NASHP

State Policy Center for Opioid Use Disorder Treatment and Access

The opioid use disorder (OUD) epidemic extends beyond the boundaries of traditional state health systems, requiring evidence-based treatment and coordination between state agencies and leaders. To optimize all potential avenues to treatment and reduce overdoses, the National Academy for State Health Policy (NASHP) is working with states to develop a “no-wrong-door” approach to OUD treatment that prioritizes cross-systems policy. NASHP is providing tools and resources, which will be frequently expanded, with support from the Foundation for Opioid Response Efforts (FORE) and its steering committee.

NASHP Opioid Use Disorder State Policy Steering Committee

Kimberly Boswell
Chief of Staff
Alabama Department of Mental Health

Allan Brenzel, MD
Medical Director
Department of Behavioral Health,
Developmental and Intellectual Disorders
Commonwealth of Kentucky

Laura Fassbender
Executive Assistant
Pennsylvania Department of Health
Office of the Secretary

Laura Garcia
Deputy Director of Bureau of Licensure, Compliance and Monitoring
Division of Substance Use Prevention and Recovery
Illinois Department of Human Services

Bob Hansen
Executive Director
Office of Drug Control Policy
West Virginia Department of Health and Human Resources

Ashley Harrell
Senior Program Advisor
Division of Behavioral Health
Virginia Department of Medical Assistance Services
Lisa Letourneau, MD

May 7, 2020 Meeting Minutes

June 4, 2020 Meeting Minutes

FORE Steering Committee Meeting Minutes

Teleconference: 2-3 p.m. (ET) June 4, 2020

Attendees: 

NASHP: Kitty Purington, Jodi Manz, Eliza Mette, Kristina Long 

FORE: Ken Shatzkes

Steering Committee: 

Kimberly Boswell, Chief of Staff, Alabama Department of Mental Health

Allen Brenzel, Medical Director, Department of Behavioral Health, Developmental, and Intellectual Disorders, Commonwealth of Kentucky

Laura Fassbender, Executive Assistant, Pennsylvania Department of Health, Office of the Secretary

Laura Garcia, Deputy Director of Bureau of Licensure, Illinois Department of Human Services

Bob Hansen, Executive Director, Office of Drug Control Policy, West Virginia Department of Health and Human Resources 

Ashley Harrell, Senior Program Advisor, Virginia Department of Medical Assistance Services

Marc Manseau, Chief of Medical Services, New York State Office of Addiction Services and Supports

1) FORE Project Policy Center Hub Update

  • NASHP Blogs, pending case study, pending resource brief

2) Discussion/updates on state policy: (naloxone distribution strategies, working with corrections on reentry, special populations, leveraging Medicaid providers and MCOs, etc.)

Key themes: 

Kentucky

      • Concern over the increasing overdose and suicide rates. EMS runs for fatal and non-fatal overdoses in rural and non-rural areas are up 40%. 
      • Also concerned over lack of access to residential services. Comorbid SMI and SUD patients are especially lacking services. 
      • Examining racial injustice of access to services. The state has convened a group around health disparities and access for SUD services. 
      • Kentucky legislation to explore an 1115 waiver proposal related to corrections and OUD treatment. In talks with CMS to modify 1115 and make services eligible behind the wall of prisons. 

West Virginia

      • West Virginia runs from EMS were down in April, but May has reversed that trend: one locality seeing a 300% increase in overdoses. 
      • Same observation about residential treatment and limited capacity as Kentucky. Due to social isolation, the state is rolling out an app to providers and individuals in recovery. This will be a tool to help people stay connected. 
      • Concern that ER SUD treatment is taking a backseat due to COVID. To compensate, the state is working to get a company credentialed to provide MOUD 24/7. The company will increase access to MOUD and provide bridge treatment. 
      • West Virginia is meeting with corrections today to further explore MOUD access. The goal is to expand services as much as possible and increase the connection between criminal justice and community. 
        • Corrections currently lean toward Vivitrol which may lead have implications for long-term continuity of care. 
      • The state wants to take advantage of increased flexibility to help as many people as possible. Promoting a help line for suicide and connection to treatment.  

Virginia 

      • The state has moved towards phase 2 of re-opening, but it is not in all localities.
      • Recently released a policy update to continue with flexibilities for telehealth. The state is getting concerned as providers want to resume face to face groups despite DMAS holding firm on telehealth for group therapy. 
      • Using the SUPPORT Act grant to expand services through the pandemic and also looking to address racial disparities. 
      • The state is experiencing the highest ever fatal overdoses, and emergency department data shows increase in nonfatal overdoses that may be inflated. 
      • State allowed licensing reciprocity and temporary licenses for out of state providers.  
      • Surveyed preferred OBOTs to see who has capacity to serve appx 4000 members throughout the state via telehealth to offer bridge bupe support. 
      • SUPPORT Act also had training component and state has pivoted to include telehealth training since April. 
      • Medicaid held open Q&A last week on bupe Rxing with LCSW and addiction specialist MD; questions included how to initiate, provide without UDS, how to take a harm redux approach right now, etc. 

Illinois 

      • Overdoses are increasing as well, and the state is currently working to gather further information. 
        • Trying to figure out how to get data as quickly as possible. Requiring OTPs to report weekly overdoses and hospitalizations instead of waiting for data from public health or examiner’s office.
      • The state has spent $2 million to make sure everyone in an overdose program received two doses of naloxone but people are remaining isolated because of COVID and may be using alone. 
      • Exceptions and take-homes for OTPs are great for COVID but is it beneficial in the long run if it is contributing to isolation? 

Pennsylvania 

      • Pennsylvania is continuing to figure out what it looks like for teams to do the same work and more to meet the needs of an increasing population with less bandwidth. 
      • The state updated guidelines for first responders for naloxone. Currently an application is open for community-based organizations to be large distributers of naloxone. Syringe service programs will be able to respond. 
      • Developed equity response groups and a subcommittee on reentry and SUD. Providing recommendations to navigate needs.
      • Budget has not received significant impact as many programs are SOR funded. State is implementing a 5-month budget period instead of 12-month. 

Alabama 

    • The state is in the midst of a COVID increase and it is hard to change the conversation to SUD. Challenging to balance impact of decisions made in the midst of COVID. 
    • Currently, 1 of 3 agencies that have not received level cutting. Crisis money for diversion centers is still in budget.
    • Community health centers must also work with diversion centers- strong relationship and a lot of work to make sure that this is a smooth transition. RFP currently open and will have information in mid-July. The state is using this time as an opportunity to transform behavioral health. The state does not have MC or expansion; thus, it is hard to drive change as there is not a mechanism to do so. 

New York 

    • The state’s experience is similar to other states 
    • NYC still not in Phase 1 of reopening, and it is too early for in-person groups. Experiencing anecdotal and preliminary data-based spike in overdoses. (EMS and police data) 
      • Spikes not from people in treatment. OTPs have had low overdoses. Hearing more about return to use and individuals not in treatment.
      • State is also experiencing a rise in fentanyl. 
    • Advertisements to inform of access to treatment during COVID. Also providing targeted naloxone and opioid prevention training that is remotes. 
    • State has developed a document about best practices for other stimulant used disorder.
    • The budget situation is likely dire. SESPDT and SOR dollars may provide some protection. 

Next Steps: 

  • Eliza Mette will follow up to reschedule next meeting (July 2, 2020)
  • Next call will include a deeper discussion of data opportunities, equitability approaches

July 9, 2020 Meeting Minutes

FORE Steering Committee Meeting Minutes

Teleconference: 2-3 p.m. (ET) July 9, 2020

Attendees: 

NASHP: Jodi Manz, Eliza Mette, Kristina Long 

Steering Committee: 

Kimberly Boswell, Chief of Staff, Alabama Department of Mental Health 

Allen Brenzel, Medical Director, Department of Behavioral Health, Developmental, and Intellectual Disorders, Commonwealth of Kentucky

Laura Fassbender, Executive Assistant, Pennsylvania Department of Health, Office of the Secretary

Laura Garcia, Deputy Director of Bureau of Licensure, Illinois Department of Human Services

Bob Hansen, Executive Director, Office of Drug Control Policy, West Virginia Department of Health and Human Resources 

Ashley Harrell, Senior Program Advisor, Virginia Department of Medical Assistance Services

Marc Manseau, Chief of Medical Services, New York State Office of Addiction Services and Supports 

Satya Sarma, Medical Director, Arizona Health Care Cost Containment System

1) Highlight of recent and upcoming resources (2:10 – 2:20)

    • Development of policy center and a case study in progress
    • Housing supports blog and a Q&A with West Virginia

2) Discussion of state experiences during COVID, including racial equity in OUD services

Key themes: training, stimulant use beyond opioids, managed care engagement

Alabama:

The state is experiencing a rapid increase in COVID cases. Fortunately, state hospitals have been able to manage COVID cases so far. The state has 3 state hospitals with 500 beds, 17 COVID cases and has had 6 deaths so far. Deaths have been primarily with geriatric patients at high risk.

Provider success: managing SUD and MH and are working to get information out

Recent increase in overdoses but not a corresponding spike in deaths. Have started a public information campaign in response.

 On the racial equity side, crisis care (including services for SUD) are being considered to decrease police involvement in minority communities. Crucial conversation as individuals with SUD and MH issues are often incarcerated rather than receiving treatment.

CIT training for law enforcement and mobile crisis units with master level LPCs and social workers, based around a new set of standards around crisis care.

West Virginia:

Also had a significant increase in COVID-19 cases. Face mask order in public buildings, delayed school starting by a few weeks so far. Detox program in southern WV closed for a short period due to COVID but is working to reopen

State has published 2019 overdose data; shows slight decrease in overdose fatality but significant and ongoing growth in Methamphetamine use.

Urgency to ramp up clinical capabilities for polysubstance issues and consider all pathways to recovery. WV recently had contingency management training (Rosen) and has opened opportunities for this training.

The state is also doubling down on naloxone distribution, including a September Naloxone Giveaway day.

Working on establishing LEAD programs in more urban environments to get individuals into treatment and an emphasis on imbalanced individuals in corrections. ANGEL bill passed for diversion from criminal justice.

Virginia:

Non-fatal overdoses slightly increasing. From October to December 2019, the state experienced the highest number of overdose fatalities for that period ever. Also seeing trends with increasing methamphetamine and cocaine overdose fatalities.

VA also just issued updated guidance to providers allowing groups to resume for BH, but also allowing telehealth flexibility to continue. Having discussions about telehealth services moving forward. Support for maintaining permanence.

SUPPORT ACT grant focuses on training. Since April, 60 trainings on SUD topics that have reached 3000 individuals in attendance.

Mannatt is conducting an analysis on laws and VA compliance. VCU is conducting a member’s survey, adding questions around COVID, telehealth, and access to SUD services.

Two race-based trainings underway but funding uncertain due to restrictions on federal funds.

Kentucky:

Working on the 1115 for folks that are pre-released. Workgroup working with corrections, trying to decide how to meet Medicaid expectations for clinical and evidence-based standards. Submitted draft, waiting for feedback now. Waiting for CMS response, but remains cautiously hopeful.

Experiencing same resurgence of COVID that other states are reporting.

Best data of overdoses is directly from EMS providers and university vendor.

Current estimates report that the state is back to pre 2017 levels of overdose deaths. More urban driven, and younger age group, most likely people returning to use. Anecdotal data reveals a significant increase in Methamphetamine use. Psychiatric hospitals may be adversely impacted.

Impact of chronic stimulant use may present similarly to MH conditions.

State ended PA for many drugs under COVID. Will be resuming but extending elimination of preauthorization for BH and SUD. Preauthorization ending for Sublocade, but the state has not seen a big increase in prescriptions. Providers do not seem comfortable.

Racial inequity is also a high focus- also focus on racial injustice and training for members in Kentucky hospital association. BH providers are uniquely positioned in leading the conversation of racial equity.

Illinois:

The state is working to encourage providers to stay open and provide services via telehealth. Recovery homes have been innovative and have worked hard to keep the doors open. Quickly identified providers that were serving majority POC and minorities, many clients did not have equipment needed to access services.

Beginning conversations about how the state can go into communities of color to help with SUD. Communities of color are disproportionally affected, both by COVID and OUD.

 Analyzing funding mechanisms and how much funding is going to communities of color. Immediately began to notice that the state has providers in communities of color that have struggled to compete for funding. The state is considering how to provide long term solutions. Also, offering $50,000 grants for any program interested in starting a system of care.

Learning collaborative with providers in community of color: Phase 1: help survive COVID, reinvent service provision, more outreach versus in reach, phase 2: empower providers and using SUPR staff to help provide guidance

Pennsylvania:

The state is experiencing an uptick in COVID cases and exploring mitigation efforts and is working to embed racial equity into COVID response.

Currently testing RFA to apply a hub and spoke model to COVID testing. Working to include requirements that an organization must report demographic data and consider community members in decision making.

Also has two health equity task forces working to address racial inequity andpublished opioid sickle cell guidelines due to outreach from POC.

Reports that initial data reveals Latinx community numbers are increasingly experiencing OUD. The state is adapting response efforts.

EMS data transport rates after naloxone provision are significantly lower, which is concerning. Thinking through solutions.

New York:

New York City was the global epicenter of the COVID-19 pandemic, but the state has gotten the case rate down and increased testing. Currently on track to contain the virus. The state has learned a lot of lessons so far. Sent a link to committee members including guidance issued so far.

NY was doing well in decreasing overdoses and saw a decrease of mortality in 2018, but preliminary data suggests an increase in certain areas over last few months; has begun a social media campaign for overdose prevention and virtual naloxone training. Working to add equity parameters.

Next Steps: Next call will include a deeper discussion of data opportunities, equitability approaches.

Aug. 6, 2020 Meeting Minutes

FORE Steering Committee Meeting Minutes

Teleconference: 2-3 p.m. (ET) Aug. 6, 2020

Attendees: 

NASHP: Kitty Purington, Jodi Manz, Eliza Mette, Kristina Long 

FORE: Ken Shatzkes, Karen Scott

Steering Committee: 

Laura Garcia, Deputy Director of Bureau of Licensure, Illinois Department of Human Services

Bob Hansen, Executive Director, Office of Drug Control Policy, West Virginia Department of Health and Human Resources 

Ashley Harrell, Senior Program Advisor, Virginia Department of Medical Assistance Services

Satya Sarma, Medical Director, Arizona Health Care Cost Containment System

  1. Highlight of recent and upcoming resources (2:10 – 2:20)
    • Launch of Policy Center Hub
    • Crisis services blog and a Q&A with WV
    • Case Study 
    1. Discussion of state experiences (2:20-2:55)

West Virginia: The state participated in a national press conference for the unveiling of the Shatterproof Atlas webpage. There is a state-wide advisory committee working to build out the webpage even more. The Office of Drug Control Policy (ODCP) also unveiled an interactive service map for SUD, drilling down to county level information, broken out by ASAM level of care. 

      • The state has retained Dr. Richard Rosen to conduct virtual trainings on stimulant treatment, including methamphetamine. The state has also released a request for proposals (RFP) to develop WV clinical capacity for poly-substance issues. 
      • There is a time lag in data reporting, but the state is concerned that overdoses are up significantly in 2020. Data from 2019 showed a decrease in overdoses from 2018, but this good news is being washed away with 2020 data. 
        • Overdose data is fairly current- and has shown a huge spike in May. In February, March and April overdoses were fairly low, with spike in May, decreasing rates in June, and early July data reveals another upward trend. The state is developing focus groups in counties with highest overdoses to discuss different interventions several meetings have been held, with another meeting scheduled for next week with over 40 individuals. 
        • The state has an RFA out to expand outreach capacity via response teams, goal is to have 65-70% of state able to follow up with an overdose via teams including: EMS agency with peers, law enforcement, other local staff, the structure is tailored based on the preference of the community. 

Illinois: The state is experiencing a lot of similar things as WV, especially in regards to increasing overdoses. Medicaid estimates that there is a 40% increase in overdoses- currently trying to work closer with the Department of Public Health (DPH) to get information faster. 

      • Agencies proactive about reaching out for any preliminary data. (Unpublishable data only for use to respond to COVID/Opioid epidemic.) 
        • Also requiring OTPs to report weekly the number of overdoses to Medicaid (i.e. if the patient has reported an overdose to the counselor, the counselor must report it to Medicaid). There are 80 OTPs in Illinois, which have been able to identify areas with higher rates of overdoses. This data has also revealed that most overdoses are occurring with people outside of the treatment realm. 
        • Also identified high rate of overdose between April-May, raising some questions about how naloxone programs may be impacting overdoses. In May, the state dramatically increased availability of naloxone. Discouraging to see higher rates of overdose at the same time. 
      • Outreach model- the state is utilizing block grant to bill for community intervention. Providers in the past have not taken advantage of this, but COVID has shown a great need for this. Majority of services people are seeking are inpatient services. Developing a series of trainings to train providers on community outreach and recovery-oriented systems of care. 
      • Also, exploring how to target interventions to people using heroin and fentanyl. COVID’s biggest challenge is that organizations have closed parts of programs and are still hesitation to have people work in the community. This is leading to the state reinventing the Department of Human Services and how prevention services are provided. 
        • Also in early conversations with the Department of Mental Health (DMH) about COVID and suicide- very clear that African American community is disproportionately affected. Working to utilize community intervention models to address the triage of problems. Very recent conversations. 

Arizona: Facing a lot of the same barriers to accessing up to date data. From state statistics, saw a spike in overdoses in March. Based on internal data, it is hard to get the current trends. Suspect a data lag that is muddying the data.

  • The state has also worked to continue treatment for OUD via telehealth, and has received positive feedback that compliance is increasing. Have also added flexibility for telephonic telehealth reimbursement. These flexibilities may remain going forward. 
        • Crisis response system touches on OUD system, shoring that up working on grant funding, also working to extend to first responders and providers in the field, behavioral health toll to individuals caring for those who are most vulnerable. Strategies being considered: expanding peer support in ED, partnering with FQHCs to expand primary care resources for OUD treatment. Formed steering committee including providers, MCOs to discuss barriers and workforce needs and plugging in peers. 
          1. SUD integration in FQHCs is challenging but FQHCs are well poised to do that work. 
          2. Medicaid separate from state health department, for a lot of reasons, but causes a lot of data sharing difficulties. Can look at claims and encounter data but encountering data is harder to move on, especially under a rapidly changing situation. Hard to rely on quality. 
          3. Potential solutions: leverage academic connections

Virginia: Fatal and non-fatal overdoses also reported by health department, just got the report for July and seeing a continuous upward trend of fatalities, close to 1700 in 2020. Nonfatal overdoses for first quarter (Jan-March) higher than any quarter looking back to 2016. Rate of individuals presenting in ED increasing, but people are also avoiding ED’s. MCV said they have seen an increased in ED visits related to non-fatal overdoses. 

  • Strategies to address this: Flexibilities around service delivery and training. Funding around increasing training. Over 80 trainings (i.e. HepC treatment and SUD) since April, goal is to increase access to training.
  • Incurred but not reported: looked from July 2019-20, have not seen a decrease in claims for service delivery, projecting an increase based on IBNR methodology. In effect until end of emergency order. 
      • Pushback from providers for in person counselling? In the next phase, groups can resume for behavioral health and telephonic delivery. Borrowed a behavioral health decision tree from Hawaii to provide information about resuming groups- happy to share. 
        1. Allowing parity for payment was also significant for sustaining providers. 
      • Agency is supporting a variety of service modalities moving forward. Unclear about telephonic telemed permanency, a lot of services where it was required in person will be supported through telehealth moving forward. 
      • Behavioral health service administrator has provided resources for providers. Consulted with local provider to do a training about race-based trauma. Shared with CMS to see if they could use federal funding, and the state was denied but eventually, this was reversed.  
      • Have also brought on a peer recovery specialist who worked at an FQHC, to figure out how to incorporate peers into EDs and all levels of care. 
    • Working with OTPs and OBOTs to explore virtual bridge model if someone presents to ED to be linked to virtual provider for induction on MOUD. Have a meeting in September to see if this would be possible 
  • Mobile clinic model in SWVA where broadband has been a challenge. Would be operated by provider (i.e. FQHC). Working with MCO to figure out billing component. 
  1. Closing remarks (2:55 – 3:00)
    • Next meeting: scheduled for September 3rd. For the next agenda, NASHP will dedicate a bit of time to discuss expanding group to include more folks. 

How States Implement Telehealth during COVID-19 to Treat Opioid Use Disorder

Before the onset of the COVID-19 pandemic, all 50 states offered at least partial coverage of telehealth services through their Medicaid fee-for-service programs. Medicaid managed care plans had increased their use of telehealth services, but coverage varied significantly across (and sometimes within) states. 

Reimbursing telehealth services at in-person rates. Parity in payment for telehealth services and in-person services is also inconsistent across states, though COVID-19 has provided an impetus for states to change this policy. 

Recently, California expedited legislation that required payment parity for telehealth services within both Medicaid and commercial insurance. The law requires contracts between health plans and providers to specify that a provider will be reimbursed for diagnosing, treating, or consulting via telehealth on the same basis as the provider would be for providing the same service in-person. 

The law was written to go into effect in January 2021, but in light of the pandemic, the state released an All Plan Letter on March 18, 2020, directing all state-regulated health plans, including Medicaid managed care plans, to reimburse providers at the same rate effective immediately, whether a service is provided in-person or through telehealth, including via telephone. 

Earlier this year, the Washington state legislature passed SB 5385, which would ensure payment parity beginning in January 2021 by requiring  health carriers to reimburse providers for the provision of health care services via telehealth at the same rate as they would for the provision of the same services in-person. In response to the emergency presented by COVID-19, however, Gov. Jay Inslee issued a proclamation implementing the bill in February 2020, establishing payment parity throughout the duration of the state of emergency.

Since the pandemic began, many states have instituted policy changes to incentivize providers to use telehealth, including temporary payment parity for those services. This interactive map and chart illustrates which states have implemented telehealth payment parity during the COVID-19 pandemic, as well as those states that had payment parity previously.

Providing billing guidance. Clear and complete Medicaid telehealth billing and reimbursement guidance has become increasingly important since the pandemic began, especially for services that have historically only been provided in face-to-face settings. While federal agencies have provided parameters for telehealth platforms, privacy provisions, and specific prescribing needs for OUD treatment in response to COVID-19, state Medicaid agencies have worked quickly to ensure that network providers have the information and resources to correctly bill for the services they provide. This 50-state chart – States that Provide Payment Parity for Telehealth and In-Person Care linkhighlights the most up-to-date COVID-19 telehealth guidance documents from each state. These documents include information about:

  • Which services can be provided via telehealth;
  • Which providers can provide these services; and
  • How to bill for these services.

Maine has issued comprehensive guidelines that cover all issues relate to telehealth during COVID-19. In addition to offering billing guidance, the document provides direction about prior authorization requirements, the prescription of controlled substances, behavioral health services, and other resources for providers. 

Oregon has published a COVID-19 Provider Guide, which includes guidance with respect to fee-for-service telehealth reimbursement, covered services, a coding chart, coverage criteria, security and privacy requirements, and documentation. 

Building telehealth infrastructure. Providing appropriate resources can support provider uptake of telehealth. With the increased demand for telehealth services, states are finding innovative ways to support their providers in connecting with their patients to ensure that patients have access to necessary services and supports. 

The Washington Health Care Authority purchased Zoom licenses for certain providers to deliver telehealth services. Licenses were apportioned to providers who:

  • Provide primary care services;
  • Serve a significant Medicaid population
  • And/or children, adolescents, pregnant or parenting women, or tribal members;
  • Do not have access to legally-compliant video technology; and
  • Are OTPs or otherwise prescribe medication-assisted treatment for OUD (MOUD). 

NASHP’s April 2020 blog, States Rapidly Build their Telehealth Capacity to Deliver Opioid Use Disorder Treatment, offers additional insight into innovative state efforts to leverage telehealth.

States that Provide Payment Parity for Telehealth and In-Person Care

Since COVID-19’s outbreak, many states have instituted policy and reimbursement changes to encourage providers to use telehealth, including mandating temporary payment parity for those services. This map and chart show which states mandated telehealth payment parity before and during the COVID-19 pandemic.

Legend: 

Purple – State requires telehealth payment parity from all insurers.

Green- State Medicaid program requires telehealth payment parity.

How States Are Revising Regulations for More Program Flexibility

During the COVID-19 pandemic, several states have revised guidelines that regulate harm reduction practices and syringe services to increase their reach and effectiveness:

  • In March 2020, Maine’s governor signed an executive order temporarily suspending some restrictions on the state’s syringe exchange programs. One-to-one needle exchange requirements were lifted and program limitations on location and hours of operation were suspended during the pandemic. 
  • The Oregon Health Authority released guidance for harm reduction and syringe services programs to support community-based efforts during the pandemic. Its guidance includes suggestions for creating roles for volunteers to continue to provide services during the pandemic and recommendations for messaging to clients. 
  • Prevent Overdose Rhode Island – an initiative of Gov. Gina Raimondo’s Overdose Prevention and Intervention Task Force – released pandemic-specific harm reduction resources for individuals with OUD. The resources include information about peer recovery supports and information on how to access naloxone, sterile syringes, and fentanyl testing strips. 

How States Are Increasing Access to Naloxone

Many states are actively working to get more naloxone (the overdose reversal drug) out to both patients and community members during the pandemic. 

  • Maryland is providing free naloxone to patients in opioid treatment programs (OTPs). OTPs are able to request naloxone kits for high-need patients and are encouraged to educate patients about overdose risk. 
  • Similarly, Ohio is using State Opioid Response (SOR) funds to provide naloxone kits to OTPs, as well as programs operated by Harm Reduction Ohio. Ohio’s distribution of naloxone kits is in support of previously issued guidance approving extended take-home doses for methadone patients. These extended take-home methadone doses are designed to reduce the number of patients visiting OTPs during the pandemic, but Ohio also mandated that patients had to possess naloxone in order to to get the methadone take-home doses. 
  • New York State’s COVID-19 Guidance for Opioid Overdose Prevention Programs provides information on the administration and provision of naloxone in overdose prevention programs. Its guidance includes recommendations for the assembly of naloxone kits, including mandating that each kit include at least two doses of naloxone, but it allows programs to add more doses at their discretion. 

NASHP Blog: Q&A: How Medicaid Expansion Put Naloxone in the Hands of the People Who Needed It Most, August 2019

NASHP Q&A: A Deep Dive into New York’s Drug User Health Hubs with New York’s Allan Clear, May, 2020

Additional Harm Reduction Resources

The Harm Reduction Coalition’s COVID-19 Guidance for People Who Use Drugs and Harm Reduction Programs outlines recommendations for safer drug use, including overdose preparedness, and tips for programs to minimize the spread of COVID-19 while continuing to provide services.  

The American Medical Association developed policy recommendations to support harm reduction efforts in communities, including increasing access to sterile syringes, designating supplies provided by harm reduction programs as essential services, and campaigns to inform the public of the importance of naloxone. 

NASHP Report: Tackling the Trifecta: State Approaches to Addressing Co-Occurring Substance Use Disorders, HIV, and Hepatitis C, April 2020

Individuals Re-entering the Community

People with opioid use disorder (OUD) who are incarcerated are often abstinent from substances upon their release, though without evidence-based treatment, they are over 12-times more likely to die of an overdose within two weeks of release than the general population. Re-entry, from this lens, is itself a risk factor for people with OUD – and many jails and prisons are releasing individuals early due to the pandemic, increasing the urgency for people to receive evidence-based treatment while incarcerated. 

Criminal justice leaders are increasingly embracing models of treatment that include the provision of medications for opioid use disorder (MOUD) in incarceration settings, recognizing that treatment for individuals with OUD is effective and contributes to reductions in overdose deaths.

Additional Resources:

Foundation for Opioid Response Efforts and NASHP webinar: Correctional Facilities and MOUD During the COVID-19 Pandemic, April 2020. This webinar provides a look at the challenges of providing MOUD in incarcerated settings, as well as how the pandemic has affected incarceration-based programs and how state Medicaid programs can support them.

State Approaches to Supporting Postpartum Women

Some states have worked to extend Medicaid coverage to postpartum women for other conditions. 

  • Missouri attempted to extend Medicaid coverage for postpartum women seeking opioid treatment services, but the proposed legislation failed to pass.

  • South Carolina submitted a Section 1115 waiver seeking to encourage new mothers to return to the workforce by extending Medicaid coverage for pregnant women from 60 days postpartum to one year after birth. Similarly, Illinois is seeking to extend coverage through an 1115 waiver for its new mothers from 60 days postpartum to one year after birth.

  • In response to COVID-19, Nebraska is allowing pregnant women to maintain continuous Medicaid eligibility through the post-partum period via a prenatal benefit, regardless of eligibility category at the beginning of pregnancy.

  • Throughout the pandemic, all opioid treatment programs (OTPs) in Colorado have continued accepting new patients – in fact, the state has opened an additional four OTPs during this time. Colorado providers have also been providing curbside MOUD dosing for individuals with dependent children or who those are symptomatic.

Additional Resources

This continually expanding list of resources are designed to help policymakers design initiatives to support pregnant and parenting women with opioid and substance use disorders.

  • Foundation for Opioid Response Efforts webinar: Caring for Pregnant and Parenting Women with OUD during the COVID-19 Pandemic, April 2020. This webinar focuses on both policy and practice elements to ensure the provision of evidence-based treatment for pregnant and parenting women during the pandemic.

  • New Jersey developed a COVID-19 webinar series to support providers serving pregnant and parenting women with substance use and mental health disorders. Topics include:
    • Maternal Child Health and OUD: Alternative Ways to Manage Patient Care/Ask Our Pediatricians – Q&A on COVID-19 in Infants and Children
    • Maternal Child Health and OUD: NJ Perinatal Care during COVID-19
    • Maternal Child Health and OUD: Adapting Delivery of Care

Webinars are still ongoing. All presentations have been archived, along with supplementary materials and the contact information of presenters, and are accessible to anyone seeking guidance in providing care to the postpartum population. For more information on New Jersey’s initiative , read NASHP’s recent blog, New Jersey’s Project ECHO Builds Provider Capacity to Support Maternal and Child Health during COVID-19

New Jersey has also added a COVID-19 field to its prenatal risk assessment forms.

Individuals Experiencing Homelessnes

Opioid use disorder (OUD) and homelessness are mutually reinforcing. Underlying risk factors for homelessness can be aggravated by OUD, while people with OUD who lack stable housing have unique barriers to maintaining recovery, including lack of access to transportation to treatment, difficulty receiving and storing medications, and inconsistent social supports. 

People with OUD who are experiencing housing instability or homelessness are particularly at risk during the COVID-19 pandemic, leaving states challenged more than ever to identify effective housing strategies that can simultaneously address the complex treatment needs of people with SUD while also curbing the spread of COVID-19 in congregate settings. 

NASHP Blog: States Craft Collaborative Approaches to House the Homeless and Curb COVID-19, July 2020. This blog explores the collaborative strategies states are taking during the pandemic to protect and support particularly at-risk individuals.

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