Indiana’s policy & programmatic response to the opioid crisis Dissemination & Implementation 2017 ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Portfolio of Indiana opioid studies 1. Indiana naloxone access and Good Samaritan laws (CDC Award# 1U17CE002721) 2. Medication assisted treatment (MAT) expansion in two Indiana counties (SAMHSA Award# 1H79TI026149) 3. Emergency department-based overdose prevention program (Richard M. Fairbanks Foundation & NIDA Award# 1R21DA045850) ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
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Defining the external implementation context • Prior work has demonstrated less attention to external factors in implementation work (Clinton-McHarg et al. 2016; Lewis et al., 2015) • Existing implementation frameworks good start, but rooted in theory (e.g., Damschroder et al. 2009, Aarons, et al. 2011) • Systematic integrative review conducted to develop external constructs based on empirical observation • Data collection July 2014-July 2015 Watson, DP, Adams, EL, Shue, S, Coates, H, McGuire, A, Chesher, J, Jackson, J, & Omenka, Isaac. (revise & resubmit). The external implementation context: an ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org integrative systematic literature review . BMC Health Services Research.
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1 Formal or informal norms, rules, policies, or standards guiding the professions or professionalization of individuals involved in the implementation. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
2 Extent of backing from public officials or special interest groups. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
3 Beliefs, values, customs, and practices of the larger community and/or system within which the intervention is embedded. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
4 Physical, technical, service, and training structures or resources existing in the community or larger system in which the intervention is embedded. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
5 Formal national, state, community, or system regulations (rules, policies, laws) impacting the intervention. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
6 Degree and quality of relationship the organization has with partner organizations and regulating agencies key to intervention delivery. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
7 Characteristics associated with individuals the intervention was designed to impact including population needs, culture, beliefs, preferences, locatability, ability to access, and motivation to engage. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
8 The character of the national, regional, or local economy and availability of funding as related to the intervention. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Table 2. Comparison of constructs evidenced through literature review with external factor constructs in existing frameworks Consolidate Framework Exploration, Preparation, Multi-level framework for Implementation Implementation, (MLF) predicting Research (CFIR) Sustainment (EPIS)* implementation outcomes Professional influences -- Interorganizational -- networks Political support -- Sociopolitical; Client Political or social climate advocacy Social climate -- -- Political or social climate Local infrastructure -- -- Infrastructure Policy & legal climate External policies and -- Public policies incentives Relational climate Cosmopolitanism Interorganizational -- networks Target population Patient needs and Client advocacy -- resources Economic & funding -- Funding Economic climate climate No directly comparable Peer pressure Intervention developers; Physical environment construct Leadership “ -- “ = No directly comparable construct *Only the active implementation phase of the EPIS framework is considered here since this was the focus ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org of the current literature review.
References Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health Ment Health Serv Res. 2011;38:4 – 23. Clinton-McHarg T, Yoong SL, Tzelepis F, Regan T, Fielding A, Skelton E, et al. Psychometric properties of implementation measures for public health and community settings and mapping of constructs against the Consolidated Framework for Implementation Research: a systematic review. Implement Sci. 2016;11:148. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. Lewis CC, Stanick CF, Martinez RG, Weiner BJ, Kim M, Barwick M, et al. The Society for Implementation Research Collaboration Instrument Review Project: a methodology to promote rigorous evaluation. Implement Sci. 2015;10:2. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Regulations to expand naloxone access and use: Citizens’ understanding as a barrier to adoption Dennis P. Watson, Bradley Ray, Lisa Robison, Philip Huynh, & Joan Duwve ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
The project • Centers for Disease Control and Prevention (CDC) – Prevention for States program (Award# 1U17CE002721). – Purpose: provide resources and support needed to advance interventions for drug overdose prevention. • Partners – Indiana State Department of Health – Indiana Professional Licensing Agency ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Policy evaluation activities • SEA 246 (2013) • Establishes prescribing rules • Pain clinics must have controlled substance registration • SEA 227 (2014) • First responder naloxone administration • SEA 406 (2015)/Aaron’s Law • Naloxone prescribed as part of addiction treatment • Lay responder naloxone administration • Naloxone standing orders • Criminal and civil liability protections ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Evaluation Approach • Focusing on Good Samaritan component of the law • Context = Distribution of naloxone at local health departments ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Methods Began in September 2016 Structured phone Postcard survey interviews ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
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Postcard response • 10,972 Kits provided to 37 counties through RFP process • Pre-use response by type (n = 1,793 from 28 counties) • 34% lay responders • 38% health professionals • 27% other/can’t identify • Post-use response by type (n = 94 from 10 counties) • 25% lay responder • 38% health professional • 37% other/can’t identify ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Pre-use postcard responses (n = 1793) • Awareness of law = 2.4 times more likely to call police (p < .001) • 33% of those who did not call 911 worried about police • Post-use cards show similar trends, with even greater percentage (43%) worried about police. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Interview respondent discussions of police interaction (n = 5) I think that’s why we lose too many people, because of the fear. Just being afraid to go to jail and you know generally there’s always drugs, things, paraphernalia in the home…. I think for the most part, that stigma stands and they [law enforcement officials] feel like addicts waste their time, you know, that they could be responding to something different. It’s taking time away from things that are more important. ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
Clarity of the law • Search of online resources demonstrates poor information about law • Follow-up discussions with key stakeholders demonstrate – No clear understanding of criminal liability protections – Unwillingness of some local health department staff to give naloxone to lay responders because they think they won’t call 911 ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
State online resource excludes discussion of criminal protections http://www.in.gov/dol/2907.htm ACCELERATING CLINICAL AND TRANSLATIONAL RESEARCH www.indianactsi.org
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