Local Responses To The Opioid Epidemic

Local Responses To The Opioid Epidemic
December 06
09:34 2017

The opioid crisis represents a clear and present danger to the nation’s public health, with drug overdoses now claiming more lives than annual deaths from car crashes and gun violence combined. A staggering 20 million adults in the United States have a substance use disorder (SUD), yet 88 percent of these individuals do not receive treatment for their conditions. Local communities are experiencing the human and economic costs of the opioid epidemic first hand, most especially rural communities where the rate of opioid-related deaths is 45 percent higher than in metro areas. Untreated SUDs contribute to rising rates of incarceration, homelessness, and use of emergency services; straining local criminal justice systems, law enforcement, first responders, and community and public health resources beyond capacity. Despite heightened federal attention to these issues—most recently with President Donald Trump’s declaration of a public health emergency to address the drug epidemic and new federal Medicaid guidance—there is no national strategy or significant funding dedicated to confronting the crisis. Cities and counties cannot wait and are stepping up, designing, funding, and launching local initiatives to alleviate the human and economic devastation of the opioid epidemic in their communities.

Local programs often operate outside of the orbit of the health care delivery system; within the walls of local courthouses and jails where they are inventing new ways to deal with burgeoning opioid caseloads. The following represent a sample of the types of initiatives that communities are supporting to confront the opioid epidemic and serious mental illness:

  • More than 2,600 communities have created police crisis intervention teams to train officers in tactics to safely de-escalate individuals experiencing behavioral health crises;
  • Cities and counties have developed “diversion programs” with first responders that divert individuals in crisis away from hospital emergency departments (EDs), jails, and courts, toward more appropriate therapeutic settings where they can receive treatment, recovery, and social support services;
  • Localities are establishing jail-based treatment programs, providing medication-assisted therapies and care transition programs to support coordinated, ongoing care upon re-entry into the community; and
  • Local agencies are adopting housing first and harm reduction programs that incorporate sustainable housing and safer or managed substance use as a means to support long-term recovery.

There are literally thousands of local program variations that have been launched to address the opioid crisis. We found that most successful efforts are marked by a set of common factors that together create client-centric systems of care that align law enforcement, criminal justice, public health, and community resources to coordinate, improve access to, and deliver a broad spectrum of treatment, recovery, health, and social services.

Two programs exemplify this comprehensive approach, others we reviewed shared some of these features.

  • Bexar County, Texas, launched a broad jail and ED diversion program that engages individuals with SUD during interactions with law enforcement, booking at local jails, and ED encounters. The county established a restoration center as a diversion destination for these individuals, where they are screened and connected with a continuum of treatment options, including onsite detoxification support, behavioral health treatment, health care services, and transitional housing. The center coordinates case management and follow-up for individuals who engage in treatment.
  • King County, Washington’s Familiar Faces program developed the concept of a “golden thread” that coordinates resources across programs and agencies. The program uses case workers and a care management approach that weaves together city, county, and community physical and behavioral health services with housing, employment, and other social supports for nonviolent repeat offenders with SUD and other behavioral health conditions.

It Takes A Village, And Village Leadership

No city or county agency can solve the crisis on its own, and public agencies need to collaborate and align with community-based health and social service providers. Strong leadership from the mayor’s office, county sheriff, judges, and others has been used to galvanize community and public support necessary for county boards of supervisors and the public to accept and pass new “problem-specific” fees, taxes, and ballot measures, and garner appropriations to construct restoration centers that provide residential detoxification, sobering, and outpatient substance use treatment services.

Access To Health And Social Service Benefits

A clear and consistent theme we observed was the profound need to ensure that people afflicted with behavioral health disorders gain access to a broad set of treatment and social support services. Addiction and serious mental illness can be extraordinarily debilitating and are typically not successfully treated simply by enrolling individuals into detox programs or various forms of behavioral health therapy.

Local programs have incorporated supportive mechanisms to help clients obtain access to social security benefits, health care coverage, most notably Medicaid, and other benefits that can help pay for clinical services and provide a source of income and other benefits that help clients recover. Without access to these dimensions of recovery, the individuals they serve are more likely to relapse, ending up in the criminal justice system or in hospital EDs.

Care Coordination And Management

Accessing and coordinating the delivery of a broad spectrum of services requires substantial effort. Just as health systems have been gravitating toward the use of navigators to support care coordination, local programs are deploying case workers and counselors to help clients navigate labyrinthine criminal justice systems and agencies and developing care and transition plans. Case workers and counselors not only coordinate and support access to services within public agencies, they also work with partners in the community to provide therapeutic treatment, housing, education, employment, and other social services.

Funding Is Scarce

Creating systems of care is time and resource intensive, and most cities and counties are hampered by limited funding for behavioral health programs, preventing them from scaling successful initiatives to fully address the need in their communities. Agencies are weaving together a patchwork of funding streams, including state and local general funds, targeted assessments or taxes, often coupled with contributions from local health system community benefit programs, local and national philanthropic organizations, and federal programs, such as those administered through the Substance Abuse and Mental Health Services Administration (SAMHSA). However, these funding streams are often time-limited and subject to legislative appropriations, limiting their scale and leaving their future uncertain.

We were particularly taken aback by the limited use of Medicaid funding to support local programs. Medicaid is the single largest funder of behavioral health services in the nation, and while many low-income adults affected by the opioid crisis are eligible for Medicaid—most especially in states that expanded their Medicaid program to low-income adults—the vast majority of local programs have not fully leveraged Medicaid funding to sustain and grow their initiatives.

The failure to fully leverage Medicaid funding suggests a breakdown in coordination across state, county, and city agencies, and a lack of understanding of how Medicaid programs can be an invaluable resource for local efforts. Beyond treatment, Medicaid can also cover a range of support services, including case management, housing, and employment supports. Moreover, states have been exploring and expanding Medicaid’s role in covering the costs of social interventions that are central to addressing the needs of those with substance use disorders and serious mental illness. Notably, few local programs have made use of Medicaid case management or targeted case management, a benefit that enables a state Medicaid agency to cover and reimburse for services that support individuals in accessing needed medical, social, educational, housing, and transportation services. Given the breadth of tools available to state Medicaid agencies to address SUDs, including the additional waiver tool the Centers for Medicare and Medicaid Services (CMS) outlined in its November 1 letter to state Medicaid directors, coordinated state and local initiatives would seem both promising and imperative.

Evaluating And Spreading Interventions

There are a plethora of local programs targeting individuals with untreated opioid addiction and other behavioral health disorders, many have not been studied and are not well understood beyond their communities. Clearly, there is a significant need for thorough evaluation and widespread dissemination of successful local approaches. More evidence will allow city and county leaders with state and federal partners to make more informed decisions about investing in programs that improve the well-being of individuals with untreated SUDs.

More research is also needed to understand which local programs are having broader and longer-term impacts on the well-being of individuals and communities; that is, programs that are breaking the cycle of substance use and reducing its prevalence; producing broader return on investment and long-term cost savings; and initiatives that are improving behavioral and physical health outcomes.

What’s Next

The opioid crisis continues unabated as every level of government struggles to identify, fund, and organize effective responses. With so much of the tragedy playing out in local communities from West Virginia to New Hampshire to California, it is not surprising that local leaders are stepping up. The challenge and the opportunity is to weave together the knowledge and capabilities of local leaders with federal and state resources to mount a more comprehensive attack on the opioid crisis. Federal agencies including SAMHSA and philanthropic organizations can create programs to fund, launch, scale, and assess city- and county-led programs. They can also foster the creation of knowledge centers and provide technical assistance to help identify successful and scalable local interventions that can be spread more broadly. Finally, the Center for Medicare and Medicaid Innovation at CMS could establish initiatives that fund and link local programs to state Medicaid programs to catalyze multipayer initiatives that empower heath care and social service providers to confront the crisis.

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