Amidst a global pandemic that has challenged states’ capacities to respond to increasing overdose deaths, collecting and sharing information across partners to effectively respond to new challenges will be more crucial than ever. Gubernatorial led cross-agency collaborative efforts can help states turn the tide on the current opioid epidemic while positioning themselves to respond to evolving challenges.
Introduction
In 2018, the United States had its first decline in drug overdose deaths in decades, with overall drug overdoses decreasing 4.1% from 2017. However, provisional data on overdose deaths released by the CDC indicate that drug overdose deaths rebounded in 2019, rising 4.6% over the previous year. Further, initial evidence and anecdotal reports indicate that overdoses continue to increase significantly during the COVID-19 pandemic , reflecting increased stress and isolation during the pandemic, as well as challenges in access to treatment and other support services. The Overdose Detection Mapping Application Program (ODMAP) has observed an increase in suspected overdose submissions when comparing the weeks before and after stay-at-home orders were issued by governors. More specifically, from March to May 2020, compared to the same time period in 2019, a rolling mean comparison indicated over a 15% increase in overdoses.
In order to accurately target interventions aimed at decreasing overdose deaths, states collect, share, and leverage available public health and safety data to drive policy and programmatic response, as well as evaluate their efforts. Despite the key role of data in shaping state opioid responses, to our knowledge, no single comprehensive review exists on how states collect, analyze, and share opioid-related public health and/or public safety data. To address this gap, the National Governors Association Center for Best Practices (NGA Center) launched a statewide opioid data survey in 2018 to all 55 governors’ offices. The NGA Center received responses from 41 states, commonwealths, and territories (collectively referred to as “states”), which highlighted state strengths, challenges, and opportunities for improving data collection and sharing across jurisdictions. Following the collection of survey results and a roundtable discussion of key findings and takeaways, the NGA Center conducted an analysis to determine the overall picture of the maturity of state data-system approaches. Though many states are proficient in their collection and utilization of data, significant challenges exist, which requires states to continue to invest in order improve their ability to target and evaluate strategies for addressing overdose deaths. By targeting interventions informed by data, states stand better positioned to drive down opioid overdose deaths.
Survey Background
While synthetic opioids-related deaths increased by 10% from 2017-2018, with other drug-related deaths on the decline, there is still an overwhelming need for states and localities to leverage public health and safety data to understand and respond to emerging trends. To inform this response, states can leverage data sources including, but not limited to, first responder data, drug-related seizure and arrest data, or Medicaid claims data. Because there is no single survey that captures how states are collecting, sharing, or leveraging opioid-related data, the NGA Center conducted a national survey to fill this gap. The purposes of developing a national survey were four-fold: 1) to capture information on opioid data sources that are being utilized to inform state opioid response activities; 2) to identify challenge and gaps in states’ abilities to collect, share, and leverage data; 3) to highlight state priorities for improving data frameworks; and 4) to collect innovative public safety and public health response efforts. To accomplish these goals, the NGA Center asked states to complete a 36-question survey.
Methodology
Prior to conducting the survey, we held a series of interviews and engagements with state officials, such as multi-state roundtable convenings, to understand which data states are utilizing. From the information gathered, we then created a survey asking states specific questions about how they are collecting, sharing, and using data in six major categories: (1) emergency department syndromic data, (2) first responder data, (3) fatal overdose data, (4) Medicaid claims data on controlled substances, (5) drug-related seizure and arrest data, and (6) Prescription Drug Monitoring Programs (PDMP/PMP) data. Not surprisingly, the data sources span multiple agencies and sectors, with a clear need for a multi-disciplinary approach across criminal justice/public safety and public health.
Surveys were sent to each governor’s office through their criminal justice policy advisor and health policy advisor. Advisors disseminated the survey to respective agency heads (such as Department of Health, Department of Public Safety, etc) to collect responses. Although the survey was reviewed by relevant agencies, we only accepted one response per question from each state.* All responses were aggregated for analysis to capture themes and national trends.
*Some states submitted multiple response by relevant data stream, while some governor’s offices assigned one lead to complete the survey. There were a small handful of cases in which we received two responses to one question; however, we were able to deconflict in the few cases of differing answers.
Survey Results
The survey was categorized into six relevant data sources. Definitions provided to participants and key results are detailed below.
- Emergency Department (ED) Syndromic Data: This data source captures hospital admissions to emergency departments coded as drug overdose-related complaints or diagnoses, opioid-related withdrawal symptoms, mental health co-occurring disorders with opioid abuse or dependence, and infections resulting from intravenous opioid use. There were four questions about ED Syndromic Data. Of the 40 states that responded, 34 states indicated that they receive syndromic data. Of those 34 that receive syndromic data, 85% (n=29) receive data for a suspected opioid overdose daily, while the other states received syndromic data weekly, quarterly, or annually. Further, when asked how states use and understand this data, three categories of responses emerged: (1) identify trends related to nonfatal overdoses, (2) connect regional trends to help allocate state and local resources, and (3) pinpoint opportunities for interventions and programmatic development.
- First Responder Data—Emergency Medical Services (EMS): This data source captures EMS responses to suspected drug overdoses. There were three dichotomous (yes/no) questions and one open-ended question; however, there were also three follow up questions contingent upon a yes/no response. Displayed logic questions focused on timeliness of data collected. Of the 38 states that responded to the EMS questions, 90% (n=34) of states receive overdose information from EMS with 60% receiving this information daily. Additionally, approximately 75% of states receive naloxone deployment data from EMS and about 50% of those receive this information daily.
- First Responder Data—Law Enforcement (LE): This data source captures LE responses to suspected drug overdoses. These questions are identical to the EMS questions discussed above. Of the 40 states that responded, 43% (n=17) of states receive overdose information from LE. Further, 48% (n=19) of responding states receive naloxone deployment information from LE. Frequency of reporting overdose data and naloxone deployment by LE varied greatly by state. In comparison to EMS responses on the same questions, law enforcement is less likely to share overdose and naloxone deployment data across the state.
- Fatal Overdose Data: Depending on the state, this data source may originate from the state’s vital statistics office, a medical examiner’s office, and/or a coroner’s office. Of the 38 states that responded, we were able to confirm medical examiner systems most commonly collected fatal overdose data at the local level. As for reporting of fatal overdose data to the state, this is generally completed by either a county or state medical examiner office (alone or in a mixed system).
- Drug-related seizure and arrest data: This type of data may include information collected by state and local law enforcement agencies. Of the 39 states that responded, 27% have a state-wide reporting system to collect drug-related seizure and arrest data. For the states that do have this system, data collection generally occurred monthly, although upwards of 25% report daily. Further, approximately 85% of states share this type of data with non-law enforcement partners, such as public health.
- Medicaid claims data on controlled substances: This type of data may include any prescribed medication defined as a controlled substance to Medicaid beneficiaries. There were three dichotomous (yes/no) questions and one open ended question. Of the 39 states that responded, almost 70% use Medicaid claims data to identify vulnerable patients for substance use disorder treatment. Twenty-six states (67%) used this data stream to identify physicians who may be overprescribing. However, when asked about data linkage for Medicaid claims and PDMPs, approximately 28% (n=11) of states report that these systems are not linked.
- Prescription Drug Monitoring Programs (i.e. PDMP) data: This data source captures prescriptions for specified controlled substances in a state. All questions related to PDMP were open-ended. Generally, PDMP data are utilized by states for: (1) informing clinical practice and educating prescribers, (2) identifying geographic trends in prescribing rates, and (3) identifying trends in prescribing behavior. Notably, about 10 states reported using this type of data to track policy changes and measure impact on prescribing patterns[v].
Understanding State Capacity
The NGA Center held an Opioid Data Roundtable in the fall of 2018 and presented the results of the national survey to representatives from ten states. Based on the takeaways noted above and the discussion by states at the roundtable, the NGA Center established a scale for assessing a state’s maturity in collecting, analyzing, and sharing opioid-related data. To that end, a point system was developed based on six criteria. Seven questions from the original 34-question survey were selected to create a six-point scale (0-6 points). Below are the questions and point system that was developed.
- ED Syndromic Data: “How often does the state receive Emergency Department syndromic data for suspected opioid drug overdoses (e.g., opioids, heroin, fentanyl, etc.)?” State must have responded as weekly or a shorter time period to earn 1 point.
- First Responder: Combined response for 1) “Does the state receive overdose information from local EMS?” and 2) “Does the state receive overdose information from local law enforcement?” State must have responded “yes” to both to earn 1 point; no points were award if only one of the two were a “yes”.
- First Responder: “Does your state receive naloxone deployment data from EMS?” State must have responded YES to earn 1 point.
- First Responder: “Does your state receive naloxone deployment data from local law enforcement?” State must have responded “yes” to earn 1 point.
- Fatal Overdose: “How often does the state’s Department of Health receive fatal overdose data from medical examiners/coroners? State must have responded annual or a shorter time period to earn 1 point.
- Drug-related seizure and arrest: “Is drug arrest/seizure data shared with non-law enforcement partners (e.g., the Department of Behavioral Health, public health, EMS, etc.)?” State must have responded “yes” to earn 1 point.
Prior to analysis, cut points were established. State point classifications are: “developing proficiency” (0-2 points), “proficient” (3-4 points), and “high proficiency” (5-6 points). It should be noted that of the 41 state responses, no state received zero points.
At least 33 states demonstrated proficiency in their opioid data collection, capacity, and sharing capabilities. Of the 41 states, eight states (19.5%) were in the “developing proficiency” category, 17 states (41.5%) were in the “proficient” category, and 16 states (39%) were in the “high proficiency” category. In fact, multiple states both scored the maximum of six points, including those who have been hit hard by opioid-related overdose deaths.
Conclusion
States have been relentless in their pursuit to curb opioid-related overdoses and fatalities. This first-of-its-kind national survey on states’ ability to collect, analyze, and share opioid-related data revealed that many states have prioritized their data capacity, which may be a function of opioid prevalence, state-level resources, or various other issues. As states glean more of a comprehensive data picture around their respective opioid fatal and non-fatal overdoses during COVID-19, states may seek to modify their response strategies accordingly.
This survey reveals that most states receive emergency department syndromic data, collect EMS first responder data, use Medicaid to identify vulnerable patient populations and physician over-prescribing, and collect drug-related seizure and arrest data. When moving beyond agency collection capacity to examine state data collection maturity, 33 states indicated moderate to high proficiency in their ability to collect and share opioid-related data.
Although states indicated data collection remains a serious challenge, we observed that most states have much of the infrastructure to capture priority data streams. While cross-agency collaboration and memorandums of understanding (MOUs) may need to be established in order to glean information at the agency-level, the states can (and do) analyze and share aggregated opioid-related data provided by individual agencies. Amidst a global pandemic that has challenged states’ capacities to respond to increasing overdose deaths, collecting and sharing information across partners to effectively respond to new challenges will be more crucial than ever. Gubernatorial led cross-agency collaborative efforts can help states turn the tide on the current opioid epidemic while positioning themselves to respond to evolving challenges.
This article appeared in The Criminologist, Vol. 46, No. 4, July/August 2021.
