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Digital Health Transformation and Alternative Delivery Models
Part one of a two part blog series on Care for Substance Use Disorder Populations during COVID-19.
Content provided by Jill S. Warrington, MD, PhD. Blog edited by Alexa De Vivo.
The COVID-19 pandemic has led to unprecedented changes globally, in our communities and in health care. Like a latex balloon that has been stretched and never bounces back to its original form, health care delivery will never be the same as we navigate through and past this emergent crisis.
The silver lining in this challenging global emergency has been the ingenuity and innovation across our country and our world. We have seen remarkable collaborations, accommodations and accelerated transformations.
Changes in health care delivery have spanned five domains of medical care. We have seen a transformation of digital health, ingenious alternatives to traditional care delivery models, adjustments in regulatory and payor strategies, an adoption of a population health approach to care and an increasing recognition of our patients’ unmet social and behavioral health needs. If progress continues in each of these domains, long-existing care gaps can be obliterated.
Digital health transformation and alternative delivery models are helping to pave the way for the future of healthcare, post COVID-19. While telehealth was being offered at most healthcare establishments in the pre-COVID-19 world, the spread of mandated stay at home orders prompted telehealth across the globe.
Large health systems such as Geisinger Health System and the Cleveland Clinic have reported a 5-10-fold increase in use of telehealth services (1). We’ve also witnessed adoption of novel strategies in surveillance and triage such as the use of Chat Bots to support patient symptom identification and facial scanners in hospitals to recognize fevers (1,2). Anecdotal reporting for the Substance Use Disorder (SUD) population suggests digital health solutions have reduced numbers of missed appointments (3).
Alternative delivery models were used before the introduction of COVID-19 but many health systems sped up the process of developing take home or remote methods for medical testing.
Prior to and in response to COVID-19, laboratory services were innovating in alternative care delivery models such as at-home blood draws (4), drone use in medical product delivery (5) and at home monitoring programs (6). Further development of these types of innovations will only be aided by COVID-19.
Part two of this blog series, "How is COVID-19 Redefining Care Delivery for the SUD Population?", will discuss regulatory shifts and population health adaption. It will also go over recognition of unmet social and behavioral health needs.
References:
1) Paddy Padmanabhan, 3-27-2020, How the COVID-19 pandemic is reshaping healthcare with technology, CIO. https://www.cio.com/article/3534499/how-the-covid-19-pandemic-is-reshaping-healthcare-with-technology.htm [last accessed, 5/5/2020].
2) Greg Nichols, 3-27-2020, Coronavirus: Business and technology in a Pandemic. Robotics. https://www.zdnet.com/article/overhead-scanners-screen-bystanders-for-signs-of-covid-19/, [last accessed, 5/5/2020].
(3) Mindy Miller, personal communication.
(4) https://www.northwell.edu/northwell-health-labs/labfly, [last accessed, 5/5/2020].
(5) Paavola A. 6 things to know about WakeMed’s drone delivery program. 2-24-2019. Becker’s Hospital Review https://www.beckershospitalreview.com/supply-chain/6-things-to-know-about-wakemed-s-drone-delivery-program.html, [last accessed, 5/5/2020].
(6) American Society of Addiction Medicine, COVID-19 Adjusting drug testing protocols. 4-29-2020. https://www.asam.org/Quality-Science/covid-19-coronavirus/adjusting-drug-testing-protocols, [last accessed, 5/5/2020].
[post_title] => How is COVID-19 Redefining Care Delivery for the SUD Population?
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Medication-Assisted Treatment (MAT; also known as Medications for Opioid Use Disorder; MOUD) is a lifeline for so many in treatment with Opioid Use Disorder. In particular, the combination product of buprenorphine-naloxone (Suboxone) has saved lives by preventing overdoses, reducing IV heroin-associated infectious diseases - such as HIV and Hepatitis C - and by improving patient's chance of staying in treatment.
Given the importance of buprenorphine treatment, patients at times can feel pressure to demonstrate that they are staying on the medications, even if they haven't been able to stick with the treatment plan. This can result in feelings of shame, fear of repercussions, or a desire to not disappoint their provider. As part of the disease process, patients may even be motivated by the desire to divert or sell some of their medications.
Due to these pressures, patients can occasionally engage in a practice where they "spike" the original drug directly into their urine. In this case, buprenorphine will be detected in a patient's urine, but it will not have been actually consumed. This practice will be missed on any common immunoassay-based screening method. However, if confirmation testing is ordered, both the original drug (also known as the parent drug) as well as the drug's metabolite (norbuprenophrine) will be detected.
Providers have increasingly relied upon the ratio of the metabolite norbuprenorphine to the original drug (buprenorphine), known as the N:B ratio, to identify this practice of spiking urine samples with drug. Since naloxone is also part of the Suboxone combination product, there has been some speculation that naloxone levels can also be used to highlight this practice.
Aspenti conducted a study to determine if elevated naloxone levels can be used to flag possible cases in which patients have spiked their urine with drug. Though only a small case study, this was the largest evaluation of urinary naloxone concentrations to date. We found that naloxone levels (>2000 ng/ml) may be useful clinically to flag cases of possible urine spiking with Suboxone.
To learn more about this recent study, please see the article here: https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-020-0178-9.
[post_title] => Using Naloxone Levels To Detect "Spiked" Urine Tests
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[post_content] => On Monday, April 1st China announced it would ban all variants of fentanyl, a powerful opioid. This decision is crucial because it would slow the influx of illegal fentanyl supply coming into the United States.
[caption id="attachment_59694" align="alignright" width="194"]
Xi Jinping[/caption]
Chinese leader, Xi Jinping, had made this pledge to President Trump late last year and the fact that it has come to fruition this quickly is an accomplishment for both nations in the war against opioids.
The export of fentanyl from China accounts for a majority of the drugs that end up in the US, and this has caused tension between the nations in the past. There are already some regulations in place that apply to 25 variants of fentanyl but a group of manufacturers have avoided the regulations by slightly changing the molecular structure to gain a legal loophole that allows them to export the drug without government assessment of medical use and safety.
Fentanyl, is a synthetic opioid that is exponentially stronger than morphine and was originally developed to help treat pain for cancer patients. However, the drug can easily be abused and added to heroin to increase it's high effects, or even disguised as heroin. Oftentimes, users will think they are purchasing heroin but are actually purchasing fentanyl, easily resulting in overdose deaths.
Mary Brandenberger, a spokeswoman for the DEA explained that this is a huge move for China and that it has the potential to even "eliminate Chinese drug traffickers and their ability to alter fentanyl compounds to get around the law".
With opioid overdose deaths hitting the US in record numbers over the last few years, there is hope that this move can help alleviate the current state of the crisis and move towards a resolution.
References:
NPR (2019). "China To Close Loophole On Fentanyl After U.S. Calls For Opioid Action" https://www.npr.org/2019/04/01/708801717/china-to-close-loophole-on-fentanyl-after-u-s-calls-for-opioid-action
NY Times (2019). "China Bans All Types of Fentanyl, Cutting Supply of Deadly Drug to U.S. and Fulfilling Pledge to Trump." https://www.nytimes.com/2019/04/01/world/asia/china-bans-fentanyl-trump.html
[post_title] => This Deadly Drug Is Now Banned In China...What Does It Mean for the US?
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[post_content] => Methamphetamine has always been an issue in more rural states, but recently Massachusetts has seen an influx of meth overdoses in the Boston area. In a recent study from the National Emerging Threats Initiative (NETI), most of the meth sold in the United States is produced in Mexico, then shipped through suppliers that are also dealing in cocaine, fentanyl, and heroin.
It was once thought that the arrest of "Chapo" Guzman in 2016 would create a substantial decline in methamphetamine manufacturing. However, the emergence of the Jalisco New Generation Cartel and the re-organization of the Sinaloa Cartel increased the problem within the last 2 years.
“New initiates of methamphetamine use (people who had not previously used methamphetamines) increased by 47% from 133,000 in 2010 to 195,000 in 2017. At the same time, HIDTA seizures of methamphetamine increased from 256% from 8,021kg in 2011 to 28,558 kg in 2017.”
[caption id="attachment_59335" align="aligncenter" width="600"]
The above graph reflects the change in methamphetamine/ice seizures, in terms of amount seized (in kilograms) and the total number of incidents (reported in Kg, dosage units and liter forms) within all HIDTA counties from 2011[/caption]
Individuals usually start with heroin that is being cut with meth, and then move on to straight meth. Meth users don’t feel as sick when they are coming down from the high and meth is cheaper than heroin. However, despite meth being an easier option for it’s users, it is not for treatment options within hospitals and clinics.
Meth overdoses have increased across the United States, and while we may not see the full impact of the influx of meth in Boston right now, it'll show up in a few years. The meth issue is compounding the opioid epidemic, because while patients addicted to fentanyl or heroin are usually prescribed a medication to curb cravings, patients have been trying to use meth while in treatment for their opioid addiction to help cope. It appears the opioid epidemic has set itself on a larger scale, with cocaine and methamphetamines and is becoming more of a drug epidemic.
References:
Martha Bebinger (2018). Meth Use Is Rising In Boston, Intensifying The Opioid Crisis. http://www.wbur.org/commonhealth/2018/11/21/meth-worsening-opioid-epidemic
National Emerging Threats Initiative (2018). Emergening Threats Report 2018: Status and Factors Affecting the United States. https://d279m997dpfwgl.cloudfront.net/wp/2018/11/1120_emerging-threats-report.pdf
[post_title] => Why is Meth Use on the Rise in Boston?
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[post_content] => Aspenti was included in a round table discussion with Governor Phil Scott regarding hiring recovering opioid addicts. “We care tremendously about recovery-friendly workplaces,” said Al Gobeille, Vermont’s Department of Human Services secretary. Gobeille went on to add, "The biggest thing the state does is we provide medically assisted treatment that allows people to get treatment for their addiciton, and then we try to couple that with employment opportunities."
There are about 8,000 people in treatment for opioid use disorder, according to the state’s agency of human services. Watch the news story here to learn about how employers are helping support recovering Vermonters seeking a fresh start.
[post_title] => Local Vermont Businesses Helping Recovering Addicts Find Employment
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[post_content] => Our kids are getting the message!
Like you, my readers, I find myself simultaneously worrying and hoping much of the time. With constant exposure to essential information regarding opioid use in America, it can be difficult to feel optimistic. Well here is some good news to start off the New Year!
There is ample reason for our country to celebrate this New Year, as one reviews the recent findings of the 2017 Monitoring The Future Study, https://www.drugabuse.gov/news-events/news-releases/2017/12/vaping-popular-among-teens-opioid-misuse-historic-lows. This study clearly reflects the ability of our youth to make healthy decisions when they are guided by the attention of adults in leadership positions, providing them with accurate information regarding drugs and decision-making skills.
Our Prevention Programs are working.
At a recent teleconference I attended led by Dr. Nora Volkow, NIDA Director, I learned adolescent tobacco use is at an all-time low since 1979.
Dr. Johnson of the University of Michigan, the Principal Investigator of this study for 42 years, stated that there has been a “tremendous decline in cigarette smoking since the mid-90s, the most prevalent cause of preventable death and disease in America.” Dr. Volkow also noted significant decreases in alcohol and pain-medication use.
Reasons For Celebration
I tuned in to the President’s Commission on Combating Drug Addiction and the Opioid Crisis’ announcement of its Final Report on November 1, with the hope that the Commission had independently done its homework and arrived at meaningful recommendations for our country’s health.
I was not disappointed.
While the broadcast itself lasted much longer than I had planned, (over two hours), I found myself thoroughly engaged from the opening comments to the unanimous vote to adopt the committee’s recommendations.
What was striking about the broadcast was the human emotion expressed by the committee, the empathy in the chamber, and the scientific data and decades of experience in this field available to the leadership. If the Administration chooses to fully utilize the potential at its disposal, as recommended by the Commission, we will be looking back at this era someday as history, rather than wondering why “history repeats itself”.
Dr. Bertha Madras, well-noted chair of the Division of Neurochemistry at Harvard Medical School, was the lead author of the 131-page final report. Dr. Madras advised “If we don’t stop the pipeline into substance use, if we don’t promote prevention, we are going to have an open-ended catastrophe that goes on for generations.”
The human tragedy and immeasurable anguish associated with this crisis was poignantly and powerfully communicated by Doug Griffin.
Mr. Griffin, a father from Newton, NH, talked about how his daughter, Courtney, struggled with opioids. Courtney died at age 20, from an overdose. Mr. Griffin, sobbing, ended his testimony with, “I pray your children are spared from this plague, and that you never know what it’s like to be me.”
As unimaginable as it may seem, to really understand the depth and magnitude of America’s drug crisis, we need to multiply Mr. Griffin’s pain by 64,000 in 2016; this is the estimated number of drug overdose deaths for that year according to preliminary data from the Centers for Disease Control and Prevention. One death every seven minutes.
The Commission’s Final Report was issued November 1, 2017…
This Blog was written on November 20, 2017…
One death every seven minutes equals 3,908 overdose deaths since the Commission’s Report. Yet there have been 0 words from the Administration regarding funding intentions or planning in response to the Report.
A link to the Commission’s Full report, and a link to a PBS analysis of the Commission’s formal announcement, including the video, are noted below. These are both worth a very close look when time permits.
Only a well-informed public can influence its leaders in meaningful and appropriate ways.
Commission’s Final Report
https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Meeting%20Draft%20of%20Final%20Report%20-%20November%201%2C%202017.pdf
PBS NEWSHOUR Summary and Video of the Commission’s announcement (Please note there is a 44 ½ minute delay in the video’s beginning. Viewers can easily advance to the starting point)
https://www.pbs.org/newshour/health/watch-live-trumps-opioid-commission-slated-to-release-final-report
[post_title] => Opportunity Knocks: The President’s Commission On Combatting Drug Addiction And The Opioid Crisis’ Final Report
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[post_content] => When I pull into my driveway after work, there is a sense of serenity and joy. The stressors of the day often fade before the garage door even opens. My home is not the house: it is defined by my family and the love and support we share. For many individuals after inpatient treatment for Substance Use Disorder(s), there is no home to return to, or it is the same one which played a significant role fueling their substance use.
One of the first acronyms someone in early recovery might hear is SOBER (Son of a B****, Everything’s Real). It can be a time of terror and uncertainty, extreme loneliness, and not knowing who to turn to for support. Paying bills, making appointments, job applications and many other day-to-day tasks can be overwhelming. Without proper support, the danger of relapse is significant and may lead to tragedy and death.
Katherine Thom, in her SAMSHA (Substance Abuse and Mental Health Services Administration) article, Recovery Homes Help People in Early Recovery, offers hope. She begins by quoting Lori Criss, Associate Director of the Ohio Council of Behavioral Health & Family Services Providers, who explains why the phrase, “People, Places and Things” has so much influence in the recovery community. “Who we spend our time with, where we go, and the things we surround ourselves with all impact who we are and the decisions that we make. Many times, people in early recovery have to give up everything they’ve known… because those people, places, and things put them at risk for relapse or continued use. Early recovery can be painful and isolating. Recovery housing can fill that void with a safe place, compassionate people, and a life full of purpose and fun that doesn’t involve alcohol or drugs,” says Criss (Thom, 2013).
The idea is not a new one. It is gaining traction nationally and here in Vermont. And there is a desperate need to expand access. Recovery homes are an effective and reasonably priced option. They provide a safe environment that empowers residents on their journey of recovery. Empowerment through support to achieve independence is what we as parents try to provide for our children. And the sober home model offers that second chance where one can redefine their life, make a difference, view one’s contribution as valuable, and consequently, feel valuable.
According to Thom, Criss is proposing private-public partnerships to create more recovery homes which offer services for lower socio-economic individuals with Substance Use Disorder(s). Criss suggests, “A responsive system will provide access to affordable, mainstream housing where people can be safely housed and supported in recovery at their own pace. The strength of recovery-focused housing is its ability to provide ongoing peer support while promoting sobriety in a natural home environment” (Thom, 2013).
No one willingly chooses a life dominated by substance use, just as no one willingly agrees to the return of cancer after treatment. We should embrace and treat those striving for a life of recovery as the truly remarkable and deserving survivors they are. Substance Use Disorder is not a choice. It is an illness, period!
Unintentionally, I take for granted just how privileged I am. It is something everyone should have and what every home should feel like.
Learn about the National Alliance for Recovery Residences (NARR) at: National Association of Recovery Residences (NARR) Their mission is “To support persons in recovery from addiction by improving their access to quality recovery residences through standards, support services, placement, education, research and advocacy.”
And learn about the Vermont Association of Recovery Residences at: https://narronline.org/cm-business/vermont-association-of-recovery-residences/
Reference
Thom, K. (2013). Recovery Homes Help People in Early Recovery. SAMSHA. Retrieved October 16, 2017 from: https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/recovery-homes-help-people[
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[post_content] => As we saw in Part 1 of this series, the tendency toward impulsive decision-making as a response to stress is a risk factor in developing substance use disorder. The opposite of impulsive behaviors are behaviors that are consciously chosen as a response to stress because they are likely to result in healthy, or positive, outcomes.
Deliberative, weighed out responses to stress are a product of “executive function processes” carried out by the pre-frontal-cortex. These are learned during childhood and adolescence, primarily. This is the key component to what is known as “Resilience”. When a concerned, committed adult supports a child’s coping with stressful situations, there is an actual effect on the development of the child’s brain, on their learned ability to cope with stress in a productive manner. This skill or function, once developed, can last a lifetime. This is Resilience.
Resilience can be defined as:
[post_title] => Resilience Part 2
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[post_date] => 2017-11-01 14:48:32
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[post_content] => I listened attentively to the speech, pulled over to the side of the road, taking notes.
I heard the President declare there were over 64,000 deaths attributable to drug overdose in 2016, with 2/3 of these being caused by opioids. Overall about 7 deaths per hour. I heard him say that in West Virginia 1 of 5 newborns come into this life with Neonatal Abstinence Syndrome as a health consequence of the birthmother’s addiction to opioids. I heard him elaborate on the importance of Substance Use Counseling being provided to people with addiction who are incarcerated. And I listened as he underlined the inestimable significance of demand reduction over the foreseeable future, the cultural mandate to protect our children by educating them and supporting them, fully equipping them with the cognitive, emotional and social skills necessary to choose healthy behaviors, and avoid the allure of psychoactive chemicals.
I couldn’t have agreed more with every point he made.
What I didn’t hear was the “first and most urgent recommendation” of the Interim Report of the Commission on Combating Drug Addiction and the Opioid Crisis*: to “declare a national emergency under either the Public Health Service Act or the Stafford Act”. This would have created a wide avenue for the quick release of funds to support initiatives, which the declaration of a public health emergency fails to do.
The National Council For Behavioral Health stated “ While the National Council is pleased to see the President recognize the opioid crisis as a public health emergency , the announcement comes without any new funding to respond to the epidemic and the specifics of the declaration are still unclear”.
It’s important to note that the following major recommendations of the President’s Commission’s Interim Report all included funding:
Digital Health Transformation and Alternative Delivery Models
Part one of a two part blog series on Care for Substance Use Disorder Populations during COVID-19.
Content provided by Jill S. Warrington, MD, PhD. Blog edited by Alexa De Vivo.
The COVID-19 pandemic has led to unprecedented changes globally, in our communities and in health care. Like a latex balloon that has been stretched and never bounces back to its original form, health care delivery will never be the same as we navigate through and past this emergent crisis.
The silver lining in this challenging global emergency has been the ingenuity and innovation across our country and our world. We have seen remarkable collaborations, accommodations and accelerated transformations.
Changes in health care delivery have spanned five domains of medical care. We have seen a transformation of digital health, ingenious alternatives to traditional care delivery models, adjustments in regulatory and payor strategies, an adoption of a population health approach to care and an increasing recognition of our patients’ unmet social and behavioral health needs. If progress continues in each of these domains, long-existing care gaps can be obliterated.
Digital health transformation and alternative delivery models are helping to pave the way for the future of healthcare, post COVID-19. While telehealth was being offered at most healthcare establishments in the pre-COVID-19 world, the spread of mandated stay at home orders prompted telehealth across the globe.
Large health systems such as Geisinger Health System and the Cleveland Clinic have reported a 5-10-fold increase in use of telehealth services (1). We’ve also witnessed adoption of novel strategies in surveillance and triage such as the use of Chat Bots to support patient symptom identification and facial scanners in hospitals to recognize fevers (1,2). Anecdotal reporting for the Substance Use Disorder (SUD) population suggests digital health solutions have reduced numbers of missed appointments (3).
Alternative delivery models were used before the introduction of COVID-19 but many health systems sped up the process of developing take home or remote methods for medical testing.
Prior to and in response to COVID-19, laboratory services were innovating in alternative care delivery models such as at-home blood draws (4), drone use in medical product delivery (5) and at home monitoring programs (6). Further development of these types of innovations will only be aided by COVID-19.
Part two of this blog series, "How is COVID-19 Redefining Care Delivery for the SUD Population?", will discuss regulatory shifts and population health adaption. It will also go over recognition of unmet social and behavioral health needs.
References:
1) Paddy Padmanabhan, 3-27-2020, How the COVID-19 pandemic is reshaping healthcare with technology, CIO. https://www.cio.com/article/3534499/how-the-covid-19-pandemic-is-reshaping-healthcare-with-technology.htm [last accessed, 5/5/2020].
2) Greg Nichols, 3-27-2020, Coronavirus: Business and technology in a Pandemic. Robotics. https://www.zdnet.com/article/overhead-scanners-screen-bystanders-for-signs-of-covid-19/, [last accessed, 5/5/2020].
(3) Mindy Miller, personal communication.
(4) https://www.northwell.edu/northwell-health-labs/labfly, [last accessed, 5/5/2020].
(5) Paavola A. 6 things to know about WakeMed’s drone delivery program. 2-24-2019. Becker’s Hospital Review https://www.beckershospitalreview.com/supply-chain/6-things-to-know-about-wakemed-s-drone-delivery-program.html, [last accessed, 5/5/2020].
(6) American Society of Addiction Medicine, COVID-19 Adjusting drug testing protocols. 4-29-2020. https://www.asam.org/Quality-Science/covid-19-coronavirus/adjusting-drug-testing-protocols, [last accessed, 5/5/2020].
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