The Opioid Crisis: A New National Strategy

Why did the White House and Federal Agencies shift their focus to harm reduction and substance use disorder (SUD) treatment during the pandemic?

107,622.

That’s how many people in the U.S. died of drug overdose between January and December 2021. Almost 80 percent of those deaths – 80,826 – involved opioids.

If you follow statistics on the opioid crisis, you know this is not good news. If you don’t, now you know the hard truth: the crisis is not getting better. It’s getting worse. And now, more than ever, it’s important for everyone in the country to do what they can to help stop the increase in drug addiction, drug overdose, and drug-related death in the U.S.

Here is another figure everyone should know: since 1999, almost 1 million people in the U.S. have died of drug overdose. That number may be too large – and the time frame too long – for most of us to process. To help clarify the situation, we’ll narrow our focus to the last three years.

Here are the fatal overdose and opioid-involved fatal overdose numbers for 2019-2021:

• 2019:
  • Total: 67,697
  • Opioid-related: 50,178
• 2020:
  • Total: 78,056
  • Opioid-related: 69,061
• 2021:
  • Total: 107,622
  • Opioid-related: 80,826

These numbers are going in the wrong direction – but it’s not through lack of collective will, effort, and commitment. Everyone directly related to the opioid crisis – and we mean everyone – is doing everything they can to help those in need. From the federal government to state governments, from local officials and policymakers to community organizers, from public to private treatment providers, the entire nation is united in addressing the opioid crisis.

Federal Response to the Opioid Crisis

In 2017, when then-President Trump called the opioid crisis a “national health emergency” and bolstered a series of policies implemented in the Comprehensive Addiction and Recovery Act of 2016 (CARA), congress followed his lead and passed the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities or SUPPORT for Patients and Communities Act of 2018 (SUPPORT Act).

The combination of those policies – and the tireless work of community organizers, treatment providers, and families – helped turn the tide. Despite the problems caused by an influx of illicit fentanyl, the overdose numbers started to drop.

Then the COVID-19 pandemic happened. This created a perfect storm of negative circumstances for people with substance use disorder (SUD). Stress and isolation increased emotional duress and led to increases in addiction and overdose. Public health measures led to job loss, housing insecurity, employment insecurity, food insecurity, and created unintentional barriers to treatment that exacerbated the opioid crisis and led to the shocking number at the beginning of this article: over a hundred thousand people dead from drug overdose in the year 2021.

In response, the White House acted. The first public evidence of our renewed federal response was during the State of the Union Address on March 1^st, 2022, when President Biden – in front of a television audience of 38 million people – said the words we all needed to hear:

“Let’s beat the opioid epidemic.”

Our response was relief. The bully pulpit is powerful. We knew when 38 million people heard the full force of the federal government’s voice commitment to ending the opioid epidemic, it would have an impact. But that’s not all he said:

“There’s so much we can do: increase funding for prevention, treatment, harm reduction, and recovery; get rid of outdated rules that stop doctors from prescribing treatments; stop the flow of illicit drugs by working with state and local law enforcement to go after the traffickers.”

We’ll describe the federal plan for addressing these action items in a moment. There’s one more line from that speech people around the country needed to hear:

“If you’re suffering from addiction, you know — you should know you’re not alone. I believe in recovery, and I celebrate the 23 million — 23 million Americans in recovery.”

That’s huge.

People with addiction often suffer in silence. Shame, fear, uncertainty, and the stigma attached to addiction and treatment prevent them from stepping forward and asking for help. This perpetuates the pain and suffering felt by millions. Those words from arguably the most powerful person on earth changes the game. On an individual level, there may have been thousands watching who’d never heard that before. On a national level, the fact those words were included in that speech means we’re ready to deploy all available tools at our disposal to end the opioid crisis once and for all.

It’s a tall order, but if we work together, we can do it.

What’s in the New Plan?

Let’s make it clear. We’re not here to cheerlead for policymakers: we’re here to share information on what our leaders are doing now and have done over the past several years to end the opioid crisis. Therefore, before we share the new plan, we’ll offer an update on how the federal government changed rules around treatment for OUD during the pandemic to address the problems caused by the public health measures implemented because of the pandemic.

Here’s what they did:

• Made it easier for providers to prescribe buprenorphine
• Increased the number of patients providers in office-based opioid treatment clinics (OBOTs) can offer medication-assisted treatment (MAT)
• Allowed providers to initiate buprenorphine treatment via telehealth
• Increased the number of take-home doses allowed for individuals in methadone treatment programs
• Revised regulations to allow mobile treatment clinics to bring MAT services to rural areas, underserved communities, and incarcerated individuals

The first part of the new national strategy involves making those rule changes – where they will reduce the most harm – permanent, rather than specific to the time period covering the COVID-19 pandemic and its denouement.

Now let’s take a look at the new five-point National Drug Control Strategy published this year by the Office of National Drug Control Policy (ONDCP). We’ll focus on three of the five priorities, and leave the remaining two, which address domestic and international drug trafficking, for another article.

Priority One: Harm Reduction

The plan defines harm reduction as “an approach that emphasizes working directly with people who use drugs to prevent overdose and infectious disease transmission, improve the physical, mental, and social wellbeing of those served, and offer flexible options for accessing substance use disorder treatment and other health care services.”

Components of the harm reduction plan include:

• Increasing the availability of, training for, and distribution of Narcan, a fast acting medication that can reverse the effect of opioid overdose and prevent fatality.
• Increasing the availability of drug testing strips, which people can use to detect the presence of fentanyl in illicit drugs. The ability to test for fentanyl will decrease overdose and overdose fatality.
• Increasing the availability of syringe services (SSP) and injection equipment. Syringe services are community based efforts that include access to addiction treatment resources, infectious disease testing, and overdose prevention efforts.

To anticipate resistance to potentially controversial harm-reduction measures such as syringe programs, the strategy outlines evidence that supports their necessity:

1. People with opioid use disorder (OUD) who use SSPs are five times more likely to initiate SUD treatment than people with OUD who don’t use SSPs.
2. People who use SSPs show an overall reduction in intravenous (IV) drug use.
3. Data shows that SSPs reduce instances of HIV and Hepatitis C in people who engage in IV drug use.
4. Economic experts have determined SSPs are cost effective when used alone, and even more cost effective when used in combination with MAT programs.

Priority Two: Substance Use Disorder Treatment

Right now, in every state in the country, effective, evidence-based treatment for OUD is available in the form of medication-assisted treatment (MAT). MAT works: to read about MAT in detail, click here. SUD treatment is a priority because of the treatment gap, which is the difference between the number of people who need SUD treatment and the number of people who receive SUD treatment. Here are the latest statistics on the treatment gap:

• 96% of people age 18-25 diagnosed with SUD did not get specialized treatment
• 86% of people age 26 + diagnosed with SUD did not get specialized treatment

In 2020, 41 million people needed SUD treatment. Those numbers tell us that under 3 million people received treatment. That’s not acceptable. That’s why this component of the strategy is based on four core principles:

1. Improving Treatment Engagement by Meeting People Where They Are

• • Identify and engage people who need treatment through community outreach
  • Encourage primary care providers to screen for SUD, the same way they screen for other chronic medical conditions
  • Offer housing, vocational support, and other social services for people in treatment who may experience income, food, or housing insecurity
  • Prioritize low threshold treatment programs. In other words, make it easier for people who need treatment to enter treatment.

2. Improving Treatment Quality Including Payment Reform

• • Simplify and streamline reimbursement practices related to SUD treatment in federal programs like Medicare or Medicaid and in the private insurance sector.
  • Increase federal block grant programs for SUD treatment managed by agencies such as the Veterans Administration (VA) and the Department of Health and Human Services (HHS)

3. Supporting At-Risk Populations

Evidence shows specific populations are at increased risk of overdose and addiction, including:

• • • Incarcerated individuals
    • Black, Indigenous, and People of Color
    • People in low-income, high crime areas
    • Evidence shows people in these groups are more likely to engage in treatment and achieve recovery when the following needs are met:
      • • Food
        • Shelter
        • Childcare
        • Basic healthcare
    • To meet these needs, the new strategy includes increased funding for:
      • • Wraparound services in underserved communities
        • MAT in prisons and jails
        • Mobile MAT units

4. Build the Treatment Workforce and Infrastructure

• • Increase and expand funding for community based mental health and substance use disorder treatment, with a priority on creating 24/7/365 access to treatment in underserved areas
  • Increase funding for treatment programs in rural areas
  • Increase HHS funding for training physicians in the field of addiction treatment
  • Increase HHS funding for training nurses, psychologists, pharmacists, and social workers to support people with SUD
  • Examine models to expand buprenorphine treatment
  • Expand telemedicine to allow providers to treat patients across state lines

Priority Three: Build a Recovery-Ready Nation

The primary job we face in creating a recovery-ready nation is reducing the stigma around substance use and treatment for substance use disorder. To do that, we need to move past our preconceptions about recovery and embrace the definition of recovery endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA):

“Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

SAMHSA identifies four dimensions of recovery:

1. Home
2. Health
3. Purpose
4. Community

The strategy goes on to make these important observations:

“Because recovery is a process, and not an event, it generally begins before substance use is stopped, continues after the cessation of use, can be sustained through a return to use, and may accommodate reduced levels of use when these permit improvements in health, wellness, and functioning.”

We’d stress this more if we could. In order to move forward, reduce harm, and encourage more people to come out of isolation and seek treatment, we need to accept this new concept of recovery. To achieve this goal, the new national strategy includes provisions to expand:

• Recovery Support Services (RSS)
  • This is a generic term that refers to any non-medical, community-based recovery support program that exists outside the parameters of official SUD treatment programs
• Peer Recovery Support Services (PRSS)
  • PRSS programs are the recovery support services most people know about, which include peer-driven programs like Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery.
  • PRSS programs revolve around the collective experience and wisdom of people who have lived through addiction themselves, and choose to support and seek support from others in similar circumstances
• Recovery Community Organizations (RCO)
  • RCOs refer to any community-based organization that supports people who need SUD treatment but have not – or are not currently – participating in any type of treatment or other support.
  • These groups offer support for various necessities like housing, employment, and health care. Many are faith-based and church-related. These organizations offer programs that can serve as a bridge that connect informal systems of support – such as church groups or mutual aid groups – with formal systems of support, such as MAT at an OBOT or opioid treatment center (OTC).

The strategy includes provisions to fund support RSS, PRSS, and RCO programs with a focus on providing housing, vocational support, access to basic medical care, and educational opportunity for all people in treatment for SUD, and all people seeking to achieve and sustain recovery form addiction.

A Paradigm Shift

To meet the challenges presented by the opioid crisis, we’ve had to change the way we think about addiction and mental health. That means we’ve also had to change the way we think about treatment for addiction and mental health. Over the past twenty years, we’ve gone from a society that unconsciously stigmatizes and judges people with addiction and mental illness to a society that has taken important first steps toward supporting and treating people with substance use and/or mental health disorders with compassion and understanding.

The change is reflected in the words of that last sentence – which is important. The way we talk about things reflects the way we think about things. The words that spring out reflexively reveal our basic instincts. That’s why we prefer words like substance use disorder over addiction and phrases like mental health disorder over mental illness. We also say alcohol use disorder instead of alcoholism and a person with substance use disorder or a person with alcohol use disorder instead of alcoholic or addict.

We tell people this decreases stigma and the new language is a concrete example of the person-first, patient-centered approach to healing that characterizes all medical practice in the 21^st century. Sometimes our peers – and even some of our colleagues – think we put too much emphasis on this careful approach to language, but a small part of the official National Control Drug Strategy – a footnote, even – indicates that policymakers at the highest level agree with us.

How do we know?

Because beginning in 2023, they’re changing the way they talk about these subjects, too.

Words Matter: Changes at the National Level

• The National Institute on Alcohol Abuse and Alcoholism will become the National Institute on Alcohol Effects and Alcohol-Associated Disorders
• The National Institute on Drug Abuse will become the National Institute on Drugs and Addiction
• The Substance Abuse and Mental Health Services Administration to the Substance Use And Mental Health Services Administration

When we see those changes happen at the national level – and know that our grassroots efforts played a part in making them happen – we know we’re on the right track. With these new policy objectives and funding priorities, we have confidence that we’re in a position to offer evidence-based treatment for substance use disorder to anyone and everyone who needs it.

Together, we can meet the challenges presented by the opioid crisis. We can exceed expectations of what’s possible for people who enter recovery. We can build a country where anyone who needs help can ask for the help they need. And when they ask for help, they can receive it without fear of judgment, stigma, or exclusion.