Alissa Beers, MA and Meryl Schulman, MPH

November 18, 2020

How can states address the challenges of the opioid epidemic on top of the COVID-19 pandemic? Particularly in a state like New Jersey, where COVID-19 cases and deaths ranked second in the nation in early April, maintaining a focus on addressing the opioid crisis takes robust partnerships. This includes breaking down historic silos to reduce drug-related deaths and increase access to services for people with opioid use disorder (OUD). Such transformative efforts require that multiple state agencies align priorities, share data effectively, and offer solid infrastructure to support sustainable partnerships. In the current environment, effective cross-agency partnerships are essential to getting things done.

The Center for Health Care Strategies (CHCS) recently spoke with Adam Bucon, LSW, state opioid treatment authority for New Jersey’s Department of Human Services, Division of Mental Health and Addiction Services (DMHAS); Natassia Rozario, JD, MPH, director of opioid response and policy at the New Jersey Department of Health (DOH); and Steve Tunney, RN, MSN, chief of behavioral health and customer service for New Jersey’s Department of Human Services, Division of Medical Assistance and Health Services (Medicaid) to understand how their collaboration has supported them in navigating the COVID-19 crisis alongside the opioid epidemic. Through support from the Robert Wood Johnson Foundation, CHCS works closely with New Jersey to inform activities to improve health outcomes for Medicaid beneficiaries.

Q: How are you adapting during this unchartered time to meet the needs of people with OUD, in both the near and long term?

Because of changes to federal and state regulations, we were able to permit the use of telehealth for individuals at a much greater capacity than ever before. This allows us to meet people where they are rather than requiring them to always come to a facility.

A: A. Bucon: New Jersey DMHAS moved swiftly to leverage increased federal-level flexibility related to opioid treatment programs (OTPs). Specifically, DMHAS increased access to take-home doses of OUD medication for people receiving services at OTPs. This has helped prevent having many people in clinics from being potentially exposed to COVID-19. In early spring, we also provided each OTP with enough naloxone (a medication designed to rapidly reverse opioid overdose) to cover at least one dose for each patient admitted. Further, we provided two rounds of personal protective equipment (PPE) for OTP staff to cut down the risk of contracting COVID-19. Because of changes to federal and state regulations, we were able to permit the use of telehealth for individuals at a much greater capacity than ever before. This allows us to meet people where they are rather than requiring them to always come to a facility. That has allowed patients to access treatment in their own environments, eliminating typical barriers to in-person visits such as child care, transportation, and the stigma and discrimination associated with OUD. DHS also partnered with more than 300 pharmacies in September for a three-day naloxone giveaway, in which people could get the antidote for free and without a prescription or ID.

S. Tunney: Unbundling rates for providers’ billing services for the Medicaid population was also key to continuing to address OUD during the pandemic. This allowed providers to more easily bill for services that can be provided either face-to-face or through telehealth visits. This policy change has helped providers remain financially stable during this difficult time. Another focus area for us has been transportation — and ensuring that individuals with substance use disorder (SUD) who had in-person appointments were able to continue their treatment and access appropriate medications. We worked closely with our partners at LogistiCare (which helps run transportation and integrated health care programs) who, due to COVID-19, made changes that limited the number of individuals allowed in their vans to support safe social distancing. We will continue to ensure that our providers and other partners that are providing these critical services continue to be reimbursed so they can keep their doors open and enable people to receive the treatment they need.

N. Rozario: Within DOH, we manage a lot of the surveillance status. For instance, we are closely monitoring suspected drug-related deaths. Those numbers are going up on New Jersey DOH’s Overdose Data Dashboard, and the overdose epidemic remains a statewide priority. The pandemic has brought about a constellation of different triggers that we know are related to substance use and overdose, which include grief, job loss, economic and housing instability, vicarious trauma, social isolation, and general anxiety related to the uncertainty surrounding COVID-19. This year, the Office of the Chief Medical Examiner reports that we experienced the highest number of suspected drug-related deaths seen in any one month (309 deaths during May 2020). From January to July 2020, there was a 12.3 percent increase compared to the same time period last year. During the current crisis, data and partnerships become all the more important because we have to rely on data to target areas most in need and work with partners to implement a comprehensive strategy. On the harm reduction side, we have worked to ensure that NJ’s seven harm reduction centers (HRCs) are deemed essential services and provided them with the PPE and other supports to help keep them open during these difficult times. On the treatment side, we’ve worked hard to keep our community-based residential and ambulatory behavioral health programs open and considered essential when stay-at-home orders were in effect. We’ve also continued to issue licenses for new programs and to renew licenses. We also issued approximately 80 waivers since March for mental health and SUD services, and we are excited to say that there is no backlog in mental health and SUD applications from providers.

Q: How have you leveraged existing partnerships during the COVID-19 pandemic?

A: A. Bucon: We have been grateful to partner on key activities, including implementing programs to support the state’s HRCs, as well as emergency medical services (EMS) related to the opioid epidemic. DMHAS has recently been able to increase funding to DOH to enable it to supply more naloxone to the HRCs, and also secured additional funding to provide EMS personnel and paramedics with naloxone in September. Our partnership with EMS is important since EMS is positioned to save individuals’ lives and link them to services. The licensing that Natassia referenced is important to underscore. There are currently 42 licensed OTPs in the state, up from 38 in early April. I give a lot of credit to the DOH Certificate of Need & Licensing for continuing this work so that important services can continue to become more widespread in different communities throughout the state. In addition, our longtime partnership with University Behavioral Healthcare has been essential in ramping up both our suicide and addiction hotlines.

S.Tunney:The amount of cooperation that I’ve seen between the different divisions, departments, and agencies has really gone through the roof during the pandemic. There are so many different waivers in play, so within Medicaid we are fielding questions all day from providers. Given all the moving pieces, we partner regularly with DOH, consumer affairs, and DMHAS to ensure providers’ questions are answered clearly and consistently. We also have contact more regularly now with the Department of Corrections for individuals with substance use needs to ensure they have continued access to services. Outside of our state-level partnerships, I also give kudos to our managed care plans and other partners like LogistiCare, who have been very understanding with regard to all the new things that we’re asking of them — including changes related to telehealth. Our close partnership with provider groups has also been fantastic. This is a challenging time for everyone, and our providers have shown their true passion for this issue.

N. Rozario:With support from Adam’s team, we were able to expand access to low-threshold buprenorphine at all harm reduction sites. This work is important as individuals are five times more likely to enter treatment through a harm reduction site.

Another partnership that we have leveraged is with our local health departments. Last month, we announced a Request for Proposals to all local health departments to set up overdose fatality review teams. This is a great example of leveraging local health departments’ robust networks and bringing together a group of stakeholders, including DMHAS, to look at the circumstances in which someone passed away — which is really profound in figuring out innovative solutions to prevent overdoses from happening. We are excited to see how these new partnerships can be leveraged to address overdose prevention.

Q: How, if at all, have COVID-19 response efforts spurred new or different ways to partner with one another?

It takes a collective effort and we need to lean on each other through these partnerships. It’s been wonderful to work with others to figure out how to address the structural inequities that feed into what we are seeing in COVID-19.

A: S. Tunney:Previously our stakeholder meetings were traditionally very division-oriented and we’d only bring in outside divisions or departments as-needed. We now proactively invite others in anticipation of their contributions. For instance, even if it’s a “Medicaid” issue, DOH brings in great insights, information, and data resources. We are seeing a much broader base of people who are attending and contributing to meetings that we are having — and I’m hopeful that will continue after COVID-19.

A. Bucon: One unique example is a recent letter that was distributed to all EMS agencies and was co-signed by executive leadership at both DHS and DOH. It’s really nice to let the EMS agencies know we’re collaborating together to support them.

N. Rozario: We’ve all been wearing many hats during the pandemic, especially in supporting vulnerable populations. All of this work has reinforced the need to address the deep health inequities that exist — racially, geographically, and economically. In particular, when you are tackling problems like social determinants of health that are large and complex, you cannot do it on your own. It takes a collective effort and we need to lean on each other through these partnerships. It’s been wonderful to work with others to figure out how to address the structural inequities that feed into what we are seeing in COVID-19.

Q: Which unique skills have you been using to address the opioid epidemic in the current environment?

A: S. Tunney: For Medicaid, it is the ability to be very data-driven in our efforts. We have leaned on data and analytics to understand what’s going on, using claims data and reports from managed care plans and our partners at Rutgers University. Being data-driven allows us to understand what is actually happening as we think through next steps. These data have helped show providers how much service they provided last year compared to this year, which helps illuminate their concerns and requests for support.

A. Bucon: One key asset is our ability to listen to providers and get their insights based on what they are seeing in the field, what the impact is, and what their recommendations are for the state. We continue to have bi-monthly meetings with the executive leadership from the NJ Association for the Treatment of Opioid Dependence to listen to what challenges they are facing and discuss potential solutions. For instance, in the beginning of the pandemic, one OTP lost three staff members to COVID-19, so having relationships in place and working to figure out solutions is important. We also continue to hold County Alcohol and Drug Abuse Director meetings as well as our county mental health directors meetings. This has been crucial in listening to providers and other professionals in the community to see what could be most impactful to help them through this trying time.

N. Rozario: There are many heroes in this pandemic and our epidemiologists are among them. We rely on them to highlight who is being affected the most, whether it’s COVID-19 or overdose data, which areas are being affected the most, and where we need to invest resources. We also started having standing calls with our HRCs during COVID-19 to keep apprised about what they are seeing on the ground, how they’re doing with naloxone, and then coordinating with DMHAS in follow-up supports. For us, it is a combination of the data and the relationships that have been so crucial.

Q: Are you learning or implementing new approaches that may be sustained beyond the COVID-19 public health crisis?

We need to understand the impact that telehealth can have, and how to sustain those positive aspects of increased access beyond the pandemic, especially for people with transportation or childcare issues.

A: A. Bucon:As providers have had to turn to telehealth, we have heard anecdotally that patients are now saying things to providers that they did not feel comfortable saying in person. We need to understand the impact that telehealth can have, and how to sustain those positive aspects of increased access beyond the pandemic — especially for people with transportation or childcare issues.

S. Tunney: For providers, telehealth has been the game changer for keeping programs open and allowing them to continue to provide needed services. I know that’s something we will continue to see after the COVID-19 emergency is ended. I’d still like to see even more innovative use of telehealth in areas where we’re really shorthanded with psychiatrists, and even down to the role of the program directors and other areas that are outside of direct clinical provision of service.

N. Rozario:My work in expanding COVID-19 testing for people experiencing homelessness and getting involved with prevention and response efforts for that population has underscored the importance of taking an iterative design approach. Starting small with a couple of pilots, listening to stakeholders, and learning as much as possible before scaling immediately, is an effective approach. We have done five testing pilots and have learned so much about what is needed to scale this work, which helped ensure we would have capacity this fall to test about a thousand individuals experiencing homelessness per week. There is opportunity for applying that approach within the OUD work.

Q: What tips might you offer to other states as they navigate the COVID-19 crisis on top of the opioid epidemic?

A: N. Rozario: Continue to nurture relationships, approach this work with a lot of compassion, and lean in on your data.

A. Bucon:  Communicate and collaborate with others. Pull in lessons learned from other states, so you’re not reinventing the wheel.

S.Tunney: Embrace change! You can change and survive.

 

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