The Opioid Epidemic
Efforts Underway Toward HEALing Communities
“The opioid overdose crisis continues to worsen despite substantial efforts to mitigate it,” said Dr. Sharon Walsh, director of the Center on Drug and Alcohol Research at the University of Kentucky. She is one of many principal investigators working to change that trajectory.
The crisis started in the 1990s with the over-prescribing of pharmaceutic opioids to manage pain. The eventual clamping down on prescription opioids then led to a fast-developing heroin market. A decade ago, the landscape shifted again: Synthetic opioids (largely fentanyl, which is at least 50 times more powerful than morphine) began to be produced and sold illicitly, spawning a lethal overdose crisis that continues today.
“We are battling against a changing background largely attributable to the widespread availability of fentanyl [which is] leading to the highest rates of overdoses we have ever seen,” said Walsh, professor of behavioral science, psychiatry, pharmacology and pharmaceutical sciences at UK, who spoke at a recent National Institute of Mental Health Director’s Innovation lecture.
And yet, “We have efficacious interventions to address opioid use disorder [OUD],” she noted. “We’ve had some of them for decades.”
Two FDA-approved medications in particular—methadone and buprenorphine—have proven effective at treating OUD. Unfortunately, though, these drugs are underutilized.
These medications, said Walsh, “have inadequate uptake and inadequate delivery to the people who need them due to structural barriers, disjointed care systems, stigma and discrimination, which play a huge role in preventing people from getting access to care.”
It’s estimated only 5-10% of people who could benefit receive medication-assisted treatment.
“This is remarkable,” Walsh exclaimed. “How could we have medications that could cut the risk of death by half or two-thirds and yet we are not able to get it to people who need them in this country where we have this enormous health care system?”
In 2019, NIH and the Substance Abuse and Mental Health Services Administration (SAMHSA) launched the HEALing Communities Study, part of the HEAL (Helping End Addiction Long-term) initiative, an agency-wide effort led by the National Institute on Drug Abuse.
The study is testing interventions that prevent and treat opioid misuse and OUD across health care, behavioral health, the justice system and other community-based settings in four hard-hit states—Kentucky, Ohio, Massachusetts and New York—to implement those deemed most effective nationwide. The overarching aim is to reduce opioid overdose deaths by 40 percent.
“The vision for this project was that large-scale community activation was needed to expand evidence-based practices and reach the individuals who need them,” Walsh said. “Along the way, we’re trying to change hearts and minds.”
Within the four states, the study is working with 67 communities, both rural and urban, with a total population of more than 10 million people. Communities in the first wave began the study in 2020 and implemented the interventions for 30 months while Wave Two communities continued usual care. Wave Two communities are now in the middle of their interventions.
The study features three buckets of evidence-based practices: education on opioid overdose and naloxone distribution; delivering approved OUD medications to high-risk populations and increasing retention in care, and promoting safer opioid prescribing and dispensing. Each bucket contains a variety of strategies that communities have devised to effect change.
The chosen strategies were implemented in partnership with hundreds of health care, behavioral health and criminal justice agencies and many community-based organizations and programs.
“With a lot of help, cooperation and coordination, it is amazing how much has actually gotten done,” Walsh said.
Hundreds of different strategies have been employed, many of them adapted to local needs.
In New York, hundreds of NaloxBoxes—boxes containing six to eight doses of naloxone that hang on walls and provide 24/7 access—were strategically placed in train stations, restaurants and other public spaces during Wave One.
In Gloucester, Mass., a “Provider on the Pier” offers direct care to the fishing community. A clinic opened in the harbor master’s office aimed at helping immigrant dock workers affected by OUD.
In Kentucky, the “hub with many spokes” model connects study team pharmacists and partner agencies to expand naloxone distribution in hundreds of locations, from mental health to primary care to criminal justice settings.
In Guernsey County, Ohio, people held in jail awaiting trial were released under supervision and some inmates were moved to house arrest two months before discharge to initiate treatment earlier.
“We see something that we have not historically seen before in these decades of the overdose crisis,” said Walsh. There has been a significant increase in the opioid overdose death rate for non-Hispanic Blacks, which recently has surpassed the death rate of Whites. With this data in mind, investigators are tailoring strategies to address this disparity.
Meanwhile, the HEALing Communities Study was repeatedly revised when the Covid-19 pandemic hit shortly after Wave One interventions began.
“We used an interrupted time-series analysis to find there was a significant jump in opioid overdoses that happened right when the state of emergency was declared,” noted Walsh. At that time, jails were letting people out while hospitals were limiting admittance to critical cases.
“And we had challenges for people who were in treatment,” Walsh said. In response, “we decided to fast-track distribution of naloxone a little earlier than we had expected in Wave One.”
Hope for HEALing
“I want to leave us with a note of hope,” said Walsh. “Despite the fact that we are seeing these outrageous rates of death and a loss of young people, there are a lot of changes happening.”
In recent weeks, the FDA approved an over-the-counter naloxone nasal spray and is reviewing potential nonprescription status for other naloxone products. Guidelines are also easing to expand access to buprenorphine. Telehealth continues to help more people start and stay in treatment. And forthcoming study data ultimately will help bring tested HEALing interventions to more communities.
“As one of the PIs,” Walsh said, “my goal is to see if we could have a significant reduction [in overdose deaths] so we could parse out what does and does not work…to adapt that and disseminate it to places so we can start saving lives.”