How States Use Opioid Use Disorder Treatment Measures to Inform Decision-Making

Overview

Most states collect and report core opioid use disorder (OUD) treatment measures that can improve OUD treatment systems through data-driven decision-making. However, many states have yet to act on this data. A look at how some states have taken the lead on using this data to inform their opioid treatment policies and programs can aid other states in implementing core OUD treatment measures that can help curb the opioid crisis.

To better understand how states have leveraged the core OUD treatment measures in their opioid policies and programming, Pew interviewed officials in 10 states from each region of the country—Alabama, Colorado, Delaware, Indiana, Louisiana, Massachusetts, New Jersey, New York, Oregon, and Washington—to identify the most relevant use cases.

These interviews revealed that states have used the core OUD treatment measures to:

• Expand access to treatment.
• Identify and replicate successful programs.
• Enhance treatment quality.
• Improve health equity.
• Assess the impact of treatment system changes.

Pew also asked interviewees what steps state officials can take to make the best use of data. Suggestions included:

• Involving people with lived experience to help understand data collected on the measures.
• Having supportive leadership, resources such as funding, and outside partners use the measures to inform better OUD treatment policy and programming.

OUD treatment measures can inform policymaking and improve treatment access

Expand access to treatment

The core OUD treatment measures can help inform policy efforts to improve access to treatment. For example, Indiana used the OUD provider availability measure, along with data on driving distances and overdose rates, to identify viable locations for opioid treatment programs (OTPs) and support an increase in the number of these facilities across the state. OTPs are critical access points for evidence-based care as they are the only setting able to offer all three FDA-approved medications for OUD.

“Governor [Eric] Holcomb wanted us to make sure that every Hoosier had access to treatment within an hour’s drive, so that’s been our goal and our mission,” said Rebecca Buhner, deputy director of the Indiana Division of Mental Health and Addiction. “We’ve been able to add nine OTPs since 2016 to our state, which has been incredible to allow for [treatment] access.” The state is also using this data to update their OTP rule to allow for mobile vans as well as medication units¹—satellite OTP locations that can offer methadone dosing. These changes will make treatment more convenient and accessible for patients.²

Similarly, in New Jersey, the measures indicated there were delays in treatment initiation related to obtaining medication for OUD following an emergency department (ED) visit. In response, the state removed several barriers to accessing office-based opioid treatment including Medicaid’s buprenorphine prior authorization requirement, as reported by Steven Tunney, the New Jersey Medicaid director of behavioral health.

Assess the impact of treatment programs on outcomes

In addition to expanding access to treatment, applying the core OUD treatment measures can help officials understand what is working well in their state—and replicate those efforts. Indiana used data on follow-ups after an ED visit to rank Indianapolis County hospital programs and identify successful models with strong care coordination. One ED stood out as having a robust follow-up program. “That data was able to tell us that if you have a real program, it drastically will change your results,” said Douglas Huntsinger, executive director for drug prevention, treatment, and enforcement, and chairman of the Indiana Commission to Combat Substance Use Disorder at the Office of Governor Eric J. Holcomb. This led Indiana officials to work on legislation that would use opioid settlement and State Opioid Response grant funds to build similar programs at other hospitals.³ While that bill was not passed, the state is now discussing creating a sustainable ED program with the hospital association.

Data on the core OUD treatment measures also helps Indiana state officials answer difficult questions. For example: How does the relocation of a substance use disorder (SUD) provider into a specific community impact the treatment ecosystem that already exists in that region? Huntsinger notes that “this data has been really a core set of what we look at on a regular basis.”

Enhance treatment quality

When Louisiana obtained baseline performance data on SUD treatment measures to see how they compared to the national average, state officials found they were below the 50th percentile in treatment initiation and engagement, according to Candace Grace, program manager at the Louisiana Office of Behavioral Health. As a result, state officials worked with the Healthy Louisiana Medicaid managed care organizations (MCOs)—responsible for managing physical and behavioral health for members—to implement a performance improvement project specific to increasing initiation and engagement in OUD treatment. This project involved collaborating with the MCOs and providing feedback on strategies to drive improvement and address barriers to treatment, with substantive results. “We went from being below the 50th percentile to our performance at the end of the project being in the 90th percentile for initiation and the 75th percentile for engagement,” said Grace. “That was, for us, a success.”

Alabama’s Medicaid quality improvement strategy provides care management entities and primary care providers with financial incentives for improved performance on selected health measures.⁴ According to Nicole Walden, associate commissioner at the Alabama Department of Mental Health, these include two core OUD treatment measures: initiation and engagement in treatment and follow-up after an ED visit.

Improve health equity

To identify communities most in need of OUD treatment services and allocate them the appropriate resources, states can disaggregate data by demographic variables. Washington state has done just that according to Kris Shera, state opioid coordinator for the Washington State Health Care Authority. The state disaggregates all of the OUD treatment measures by age, race, gender, veteran status, and more. Doing so allowed Washington to recognize disparities related to treatment access among Tribal communities and use this data to justify investments from state funding and opioid settlements. This resulted in direct distributions to Tribes during the most recent state budget process.

Similarly, the Louisiana Office of Behavioral Health’s new procurement contract, which went into effect this year, is calling for the measures to be stratified by race/ethnicity, primary language, and age group. Program manager Grace said the agency also disaggregates data from the Centers for Medicare & Medicaid Services 1115 SUD waiver—which includes several core OUD treatment measures—by age, pregnancy status, and criminal legal system involvement. Further, as part of the treatment initiation and engagement performance improvement project, Louisiana required the MCO plans to stratify data collected by race and ethnicity. Based on the results, MCOs were asked to tailor interventions to specific populations.

Additional action can enhance implementation of measures

Pew identified several factors that could help states use the core OUD treatment measures to improve state treatment systems.

Involving people with lived experience to help understand the data collected

People with lived experience have unique expertise that can help assess whether a state’s OUD treatment system is effective and inform ways to improve care. Washington involves people with lived experience in a variety of ways to interpret data and develop plans to improve. Shera seeks opportunities to share, discuss, and apply the metrics with community members through state overdose and opioid response data and OUD services work groups, bimonthly public meetings through the Department of Health. An academic research work group through the University of Washington and a substance use statutory committee make recommendations to the state Legislature.

In Indiana, people with lived experience are involved in all aspects of the Division of Mental Health and Addiction’s efforts through a work group comprised of and led by people in recovery that participates in every departmental meeting, per Huntsinger.

“It’s not just about them having a seat,” said Buhner. “They have a voice, and I think we’ve [progressed as a state] to the point where now they are full partners and decision-makers and often driving our policy.”

Other states explained their interest in including people with lived experience and said they are discussing options to incorporate their perspectives in meaningful ways. For instance, Massachusetts could leverage advisory boards that already exist within state government and include people with lived experience, according to Tracey Nicolosi, director of addiction services at the MassHealth Office of Behavioral Health. And Tunney shared that New Jersey Medicaid is hoping to expand their peer program, which could be an avenue for getting feedback from people with lived experience through surveys.

How to leverage supports, use the measures to inform OUD treatment policy and programs

States identified strong leadership, dedicated resources, and external partners as supports for using the core OUD treatment measures and addressing any implementation barriers.

1. Strong leadership

Several states—including New Jersey, Massachusetts, Louisiana, and Indiana—emphasized the importance strong leadership support has on implementation efforts related to the core OUD treatment measures. “When you’re traveling around and you’re saying the governor’s on board and his team is here—there’s nothing you can use to replace that,” said Indiana’s Buhner. “That to me is the foundation [for these efforts].”

State officials also noted that cooperation across state agencies, which can be a result of strong leadership support, is also very helpful.

2. Dedicated resources

Allocating resources, such as funding specifically for staffing and initiatives related to the core OUD treatment measures, is another way states can support implementing the measures. To address shortages in internal resources and staff capacity to work on measurement-related efforts within state planning, Shera noted that Washington intends to use opioid settlement funds. This will let the state invest in planning efforts and develop online resources to share data and responses to the measures.

In addition, several officials mentioned grant funding as a helpful resource to implement the core OUD treatment measures. Federal rules allow states to use a portion of both the State Opioid Response and the Substance Use Prevention, Treatment, and Recovery Services Block grants to improve data.⁵

3. External partners

Another support, according to Shera, is the role external agencies such as community-based organizations can play when engaging with communities to develop action plans related to the measures. Shera said that “engaging communities with third-party organizations is helpful because we [the government] are not always trusted in the communities that we want to help.” He noted this is likely due to the history of drug policies including the war on drugs and the mistreatment of and discrimination against people who use drugs, so external organizations can help provide mediation between state entities and the communities they would like to serve.

Exploring recovery measures for SUD or OUD

Since there are no standardized recovery measures, Pew recommends states identify one or more patient-reported outcomes in collaboration with people with lived experience and experiment around this to find what measures are most appropriate for their state and the populations they serve.⁶ For example, Indiana explored measuring recovery through the Recovery Capital Index Initiative.⁷ Huntsinger noted that the state learned important lessons with this first attempt at measuring recovery, and may try a different approach by scaling down the project to measure recovery-related outcomes at the community or locality-level to see if it helps to measure growth related to recovery.

Other state officials expressed interest in learning more about recovery data and relevant measures, however, they were uncertain on how to go about measuring recovery given that to date there are no standardized measures. More research is needed to help states identify appropriate recovery measures and how to apply them.

Conclusion

States from all regions of the country have found ways to act on the data that most states already collect to inform opioid policymaking and programming. If other states follow suit, they can improve their OUD treatment systems and ensure their residents will be able to access to lifesaving care.

Endnotes

1. Substance Abuse and Mental Health Services Administration, “Certification of Opioid Treatment Programs (OTPs),” last modified April 4, 2024, https://www.samhsa.gov/medication-assisted-treatment/become-accredited-opioid-treatment-program.
2. A. McBournie et al., “Methadone Barriers Persist, Despite Decades of Evidence,” Health Affairs Forefront (blog), Sept. 23, 2019, https://www.healthaffairs.org/do/10.1377/hblog20190920.981503/full/#_ftnref1.
3. Indiana General Assembly House Bill 1462 (2023), https://iga.in.gov/legislative/2023/bills/house/1462/details.
4. Alabama Medicaid, “Alabama Coordinated Health Network (ACHN) Quality Strategy” (2023), https://medicaid.alabama.gov/documents/5.0_Managed_Care/5.1_ACHN/5.1.4_ACHN_Administration/5.1.4_Proposed_Draft_ACHN_Quality_Strategy_7-11-23.pdf.
5. National Academy for State Health Policy, “Funding Options for States” (2022), https://nashp.org/funding-options-for-states.
6. The Pew Charitable Trusts, “States Should Measure Opioid Use Disorder Treatment to Improve Outcomes” (2022), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2022/10/states-should-measure-opioid-use-disorder-treatment-to-improve-outcomes.
7. Indiana Family and Social Services Administration, “FSSA Encourages Hoosiers to Participate in Survey to Measure Addiction Treatment, Recovery Resources in Indiana,” news release, June 17, 2022, https://www.in.gov/fssa/files/Recovery-Capital-Index-Release-6-17.pdf.