Combating the opioid epidemic in the United States

Abstract

This editorial discusses the series of papers that feature initiatives to mitigate the opioid epidemic in the United States, and challenges encountered during the COVID-19 pandemic.

The United States is at the epicentre of an epidemic propelled by opioids and other potential drugs of abuse, with a devastating impact on the lives of Americans to the extent that it was responsible for the first decline in life expectancy in decades.1,2 The opioid epidemic has accelerated a shift in societal attitudes and policies regarding drugs of abuse. Past approaches, like the war on drugs, were also a war on people, viewing and treating those caught up in a cycle of addiction that is very difficult to break with scorn rather than compassion. State, local and government agencies, the research community, law enforcement, advocacy groups and other stakeholders began to invest in and undertake initiatives to mitigate the impact of opioid-related misuse and abuse and their consequences. No sooner did the trends begin to change in a positive direction when COVID-19 struck in early 2020, resulting in economic hardship and social isolation that disproportionately impacted the most vulnerable in society.3,4

COVID-19 has been transformative for economies and health systems around the globe.5 In the United States, COVID-19 interrupted continuity of care and programmes intended to support the treatment of patients with substance use disorders.6 The human and economic toll of the opioid epidemic on the US society is clear justification for long-term investments in education, preventative programmes and systems of care and support for stakeholders involved in the treatment and support for patients, families and their communities. Such investments require broad-scale implementation of evidence-based programmes demonstrated to improve health and social outcomes as well as initiatives that involve the exploration of innovative ways through which systems – social, health and legal – can rethink the way in which education and care is delivered and the management and care of patients with substance use disorders.

This supplement features a series of papers that provide insight into the opioid epidemic and programmes that seek to improve the care and management of patients with opioid-related substance use disorder. We are privileged to have a commentary from officers based at the United States Centers of Disease Control and Prevention (CDC), which discusses the CDC’s overdose prevention research and evaluation efforts and outlines ways to ensure flexibility in prevention research and evaluation as the epidemic continues to evolve.7

Several papers on educational and legal system-based initiatives that have been complicated by COVID-19 highlight challenges to implementation and evaluation and in the efforts to manage them. Education through knowledge and awareness is critical for both providers and patients and educational outreach to providers in the form of academic detailing is an established approach to improve prescribing through one-on-one visits. The effectiveness and design of such opioid-related educational outreach activities are described in a scoping review8 that summarizes the evidence on the effectiveness of various approaches and challenges to evaluating educational outreach programmes. Of note, there is no single best metric for evaluating programme effectiveness focused on provider education, as appropriate opioid prescribing is the goal, not the elimination of opioids. COVID-19 has presented new challenges to the delivery of academic detailing programmes, with providers and health systems strained by COVID-19 and the necessary transition of educational outreach from in-person to virtual delivery. Adaptations necessitated by constraints imposed by the pandemic are described in a paper by Morgan et al.,9 which focuses on a systems-level approach to practice-based interventions intended to enhance opioid safety through the development of a linked data resource that allows for evaluation of opioid-related outcomes. McQuade et al.10 demonstrate the value of adopting educational outreach with patients and their families, using an intervention that focused on the elderly and their families, who reported improvement in the knowledge of opioids and naloxone use. In the legal system, Van Nostrand et al.11 highlight problem-solving courts leading up to and after COVID-19, which take a more compassionate approach to the management of individuals with substance use disorders.

The lessons learned and programmes developed in combating the opioid epidemic may be transferable to other healthcare and social care issues within and outside the United States. The specific programmes may or may not be directly applicable and implementation science can help bridge that gap. Much of this work is ongoing and may require further revisiting of established approaches to educational outreach, clinical management, law enforcement and legal remedies. Investment in programmes that mitigate and prevent the opioid epidemic is essential to improve population health as well as economic and social well-being and this supplement illustrates some of the efforts that aim to support those goals and improve opioid-related prevention and research programmes in the years to come.