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5. From Research to Legislation: a Qualitative Case Study of Massachusetts’ 2018 CARE Act Expanding Emergency Department Initiation of Medication for Opioid Use Disorder

      Purpose

      Many individuals with opioid use disorder or opioid overdose do not receive the recommended life-saving medication for opioid use disorder (MOUD), particularly adolescents and young adults. During the COVID-19 pandemic, opioid overdoses have substantially increased and existing health disparities in treatment access have worsened. Initiating treatment with MOUD for individuals presenting with opioid overdose to the Emergency Department (ED) has been demonstrated to increase access and improve treatment retention, decrease opioid use, and is cost-effective. ED MOUD induction programs now exist throughout the US, though Massachusetts was the first state to pass legislation in 2018 mandating that all acute-care hospitals that provide emergency services must be able to provide opioid agonist MOUD for individuals presenting with opioid overdose. We sought to characterize the formulation and policymaking process for this groundbreaking legislation, with particular attention to the role of research, personal stories, economic and public health considerations, and whether and how the specific needs of youth were addressed.

      Methods

      We conducted semi-structured qualitative interviews between August and November 2019 with 10 key stakeholders from Massachusetts involved in the policymaking process from multiple sectors including state government, hospitals, physicians, and related recovery and behavioral health organizations. Two coders analyzed transcripts using a hybrid inductive-deductive approach based on themes identified using an iterative process. The study was deemed exempt as non-human subjects research by the Johns Hopkins School of Public Health IRB.

      Results

      Key themes identified regarding factors in the policymaking process included the pressing need for action amidst an opioid overdose crisis and the strong role of research. Stakeholders agreed that the evidence was unequivocal that ED inductions save lives: “The fact that there's clear research and data that makes MAT evidence-based was critical…if you're objective and you're really concerned about the people coming into your hospital and your ED and you look at the research, it's clear.” Additional themes including multiple stakeholders coming together to collaborate throughout the process, overcoming financing and feasibility concerns including the necessity of budget-neutral legislation, processes taken to move towards feasible implementation, and a complete lack of youth consideration during the policymaking and initial implementation planning process.

      Conclusions

      These study results suggest that rather than personal stories, research supporting the effectiveness of ED MOUD induction was the driving factor in passing the Massachusetts legislation, and that the success of this legislation is attributable to diverse stakeholders collaborating towards a common goal of increasing access to evidence-based treatment in an attempt to respond to the opioid epidemic. The unique needs of youth were not addressed in this policymaking process, and should be considered in future implementation and policymaking. Policymakers and advocates in other states may look towards this legislative process in Massachusetts as a model for implementing similar legislation as states grapple with worsening opioid-related morbidity and mortality in the wake of the COVID-19 pandemic.

      Sources of Support

      Alinsky, Silva: T32HD052459.