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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
January 21, 2020
State Health Policy Leadership Mental Health The Center for Evidence-based Policy
Allison Leof Read Bio
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The opioid epidemic kills tens of thousands of Americans annually, yet decision makers report that they’ve struggled to make sense of an overwhelming amount of data about approaches to prevention and treatment. It can be hard to discern which studies may be affected by bias, conflicts of interest, or inadequate methodology. For state policymakers, such confusion makes it challenging to develop effective policies. And as states await the settlement of pending lawsuits against opioid pharmaceutical companies and distributors, an understanding of the evidence becomes even more critical.
That’s why we at the Center for Evidence-based Policy (CEbP) at Oregon Health & Science University are proud to announce the launch of the CLOUD, or the Curated Library about Opioid Use for Decision-makers. The CLOUD was built through a $760,000 grant CEbP received from the Consumer and Prescriber Education Grant Program, a fund established through a nationwide consumer protection settlement over off-label marketing of Neurontin. Its mission was to provide a centralized place for actionable, evidence-based resources for anyone working on issues related to the opioid crisis. Other partners include the National Governors Association Center for Best Practices and the Milbank Memorial Fund.
The CLOUD offers resources on a broad range of topics, including addiction treatment, harm reduction, prevention, and recovery, and alternative treatments for pain. The materials include downloadable documents, such as policy reports, implementation guides, and government documents such as relevant legislation, as well infographics, videos, and website links. We feature information about authors and funding sources for all of the resources. (The CLOUD only includes non-proprietary materials, but we are working with researchers and program managers to prepare summaries of research published in proprietary journals.)
We are particularly interested in including resources that describe programs and initiatives shown through research or program evaluation to be effective at achieving their intended goals. Where possible, resources include a ranking of the strength of the evidence for a particular strategy, clinical intervention, or community initiative’s effectiveness at addressing a challenge related to the opioid crisis. The supporting evidence is ranked on a four-point scale from “proven” to “problematic” to show whether a particular strategy, clinical intervention, or community initiative is successful.
The resource was developed for policymakers and community leaders, payers and health providers, and patients and caregivers who make decisions about opioids and related issues. Potential CLOUD users might include payers looking to evaluate the effectiveness of programs suggested by providers, service providers looking to refine existing programs, government officials assessing funding priorities, or private funders looking for innovative ideas of what works.
Here are the lessons we’ve learned through the initial year of CLOUD’s development that may be relevant to those trying to address the epidemic in their states, cities, and towns.
While the opioid addiction and overdose crisis has drawn the lion’s share of attention, opioids are only part of the problem. What we are really facing is an addiction crisis. Many individuals with opioid use disorder abuse multiple substances, and poly-substance addiction is a very real problem. Furthermore, in many communities the toll incurred from alcohol addiction/abuse and methamphetamine use exceeds the burden caused by both prescription and illicit opioids combined. While the CLOUD has the word “opioid” in its name, our mission is larger and includes information about addiction prevention and treatment in general.
Substance misuse is estimated to cost more than $820 billion a year in the United States. In addition to the costs of treatment and related health services, substance misuse contributes to the spread of infectious diseases such as HIV/AIDS and hepatitis C; increases in crime, unemployment, domestic abuse, divorce, and homelessness; reductions in workplace productivity; increased incarceration costs; and the effects of vicarious trauma on our first responders and health care providers who work on the first lines of the crisis.
Policymakers and community leaders are working across agencies, branches, and jurisdictions to take on the challenge. These efforts include developing pre-arrest diversion programs to help individuals whose primary problem is substance misuse get treatment and avoid the criminal justice system when possible, and quick response teams who follow up with individuals treated for a drug overdose and offer connections to treatment. Employers have also responded to this crisis, as in Connecticut, where the Department of Health led employers in the development of new workplace policies that connect employees with substance misuse disorders to treatment and support.
While progress has been made in educating people about the reality that addiction is a brain disease and not a moral failing, we need to continue to work to spread the message that treatment works, recovery is possible, and people can rebuild hopeful, contributing lives. The increasing willingness of people to be honest about their recovery is an important part of this movement, as is building recovery-oriented communities like the Phoenix and Young People in Recovery. The CLOUD makes a special effort to include information to help reduce stigma and encourage recovery.
A recently published Milbank Quarterly study by Andrea Mauri and colleagues at the University of Michigan School of Public Health, showed we do not always collect data or collect the right data to evaluate whether a specific program or intervention is effective at achieving its goals. We are pleased when a state or non-profit organizations publishes evaluations of programs or initiatives. Two recent examples include an Arizona report on a pilot of a Police-Assisted Addiction and Recovery Initiative in three counties, and the Camden Coalition of Health Care Providers’ evaluation of a project that removed prior authorization requirements for buprenorphine for Medicaid patients. Researchers, program managers, and policymakers should prioritize smart program evaluations and freely share the results of such studies.
One of the risk factors for developing a substance use disorder is to have experienced an adverse event or trauma in childhood. We know the large number of children affected by the addiction crisis in our country are at risk for perpetuating the cycle of addiction and dysfunction unless we are able to prevent adverse childhood events (ACES) and help children and their families recover and rebuild their resilience. The recent report from the Milbank Memorial Fund and the United Hospital Fund, The Ripple Effect: The Impact of the Opioid Epidemic on Children and Families, examines the effect of the addiction crisis on children and grandparents and others, and emphasizes the importance of having family-centered treatment options available. And the Sesame Street in Communities project on parental addiction is an excellent resource for people who work with children affected by addiction, as are programs such as the Eluna Network, which provides camps and programs for children and families affected by grief or addiction. We can and must do more.
The CLOUD library is a dynamic project and we are regularly measuring what information is being accessed and adding resources to ensure users have the latest information. If you have materials you would like included in the CLOUD, please see our call for submissions page. We are interested in resources that showcase programs or interventions shown through research or program evaluation to be effective. By working together and sharing best practices, we can make real progress in addressing this crisis.
Allison Leof, PhD, is a Senior Policy Analyst at the Center for Evidence-based Policy at Oregon Health & Science University.
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