Creating scalable solutions for substance use disorders

The opioid health crisis may have already peaked. However, substance use disorder (SUD) related deaths are on the rise for other controlled and illicit substances. Opioid addiction and treatment have different clinical and technical protocols, so solutions put in place to address the opioid addiction and death crisis may not necessarily scale to address other substances. 

 

Since 2017, between the CURES Act and the SUPPORT Act, the federal government has distributed billions of dollars in opioid-related grants to states and providers. Addressing opioid use disorder (OUD) differs from the approach used for more broad SUD in some key ways:

 

1. Some OUD can be tracked through patient and prescriber data — particularly for prescribed painkillers. However, heroin and fentanyl would have the same data challenges as other illicit substances. 
2. The medical treatment protocol for OUD offers Medication-Assisted Treatment (MAT), which is the use of approved drug-therapy medications in conjunction with counseling and behavioral therapies. This protocol is available for alcohol use disorder, but not for many other SUDs.
3. Law enforcement and emergency medicine protocols differ for OUD and other SUD. Preventing death from an OUD overdose can be facilitated with doses of Naloxone, which only works on opioid-related overdoses. 

 

While state and federal governments have addressed the supply of opioids, there has been a rise in addiction and deaths related to other substances. This includes methamphetamines (“meth”), cocaine, and benzodiazepines (an addictive class of sedatives that include Xanax and Valium). While these drugs alone have addictive and deadly properties, evidence shows that many may become laced with fentanyl, which increases the addiction and danger for users. Consider the following:

 

• This Journal of the American Medical Association (JAMA) article shows that prescription rates for benzodiazepines have nearly doubled since 2003. 
• Death rates have increased substantially for many drugs — including benzodiazepines, cocaine, and methamphetamines — between 1999 and 2017. 
• Additions of fentanyl to cocaine appears to be “the primary driver of cocaine-involved death rate increases,” according to the Centers for Disease Control and Prevention (CDC). 

 

To the extent allowed and practicable, states would be prudent to leverage opioid-related grant funding to address the bigger picture of SUD, behavioral health, and pain management. Some considerations for states:

 

• States should have a multi-agency, multi-stakeholder, multi-payer statewide plan for addressing SUD, behavioral health, and pain management. While OUD may be a prominent chapter in this larger plan, it should not drive all SUD policy. Including many stakeholders, as well as addressing behavioral health and pain management, allows states to efficiently address related public health goals such as reducing suicide deaths, sexually transmitted diseases and infections, and fetal dependency syndromes. 
• Tracking prescribing behavior by providers should include a broad array of controlled substances, updated by the U.S. Department of Justice. 
• Systems to manage data related to public health issues should be developed in a scalable fashion. For example, syndromic surveillance data should include controlled and illicit substances, not just related to an opiate class, but also to allow officials to concentrate on specific substances.