Among the many issues confronting new state governors and their administrations, the opioid crisis may be one of the most urgent and complex, and may leave the most devastating legacy. Opioids kill 130 Americans every day. For state policy makers, the ripple effect of the crisis reaches beyond health care systems to impact public safety and corrections, child protective services, and other state agencies and functions.
As part of National Academy for State Health Policy’s (NASHP) work under a National Organizations of State and Local Officials cooperative agreement with the Health Resources and Services Administration, NASHP officials met with policy makers from a dozen states to talk about their challenges and most promising policy strategies to tackle the opioid crisis.
The group discussed and evaluated a range of policy approaches involving Medicaid, behavioral and public health departments, and governors’ offices. State leaders are on the front lines of the opioid crisis, and while the challenges and complexity of this work can be staggering, states generally share a few common goals: prevent addiction, stop people from dying, and get people into treatment.
With those common goals in mind, NASHP identified a few key strategies from the field that are showing results:
- Track opioid prescribing: While the majority of states now have prescription drug monitoring programs (PDMPs), Florida was one of the first states to establish a PDMP. Since establishing its program in 2009 (and continuously refining it over the last decade), Florida has achieved a 69.3 percent decrease in the number of individuals having “multiple prescriber episodes” – doctor-shopping for multiple opioid prescriptions. Florida also recently implemented one of the country’s strictest limits on opioid prescribing. Legislation passed in 2018 restricts opioid prescriptions to no more than a three-day supply, with certain exceptions, such as for palliative care.
- Invest in harm reduction: In Massachusetts, the Department of Health launched an Overdose Education and Naloxone Distribution (OEND) program. The program has trained more than 64,000 people to administer naloxone, invested in training for first responders, provided naloxone doses to community health centers, and participated in a bulk-purchasing program allowing communities to purchase naloxone at a significant discount. The program reports that close to 11,922 overdose reversals had occurred through the use of OEND naloxone kits.
- Build capacity for medication-assisted treatment (MAT). MAT– an approach that includes both medication, counseling, and other supports — is an effective and evidence-based treatment for opioid addiction. However, states have struggled to build sufficient capacity for MAT to address the enormous need created by the opioid crisis. Virginia is addressing this challenge and is starting to see results: the state implemented its Addiction, Recovery, and Treatment Services program through an 1115 waiver. The state is investing in a comprehensive continuum of care that supports primary care practices and a range of other community providers to deliver office-based MAT. Since implementing these wide-ranging delivery system reforms in 2017, the state has seen treatment rates for individuals with opioid disorders increase by more than 70 percent.
- Engage corrections: The first two weeks after release from a corrections facility can be one of the most lethal periods of time for individuals with opioid use disorder (OUD). States can take a number of steps to target and assist this high-risk population:
- Rhode Island offers MAT to inmates statewide. The program, which also includes linkages to continued treatment following release, has shown promising results. A recent study in the Journal of the American Medical Association reported a 60 percent reduction in post-incarceration, opioid-related deaths after the program was implemented.
- Although individuals are not permitted to receive Medicaid benefits while incarcerated, the Medicaid enrollment process can get started before their release. NASHP’s State Strategies to Enroll Justice-Involved Individuals in Health Coverage provides examples and resources for states to maximize Medicaid enrollment and link people to services as they leave corrections settings.
- Ensure access in rural areas: Access to addiction treatment in hard-hit, rural areas is especially challenging. Overcoming transportation barriers, attracting and supporting specialists, and combatting the stigma associated with accessing (and delivering) services, such as methadone treatment in smaller, more rural communities can be difficult. States are seeing success using the Project Echo model to help providers develop the capacity to deliver treatment. This model links clinical specialists with practitioners in rural areas, facilitating long-distance learning and peer-to-peer mentoring. New Mexico has used the Project Echo model for substance use disorder (SUD) since 2005, and ranks fourth in the country in the number of providers able to deliver MAT services, in spite of its ranking as one of the most rural states in the country.
- Expand Medicaid: States that have not expanded Medicaid may be missing an important policy lever to support access to SUD treatment. Recent research found that states that expanded Medicaid saw a significant increase in prescriptions used to treat opioid disorders. Prescriptions for opioids themselves experienced only a modest increase compared to other medications in those .
These strategies represent just a few of the many state innovations happening across the country as health policy makers confront the opioid epidemic. NASHP is continuing to work closely with states to support their opioid epidemic responses and will share other lessons learned in the months ahead.