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August 31, 2021
This evaluation report has been prepared by the Pacific Health Analytics Collaborative (PHAC) at the Center on Aging and Health in the Thompson School of Social Work & Public Health at the University of Hawaiʻi (UH) at Mānoa at the request of the Behavioral Health Administration’s Hawaiʻi Opioid Initiative (HOI). The HOI is a partnership led by the Alcohol and Drug Abuse Division (ADAD) of the Hawaiʻi State Department of Health (DOH) and represents the collaborative efforts of stakeholders, researchers, volunteers, and both public and private organizations. The main objective of this report is to inform readers on the progress of the HOI to mitigate the harmful and adverse effects of opioid use disorder (OUD) on patients, communities, and systems of care in the state of Hawaiʻi.
The partnership between DOH and UH has led to the creation and launch of multiple data dashboards that were used to develop a series of infographics that illustrate the current state of substance use, abuse, and misuse in the state of Hawaiʻi. This section provides readers with a tutorial on how to navigate and access information in the dashboards to increase relevance and utility.
This section utilizes infographics and rapid evidence synthesis to inform and educate readers on the prevalence and impacts of OUD in Hawaiʻi as well as current prevention and treatment interventions. Topics include the rise of opioid misuse during the coronavirus disease (COVID-19) pandemic, the role of adverse drug events in opioid overdose, understanding addiction vs dependence, Medicare services, prescriber education, naloxone training, and interprofessional communication regarding OUD.
Each year the HOI identifies strategic objectives that guide Work Group activities. The HOI scorecards track progress on 1.0 objectives from 2018, 2.0 objectives from 2019, and 3.0 objectives from 2020. Each scorecard includes the contact information of the sitting Work Group Co-chairs. Anyone interested in supporting the HOI is encouraged to join a Work Group by contacting the Co-chairs.
This section inventories activities that have contributed to the progress of the HOI on 1.0, 2.0, and 3.0 objectives through a series of infographics. Information was collected from the survey, interview, and observation of participants through their attendance and engagement in the HOI Work Group meetings. Featured highlights include data from the Hawaiʻi Coordinated Access Resource Entry System (Hawaiʻi CARES), the National Take Back Initiative, naloxone kit distribution, policy enforcement, and training initiatives.
One challenge faced by the HOI is inconsistent engagement across Work Groups, with some Work Groups being more active than others. While the HOI persevered through the early months of the pandemic, some critical activities were limited by physical distance, including securing data use agreements and policy advocacy. As a result, some Work Groups made more progress than others on 2019 recommendations, such as increasing cultural competency by addressing strategic objectives related to the inclusion of Native Hawaiian cultural intervention treatment programs, wellness plans, and holistic living systems of care.
Opportunities for growth include increasing targeted recruitment, responding with forward action, Work Group collaboration, establishing additional Focus Areas to overcome challenges, and identifying a framework that can increase Work Group member cohesion and align objectives across Focus Areas.
Pūpūkahi I Holomua Unite to Move Forward
Starting in 2020, the coronavirus disease (COVID-19) pandemic ravaged the world, instigating massive economic and social disruption and psychological trauma, and in turn compounding other epidemics such as the opioid epidemic. Starting in the late 1990s, increased opioid prescribing led to misuse of prescription and illicit opioids. In 2017, the United States Department of Health and Human Services declared a public health emergency. The COVID-19 pandemic has further perpetuated, while exacerbating, the impacts of increased substance use which has already been well documented in past evaluation reports to disproportionately impact vulnerable populations and communities including kūpuna (older adults) and Native Hawaiians (1-2).
COVID-19 has limited access to care such as treatment and recovery services, transition to telemedicine for mental health services, and peer support. COVID-19 has also resulted in major economic and social disruptions including job loss and unemployment as well as the subsequent impacts on hunger, housing, and increased demand for social services. For others, COVID-19 has resulted in a disruption of routines, greater social isolation, and less physical activity. Additionally, opioid misuse can worsen respiratory and pulmonary health, which can make those more susceptible to COVID-19. In September 2020, a review of 73 million patients in the United States showed that those with substance use disorders (SUD) accounted for 10.3% of the population; they also accounted for 15.6% of patients diagnosed with COVID-19. Those with any history of SUD had a 1.5 times higher risk of being diagnosed with COVID-19 compared to those without, and had a higher risk of hospitalization (41% vs 30%) and death (9.6% vs 6.6%) (3).
Use of opioids and methamphetamines have also increased in the COVID-19 pandemic. Prevalence of fentanyl positive drug tests was significantly higher after the start of the pandemic compared to before (7.32% vs 3.80%). Methamphetamine positive drug tests were also significantly higher (8.16% vs 5.89%) (4). In a single emergency department study, cases of non-fatal opioid-related overdose more than doubled from 102 to 227 from March-June 2019 vs 2020 (5). On a national level, over 81,000 drug overdose deaths have been recorded over 12 months ending in May 2020. This number is the highest number of overdose deaths ever recorded in a 12-month period. The main driver for overdose deaths has been synthetic opioids (fentanyl), which experienced a 38.4% growth after the pandemic. Almost all (37/38) of United States jurisdictions with available data show an increase of synthetic opioid-involved overdose deaths. Additionally, 18 jurisdictions experienced an over 50% increase, and 10 western states experienced an over 98% increase in synthetic opioid-involved deaths. In addition to opioids, stimulant-involved overdose deaths (e.g., from methamphetamine) have continued to increase at a substantial growth rate of 34.8% (6).
In the third year of the Hawaiʻi Opioid Initiative (HOI), the 7 Focus Areas and Work Groups diligently addressed the opioid epidemic during a rather difficult year. As with previous years, the 7 Work Groups include:
These Work Groups have continued to voluntarily meet virtually during the COVID-19 pandemic. Moreover, the Work Groups have been tasked with addressing growing stimulant (e.g., methamphetamine) misuse, paramount for inclusion as part of the HOI.
The Pacific Health Analytics Collaborative (PHAC) in the Center on Aging and Health in the Thompson School of Social Work & Public Health at the University of Hawaiʻi (UH) at Mānoa continues to serve as the HOI evaluators.
The goal of this evaluation report is to document the programmatic successes, opportunities for growth, and technical assistance achieved by the HOI in its third
year. In alignment with the Alcohol and Drug Abuse Division (ADAD) objectives, the purpose of this evaluation is to illuminate the hard work and effort that has been accomplished by the 7 HOI Work Groups and UH Evaluation Team to address the opioid epidemic in Hawaiʻi. This report also aims to illustrate future directions for the prevention and treatment of opioid use disorder (OUD) and opioid overdose in Hawaiʻi. Key decision makers, HOI Work Group members, and community members may utilize this evaluation report to help make evidence-based decisions to mitigate the opioid epidemic and to ensure that public health programs continue to improve and sustain essential health services to the community.
This evaluation report aims to synthesize evidence from various public and private entities represented by HOI Work Group members. By integrating these data sets, ideas, information, and strategies into one document, we seek to highlight the interprofessional collaboration of the HOI as a best practice for “de-silozing” the healthcare system.
While this report features data from 2020, it can be seen as a living document as program evaluation is ongoing and ever-evolving. With a multisystem, complex public health problem such as opioid and stimulant misuse, this evaluation organizes and amplifies the voices of HOI stakeholders as a unified statement to share with others on an ongoing basis.
The epidemiologic landscape provides an emerging picture of the complex and dynamic nature of substance use, misuse, and abuse in the state of Hawaiʻi. Data visualization promotes understanding of the impact of the Hawaiʻi Opioid Initiative (HOI) activities on epidemiologic changes. One major accomplishment of the HOI Work Group 3, Data-Informed Decision Making, has been the creation and launch of five data dashboards in 2020 that draw on multiple data sources and present the current status of opioid and other substance use across the state. These five dashboards include:
In previous HOI evaluation reports, this section emphasized the static, flat media graphics of the epidemiologic landscape. This year, with the launch of these dashboards, the “live” dashboards are interactive and updated regularly. These dashboards help widen the aperture to capture a fuller, up-to-date picture of the state’s health during the coronavirus disease (COVID-19) pandemic.
In this year’s epidemiologic landscape presented in this report, the overviews of these dashboards demonstrate a snapshot in time with key highlights for navigation. In order to promote public accessibility of these dashboards, this report provides a tutorial on how to use the first four dashboards, which represent multiple data sources that have been compiled, analyzed, and visualized through the partnership between the Department of Health (DOH) and the University of Hawaiʻi (UH). Guidance on how to utilize each dashboard is provided in the infographics titled Hawaiʻi Opioid Initiative Dashboard Guide and The BHHSURG Isolation and Quarantine Dashboard & Hawaiʻi CARES Dashboard Guides. A fourth infographic titled Hawaiʻi Behavioral Health Dashboard provides a general overview of the breadth and depth of multiple data sources included in this behavioral health dashboard, focusing on the key areas of substance use, mental health, and homelessness.
The Hawaiʻi Pandemic Applied Modeling Work Group (HiPAM) COVID-19 Forecast website, though not summarized in this report, is noted as a relevant dashboard to assess the trajectory of the COVID-19 pandemic, which in turn has economic, social, and psychological ramifications for Hawaiʻi.
This chapter on evidence-informed strategies utilizes infographics and rapid evidence assessments on current affairs surrounding the opioid crisis. These infographics were based on consultations, engagements, and technical assistance requests by the Hawaiʻi Opioid Initiative (HOI) Work Groups to fill in the gaps and address the need for knowledge and information dissemination.
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This chapter on the achievements of the Hawaiʻi Opioid Initiative (HOI) is a product of our own assessment of progress by the individual Work Groups. In our iterative approach to evaluation, the first step to ensuring that we were assessing Work Group progress was collecting data that was accurate and complete. The primary expectation of the Work Groups is that they initiate and monitor activities guided by their expertise to complete their objectives, which are designed to support one or more of the following HOI themes:
Each Work Group’s objectives became the domains by which the Work Group minutes were summarized. To ensure quality data, we utilized Zoom recordings and transcripts to complete the meeting minutes. To increase fidelity, draft meeting minutes were routinely sent to the members of the Work Group for review and ratification. Detailed minutes serve a dual purpose: to facilitate the minutes review process, and to provide members with as much information as possible for activity tracking.
A matrix of the domains was used to extract key concepts from the meeting minutes. Additional information was also gathered to provide situational awareness, including indication of possible Work Group collaboration and soft technical assistance requests. Extra information aided our Evaluation Team in better anticipating the needs of the Work Group.
The matrices of qualitative data were merged with quantitative data from primary resources such as the Hawaiʻi Coordinated Access Resource Entry System (Hawaiʻi CARES) in-service training numbers, naloxone kit distribution numbers, National Take Back Initiative collection numbers, and attendance to Work Group meetings. Quotes were extracted from the feedback received on individual Work Group progress following the scorecard and achievements review sessions with the Co-chairs and members throughout April 2021.
All of these data sources were compiled to create the achievements section of this report, which consists of individual infographics for each Work Group and additional infographics related to membership participation and the State Opioid Response (SOR) grant. This multimodal approach has been the preferred method of highlighting achievement as it brings dimensionality to each Work Group and the HOI overall.
The year 2020 was mired with challenges that were compounded by the severe acute respiratory syndrome coronavirus (SARS‑CoV‑2), or COVID-19, pandemic. With a strong foundation in convening stakeholders across the islands established in years 1 and 2 of the Hawaiʻi Opioid Initiative (HOI), all Work Groups persevered and maintained responsiveness to a growing need to address the opioid epidemic and other substance use disorders (SUD).
The most significant challenges that the HOI encountered in 2020 included difficulty with inclusion of Native Hawaiian health practitioners, stakeholders and cultural interventions for opioid use disorder (OUD), engagement of key stakeholders, securing data use agreements, administrative challenges, as well as physical distancing. Through constant communication and efficient teamwork, the Alcohol and Drug Abuse Division (ADAD) and the University of Hawaiʻi (UH) HOI Evaluation Team was successful in the early identification of these challenges and efforts were made to mitigate negative impacts.
This resolution urges the inclusion of Native Hawaiian cultural intervention treatment programs, wellness plans, and holistic living systems into the response to opioid use disorder and other illicit substance use disorders. It pushes for an appropriate representation within Work Group initiatives. In 2020, HOI Work Groups incorporated objectives to include Native Hawaiian cultural interventions.
However, these objectives have been slow to be implemented consistently, although Work Groups 1, 3 and 4 made significant progress. As the HOI affirmed in last year’s evaluation report, members agree on the importance of addressing SCR 103 (2019) but vary in readiness to implement culturally safe approaches. As stipulated in the senate’s request, creating a Focus Area Work Group specifically for Native Hawaiian health may be the best way to ensure all objectives are met moving forward.
Even as the HOI continues to bring together a diverse group of voluntary professionals and community members, time and resources for novel and innovative directions to combat the opioid epidemic have been limited due to the COVID-19 pandemic. This pandemic has hidden OUD in plain sight, resulting in greater priority of COVID-19 over other areas of concern in many organizations. However, in light of new evidence to support an acceleration of opioid and other substance use (e.g., methamphetamine) during the COVID-19 pandemic, the importance of OUD and other SUD should be a reinvigorated focus of HOI.
To make optimal data-informed decisions, up-to-date information from multiple agencies is needed to appropriately display accurate health information. In regard to opioid use disorder, information from the opioid related deaths, hospital admissions, opioid utilization, and data from the Prescription Drug Monitoring Program (PDMP) are examples of essential data. For each distinct data source, an agreement between that agency and program evaluators is typically made. These agreements as well as the process and timeline for building mutual trust may take a significant amount of time, or may not happen at all. Throughout 2020, there have been significant barriers to securing multiple data use agreements which have slowed the process of providing optimal data to make informed decisions. The HOI has worked tirelessly to “link and sync” different agencies to form relationships that may lead to timely data sharing.
The COVID-19 pandemic has adversely impacted many workflows, including putting a strain on administrative operations such as contracting and hiring. With many programs acknowledging the need for increased vigilance and treatment of substance use disorder during the pandemic, resources dedicated to the approval of necessary contracts have not been expedited. The delay in contracting, and subsequent hiring of essential staff and purchasing, has prompted those on the front lines to do their best with the resources on hand. While these short fixes may alleviate some burden in the immediate future, long-term solutions for timely implementation of SUD programs are necessary. The HOI will continue work in tandem with private and public agencies to ensure minimal disruption of care and timely implementation of services regardless of administrative difficulties.
In-person meetings have been a great way to bring the HOI Work Group members together. At the onset of the pandemic, the shift to virtual meetings presented logistical challenges. Scheduling, technology, and familiarity with conferencing software proved difficult. However, the HOI Evaluation Team worked to provide an optimal environment for virtual meetings. This challenge pushed the team to work through difficulties to ensure regular Work Group meetings with minimal technological difficulties.
This chapter provides a summary of recommendations by the University of Hawaiʻi (UH) Hawaiʻi Opioid Initiative (HOI) Evaluation Team. A careful assessment of the overall performance of the initiative has revealed several areas of improvement. We present our suggestions as a guide intended to help navigate the initiative’s future course of action.
Membership to the Hawaiʻi Opioid Initiative (HOI) has been and continues to be an open invitation to stakeholders from the public and private sectors. The minimization of membership regulation draws inspiration from the Governor’s initial call for the Hawaiʻi State Department of Health (DOH) to “include everyone who wants to be included.” In previous HOI evaluation reports, we recommended increasing Work Group member diversity by extending invitations to community members. Evidently, the most common method of recruitment to date has been the “strike while the iron is hot” approach, or snowball recruitment, which relies on a targeted recruitment and timely delivery of invitations following a discussion wherein an entity or individual’s presence was determined as essential. Creating an opportunity to invite new members to fill in areas where their representation and perspective are lacking gives prospective partners the opportunity to engage with the HOI from the very beginning.
Targeted recruitment was a common method used by Work Group 1 to build up their smaller, more focused subgroup committees. Inclusion of managed care organizations (MCOs) in the subgroup for Provider Access and Medication-Assisted Treatment (MAT) has enriched discussions on increasing MAT/Medication for Opioid Use Disorder (MOUD) services by reducing access barriers and responding to provider needs.
Likewise, the invitation of community stakeholders to Work Group 7, such as Hawaiʻi Primary Care Association (HPCA), has brought new eyes to recurring issues and vigor to innovative ideas, such as integrating screening, brief intervention, and referral to treatment (SBIRT) into electronic health records systems for ease of SBIRT implementation and reporting and supporting the interoperability of the systems for improved continuity of care.
To facilitate targeted recruitment, our UH Evaluation Team has readied a streamlined process whereby a candidate receives a welcome or invitation to the HOI email, which provides a background on the HOI and includes a link to our last HOI evaluation report. Work Group members are periodically informed that recruitment support is available and only a referral is needed to initiate the process.
The “Connecting the Dots: A Map of the Hawaiʻi Opioid Initiative” infographic demonstrates that the HOI is held together by the collective work of its stakeholder partners on the Work Group objectives. Data sharing rises above with the most connections to the HOI stakeholder community, largely due to the overlapping Overdose Data to Action (OD2A) strategies and HOI objectives. Data sharing, however, should not be mistaken as a means to an end. Data dissemination needs to be followed by a response and forward action to be truly useful. With such a diverse membership that is inclusive of individuals that work directly with the substance use disorder (SUD) population, have lived experience caring for those with SUD, and advocate for chronic pain patients, the HOI Work Groups have an immense potential to directly impact our communities by aligning HOI objectives with issues that resonate best with this demographic.
Data dashboards advance equity of access and transparency of information. The HOI dashboard helps to remove some of the mystery of where the numbers originate and invites consumers to be empowered to trace the historical data on their own and use the tools available to slice and dice the data to gain more granular insight. The availability of information may also produce some unintended consequences if not followed by guidance, unified messaging, and a strategic plan. A general decline in fatal and non-fatal opioid overdoses combined with a decrease in dispensed opioid prescriptions may easily be interpreted as an overall achievement. What might not be as apparent are the numerous public health efforts, such as the implementation of the prescription drug monitoring program (PDMP) registration mandate in 2016 and the increase in naloxone training and education, that have supported the decline.
Sustaining work in this area is possible through the collaborative planning and follow-through of HOI stakeholder partners. With a growing list of activities simultaneously worked on within the HOI, the call for others to seize the opportunity to claim a stake in the HOI is here.
Work Groups, while separate in their Focus Areas, are designed to provide just enough overlapping coverage of the opioid and substance use issues. Work Group 4 has, thus far, been in the best position to collaborate with most of the Work Groups as it convenes together the communication-centered stakeholders that manage the public-facing platforms, like the HOI website and the HOI and partner social media pages. One of the more prominent collaborations to have come out of 2020 was the partnership between Work Group 4 and Work Group 5 on the creation and launch of the naloxone availability map onto the HOI website. Other areas of potential collaborations include coordinated re-entry and diversion, training programming, prescribing practices, provider education, naloxone distribution, and prescription drug monitoring.
As the Biden-Harris Administration puts forth their plans to address the overdose and addiction epidemic, it is imperative that the HOI come together to take on the Drug Policy Priorities for Year One (1). Some Work Groups have had difficulties maintaining support of their objectives due to pivoting responsibilities, especially in the early months of the pandemic. Just as some Work Groups have had to reset their focus, so too did the federal government with the national spotlight shifting to strengthening efforts in expanding access to prevention, treatment, harm reduction, recovery services, and reducing supply of illicit substances. In a way, this turning point might just be the perfect excuse for the Focus Areas to recalibrate and plan out how to more deliberately connect with one another.
In last year’s report, we strongly recommended that experts in Native Hawaiian Health and Healing be included in the HOI to meet the requests put forth by Senate Concurrent Resolution (SCR) 103 (2019), which is a resolution that urges the inclusion of Native Hawaiian cultural intervention programs, wellness plans, and holistic living systems of care. Some Work Groups have been intentional in their inclusion of cultural programming through the formation of a subgroup committee dedicated to this topic and targeted recruitment of members from the Native Hawaiian Health Care System; others have yet to formally work the HOI 3.0 Objective into their work plan.
Inviting subject matter experts as key informants has been an initial strategy to increase consultation, as it allows experts to participate in the HOI without committing to year-round volunteer positions. Engaging subject matter experts as key informants is not sustainable because the HOI has limited opportunities for reciprocity. In consideration, we support the addition of a new Focus Area Work Group on Native Hawaiian health in order to more purposefully allow more time and dedication for growth and development in this area so that sustainable, long-term changes may follow.
At its core, the HOI is a strategic and coordinated plan designed to respond to the opioid crisis. In order to incur the changes that move the needle on opioid overdose related deaths, it is recommended that a methodology be established to ensure that any evidence to support system-level changes in the form of rapid evidence synthesis and proof-of-concept projects is escalated to the Executive Substance Use Policy Steering Committee (ESC).
The HOI has an unrealized potential to effect change in policy outcomes. The heterogeneity that comes from the HOI’s diverse membership is both a strength and a barrier to forward movement. As a strength, diversity serves as the underpinning of balanced decision-making. As a barrier, working interprofessionally may increase miscommunication. A framework that can increase cohesion, shared language, and shared beliefs could increase capacity to work on a systems level by aligning objectives across Focus Areas.
During the 2021 legislative session, Senate Bill 1192 on requiring the dispensing of pharmacist-prescribed opioid antagonists to be reported to the State’s Electronic Prescription Accountability System (the PDMP) was introduced. Although groups within the HOI were in support of the administration of this bill, in the end, the passing of the bill was a missed opportunity (2).
Support in membership numbers are of most value when efforts are coordinated and actions align. The HOI stands to benefit from adoption of a framework that can not only provide the necessary infrastructure that accommodates interdisciplinary work, but also drives into action a vision that supports the directives of the collaborative.
This document is the evaluation report of the Hawaiʻi Opioid Initiative (HOI), a partnership led by the Alcohol and Drug Abuse Division (ADAD) of the Hawaiʻi State Department of Health (DOH) with more than 100 different stakeholders, and numerous public and private agencies across the state.
This report is authored by Charmaine Aoki, Keani Valdez, Andrew Abe, Katherine Burke, Benjamin Chu, Cielo Subia, Samantha Lumbao, Rachel Untalan, Shelby McKee, Edra Ha, Deveraux Talagi, Tiana Fontanilla, Katia Worley, Daniel Galanis, Angela Bolan, and Victoria Y. Fan.
The authors are grateful to Edward Mersereau, Amihan Aiona, Tammie Smith, John Valera, Jared Yurow, Jared Redulla, Gary Yabuta, Valerie Mariano, Mike Kobayashi, Ramon Ibarra, all the Executive Steering Committee members, Work Group Co-chairs, and members for all their contributions to the HOI and their participation in this evaluation report. The authors are also grateful to ADAD, the Substance Abuse and Mental Health Services Agency (SAMHSA) State Opioid Response (SOR), and the ADAD State Plan for Substance Use Treatment Project. All errors and omissions are our own.
The principal investigator (PI) of the UH HOI Evaluation Team is Dr. Victoria Y. Fan of the University of Hawaiʻi (UH) at Mānoa, Thompson School of Social Work & Public Health, Center on Aging and Health, Pacific Health Analytics Collaborative (PHAC). Please send all comments on the report to the UH HOI Evaluation Team at email@example.com.
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Pacific Health Analytics Collaborative
Center on Aging
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University of Hawaiʻi at Mānoa.
Hawaiʻi Opioid Initiative Evaluation Report.
Report Submitted to the
Alcohol and Drug Abuse Division
Hawaiʻi State Department of Health.
November 25, 2020.