The scale of the opioid crisis in the United States highlights the need to identify and implement the most effective approaches to prevent overdose fatalities. Over the last 15 years, deaths due to opioid overdoses have exceeded 500 000,1 and declines in overall US life expectancy are partly explained by this increase in overdose mortality. The Healing Communities Study (HCS), part of the National Institutes of Health Healing Addiction Long-Term initiative to address the opioid crisis, is testing whether an integrated set of evidence-based prevention and treatment interventions can reduce overdose mortality by 40% over a 3-year period (the first year to select interventions and train personnel and 2 years of implementation).
Initiated in 2019, the HCS targets 67 urban and rural communities in 4 states (ie, Kentucky, Massachusetts, New York, and Ohio) with some of the highest rates of overdose fatalities in the country.2 The HCS multiprong approach includes the most effective interventions for decreasing overdose fatalities: increasing the number of individuals receiving medication to treat opioid use disorder (OUD), retaining them in treatment, and expanding naloxone’s distribution, as key components while using regional data to adjust the targeted interventions for a given community and promoting collaborations across health care, justice, and community settings.
In this decision analytical modeling study, Linas et al3 used the Researching Effective Strategies to Prevent Opioid Death model, a dynamic population state-transition model of OUD and OUD treatment, to simulate the population with OUD living in Massachusetts from 2015 to 2022, and forecast the potential impact of the evidence-based interventions proposed by HCS to prevent overdose over a 2 year period. The study simulated the effect of 3 interventions: initiating more people on medications for OUD (MOUD), improving retention with MOUD, and increasing naloxone distribution. They found that no intervention alone could reduce overdose mortality by 40%, supporting the multiprong design of HCS.3
Linas et al3 asked a highly relevant question: what is the best way to reduce opioid overdose deaths by 40% based on the characteristics of a given community? The answer is clear: to achieve this goal, no strategy would suffice if applied alone. The results of the model suggest that at least 10% of the estimated OUD population should be initiated in MOUD every month and that 50% of these should be retained in care for at least 6 months, while also increasing naloxone distribution. Other pathways are possible, but decreases in one metric, such as lower MOUD initiation rates, would require compensatory increases in others. From the public health point of view, comparing these pathways allows communities to optimally allocate their resources to reach the goal.
Results of the study by Linas et al3 further suggest that the implementation goals should be adjusted to the specific communities. For example, rural communities would need to initiate MOUD and retain in treatment a greater proportion of individuals with OUD and expand naloxone distribution to a greater extent than urban communities. Apart from validating the multiprong approach of HCS, this study also quantifies the expected outcomes based on the success in implementing the interventions. The emphasis of the HCS in guiding interventions based on regional up-to-date data could allow researchers to test the accuracy of the model by Linas et al.3
From the scientific point of view, examining the effectiveness of existing interventions suggests areas in which further research is needed, including development and implementation of interventions to increase MOUD initiation, such as telehealth or the use of pharmacies, as well as interventions to improve retention in MOUD, such as behavioral interventions (eg, contingency management) and treatment of comorbid conditions (eg, depression, anxiety, pain, insomnia), among others. Although not explicitly addressed, the study implicitly highlights that a key component for success is addressing the barriers to implementation, which may include lack of trained personnel or financial resources, insufficient reimbursement, lack of champions, and opposition to the use of MOUD based on nonscientific preconceptions.
To model the outcomes associated with implementation to project overdose mortality, Linas et al3 treated the opioid epidemic as a stable phenomenon, even while allowing for model variations between urban and rural communities. However, the opioid crisis is dynamic and has already moved through at least 3 overlapping phases4: an initial phase with predominant misuse of prescription opioid analgesics, a second phase with increased use of heroin, and a third phase characterized by deliberate and unintentional use of fentanyl and its analogs. Fentanyl’s very high potency and fast pharmacokinetic action make overdoses more difficult to reverse with naloxone. Furthermore, there is limited experience of MOUD treatment in individuals addicted to fentanyl, who may be harder to initiate with buprenorphine.
A more recent phase in the opioid epidemic shows a rapid increase in fatalities associated with stimulants (eg, methamphetamine and cocaine). This has created additional challenges, as there are currently no Food and Drug Administration–approved medications for their treatment nor to reverse their toxic effects. The changing landscape of the opioid crisis underscores the importance of collecting regional data in real time to inform on the nature of these changes and their consequences so that interventions can be modified appropriately.
Importantly, the modeling study by Linas et al3 is based on data from the Massachusetts population and an OUD treatment capacity that assumed the status quo. Similarly, HCS strategies and goals were selected based on the prevailing conditions for overdose mortality and community resources available in 2018, when the study was designed. However, these conditions have dramatically changed with the advent of the coronavirus disease 2019 (COVID-19) pandemic. Although access to up-to-date accurate data on patterns of drug use and overdoses across the US during the COVID-19 pandemic is not available, there are indications from different sources (eg, Overdose Detection Mapping Application Program, preliminary Centers for Disease Control and Prevention data, medical laboratories) of increased fentanyl and methamphetamine use and of an increase in overdoses. Meanwhile, reallocation of public and private resources to combat COVID-19 has eroded the ability of health care systems and public health departments to focus on the opioid crisis, and the community resources available to support individuals with OUD have become scarcer. The social distancing requirements to control the COVID-19 pandemic could further isolate individuals with OUD, and the challenges from potential evictions and loss of jobs could exacerbate drug use and increase relapse. On the other hand, the temporary changes in regulations to facilitate access to methadone and buprenorphine and easier access to telehealth has made these treatments more accessible to individuals with OUD, including those in hard-to-reach rural communities.5 Amidst the COVID-19 pandemic, integrated approaches to expand MOUD initiation, increase the retention in MOUD treatment and expand naloxone distribution need to be prioritized to help mitigate mortality from opioid overdoses during the COVID-19 pandemic. Furthermore, because individuals with OUD are at greater risk for contracting COVID and for more severe outcomes,6 their engagement in MOUD treatment will help mitigate the adverse effects of the pandemic.
Provisional data from the Centers for Disease Control and Prevention7 estimate that there were 83 335 overdose deaths for the 12-month period ending in June 2020, and it is likely that the rate of overdose has increased further as the pandemic has spread. The study by Linas et al3 helps us project the outcomes associated with implementing evidence-based interventions to reduce overdose mortality, while conveying the dire consequences of inaction. Neglecting the opioid crisis could hinder control of the COVID-19 pandemic and add to the increasing number of preventable overdose deaths in the US.
Published: February 15, 2021. doi:10.1001/jamanetworkopen.2020.37385
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Volkow ND et al. JAMA Network Open.
Corresponding Author: Nora D. Volkow, MD, National Institute on Drug Abuse, National Institutes of Health, 6001 Executive Blvd, Bethesda, MD 20852 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Disclaimer: The views and opinions expressed in this work are those of the authors and should not be construed to represent the views of any of the National Institute on Drug Abuse, the National Institutes of Health or any US government agency.
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Volkow ND, Blanco C. Interventions to Address the Opioid Crisis—Modeling Predictions and Consequences of Inaction. JAMA Netw Open. 2021;4(2):e2037385. doi:10.1001/jamanetworkopen.2020.37385
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