response to the opioid crisis Dissemination & Implementation - - PowerPoint PPT Presentation

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response to the opioid crisis Dissemination & Implementation - - PowerPoint PPT Presentation

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Indianas policy & programmatic response to the opioid crisis Dissemination & Implementation 2017 ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org Portfolio of Indiana opioid studies 1. Indiana naloxone access

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Indiana’s policy & programmatic response to the opioid crisis

Dissemination & Implementation 2017

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Portfolio of Indiana opioid studies

  • 1. Indiana naloxone access and Good Samaritan

laws (CDC Award# 1U17CE002721)

  • 2. Medication assisted treatment (MAT) expansion

in two Indiana counties (SAMHSA Award# 1H79TI026149)

  • 3. Emergency department-based overdose

prevention program (Richard M. Fairbanks Foundation & NIDA Award# 1R21DA045850)

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Defining the external implementation context

  • Prior work has demonstrated less

attention to external factors in implementation work (Clinton-McHarg et al. 2016; Lewis et al., 2015)

  • Existing implementation frameworks

good start, but rooted in theory (e.g., Damschroder et al. 2009, Aarons, et al. 2011)

  • Systematic integrative review

conducted to develop external constructs based on empirical

  • bservation
  • Data collection July 2014-July 2015

Watson, DP, Adams, EL, Shue, S, Coates, H, McGuire, A, Chesher, J, Jackson, J, & Omenka, Isaac. (revise & resubmit). The external implementation context: an integrative systematic literature review. BMC Health Services Research.

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Formal or informal norms, rules, policies, or standards guiding the professions or professionalization of individuals involved in the implementation.

1

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Extent of backing from public officials or special interest groups.

2

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Beliefs, values, customs, and practices of the larger community and/or system within which the intervention is embedded.

3

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Physical, technical, service, and training structures or resources existing in the community or larger system in which the intervention is embedded.

4

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Formal national, state, community, or system regulations (rules, policies, laws) impacting the intervention.

5

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Degree and quality of relationship the

  • rganization has with

partner organizations and regulating agencies key to intervention delivery.

6

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Characteristics associated with individuals the intervention was designed to impact including population needs, culture, beliefs, preferences, locatability, ability to access, and motivation to engage.

7

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The character of the national, regional, or local economy and availability of funding as related to the intervention.

8

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Table 2. Comparison of constructs evidenced through literature review with external factor constructs in existing frameworks Consolidate Framework for Implementation Research (CFIR) Exploration, Preparation, Implementation, Sustainment (EPIS)* Multi-level framework (MLF) predicting implementation outcomes Professional influences

  • Interorganizational

networks

  • Political support
  • Sociopolitical; Client

advocacy Political or social climate Social climate

  • Political or social climate

Local infrastructure

  • Infrastructure

Policy & legal climate External policies and incentives

  • Public policies

Relational climate Cosmopolitanism Interorganizational networks

  • Target population

Patient needs and resources Client advocacy

  • Economic & funding

climate

  • Funding

Economic climate No directly comparable construct Peer pressure Intervention developers; Leadership Physical environment “--“ = No directly comparable construct *Only the active implementation phase of the EPIS framework is considered here since this was the focus

  • f the current literature review.
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References

Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health Ment Health Serv Res. 2011;38:4–23. Clinton-McHarg T, Yoong SL, Tzelepis F, Regan T, Fielding A, Skelton E, et al. Psychometric properties of implementation measures for public health and community settings and mapping of constructs against the Consolidated Framework for Implementation Research: a systematic review. Implement Sci. 2016;11:148. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation

  • science. Implement Sci. 2009;4:50.

Lewis CC, Stanick CF, Martinez RG, Weiner BJ, Kim M, Barwick M, et al. The Society for Implementation Research Collaboration Instrument Review Project: a methodology to promote rigorous evaluation. Implement Sci. 2015;10:2.

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Regulations to expand naloxone access and use: Citizens’ understanding as a barrier to adoption Dennis P. Watson, Bradley Ray, Lisa Robison, Philip Huynh, & Joan Duwve

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The project

  • Centers for Disease Control and Prevention

(CDC)

– Prevention for States program (Award# 1U17CE002721). – Purpose: provide resources and support needed to advance interventions for drug overdose prevention.

  • Partners

– Indiana State Department of Health – Indiana Professional Licensing Agency

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Policy evaluation activities

  • SEA 246 (2013)
  • Establishes prescribing rules
  • Pain clinics must have controlled substance

registration

  • SEA 227 (2014)
  • First responder naloxone administration
  • SEA 406 (2015)/Aaron’s Law
  • Naloxone prescribed as part of addiction treatment
  • Lay responder naloxone administration
  • Naloxone standing orders
  • Criminal and civil liability protections
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Evaluation Approach

  • Focusing on Good Samaritan

component of the law

  • Context = Distribution of

naloxone at local health departments

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Methods

Postcard survey Structured phone interviews

Began in September 2016

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Postcard response

  • 10,972 Kits provided to 37 counties through RFP

process

  • Pre-use response by type (n = 1,793 from 28

counties)

  • 34% lay responders
  • 38% health professionals
  • 27% other/can’t identify
  • Post-use response by type (n = 94 from 10

counties)

  • 25% lay responder
  • 38% health professional
  • 37% other/can’t identify
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Pre-use postcard responses (n = 1793)

  • Awareness of law

= 2.4 times more likely to call police (p < .001)

  • 33% of those

who did not call 911 worried about police

  • Post-use cards

show similar trends, with even greater percentage (43%) worried about police.

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Interview respondent discussions

  • f police interaction (n = 5)

I think that’s why we lose too many people, because of the fear. Just being afraid to go to jail and you know generally there’s always drugs, things, paraphernalia in the home…. I think for the most part, that stigma stands and they [law enforcement officials] feel like addicts waste their time, you know, that they could be responding to something different. It’s taking time away from things that are more important.

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Clarity of the law

  • Search of online resources demonstrates poor

information about law

  • Follow-up discussions with key stakeholders

demonstrate

– No clear understanding of criminal liability protections – Unwillingness of some local health department staff to give naloxone to lay responders because they think they won’t call 911

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State online resource excludes discussion of criminal protections

http://www.in.gov/dol/2907.htm

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Implications

  • High awareness of the Aaron’s Law and

respondent reports of calling 911 provide some indication of the laws effectiveness.

  • Lower awareness of law and lower reports of

calling 911 among lay professionals indicate public education could improve outcomes.

  • Work with communities to overcome fears of

police could improve 911 call rates.

  • Work with police to make sure they are

implementing the law correctly.

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Thank you!

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Expansion and Implementation of Medication Assisted Treatment (MAT) in Two Rural Communities

10th Annual Implementation and Dissemination Conference December 5, 2017 Brad Ray, PhD, Johanne Eliacin, PhD, HSPP, Dennis P. Watson, PhD, Lisa Robison, MPH, & Phil Huynh, MPH

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MAT-PDOA Program

  • Medication Assisted

Treatment (MAT)-Prescription Drug and Opioid Addition (PDOA) program

  • IN Medication Assisted

Treatment Program (IMAP)

  • Aims to decrease barriers

between providers and individuals in rural communities in need of

  • pioid addiction treatment
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MAT-PDOA Program

  • Porter Starke Services (PSS)

– Porter, Stark, and LaPorte Counties

  • LifeSpring Health Systems (LSHS)

– Scott County

  • We were interested in

looking at how external factors impact implementation efforts

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Methods

  • Program implementation & sustainability

– Qualitative interviews with staff and clients – Field notes from monthly phone calls and site visits – Program Sustainability Assessment Tool

  • Program effectiveness

– REDCap data collection

  • Staff collected GPRA data
  • Client-administered recovery indicators
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Site Characteristics

Porter Starke Services LifeSpring Health Systems

Program Characteristics

  • Started MAT PDOA in Feb. 2016
  • Targets persons below poverty line

with barriers to MAT

  • Methadone
  • Continuum of care is encouraged
  • Started MAT PDOA in July 2016
  • Targets individuals with or at risk for

HIV/Hep C, or barriers accessing MAT

  • Suboxone
  • Counseling is required

Location Characteristics

  • Semi-rural
  • Fairly affluent county
  • Rural with high levels of poverty
  • Recent HIV/Hepatitis C outbreak
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Site Characteristics

Porter Starke Services LifeSpring Health Systems

Client Characteristics

Age (average) 35.0 Female 51% Male 49% Unemployed 64% Probation/Parole 17% Illegal Drug Use 82% Opioid Use 71% IV Drug Use 55% Age (average) 36.3 Female 62% Male 38% Unemployed 49% Probation/Parole 34% Illegal Drug Use 50% Opioid Use 31% IV Drug Use 19%

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Outcomes: Acceptability and Sustainability

External Factors

Funding & Economic Target Population Policy & Legal Local Infrastructure Professional Influences Political Support Social Climate Relational Climate

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External Factors Impacting Acceptability

Porter Starke Services LifeSpring Health Systems

Located close to Chicago metropolitan area, so slightly more accepting of harm reduction Long history in the community; existing facility, local reputation and community networks Part of large, locally integrated health program, which facilitates referrals and name recognition Distance for rural clients increased fuel costs and time Conservative community with resistance from churches and community leaders = stigma Difficulties forming relationships with existing health providers Difficulty recruiting HIV-impacted population program meant to serve = internalized stigma Clients lack transportation, even though within short distance of clinic

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Sustainability

  • Long term success of MAT programs and ability to

maintain services once funding ends

  • Program Sustainability Assessment Tool

– 40 questions in 8 domains 1. Environmental 2. Funding 3. Partners

  • Follow-up interviews
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Environmental Sustainability

Porter Starke Services LifeSpring Health Systems

Luke, D. A. (2014). The Program Sustainability Assessment Tool: a new instrument for public health programs. Preventing chronic disease, 11.

INTERNAL FACTORS EXTERNAL FACTORS

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External Factors Affecting Environmental Sustainability

Porter Starke Services LifeSpring Health Systems Strong champions for MAT are outside of the program Community stigma against MAT Community stigma against MAT Lack of community trust

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Funding Sustainability

Porter Starke Services LifeSpring Health Systems

Luke, D. A. (2014). The Program Sustainability Assessment Tool: a new instrument for public health programs. Preventing chronic disease, 11.

MAT is not seen as priority in marking and they cannot circumvent Discontinue comprehensive services without additional funding

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External Factors Affecting Funding Sustainability

Porter Starke Services LifeSpring Health Systems High need pop. w/ limited resources Loosing traditional self-pay clients to new MAT-PDOA clients Private funders prefer to give to prevention services High need pop. w/ limited resources Grant funding is only source of funding for comprehensive services Uncertainty regarding ACA

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Partnership Sustainability

Porter Starke Services LifeSpring Health Systems

Stigma and a need for stronger community partners

Luke, D. A. (2014). The Program Sustainability Assessment Tool: a new instrument for public health programs. Preventing chronic disease, 11.

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External Factors Impacting Partnership Sustainability

Porter Starke Services LifeSpring Health Systems

Stigma and a need for stronger community partners

Caution around promoting MAT Physician stigma regarding MAT Small community with strong ties means new partnerships are hard to develop Religious values are anti-MAT

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Summary of Findings

  • External factors play a significant role related

implementation outcomes for the IMAP program

  • There is significant overlap between issues related to

different external factors: social, political, relational

  • External factors play a greater role at LifeSpring due to

community values and interlinked small town networks

  • Better understanding of external factors can improve

implementation outcomes

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Implementation of planned

  • utreach, intervention, naloxone,

and treatment (POINT): An emergency department-based program to prevent fatal opioid

  • verdose

Alan McGuire, Ph.D., HSPP; Dennis Watson, Ph.D.; Katherine Cheesman; Krista Brucker, M.D.

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Project POINT

  • Naloxone is effective in preventing death due

to opioid overdose…

  • But then what?
  • Project POINT links w/ treatment
  • But how? What are the critical elements?
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Why the ED?

  • Inconsistent use of non-emergent care
  • 35:1 opioid-related ED visit/overdose1
  • Very few referred to SA treatment
  • Social emergency medicine
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Other ED Efforts

  • Initiate buprenorphine in ED
  • Reduced likelihood 30 day readmission2
  • 3 Month gains in:

– Treatment engagement – Drug use – Less expensive treatment use

  • NS at 6 Months
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Project POINT

  • A promising practice that WILL be replicated
  • Evidence is emerging (not evidence-based)
  • However

– Stakeholder pull – High-visibility problem and approach – NIDA RFA

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Why D&I Now?

  • Shorten the pipeline (e.g., Hybrid Designs)
  • Strike while the iron is hot
  • Influence trajectory of spread
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Spread: if and what

  • Spread rarely happens, but when it does…
  • Fidelity generally low
  • Adaptations are the norm
  • Model clarity may guide implementation by

demarcating what can and cannot be modified without affecting fidelity

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The Current Project

  • Critical elements
  • Ethnographic approach4

– Examine established model program

  • Focus on elements explicitly reported as critical
  • Placing in the context of emergent elements
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Methods

  • Semi-structured interviews (n = 5), document

review, observation

  • Analyses: immersion/crystallization
  • Critical?

– Explicitly stated as critical – Consensus from sources – Corroborated Hx or QA – Emergent Themes

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Results

  • 8 Critical Elements
  • Vary by

– Strength of Evidence – Specificity/Abstraction

  • Candidate Critical Elements
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The Big Picture

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ED-Based

  • Physical Presence in

ED

  • ½ of Respondents
  • Observations Confirm
  • Historical Experience
  • When the program first started,

someone from that team would come to the emergency department to see overdose patients…Didn't work out very well because often by the time the person extricated themselves from whatever they were doing and got here…Sometimes the patient was gone, or they were ready to be gone

  • r the team…the ED team…was like

"what…who are you and what are you doing?”

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Peer Recovery Coach

  • Highest Support

– Universally reported/Observed – QA data confirms

  • But it takes more than just hiring a peer…

– if the state, if some hospital administrator had written a grant to the state to plop a recovery coach in our ED I would probably be like "what…I don't even know who that is" like "whatever, good for you"

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Alert/Referral System

  • ½ Respondents
  • Currently

– Automated System – Scan Track-Board – Direct Referrals

  • Only ED Process Element
  • Majority
  • Arranging
  • But how?

– Bus Passes? – Direct Provision?

Transportation

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Special MAT Prescriber

  • Emergent & Non-Specific
  • Majority Some Form
  • Organizes Other CEs

Special MAT Prescriber

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Walk-In Clinic

  • Majority of Sources
  • Historical Experience
  • Because originally we had been

giving them appointments. They're not gonna keep an appointment, that's not how they're living their

  • life. And so all these timeslots were

just going wasted. But if we can say "hey 3 days out of the week, you can just walk in at 10 am"…they can do that. That's how they

  • perate.
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Buy-In/Communication w/ Provider

  • Non-Specific
  • “Buy-in”
  • With Whom?

– MAT Provider – CMHC – SA Providers, in general

Funding

  • Majority
  • Grant Funding

– Start-up & non- billables

  • Insurance

– Common barrier

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Discussion

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External Factors

  • Project POINT exists because of external

factors

  • No MAT in ED
  • Waiting Lists for Tx
  • Funding for Tx
  • Patient Factors
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Danger & Opportunity

  • Need + Promising Intervention
  • Example: Crisis Intervention Team (CIT)

experience

  • POINT Replication could “plop” peers
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May the Circle Be Unbroken

  • Continued evidence should inform

– Scale – Model Development – > “outcomes”

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References

1- Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers---United States, 1999--2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487–92. 2- D’Onofrio, G., O’Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens,

  • P. H., ... & Fiellin, D. A. (2015). Emergency department–initiated

buprenorphine/naloxone treatment for opioid dependence: a randomized clinical

  • trial. Jama, 313(16), 1636-1644.

3- Bond, G. R., Williams, J., Evans, L., Salyers, M., Kim, H. W., Sharpe, H., & Leff, H. S. (2000). Psychiatric rehabilitation fidelity toolkit. Cambridge, MA: Human Services Research Institute.