Prescription opioid abuse has reached staggering levels, resulting in a public health crisis in urban and rural communities throughout the United States. Recent epidemiological studies have shown an unprecedented increase in the rates of morbidity and mortality associated with prescription painkillers and opioid medications, contributing to an extensive socioeconomic burden involving reductions in social capital and workforce participation, increased utilization of emergency medical services, and higher health care costs (e.g., Kolodny, Courtwright, Hwang, Kreiner, Eadie, & Clark et al. 2015; Ghertner & Groves, 2018; Meyer, Patel, Rattana, Quock, & Mody, 2014). According to the Centers for Disease Control and Prevention (CDC), more than 700,000 deaths in the U.S. between 1999 and 2017 were the result of drug overdose. In 2017 alone, nearly 68% of the 70, 200 recorded incidents of death by overdose involved some form of an opioid. Moreover, the rate of mortality secondary to opioid use has tripled since 1999, with nearly 130 Americans dying every day from an opioid overdose (CDC WONDER, 2017). While the opioid epidemic continues to affect individuals and communities regardless of region, counties with higher rates of poverty and unemployment have generally been found to have higher rates of opioid sales (including Medicaid opioid prescriptions filled) and increased prevalence of death associated with drug overdose and opioid-related hospitalization (see Ghertner & Groves, 2018). Thus, understanding the links between community-level prevalence of opioid use and social, cultural, and economic factors is crucial for decision-makers at federal, state, and local levels (Meyer et al., 2014; Ghertner & Groves, 2018).
Despite the clear need for an innovative approach to managing the opioid crisis, most efforts have primarily focused on limiting access to opioids with the goal of reducing dependence, rather than addressing the multidimensional factors that contribute to opioid addiction (Kolodny, Courtwright, Hwang, Kreiner, Eadie, Clark & Alexander, 2015). It has only been in recent years that targeted efforts have been made to better understand the complex interplay between psychological, social, institutional, and cultural factors that contribute to opioid abuse in diverse and dynamic populations and systems of care. Developing more comprehensive conceptual models and tailored systems/processes for studying, treating, and preventing opioid use disorders will allow local communities to more effectively identify and define their unique needs, evaluate efforts aimed at addressing factors associated with opioid misuse/overdose specific to the community, and develop/adapt treatment and prevention interventions accordingly. To facilitate these outcomes, opioid treatment-prevention evaluation programs should be designed to align with the goals of the CDC’s Data-Driven Prevention Initiative (DDPI). Namely, services should be designed to improve data collection and analysis in the context of opioid misuse, abuse, and overdose; develop strategies that target behaviors driving prescription opioid dependence and abuse; work with local communities and agencies to develop comprehensive opioid overdose prevention and treatment programs; and advance opioid research, education and delivery of clinical services (CDC, 2017, 2018).
To satisfy the objectives set forth by the CDC’s DDPI, a well-developed opioid addiction evaluation service should be positioned at the forefront of innovative models of integrated care and community-based prevention efforts to address urgent population specific health needs and risks. The evaluation team should be skilled in working collaboratively with diverse systems of care, including health service providers, criminal justice and community-based agencies, and advocacy group to provide a tailored and targeted approach to understanding the needs of various populations of focus and the communities in which they reside. The team should have extensive experience assessing program process, outcomes, and impact through formative and summative evaluations guided by a foundation rooted in the principles of the “Triple Aim” to transform services for improved care, lower cost and better outcomes. An opioid addiction evaluation service should also be focused on assisting providers and systems of care at the local and state levels to address the complexity of behavioral health needs and substance use disorders with carefully planned, targeted initiatives inclusive of social determinants and related outcome reporting. Evaluation services should be heavily informed by high impact national and local policy changes, as well as state and federal legislation authorizing additional funding for opioid treatment and prevention, thus enabling the translation of expert implementation and evaluation of community prevention models from theory to practice. Overall, a successful opioid addiction evaluation service should have demonstrated competence in analyzing epidemiological data and translating data points into indicators of risks; monitoring needs and outcomes for specific populations of focus; identifying the gaps in services that different populations face; and developing capacity and resource planning to integrate the necessary services to better serve these populations and reduce risks and minimize poor outcomes.
As noted above, opioid addiction evaluators should work closely with state and local government, regional taskforces, foundations, project grantees, treatment networks and their collaborating partners, and community-based providers (including key community stakeholders) to design and implement formative and summative evaluations of specific opioid treatment and prevention efforts and interventions. From the outset of project design, the evaluation team should collaborate with participating members and key stakeholders to identify and measure attainment of project goals and deliverables with a focus on ensuring accurate data collection, appropriate use of data management tools, and accurate baseline reporting as a foundation of improving care. Encouraging active stakeholder involvement is based on the belief that such a commitment will yield participant fidelity to process implementation, improved reporting and applicability of replication, and provide opportunities for project course corrections. In addition, a successful evaluation team should be skilled in identifying high-impact local measures for specific population needs based on an analysis and understanding of population-specific health disparities and regional epidemiological events. Strong attention should also be given to process implementation and monitoring of the project’s deliverables as defined by proposed prevention efforts. Benchmark objectives should be translated and communicated across service providers, community service agencies, and stakeholder contacts to identify values for data reporting of identified outcomes at each level of service and contact. Formative evaluation should include all qualitative or process evaluation activities such as focus groups with opioid abusers and agency stakeholders, and formal interviews and interactions with stakeholders. Summative evaluation should include quantitative outcomes or product evaluation as specified in the proposed evaluation design (noted below).
An initial approach to identifying and analyzing a range of psychological, social and structural determinants of health in the targeted communities should include examination of educational and employment levels, housing options, health literacy levels, and access to health insurance and mental health and substance abuse services as well as nontraditional health care resources. Incidence of trauma, and experiences of discrimination and marginalization should also be obtained through a comprehensive health needs assessment of the targeted communities and the relevant populations of focus. Concomitantly, the evaluation team should determine the degree of access to harm reduction programs, such as drop-in centers, and needle and syringe exchange programs in the targeted communities. This could be accompanied by a similar analysis indicating the degree of consumer access to alternative pain management services and medication-assisted treatments in community clinics, county jails, emergency departments and the primary care medical system. The purpose of this initial effort would be to obtain a picture of the strengths and limitations of the project’s service delivery systems tasked to address this daunting Opioid addiction crisis in a region and its adaptive capacity to carry out the proposed intervention and prevention initiatives. This initial step is essential in working directly with any provider, grantee and representatives of state and local government as well as taskforce/community partners/ community stakeholders to establish a project’s baseline, and to obtain a clearer understanding of potential sociodemographic disparities with regard to access to and utilization of prevention and treatment services.
A successful evaluation team simultaneously recognizes the need to obtain an emerging picture of the state of the opioid addiction treatment and prevention networks in the targeted project communities that has its origin in the community’s stakeholders’ perceptions. This requires an additional review of, and input from the residents of these affected communities (i.e., the current and potential consumers of this service network), and the region’s social, governmental and health care service providers. These are the key stakeholders who have experienced, developed and delivered the addiction services, both treatment and preventative in nature. Through focus groups, constituents can offer a clearer picture of the reality of the current regional network’s functions; its gaps in services, and most importantly, keys to improved access to care and community acceptance of prevention as well as improved treatment services. This effort can help the evaluation team obtain a better sense of the region’s ability to carry out its proposed treatment and preventive initiatives, and its ability to address and integrate changes that may evolve from evaluation efforts and findings. While the evaluation team recognizes that an effective prevention approach is informed by the need to promote information on prevention, recognition, and treatment of opioid overdose, it also understands that active prevention must include not only those vulnerable to use and their social supports, but also the medical and social service providers and first responders in every community including EMT workers, firemen, police, and hospital ER staff among others. All are involved in making and promoting critical changes in the systems of care to transform it into a responsive and effective service and preventive array that is interactive and prevents gaps-in-care and community ignorance about the issue of substance abuse treatment and prevention that can lead to cycles of relapse and death. Therefore, it is also critical that the evaluation team meet regularly with these taskforce members to provide feedback on the development of evaluation data and findings regarding the effectiveness of these critical agents in the regional prevention efforts. Indeed, this critical collaborative process will further facilitate the use of project data to inform implementation efforts and support continuous improvement and help the grantee to identify additional measurable, realistic, and valuable outcomes that may be relevant to the goals of the project.
In addition to aligning with the CDC’s DDPI, the comprehensive evaluation approach described above is also consistent with the five-point Opioid Prevention Strategy outlined by the National Institute on Drug Abuse (NIDA, 2017). Namely, evaluation services are designed to assist the community agency in identifying relevant prevention benchmarks; and documenting access to prevention, treatment, and recovery support services with the objective of mitigating the health, social, and economic consequences associated with opioid addiction and opioid deaths. Throughout the course of the evaluation process, the opioid addiction evaluation service should provide data and corresponding recommendations to enable community agencies with tracking benchmarks to evaluate project participant’s long-term recovery. To meet these goals, evaluators assist with identifying subpopulations with the greatest barriers to seeking/accessing health care (medical and psychiatric) and substance use treatment services, as well as those with unmet needs (including undiagnosed medical and mental health conditions including trauma). These subpopulations can be identified via comprehensive descriptive and demographic analyses of available population health statistics and service sector reports.
The evaluation team can utilize additional qualitative focus groups and multivariate group-based analyses (both within and between groups) to examine specific characteristics that may lead to barriers in care, given that individuals with complex chronic medical conditions (e.g., HIV, cancer, MS, etc.), comorbid psychiatric disorders and/or affective symptoms (e.g., anxiety, depression), histories of trauma (often complex and unidentified/untreated), poor systems of social support, and other sociodemographic health disparities (in terms of exposure to discrimination, limited income and access to high quality education and other social and structural resources) are likely to be at the highest risk of developing opioid use disorders and subsequently suffering the devastating consequences of this epidemic. As such, opioid addiction evaluators should identify any health disparities and barriers/differentials in health status and access to preventative services and care within and across these subpopulations based on race/ethnicity, socioeconomic status (including income, education, etc.), disability status (i.e., physical, medical, cognitive), etc. A variety of empirically validated assessment measures can be used to collect the aforementioned data according to the selected functional indicators and treatment/prevention outcomes of interest specified by the community agency.
As the opioid addiction evaluation team completes statistical analyses and focus groups to determine the prevalence and quality/nature of the risk factors previously described, recommendations will be offered to the Project Grantee, the Foundation and project stakeholders with regard to program implementation, the tailoring of treatment services, and referral to services presumed to prevent opioid abuse. The focus may include: chronic pain management programs, which approach pain management through psychological modalities including dialectical behavioral and cognitive behavioral therapies that provide goal-directed approaches to help patients learn how to modify physical, behavioral, and emotional triggers of pain and stress; buprenorphine outpatient services and other medication-assisted therapies to support clients in long-term recovery and prevent opioid related overdose; trauma-informed treatment to address underlying emotional/psychological, physical, and relational mechanisms contributing to opioid abuse and addiction in general; social and peer support to target the social components of opioid abuse; and perceptions of service delivery and satisfaction of program consumers. Finally, the evaluation team should produce high quality reports (quarterly, semi-annually, and/or annually) which present clear and informative conclusions regarding program process, outcomes, and impact to the community, practice and policy audiences.