Indiana is no stranger to the opioid epidemic affecting the nation. State numbers show a worsening problem: Visits to emergency departments linked to suspected opioid overdoses increased 35.1 percent from July 2016 to September 2017. The opioid prescribing rate is higher in Indiana than the national average (83.9 versus 66.5 prescriptions per 100 people in 2016). And 1,526 Hoosiers died from drug overdoses in 2016, an increase of 23.1 percent from the previous year.
Like many Americans with opioid use disorder (OUD), Indiana residents have trouble accessing evidence-based treatment. Medication-assisted treatment (MAT)—the gold standard therapy that combines Food and Drug Administration-approved medications with behavioral counseling—has been shown to increase patient adherence to treatment and reduce illicit opioid use compared with other approaches.
Now, however, Indiana has begun to expand access to treatment for people with OUD and help them maintain successful recoveries. In 2017, Governor Eric Holcomb (R) made tackling the opioid crisis a priority of his policy agenda. At that time, Jim McClelland, state executive director for drug prevention, treatment, and enforcement, began a partnership with The Pew Charitable Trusts to assist state leaders in addressing problems associated with opioid use.
Over 12 months, Pew met with more than 100 stakeholders in Indiana to help craft six policy recommendations that would result in a more comprehensive treatment system. The following highlights from the proposals span three broad categories: treatment system transformation, the substance use disorder workforce, and underserved populations.
Treatment system transformation
Three Pew recommendations focus on transforming and improving Indiana’s OUD treatment system. Under a comprehensive system, people with OUD should be able to access all three MAT medications: buprenorphine, methadone, and naltrexone. Indiana has a comparatively low rate of health care providers who can prescribe buprenorphine, however. A 2015 study reported a maximum potential buprenorphine treatment capacity rate of 2.8 patients per 1,000 Hoosiers, compared with 4.1 patients per 1,000 people nationwide.
The state also should evaluate how it oversees the prescribing of buprenorphine in primary care settings. As part of this evaluation, policymakers should focus on how best to improve quality of care in these settings, increase the number of providers, and decrease the transfer of drugs for illicit use.
Patients’ success with MAT depends, at least in part, on their ability to stay in treatment. Facilities such as recovery houses (residential environments that provide alcohol- and drug-free cohabitation spaces) could help, but many of them discourage or prohibit use of MAT. Pew has called on Indiana to revise its legal definition of recovery housing to explicitly prevent the exclusion of those taking FDA-approved medications as part of their treatment. Policymakers also should ensure that the state is funding programs rooted in quality and evidence-based care.
Substance use disorder workforce
An effective treatment system requires sufficient providers that can deliver needed services. Unfortunately, Indiana has a shortage of substance use disorder (SUD) counselors—its patient-to-specialist ratio places it in the lowest quartile of states. These providers offer behavioral counseling services—an essential part of MAT—and can work in a range of locations, including opioid treatment programs, community mental health centers, and various private inpatient and outpatient settings.
As a first step in expanding Indiana’s SUD workforce, Pew recommends that the state assess reimbursement rates for SUD counseling services in community-based settings and increase those rates as appropriate to improve access to services.
Individuals in jails and prisons, on probation or parole, or otherwise linked to the criminal justice system can face greater difficulties than other populations in securing effective care for OUD. Some Indiana county jails offer MAT to inmates, an approach that has been associated with reduced recidivism rates, decreased overdose rates, and improved health outcomes. However, many of these people may be unaware of medical care options after release and therefore may not continue treatment.
Pew recommends that Indiana start a pilot program to help ensure that Medicaid-eligible inmates re-entering the community from jail can get access to health care services. Currently, the benefits of those enrolled in Medicaid are discontinued after 24 months of continuous incarceration. Indiana jails should follow the lead of the state’s Medicaid program and Department of Correction and ensure that inmates’ Medicaid benefits are reactivated upon release while also educating them about those benefits and connecting them with health care in their communities.
A pilot program could test innovative approaches for increasing access to evidence-based treatment. These could include using “telenavigation” services delivered by a remote health navigator to assist inmates with Medicaid eligibility and care coordination, implementing a partnership with one of the state’s Medicaid managed care entities, and developing an automated process to inform Medicaid of upcoming releases.
What’s next for Indiana
Indiana’s public officials now can consider these recommendations as part of the 2019 legislative agenda. Implementing the proposals would be an important step forward in creating an effective, comprehensive SUD treatment system in the state.
Josh Rising is director of The Pew Charitable Trusts’ health care programs.