On August 16, 2022, Sarah Wakeman, MD, shared her perspective on how the U.S. is taking the wrong approach to addressing the drug overdose crisis. As part of MedPage Today‘s review of the past year’s top events, Wakeman follows up with her thoughts on how states can correct the current failing approach and best use funds from the opioid settlement to make a real impact.
As hundreds of millions of dollars start rolling into states from opioid settlement funds, spending these dollars wisely is critical. The significant missteps in how tobacco settlement funds were used offers a lesson in what can go wrong when these massive amounts of money are not used to meaningfully address public health gaps related to substance use and addiction. States have a crucial opportunity to respond differently, and thankfully a tremendous amount of research to guide funding priorities.
The urgency to get this right is evident in the numbers; the nation topped 110,000 provisional overdose deaths per year in March 2022, the most grim outlook our country had ever seen. Tragically, racial and ethnic disparities in overdose death have only worsened, with the greatest rates of increase in death seen among American Indians and Black Americans. These hundreds of thousands of lives lost are made all the more wrenching because they are the result of decades of failed policies, stigma, and problematic approaches to substance use and addiction.
So, what works and where should funding be directed? The science is clear that to reduce deaths we must expand the availability of effective treatment including access to opioid agonist medications and full-spectrum harm reduction services. We also must undo harmful policies, and address structural inequities and social drivers of chaotic drug use. Within each of these buckets are concrete and bold efforts that states should undertake.
Expand Access to Treatment and Harm Reduction Services
To expand access to buprenorphine and methadone, we need legislative action to remove prescribing barriers and the restriction that methadone can only be dispensed in opioid treatment programs. In a major win for opioid addiction treatment, the recently passed government spending bill repealed the x-waiver requirement for buprenorphine prescribing.
However, other reforms are essential, too. While funding may not drive needed legislative change, states could use funding to incentivize providers and institutions to offer these treatments more readily, even within the current restrictive landscape. For example, states could provide funding to healthcare settings like hospitals, emergency departments, primary care practices, addiction treatment settings, and community health centers. These funds could be used to hire additional staff; provide capital for space renovations needed to deliver treatments such as methadone; augment salaries to recruit the best and the brightest into delivering opioid use disorder treatment; offset the cost of offering services that are not well reimbursed; and provide technical assistance and administrative support to complete the onerous application processes currently necessary to obtain an opioid treatment program license.
Another crucial part of delivering effective treatment is having a well-trained workforce. Currently, there are limited sustainable funding pathways for addiction medicine or psychiatry fellowships to train physicians to become specialists. Many programs rely year-to-year on unpredictable philanthropy and time-limited grants to train this essential physician workforce. States could use opioid settlement funds to create and sustain addiction medicine and psychiatry fellowship programs for physicians. In addition, novel fellowship programs for psychologists, nurse practitioners, and social workers are gradually being established and are in need of durable funding sources.
Harm reduction is an essential component of any intervention to address the opioid-related overdose crisis, and has long suffered from lack of funding and support. Opioid settlement funds could be directed to fund bold efforts like overdose prevention sites, which have been implemented successfully in countries around the globe and have a demonstrated capacity to reduce overdose mortality.
States like New York and Rhode Island have taken the lead on piloting sites, and others could follow suit with funding to drive implementation and address the hurdles of political and community support. Additionally, expanded drug-checking resources, including but not limited to fentanyl test strips and expanded drug checking services, are a crucial tool to reduce harm from the unpredictable drug supply. Syringe service programs, safer smoking supplies, and ongoing naloxone access are other harm reduction efforts that continue to need durable funding.
Update Policy and Address Structural Inequities
Addressing the dire lack of affordable housing and needed congregate and non-congregate housing options for people who are unsheltered is another critical step to address the overdose crisis. Unstable housing can drive chaotic substance use and increases the risk for overdose, and lack of safe housing can make it nearly impossible for people to engage in and stay connected to effective treatment.
The only solution to homelessness is housing. The intersecting challenges of the overdose crisis and homelessness has only been made more challenging by rising income inequality and housing prices, coupled with restrictive policies related to drug use and not-in-my-backyard opposition to affordable housing. Funding should be invested in a range of low threshold, supportive housing models that incorporate harm reduction and addiction services and address the needs of people who use drugs.
Lastly, effectively addressing the overdose crisis requires centering racial justice efforts. The ongoing harms of the war on drugs are seen in both historical and current approaches to drug use and addiction, which have criminalized communities of color. In contrast, the current opioid-related overdose epidemic was largely painted as an issue impacting white individuals in the media and the resultant softer, gentler public health narrative illuminates a disparate approach compared to past drug crises. Fundamentally ending the racist war on drugs is critically important. Opioid settlement money could incentivize needed policy changes and innovations around alternatives to incarceration and true family-based support for families impacted by substance use, instead of the punitive model of the existing child welfare system.
This funding could also be used to invest in strategies to address racial and ethnic disparities in overdose mortality. These could include investments to build a diverse addiction and harm reduction workforce through strategies like salary incentives, start-up packages for new faculty, loan repayment programs, and pipeline efforts to create early internships and student and trainee experiences in addiction medicine.
Funding could also be used to support partnerships between addiction treatment providers with trusted community partners like faith-based organizations and to develop community centered care models that bring treatment into nontraditional, accessible settings, such as local organizations or mobile care. In addition, funding could be directed to communities most harmed by the war on drugs to invest in initiatives such as remediating abandoned buildings and lots, building parks and libraries, and creating employment and expanded educational opportunities.
There are many opportunities to direct the large amounts of money from opioid settlement funds towards interventions that have been demonstrated to save lives and improve health. The hope is that states will do just that.
Sarah Wakeman, MD, is medical director for Substance Use Disorder at Mass General Brigham and an associate professor of medicine at Harvard Medical School.