Spurred by a soaring rate of US deaths from drug overdoses, the Department of Health and Human Services (HHS) announced a new plan that pledges more federal support for a range of strategies to prevent overdoses, including needle-exchange programs and efforts to distribute test strips to check for fentanyl in street drugs, as well as other actions.
Fatalities from drug overdoses have escalated over the past decade, with an estimated 840 000 such deaths occurring from 1999 through 2019. Overdoses have been driven predominantly by illicitly manufactured fentanyl. Overdoses from psychostimulants such as methamphetamine—both with and without synthetic opioids—are also on the rise.
“The crisis has continually evolved and escalated, including during COVID-19, when an estimated 93 000 persons lost their lives to drug overdose in 2020—approximately a 30% increase over the year prior,” notes an HHS issue brief on the new overdose prevention plan.
Harm reduction strategies for people with substance use problems include such measures as syringe services programs (needle exchanges) to provide sterile syringes and needles to people who inject drugs; distribution of naloxone to reverse opioid overdoses and coprescribing it with opioid medications; and test strips to detect whether illicit substances, such as heroin, methamphetamine, or cocaine, contain (unknown to the user) the extremely potent opioid fentanyl, posing the risk of accidental overdose. Research shows that evidence-based harm reduction efforts can cost-effectively minimize negative consequences of drug use, such as drug overdose and the transmission of HIV and hepatitis.
However, harm reduction programs, such as syringe exchanges, have been controversial, in part because of the stigma associated with use of illicit drugs. In some states syringe services programs are illegal, although that number has decreased in recent years as the opioid epidemic has worsened. The legality of fentanyl testing strips also varies state to state, with some classifying them as illicit drug paraphernalia.
Although harm reduction strategies have been supported by grassroots efforts for decades, the agency’s prevention strategy “breaks new ground” by providing coordinated federal support for harm reduction, HHS said. In the issue brief, the agency said it plans to expand sustainable funding for harm reduction services, including those that are integrated with health care delivery, as well as promote evidence-based harm reduction services and develop educational materials and programs to reduce stigma.
For example, the plan extends recent harm reduction efforts such as one announced in April 2021 by the Substance Abuse and Mental Health Administration (SAMHSA) and the Centers for Disease Control and Prevention that certain federal grant funds can be used to purchase fentanyl test strips. Both the National Institute on Drug Abuse and the Food and Drug Administration are supporting studies of the effectiveness of rapid-acting fentanyl test strips in “modifying drug use behaviors and exploring drug checking needs in clinical settings.”
However, one harm reduction measure not mentioned in the plan is the creation of safe, supervised drug injections sites, which often face resistance from law enforcement and local officials. Philadelphia’s attempt to open such a site was blocked under a legal challenge from the Trump administration’s Department of Justice. Rhode Island passed a law in July authorizing a 2-year pilot program of safe injection sites, the first by a state.
In addition to harm reduction measures, HHS’s strategy targets 3 other key areas: primary prevention, evidence-based treatment, and recovery support.
Primary prevention priorities cited by HHS include reducing inappropriate prescribing of opioid painkillers by educating clinicians about best practices for opioid and nonopioid pain management, such as through the prescriber outreach program offered by the Centers for Medicare & Medicaid Services (CMS).
Other components cited in the HHS plan include supporting the development and promotion of evidence-based treatments that effectively manage pain, supporting research and surveillance to develop and improve delivery of interventions for preventing substance use, and boosting the implementation of evidence-based primary prevention across the lifespan. As an example, the agency cited a SAMHSA program that “raises community awareness and advances prescription drug misuse prevention activities and education to schools, communities, parents, prescribers, and their patients.”
Given that the adolescent and young adult years “are particularly critical at-risk periods,” evidence-based prevention efforts should particularly target teens and young adults, the HHS plan said. Research has found that the majority of adults who meet the criteria for having a substance use disorder started using substances when they were teens or young adults, and that evidence-based prevention reduces the negative consequences of substance use during young adulthood, HHS notes.
Another pillar of the HHS’s overdose prevention strategy is expanding access to evidence-based treatment for people with a substance use disorder. Medications such as methadone and buprenorphine can reduce opioid use and overdose deaths, although finding and entering treatment is hindered by problems such as cost, lack of health insurance, and stigma.
According to the 2020 National Survey on Drug Use and Health, only 1 in 15 individuals with a substance use disorder receive any type of specialty treatment. The HHS plan calls for broadening access to “evidence-based care that increases willingness to engage in treatment” and promoting strategies that improve engagement and retention in treatment programs, including integrating substance use treatment with primary care and specialty mental health care.
The agency cites examples of current efforts to advance access to and engagement with evidence-based treatment. These efforts include a program implemented by the Health Resources Services Administration to help bring such treatment to rural communities that lack access to high-quality treatment; the Justice Community Opioid Innovation Network at the National Institutes of Health, which seeks to develop optimal approaches to treat opioid use disorder in criminal justice settings and to encourage former prisoners reentering the community to continue treatment; and a CMS Maternal Opioid Misuse demonstration model that provides high-quality care for pregnant and postpartum Medicaid beneficiaries with opioid use disorder in the context of coordinated and integrated medical and behavioral health care services.
The fourth primary strategy focuses on recovery support, which encompasses resources such as peer support services and recovery housing. The HHS plan outlined the need for efforts to improve the quality of recovery support services, strengthen the workforce that provides such services, and improve access to and encourage the use of recovery support services.
According to HHS, the strategy reflects the administration’s core principles, which include improving health equity for underserved populations, using the best available data and evidence to guide policy decisions, integrating services for substance use disorders into other types of health care and social services, and reducing the stigma associated with substance use.
The 2021 American Rescue Plan, which became effective in March, designated $3 billion for the SAMHSA and the Health Resources Services Administration to implement new strategies to tackle overdoses and to expand access to services.
As a result of this funding, “we can address what so many people have seen in recent years: a rise in overdoses that can risk a person’s life—and affect their entire family,” HHS Secretary Xavier Becerra said in a press statement.
Published: November 2, 2021. doi:10.1001/jamahealthforum.2021.4252
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.
Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).
Conflict of Interest Disclosures: None reported.