In 2015, a burgeoning opioid epidemic was unfolding in California. Nearly 2,000 people died of opioid overdoses that year, while 7,800 others were treated for it in emergency departments. The need for new solutions was great.

That same year, Kelly Pfeifer, MD, joined the staff at CHCF and was determined to combat these trends and to prevent overdose deaths. She soon got to work in collaboration with partners statewide. CHCF invested $7 million over five years to launch pilot programs and test multiple strategies to reduce the supply of prescription opioids, promote evidence-based addiction treatment, and expand access to a drug called naloxone that reverses opioid overdoses.

No one expected what would happen next: Many of the projects were so successful that California state government soon adopted them and spread them statewide.

We know recovery is possible. Treatment works.

—Kelly Pfeifer, DHCS deputy director for behavioral health

This complex body of work funded by CHCF is the subject of a new article in Foundation Review, a peer-reviewed journal of philanthropy. In “Placing Bets in a Complex Environment: One Foundation’s Approach to the Opioid Epidemic,” author Jill Yegian tells the story of CHCF’s portfolio of “opioid safety” projects designed to advance treatment and reduce deaths.

CHCF approached the challenge by selecting meaningful targets to be able to quickly discern what was working, Yegian said in an interview. “Pfeifer had a nimble, pragmatic approach, focused on a fast turnaround. It was very much, ‘Let’s track it. Let’s see how we’re doing. Let’s refine and make it better,’ rather than, ‘Let’s build this big thing, and then in four years we’ll tell you whether it worked, whether it’s going to be worth scaling.’”

Ending the Blame Game

In 2015, when it seemed as if everything needed to change at once, it was hard to get anyone to agree on anything.

“In the beginning, it was a very much a blame game,” Pfeifer said in an interview. “People blamed the doctors. The doctors blamed medical societies for urging them to treat pain as a ‘fifth vital sign’ and prescribe more and more opioids.” And everyone blamed pharmaceutical companies for their aggressive marketing of prescription opioids.

But people who work in the field of addiction saw that it was also a systemic problem — insufficient availability of effective treatments, providers who didn’t understand addiction, health plans such as Medi-Cal that made people jump through hoops to get care for substance use disorders. The overarching problem was stigma. Too many people view substance use disorder as a moral failing, when in fact it is a complex brain disease. Yegian’s article described CHCF’s approach as working toward “a paradigm shift from stigmatizing individuals with opioid use disorder to viewing them as individuals with a chronic condition that requires treatment. Sustainable change requires that physicians, hospitals executives, corrections officers, police, judges, and many others adopt a new perspective.”

To foster that change, Pfeifer would frequently tell her personal story of once being among those who prescribed opioids out of a sense of compassion and desire to help patients. That changed the day a coroner stunned Pfiefer with a phone call informing her that a local person had died holding a pill vial bearing Pfeifer as the prescriber. She was suddenly forced to grapple with her own role in the epidemic.

“I think it was helpful for me to say, ‘I was wrong,’ and try to model that everyone needs to own this,” she said. “We all made mistakes. We all have to have a part in fixing this.”

Experts were battling the stigma of using effective medications to treat opioid use disorder, such as methadone or buprenorphine. Too many people believed “treating a drug with a drug” was the wrong approach.

Constructing Local Coalitions

Pfeifer sought to replicate the success of community coalitions in San Diego and Marin Counties, which brought together local leaders committed to expanding access to addiction treatment medications, decreasing opioid overprescribing, and reducing overdose deaths. Advocates and leaders from public health, hospitals, addiction treatment, law enforcement, health plans, and other institutions held meetings to devise creative ways to solve the opioid epidemic in their areas.

In 2015, CHCF funded 16 opioid safety coalitions covering 23 counties, including providing technical assistance. A key goal of the foundation was to disseminate accurate, evidence-based information. Within 18 months, 90% of the coalitions had distributed updated prescribing guidelines to local doctors, more than 75% increased access to a naloxone, and more than 50% expanded the use of medication-assisted treatment (MAT), which combines medications with counseling and behavioral therapies. In 2017, CHCF provided grants to support additional coalitions, and the number grew, spreading the efforts to 36 counties. What made them succeed was their local focus. Coalition leaders tailored solutions to the unique needs of their communities.

By building on the pilot projects started by CHCF, the state of California was able to move much more quickly to allocate the new resources and implement major initiatives than would otherwise have been possible.

—Jill Yegian, Yegian Health Insights

Emergency departments, or EDs, presented another key opportunity. People who overdosed typically received treatment for symptoms and left EDs with little more than the phone number of a treatment center. Highland Hospital in Oakland was running an innovative program to have emergency physicians start patients on buprenorphine, an FDA-approved drug that calms cravings of people addicted to opioids. Pfeifer partnered with the lead of Highland’s program, and they developed a pilot project in eight hospitals that offered a promising “bridge to treatment” program. Because some hospital-based physicians thought inpatient stays also offered a significant opportunity to treat addiction, CHCF funded Project SHOUT (Supporting Hospital Opioid Use Treatment) to share best practices related to starting MAT for patients with opioid use problems during any type of hospitalization.

Other CHCF-funded projects included:

• Treating Addiction in Primary Care, which assisted 25 California clinics and health centers to implement MAT services
• Smart Care California, which developed ways for large government health care purchasers and other health plans and provider groups to align their opioid work
• Smaller, crucial grants to advance the use of MAT for inmates in county jails
• Numerous publications sharing best practices about opioid safety

Even with great results in these pilot projects, it was well beyond CHCF’s financial capacity to scale these programs to serve 40 million Californians spread out over 164,000 square miles. In 2017 the federal government stepped in to help the state address the epidemic with grants that eventually totaled $266 million over two years. The federal funding created a tremendous opportunity to bring several of the opioid safety projects to scale across California.

Partnerships Led to Effective Pilots

Since its founding in 1996, CHCF has had a history of close partnerships with California policymakers, and Pfeifer supplemented those with her own experience networking with state leaders.

“The fact that CHCF had teed up so many successful pilots that they could scale meant that the foundation could help the state solve a problem” of using the money on proven projects, Pfeifer said.

“It was somewhat extraordinary, the combination of the discipline in planning and implementation that had gone into the pilots,” Yegian said. “Collectively, the pilots covered multiple different areas, and addressed multiple different audiences. And we saw the serendipity of the federal funding coming in at that particular moment.”

Pfeifer believes that care and treatment of opioid use disorder and other behavioral health challenges should be fully integrated across the health care system.

Things happened fast. The eight-hospital “bridge to treatment” pilot program was among the first pilots to receive state funding. It became CA Bridge and was initially adopted by 31 hospitals in 27 counties. CA Bridge absorbed Project SHOUT too. The program later received another tranche of funding, and today over 200 California hospitals have a bridge program.

The local coalition program is now the state-supported California Overdose Prevention Network. With government support, it is thriving and serves as a model for other states. The small grants CHCF made to ensure access to MAT in a few county jails planted a seed, and now over 30 county jails participate in the state-funded MAT program. In addition, California state prisons now offer all forms of MAT. While many factors may be involved, early data show that 2020 opioid overdose deaths in California prisons have declined from the previous year.

Since 2017, opioid-related programs that CHCF started with investments of about $4 million have received more than $53 million in federal funds administered through the California Department of Health Care Services. From Yegian’s article:

“By building on the pilot projects started by CHCF, the State of California was able to move much more quickly to allocate the new resources and implement major initiatives than would otherwise have been possible. Moreover, the investments were more strategic due to the years spent incubating ideas, cultivating collaboration, and road-testing concepts.”

The state was building these and other related programs, including expanded naloxone distribution. While the death rate continued to climb nationally, it held steady in California in 2016 and 2017. Progress came in 2018 as the state’s opioid overdose death rate dipped, giving rise to optimism that the tide was turning. The next year, Pfeifer was offered the opportunity to join the state’s Department of Health Care Services as deputy director for behavioral health.

Only six months after she moved to Sacramento, however, the world changed dramatically with the arrival of COVID-19. Overdose deaths, which had ticked up modestly in 2019, suddenly spiked dangerously during the pandemic.

“The amount of stress and anxiety and social isolation and trauma that Californians have endured in this last year is incredible,” Pfeifer said in the interview. “There’s a lot of self-medication.”

More Than Opioids

“We need to do a continued big push on harm reduction,” she said, referring to practical interventions intended to reduce negative consequences associated with drug use. “We at the state are working hard to distribute naloxone broadly, so that if someone witnesses an overdose, they can give them the medication. We’ve seen over 30,000 overdose reversals, so the death rate would be much higher had we not pushed out that much naloxone. Still, it’s really hard. The pandemic was definitely a setback.”

In California, opioids are not the only significant substance use problem. The use of methamphetamines — which cause as many overdose deaths as opioids — increased during the pandemic. While there are no medications to treat methamphetamine addiction, “contingency management” is an effective evidence-based treatment that has received little backing. In contingency management, patients who show evidence of positive behavioral changes receive small gift cards. Many consider contingency management to be similar to the MAT debate of years ago. While evidence that it works is strong, it requires a new way of thinking about addiction treatment.

For too long, substance use disorder has been treated in a separate system and in separate facilities, apart from other health problems. California’s work to expand opioid treatment has been a good start, and Pfeifer believes that care and treatment of opioid use disorder and other behavioral health challenges should be fully integrated across the health care system.

“We have a generational opportunity to change how substance use disorder care is delivered, so it’s not siloed and carved out,” Pfeifer said. “The goal should be to change health care so substance use disorder is treated within both the health care system as well as the behavioral health system — and then use the momentum around opioids to keep changing attitudes around other stigmatized conditions, like methamphetamine use.”

“We know recovery is possible,” she said. “Treatment works.”

Lisa Aliferis

Lisa Aliferis is a senior communications officer focused on CHCF’s work in behavioral health, and homelessness and health care. She also coordinates communications in cross-foundational work involving CalAIM, the state’s multi-year initiative to improve the health outcomes and overall well-being of Medi-Cal enrollees. Read More

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