At the Crossroads in the Opioid Overdose Epidemic: Will Evidence-Based “Radical” but Rational Drug Policy Strategies Prevail?

The current opioid drug overdose epidemic shows little sign of abating as more than 100 000 Americans needlessly died of drug overdose in 2022.¹ US efforts to mitigate this health crisis have been insufficient, and we need to reexamine our current drug policy priorities, practices, and strategies to ensure that they are based on science and empirical evidence. Ray et al., in this issue of AJPH (p. 750), examined the effects of police drug seizures on overdose in Indianapolis, Indiana, and found a consistent pattern of increased drug overdoses. The authors’ findings suggest three strategic public health priorities that we believe are needed to improve our nation’s response to the current opioid overdose crisis: (1) prioritizing cross-system and interorganizational collaborations to improve the effectiveness of existing health care and social service resources, (2) expanding the use of innovative geospatial data and methods to improve contextual understanding of policy and program effects, and (3) prioritizing demand reduction by expanding current harm-reduction approaches and implementing promising new “radical” but rational evidence-based interventions to save lives.

IMPROVING INTERORGANIZATIONAL LINKS

Ray et al. advocate greater collaboration among law enforcement and social service agencies that serve people who use drugs to prevent overdoses following police drug seizures. Prioritizing increased interorganizational links and collaborations is essential not only between law enforcement and service organizations but also across the many institutions and health care and social service systems already involved in mitigating addiction. The effectiveness of existing service system resources in the health care, addiction treatment, mental health, and social services sectors can be far more effective through lowered barriers and increased coordination, collaboration, linkages, and integration with one another to better serve the multiplicity of needs of people struggling with addiction. The siloing of these systems of care and lack of integration limits access to treatment and other needed services, especially for people of color, who are disproportionately affected by structural barriers such as poverty, racism, and stigmatization.

Unfortunately, fostering and sustaining these collaborations to reduce overdose is difficult given the disparate missions and cultures of different systems and agencies. The field of implementation science provides theoretical frameworks, interventions, measures, and tools to improve the uptake and implementation of evidence-based practices across systems, such as local change teams, needs assessments, coaching and feedback, and data-driven decision-making.² A good example of this approach involves the National Institute on Drug Abuse’s Justice Community Opioid Innovation Network (JCOIN) initiative. Because of the high prevalence of opioid use disorder among people under criminal justice supervision, this network’s projects are using implementation science methods to guide the development and evaluation of interventions that facilitate and sustain linkages between criminal justice systems and treatment organizations to improve access to opioid use disorder services.³

USING INNOVATIVE GEOSPATIAL METHODS

Ray et al. also illustrate the significant contributions that geospatial analysis can make to understanding and addressing addiction. Geospatial data capture key social and environmental determinants of health that relate to substance use, such as neighborhood disadvantage, segregation, and access to health care.⁴ Novel mapping and geospatial statistical techniques, such as spatiotemporal clustering, use such data to reveal how environmental and biopsychosocial factors interact to influence substance use behaviors and treatment outcomes, both among individuals and across communities.⁵ Interdisciplinary collaboration between public health researchers and geospatial scientists is key to advancing the effectiveness of drug policies, prevention, and intervention programs aimed at reducing overdose and other harms.

PROMISING RADICAL HARM-REDUCTION POLICIES

Although opioid overprescribing may have fueled the overdose crisis by increasing drug supply,⁶ Ray et al. illustrate the limitations and complexities of relying on supply-side interventions targeting the illicit drug market. Consistent with previous research concerning local drug supply disruptions, the increased incidence of overdose in their study likely resulted from reduced tolerance among users who cannot easily access opioids, increased use of unfamiliar fentanyl-contaminated polydrug combinations, and seeking out unfamiliar drug sellers who provide drugs with unknown potency.⁷

Between 2014 and 2022, federal funding for supply reduction efforts (e.g., law enforcement and interdiction) comprised 52% of the federal drug control budget. We are encouraged that the fiscal year 2023 budget request for President Biden’s administration’s latest national drug control strategy devotes 57% to demand reduction. The strategy includes harm reduction as one of its seven major policy priorities, along with advancing racial equity in drug policy and expanding recovery support services (https://bit.ly/43H7U6u; https://bit.ly/3MW3nqS). Also, recent federal regulatory changes will increase access to buprenorphine and naloxone.

Unfortunately, even with massive efforts to link existing systems, expand prevention programs, and increase access to evidence-based opioid use disorder treatment, there will still be people who use drugs who do not have an opioid use disorder but still use opioids, people with opioid use disorder who are either not yet ready to engage in treatment or will never seek treatment, and many for whom treatment has been either effective or ineffective who return to drug use. The increasingly lethal illicit street drug supply, in which fentanyl, xylazine, and other dangerous adulterants predominate, places these people at great risk for overdose.

You cannot treat the dead. It is for groups of high-risk people that two additional so-called “radical” but promising evidence-based harm-reduction interventions are needed to save lives: overdose prevention sites and safe supply policies.

Research evidence suggests that overdose prevention sites (i.e., safe injection sites), where people who use drugs inject under medical supervision, are effective in reducing overdose deaths and serve as a low barrier gateway to treatment and other services without increasing opioid use or crime.^8,9 More than 160 sites have been implemented in Europe, Canada, and Australia, and two sites are currently operating in New York City, with others planned in Rhode Island and Philadelphia, Pennsylvania.⁹ Rigorous evaluations informed by implementation science should be undertaken to assess the implementation and effectiveness of these sites, including how best to facilitate low barrier linkages to treatment and other services.

Serious consideration should also be given to modifying current prescribing regulations to examine safe supply interventions, such as heroin-assisted treatment, in which pharmaceutical grade opioids (e.g., hydromorphone and diacetylmorphine) are prescribed to divert people who use drugs to safer alternatives and away from the unregulated illicit drug market, where there is high risk for overdose.¹⁰ One recent systematic review found substantial evidence of heroin-assisted treatment effectiveness in increased treatment retention and reduced illegal drug use compared with methadone maintenance treatment.¹¹

As Ray et al. illustrate, addressing the opioid overdose crisis strictly through supply-side interventions is unlikely to be successful, as the United States’ long history of prohibitionist drug control policies have shown.⁶ Considering the current lethality of the opioid crisis, greater interorganizational linkages and collaborations are needed among treatment, health care, social services, criminal justice, and harm-reduction organizations to reduce treatment barriers and increase access to needed services. Harm-reduction interventions should be scaled up for those most at risk for overdose, including overdose prevention sites and safe supply prescribing policies, and rigorously evaluated with both traditional research and innovative geospatial and implementation science methodologies. Our systems of care need to provide equitable, nonstigmatizing, and respectful services for all individuals who currently use drugs regardless of their stage in the recovery continuum.¹²