Opioid Use Disorder Project Phase 1 Results

Summary

The State of Ohio conducted an exploratory analytics study to better understand the relationships between opioid use, involvement in the criminal justice system, and the efficacy of various types of treatments. The agencies involved in this study include the Department of Rehabilitation of Correction (DRC), Department of Medicaid (ODM), Department of Health (ODH), Department of Mental Health and Addiction Services (OhioMHAS), Department of Job and Family Services (JFS), and Department of Pharmacy. The goal of this project was to provide State leaders with the data-driven insights across two key areas: 1) Who is at Risk? and, 2) What is Working?

Key Findings

• There is over a 20x higher prevalence of hepatitis in opioid-involved individuals.
• A higher prevalence of mental health conditions (anxiety, depression, psychotic disorders, etc.) are seen across both the opioid-involved and criminal-justice involved populations, with over 20% of the opioid-involved population suffering from depression.
• Methadone and buprenorphine treatments have significantly higher rates of adherence than naltrexone treatments.
• Utilizing psychosocial services in addition to MAT produces up to 50% higher rates of adherence 4 months into treatment.
• Initiating MAT within 1 month from an incarceration release improves adherence by up to 25% 4 months into treatment.
• Younger populations (19-26 years old) have lower rates of MAT adherence.

Project Summary

Opioid addiction is a crisis that continues to place stress on Federal, State, and Local government resources to fight the opioid and heroin epidemic. The goal of this project was to help understand the precursors and risks of opioid involvement and drive better outcomes for impacted individuals within the State’s criminal justice system.

Near Term State Outcomes:

• Determining gaps in diagnosis, treatment, social supports, and care management for individuals with opioid involvement that could present opportunities for State agencies to better support;
• Identifying opportunities for agencies to share information regarding individuals with opioid involvement to better connect them to needed care and services along their care continuum;
• Identifying effective strategies to better provide health care and enlist the support of other groups and other social support methods for people with opioid involvement while modifying or eliminating unnecessary or ineffective programs or services.

Long Term State Outcomes:

• Improved efficacy of and access to opioid use disorder treatment for those individuals with exposure to the criminal justice system, those recently released from incarceration, and those likely to enter the incarcerated population;
• Identifying indicators and precursors to the “first incarceration” that support the prevention of first and repeated opioid use as well as identifying solutions for those individuals;
• Identifying any differences between criminal justice and non-criminal justice populations to provide opportunities to examine this category of Medicaid spending, and to identify opportunities to improve care for people with opioid involvement in the criminal justice system;
• Reducing criminal justice involvement for individuals with opioid involvement;
• Reducing overdose rates for individuals with opioid involvement.

Using evidence and data-driven insights, the ultimate goal of this project was to empower the State to better understand:

• The profiles of individuals with opioid and criminal justice involvement;
• The risk factors for different profile types; and
• The treatments and interventions for the different profile types where the data suggests there is a higher probability of success.

Data Used in the Analysis

The analysis utilized 20 different datasets from six State agencies, including, DRC, ODM, ODH, OhioMHAS, JFS, and Pharmacy. Within these datasets, an identified population of over 5 million individuals who had an interaction with at least one State system over the course of the last several decades were identified. All data was de-identified by the InnovateOhio Platform (IOP) team and only a subject’s token value, first three digits of their zip code, and year of birth were applied. Four outcomes of interest were analyzed- opioid involvement, overdose, overdose death, and criminal justice involvement.

Analysis: What is working?

Medication-Assisted Treatment (MAT) consists of medication and psychosocial treatment intended to help patients stop abusing opioids. Opioid receptor agonist and partial agonist medications, such as methadone and buprenorphine, provide a “maintenance dose” of opioids, allowing a patient to avoid withdrawal symptoms and pursue a healthy lifestyle without opioid cravings leading to relapse. Adherence to MAT medications is associated with better outcomes for patients: fewer overdoses, less medical cost to the system.

Based on the research conducted,

• Methadone treatments had the highest adherence, followed by buprenorphine; naltrexone treatments resulted in the lowest adherence;
• Women had slightly better adherence outcomes than men, especially over a long period of time; older people had better adherence than younger people;
• People with no mental health conditions had better adherence than people with mental health comorbidities, especially schizophrenia and personality disorders. The cohort with any contact with psychosocial services (70% of the studied population) showed better MAT adherence than the cohort who did not receive any psychosocial treatment.

OhioMHAS and DRC provide a variety of alcohol and other drugs (AOD) treatment services in Ohio prisons, where incarcerated individuals have the ability to voluntarily participate in treatment services. To analyze these services, a dataset of participants in each prison based AOD program was examined over a three-year outlook for the cohort of individuals released in 2015.  Results show that those individuals who stayed in the program through successful completion had lower rates of both nonfatal overdoses and deaths over a 3-year period.

Tableau Dashboards: Driving progress through visualizations

The three finalized dashboards that were created for this project visualized information related to risk factors, treatment efficacy and outcomes, and geographic variation in population-level risk.

• Risk Factors Dashboard: Built to allow for researchers to study risk factors that are highly correlated and prevalent for various populations such as the opioid involved or people experiencing nonlethal overdose.  These risk factors were grouped by category, including social determinants, prescription factors, health conditions, and mental health conditions;
• Treatments and Outcomes Dashboard: Built to allow researchers to explore adherence to MAT for subpopulations stratified by demographic or domain specific characteristics like time to MAT initiation from prison release while comparing outcomes for each MAT;
• Geographic Risk Dashboard: Built to allow researchers to identify geographic regions with high opioid involvement (OI) risk, poor access to treatment, or high prevalence of conditions correlated with OI to improve quality of strategic and programmatic planning.

Overall, stakeholders felt that the dashboards were further demonstration of the value created by sharing data across agencies in the Cloudera environment on IOP. By continuing this process, protocols can then be established to persist data in the Cloudera environment on that is necessary to operationalize these dashboards as true, real-time tools for research and decision-making.

Policy Considerations: A call to action

Further evaluate targeted programs designed to prevent the spread of viral hepatitis.

• Hepatitis C, contracted through needle sharing, is a known heroin use comorbidity. There were over 8,200 new cases every year between 2014-2018 and the average cost to the State for treatment is approximately $84,000.

• The State has an opportunity to continue to identify the highest risk populations and geographical locations prone to contracting Hepatitis C. Through these new insights, the State could identify targeted programs to improve treatment efforts and eliminate the disease in those most at-risk groups and locations.

Identify ways to improve the access to MAT treatments for at-risk individuals.

• Methadone treatments have significantly higher rates of adherence among the available MAT types. Four months into treatment, methadone patients were 1.5x more adherent than buprenorphine patients and 3x more adherent than naltrexone patients.
• While these are the most effective, certain at-risk individuals do not receive treatment because of their proximity to facilities in rural areas and lack access to insurance in certain populations.
• The State has already identified this issue and is making strides to address it. Through federal grants, MAT is becoming more widely available and a greater emphasis is being placed on service integration between physician, emergency, behavioral healthcare, criminal justice, and child welfare. The Screening, Brief Intervention and Referral to Treatment (SBIRT) program is designed to provide earlier intervention and Project ECHO to expand treatment capacity and training among physicians.
• The State should build on these initiatives and evaluate the number and proximity of the facilities administering treatments across the State to further improve access for high-risk individuals. Governor DeWine created a specialty court docket that enables those charged with a drug violation to get treatment instead of serving jailtime. OhioMHAS will target an additional $7.5 million, for a total of $17.5 million in FY 20-21, towards maintaining current court supports and expanding specialty docket access to more communities. DeWine committed to adding 30 of these specialty dockets over the first 2 years of his administration. In FY 18, over 6,300 adult offenders, adults and children were served through specialized dockets involved in OhioMHAS’ subsidy program. Ninety-seven percent of adults successfully completed the program, meaning that only 87 of the 2,900 adults discharged from these programs were committed to the Ohio Department of Rehabilitation and Correction. Through the drug court programs, 50 children were reunified with 62 participants discharged from family drug courts.

Identify approaches to expand psychosocial treatment for opioid-involved individuals.

• Utilizing psychosocial services (individual or group therapy, counseling, etc.) in addition to MAT produced up to a 50% higher rate of adherence among opioid-involved individuals 4 months into treatment. The State could focus integrated health services for those individuals most in need of mental health and addiction services.
• MAT allows for opioid-involved individuals to re-take charge of their lives, by participating in day-to-day tasks like picking up their kids from school, going to work, and even something as small as shoveling their sidewalks. By becoming active members of their community, they are able to rebuild their families and no longer be a burden to society. If people can stay off of drugs and out of prison, we have a cost avoidance. The results of OUD Phase 1 allow agencies to re-allocate resources towards something more evidence based.
• OhioMHAS has staff in every prison treating OI individuals before their release.
• OhioMHAS created a fentanyl awareness campaign with ODH to raise overdose awareness. This ODH opioid stigma campaign reached out to doctors to get them involved in full aspect of care, from diagnoses all the way through treatment. OhioMHAS contributes funding for training these doctors.

Identify opportunities to accelerate access to MAT treatment for the criminal justice involved population.

• Initiating MAT within 1 month from being released from prison improves adherence by up to 25%. Pre-release enrollment in Medicaid allows for a seamless transition to community living and eliminates gaps in healthcare coverage, allowing for greater adherence to medications and other treatments for chronic health conditions that may create more harm and higher costs if not addressed. This process creates a continuum of healthcare within the criminal justice system in Ohio by connecting inmates to appropriate medical, mental health, and substance use services, which in turn has the potential to reduce recidivism, improve public health, and make communities safer.
• Ohio is currently making efforts to offer MAT to the criminal justice involved population. DRC and OhioMHAS have jointly implemented a treatment program for inmate utilizing Vivitrol (injectable naltrexone) because of its lower risk of diversion among incarcerated populations. Inmates currently receive the first two injections prior to release, and a post-release injection is scheduled by the inmate’s Managed Care Plan, and information regarding this is provided to the inmate.
  • A joint evaluation by ODM, OhioMHAS, and DRC is investigating the outcomes among participants relative to those who opt out of treatment and a control group, including emergency department visits, hospitalizations, overdoses, adherence to first appointment in the community after release, arrests under supervision, positive urinalysis, and recidivism.
  • Agencies are working with pharmacies to see them as providers, so they can do some of the care traditional providers would be able to do, because they are more accessible and become another healthcare face in local communities.
• After prison, OhioMHAS also supports citizens returning to the community after incarceration in state prisons through programming designed to help people achieve their recovery goals in prison and continue that success as they transition back into the community. This programming connects people who have received addiction treatment in prison with a transitional benefit for drug and alcohol treatment and assistance with recovery support services such as housing, transportation, work and education upon their release. The goal is to help individuals avoid relapse upon release, which is often a stressful time of transition. The Investing in Ohio’s Future Budget provides funding in the amount of $6 million per year to support these services.
• As agencies get more opioid-involved parents recovered, there are more kids in the foster system for longer periods of time. Because parents can’t recover in a short enough time in order to get their kids back, the same kids are in the system for a long time. If these parents can recover more quickly, they will be able to rejoin as a family sooner, and these children will no longer be in the system, lessening the emotional toll on the children and the financial toll on the system.

Identify approaches to mitigate risk of recidivism for young adults with history of drug abuse.

• Young adults, ages 19-26 years old, exiting prison incarceration are less adherent to MAT compared to older age groups. The State could benefit from identifying programs and treatment modalities that are tailored to the needs of young adults.
• Across the country, some states have implemented specialized prison-based programs for the young adult population.  These programs provide specialized case managers, behavior and coping skills training, educational curriculums, and socialization skills. In Ohio, DRC recently obtained a $750,000 grant from the Bureau of Justice Assistance to target moderate to high risk young adults 18-24 years old. In this pilot, staff are trained in trauma-informed approaches and motivational interviewing and perform an in-reach prior to the young adults’ release from prison. It provides employment in community through the Center for Employment Opportunities which includes daily pay, soft skills, and career coaching, and the young adults participate in cognitive behavioral programming.
• Medicaid is using data from this project to establish policies with Managed Care Plans to make sure that before release individuals can get on a treatment plan that works for them. Instead of solely taking someone’s word that Managed Care Plans are working, Medicaid is tying evidence-based information to the treatment options laid out in these plans. In the past, inconsistencies in plans have given inconsistent results, but now that there is evidence into the choices, Medicaid is paying for what works based on evidence.
• Arno Ventures has provided substantial funding to shape Centers for Excellence by partnering with OhioMHAS and ODM to help opioid treatment centers build better businesses. These centers will help share information around the region and will provide funding to agencies to continue research in the opioid use disorder field and build these centers.