Factors associated with state legislators' support for opioid use disorder parity laws

Understanding the Political Frames of the Opioid Crisis: A Content Analysis of U.S. Senators' Tweets

The opioid epidemic in the United States is a public health emergency that has triggered calls to action for policy reforms. However, variations exist between political parties and policymakers on how this issue is communicated to the public. With the substantial growth in the use of social media by policymakers as a tool for disseminating policy-related information affecting their constituents, examining their communication strategies on public health emergency issues is imperative. To better understand how U.S. Senate members use Twitter (now known as X) to communicate opioid-related issues, we conducted a quantitative content analysis of their opioid-related tweets (N = 697) from January 1 to August 25 2022. Findings reveal a significant political divide regarding how senators characterize the opioid crisis, influencing user engagement on Twitter. Guided by the moral foundation theory, the results suggest that Democratic senators were more likely to employ care/harm or fairness/cheating moral foundations, relative to Republican senators, who used more loyalty/betrayal or authority/subversion. Additionally, Democratic senators framed the opioid crisis as a health or policy issue, relative to Republican senators' immigration/border frame. For inclusion of information sources, Democratic senators included significantly more health sources compared to Republican senators' use of media or law enforcement sources. Issue frame and source type significantly influenced user engagement in the form of likes and retweets. These findings provide both practical and theoretical implications.

How policymakers innovate around behavioral health: adoption of the New Mexico "No Behavioral Health Cost-Sharing" law

State policymakers have long sought to improve access to mental health and substance use disorder (MH/SUD) treatment through insurance market reforms. Examining decisions made by innovative policymakers ("policy entrepreneurs") can inform the potential scope and limits of legislative reform. Beginning in 2022, New Mexico became the first state to eliminate cost-sharing for MH/SUD treatment in private insurance plans subject to state regulation. Based on key informant interviews (n = 30), this study recounts the law's passage and intended impact. Key facilitators to the law's passage included receptive leadership, legislative champions with medical and insurance backgrounds, the use of local research evidence, advocate testimony, support from health industry figures, the severity of MH/SUD, and increased attention to MH/SUD during the COVID-19 pandemic. Findings have important implications for states considering similar laws to improve access to MH/SUD treatment.

On the Relationship Between Stakeholder Affiliation and Attitudes Toward Behavioral Health Reform in Kansas

Introduction

The lack of access to behavioral health care, trends in behavioral health issues, and the impact of social determinants of health underlie the need for behavioral health reform in Kansas. However, stakeholders may affect progress toward behavioral health reform. This study examined stakeholders' attitudes toward behavioral health reform.

Methods

The authors analyzed data from a survey administered to elected officials, members of health advocacy groups, state employees, and payers in Kansas. Main outcome measures included attitudes toward the perceived benefit of certain behavioral health and social determinants of health policies and the perceived performance of the primary care and behavioral health care systems in Kansas.

Results

Payers perceived legislation to improve insurance coverage for behavioral health issues as less beneficial than state employees and members of health advocacy groups. Elected officials perceived legislation to address various social determinants of health as less beneficial than health advocates. Members of health advocacy groups rated the behavioral health care system more poorly than elected officials did.

Conclusions

Preliminary findings reflected both the barriers and facilitators to behavioral health reform in Kansas. However, several limitations undermined the generalizability of these findings. Future studies should consider more representative sample sizes, additional variables in behavioral health and social determinants of health policies, and more comprehensive, validated measures.

An Examination of Factors Affecting State Legislators' Support for Parity Laws for Different Mental Illnesses

Mental health parity legislation can improve mental health outcomes. U.S. state legislators determine whether state parity laws are adopted, making it critical to assess factors affecting policy support. This study examines the prevalence and demographic correlates of legislators' support for state parity laws for four mental illnesses- major depression disorder, post-traumatic stress disorder (PTSD), schizophrenia, and anorexia/bulimia. Using a 2017 cross-sectional survey of 475 U.S. legislators, we conducted bivariate analyses and multivariate logistic regression. Support for parity was highest for schizophrenia (57%), PTSD (55%), and major depression (53%) and lowest for anorexia/bulimia (40%). Support for parity was generally higher among females, more liberal legislators, legislators in the Northeast region of the country, and those who had previously sought treatment for mental illness. These findings highlight the importance of better disseminating evidence about anorexia/bulimia and can inform dissemination efforts about mental health parity laws to state legislators.

Where is "policy" in dissemination and implementation science? Recommendations to advance theories, models, and frameworks: EPIS as a case example

BACKGROUND

Implementation science aims to accelerate the public health impact of evidence-based interventions. However, implementation science has had too little focus on the role of health policy - and its inseparable politics, polity structures, and policymakers - in the implementation and sustainment of evidence-based healthcare. Policies can serve as determinants, implementation strategies, the evidence-based "thing" to be implemented, or another variable in the causal pathway to healthcare access, quality, and patient outcomes. Research describing the roles of policy in dissemination and implementation (D&I) efforts is needed to resolve persistent knowledge gaps about policymakers' evidence use, how evidence-based policies are implemented and sustained, and methods to de-implement policies that are ineffective or cause harm. Few D&I theories, models, or frameworks (TMF) explicitly guide researchers in conceptualizing where, how, and when policy should be empirically investigated. We conducted and reflected on the results of a scoping review to identify gaps of existing Exploration, Preparation, Implementation, and Sustainment (EPIS) framework-guided policy D&I studies. We argue that rather than creating new TMF, researchers should optimize existing TMF to examine policy's role in D&I. We describe six recommendations to help researchers optimize existing D&I TMF. Recommendations are applied to EPIS, as one example for advancing TMF for policy D&I.

RECOMMENDATIONS

(1) Specify dimensions of a policy's function (policy goals, type, contexts, capital exchanged). (2) Specify dimensions of a policy's form (origin, structure, dynamism, outcomes). (3) Identify and define the nonlinear phases of policy D&I across outer and inner contexts. (4) Describe the temporal roles that stakeholders play in policy D&I over time. (5) Consider policy-relevant outer and inner context adaptations. (6) Identify and describe bridging factors necessary for policy D&I success.

CONCLUSION

Researchers should use TMF to meaningfully conceptualize policy's role in D&I efforts to accelerate the public health impact of evidence-based policies or practices and de-implement ineffective and harmful policies. Applying these six recommendations to existing D&I TMF advances existing theoretical knowledge, especially EPIS application, rather than introducing new models. Using these recommendations will sensitize researchers to help them investigate the multifaceted roles policy can play within a causal pathway leading to D&I success.

Coverage of the opioid crisis in national network television news from 2000-2020: A content analysis

Background: News coverage has both negatively and positively influenced public awareness and perceptions surrounding the opioid crisis. This study aimed to describe and analyze national network television news framing of the scope and impact of the opioid crisis in the United States. Methods: We performed a retrospective content analysis on national network television evening news segments covering the opioid crisis from 1/2000 to 8/2020, which were obtained from the Vanderbilt Television News Archive. The database was queried for: opioid epidemic, oxycontin, heroin, fentanyl, and naloxone. Two independent reviewers quantitatively coded segment characteristics, including theme, geographic location, opioids mentioned, strategies for combatting the epidemic discussed, interviews conducted, and patient demographics. Changes in segment characteristics over time were analyzed using chi-square analyses and Fisher's exact tests. Results: News segments (N = 191) most commonly provided an overview of the epidemic (55.5%) and/or conveyed personal stories (40.3%). Prescription opioids (59.7%) and heroin (62.8%) were more often referenced than fentanyl (17.8%); the focus on heroin peaked in 2011-2015 (84.8%), while references to fentanyl significantly increased over time (p = 0.021). The most frequently interviewed people included patients with opioid use disorder (OUD) (47.1%), healthcare providers (36.7%), family members/friends (31.9%), and law enforcement (30.9%). Most of the featured patients with OUD were male (63.0%), white (88.4%), and young (< 40 years) adults (77.9%). Coverage of the crisis peaked in 2016. Conclusions: Evening news segments' emphasis on personal stories, while emotionally compelling, came at the cost of thematically-framed coverage that may improve public understanding of the complexities of the epidemic. The depiction of primarily white, young adult patients with OUD revealed a need for a greater emphasis in the news on underrepresented minorities and older adults, as these populations face additional stigma and disparities in OUD treatment initiation and retention.

Policy Makers' Priorities for Addressing Youth Substance Use and Factors That Influence Priorities

OBJECTIVE

Understanding public policy makers' priorities for addressing youth substance use and the factors that influence these priorities can inform the dissemination and implementation of strategies that promote evidence-based decision making. This study characterized the priorities of policy makers in substance use agencies of U.S. states and counties for addressing youth substance use, the factors that influenced these priorities, and the differences in priorities and influences between state and county policy makers.

METHODS

In 2020, a total of 122 substance use agency policy makers from 35 states completed a Web-based survey (response rate=22%). Respondents rated the priority of 14 issues related to youth substance use and the extent to which nine factors influenced these priorities. Data were analyzed as dichotomous and continuous variables and for state and county policy makers together and separately.

RESULTS

The highest priorities for youth substance use were social determinants of substance use (87%), adverse childhood experiences and childhood trauma (85%), and increasing access to school-based substance use programs (82%). The lowest priorities were increasing access to naloxone for youths (49%), increasing access to medications for opioid use disorder among youths (49%), and deimplementing non-evidence-based youth substance use programs (41%). The factors that most influenced priorities were budget issues (80%) and state legislature (69%), federal (67%), and governor priorities (65%). Issues related to program implementation and deimplementation were significantly higher priorities for state than for county policy makers.

CONCLUSIONS

These findings can inform the tailoring of dissemination and implementation strategies to account for the inner- and outer-setting contexts of substance use agencies.

Translating Medicaid policy into practice: policy implementation strategies from three US states' experiences enhancing substance use disorder treatment

BACKGROUND

Despite the important upstream impact policy has on population health outcomes, few studies in implementation science in health have examined implementation processes and strategies used to translate state and federal policies into accessible services in the community. This study examines the policy implementation strategies and experiences of Medicaid programs in three US states that responded to a federal prompt to improve access to evidence-based practice (EBP) substance use disorder (SUD) treatment.

METHODS

Three US state Medicaid programs implementing American Society of Addiction Medicine (ASAM) Criteria-driven SUD services under Section 1115 waiver authority were used as cases. We conducted 44 semi-structured interviews with Medicaid staff, providers and health systems partners in California, Virginia, and West Virginia. Interviews were triangulated with document review of state readiness and implementation plans. The Exploration, Preparation, Implementation, Sustainment Framework (EPIS) guided qualitative theme analysis. The Expert Recommendations for Implementing Change and Specify It criteria were used to create a taxonomy of policy implementation strategies used by policymakers to promote providers' uptake of statewide EBP SUD care continuums.

RESULTS

Four themes describe states' experiences and outcomes implementing a complex EBP SUD treatment policy directive: (1) Medicaid agencies adapted their inner/outer contexts to align with EBPs and adapted EBPs to fit their local context; (2) enhanced financial reimbursement arrangements were inadequate bridging factors to achieve statewide adoption of new SUD services; (3) despite trainings, service providers and managed care organizations demonstrated poor fidelity to the ASAM Criteria; and (4) successful policy adoption at the state level did not guarantee service providers' uptake of EBPs. States used 29 implementation strategies to implement EBP SUD care continuums. Implementation strategies were used in the Exploration (n=6), Preparation (n=10), Implementation (n=19), and Sustainment (n=6) phases, and primarily focused on developing stakeholder interrelationships, evaluative and iterative approaches, and financing.

CONCLUSIONS

This study enhances our understanding of statewide policy implementation outcomes in low-resource, public healthcare settings. Themes highlight the need for additional pre-implementation and sustainment focused implementation strategies. The taxonomy of detailed policy implementation strategies employed by policymakers across states should be tested in future policy implementation research.

State Legislators' Divergent Social Media Response to the Opioid Epidemic from 2014 to 2019: Longitudinal Topic Modeling Analysis

BACKGROUND

The opioid epidemic is widely recognized as a legislative priority, but there is substantial variation in state adoption of evidence-based policy. State legislators' use of social media to disseminate information and to indicate support for specific initiatives continues to grow and may reflect legislators' openness to opioid-related policy change.

OBJECTIVE

We sought to identify changes in the national dialogue regarding the opioid epidemic among Democratic and Republican state legislators and to estimate changing partisanship around understanding and addressing the epidemic over time.

DESIGN

Longitudinal natural language processing analysis.

PARTICIPANTS

A total of 4083 US state legislators in office between 2014 and 2019 with any opioid-related social media posts.

MAIN MEASURES

Association between opioid-related post volume and state overdose mortality, as measured by Kendall's rank correlation coefficient. Latent Dirichlet allocation analysis of all social media posts to identify key opioid-related topics. Longitudinal analysis of differences in the prevalence of key topics among Democrats and Republicans over time.

KEY RESULTS

In total, 43,558 social media posts met inclusion criteria, with the vast majority to Twitter (n=28,564; 65.6%) or Facebook (n=14,283; 32.8%). Posts were more likely to mention fentanyl and less likely to mention heroin over time. The volume of opioid-related content was positively associated with state-level unintentional overdose mortality among both Democrats (tau=0.42, P<.001) and Republicans (tau=0.39, P<.001). Democrats' social media content has increasingly spoken to holding pharmaceutical companies accountable, while Republicans' social media content has increasingly spoken to curbing illicit drug trade. Overall, partisanship across topics increased from 2016 to 2019.

CONCLUSION

The volume of opioid-related social media posts by US state legislators between 2014 and 2019 is associated with state-level overdose mortality, but the content across parties is significantly different. Democrats' and Republicans' social media posts may reflect growing partisanship regarding how best to address the overdose epidemic.