Opioid Safety Lessons Put Physician on Path to State Policymaking
After five years leading the California Health Care Foundation’s High-Value Care Team and its opioid safety portfolio, Kelly Pfeifer, MD, is leaving Oakland for Sacramento to become deputy director of mental health and substance use disorder services for the California Department of Health Care Services (DHCS). In the last four years, CHCF has invested $7 million in innovative opioid safety work. I asked Pfeifer to reflect on California’s response to the opioid crisis and what she’s looking forward to accomplishing in her new role. Our conversation has been edited for length and clarity.
Q: When you started at CHCF in 2014, there were counties in California with opioid overdose death rates among the worst in the country. How did CHCF help to address this crisis?
A: It seemed like everything needed to change at once. Because too many areas of the state were awash in prescription opioids, we needed policies to reduce overprescribing while simultaneously increasing access to medication-assisted treatment (MAT) and the overdose antidote naloxone. We helped create local opioid safety coalitions to activate leaders and to change hearts and minds about solutions. We teamed with health plans, hospitals, clinics, and provider groups to integrate MAT into all points of care. And we worked with state leaders to align the many efforts around the state and help us pull in the same direction.
For people with substance use disorders, fragmented health care services are life-threatening. The only way to reverse the opioid epidemic and pave the way for better treatment of all brain disease is to get the local care system to work together cooperatively. That means primary care practices, mental health clinics, and treatment programs; hospitals, emergency departments, and paramedics; health plans and pharmacies; law enforcement and correctional facilities; schools; advocates; and many others. These relationships are all local.
Q: Where did the idea for these local coalitions originate?
A: We learned a lot from San Diego and Marin Counties. They brought these players around a table to review local data, create a plan, and take action. It became clear that stopping overdose deaths involved changing local culture and making sure everyone dealing with the overdose crisis had the most up-to-date information and understood that addiction is a disease, not a moral failing. We soon realized we would need local coalitions like this all over the state. That’s how they became a centerpiece of CHCF’s opioid safety initiative. Today, 45 of California’s 58 counties have coalitions, and they are linked together through the California Opioid Safety Network. The Center for Health Leadership and Practice at the Public Health Institute provides education and training to the network, with CHCF support.
Collaboration at the state level was equally important. Covered California [the health insurance marketplace], CalPERS [the California Public Employees’ Retirement System], and DHCS [which runs Medi-Cal] — organizations that collectively purchase health care for 16 million people — started coordinating their opioid safety efforts under the umbrella of Smart Care California. These activities included disseminating an opioid safety toolkit for health plans so the plans could develop their own initiatives.
In 2014, the California Department of Public Health convened the Statewide Opioid Safety workgroup, which brought together more than 40 state and nongovernment organizations to improve coordination and to expand joint efforts to address opioid misuse, addiction, and overdose deaths.
The overdose crisis challenged all of us to work together in new ways. In the long run, the biggest legacy of our coalition work might be that local communities were empowered to leverage these new relationships to tackle other public health problems.
Q: How would you characterize California’s progress against unsafe opioid practices?
A: The good news is that opioid prescribing has declined 38% in the last four years and that California’s opioid overdose death rate is substantially lower than the national rate. The national opioid overdose death rate increased by 66% from 2014 to 2017, while California’s rate rose 6%. In the same period, overdose deaths for all drugs increased by almost 50% in the US, while increasing by 5% in California. We also are seeing increased access to treatment. For example, the number of Medi-Cal enrollees who received the opioid addiction medication buprenorphine almost quadrupled between 2014 and 2018. The number of Medi-Cal enrollees receiving the opioid overdose antidote naloxone went up almost 30-fold between 2014 and 2018, reflecting the much greater availability of this rescue drug.
But now there is some worrisome news for California too. Earlier this month, the US Centers for Disease Control and Prevention released provisional data for 2018 showing the first decline in the national all-drug overdose death rate since the 1990s. Meanwhile, California’s rate is estimated to have risen nearly 7%, the second consecutive year of increases. This is troubling.
The uptick in the overdose death rate shows the work is not done. We are still losing too many before their time, and we have the growing threat of methamphetamine, as well as the ongoing problems of alcohol and other drugs. California needs to continue to focus on the multipronged strategy that has kept our death rate comparatively low. The state has more tools, resources, and networks in place to build on its progress.
Q: The opioid crisis required California to innovate quickly, and you launched or supported many new ideas. Is there one pilot project you consider especially successful?
A: People with addiction may show up in many different places asking for help. Opioid overdoses continue to happen after people have reached out for help in health care or corrections settings, and that’s often a tragic missed opportunity. We wanted to change that. CHCF helped emergency departments and hospitals to start using MAT more routinely, and today 31 hospitals in 27 counties are part of the California Bridge Program, which uses a medication-first model for opioid addiction. They promptly treat the craving and withdrawal symptoms, then connect patients to resources for ongoing recovery. This is one of dozens of DHCS integration programs in the MAT Expansion Project, and it’s supported by over $240 million in federal funds. I am especially proud that our work helped inspire 30 counties to commit to providing MAT in jails. Some counties have already started, and others will soon. Most people in jail – 65%, according to one study – have substance use issues, but effective treatment for opioid addiction wasn’t available before.
Q: What did we learn from the opioid safety effort that can help California address other substance use disorders?
A: California has been smart about using federal funds to build infrastructure that can help people with any kind of addiction. As a society, we can’t afford to build a one-drug system. The opioid epidemic gets headlines partly because one wrong dose can kill you in minutes, but California also has a surging methamphetamine problem. And let’s not forget that alcohol causes more deaths than either meth or opioids. California needs a system that doesn’t pick winners and losers among the misused substances. Everyone deserves compassionate treatment.
CHCF has been very involved in helping DHCS and counties overhaul Medi-Cal’s program for substance use disorder services, known as the Drug Medi-Cal Organized Delivery System. It’s up and running in 30 counties so far. These new programs are building local capacity for treatment that spans the full spectrum of evidence-based care of addictions. It was the first expansion of its kind in the nation, and other states are watching and learning from it.
Q: CHCF is very focused on behavioral health integration. Why?
A: With everything we know about brain science and the interconnection of physical health, mental health, and substance use, our fragmented systems of care don’t make sense anymore. That’s why CHCF made it a priority to bring a whole-person approach to behavioral health in Medi-Cal.
CHCF convened meetings with a wide range of stakeholders last year to find ways to improve outcomes for people in Medi-Cal struggling with mental health challenges. CHCF recently published a blueprint for integration based on that work. The blueprint calls for every person in Medi-Cal to be associated with a single accountable entity that can arrange physical and behavioral health. That doesn’t mean one entity provides all the care and treatment, and it doesn’t mean that every county or region does it the same way. It does mean that at the end of the day, there is someone responsible for making all the different parts of the system work together for a patient’s total health.
Q: What are your hopes for your work in Sacramento?
A: This is an exciting time to be joining state government. We have a governor committed to universal coverage and to a better system for people with mental health and substance use disorders. We have a bold and innovative health and human services secretary, Dr. Mark Ghaly, a leader in integrating care for vulnerable populations. And for the first time in California history, we have a mental health czar, Tom Insel. It’s an incredible opportunity to contribute to the improved well-being of millions of Californians and to help the state set a positive example for the nation.