The National Academy for State Health Policy (NASHP) recently spoke to Robert Hansen, executive director of West Virginia’s Office of Drug Control Policy, to learn how the state is expanding opioid use disorder (OUD) treatment access and capacity through strategic partnerships that support its Substance Use Response Plan’s goals.
West Virginia has made expanding access to medications for opioid use disorder (MOUD) a priority. How are you doing this?
In an experiment, conducted by the West Virginia Drug Intervention Institute at the University of Charleston, to locate a treatment provider willing to accept a new patient immediately, we found that access was dismal – no messages or voicemail and no appointments available until seven to ten days, or three weeks, or a month down the road. If you look at a listing in Kanawha County, you’ll see a lot of providers and you might assume that means a lot of treatment. But can you get in when you need help? West Virginia has had a growth in medically assisted treatment availability throughout the state. At last look, we have had a 59 percent increase in the number of waivered providers, but access is still an issue. Our state is very rural and most providers are available 9 to 5, Monday through Friday.
If we know anything about substance use disorder (SUD), we know people need access to treatment as quickly as possible. So, how do you do that in a state with many transportation challenges? West Virginia is tackling access issues by working with Bright Heart Health, which is helping the state expand MOUD availability. This national, for-profit organization specializes in using telehealth to provide round-the-clock treatment as well as rapid access to virtual assessment, enrollment, and crisis intervention. Through this partnership, people living in West Virginia can access care and treatment when they need it and regardless of where they are located, so long as they have access to a phone, tablet, or computer, and a reliable internet connection.
You’ve indicated that West Virginia’s expansion of Medicaid has been crucial in facilitating access to treatment in the state, how is Medicaid supporting this particular partnership?
Medicaid is very central to paying for ongoing services. We have three managed care companies that were just re-awarded contracts to work with our bureau of medical services. All three of them were able to fast track BHH’s application and enrollment, ensuring that these services could be implemented for Medicaid coverage quickly. Sometimes credentialing gets very bogged down, but I think all three companies in West Virginia have embraced this concept and this company.”
How have the state’s emergency departments supported access to OUD treatment? Is COVID-19 a factor?
Increasing access to treatment has to be a goal for addressing not only the COVID pandemic, but the opioid epidemic. We have several emergency rooms in our state that were [providing buprenorphine] before COVID, and that’s why we’ve made it a big initiative and worked with Mosaic to build out assessment, identification, and linkage to SUD services. Mosaic’s approach is multifaceted and involves working with ERs to screen all patients for SUD and develop clinical pathways to address individuals’ treatment needs, including incorporating peer recovery coaches into ER settings in order to fast-track people into treatment. There’s still stigma within the medical community, as there is in the community at large. I think that we lost momentum in [some of our initiatives] since mid-March, and now we’ve got to pick it back up.
How will West Virginia ensure that individuals remain engaged in treatment once they have been linked to treatment?
We are working on measuring [treatment] retention and continuous engagement, and I think we’re making strides – but, we have a long way to go. [Soon], as part of the Shatterproof ATLAS pilot initiative, we plan to go live with a webpage about West Virginia’s providers and how well they’re doing in delivering services according to Shatterproof’s National Principles of Care for addiction treatment. Through this pilot, West Virginia will be working with Shatterproof’s data partner to review Medicaid claims data and determine how providers are performing on a variety of key indicators, including treatment retention. These data will be available to state officials, as well as to managed care companies and individual providers.
How will West Virginia measure the effectiveness of these initiatives?
There are two big benchmarks that I live and die by – one is the number of overdose fatalities and two is the number of suspected overdose incidents. If you look at the national CDC (Centers for Disease Control and Prevention Centers) data on West Virginia fatalities, our rate per 100,000 is so much higher than the national average. [These projects] are just starting to hit the ground in West Virginia, and it’s going to be an evolutionary process, but the more individuals [we] engage, the better.
This blog is funded through a two-year grant awarded by the Foundation for Opioid Response Efforts (FORE). NASHP would like to thank Catherine Dunne, court accounts and special projects manager with Bright Heart Health, for her valuable contributions.
During the COVID-19 pandemic, the opioid epidemic has quietly raged on, requiring states to fight a costly, two-front war. While states have rallied to ensure that opioid use disorder (OUD) treatment remains accessible, organizational and workforce challenges persist and the resources and revenue needed to address them are rapidly changing.
Gaps in treatment infrastructure and behavioral health workforce shortages have historically challenged states’ OUD treatment delivery. In the midst of the pandemic, states are optimizing current flexibility and supports for their behavioral health workforces to help maintain treatment access during the COVID-19 pandemic, while also monitoring how or whether these new strategies will be maintained in the future.
Here are some approaches states are taking to increase access to treatment and address workforce shortages by expanding job descriptions, offering flexible training, and changing licensing requirements:
Modifying licensure requirements. Licensing requirements for providers vary significantly by state, creating barriers for out-of-state practitioners to providing services across state lines. Expanding out-of-state license recognition and preventing licensure lapses can help ensure and expand access to treatment, promote adoption of telehealth services, and address provider shortages.
- New Hampshire, New York, and Pennsylvania have all expanded the ability of out-of-state providers to deliver services within their states through executive orders. New Hampshire allows out-of-state providers to deliver medically necessary services both in person and via telehealth. Similarly, Pennsylvania has issued temporary licenses for out-of-state medical providers and has expedited issuance of temporary licensing. New York has allowed providers licensed in other states and Canada to practice in the state without penalty due to lack of licensure.
- States may also consider delaying the expiration of provider licenses during the pandemic to remove any potential barriers providers may have to delivering services. Following an executive order that extended license expiration dates across provider types, Maryland’s Behavioral Health Administration (BHA) released guidance on licensure extension and new licensure processing specific to behavioral health providers. Professional licenses that would have expired during the period of the current emergency will be extended for 30 days after the emergency order is lifted, though the BHA continues to process licensure and re-licensure applications that are mailed or submitted electronically.
Leveraging licensed providers. As states face workforce shortages that are amplified by COVID-19, officials may find opportunities to leverage licensed providers in unique capacities, particularly in the provision of OUD treatments.
- In Massachusetts, under order of the commissioner of public health, pharmacists may now administer medications for opioid use disorder (MOUD) in clinical settings, a policy shift designed to allow nursing staff who ordinarily handle such responsibilities to be reassigned to treat COVID-19 patients.
- The Ohio’s Board of Pharmacy has adopted temporary regulatory guidance to allow authorized prescribers in opioid treatment programs (OTP) to delegate buprenorphine administration to registered nurses (RNs) and licensed practical nurses (LPNs).
Providing buprenorphine waiver trainings. States have been working to encourage and train providers to become “waivered” or licensed to prescribe buprenorphine long before this pandemic began, and several organizations are now taking advantage of increased flexibility in provider schedules to provide training. Anticipating that overdoses may increase during the pandemic, states can encourage provider engagement with these and similar programs to grow their waivered workforce.
- California Bridge, a program supported in part by the California Department of Health Care Services (DHCS), is offering free online buprenorphine trainings that emphasize the immediate needs of vulnerable individuals during COVID-19.
- Get Waivered, a non-profit program promoting and providing emergency department (ED) provider training, is offering a “Get Waivered Remote” training aimed at ED providers and medical students, recognizing that with clinics operating at limited capacity during the COVID-19 pandemic, EDs may become a more necessary point of care for people with OUD. This training is free and fully remote.
Supporting behavioral health workforces. As with other frontline workers, behavioral health staff working in residential care, institutional settings, and in direct contact with patients are experiencing significant stress working during the pandemic. To support staff without creating new programs and resulting budget demands, states may consider developing resources to support the mental health needs of both licensed and unlicensed workforces.
- The Interim COVID-19 Guidance to Providers and Stakeholders for Behavioral Health and Homelessness Services from the Hawaii Department of Health includes specific burnout prevention and self-care strategies for providers to reduce secondary trauma and help monitor workload and stress.
- Through support provided by the Washington State Health Care Authority and the Division of Behavioral Health and Recovery, the Washington Council for Behavioral Health has developed BH Providers Connect, a listserv for behavioral health providers to connect and support one another through the COVID-19 pandemic.
- As part of their COVID-19 response, Michigan has released “Supporting Emotional Health of the Behavioral Health Care Workforce during COVID-19,” a guide that outlines self-care strategies, resources for providers and their families, and stress management techniques. Additionally, in response to the heightened stresses on long-term substance use disorder recovery, Michigan has also developed guidance on supporting peers during this pandemic.
While these steps in response to COVID-19 are designed to address concerns about treatment access during the pandemic – sometimes, explicitly – policymakers are also considering the long-term service and budget implications of these changes. In a time of historically reduced state revenues, leaders will be considering how policy shifts and adjustments made during this pandemic can or should be adapted for the post-pandemic treatment of OUD, with likely fewer resources to do so.