# Evaluation of Opioid-Focused ECHO Programs The opioid epidemic has been a critical health issue in the United States since the late 1990s. In Minnesota, 4,821 people have died from opioid-involved overdoses since 2000. There were nearly 8,500 visits to emergency departments in the state for nonfatal overdoses between 2016 and 2019 (Minnesota Department of Health, n.d.). These numbers appear to be worsening over time, particularly with the increasing availability of synthetic opioids like fentanyl. A range of treatments and prevention measures are needed to reverse this trend. One highly effective treatment for opioid use disorder (OUD) is medication-assisted treatment (MAT), which is the combination of medications, counseling, and behavioral therapy. There are three primary medications for OUD: methadone, buprenorphine, and naltrexone. Methadone can only be distributed by certified opioid treatment programs. There are 16 such programs in Minnesota, and only four are located in rural areas outside the Twin Cities metro area, making it challenging for many Minnesotans to access them. Buprenorphine and naltrexone can be prescribed by primary care providers, but providers must receive a Drug Abuse Treatment Act waiver (DATA-waiver) from the DEA to prescribe buprenorphine. Buprenorphine and naltrexone are both effective for treating OUD and preventing the use of opiates (Syed & Keating, 2013; Washington State Institute of Public Policy, 2016), but there are a number of drawbacks to treatment with naltrexone. The most effective form of naltrexone for OUD is through monthly injections, whereas buprenorphine can be taken orally on a daily basis at home (e.g., Morgan et al., 2017). In addition, patients using extended-release naltrexone lose tolerance for opiates, leading to a greater risk for overdose if they become non-compliant (Binswanger & Glanz, 2018). Given challenges with naltrexone induction and non-compliance (e.g., Lee et al., 2018) and scarcity of certified opioid treatment programs that dispense methadone, buprenorphine is often the preferred medication. However, access to buprenorphine is limited because very few primary care providers have the DATA-waiver needed to prescribe it (only about 4.6% of prescribers in Minnesota). There is considerable interest in interventions to increase access and capacity for providing MAT in primary care settings, such as Project ECHO (Extension for Community Health Outcomes). ECHO is a tele-mentoring program that creates a virtual learning community. Each ECHO consists of a “hub” where specialists work in an interdisciplinary team and “spokes” (typically rural providers or primary care providers who do not have specialized training in treating a particular illness) who connect to the hub through regular videoconferences for didactic and case-based learning. The purpose of ECHO is to expand access to specialty care, particularly in rural areas, through learning and guided practice for primary health care providers (Komaromy et al., 2016). A small number of studies have examined the effect of ECHO or ECHO-like programs for treating OUD or substance use disorders (SUDs) more generally. Most of these studies used a pre-post design without a control group. In our literature review, we found very few methodologically rigorous studies that included comparison groups to isolate causal effects. The studies that are designed to test causal effects provide some evidence that ECHO may increase providers’ clinical knowledge (Anderson et al., 2017), reduce their opioid prescribing (Katzman et al., 2019), and increase their buprenorphine prescribing (Gadomski et al., 2020), compared to non-ECHO trained providers. The purpose of this project is to assess the causal impact of two OUD-focused ECHO programs in Minnesota on increasing access to MAT and reducing opioid prescriptions and nonfatal overdoses. During the study period, the ECHO hubs were run through Hennepin Health Care and CHI St. Gabriel’s Health.* Each program offers weekly 1-hour virtual sessions that include a didactic presentation from an expert in the field and an opportunity for providers to share a specific case they are working on. The ECHO hubs have been receiving funding from the state of Minnesota since 2017 as part of the state’s response to the opioid epidemic. We will address the following research questions: - Among Medicaid enrolled primary care providers who are eligible to obtain a DATA-waiver to write buprenorphine prescriptions, does attending one or more ECHO sessions change the likelihood that the provider a) obtains a DATA-waiver, b) prescribes MAT, or c) prescribes opioids or high-dose opioids (>= 90 morphine milligram equivalents/day), compared to well-matched providers who do not attend any ECHO sessions? - Among adult patients who are enrolled in Medicaid, does being treated by a provider who attended at least one ECHO session change the patients’ likelihood of a) being prescribed MAT for OUD or b) visiting the emergency department with a nonfatal opioid overdose, compared to well-matched patients who are treated by providers who did not attend any ECHO sessions?