Key Lessons From a Minnesota Multi-Stakeholder Opioid Policy Forum

Pinar Karaca-Mandic, Professor, University of Minnesota; Ralph Hall, Professor, University of Minnesota, Principal, Leavitt Partners; Kimberly Choyke, Program Director, MILI, University of Minnesota

Contact: pkmandic@umn.edu

Minnesota’s opioid overdoses, while well under the national average^1,2, are disproportionately concentrated among Native American and African American populations.  In 2016, Native Americans were six times more likely and African Americans were twice as likely to die of drug overdose compared to white Minnesotans. This is the worst race-based disparity in the United States. ^3,4

In order to adequately address these and other opioid use issues in Minnesota, in October 2019, the Carlson School of Management’s Medical Industry Leadership Institute (MILI) at the University of Minnesota convened a multi-sector forum, “Combating Minnesota’s Opioid Epidemic”. The forum had active collaboration from the University’s Office of Academic Clinical Affairs, Law School, School of Public Health, State Health Access Data Assistance Center as well as Mayo Clinic, Leavitt Partners, and other organizations.  The forum included federal and state policy makers; local, tribal, state health department and judicial representatives; state legislators, healthcare and payer systems; and recovery organizations.  The participants and panelists coalesced around five key learning points.

Point 1. Local contexts: While national policies and strategies are critical, unique state and local conditions must be identified and addressed

Minnesota has unique challenges regarding opioid abuse among its Native American and African American populations.  Other jurisdictions have their own specific local issues and challenges. While national policies are vitally important, one size solutions do not fit all situations.

The Twin Cities has the most Native Americans per capita in the country, and Minnesota is home to 13 tribal nations and communities. Tribal representatives emphasized that tribes do not necessarily fit into the standard mold of evidence-based medicine, and new solutions are needed to include tribes in policy development and to address tribal needs. These communities need authentic listening and direct involvement in policy development.

Another example of local challenges was identified when local representatives in the forum emphasized their inability to sufficiently work on prevention because their resources are often largely consumed by efforts to get used syringes off the streets. City officials report this has been an increasing issue, particularly across Minneapolis, as the opioid crisis continues.  Fire departments, city health workers, and the city and state health departments are working to clean up the syringes on the streets and implement new initiatives to encourage safe disposal.

The participants also stressed that state and local initiatives can serve as test beds for identifying successful innovative strategies to substance abuse.  This approach allows areas to pilot new strategies, gather data, and closely monitor the impact of strategies specific to their populations.  Local officials can then make a case to expand these strategies with evidence and as a model for others. 

Point 2. Funding: Innovative public and private funding sources and payment models need to be explored

Currently, much of the financial support for initiatives to combat the opioid epidemic come from federal and grant funds; however, these sources can be limited and uncertain.  Therefore, new, innovative funding sources are needed, and existing treatment/recovery reimbursement concepts rethought in order to ensure critical efforts continue.

As an example, forum panelists highlighted the recently passed Minnesota Statute 151.066.  This law was the first in the country to impose licensing fees on pharmaceutical companies. These fees are earmarked to a special stewardship account for opioid abuse and recovery/treatment efforts. Activities include the following targets:

• The Opiate Epidemic Response Advisory Council
• A five-year opioid initiative leveraging $20 million in annual revenue
• Physician training in opioid prescribing and opioid alternatives,
• Non-pharmaceutical pain management mapping,
• Funding for Native American communities to help support their tribal healing programs.

Payer organizations discussed the need to improve access and coverage for non-opioid pain management strategies. Participants also discussed whether to waive prior authorization to facilitate access to medication assisted treatments. Other payers addressed variations in front-end insurance coverage for detox; and increased access to telehealth services particularly for low-access communities.

Point 3. Structural challenges: Additional efforts are needed to identify and resolve structural determinants of health that exacerbate opioid issues

There must be consideration of specific structural determinants of health impacting opioid abuse, treatment and recovery.  Often these are unintentional barriers or reflect past practices.

Due to the workforce disparity among care professionals, many Native Americans and African Americans do not have access to the addiction care they need within their communities.  For example, a college degree is required to have an alcohol dependency counselor license, yet this well-intentioned requirement is currently a structural barrier to finding Native American alcohol and drug abuse counselors. By refining requirements for addiction counseling qualifications, otherwise qualified peers without traditional credentials could provide treatment and recovery services to their communities.

Point 4. Coordination: On-going coordination efforts, including sharing of best practices, successes and failures must accelerate

One constant theme among panelist is the need to coordinate across the public and private sectors, to share best practices, and to create new approaches to opioid abuse prevention and treatment. The following points were central to this part of the discussion.

• Physicians in the forum noted that often a person will present with opioid use disorder, but is not yet ready for treatment. New approaches are needed to provide these patients with immediate and longer-term treatment options.
• Licensing, credentials and business models need to revamp and leverage coordination between recovery workforce, community health workers, community health centers, and sober living facilities.
• Pain management and recovery care should include a holistic approach including:
  • Comprehensive training programs on addiction treatment and prescribing practices
  • Patient education on treatment options and risks
  • More point of care support including prescribing limits and increased efforts in opioid avoidance
  • Increased utilization of telemedicine, medical home and other team-based approaches
  • Development and access to non-opioid pain management tools
  • Patient education on availability of alternative treatments

Point 5. Beyond opioids: Addiction and recovery issues are broader than opioids and must address other substance abuse issues such as meth and alcohol abuse

While the focus of the policy forum was on opioids, all stakeholders emphasized that this is a substance use disorder, not just an opioid use problem.  Some policies may, for example, push patients from one substance being abused (e.g., prescription opioids) to another substance (e.g., heroin or meth).  A meaningful fraction of individuals in the Twin Cities are getting addicted directly to heroin rather than through prescription opioids, and we need policies to address this phenomenon. In other communities, meth is a critical issue. National, state, and local policies need to address substance abuse broadly and not just prescription opioid abuse.

Looking Forward

The opioid crisis is pervasive and cannot be fought in isolation. A one-size fits all approach will not work to resolve the opioid epidemic.  Without cross-disciplinary, cross-sector partnerships to develop and implement new policies, practices, training, and education, we will not overcome the crisis.  Collaborative discussions must not only include practitioners, policy experts and law makers, but also individuals.  The work must consider the communities served and the policies that impact them.

 References

1. Opioid overdose prevention, Minnesota Department of Health, www.health.state.mn.us/communities/opioids/index.html, Accessed January 24, 2020.
2. SHADAC analysis of opioid-related and other drug poisoning deaths, State Health Compare, SHADAC, University of Minnesota, statehealthcompare.shadac.org, Accessed January 24, 2020.
3. The opioid epidemic in Minnesota, Minnesota Department of Human Services, mn.gov/dhs/assets/federal-opioid-briefing_tcm1053-336378.pdf, Accessed February 3, 2020
4. Race Rate Disparity in Drug Overdose Death, Minnesota Department of Health, https://www.health.state.mn.us/communities/opioids/documents/raceratedisparity.pdf, Accessed February 8, 2020