Tackling The Drug Overdose Crisis: A Novel Health And Human Services Strategy

The drug overdose crisis worsened during the COVID-19 pandemic, claiming more than 100,000 US lives in the year ending April 2021—an unprecedented number and almost 30 percent more than the prior year. Between 1999 and 2019, more than 840,000 people died from drug overdoses in the United States. Non-fatal overdoses are even more numerous than fatal ones and contribute to substantial increases in hospitalizations and emergency department visits. These harms are costly: The opioid crisis costs society a staggering half a trillion dollars per year.

Overdose-related harms have escalated in part because the substances involved have become more lethal, shifting from prescription opioids, to heroin, to illicitly manufactured synthetic opioids—namely fentanyl—and stimulants. We also know the current crisis varies by geography and population in ways that warrant attention to minimize acute harms. For instance, use of psychostimulants such as methamphetamine and associated harms have risen recently in the Northeast, whereas they were previously predominantly used in the West and Midwest.

Recognizing the need to address the drug overdose crisis holistically—across the continuum of substances, prevention, and services—and to meet the needs of people who misuse drugs and their communities, the US Department of Health and Human Services (HHS) developed a novel Overdose Prevention Strategy (Strategy) for the Biden administration. Agencies across HHS came together in a collaborative effort around evidence-based activities in four priority areas: primary prevention, harm reduction, evidence-based treatment, and recovery support. HHS Secretary Xavier Becerra released the Strategy on October 27, 2021. The Strategy consists of more than 40 public-facing high-impact activities recently launched or underway around substance use disorders (SUD) and overdose, representing the backbone of the many complementary initiatives ongoing in HHS.

The administration is putting substantial money behind these activities. The American Rescue Plan Act of 2021 provided HHS with nearly $4 billion to invest in the nation’s behavioral health infrastructure. Additionally, in the fiscal year 2022 President’s Budget, HHS has requested significant increases in funding for the Strategy’s priority areas totaling $11.2 billion, 54 percent more than what was enacted for fiscal year 2021.

Guiding Principles Of The Strategy

The Strategy is groundbreaking in several ways. Compared to the prior two administrations’ opioid strategies, the focus of this new Strategy has shifted from solely opioids to overdoses more generally. This reflects recent increases in stimulant-involved overdoses and the aim to be inclusive of populations affected by different substances. The Strategy’s robust inclusion of harm reduction and recovery supports is also unprecedented. HHS acknowledges that we must save lives in addition to engaging people in treatment and that recovery is more successfully sustained with key social supports.

The Strategy prioritizes two hallmarks of the Biden administration: equity and evidence-based policy making. The overdose crisis has been characterized by stark inequities. Underserved communities have experienced heightened overdose-related harms and face barriers to treatment and supports. For instance, from 2013 to 2018, the annual percentage change in opioid overdose for African Americans surpassed that for Whites in the US, yet Black Americans are less likely to receive many forms of SUD treatment than White Americans. Many of these vulnerabilities relate to social and structural determinants of health. HHS is motivated to implement data-driven solutions to these issues, and where the evidence is underdeveloped, our substantial research portfolio is working to develop it.

Two additional guiding concepts support the Strategy: coordination and integration and reducing stigma. SUD care is often siloed from other forms of physical and mental health care, which hinders care along the continuum. Integration of primary care and specialty SUD care is critical to providing different levels of care and treating the various needs and comorbidities of people who misuse drugs. Improved coordination among harm reduction efforts, criminal justice, health care, and social support settings could help people segue from high-risk episodes to more routine, sustained care and supports. Stigma pervades substance use and SUD treatment, and this must change to facilitate treatment and recovery. Drug use is not a moral failing or reason to judge character. Compassion and extending supports to individuals help communities avoid dire outcomes and heal.

Four Priority Areas

Primary Prevention

We know that prevention is critical to reducing the development of SUD, experienced by more than 40 million people across the US in 2020, 18.2 million of whom experience illicit drug use disorders. Substance use can start at any age, which is why HHS focused on evidence-based prevention across the lifespan. Adolescence is a particularly high-risk period for exposure, with young adults ages 18–25 more likely than other age groups to use illicit substances and to view substance use as not harmful. Among adults who develop SUD, substance use often starts in teen and young adult years. HHS has several activities focused on this vulnerable age group. For instance, the National Institute on Drug Abuse’s (NIDA’s) Adolescent Brain and Cognitive Development study tracks the biological and behavioral development of nearly 12,000 participants from adolescence through early adulthood to provide rich information about risk and protective factor profiles to improve prevention of SUD.

Another focus within primary prevention is reducing high-risk opioid prescribing that is not clinically indicated, while also ensuring that people’s pain is effectively managed. Chronic pain is a crisis in and of itself in the US, affecting more than 20 percent of adults in 2019. Opioids are one option for the treatment of chronic pain and require careful clinical consideration to avoid harm when tapering or discontinuing. For other conditions, such as acute dental pain, opioids have been demonstrated to be non-superior to other forms of pain relief, such as nonsteroidal anti-inflammatory drugs. The Strategy seeks to ensure that use of medications to treat pain is evidence-based and that we consider how to prevent serious risks associated with the prescribing of medications with significant potential adverse effects. For instance, the Food and Drug Administration (FDA) is working to warn Americans about serious risks associated with combinations of benzodiazepines with other medications, such as opioids and alcohol. The National Institutes of Health (NIH) is advancing clinical research on pain management as a core goal of the Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative®. And the Centers for Disease Control and Prevention (CDC) is updating and expanding its 2016 Guidelines for Prescribing Opioids for Chronic Pain to include recommendations for prescribing of opioids for acute and chronic pain.

Harm Reduction

The Strategy’s expansive conception of harm reduction at the federal level is truly novel and demonstrates HHS’s eagerness to follow the evidence to save lives. All people, regardless of whether they misuse drugs or are ready to enter treatment, deserve services that promote their health and well-being. Evidence-based harm-reduction approaches reduce risks associated with drug use, including infectious disease transmission and overdose. Expanding the delivery of and access to naloxone has been a focus of past administration opioid strategies; the current Strategy goes further to embrace additional forms of evidence-based harm reduction.

First, we at HHS are researching the effectiveness of harm reduction approaches and how to expand their use. For instance, the NIH is researching the relationship between syringe services programs and transmission of HIV and other infectious diseases. The NIH and the FDA are researching the effectiveness of rapid-acting fentanyl test strips in modifying drug use behaviors. At the same time, the CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA) have allowed certain program funds to be used to purchase these strips.

An infusion of grants, technical assistance, and stigma-reduction activities are further advancing HHS’ harm reduction efforts. SAMHSA is making available the first ever grants totaling $30 million over three years targeted specifically for harm reduction efforts. The CDC is partnering with SAMHSA to establish a Harm Reduction Technical Assistance program to support syringe services programs, helping to implement best practices for patient navigation from these programs to community-based health and social services to help foster care integration.

Evidence-Based Treatment

Although there are evidence-based medications and behavioral therapies to treat SUD, only a small proportion of those in need receive treatment. Even for opioid use disorder (OUD), only 11 percent of people received any of these medications in 2020, despite the availability of medications such as methadone, buprenorphine, and naltrexone that can reduce opioid use, mortality, and transmission of HIV and hepatitis C. The Strategy’s approach recognizes the need to make high-quality treatment more available to those who need it and are ready to seek it, and to minimize barriers such as cost, insurance coverage, provider supply, and stigma—particularly for underserved communities. To accomplish this, the NIH’s Justice Community Opioid Innovation Network advances knowledge about the best ways to treat OUD in criminal justice settings, and to sustain care post-reentry into the community. The Health Resources and Services Administration (HRSA) has a Rural Community Opioid Response Program, bringing evidence-based treatment to rural communities that often lack it, despite having a disproportionately high need.

To further minimize barriers to effective treatments, HHS is focusing on the provider workforce and integration across care settings. Critical to our efforts is promoting the integration of SUD treatment into other types of care, to ensure that patients are receiving comprehensive care and efficient referrals. For instance, the Centers for Medicare and Medicaid Services (CMS) implemented its Maternal Opioid Misuse model to advance high-quality care for participating pregnant and postpartum Medicaid beneficiaries with OUD by providing coordinated and integrated physical and behavioral health care services.

Finally, HHS research programs are developing new therapeutic approaches for conditions such as stimulant use disorder, for which medications are not yet options. For example, the NIDA is working to identify and develop new stimulant use disorder treatments through its Medications Development Program and its National Drug Abuse Treatment Clinical Trials Network.

Recovery Support

The Strategy’s final priority area, recovery support, recognizes that investments in additional supports to address life circumstances will generate positive outcomes, such as retention in treatment, lower rates of substance use recurrence, and higher employment. SUD is a chronic health condition that often requires long-term treatment and close collaboration from a multidisciplinary team. By providing peer, employment, recovery housing, and other life supports—or approaches that aim to address social determinants of health and to promote community inclusion—individuals are more likely to succeed in their recovery. HHS is investing robustly in recovery supports in coordination with other federal partners.

Researching and disseminating information on evidence-based implementation of recovery supports is the first step of this priority area. SAMHSA, through its Peer Recovery Center of Excellence, is providing training and technical assistance on clinical integration of peer support specialists and augmenting the capacity of recovery community organizations. To further grow the evidence on effective recovery support models, the NIH through its Research Networks for the Study of Recovery Support Services for Persons Treated with Medications for Opioid Use Disorder grants supports research on topics such as peer support services, recovery housing, and recovery community centers.

Although the evidence suggests recovery supports can facilitate recovery, various barriers to widespread implementation exist. Support services are not routinely covered by insurance and can require coordination between the health care and other sectors. HHS is seeking to lower these barriers with programs such as CMS’s Value in OUD Treatment Demonstration, which includes an alternative payment model that pays a care management fee to participants for furnishing OUD treatment services and permits them to use such payments to deliver additional services to participating beneficiaries, including services not otherwise eligible for payment under Medicare such as peer supports, recovery housing, job training, and nutritional support. SAMHSA is providing grants specifically targeted to recovery supports, through the Building Communities of Recovery and the Recovery Community Services Program. The HRSA’s Behavioral Health Workforce Education and Training Program for Paraprofessionals funds community-based training programs for peer support specialists and other paraprofessionals.

Next Steps

As the overdose crisis worsens, HHS’s resolve to address it becomes only more critical. While the federal government requires the partnership of communities, providers, and patients to tackle this crisis, our Strategy elevates areas, objectives, and activities to promote a comprehensive response. Using this framework, we at HHS will regularly assess our progress on current activities and add new activities as we see the need and are poised to roll them out. Our pragmatic, evidence-based approach to saving lives, reducing risk, and lowering barriers to effective interventions aims to always prioritize the health and dignity of people who misuse drugs or experience SUD. Together with our partners, we believe we can save lives, and we know we need to do so quickly.

Author’s Note

I acknowledge with gratitude the collaborative, extensive work of the HHS Overdose Prevention working group, who led development of the HHS Overdose Prevention Strategy. I also acknowledge the dedicated work of professionals across HHS on this topic to improve the health and well-being of Americans.