By Iris Smith, Ph.D., M.P.H.

The U.S. opioid epidemic has been characterized as consisting of four overlapping waves: overuse of prescribed opioids; decrease in prescription overdose deaths and rise in heroin use; advent of illicitly manufactured fentanyl and other high potency synthetic opioids (HPSOs); and combined use of HPSOs and psychostimulant drugs such as cocaine and methamphetamine, particularly during the COVID-19 pandemic.

Each wave of the epidemic has resulted in needless loss of life through overdoses and associated medical, social, and psychiatric complications resulting from use. At the individual level, risk factors for opioid use disorder (OUD) include younger age, being male (although overdose deaths increased among women between 1999 and 2017), and economic stress due to unemployment and poverty. At the community level, risk factors include social and economic barriers to treatment, lack of treatment programs/facilities, illicit drug availability, and the lower manufacturing and distribution costs associated with HPSOs. 

While early data indicates a rise in use among White males, emerging data suggest that rates among non-Hispanic and Hispanic populations are also increasing.¹  The combination of medically assisted treatment using opioid agonists such as methadone, opioid antagonists such as naloxone or partial agonists such as buprenorphine is recognized as the most effective approach to OUD treatment.² Such medically assisted treatment has been found to reduce mortality associated with overdoses, although these drugs may not be as effective in treating fentanyl and other HPSOs, especially when used in combination with non-opioid drugs.³

Harm reduction has been advocated as a more comprehensive system level intervention for OUDs encompassing evidence-based treatment as well as interventions designed to minimize the harm (personal and societal) associated with OUD.⁴  Harm reduction approaches include:

• Promoting safe injection and equipment sterilization practices for users to reduce the risk for infectious disease.
• Eliminating barriers to treatment by creating more “same-day” access to treatment programs and not requiring concurrent behavioral health treatment or complete abstinence from all drugs.
• “Housing first” models of care for homeless addicts.
• Overdose prevention sites and safe injection facilities and consumption sites (currently not legal in the U.S.).
• The use of take-home Fentanyl testing strips for users to prevent unintentional ingestion of Fentanyl or Fentanyl analogues by non-opioid users.

There is clearly a need for continued research to assess the effects of government policies on access to care and prescription analgesics; monitoring markets for illicit opioids, evaluating systems of care to enhance treatment effectiveness and access, especially non-traditional approaches such as harm reduction.⁵  A 2021 study that mapped trends in National Institute of Drug Abuse (NIDA) investment in implementation studies on opioids and/or stimulants, found that out of 666 research studies on opioids, only 2.4% were classified as implementation research and only 4.2% were considered implementation preparation studies that examined implementation strategies or the potential for “scaling up the intervention being studied to community wide implementation. ⁶

Resources

Centers for Disease Control and Prevention Resources on Prevention/Treatment of Opioid Use Disorder

Chan CA, Canver B, McNeil R, Sue KL (2022). Harm Reduction in Health Care Settings. Med Clin North America 106; pg.201-217. https://pubmed.ncbi.nlm.nih.gov/34823731/

National Institute on Drug Abuse Resources on Opioid Crisis and Pain Management: https://nida.nih.gov/nidamed-medical-health-professionals/opioid-crisis-pain-management

Peterkin A, Laks J, Weinstein ZM (2022).  Current Best Practices for Acute and Chronic Management of Patients with Opioid Use Disorder.  Med Clin North Am 106(1); pg. 61-80. PMID: 34823735  https://pubmed.ncbi.nlm.nih.gov/34823735/

Substance Abuse and Mental Health Services Administration (SAMHSA):

• The Opioid Crisis and the Black/African American Population: An Urgent Issue
• The Opioid Crisis and the Hispanic/Latino Population:  An Urgent Issue