Analyzing Overdose in Allegheny County
The recent Allegheny County report, “Opiate-Related Overdose Deaths in Allegheny County: Risks and Opportunities for Intervention,” suggests we’re getting the results we should expect to get. Until you see the data, you wouldn’t guess it.
What Does the Data Tell Us?
Between 2008 and 2014, over half the overdose deaths following release from the County jail occurred within 90 days after release and the largest proportion of those deaths (54 of 211) occurred during the first 30 days after release.
For individuals receiving publicly-funded substance use disorder treatment in the year prior to their death, 38% (134 of 350) died within 30 days of a recent treatment service. Short-term residential “rehab” programs and methadone maintenance were the most common services received. And 63% of the people who died in that first month (85 of 134) died within one week of the service.
In short, a significant number of people with opioid addictions were released from a jail and—very quickly thereafter—used an opioid and died; people with opioid addictions left treatment, and—too often—died soon after.
Three Points About the Report
First, let’s acknowledge that this is good data and an important report. It is as complete as any investigator can get using existing data sources and the constraints of privacy. Well done, Allegheny County!
Second, let’s be clear that there are a number of effective community responses to opioid overdose deaths and that should be deployed in concert. Broader availability of the overdose antidote naloxone, an easy-to-use prescription drug monitoring program, and effective prevention programs are all part of a public health response to opioid overdose.
But third, this report shows us that we need to rethink the way we provide services that are supposed to help people. Why? Because the standard menu of services and practices are not working. But if that’s all you have available, that’s what you do. In other words, we are getting the results we are built to get.
How to Rethink Criminal Justice and Addiction Treatment Services
When a person with an opioid addiction is incarcerated and the jail does not offer medication, it is life-threatening. No medication means a “cold turkey” detox, a brutal process returning the brain to an opioid naive state. Worse yet, it does nothing for craving. So upon release, with cravings not controlled and tolerance so rapidly changed, any opioid use is a set up for an overdose. And that’s what happens.
But this can change. The Allegheny County Jail is piloting a medication-assisted treatment program for inmates in custody. Operated by a community health provider, the program is in its earliest stages and is a sound, practical, humane response to substance use disorders in a justice setting. This program will greatly reduce the risk of overdose and increase the probability of a “warm handoff” to community-based treatment on release since jail care is provided by a community agency.
Patients usually receive program-focused care, not individual-focused care.
Let’s look at short-term residential rehabs. Typically, rehabs are 14-28 day programs. Originally designed primarily for people with alcohol use disorders, nowadays some rehabs eschew the use of addiction medications and require the patient to be drug free on admission. It is no surprise, then, that a rehab stay produces the same risks and results as time in jail. Offering medication and introducing the shift to medication-assisted recovery has support in the empirical literature and in practice. A residential setting is an ideal place for medication induction and stabilization. Why isn’t it universally offered? Because it is antithetical to recovery defined as abstinence only. In this case, ideology trumps science.
The data also suggest a problem with methadone maintenance. But this seems to be for a different reason. At the present time, most methadone maintenance programs provide minimum counseling services. In fact, national accreditation standards call for a paltry two hours of counseling a month, which is hardly sufficient for an individual doing well, let alone someone in the swirl of an opioid addiction. Methadone clinics are also only required to perform drug tests for patients eight times per year, which is often not sufficient for keeping a patient safe from fatal drug combinations, much less for promoting recovery from opioid addiction.
But this is not the way it has to be. For years, methadone has been treated not as a medication, but as a level of care. That means that all patients in methadone treatment receive the exact same services, regardless of their individual needs. Right now in western Pennsylvania, there are initiatives to separate the use of methadone, the medication, from the level of care the patient receives. In this new treatment model, the patient receives the medication in conjunction with the level of clinical support that he or she needs. So instead of getting two hours of counseling a month (no matter who you are), you may get up to nine hours a week in outpatient or between nine and 16 hours per week in intensive outpatient. These recommended hours of service are based on the ASAM Criteria, which should be used to assess all patients who present for addiction treatment. Someday, this level of individualization will not be the exception, but the standard of care for medication-assisted treatment.
Paying for Quality Leads to Better Outcomes
You can’t leave this discussion without talking about the way we finance services. The quality of treatment is inevitably related to the ways it gets paid for. A substance use disorder treatment program operates within the bounds of its license, providing what it is licensed to provide. On its face, this is reasonable. The flaw, though, is that patients usually receive program-focused care, not individual-focused care. The program is unlikely to change its approach to fit the need of the individual. It may admit the person because the payer permits it, not necessarily because it is the right fit. If it doesn’t work out, well then, the individual was not motivated to change. But the program is still reimbursed for the service, regardless of the outcome.
In these cases, the client may or may not be motivated to change, but the program certainly isn’t. If you are not paid for patient outcomes (known as a value purchase) you may not have to take a cold-eyed dispassionate look at your results. There is no incentive to do things differently. And this is a problem. However, if reimbursement shifts to value and improved outcomes, then there is an incentive to adopt clinical practices that fit the needs of an opioid-addicted individual. Improved treatment outcomes mean fewer relapses and fewer overdoses.