In 2015, 1,307 people died from opioid overdoses in Kentucky, resulting in Kentucky having the third-highest overdose mortality rate in the country. What’s more, of the approximately 50,000 babies delivered in Kentucky that year, more than 1,000 had Neonatal Abstinence Syndrome. , As Kentucky Governor Matt Bevin said, “We don’t have the luxury of pretending there isn’t a problem. Every life is worth saving. There is not a person we would not want to see redeemed and removed from this addiction, and it is up to all of us to work together and find solutions.”
Kentucky has responded with a multifaceted, collaborative, and data-driven strategy to combat the opioid epidemic. This approach—which includes key partners from public health, behavioral health, Medicaid, academia, and the private sector—involves efforts to improve regulation, promote healthy lifestyles, and introduce new treatment programs. However, the core of Kentucky’s response revolves around an attempt to refine, integrate, and leverage the commonwealth’s data on opioid abuse. “This in my mind really illustrates the need for data because the game keeps changing on us,” said Allen Brenzel, the Medical Director of the Kentucky Department of Behavioral Health, in a reference to the fact that the kind of opioid that people are abusing has repeatedly shifted. “This is one of those things where knowing what’s happening and how the problem is evolving has been critical.”
While the strategy of leveraging data more effectively is sound, it is by no means guaranteed to succeed. Rather, Kentucky officials have had to wrestle with—and will continue to confront—difficult questions. Could they persuade departments accustomed to operating in silos to share data and cooperate? Could they overcome the political, legal, financial, and technical barriers to data integration? Could they foster cooperative relationships with local health departments and draw on data to design effective intervention strategies? Most fundamentally, could they develop a collaborative ecosystem, scale the Health and Human Services Value Curve, and in the process, combat an enormous public health threat?
Since 1999, the rate of opioid overdose deaths has nearly quadrupled nationally. Nonetheless, the epidemic represents a particularly acute challenge in Kentucky. This is in part because of the decline of the state’s economy and civic infrastructure (especially in rural areas) as well as the excessive prescription and marketing of painkillers. It also stems from the fragmented structure of the public health system. Kentucky has 120 counties, each with its own health department. Unfortunately, many of these agencies are small and under resourced, meaning that the communities that are most vulnerable to opioid abuse are least equipped to address it. Harvard Kennedy School faculty member Julie Boatright Wilson observed:
The opioid crisis…is not affecting the normal group that we’ve been working with in the concentrated areas. It’s often in the rural areas where there are fewer resources, and as our budgets have shrunk, we have closed hospitals, health clinics, other services in those areas, and it’s a population with whom we have not necessarily had a lot of connections over time. And so, the challenge for many of the states is in under-resourced areas…how do we manage to pull everything together and work collectively to address this?
In 2010, as Kentucky officials started plotting their response to the opioid epidemic, they began to confront a foundational problem: they lacked integrated, comprehensive data about opioid abuse. The challenge lay in part with the fact that data was closely guarded in organizational silos. In addition, there were significant barriers to greater cooperation, including laws governing access to data; a paucity of funding, staff, and infrastructure; and political concerns about the state “operating ‘big data’ repositories.” Of the latter difficulty, Brenzel said, “I can remember testifying and breaking into a sweat knowing three or four representatives were going to come after me on this issue.”
The absence of strong, integrated data created significant impediments to effective policymaking. One was what Brenzel characterized as a “baseline myopia” in individual agencies and offices. These entities used their data to create internal reports that were often used to justify expanding existing strategies but shed little light on what was causing the epidemic. Absent a foundational understanding of the crisis, state policy was driven by fallacious assumptions, including, as Brenzel said, that “abstinence is the only true form of treatment.” Finally, the state lacked common definitions and agreed-upon outcome measures, making it impossible to capture who was dying and overdosing, complicating efforts to grasp the full scope of the crisis, and creating a frustrating process in which officials scrambled to respond to one-off data requests. “We spun our wheels a lot,” Brenzel said, “because we did not have consistent data, and it was due to the one-off data request that was leading with different definitions.”
House Bill One: “Regulation of Pain Clinics and Prescription Drug Abuse”
Without strong baseline data, let alone a collaborative atmosphere, Kentucky was not ready to pursue integrative and generative approaches to combat the opioid epidemic. Rather, it initially focused on regulating prescriptions for opioids. In 2012, the legislature passed House Bill One, which attempted to curtail inappropriate and possibly illicit prescription of opioids. Among other steps, the legislation promoted “strong scope of practice expectations for opioid prescribing” and mandatory continuing medical education and possible sanctions for practitioners who did not adhere to those guidelines. In addition, in an effort to bolster Kentucky’s use of data in their prescription drug monitoring program (Kentucky All Schedule Prescription Electronic Reporting--KASPER), the commonwealth mandated that practitioners use KASPER to access data on opioid prescriptions. This data set allowed Kentucky to identify prescribers who were falling outside the norm for opioid prescriptions and simultaneously begin to acquire and illustrate the benefits of robust data. The sense, as Brenzel recalled, was, “We can now show you who the bad actors are. We can show you what’s happening out there.”
In 2015, following the election of Matt Bevin as governor, Kentucky began a push to acquire and leverage more sophisticated data in its response to the opioid epidemic. “Their [the Bevin Administration] level of frustration with the lack of data is one of the things that drove us,” Brenzel recalled. “They found that only beginning steps had been accomplished in terms of the data integration and data infrastructure.”
Thus, Bevin and his staff accelerated efforts to establish globally agreed-upon measures, integrate data across departments, and hold meetings where leaders from different agencies would share and analyze information.
Kentucky also forged a public-private partnership with Aetna, a managed health care company with more than 250,000 Medicaid members in Kentucky, to enhance the commonwealth’s data and analytics work. Specifically, Kentucky and Aetna began employing predictive modeling tools to use available data (e.g., medical, behavioral, and pharmaceutical records) to identify Kentuckians who might be at risk. Of the partnership’s long-term objectives, Kimberlee Richardson, the Director of Behavioral Health at Aetna, said, “What we would like to do, as our deep dive into analytics moves a bit further, is really look to see: What are the trends that the data is showing us? Are there particular geographic areas where the risk factors are higher? …Do the identified members share any significant common factors?” Richardson added, “In Kentucky, Aetna is using their own internal data and partnering with external experts to implement strategies for improving health outcomes based on analytics. The data illustrates where gaps in care may be occurring and the avenues in which Aetna can deploy additional resources in order to support a healthier ecosystem.”
Taken together, these efforts allowed Kentucky to leverage data and an increasingly collaborative ecosystem to enhance its response to the opioid epidemic. A case in point involved the implementation of Senate Bill 192, which supported the creation of local Harm Reduction Syringe Exchange Programs (HRSEP). In a sign of Kentucky’s more sophisticated use of integrated data, the state overlaid the needle exchanges in counties that were considered most vulnerable to HIV and hepatitis C outbreaks; this was because of growing concern that the needles used to abuse opioids could contribute to the spread of hepatitis C and HIV. In addition, in a move that reflected an increasingly collaborative dynamic, officials from the Justice and Public Safety Cabinet sought advice from behavioral health officials about how to spend approximately $20 million in substance use disorder funding that they had received as part of the legislation. “The good news,” Brenzel said, “is we built an ecosystem where they came to us and said, ‘We need help in using data to determine how to target and buy quality services, we need help in engaging in active contract management around this.’ And they did work with us, which has brought us all to the table.”
The collaborative and statistically driven approach soon permeated the broader response to the opioid epidemic. Following numerous public requests for data, Kentucky officials created county profiles on opioid-related issues as well as publicly facing dashboards with granular local data. They also partnered with the University of Kentucky’s Injury Prevention and Research Center and began incorporating real-time syndromic surveillance data to help to guide the distribution of resources, such as Mobile Harm Reduction Units, to communities in need. Finally, Kentucky undertook preventative measures, including partnering with public schools to promote healthy lifestyles and awareness surrounding opioid abuse. “We’ve started thinking about that continuum,” said Jonathan Ballard, the State Epidemiologist in the Department for Public Health. “How do we address the next wave in addiction prevention?”
A little over seven years after recognizing that their response to the opioid epidemic was fractured and statistically ill-informed, Kentucky officials still see room for improvement. This is in no small part because the rate of overdose deaths increased by 7.4 percent from 2015 to 2016. Thus, state officials are continuing to explore new reforms. These include leveraging data “to drive targeted interventions”; partnering with Aetna to distribute medication; and working across state agencies to create more cross-disciplinary treatment programs. Of Kentucky’s diverse tactics, Gil Liu, the Medical Director for the Kentucky Department for Medicaid Services, said, “We are riding every big ticket we can, to build new information technology and form bigger response teams through resources such as Medicaid waiver proposals, federal programmatic funding associated with the 21st Century Cures, and research grants.”
Nonetheless, there is a growing recognition that the state is at the cutting edge of combatting the opioid epidemic. In one sign of progress, Kentucky now has 39 Harm Reduction Syringe Exchange Programs, many of which are already producing significant cost savings by bringing new patients into the health care system, allowing for less expensive preventative treatment. In addition, Kentucky’s Department for Medicaid Services is partnering with other state agencies and payers to support an innovative program focused on combatting Neonatal Abstinence Syndrome. More broadly, there is a sense that Kentucky officials have transformed a previously conflictive landscape and created a collaborative and statistically driven ecosystem that is helping the commonwealth to push toward the generative stage of the Health and Human Services Value Curve. Brenzel reflected, “We may have lacked the constructs and the names of the strategies, but I think what we have developed is an ecosystem, and we have been moving up the Health and Human Services Value Curve without knowing it.”
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