Technology and the Opioid Epidemic: Your Questions Answered

Relias hosted a webinar on The Role of Technology in Solving the Opioid Crisis with a panel of experts from National Council, myStrength, Relias, and Beacon Health Options discussing the current state of the opioid crisis and different types of newer technology that can help providers make a positive impact on outcomes.

We were pleased to see the interest in this topic and response by the hundreds of professionals from different segments of healthcare who joined the webinar and asked for the recording. Due to the discussion nature of the webinar, we were unable to address questions in a typical end of webinar Q&A session, so we created this blog post to address everything our audience brought up.

If you would like, you can view the webinar recording and be sure to check the Relias webinar page for information about upcoming webinars on topics related to healthcare and human services. We host regular webinars to support you with helpful, relevant information.

Our webinar presenters listed below collaborated to provide the answers to these questions, a special thanks to our esteemed group of colleagues:

Aaron Williams, MA, Senior Director of Training and Technical Assistance for Substance Abuse, National Council for Behavioral Health
Abigail Hirsch, PhD, Chief Clinical Officer, myStrength
Carol Duncan Clayton, PhD, Translational Neuroscientist, Relias

Question: What tools do you believe are most effective for those clients who are trying to reduce use/maintain sobriety?

Answer: For opioid use disorders (OUDs), medication-assisted treatment (MAT) is a highly effective, gold standard treatment. At the same time, it’s important to note that MAT is most effective when coupled with talk therapy interventions. myStrength’s digital behavioral health self-care tools can be a valuable piece of such a program.

Relapse prevention based in motivational interviewing, stages of change, and cognitive behavioral therapy (CBT) have strong evidence base for substance use disorders (SUDs) as well. Additionally, social support is an important aspect of recovery. People experiencing SUDs trust peers. Stories, peer support, and testimonials from others are immensely powerful. These evidence-based approaches are integrated into myStrength’s Opioid, Alcohol and Drug Recovery resources.

Finally, SUD comorbidities with behavioral health concerns, especially depression, anxiety and trauma, are very high. myStrength’s platform facilitates support for both SUDs and behavioral health concerns. Likewise, treatment programs must work effectively in conjunction with pharmacological interventions.

New models of risk based modelling for early detection of risk for opioid dependency or later risk of mortality should be mentioned here as emerging tools to assist providers with pinpointing evidenced based interventions based on the continuum of sobriety to dependency.

Question: You indicated only 20% of those who have a substance use disorder (SU d/o) are receiving treatment. Is this entirely due to the lack of availability of treatment or is the percentage also due to those with SU d/o not seeking/wanting treatment?

Answer: It is a little bit of both. A significant number of those who meet criteria for treatment don’t feel they have a problem and therefore do not seek treatment. There are also a host of other reasons why people don’t seek treatment, such as under detection. As mentioned above, newer risk modelling tools assist providers with reaching out and being proactive in consumer engagement for those that might benefit from a “nudge” in awareness or engagement. We have included a slide from SAMHSA that discusses some of those reasons. Given the waiting lists and lack of providers in some parts of the country, there is little doubt that the substance use treatment system has serious issues with the availability of treatment services and that needs to be addressed as well.

Question: It looks like Suboxone is showing better outcomes than Vivitrol but jails are very resistant in allowing this as an option. How can we help corrections understand and get it?

Answer (Aaron Williams, National Council): In most of the research I am familiar with, buprenorphine (suboxone) and extended-release naltrexone (Vivitrol) have comparable outcomes once patients are initiated on the medications (NCBI article). Extended-release naltrexone is more difficult to initiate because patients need to be opioid abstinent for about 5-10 days before starting extended-release naltrexone. Having a controlled substance such as buprenorphine in a locked environment presents a different set of logistical concerns for jails and prisons and will require more training and education to get staff comfortable with the medication and how to use it in a safe and effective manner. Generally, I support the idea that jails and prisons should provide access to ALL the evidence-based practices and medications to effectively address clients that may have a substance use disorder. One size does not fit all, so in my view, it is not a matter of “either/or” but one of “both/and” in terms of what should be available in these locked settings.

Question: I was hoping this webinar could talk more about 42 CFR and health care information exchanges, can substance use consults for general hospital patients be in the chart? Who should be able to read it?

Answer: Before we get into the answer to this question, it’s important to mention that when assessing concerns with 42 CFR it is always good practice to work with legal counsel when these matters arise. We also invite you to review available resources for further knowledge and understanding:

SAMHSA Final Rule on 42CFR

Disclosure of Substance Use Disorder Patient Records: Does Part 2 Apply to Me?

Legal Action Center

The short answer to the specific questions is, it depends. It depends on whether the entity involved is considered a “covered entity” under 42 CFR. 42 CFR has two-prong criteria for determining whether an organization or entity is a “covered entity” and 42 CFR applies. The first criteria is whether the entity is federally funded in some way. The second criteria is whether the entity is holding itself out “to be a substance use treatment entity.” Making this determination in concert with legal counsel and your executive staff should be the first step in addressing the scenario you have cited. Once you have done that, then you can put in the proper agreements and consent forms necessary to move forward. The SAMHSA Disclosure of Substance Use Disorder Patient Records: Does Part 2 Apply to Me document referenced above describes some useful scenarios that may help you further.

Question: Do you find there is an “addictive” personality component with opioid usage vs. alcohol abuse?

Answer (Aaron Williams, National Council): While I don’t know what is meant by “addictive personality”, what I can tell you is that both opioids and alcohol are highly addictive substances and when abused/misused they can cause significant negative and harmful consequences to the user, other related parties, and the society at large. Evidence also shows that there is significant overlap of substance use disorders with mental health disorders compared to either alone.

Question: Hi, I am an RN Case Manager and it seems that more providers are stopping Opioids cold turkey, and members are actually going through withdrawals, going to the ED and being admitted. These are people who have been taking opioids for more than 10 years. How can we educate the providers, that they do not need to stop these medications, but rather add to the course of treatment, which might include behavioral healthcare (BH)?

Answer: The questioner is correct that providers do need additional education on what to do. One of the unintended consequences of the CDC guidelines is that many providers are using them as an excuse to terminate opioid prescriptions. It is crucial to educate prescribers of opioids that it is his or her responsibility to manage the discontinuation of the opioids and to provide education about how to do so. This management might include providing a taper themselves, referring for addiction treatment, or in some cases, rapid termination. Hospital admission may be necessary to manage the withdrawal symptoms in some cases. Some prescribers think an appropriate triage is to say “go to the ER” and their work is done. This action is not appropriate triage.

The Relias Performance Solution for Opioid Improvement includes brief educational cautions on these points of responsibility and appropriate tapering actions. We also have metrics that identify and encourage the use of medication assisted treatment when the clinical picture suggests MAT as an appropriate alternative treatment.

One of the Relias medical experts in pain management, Dr. Karl Haake stated: “I am working with a small hospital in Missouri where we are seeing a lot of this inappropriate pattern. We have put together a team of physicians including the hospitalists and the primary care providers to work with a behavioral health specialist who is working for the hospital in an inpatient setting to help with those patients. That way everyone has a plan when an opioid is discontinued and patients have an expectation about what will happen when it is discontinued. Care Coordination and patient education are key.”

Question: Have any of you partnered directly with any PBM (pharmacy benefit managers)?

Answer: myStrength is currently developing partnerships in the pharmaceutical space. Relias partners with PBM, health plans or others who have access to pharmacy data in order to fuel its data driven platform that includes risk modelling for early opioid dependency detection and later risk of mortality.

Questions for myStrength on Application/Platform:

Watch this quick video to learn more about Opioid Recovery with myStrength’s digital behavioral health platform.

Question: Is myStrength a free application? And how much does myStrength cost?

Answer: Consumers gain no-cost access to myStrength through a sponsoring organization. This could be through their healthcare provider, payer, employee assistance program (EAP), etc. If through a community provider, myStrength contracts through an Enterprise License, aligning its annual licensing fee to the overall size of an organization (specifically, looking at the total number of unduplicated consumers served annually and applying that to a graduated scale to determine an annual licensing fee). If through a health plan, EAP or health system, myStrength typically contracts through a pm/pm model. Visit www.myStrength.com for more information.

Question: How does data get entered into this platform? Does it work bidirectionally with EHRs to get that information, or does it need to be manually entered? And is this included if you purchase myStrength? Does the myStrength platform connect the data to providers or Health Plans?

Answer: myStrength offers application programming interfaces (APIs) to support seamless, HIPAA-compliant connection into clinical workflows and support systems. myStrength’s APIs enable care teams to easily connect consumers with myStrength and monitor their progress as they engage with myStrength assessments and resources. This enables integration of relevant, timely myStrength user data back into care management or EHR systems, including registration completion data, health assessment and mood tracker results, and myStrength activity completion information. Basic consumer data can also be passed to myStrength directly from client records stored in third-party platforms. This functionality is included when purchasing myStrength, although you may need to work with your EHR provider for their system to accept the appropriate data.

Question: Can we track outcomes via this application?

Answer: myStrength provides outcome data on a number of levels, including changes in a consumer’s depression and anxiety symptoms. Monthly reporting provides partners with metrics on adoption, consumer demographics and engagement. Partners also receive clinical outcome data based on their preferred user assessment, such as the PHQ-9 (Patient Health Questionnaire) or WHO-5 (World Health Organization Well-Being Index). myStrength users are prompted to complete the assessment upon account creation to provide a baseline, and are prompted to re-take the assessment at 14, 60, 180 and 365 days later to measure long-term success.

Question: Does myStrength content about MAT address the stigma that people face when using MAT? I know that many folks I have worked with in treatment struggle to find peer support networks that respect MAT and don’t consider it “trading one addiction for another.”

Answer: Yes, myStrength’s Opioid Recovery resources support all stages of medication-assisted treatment (MAT), with tools that help people bust MAT myths (it is not trading one drug with another), and educates the consumer on what MAT is, whether MAT is for them, the goals of MAT, and other treatment options. myStrength also offers tools to build a healthy support network, plus insights on shame, forgiveness, and the emotional fallout of addiction.

Question: Very interested in risks assessments…treatment paradigms including myStrength and finally the comorbidities of MH and SA.

Answer: myStrength offers a consumer assessment to help individuals understand if their opioid use is problematic, in addition to customizable health and well-being trackers and goal-setting tools. When consumers have multiple downward trending health assessment results, myStrength recommends they seek additional help via partner-provided resources.

Combining personalized risk assessments with relatable, evidence-based and interactive behavioral health self-care resources encourages individuals to be actively involved with their care team to create a custom plan for living fully. myStrength offers whole-person support as a standalone self-care platform or adjunct to traditional therapy, including for comorbid conditions like depression, anxiety, stress, and insomnia – all of which can amplify substance use challenges.

Question: Is myStrength available to everyone in the US?

Answer: myStrength partners with healthcare providers and payers nationwide to provide myStrength access to their clients.

Question: I appreciated the data on the chronic pain program on myStrength. Are there data on the OUD version targeting education and compliance on MAT? Or ongoing studies?

Answer: myStrength is launching early trials on its opioid use disorder (OUD) resources. Preliminary study results should be available by fall 2019.

Question: Who are the ideal individuals who make use of technology/app based treatments? Is there a clearly identified profile?

Answer: The myStrength platform can support anyone aged 13 and older, and can help relieve common, daily stressors, all the way to long-term challenges like clinical depression, substance use disorders, chronic pain, and more. myStrength adjusts each day and with every interaction. Preferences and goals, current emotional and motivational states, and ongoing life events are all captured. myStrength’s sophisticated machine learning algorithms create individualized myStrength experiences that include interactive self-care programs, in-the-moment coping tools, inspirational resources, and community support.

Question: What are some strategies you have considered to make these technological tools accessible to communities who may not have a high level of technical literacy?

Answer: myStrength is designed to be simple and user friendly. With a large portion of our userbase in Medicaid populations, we adhere to best practices in software development for such populations. For example, myStrength can be customized to contain content only at a 5^th grade reading level. The site is also WCAG accessibility compliant.

myStrength’s digital self-care platform can be utilized across diverse use cases. In addition to use as a self-care application that extends care after hours, between sessions, to rural populations, and more, myStrength can be used in real-time during live sessions with providers, peers or clinicians. Additionally, many of myStrength’s clinical tools can be printed and provided to the client in paper form to bridge and augment treatment. These are often positioned to the client as “homework” with blank fields the consumer can fill in with a pen or pencil.

myStrength not only emphasizes proven, evidence-based therapeutic approaches, but also delivers a positive, personalized and rewarding user experience. Prior to the introduction of new features, programs or content, myStrength conducts rigorous satisfaction and user experience testing by diverse end-users and providers, in addition to actively soliciting feedback from these groups regularly. User testing always includes users with low technical literacy to insure the site is simple to use. Additionally, myStrength offers guided behavioral health support as well as the option to explore the platform freely to meet various users in their unique path to recovery.

Questions for Relias Regarding the Platform and Tools:

Question: On side 21 (results), do you have any results specific to certain populations? e.g. Medicaid or uninsured? Is there a target population for Relias – outside of those with substance use disorder?

Answer: Relias has seen positive outcomes across its customer base. Results have been demonstrated across Medicaid, Medicare and commercial insurance. The results are universal because the pain experience is universal–not specific to race, age, class, SE status, geography or ethnicity. However, there are certain factors within subpopulations that create higher risk. For example, younger white males (ages 35-44) living in rural areas are at a higher risk of opioid dependency compared to other age/race/geography counterparts. The Relias solution targets an entire population, using artificial intelligence to identify pockets of risk for dependency and mortality within that population to then target learning and consumer directed targeted actions to reduce risk. And yes, the Relias Performance Solution reaches beyond OUD in identifying, tracking and reporting on outcomes relative to a broad range of health conditions – behavioral health, chronic health, and multi morbid conditions.

Question: Really enjoying your presentation! I loved the provider dashboard. However, how does the system access the data for the dashboard? Is this somehow connected to the EMR? Getting data is a major challenge. How is this done?

Answer: The Relias Opioid Performance Solution is powered by paid claims data. Relias has joined with Substance Use State Agencies, HealthPlans and Providers in data cooperatives to gain access to data to drive improvements in opioid dependency and risk. When payers and providers are joint together in a public health endeavor, the data challenges are much diminished. All stakeholders are working toward a common goal – to reduce dependency, educate providers and consumers and ultimately save lives.

Question: Can we track outcomes via this application? does info from application interface w/EHR?

Answer: The Relias Opioid Performance Platform is a ready built outcomes measurement tool. It is a performance tracking and trending solution that tracks reduction in clinical variation that is outside of best practice in the use of the opioid medication driving poor outcome and high costs. Performance measures are tracked to benchmark, tracked to financial incentives and tracked toward improved clinical outcome. The solution allows the provider to track outcomes with the contract year for modelling and versioning relative to incentive or other risk based contracting. The solution also includes performance benchmarking in which clinicians and prescribers can monitor their own individual outcomes, compared to peers, while also viewing overall agency outcomes and improvements.

The Relias performance technology extends beyond the opioid epidemic to track outcomes relative to over 200 performance outcomes important to healthcare payers and providers such as HEDIS, SAMHSA Core Health Home Measures, CCBHC Measures, pharmacy management, and/ or other state or payer specific outcome metrics.