The Opioid Epidemic’s Prevention Problem

With more than 115 overdose deaths a day from prescription and illicit opioid misuse, public health leaders have called the opioid crisis one of the most urgent public health challenges of our time. Increases in overdose deaths from prescription and illicit opioids are driving a decrease in America’s life expectancy for the first time in generations.¹ With the number of deaths from drug overdose in 2016 surpassing the total number of American deaths in the Vietnam War, clear action is needed.²

We are making progress. The US Surgeon General’s recent public health advisory calls for all Americans to keep the overdose-reversing medication naloxone within reach,³ and state health agencies have issued standing orders to make the drug widely available. These are good moves: access to naloxone not only saves lives but also demonstrates that all lives are worth saving and will reduce the stigma associated with opioid use disorder and addiction. All states now have prescription drug monitoring programs that allow health care providers to view prescription histories and identify individuals who may be “pill-seeking.” President Donald Trump’s opioid emergency declaration and his call for a “really tough, really big, really great” campaign provides a mandate for further action directly from the commander-in-chief.⁴

But these strategies alone will not end the opioid epidemic. Naloxone is a lifesaving tool but does nothing to prevent drug use in the first place. Treatment prevents individual suffering, but its role is limited in addressing the many social and environmental factors that act as enablers or buffers against future drug use. Prescription monitoring programs address some of the “supply-side” issues of opioid addiction but do not do much to curb demand. Trump’s call for action and awareness is just that: a call.

To answer that call, we must continue to deploy more and better clinical options to treat addiction, support evidence-based recovery programs, and increase attention to opioid use disorder and addiction from a community perspective. This is the opioid epidemic’s prevention problem: we are relying too heavily on clinicians and the health care system to prevent opioid misuse and not enough on community-driven public health approaches to addressing the root causes of addiction. The breadth of the problem is now widely understood, but how to effectively intervene at the population level to prevent addiction in the first place continues to be a challenge. It is also public health’s “sweet spot.”

One place to start solving this problem is to build upon community-based approaches that have been effective in the past. Influenza, Ebola, and other infectious diseases are best controlled through primary prevention strategies: keeping groups from becoming infected in the first place. And although opioid use disorder is different from traditional communicable and noncommunicable diseases, the same guiding principles apply: primary prevention of opioid misuse and addiction at the community level should be our goal. Had we used a treatment-only approach with the Ebola outbreaks in 2014 and 2015, society as we know it would have been decimated. Instead, national public health leaders recommended primary prevention strategies to end the outbreak with ongoing, real-time disease surveillance, community engagement and workforce development, and early intervention in communities at highest risk.

The primary prevention of addiction requires a multidisciplinary approach, using population-based strategies, in addition to actions aimed at high-risk groups and individuals. The National Academies of Science, Engineering, and Medicine developed a framework that groups prevention strategies into universal, selective, and indicated interventions.⁵ We suggest employing this framework to operationalize a primary prevention approach to addiction that provides practitioners with the specificity and direction needed to successfully intervene at both the clinical and community levels.

UNIVERSAL INTERVENTIONS

Limiting exposure to increasingly potent painkillers is an important part of current efforts to prevent addiction in the first place. Clinical guidelines that specify limited indications for prescribing opioids and suggest evidence-based alternatives to treat pain should be implemented universally. The medical community, including pharmacy and dentistry, has a major role in primary prevention of opioid addiction, and prescription drug monitoring programs are important tools to help assess prescriber and dispenser adherence to practice guidelines.

Larger social and environmental factors, such as lack of hope and purpose, are powerful drivers of addiction that require community-level intervention. Broad strategies to increase community resilience, such as those suggested in the Trust for America’s Health National Resilience Strategy (https://bit.ly/2Q5lWIW), require policies that prevent despair and support quality education, meaningful employment, stable housing, and justice reforms supportive of recovery. These evidence-based policies are strategies to improve community health and well-being and are just as crucial to preventing addiction as clinical guidelines and standards for evidence-based medical practice.

SELECTIVE INTERVENTIONS

Interventions with groups at greatest risk for addiction refine the response to the epidemic by focusing resources where they are most needed. “Selective” prevention strategies are directed toward specific communities or subpopulations in which the risk of developing addiction may be higher than average. Research on adverse childhood experiences shows a dose–response relationship between traumatic childhood events and future drug use. Evidence-based interventions including home visitation and parenting supports and early childhood programs are proven to mitigate these experiences in communities where they are prevalent.⁶ Adverse community events such as joblessness, lack of economic and educational opportunity, and loss of family support and community cohesion are correlated with addiction. Targeted, selective approaches to mitigating the impact of adverse community events include expanding life-skills training in areas that are economically distressed, proactive screening and treatment of maternal depression, changing treatment and prevention services in jails and prisons, and creating a culture of trauma-informed care in health, social service, and law-enforcement worksites.⁷

INDICATED INTERVENTIONS

Indicated strategies can be used to screen and identify individuals who may be in the early stages of addiction. In clinical settings, prescription drug monitoring programs allow clinicians to monitor individual patient use, to identify those seeking opioids inappropriately, and to counsel and refer patients to treatment and recovery programs when indicated. In community settings, controversial but effective harm-reduction strategies such as syringe and needle exchange programs are saving lives and providing direct opportunities for public health and health care professionals to refer individuals to treatment and recovery programs.

Regardless of universal, selective, or indicated prevention strategies, clinical and community efforts to address opioid use disorder and addiction require an honest and direct examination of the reasons individuals use drugs in the first place. This requires collaboration among disciplines with different approaches and cultures, unified by the need for an enduring solution. Public health leaders have a responsibility to engage with mental health, substance abuse, social services, law enforcement, community development, and others just as they have done with the medical community. These engagements must also include individuals and communities that have suffered the most from adverse social and economic conditions. The opioid epidemic’s prevention problem is rooted in our inability to see the problem from both the clinical and community perspectives and then take an approach to primary prevention that relies on the best of health care but also the best of public health. Solving the problem is well within reach if we effectively use new resources and increase attention to the prevention of addiction at both the clinical and community levels.