The Ecosystem Approach to Opioid Policy

Help family members cope with the stress and other psychological consequences of having a family member with opioid use disorder (OUD)

Social service and medical care agencies could help family members deal with the stress and other psychological consequences of having a family member with OUD—perhaps as part of a follow-up after an overdose.

This could require efforts to enhance the linkages between (1) systems that serve people with OUD and their families and (2) local mental health providers; efforts to increase the services provided for family members by clinical systems serving people with OUD; and efforts to educate families and address the stigma of having a family member with OUD.

Learn more about this and other ideas related to family resources in Chapters 3, 4, 10, and 13 of the report.

Merge individual-level data across multiple systems

Merging individual-level data across multiple components could help stakeholders across systems better understand how components interact and how individuals flow across components.

This information could also be used to conduct more-rigorous evaluations of policy interventions intended to reduce nonprescribed use of opioids and related harms.

Learn more about this and other ideas in Chapter 14 of the report.

Build on efforts to revise laws and other policies that make it harder for people with drug convictions to access services

Stability in a person's life often promotes reduced drug use and better treatment outcomes. Building on efforts to revise policies that make it harder for people with drug convictions to access such services as nutritional assistance and public housing could help create stability.

For example, housing is consistently identified as one of the main facilitators of recovery from opioid use disorder (OUD). And yet, criminal records can continue to be an impediment to accessing housing support.

Learn more about this and other ideas related to comprehensive support in Chapters 6, 10, 11, and 13 of the report.

Provide additional support to informal caretakers

The fallout from opioid use disorder (OUD) reaches far beyond people who have OUD. The burdens it can impose on family members might include financial stress, emotional hardship, physical health issues, and involvement with the justice system.

Providing additional support to informal caretakers of the children of people with OUD may relieve stress on the caretakers and reduce the probability that these children suffer a variety of adverse outcomes, including ending up in the child welfare system.

Learn more about this and other ideas related to family resources in Chapters 3, 4, and 10 of the report.

Consider amending the Adoption and Safe Families Act

Parent and child outcomes improve when parents and children engage in comprehensive family-centered treatment that meets the needs of the whole family.

This could be supported by amending the Adoption and Safe Families Act (ASFA), which requires termination of parental rights if a parent is not ready for reunification after the child has been in foster care for 15 of the past 22 months. As a result of ASFA, when parents struggle with opioid use disorder, they are generally not afforded the time to engage in treatment while retaining custody of their children. Because of federal guidelines on permanency planning, parents are sometimes unable to complete their treatment plan in time to reunite with their children.

Learn more about this and other ideas related to family resources in Chapter 10 of the report.

Increase preclinical and clinical training related to treatment of substance use disorders

Many medical students, physician residents, and other clinical trainees receive minimal instruction about treating substance use disorders (SUDs).

Enhancing such training will increase awareness that individuals with opioid use disorder and other SUDs can be successfully treated. The training would also normalize treatment of such disorders.

Learn more about this and other ideas related to stigma in Chapters 5 and 14 of the report.

Make it easier for people with low-level drug convictions to expunge or seal these offenses from their criminal records

State and federal laws allow—and sometimes require—that people with criminal records be prevented from accessing certain government services or opportunities. Some of these laws are specific to people with criminal records for drug violations.

Making it easier for individuals with low-level drug convictions to expunge or seal these offenses from their criminal records could reduce barriers to accessing social services and possibly increase employment opportunities. In some states, the adjustment will require legal changes. Additionally, the process could be made automatic instead of putting the onus on the individual to petition the court.

Learn more about this and other ideas related to stigma in Chapters 6, 10, and 11 of the report.

Use wastewater testing to track and possibly measure the consumption of opioids and other drugs

Novel approaches to measuring drug consumption might be needed, especially because many fentanyl analogs and other synthetic opioids enter and exit markets quickly. Users themselves might not know that they consumed a synthetic opioid, let alone be able to point to which compound was supplied.

Wastewater testing is another way to monitor the spread of new psychoactive substances and to measure consumption. This technique—used in Europe and, to a much lesser extent, the United States—can supplement traditional epidemiological drug indicators, such as prevalence or overdose rates.

Learn more about this and other ideas related to data infrastructure in Chapter 2 of the report.

Consider reforming drug possession laws and/or how they are enforced

Criminalization of drug possession and/or use creates barriers in many components of the ecosystem.

Jurisdictions could consider alternatives from changing enforcement practices to changing laws. Reducing punishment for possessing drugs and collateral consequences can take many forms, including altering policing practices, reducing penalties, and/or changing laws. New approaches like these need not be permanent and should include objective evaluation.

Learn more about this and other ideas related to reforming drug possession laws and their enforcement in Chapter 6 of the report.

Get creative about disrupting the supply of illegally produced synthetic opioids

Significantly reducing the supply of illegally produced fentanyl and other synthetic opioids is extremely difficult, especially given the potency of these drugs. However, delaying the entrenchment of fentanyl or other synthetic opioids in a community’s drug supply could save some lives.

Making it harder to order these drugs and their precursors online might create some barriers. Disrupting transactions by hacking or creating fake websites is a low-cost approach worth considering. Stakeholders should also consider working with social media companies to make it harder to buy these substances online.

Learn more about this and other ideas related to overdoses in Chapter 7 of the report.

Consider expanding Social Security Insurance Outreach, Access, and Recovery (SOAR)

SOAR is funded by the Substance Abuse and Mental Health Services Administration. SOAR is designed to increase access to the disability income benefit programs administered by the Social Security Administration for adults and children who are experiencing or are at risk of homelessness and have a serious mental illness, medical impairment, and/or a co-occurring substance use disorder.

The program was created to help address low benefit-approval rates among people experiencing homelessness. SOAR facilitates communication among Social Security disability benefit applicants, case managers, Disability Determination Services, and community providers, helping ensure that an application for disability moves forward smoothly and does not fall between cracks in the system.

Learn more about this and other ideas related to comprehensive support in Chapter 11 of the report.

Increase market surveillance so that people who use drugs and public health and public safety practitioners know what is being consumed or purchased, especially in areas at risk of synthetic opioid exposure

There is an urgent need for early-warning systems to detect synthetic opioid supply. Surveillance should include not only traditional efforts, such as forensic examinations and law enforcement seizure analyses, but also novel programs, such as wastewater-monitoring or drug content–testing services to offer real-time information on substances available in a given jurisdiction.

This is especially important with respect to novel synthetic opioids and the heightened risks they introduce.

Learn more about this and other ideas related to overdoses in Chapters 7 and 8 of the report.

Resurrect some version of the Arrestee Drug Abuse Monitoring (ADAM) program

The ADAM program collected rich drug market data (including urinalysis results) from thousands of people arrested and jailed for any offense. It was critical for generating estimates of the number of people who use drugs, how much they consumed, and how much they spent on illegal drugs. ADAM’s biological testing could serve as an early warning and monitoring system.

One could also imagine modules that ask people who use heroin, sell it, or both about their experiences and decisions around fentanyl and other synthetic opioids. Another idea is to reimagine a version of ADAM, supported by the various federal agencies that address this population, that could sharpen understanding of people who use drugs and their needs, service utilization, and cross-sector barriers to reducing drug-related harms.

If federal agencies will not fund this, states could create their own programs in collaboration with local officials.

Learn more about this and other ideas related to data infrastructure in Chapter 2 of the report.

Introduce an emergency response system for reporting suspected drug overdoses

In some communities, there may be a reluctance to call 911 for an overdose because callers fear being arrested.

One idea is to introduce an emergency response system that guarantees that police will not be among the responding personnel. Some communities may decide to introduce a non-911 emergency number dedicated to reporting overdoses that connects to local responders, while the 911 option remains available to those who wish to use it. Other communities may instruct dispatchers to not summon police for calls involving drug overdoses.

Learn more about this and other ideas related to overdoses in Chapter 9 of the report.

Support research and data-collection efforts to learn more about the size and characteristics of the drug-using population and how it is changing

Improved research efforts could improve understanding of the size and characteristics of the population of people who use drugs and how it is changing. Better understanding of drug markets in the era of fentanyl and other synthetic opioids (via qualitative research methods) would help with these efforts.

Learn more about this and other ideas related to data infrastructure in Chapters 2, 6, 7, 10, and 11 of the report.

Expand integration of the Housing First model with opioid use disorder (OUD) treatment

Some shelters prohibit people who use drugs from entering, and people with drug convictions can have problems obtaining public housing. However, being housed greatly increases a person's ability to find work and stay in treatment.

The Housing First model has emerged as an approach that addresses the needs and concerns of people experiencing homelessness by placing few or no entry requirements on treatment participation or other conditions.

Key features of a Housing First approach that offers people experiencing homelessness access to permanent housing options include few to no treatment preconditions, low-barrier admission policies, rapid and streamlined entry into housing, voluntary supportive services, and the incorporation of practices and policies that prevent lease violations and evictions among tenants. Existing literature demonstrates that this approach is effective in providing stable housing, although evidence with respect to clients with OUD needs strengthening.

Learn more about this and other ideas related to comprehensive support in Chapters 4 and 11 of the report.

Reduce state and federal barriers to local experimentation with or implementation of supervised consumption sites (SCSs)

The federal government could reduce barriers for local jurisdictions to experiment with harm reduction programs. For example, the U.S. Department of Justice could make it easier for local jurisdictions to pilot and evaluate SCSs by releasing a memorandum indicating that it will not prioritize targeting sites as long as those sites follow certain guidelines.

The federal government could also reduce barriers by amending the Controlled Substances Act to explicitly allow SCSs or by passing a budget rider that prohibits federal funds from being used to enforce the law against the programs.

Learn more about this and other ideas related to overdoses in Chapters 6 and 8 of the report.

Support individuals with comprehensive case management

This approach proactively addresses the needs of individuals by going beyond regular case management to help people with opioid use disorder navigate the landscape of existing providers, develop a plan for appropriate services, and establish linkages and relationships with corresponding agencies before, during, and after treatment and as they encounter non-treatment systems.

Such a model would likely require new sources of funding, probably from state and local governments or foundations. Case managers would be involved with individuals when they are uninsured and not supported by social services.

Learn more about this and other ideas in Chapter 14 of the report.

Clearly communicate that no one will be arrested for patronizing or working at syringe service programs or places where people can test the content of their drugs

Some laws and criminal legal efforts have been changed to make it easier for communities to implement harm reduction interventions, but more could be done.

For example, law enforcement could clearly communicate that no one will be arrested for patronizing or working at syringe service programs or places where people can test the composition of their drug sample for fentanyl. This could also send a signal that people who use drugs and those who help them are valuable members of the community who should not be stigmatized.

Learn more about this and other ideas related to overdose prevention in Chapters 6 and 8 of the report.

Implement and enforce laws and regulations requiring true parity in coverage of substance use disorder (SUD) or opioid use disorder (OUD) services

The Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act sought to create parity of coverage between medical surgical care and mental health and SUD treatment. However, there are aspects of treatment—such as prior authorizations, concurrent review, and reimbursement rates—in which disparities likely remain.

Ongoing efforts could improve OUD services and decrease the frequency with which people seek care outside their networks and pay more out of pocket—an expense that many cannot afford.

Learn more about this and other ideas related to treatment in Chapters 4 and 12 of the report.

Increase community provision of drug content testing services

Drug content testing services, such as fentanyl test strip distribution schemes, could allow people to confirm the chemical composition of drugs before consuming them.

Where the testing is done by service providers rather than by people who use drugs themselves, results may also be provided to public health and public safety authorities for market-surveillance purposes.

Learn more about this and other ideas related to overdoses in Chapter 8 of the report.

Cultivate, identify, and support system stewards

Some states have been successful at creating interagency task forces to mitigate opioid-related harms, involving stakeholders from the health, criminal legal, and social service systems.

In the areas of health and well-being, the idea of cultivating and supporting system stewards is increasingly discussed as an approach to addressing cross-sectoral challenges and exploiting opportunities at the intersection of these systems. This is a position that could be funded by government agencies or foundations, but the desire to create such a role must be endorsed by local decisionmakers.

Learn more about this and other ideas related to systemic barriers in Chapter 14 of the report.

Develop local networks of service providers to identify people who could benefit from engaging in multiple services and develop an outreach and engagement plan

One emerging model worth exploring brings together representatives of relevant service providers and partner organizations across various ecosystem components to confidentially discuss individuals who present frequently at the services of one or more participants and are at elevated risk of adverse outcomes (not limited to substance-related risks).

If there is consensus that the person is at risk, then the group develops an individual intervention plan to engage the individual and offer access to services. This is typically led by representatives of the agency that is already in touch with the person. This "hub" model of service engagement originated in Canada and has been implemented in a small number of localities in Massachusetts.

Learn more about this and other ideas in Chapter 14 of the report.

Amend punitive state laws regarding drug use in pregnancy

Punitive state policies regarding drug use among pregnant women may deter women from seeking treatment, increasing the risk that a child will be born with neonatal opioid withdrawal syndrome. Such laws include those that criminalize substance use during pregnancy and consider this behavior grounds for civil commitment or child abuse.

Policies that encourage “family-friendly” treatment could eliminate some of the barriers that prevent pregnant women from receiving such treatment by allowing parents to enter treatment without giving up custody of their children. Such policies could also enhance the willingness of parents with opioid use disorder to engage in effective treatment.

Learn more about this and other ideas related to family resources in Chapter 10 of the report.

Improve systems-level coordination on opioid policy at the federal level

The Office of National Drug Control Policy (ONDCP) was created to help coordinate the various federal systems addressing substance use and drug problems. However, the role ONDCP plays waxes and wanes over time, partially because of staffing and funding issues.

One approach to cementing ONDCP's role as the primary federal coordinating body on issues surrounding substance use and drug policy could include returning the director of ONDCP to the President’s Cabinet—as recommended by the Commission on Combatting Synthetic Opioid Trafficking.

Learn more about this and other ideas in Chapter 14 of the report.

Create opioid policy gaming exercises

State and local system leaders could consider new approaches and work through how certain decisions may affect the various ecosystem components and their interactions.

Gaming is consistent with calls to use additional methods to understand the bigger picture with respect to opioids and its complexities and interrelationships. Gaming exercises could prompt decisionmakers to consider new approaches and bring coordination issues and mission conflicts to the forefront.

Learn more about this and other ideas in Chapter 14 of the report.

Introduce a community behavioral surveillance program

One option that can be used to generate knowledge about local drug markets and collect insights from people who use opioids is to introduce a community-based behavioral surveillance program. Such a program could engage with people who are neither in treatment nor subject to criminal legal supervision, thus addressing a major information gap.

One such model that could be adapted for work with people who use opioids is the National HIV Behavioral Surveillance program, which already surveys people who inject drugs. A similar principle, perhaps involving low-threshold facilities, such as syringe service programs, could be applied in the context of people who use opioids.

Learn more about this and other ideas related to data infrastructure in Chapter 2 of the report.

Improve analyses of data collected by the U.S. Drug Enforcement Administration (DEA)

For decades, the DEA has collected data on the price and purity of drugs purchased in undercover buys and data on the purity of seizures analyzed in federal laboratories in an administrative dataset known as the System To Retrieve Information from Drug Evidence (STRIDE), which has now been reinvented as STARLiMS. These price and purity data have been a mainstay of empirical research in drug markets, but they have been made decreasingly available to researchers.

The National Forensic Laboratory Information System collects results of forensic tests of seized drugs for many state and local law enforcement agencies. However, only aggregate-level reports—such as the share of all cocaine samples that also contained a synthetic opioid—are made public. Much could be learned by making the incident-level data available for research purposes, with appropriate privacy protections, such as removing exact dates and locations.

Learn more about this and other ideas related to data infrastructure in Chapter 7 of the report.

Increase education for the media and decisionmakers in the use of nonstigmatizing language

Long-standing concerns about stigma of and discrimination against people who use opioids and other drugs shape responses to the opioid crisis. For example, a growing body of research suggests that stigmatizing labels such as addict or substance abuser can influence how individuals, including medical professionals, perceive people with substance use disorders.

Several existing resources offer useful suggestions for discussing substance use, addiction, and people who use drugs in a nonstigmatizing manner.

Learn more about this and other ideas in Chapter 14 of the report.

Increase referrals and access to quality mental health care

Increasing the likelihood that people with mental health disorders receive quality care can reduce the odds that they will be prescribed opioids, misuse opioids, and develop an opioid use disorder.

Steps to achieve this goal touch on many components of the opioid ecosystem and include increasing treatment capacity, incentivizing the use of effective mental health interventions, promoting the integration of substance use disorder and mental health treatment, and enhancing reimbursement of mental health treatment.

Learn more about this and other ideas related to prevention in Chapter 5 of the report.

Reduce barriers to nonmedication treatments for chronic pain

The more than 19 million Americans with severe chronic pain need better access to effective, nonaddictive pain management.

Improved access could include increased insurance coverage of nonpharmacological interventions; increased access to nonpharmacological approaches to pain management (in person or virtually, when appropriate); and efforts to develop effective, nonaddictive analgesic medications.

Learn more about this and other ideas related to prevention on pages in Chapters 5 and 12 of the report.

Take steps to reduce unnecessary prescribing of opioid analgesics

Decisionmakers could build on previous efforts to decrease the availability of clinically unnecessary opioid analgesics, while being mindful of potential unintended consequences of reducing access to beneficial medications.

Possible steps to be considered include clinical prescribing guidelines, prescription limits, changes to defaults in electronic prescribing systems, feedback to clinicians regarding opioid prescribing or outcomes, and safe ways to dispose of unused or expired opioid analgesics.

Learn more about this and other ideas related to prevention in Chapters 1, 4, 5, and 12 of the report.

Promote interagency collaboration and care integration

Care could be integrated by developing networks that link buprenorphine-prescribing primary care providers and substance use treatment experts. Fostering links between substance use disorder (SUD) treatment and almost all other systems would also help integrate care.

Efforts should be made to develop integrated health and social service models that screen for vulnerabilities in social determinants of health at any point of entry, whether through the medical care system, the SUD treatment system, the child welfare system, or the criminal legal system. Services could be tailored to individual needs and should provide integrated services in the setting that is most convenient for the patient.

Learn more about this and other ideas related to treatment in Chapters 4, 5, 6, 8, 9, 10, 11, and 13 of the report.

Increase capacity for high-quality substance use disorder (SUD) treatment in specialty settings

Enhancing access for people who require specialty treatment for opioid use disorder could help ensure that the treatment is effective and likely to result in positive outcomes.

Achieving this will require multiple efforts, including an expansion of the SUD workforce, an emphasis on training clinicians in effective treatment approaches, and an infusion of funds to support an expanded system that provides higher-quality care.

Learn more about this and other ideas related to treatment in Chapters 4 and 5 of the report.

Increase access to quality medications for opioid use disorder (MOUD) in primary care settings

Primary care clinicians could be trained in the use of buprenorphine. Decisionmakers could also provide the incentives and infrastructure to support buprenorphine-trained clinicians in the ongoing treatment of people with opioid use disorder.

One recent action that will likely improve access to MOUD in primary care settings is federal legislation abolishing the requirement to obtain a waiver from the Drug Enforcement Administration to prescribe buprenorphine.

Learn more about this and other ideas related to treatment in Chapters 4 and 5 of the report.

Reduce barriers to effective opioid use disorder (OUD) treatment for individuals involved in the criminal legal system

State and local criminal legal agencies could intensify existing efforts to implement various forms of diversion and deflection programs intended to connect people with OUD to treatment services before or during their involvement with the criminal legal system and to reduce barriers to community corrections–based OUD treatment.

Expansion of Medicaid could also help people involved in the criminal legal system access treatment for OUD.

Learn more about this and other ideas related to treatment in Chapters 4, 6, and 9 of the report.

Increase funding for community provision of naloxone

Greater investment could be made to increase the availability of naloxone, an overdose-reversal agent. Such funding could support training and distribution of naloxone through Overdose Education and Naloxone Distribution programs, use of naloxone by first responders, and naloxone dispensed through pharmacies when the naloxone is not covered by insurance.

It could also be used to support first responder naloxone leave-behind programs, as well as enable first responder agencies to serve as naloxone distribution centers—even beyond the context of responding to overdoses.

Learn more about this and other ideas related to overdoses in Chapters 8 and 9 of the report.

Change laws so that Medicaid benefits are not terminated as a result of incarceration

Changing laws so that Medicaid benefits are not terminated as a result of incarceration could help retain and increase access to treatment and other health services.

Access to Medicaid is likely to improve outcomes for people with opioid use disorder who are incarcerated.

Learn more about this and other ideas related to treatment in Chapter 6 of the report.

Increase access to naloxone and trainings on how to administer it

Making it easier for families to access and use naloxone could reduce the probability that an overdose becomes fatal, thus helping alleviate at least some concerns of family members.

This could be a coordinated effort with first responders and community organizations focused on harm reduction. This effort can also be used to educate families about Good Samaritan Laws.

Learn more about this and other ideas related to family resources in Chapters 3, 8, and 9 of the report.

Validate the National Survey on Drug Use and Health (NSDUH) and add questions specific to synthetic opioid use and consequences of opioid use for families

NSDUH will likely continue to play a major role in policy discussions and evaluations on drug-related matters, so its accuracy is important. Validation does not need to happen annually, but incorporating a regular validity test into a survey that costs approximately $50 million per year could be a wise investment—especially as more information is sought about illegally produced fentanyl that respondents may not know they are consuming.

It would also be astute to add a market module that focuses on the amount of opioids obtained during the most recent or typical transaction. NSDUH could add questions to learn more about how families are affected by a relative’s opioid use and/or opioid use disorder (OUD). Getting a better sense of how many people have been affected and how they have been affected would be helpful in understanding the full social costs of OUD.

Learn more about this and other ideas related to data infrastructure in Chapter 2 of the report.

Enhance efforts to offer evidence-based skills training and drug prevention

Schools represent an important setting for prevention interventions. Schools have increasingly become venues for the storage and distribution of naloxone kits and for providing training to both school staff and students on how to administer naloxone. Empirical studies provide some evidence that skills-based prevention programs can decrease the use of other substances.

Learn more about this and other ideas related to prevention in Chapters 10 and 13 of the report.