal dollars on supplies, such as syringe. The third is identifying state laws that limit access to SSP, naloxone and other services.

Tom Hill (00:33:32):

So, we know that many states in recent years have changed their mod that now makes syringe service programs legal, but sometimes the other state laws are inconsistent with this. They may have paraphernalia laws that includes syringes or fentanyl test strips and make them illegal, even though they've legalized safe SSPs. So to do some work to make those laws alive so that people, who are practicing in those service provisions are able to do so without any kind of barriers. The next one is examine the naloxone availability on each with high rates of overdose. So, looking at those counties, seeing what the naloxone availability is, and then identifying opportunities to expand access and target areas among pharmacy, clinicians, peer support workers, family, community members, and people who use drugs.

Tom Hill (00:34:35):

And then on this slide, the final one is amplified best practices for fentanyl test strips services, standards for fentanyl test kits and use of fentanyl test strips as a means of engagement into healthcare systems, as I talked about earlier. So the next slide, please. So we may need to, in this area, are develop and evaluate the impact of education material that feature evidence-based harm reduction approaches to looking at those educational materials that think people who use drugs with harm reduction, treatment, recovery support, conference social services, through a diverse range of community members, and looking at what a team of community members might look like in terms of how to train law enforcement officials, and evidence-based approaches that address overdose and provide police assisted recovery.

Tom Hill (00:35:35):

And then the final one in this area is supporting research on the clinical effectiveness of emerging harm reduction practices in real-world settings and testing strategies that best implement these evidence-based practices. So, looking at a whole range of practices emerging, promising stats and moving them up to an evidence base. And then the final one we're going to talk about, if we switch slides, we're going to go to the sixth policy priority, and that's advancing recovery-ready workplaces, and expanding the addiction workforce.

Tom Hill (00:36:19):

We can start with the workforce and talk about a request federal agency to support training for clinicians in addiction with special emphasis on community-based services in underserved areas. So, that would be like the veterans health administration, such as federally qualified health center and the Indian health service. And the supports on that to identify authorized vocational programs that can expand the addiction workforce and evidence-based practices that have not yet secured appropriation. So, we're doing that now, some of those were named and support redact, but the appropriations were never made. So we're getting those aligned with appropriation so that they can be funded. And the other one is to explore opportunities for training bilingual immigrants, who are addiction professionals in their home countries to become case managers.

Tom Hill (00:37:19):

So, I'm going to say also take a moment to explain that all these policy priorities came from not only our best thinking, and in February convened a series of stakeholder round table to get people in the field, that's thinking about how to enhance the public piece of these priorities. And that one in particular came from directly from one of our stakeholders in a round table. The next one is to seek opportunities to expand the workforce of bilingual prevention professional and peer specialists by offering a sense of the train and identifying areas to treatment and prevention for populations with limited English.

Tom Hill (00:38:03):

So, another thing that I think about is that even though equity is its own policy priority, it's woven into all of these priorities in various ways. So we talked about access and we talked about language. We talked about bearing and surrounds people with limited English. We're talking about a lot of health equity issues and even social determinants of health. So, if we go to the next slide. This one has more of the recovery focus and it's identifying ways in which federal government can remove barriers to employment and create employment programs for people in recovery from addiction.

Tom Hill (00:38:46):

So, a thinking there is... If we can figure out how to make this work on a federal level, we can really bowl model that out to the field and to labor in a way that makes it achievable, but also something that's attractive in terms of how to do it and why to do it. The second is to conduct a landscape review of existing programs, because there are many states that are doing recovery ready, or recovery friendly workplaces, as well as local governments employers, and members of the workforce. And offering grant opportunities to support recovery in the workplace and remove hiring and employment barriers that exists and provide recommendations to ensure all communities, including rural and underserved areas have access to these recovery ready programs. We need to identify a research agenda to examine what the existing recovery rate of workplaces looks like and how to evaluate and research them.

Tom Hill (00:39:53):

And then finally, to produce guidelines for federal managers on hiring and working with people in recovery from SUD, that is connected to that first bullet on this slide is to, a lot of what's required in recovery ready workplaces, it's not just a hiring and training, but also training employers and staff, how to be a part of a recovery environment or recovery culture that exists in the workplace. So, that is our high level and drill down on four of the seven priorities. And I know we're going to have a section or Q&A, but I think we're going to have another speaker before we do that. So thank you very, very much. Those are our contacts if you need to get a hold of us to learn more or get more details. We're happy to do that.

Kathryn Santoro (00:40:52):

Thank you so much, Tom and Dr. Spitznas for sharing the administration's priorities and this bold approach to strengthening the nation's approach to prevention and recovery. Under the leadership of president and CEO, Andrew Dreyfus, Blue Cross Blue Shield of Massachusetts has created groundbreaking programs that expand access to care for people with opiod use disorder and other substance use disorders. And they also have provided education and other resources to reduce stigma. To hear more about their leadership on this issue, we are now joined by Dr. Gregory Harris, senior medical director of behavioral health at Blue Cross Blue Shield of Massachusetts. Dr. Harris is a board certified adult psychiatrist with a master's in public health and over 20 years of practice, and he continues to see patients and a part-time clinical practice. Dr. Harris.

Gregory Harris (00:41:56):

Thank you very much. I'm happy to be here and share some of the approaches we have tried over the last several years. Next slide. Thank you. So I'm going to highlight a few areas of focus. This is the scope of things for the opiod epidemic, as well as for other substance use disorders. And I should say Blue Cross and Blue Shield of Massachusetts is a local, mostly commercial health plan based in Massachusetts, about two thirds of our members are based in Massachusetts. Oops. We've gone all the way to the end of the talk here. So I'm going to take you through some elements related to prevention, intervention, treatment, and recovery, and I'm particularly going to focus on some treatment ideas, but we'll start first with prevention.

Gregory Harris (00:43:09):

Next slide, please. So, starting in 2012, you've seen the data from the other presenters about the rise in the opioid epidemic related to prescription drugs. And our leadership began when we began to work with state leaders in Massachusetts, as well as with the medical society and our local providers to jointly work on collaboration for prescription drug safety. So, this program in three years removed 21 million opioid pills from circulation by jointly coming up with criteria for reducing those initial opioid prescriptions for a variety of medical conditions working at the level of changing physician behavior on the ground, not as easy a thing to undertake, but in a collaborative manner with our providers we're able to initiate this program.

Gregory Harris (00:44:24):

The program is still in effect now and reinforced in many other areas with prescription drug monitoring programs in requirements in the state. But as a plan we were really important to having that go into effect. And we have the second lowest rate of opioids prescribed in the blues nationally. Another prevention intervention was an investment in something called Drug Story Theater, which is really a primary prevention program aimed at youth. And this was a local development using storytelling to reach out to youth who have had experiences with drugs. And on the recovery side, we were also a founding member of RIZE Massachusetts.

Gregory Harris (00:45:19):

Next slide, please. On the intervention side, we were first in health plans to provide an opioid toolkit. So this was the naloxone to reduce overdose. And this was targeted at our employer groups, our accounts to implement the Narcan toolkits in their employment. These are municipalities, large companies, small companies, the librarians, we're finding many people with overdose in some of our communities and having these kits available in the workplace was lifesaving for many people. And that was something we worked with creating the kits and then distributing the kits with our employers.

Gregory Harris (00:46:22):

We also removed copays and cost sharing for Narcan. And the access has become easier over time, but you could walk into a pharmacy and get Narcan prescription. Our ID cards of substance use and support services for mental health. Now we at Blue Cross, we have an integrated medical surgical mental health and substance use program so that when people are calling in, they're getting us at Blue Cross and we have series of professionals behind the scenes that can help our members find treatment. And then, we instituted Learn to Live. Next five, please. I'm going to talk a little bit about our program. So, one of the things that we find on the ground is we have a very decentralized healthcare system in the substance use world in particular, we really have really three systems of care.

Gregory Harris (00:47:21):

There's the medical surgical system, the mental health system and the substance use. And so, finding a clinician with the right specialty is non-trivial for a lot of people. And so, we have provider directories and all sorts of tools, but on this as a continuum of our electronic tools find a doctor tool, reaching out to member services and then case management and our case management team, social workers, nurses backed up by physicians and psychologists, can help our members try to find the right level of care if they reach out to us.

Gregory Harris (00:47:59):

Not everyone thinks to reach out to the insurance company for this type of assistance, but we've really been pushing the notion that we could be the ally of our members, trying to find the right care at the right time and helping take off some of the burden. I was involved with a provider search just today where a person got a list of 20 something doctors we could make those calls, see who had availability and try to direct our members in real time. So this is before they really get into treatment and when they're not sure where to go. Next slide. And then, another thing that we implemented is Learn to Live. Now, this is a mental health tool. It's cognitive behavioral therapy, a skills-based therapy is some of the foundation of this, this isn't treatment though.

Gregory Harris (00:48:56):

But this tool really aims at five main domains, stress and anxiety, depression, social anxiety, substance use, and insomnia. So, this is not an opioid addiction tool, but this is aimed at our membership, many who aren't getting treatment at all. So, we know that really only 10% of people with substance use disorders and maybe 50% of mental health conditions really even seek treatment. And so, you're going to hear more things that we're doing to try to bring our members who are struggling with substances into the healthcare delivery system. Learn to Live is one tool, and we've had a thousand members a month doing this tool, benefiting from this tool and learning about all these areas of focus and it's really a screening because if they get notification, if they should seek further help than this, but we're getting 60% of people who are on this tool have sought no mental health care before this tool.

Gregory Harris (00:50:08):

Next slide, please. But it's shifted a little bit to treatment. So, we've done a number of things for medication assisted treatments in particular and for admission. So, the first on this list is no prior authorizations for detox admissions from emergency departments. We really think of this as urgent emergent medical care. Like if there's a stroke, you get admitted. If you have a suicide attempt, you get admitted. If you needed to detox, you get admitted. We have access to medication assisted treatment. This has been over a period of time to make sure that as many of our members as possible have access to all types of medication assisted treatment, are reducing prior authorizations, reducing the deductible, eliminating the deductible and copay for methadone, which a lot of commercial, new for commercial plans to do this, not all of our employers understood this in a work to work with our employers to understand this really does need to be part of a standard medical benefit medication assisted treatment.

Gregory Harris (00:51:26):

And what we find is our members who are actually engaged, have admissions rate and costs really dropped and the more engaged they are with medication assisted treatment, the better they do, not surprising to this audience, but that data is very compelling when we speak with our accounts and employers. We've also expanded our network of opioid treatment providers and other substance use providers eliminated prior authorization for our routine outpatient visits for mental health and substance use disorders. So, hassle and payment are what our providers complain about it. And we've tried to make it as friction free as possible for our providers so that our members can get care.

Gregory Harris (00:52:15):

And then, I'm going to talk about a few of these options listed here that have to do with contracting collaborative care management in aware recovery care. Now, we'll end a little bit with talking about tele-health. So next slide, please. We were early about 10 years ago at Blue Cross with contracting using value-based contracts accountable care organizations with most of our medical providers, that occurred about 10 years, and it's been well studied peer reviewed journals in New England journal medicine for a highly effective reorganization of our medical practices. And that's really been an important thing to get our practice thinking about the total care of the patients that they treat our members and adding mental health and substance use disorder care as part of the outcome measures that these groups are accountable to.

Gregory Harris (00:53:28):

So, that's been going on for a while and that's been an improvement, but what we've also then added in this last year is if you go to next slide, an incentive program for psychiatric collaborative care management, this is a model and I want to take a little bit of time. It's not specific to substance use disorders, but what we see is that our medical providers are still somewhat siloed from mental health and substance use providers. And this is a model of care that's population-based, brings a psychiatric consultant alongside a primary care practice with a behavioral health care manager in the center of the treatment, really the patients in the center of all of this activity that goes around. It's paying for a population-based model for the primary care practice.

Gregory Harris (00:54:23):

So, the behavioral health care manager is screening the population of that primary care and intervening. So common concerns like anxiety, depression, substance use disorders. So those are really three of the primary things. It's why we have our Learn to Live program. These things are screened, picked up in the behavioral health care manager becomes the first point of contact with the member and consults with a psychiatrist. The psychiatrist can consult to the PCP. So, the team gets the benefit of the psychiatrist being involved and can initiate care without even requiring the traditional care model of seeing an individual patient going to an individual physician or a psychotherapist.

Gregory Harris (00:55:14):

And then, if subspecialty care is needed, the team can then initiate that. What this gets our practices doing is really leaning into mental health and substance use disorders in a way that they hadn't really done before, because it provides an internal resource to the primary care practices. So, it's trying to work our medical practices to pay attention to these issues, become accountable for them in their value-based contracts and be incentivized for really thinking about really integrating mental health and addiction care into the care of all their practices.

Gregory Harris (00:55:57):

Next slide, please. What we've also added in this past year is a relationship with a group called Aware Recovery, and Aware Recovery has really a very novel home-based comprehensive program that really... I've put here in a salmon color, where they fit in the continuum from inpatient. So, the kind of patients that are where recovery sees are people who've tended to be in and out of rehabilitation programs and detoxes. So they have significant substance use disorders, but some of them improve. They have a course of treatment and they recover and they get better, but many people end up in and out of treatment. And so, the idea with aware recovery care is to meet them more in the home environment and to help them build skills themselves with family members, intervene with the family, the providers, and really wrap around care for our members in their home environments.

Gregory Harris (00:57:17):

The program is built around phases of a few months and they tend to be in this program for a year and they have... Next slide, please, really excellent and success rate in engagement and longer-term recovery, which is a program that we really want to see more of, a program to really stop the cycle for our sickest members. So, we're with Learn to Live, being more about screening and collaborative care about integration. This program is really aimed at our members who are well along a journey of substance use, and they're really trying to break a cycle and involve their family, try to preserve their job, and not go further down hill and with more and more serious consequences of this substance use.

Gregory Harris (00:58:14):

Next slide. And I just want to end my piece on talking a little bit about tele-health, because this is just to show to little bit of data and also to leave us with a question of what comes next with tele-health. We at Blue Cross went from 200 tele-health claims a month to 40,000 in the peak of the pandemic. And 8.8 million tele-health claims 54% of claims that we receive are for mental health, and within that mental health and substance use disorders. And we have overall utilization to go to the next slide. This is just some data that we released about two months ago, increase in outpatient mental health services. And we were seeing that year over year before the pandemic, but this is a sharp increase of 20% just over the past year increase for substance use spending or astounding 9500% increase in telehealth visits.

Gregory Harris (00:59:23):

I see patients still, and I went from 0.5% tele-health prior to the pandemic, which was a higher percentage than a lot of my colleagues to a hundred percent and to state it a hundred percent. And we'll just go to the final slide. So the top graph is telehealth nationally for all specialties, it peaks around 51% and it drops to about 18%. So, there was a sharping uptick in tele-health in all medical specialties, and then dropped to 17%. I pull out psychiatry and the lower one, and you can see that it goes up and it's still up and it's at 73%, and that's about consistent with what we see at Blue Cross as a company.

Gregory Harris (01:00:13):

This is just data broadly but it's consistent with our Blue Cross data. So, we see our mental health and substance use providers still using tele-health and it's not decreasing. And as a plan, we're intending to pay at the same rate for telehealth visits versus an in-person visit. And we're thinking really broadly because these numbers, a lot of them are focused on outpatient psychotherapy and some of those services, but what we're also seeing is a huge uptick of tele-health in intensive outpatient of partial hospital programs. It's harder to tease out with those programs what's being done on the claims side of telehealth or not, but we've broadly allowed those in our teams really hear that our members are attending a lot of programs remotely that wouldn't have kept going if they hadn't had tele-health availability.

Gregory Harris (01:01:22):

And in some cases going on in better, more fewer no shows up from the provider side or more engagement from the member side by having a telehealth option. So, while the opioid numbers that my colleagues have showed are really alarming, these numbers have allowed a lot of care to go on that were it not for telehealth would not have happened. And I think we would have been in a much worse state. And I think that this is going to be an important story for access to care in all environments. We're in the state of Massachusetts, we have rural and urban, our urban members get as much benefit from telehealth as are our rural, because access is difficult in the city as well as in a more rural area. So this is just food for thought, and I'm going to next slide and we'll end it there. And thank you very much.

Kathryn Santoro (01:02:23):

Thank you, Dr. Harris for ending us on that bright spot and for your continued leadership, working with your members and community partners. Unfortunately, we are out of time today. I do want to thank our audience for their questions. We will follow up with you online and ask our speakers to answer some of the questions specific to their presentations. I'd like to thank our excellent panel of speakers for being with us today and sharing your valuable work and your perspectives, and thank you to our audience for joining us. We do appreciate your feedback. Please take a moment to complete a brief survey that you can find on the bottom of your screen. And please also check out our other resources on our website, including our recent infographics on stimulant and opioid overdose deaths. Thank you all again so much for joining us today.