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Social Determinants of Health
March 24, 2021

Our Other Epidemic: Addiction

Author Affiliations
  • 1Margaret T. Morris Professor of Health Economics, Harvard Medical School, Boston, Massachusetts
  • 2Esther Ting Memorial Professor, Stanford University, Stanford, California
  • 3Helen Ross Professor, University of Chicago, Chicago, Illinois
JAMA Health Forum. 2021;2(3):e210273. doi:10.1001/jamahealthforum.2021.0273

Distribution of vaccines against COVID-19 prompts conversations about our “return to normal.” Unfortunately, the “new normal” for addiction will be worse than what preceded the COVID-19 pandemic. The opioid epidemic continues apace, greatly harming public health and safety across the country. As has happened with every prior opioid epidemic in US history,1 a stimulant epidemic has come on its heels, worsening the opioid epidemic and causing great harm of its own.

Available data indicate that death rates from stimulants, such as methamphetamine, amphetamine, and methylphenidate, grew by more than a factor of 6 from 2012 to 2019. Evidence is mixed regarding underlying changes in methamphetamine use. Data from the National Survey on Drug Use and Health show only a 17% increase over the past 5 years, though such surveys severely undercount stimulant use.2 Treatment-based data show larger increases. The US Drug Enforcement Administration reports extensive Mexican production of high-purity methamphetamine. These producers have essentially priced their domestic counterparts out of the market. Death rates from cocaine overdoses grew 3.5-fold between 2012 and 2019. Current cocaine imports are considerably higher than in 2015, despite a slight ebb since 2017. The National Institute on Drug Abuse reports that 6% of high school seniors misuse prescription stimulants used to treat attention-deficit/hyperactivity disorder.

As we consider these alarming trends, we review whether history and our mistakes in addressing the opioid epidemic can help us do better this time. The opioid epidemic caused widespread alarm among the public health community, the US public, and elected officials across the political spectrum. Yet the policy response was sluggish and remains so.

Root Causes of the Slow Response

First, the data systems traditionally used to conduct surveillance of substance use disorder (SUD) flare-ups (eg, the Drug Abuse Warning Network and the Arrestee Drug Abuse Monitoring program) have either been discontinued or were in disrepair. Thus, it was only when overdose mortality trends—a lagging indicator—were well established that the gravity of the situation became clear. This is a shameful contrast with the epidemiologic systems that were built in less than a year to monitor COVID-19 far more effectively than addiction has been monitored for many decades.

Second, states and the federal government took slow, often inconsequential action to monitor and enforce existing regulations pertaining to the prescribing, promotion, and distribution of opioid medications.

Third, public and private insurance plans had historically offered poor coverage for evidence-based SUD treatments. The Mental Health Parity and Addiction Equity Act (MHPAEA) partially remedied that for private insurance and Medicaid-managed care plans but did not address many impediments to accessing care. At the same time, health insurers readily paid for a variety of services that either do not work or that may even increase overdose risk.3

Finally, due to years of underfunding through long-standing grant programs, local SUD treatment systems lacked capacity to provide modern addiction treatments or services that reduce the harms of substance misuse.

The opioid epidemic is exacerbated by fentanyl and other synthetic opioids (eg, isotonitazene), as dramatically cheaper production costs lead these substances to supplant heroin in illicit markets, just as heroin supplanted morphine a century ago. Fentanyl was implicated in roughly 73% of all opioid-related overdose deaths in 2019. Because fentanyl also contaminates the supply of stimulants, it is involved in about half of stimulant-related overdose deaths as well.4

As we craft a national response to stimulant-related morbidity and mortality, policy makers and the public must learn from our mistakes in addressing the opioid epidemic. Five characteristics of the stimulant problem must particularly be considered:

  • The lethality of illicit stimulants (cocaine and methamphetamine) has markedly increased.

  • Unlike the case of opioids, there are no US Food and Drug Administration–approved medications for stimulant use disorder.

  • While prescription stimulant misuse is prevalent and associated with misuse of other drugs, its direct contribution to the rise in mortality is small.

  • Stimulant misuse is markedly more concentrated in rural areas.

  • Serious mental illness is more prevalent among people who misuse illicit stimulants (26%) than among people who misuse opioids.

Essential Elements in Addressing These Challenges

First, we must explicitly recognize fentanyl’s role in the stimulant epidemic. A public health response should thus include efforts to equip people involved in illicit stimulant misuse with high-dose naloxone to reverse overdoses. These patterns also underscore the need for coordinated international policy to reduce importation of fentanyl from China and Mexico.

Second, we must expand our capacity to conduct surveillance and establish early warning indicators of outbreaks.

Third, we must promote payment models and regulatory measures that expand treatment access. In doing so, we should scrutinize measures, such as the Medicaid kickback rule, that limit use of contingency management treatments for patients with stimulant use disorder. In the COVID-19 era, we should also adjust insurance designs and regulations to advance outreach, mobile treatment, and telehealth. These efforts should be especially focused on rural areas. This means enforcement of MHPAEA provisions, making permanent the COVID-19–related emergency regulations promoting telehealth, investing in mobile treatment teams, and addressing the mental health needs of people who use substances. As with opioids, the prescribing deserves careful attention, as well.

Finally, we must establish accountability systems, including performance measurement, that increase the degree to which payments are made for treatment and service interventions that work, and not for those that do not.

In both the COVID-19 and opioid epidemics, policy makers and the public have supported major investments in treatment, prevention, and harm reduction interventions. This is a heartening foundation. It is essential that these investments go to evidence-informed efforts that actually help.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Frank RG et al. JAMA Health Forum.

Corresponding Author: Richard G. Frank, PhD, Margaret T. Morris Professor of Health Economics, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (frank@hcp.med.harvard.edu).

Conflict of Interest Disclosures: Dr Frank reported receiving financial support from Arnold Ventures and advising state attorneys general on opioid-related matters. Dr Humphreys was supported by grants from the National Institute on Drug Abuse (2UG1 DA015815-19) and the Veterans Affairs Health Services Research and Development Service (RCS 04-141-3); his opinions do not necessarily reflect the official policy views of those agencies. Dr Pollack reported receiving consulting fees from Monument Analytics, which was funded in part by plaintiffs in opioid litigation as part of multidistrict litigation (MDL 2804) in the Northern District of Ohio, US District Court. All authors participated in the Biden-Harris campaign.

Musto  DF.  The American Disease: Origins of Narcotic Control. 3rd ed. Oxford University Press; 1999.
Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. HHS Publication No. PEP20-07-01-001, NSDUH Series H-55. Accessed March 16, 2021. https://store.samhsa.gov/product/key-substance-use-and-mental-health-indicators-in-the-united-states-results-from-the-2019-national-survey-on-Drug-Use-and-Health/PEP20-07-01-001
Beetham  T, Saloner  B, Gaye  M, Wakeman  SE, Frank  RG, Barnett  ML.  Therapies offered at residential addiction treatment programs in the United States.   JAMA. 2020;324(8):804-806. doi:10.1001/jama.2020.8969 PubMedGoogle ScholarCrossref
O’Donnell  J, Gladden  RM, Mattson  CL, Hunter  CT, Davis  NL.  Vital signs: characteristics of drug overdose deaths involving opioids and stimulants—24 states and the District of Columbia.   MMWR Morb Mortal Wkly Rep. 2020;69(35):1189-1197. doi:10.15585/mmwr.mm6935a1PubMedGoogle ScholarCrossref
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    1 Comment for this article
    No-cost substance abuse prevention option is being overlooked
    Francis Holt, PhD, RN |
    The authors note: "In both the COVID-19 and opioid epidemics, policy makers and the public have supported major investments in treatment, prevention, and harm reduction interventions." Prevention can get a substantial prevention boost with no further investment at this point. The Federal Substance Abuse Block Grant (SABG) from the Substance Abuse and Mental Health Service Administration to States specifies that a minimum of 20% of SABG funds be used for prevention. The funds distribution formula predates both the Wellstone-Domineci Mental Health Parity and Addiction Equity Act and the Affordable Care Act; both of which have opened up more pathways to funded treatment for Substance Use Disorders (SUD). Since many more people now have health insurance coverage for SUD, simply increasing the required minimum investment of SABG funds for prevention will help prevention efforts without adversely affecting treatment potential and without increasing costs. Some sub-set of the population with SUD will always need SABG treatment funds because they will be Eligible But Not Enrolled (EBNE) in health insurance coverage. The EBNE population can be reduced through efforts also funded by the SABG. There is no longer a need for almost 70% of SABG funds to be used for treatment.