Studying How State and Local Health Services Delivery Policies can Mitigate the Effects of Disasters on Drug Addiction Treatment and Overdose: A Mixed-Methods Study of COVID-19.

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ABSTRACT Public health disasters and the drug addiction and overdose epidemic are among the foremost public health issues facing the United States. Disaster-related disruptions to drug addiction treatment and overdose prevention services can be life-threatening to people with drug addiction. Public policies form the backbone of disaster response by delineating what health systems can and cannot do in the midst and aftermath of disasters. There are several types of state health service delivery policies with the potential to enhance access to drug addiction treatment and prevent overdose during disasters e.g., state telehealth policies allowing addiction treatment services to be delivered by phone, as opposed to video conference (a policy that may benefit people with drug addiction who lack computer and/or high-speed internet access); state harm reduction policies loosening restrictions on naloxone distribution during disasters; and state policies waiving in-person methadone dosing requirements and allowing individuals with opioid use disorder to take home a 14-28 days' supply. The implementation and effects of these policies on addiction treatment and overdose in the disaster context have not been studied; we will fill this gap by studying these policies in the context of the COVID-19 pandemic. We propose a mixed-methods study using a concurrent-embedded design. In Aims 1-2, we will conduct a 50-state study using a difference-in-differences approach to examine the effects of the state health services delivery policies of interest on rates of drug addiction treatment and fatal and non-fatal drug overdose. Data sources for Aims 1-2 will include 50-state administrative databases capturing services delivered in the general medical sector (IQVIA LRx/Dx and United Healthcare) and specialty addiction treatment sector (TEDS), as well as CDC fatal drug overdose data. In Aim 3, we will conduct in-depth qualitative case studies of eight US states hard-hit by COVID-19, with embedded case studies of local public health and healthcare systems in urban and rural counties within those states. A strength of the proposed study is its use of a concurrent embedded mixed-methods strategy, where qualitative case studies (Aim 3) will answer questions not addressed by the primary quantitative method (Aims 1-2). Our study will yield actionable evidence to inform policy development and implementation to enhance continuity to addiction treatment and prevent drug overdose during future disasters.