(¢ ASPE ISSUE BRIEF ASSISTANT SECRETARY FOR PLANNING AND EVALUATION October 27, 2021 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OVERDOSE PREVENTION STRATEGY KEY POINTS e The overdose crisis is largely driven by synthetic opioids, predominantly illicitly manufactured fentanyl. Drug overdoses involving psychostimulants such as methamphetamine are also increasing, both with and without synthetic opioid involvement. e The public health burden of drug overdose expands far beyond the devastating impact of overdose deaths to other consequences of substance use disorders (SUDs), including nonfatal overdose. The human cost of this crisis also has a radiating impact on families, caregivers, and communities. e Given the changing face of the crisis and escalating harms, including during the COVID-19 pandemic, the U.S. Department of Health and Human Services (HHS) is releasing a new, comprehensive, resourced Overdose Prevention Strategy to strengthen our primary prevention efforts and increase access to the full continuum of care and services for individuals with SUD and their families. e Experts across HHS came together to leverage the best evidence to prioritize four key target areas for the strategy: primary prevention, harm reduction, evidence-based treatment, and recovery support. e The strategy embodies HHS's reinvigorated efforts to strengthen prevention and treatment, as well as its more recent commitment to robust harm reduction and recovery support services. The strategy recognizes that addressing the overdose crisis requires a multifaceted and integrated approach spanning public health, health care, human services, and many other sectors. e The HHS Overdose Prevention Strategy reflects the Biden-Harris Administration principles of equity for underserved populations and evidence-based policy by being more inclusive of all populations affected. It also prioritizes translating research into equitable practice, and it identifies ways to further our understanding of how to mitigate overdose harms. INTRODUCTION From 1999 through 2019, there were more than 840,000 drug overdose deaths in the United States. The crisis has continually evolved and escalated, including during COVID-19, when an estimated 93,000 persons lost their lives to drug overdose in 2020--approximately a 30% increase over the year prior." In response to the devastating human toll of SUDs and overdose, HHS is redoubling its work and bringing the best science and evidence to bear to respond to the crisis. The history of substance use in the U.S. is long, complex, and characterized by changing patterns of use. Overdose deaths have increased exponentially since at least 1980, driven by different substances at different times.? The overdose crisis of the twenty-first century began as primarily a prescription opioid crisis, but now is more accurately characterized as a polysubstance overdose crisis, as depicted in Figure 1. The late 1990s and first decade of the 2000s saw increased opioid prescriptions followed by increased overdose deaths from October 2021 ISSUE BRIEF 1 natural and semi-synthetic opioids and methadone. Beginning in 2010, the U.S. saw a rapid increase in overdose deaths involving heroin. Then, starting in 2013, overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, rose dramatically. Today, stimulants--particularly methamphetamine, both with and without co-involvement of opioids--also play a prominent role in escalating overdoses. From 2012-2019, the rate of deaths involving psychostimulants (mainly methamphetamine) increased more than 6-fold (from 0.8 to 5.0 per 100,000).* Other drugs, including cocaine and benzodiazepines, also contribute notably to the crisis. Figure 1. Drug Overdose Death Rates, United States, Selected Drug Classes: 1999-2019 12.0 °o 11.4 8 S 10.0 o a 2 8.0 w s S 6.0 os 5.0 s 4.9 ov 4.4 e 4.0 3.6 2 , 3 d 2.0 an <x 0.8 0.0 PPD SH _ ?_ M _ _ HF HM WO WS Wh W? BW ww? © wt Wh PSL KF KKK KK LK wv" Ww" HW" W" WH" W" WH" w" wf oe Cocaine === Heroin oe Vethadone eo Psychostimulants e==-= Natural and semisynthetic opioids ex Synthetic opioids other than methadone Source: National Center for Health Statistics, National Vital Statistics System, Mortality, 2019. The public health burden of drug overdose expands far beyond the devastating impact of fatal overdoses. Some estimates suggest that 20-30 non-fatal overdoses occur for every fatal overdose, and non-fatal overdose can result in permanent disability.> Emergency department visits and inpatient admissions involving drug misuse have escalated substantially in the past decades. For instance, the rate of emergency department visits involving nonmedical use of prescription drugs (primarily opioids) more than doubled from 214 visits per 100,000 people in 2004 to 458 in 2011; a large proportion of these visits involved at least one other drug (e.g., benzodiazepines, cocaine, or heroin). More recently, emergency department visits attributable to nonfatal opioid overdose increased across six major U.S. health care systems by 10.5% in 2020 during COVID-19, as compared to 2018 and 2019--despite a 14% decline in all-cause ED visits during the same period.' The societal cost of this crisis is substantial and has a radiating impact on families, caregivers, and communities. Studies estimating the total cost of the opioid crisis alone vary.2" Those that include the value of lost lives (e.g., foregone labor, criminal justice costs, and noneconomic costs) in addition to health care costs find annual costs on the order of half a trillion dollars.7° The overdose crisis does not look the same in every community or for every individual. Because of geographic differences in the types of drugs most commonly consumed, communities see variation in the proportion of overdoses and related harms attributed to any given drug.'? Methamphetamine use and related harms, for example, has historically been more common in the West and Midwest, while overdoses involving synthetic opioids were more concentrated in the Northeast." Between 2018 and 2019, however, the West experienced October 2021 ISSUE BRIEF 2 the largest relative increase in synthetic opioid overdoses and the Northeast experienced the largest relative increase in psychostimulant-related deaths, illustrating the dynamic regional differences in the crisis.43 Rural areas and certain geographic regions also face more pronounced shortages of many forms of SUD treatment compared to urban areas,?*5 In recent years there have been marked increases in overdose deaths among racial and ethnic minority populations,?° who are also more likely to face barriers in accessing equitable treatment and recovery services." Between 2012 and 2018, the annual percentage change in opioid overdose for African Americans surpassed that for Whites in the U.S."* The increases during this period were largest for older non-Hispanic Black men and women (50 or older and 45 or older, respectively).'° The crisis is further complicated for underserved populations by social determinants of health that contribute to chronic and acute life stresses that interact with SUDs, as well as co-occurring mental and physical health conditions, that complicate SUD treatment (e.g., complex chronic pain). Criminal history and socioeconomic status have been identified as mechanisms underlying race/ethnic differences in receipt of SUD treatment. According to national data, the odds of receiving specialty SUD treatment among Latinos with SUD, for example, were less than half of those for Whites after adjusting for criminal history and socioeconomic status." The same study identified similar Black-White disparities in SUD treatment. In another study of publicly funded SUD treatment programs, Black and Hispanic people were less likely than Whites to complete treatment; these differences were also largely explained by socioeconomic factors such as unemployment and housing instability."* Additional complications of the current overdose crisis warrant urgent attention. Shifts in drug supply and use patterns referenced above make surveillance, prevention, and treatment more complex.22 Another concern is the separation of SUD care from other health services, harm reduction interventions, and recovery supports, and the resulting lack of integrated care delivery.2** Finally, persistent stigma associated with drug use inhibits effective prevention, treatment, and recovery for SUD. DEVELOPMENT OF THE OVERDOSE PREVENTION STRATEGY At the direction of the Secretary of HHS, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) convened an interagency workgroup of key HHS experts in overdose prevention and SUDs to develop a new strategy to address the evolving nature of the broadened overdose crisis. HHS's updated plan focuses on SUD-related issues across the lifespan and stages of drug use, and it was constructed within the changing environment of the COVID-19 pandemic. Its components also reflect many of the priorities outlined in the Biden-Harris Administration's Statement of Drug Policy Priorities for Year One."° Addressing the various components of the overdose crisis requires a multifaceted and integrated approach involving agencies across HHS. In addition to continuing longstanding HHS efforts to support prevention and treatment for the types of substance use that are heavily connected to overdose risk, the new strategy places equal emphasis on HHS-wide efforts to expand accessible services and supports for those in or seeking recovery, and also to intervene early to reduce the risk for harm among people who are actively using substances. The newly developed Overdose Prevention Strategy ("Strategy") consists of four priority areas: (1) primary prevention; (2) harm reduction; (3) evidence-based treatment; and (4) recovery support. In addition, the Strategy is guided by the cross-cutting principles of enhancing equity; improving coordination, collaboration, and integration across government and relevant service sectors; using the best available science to guide actions, while identifying research gaps and needs; and reducing the stigma associated with substance use, which has always been a significant barrier to progress. October 2021 ISSUE BRIEF 3 The priority areas and cross-cutting guiding principles are outlined in Figure 2 and explained in further detail in the next section. Within each priority area, the Strategy identifies specific objectives for decreasing overdoses and their related harms. For each objective, in turn, there is an accompanying list of supporting key activities that HHS is undertaking to achieve these goals and objectives. The activities highlighted with the Strategy are by no means exhaustive of HHS's efforts to address overdose risk; they are, however, representative of high impact efforts expected to yield measurable results. GUIDING PRINCIPLES Each priority area of the Strategy is underpinned by the following cross-cutting guiding principles. Equity The overdose crisis is characterized by stark disparities, in which rural populations, racial/ethnic minorities, pregnant people and mothers, and other historically underserved groups face heightened overdose-related harms and barriers to accessing treatment, services, and supports."° In 2019, for example, Native Americans and Alaska Natives had a higher drug overdose death rate than any other racial or ethnic group.2" The rate of overdose deaths among non-Hispanic Black Americans more than tripled between 2010 and 2019, but Black Americans are still less likely to receive SUD treatment than White Americans."2 Maximizing health equity for disproportionately affected populations is therefore an essential component of each priority area, objective, and activity. Strategy activities will include efforts to increase the availability of culturally competent care, to address underlying social determinants of health that increase overdose risk, and to provide evidence-based SUD treatment to heavily impacted urban and rural populations. This emphasis on equity is also consistent with the Biden-Harris Administration's commitment to achieving more equitable outcomes for underserved and marginalized populations.29203132 Data and Evidence Research, data, evaluation, and translation are critical components to each priority area in the Strategy. To be effective, policies must be informed by strong evidence and revised in response to new evidence, and data must be available to measure, monitor, and track patterns, trends, and progress. This is particularly important given the rapidly evolving nature of the overdose crisis, including changes in the types of substance involved and communities at greatest risk.3234 Evidence of sharp recent increases in fentanyl overdoses in Western states, for example, have informed policy efforts and public health messaging about the appropriate use of fentanyl test strips and the need for multiple naloxone doses in the event of an overdose.**°° At the same time, we must identify what gaps exist in our current understanding of what works to effectively address the overdose crisis. Through HHS's substantial research agenda, we are elevating robust research for implementation and filling knowledge gaps--for instance, in identifying and translating into practice effective treatments for stimulant use disorders. Coordination, Collaboration, and Integration Lack of coordination among programs and activities, lack of collaboration across practice areas, and disconnected care and services systems all serve as barriers to implementing and sustaining effective policies, programs, and practices to address overdose. The lack of integration of SUD interventions into general health care settings--and even the specialty mental health care sector--is a longstanding contributor to difficulties in addressing these conditions, particularly given the shortage of specialty SUD treatment providers.3"3%9 For example, despite the high burden of co-occurring mental health conditions among people with SUD and their contribution to poorer treatment and health outcomes, only 10%-30% of individuals with these co-occurring disorders receive treatment for both.*"** Similarly, the isolation of harm reduction services and recovery supports away from health care settings limits access to the full continuum of SUD care and hinders coordination between care providers.***** Accordingly, within each priority area, HHS's Strategy seeks to October 2021 ISSUE BRIEF 4 break down barriers that separate SUD services from other health and human services, and that separate public health approaches from public safety approaches.*>© Reducing Stigma Stigma surrounding substance use discourages people with SUDs from seeking and accessing the services they need, contributes to inadequate investment in and quality of care for people with SUDs, and fuels negative attitudes towards people who use substances resulting in discrimination.*"** Stigma can then become embedded into laws and policies that hinder efforts to expand access to evidence-based treatment and harm reduction services." Punitive policies towards pregnant women with SUDs--which are actually associated with an increased risk of neonatal abstinence system, potentially by discouraging pregnant women from seeking care--are an example of the counterproductive effects of stigma.°°>* HHS has worked over the past decade to better understand the manifestations and impacts of stigma, notably through past collaborative work with the National Academies of Sciences that describes stigma as "a dynamic multidimensional, multilevel phenomenon that occurs at three levels of society--structural (laws, regulations, policies), public (attitudes, beliefs, and behaviors of individuals and groups), and self-stigma (internalized negative stereotypes)."** To address this, activities in each priority area will include efforts to reduce false perceptions about SUD, related treatments and people who use drugs, including through evidence-informed public awareness and education campaigns. Figure 2. HHS Overdose Prevention Strategy: Priority Areas HHS Overdose Prevention Strategy Primary Prevention Harm Reduction Recovery Support Evidence-Based Treatment October 2021 ISSUE BRIEF 5 PRIORITY AREAS Primary Prevention Preventing substance use and SUDs is critical PRIMARY PREVENTION: OBJECTIVES to reducing the number of overdoses and e Support research and surveillance to develop and overdose deaths. In 2020, approximately improve delivery of prevention interventions. 40.3 million people aged 12 or older had a e Facilitate the implementation of evidence-based SUD in the past year." Although substance primary prevention across the lifespan. use can begin at any age ane ns factors t e Support development of and promote evidence- may vary across age groups, the adolescen based treatments to effectively manage pain. years are particularly critical at-risk periods. o) Reduce clinically inapere priate preseribingiok Young adults aged 18-25 are more likely to - . . . medications with misuse potential. use illicit substances and are more likely to think substance use is not harmful than other age groups.** Research also shows that the majority of adults who meet the criteria for having an SUD started using substances during their teen and young adult years.*> Evidence-based prevention efforts have been shown to reduce the negative consequences of substance use during young adulthood.*® Primary prevention is also important in adults, as developmental and life stressors unique to different stages of adulthood can also put some individuals at greater risk of an SUD.°" This priority area supports a tiered approach to prevention, including population-level strategies as well as targeted interventions aimed at high-risk individuals. For example, the Substance Abuse and Mental Health Administration (SAMHSA) Strategic Prevention Framework for Prescription Drugs program raises community awareness and advances prescription drug misuse prevention activities and education to schools, communities, parents, prescribers, and their patients. The Food and Drug Administration's (FDA) regulatory work includes updated requirements to warn Americans about the serious risks associated with benzodiazepines, especially when combined with other medications such as opioid pain relievers, alcohol, or illicit drugs, and consideration of mandatory prescriber education via the Opioid Analgesic Risk Evaluation and Mitigation Strategy. Since adolescents exposed to substances are particularly vulnerable to developing a SUD, the National Institute on Drug Abuse's (NIDA's) Adolescent Brain and Cognitive Development (ABCD) Study is tracking the biological and behavioral development of nearly 12,000 adolescents into young adulthood and is poised to produce detailed risk and protective factor profiles to improve SUD prevention. Multidisciplinary prevention activities are necessary to address the biological, behavioral, social, and environmental risk and protective factors that impact substance use and SUDs. Accordingly, prevention activities in the Strategy not only engage health and human services providers directly--for instance, the Centers for Medicare & Medicaid Services' (CMS's) Prescriber Outreach educates and provides outreach to prescribers around best practices for prescribing opioids and about non-opioid pain management--but also facilitate cross-sector collaboration on prevention by investing in data infrastructure. An example of this is the Centers for Disease Control and Prevention's (CDC's) Preventing Adverse Childhood Experiences (ACEs): Data to Action program, which is designed to build state-level surveillance infrastructure that ensures the capacity to collect, analyze, and use ACEs data to inform ACEs prevention activities which can have lasting protective effects against substance use and other health-risk behaviors. In addition, CDC's Overdose Data to Action (OD2A) initiative supports innovative and critical surveillance through the collection of comprehensive data on nonfatal and fatal overdoses to inform prevention and response efforts. October 2021 ISSUE BRIEF 6 Harm Reduction All people deserve services that promote HARM REDUCTION: OBJECTIVES health and wellness, regardless of whether they use drugs or other substances. It is crucial to acknowledge that people fall on a continuum in terms of their readiness for change" and to reverse the increasing rates of overdose we must craft policy and interventions that address each stage. Evidence-based harm reduction strategies can cost-effectively minimize negative consequences of drug use. For example, a recent study from rural Kentucky found that providing clean syringes to people who use drugs via injection (syringe services programs) significantly reduced the transmission of infectious disease such as HIV, hepatitis and endocarditis.*> Furthermore, three decades of NIDA-funded research demonstrate that syringe services programs are safe, effective, cost-saving, and are not associated with increases in crime or drug use.™ Distributing Naloxone to communities to reverse opioid overdoses and co-prescribing it when opioid medications are dispensed are other high impact harm reduction interventions; HHS resources and actions have been instrumental in deploying Naloxone widely across the U.S. In addition to specific harm reduction practices, it is also an approach that, supports an environment that challenges stigma; incorporates the culture, language, and beliefs of the community served; and meets people where they are in terms of their drug use patterns. For people with SUD who do not receive specialty SUD treatment (97.5% of whom do not perceive any need for treatment),®" harm reduction lessens health risks and overdose harms." e Advance research and demonstrations on innovative harm reduction approaches. e Promote evidence-based harm reduction services, including those that are integrated with health care delivery. e Expand sustainable funding strategies for harm reduction services. e Develop educational materials and programs to reduce stigma. The Strategy reflects HHS's commitment to promoting harm reduction across its programs. It extends recent notable HHS harm reduction efforts, such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and CDC's April 2021 announcement that certain federal grant funds can be used to purchase fentanyl test strips,© which some people use to avoid or take additional precautions when using drugs adulterated with fentanyl. HHS recognizes the need for additional work to mitigate the risks associated with drug use, and therefore this priority area supports further expanding access to a broader array of harm reduction interventions and better integrating harm reduction principles and practices into specialty SUD treatment and general medical care. Examples of activities within this priority area include the National Institute of Health's (NIH's) Comprehensive HIV Services in syringe services program settings, which will support research to develop and test intervention models for syringe services programs; SAMHSA's Harm Reduction Grants, which will support community-based overdose prevention programs, syringe services programs, and other harm reduction services; and CDC's Rx Awareness Campaign, which promotes awareness of the impacts of prescription opioid misuse and overdose through storytelling, and emphasizes that support is available for people with OUD. Recent campaign messaging has also focused on fentanyl as well as stigma around substance use disorder. FDA and NIH are also collaborating to collect community and clinical input on utilizing fentanyl test strips. October 2021 ISSUE BRIEF 7 Evidence-Based Treatment EVIDENCE-BASED TREATMENT: OBJECTIVES e Support research on and development of new treatments and strategies to improve engagement and retention in care. e Broaden access to evidence-based care that increases willingness to engage in treatment. e Increase the uptake of evidence-based treatment delivery that improves engagement and retention in care. e Promote evidence-based integrated care for people with co-occurring conditions across lines of service and care settings. Availability of treatment for those who develop SUD is essential to reducing the negative health and social consequences of substance use, including death from overdose. For example, medications for opioid use disorder (MOUD) can reduce opioid use, overdose deaths, and infectious disease transmission, as well as increase social functioning and retention in treatment.©> However, data show that only 1 in 15 people with a SUD receive any type of specialty treatment, which is unchanged from recent years." While there are many who need treatment but are not seeking it, high-quality treatment must be available without delay for those who decide to seek treatment. At present, however, finding and entering treatment remains far too challenging for a variety of reasons such as cost, lack of health insurance, and stigma.™ For those who do find it, treatment quality is extremely variable, and retention remains low among those who initiate treatment. In addition, despite rising overdoses involving stimulants, access to evidence-based treatments for stimulant use disorder--especially contingency management--remains inadequate, and there are currently no approved medications for the treatment of stimulant use disorders, or for the reversal of stimulant overdose. Although evidence-based treatment exists, there is a lack of knowledge about how to implement them in communities across the country."" The evidence-based treatment priority area in the Strategy focuses on reducing barriers to accessing effective treatments, using motivational and cultural enhancements to encourage people who might be reluctant to seek treatment, advancing strategies to improve engagement and retention, and continuing to develop new therapeutic approaches. A major opportunity to enhance access to evidence-based treatment is the potential improvement of the integration of SUD treatment with primary care and specialty mental health care. Key examples of current work to advance this priority area include the Justice Community Opioid Innovation Network (JCOIN) at NIH, which seeks to advance knowledge about optimal approaches to treat OUD in criminal justice settings, and to sustain quality care after community reentry. Another example is the Health Resources and Services Administration's (HRSA's) Rural Community Opioid Response Program, which brings more evidence-based treatment to rural communities that often lack access to high quality treatment despite having disproportionately high need. HHS also recently issued practice guidelines to reduce barriers to MOUD by removing training, counseling, and other ancillary service requirements for health care providers to treat up to 30 people at a time."1 FDA and NIH are also collaborating on supporting development of treatments for stimulant use disorder. CMS is working to advance care for mothers and infants with the Maternal Opioid Misuse demonstration model that advances high-quality care for participating pregnant and postpartum Medicaid beneficiaries with OUD through the provision of coordinated and integrated physical and behavioral health care services. NIDA is seeking to identify and develop new treatments for stimulant use disorder through both its Medications Development Program and its National Drug Abuse Treatment Clinical Trials Network, including a recent study with promising findings on a potential combination medication treatment option." October 2021 ISSUE BRIEF 8 Recovery Support RECOVERY SUPPORT OBJECTIVES e Enable access to and encourage use of recovery support services. e Improve the quality of recovery support services. e Strengthen the recovery support services workforce. e Research and identify best practices for recovery support services and strategies to sustain these services. Treatment alone may not be enough to support long-term recovery. According to SAMHSA, recovery "is a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential.""2 For many people with SUD, recovery support services help them by bolstering their recovery capital--the range of resources that enable someone to be in recovery." Recovery looks different to different people and recovery support services must be flexible and strive to meet the individual where they are, taking into account an individual's beliefs, practices, and culture."" Many of the resources targeted by recovery support services are characterized as social determinants of health, including housing, education, employment, and social connection. Studies have found that recovery support services such as peer support services and recovery housing are associated with a variety of positive outcomes, including greater retention in treatment, lower rates of substance use recurrence, and more employment.'©"7 Provision of these supports foster an environment in which recovery can be sustained and quality of life improved. Sustaining recovery for individuals with SUD is a lifelong process and needs close collaboration with a multidisciplinary care team." Despite the promising evidence of many types of recovery support services, various challenges impede their availability and uptake, and many recovery support services could benefit from additional study and evidence- building.'"? CMS has made efforts to address recovery through its Value in OUD Treatment Demonstration, which consists of an alternative payment model that allows certain Medicare funds to be used for services that are not typically covered in its programs, such as peer support services, recovery housing, job training, and nutrition support.®° A lack of readily available information on evidence-based implementation of recovery support services necessitates development and dissemination of resources. SAMHSA is promoting high-quality implementation through the Peer Recovery Center of Excellence, which provides training and technical assistance on topics such as clinical integration of peer support specialists and enhancing the capacity of recovery community organizations. Strengthening the recovery support services workforce is essential to promoting access and quality. HRSA's Behavioral Health Workforce Education and Training Program for Paraprofessionals is expanding the recovery support services workforce by funding community-based training programs for peer support specialists and other paraprofessionals working in behavioral health. Furthermore, there is an ongoing need for research to inform the effective delivery of recovery support services. NIH supports a portfolio of research on topics including peer support services, recovery housing, and recovery community centers through its Research Networks for the Study of Recovery Support Services for Persons Treated with Medications for Opioid Use Disorder grants. CONCLUSION The Overdose Prevention Strategy is an important step forward in HHS's approach to addressing the evolving overdose crisis. The activities included within each of the four objectives--primary prevention, harm reduction, evidence-based treatment, and recovery support--represent a comprehensive set of efforts aimed at reducing morbidity and mortality related to substance use and SUD. They represent a host of new activities undertaken in this Administration, which HHS intends to build upon in the coming years. October 2021 ISSUE BRIEF 9 The evolving nature of the overdose crisis demands a dynamic response. HHS will be closely tracking the implementation of the Strategy's activities over time to assess progress toward objectives. As new data and evidence emerge, HHS will update and build upon the Strategy as the science and evidence reveal best policies to pursue, including in collaboration with partners across the federal government and working with state, local, tribal, and territorial partners. HHS is steadfast in its commitment to overcoming the overdose crisis and continues to explore ways to bolster efforts to tackle this issue. All stakeholders are invited to join us in carrying out the Strategy to achieve maximum impact. October 2021 ISSUE BRIEF 10 REFERENCES 1. 10. 11. 12. 13. 14. 15. 16. 17. Data Brief 394. Drug Overdose Deaths in the United States, 1999-2019. National Center for Health Statistics, National Vital Statistics System, Mortality. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db394-tables- 508.pdf#1. National Center for Health Statistics, National Vital Statistics System. Estimates for 2020 are based on provisional data. Retrieved from https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science. 2018 September. Vol 361, Issue 6408. doi:10.1126/science.aau1184. Data Brief 394. Drug Overdose Deaths in the United States, 1999-2019. National Center for Health Statistics, National Vital Statistics System, Mortality. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db394-tables- 508.pdf#1. Winstanley EL, Mahoney JJ 3rd, Castillo F, Comer SD. Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses: A systematic review. Drug Alcohol Depend. 2021; 226: 108838. doi:10.1016/j.drugalcdep.2021.108838. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Retrieved from http://www.samhsa.gov/data/sites/default/files/DAWN127/DAWN127/sr127- DAWN-highlights.htm. Soares WE 3rd, Melnick ER, Nath B, D'Onofrio G, Paek H, Skains RM, Walter LA, Casey MF, Napoli A, Hoppe JA, Jeffery MM. Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems. Ann Emerg Med. 2021 Mar 19: $0196-0644(21)00226-2. doi:10.1016/j.annemergmed.2021.03.013. Rhyan C. The Potential Societal Benefit of Eliminating the Opioid Crisis Exceeds $95 Billion per Year. ALTARUM. 2016 November. Retrieved from https://perma.cc/A3TN-UJ9M. Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care. 2016; 54(10): 901-906. doi:10.1097/MLR.OOO0000000000625. Council of Economic Advisers, Executive Office of the President. The Underestimated Cost of the Opioid Crisis. 2017 November. Retrieved from https://permanent.fdlp.gov/gp086686/The%20Underestimated%20Cost%200f%20the%200pioid%20Crisis.pdf. Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL. Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths--United States, 2013-2019. MMWR Morb Mortal Wkly Rep 2021; 70: 202-207. doi:10.15585/mmwr.mm7006a4. Drug Enforcement Administration. 2019 National Drug Threat Assessment. Retrieved from https://www.dea.gov/sites/default/files/2020-01/2019-NDTA-final-01-14-2020 Low_Web-DIR-007-20 2019.pdf. Mattson CL, Tanz LJ, Quinn K, Kariisa M, Patel P, Davis NL. Trends and Geographic Patterns in Drug and Synthetic Opioid Overdose Deaths--United States, 2013-2019. MMWR Morb Mortal Wkly Rep 2021; 70: 202-207. doi:10.15585/mmwr.mm7006a4. Ali MM, Nye E, West K. Substance Use Disorder Treatment, Perceived Need for Treatment, and Barriers to Treatment Among Parenting Women With Substance Use Disorder in US Rural Counties [published online ahead of print, 2020 Jul 2]. J Rural Health. 2020. doi:10.1111/jrh.12488. Haffajee RL, Lin LA, Bohnert ASB, et al. Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder. JAMA Netw Open. 2019; 2(6): e196373. doi:10.1001/jamanetworkopen.2019.6373. Lippold KM, Jones CM, Olsen EO, Giroir BP. Racial/Ethnic and Age Group Differences in Opioid and Synthetic Opioid- Involved Overdose Deaths Among Adults Aged 218 Years in Metropolitan Areas--United States, 2015-2017. MMWR Morb Mortal Wkly Rep 2019; 68: 967-973. doi:10.15585/mmwr.mm6843a3. Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. 2019; 76(9): 979-981. doi:10.1001/jamapsychiatry.2019.0876. October 2021 ISSUE BRIEF 11 18. 19. 20. 21. 22. 23. 24, 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. Furr-Holden D, Milam AJ, Wang L, Sadler R. African Americans now outpace Whites in opioid-involved overdose deaths: A comparison of temporal trends from 1999 to 2018. Addiction. 2021; 116(3): 677-683. doi:10.1111/add.15233. Shiels MS, Freedman ND, Thomas D, Berrington de Gonzalez A. Trends in U.S. Drug Overdose Deaths in Non-Hispanic Black, Hispanic, and Non-Hispanic White Persons, 2000-2015. Ann Intern Med. 2018; 168(6): 453-455. doi:10.7326/M17-1812. Cook BL, Alegria M. Racial-ethnic disparities in substance abuse treatment: The role of criminal history and socioeconomic status. Psychiatr Serv. 2011; 62(11): 1273-1281. doi:10.1176/ps.62.11.pss6211_1273. Saloner B, L@é Cook B. Blacks and Hispanics are less likely than Whites to complete addiction treatment, largely due to socioeconomic factors. Health Aff (Millwood). 2013; 32(1): 135-145. doi:10.1377/hlithaff.2011.0983. Jones CM, Bekheet F, Park JN, Alexander GC. The Evolving Overdose Epidemic: Synthetic Opioids and Rising Stimulant-Related Harms. Epidemiologic Reviews. Volume 42, Issue 1, 2020, Pages 154-166. doi:10.1093/epirev/mxaa011. Lardiere MR, Jones E, Perez M. 2010 Assessment of Behavioral Health Services Provided in Federally Qualified Health Centers. National Association of Community Health Centers. January 2011. Retrieved from http://www.nachc.org/wp-content/uploads/2015/06/BHReport.pdf. Croft B, Parish SL. Care integration in the Patient Protection and Affordable Care Act: Implications for behavioral health. Adm Policy Ment Health. 2013; 40(4): 258-263. doi:10.1007/s10488-012-0405-0. Office of National Drug Control Policy, Executive Office of the President. The Biden-Harris Administration's Statement of Drug Policy Priorities for Year One. April 2021. Retrieved from https://www.whitehouse.gov/wp- content/uploads/2021/03/BidenHarris-Statement-of-Drug-Policy-Priorities-April- 1.pdf?fbclid=IwAR2TBk34U XRqlqK pAYnUd 9f7zY3IbCQI9KxI6SS5eYeRJdFzlI9BO9hZ84Published. Cook BL, Alegria M. Racial-ethnic disparities in substance abuse treatment: The role of criminal history and socioeconomic status. Psychiatr Serv. 2011; 62(11): 1273-1281. doi:10.1176/ps.62.11.pss6211_1273. National Drug Overdose (OD) Deaths, 1999-2019. CDC WONDER, Multiple Cause of Death (Detailed Mortality). For information about this data go to https://wonder.cdc.gov/mcd.html. National Drug Overdose (OD) Deaths, 1999-2019. CDC WONDER, Multiple Cause of Death (Detailed Mortality). For information about this data go to https://wonder.cdc.gov/mcd.html. Exec. Order No. 13985. Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. January 20, 2021. Retrieved from https://www.federalregister.gov/documents/2021/01/25/2021- 01753/advancing-racial-equity-and-support-for-underserved-communities-through-the-federal-government. Exec. Order No. 12995. Ensuring an Equitable Pandemic Response and Recovery. January 21, 2021. https://www.federalregister.gov/documents/2021/01/26/2021-01852/ensuring-an-equitable-pandemic-response- and-recovery. Cook BL, Alegria M. Racial-ethnic disparities in substance abuse treatment: The role of criminal history and socioeconomic status. Psychiatr Serv. 2011; 62(11): 1273-1281. doi:10.1176/ps.62.11.pss6211_1273. Saloner B, Lé Cook B. Blacks and Hispanics are less likely than Whites to complete addiction treatment, largely due to socioeconomic factors. Health Aff (Millwood). 2013; 32(1): 135-145. doi:10.1377/hlthaff.2011.0983. Jones CM, Bekheet F, Park JN, Alexander GC, The Evolving Overdose Epidemic: Synthetic Opioids and Rising Stimulant-Related Harms. Epidemiologic Reviews. Volume 42, Issue 1, 2020, Pages 154-166. doi:10.1093/epirev/mxaa011. Barry CL. Fentanyl and the Evolving Opioid Epidemic: What Strategies Should Policy Makers Consider? Psychiatric Services 2018; 69: 100-103. doi:10.1176/appi.ps.201700235. Shover CL, Falasinnu TO, Dwyer CL, et al. Steep increases in fentanyl-related mortality west of the Mississippi River: Recent evidence from county and state surveillance. Drug Alcohol Depend. 2020; 216: 108314. doi:10.1016/j.drugalcdep.2020.108314. Stephenson J. CDC Warns of Surge in Drug Overdose Deaths During COVID-19. JAMA Health Forum. 2021; 2(1): e210001. doji:10.1001/jamahealthforum.2021.0001. Urada D, Teruya C, Gelberg L, et al. Integration of substance use disorder services with primary care: Health center surveys and qualitative interviews. Subst Abuse Treat Prev Policy. 9, 15 (2014). doi:10.1186/1747-597X-9-15. October 2021 ISSUE BRIEF 12 38. 39. 40. Ai. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. National Academies of Sciences, Engineering, and Medicine. Opportunities to Improve Opioid Use Disorder and Infectious Disease Services: Integrating Responses to a Dual Epidemic. National Academies Press 2020 Jan 23. Retrieved from: https://www.ncbi.nim.nih.gov/books/NBK555819/. Vestal C. How Severe is the Shortage of Substance Abuse Specialists? Pew Charitable Trusts. April 2015. Retrieved from: https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/4/01/how-severe-is-the-shortage- of-substance-abuse-specialists. Han B, Compton WM, Blanco C, and Colpe U. Prevalence, Treatment, and Unmet Treatment Needs of US Adults with Mental Health and Substance Use Disorders. Health Affairs. 2017; 36:10. doi:10.1377/hIthaff.2017.0584. Jones CM, McCance-Katz EF. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence. 2019; 197: 1. doi:10.1016/j.drugalcdep.2018.12.030. Allen ST, O'Rourke A, White RH, et al. Barriers and Facilitators to PrEP Use Among People Who Inject Drugs in Rural Appalachia: A Qualitative Study. AIDS Behav 24, 1942-1950 (2020). doi.org/10.1007/s10461-019-02767-3. Henry BF, Campbell A, Hunt T, Johnson JK, et al. COVID-19 related substance use services policy changes: Policymaker perspectives on policy development and implementation. Journal of Substance Abuse Treatment. 2021. doi:10.1016/j.jsat.2021.108550. Burr CK, Storm DS, Hoyt MJ, et al. Integrating health and prevention services in syringe access programs: A strategy to address unmet needs in a high-risk population. Public Health Rep. 2014; 129 Suppl 1(Suppl 1): 26-32. doi:10.1177/00333549141291S105. Compton WM 3rd, Cottler LB, Jacobs JL, Ben-Abdallah A, Spitznagel EL. The role of psychiatric disorders in predicting drug dependence treatment outcomes. Am J Psychiatry. 2003; 160(5): 890-895. doi:10.1176/appi.ajp.160.5.890. RachBeisel J, Scott J, Dixon L. Co-Occurring Severe Mental Illness and Substance Use Disorders: A Review of Recent Research. Psychiatry Online. 1999. doi:10.1176/ps.50.11.1427. McGinty EE, Barry CL. Stigma Reduction to Combat the Addiction Crisis--Developing an Evidence Base. N Engl J Med 2020; 382: 1291-1292. doi:10.1056/NEJMp2000227, Tsai AC, Kiang MV, Barnett ML, Beletsky L, Keyes KM, McGinty EE, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019; 16(11): e1002969. doi:10.1371/journal.pmed.1002969. Tsai AC, Kiang MV, Barnett ML, Beletsky L, Keyes KM, McGinty EE, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019; 16(11): e1002969. doi:10.1371/journal.pmed.1002969. Faherty LJ, Kranz AM, Russell-Fritch J, Patrick SW, Cantor J, Stein BD. Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome. JAMA Netw Open. 2019; 2(11): e1914078. doi:10.1001/jamanetworkopen.2019.14078. Patrick SW, Schiff DM. A Public Health Response to Opioid Use in Pregnancy. Committee on Substance Use and Prevention. Pediatrics. Mar 2017; 139(3): e20164070; doi:10.1542/peds.2016-4070. National Academies of Sciences, Engineering, and Medicine. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press. 2016. doi:10.17226/23442. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2020 National Survey on Drug Use and Health. *This estimate includes both drug use disorders and alcohol use disorders. US Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. November 2016. Retrieved from https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf. US Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. November 2016. Retrieved from https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf. Substance Abuse and Mental Health Services Administration. Substance Misuse Prevention for Young Adults. December 2019. Retrieved from https://store.samhsa.gov/sites/default/files/d7/priv/pep19-pl-guide-1.pdf. Afuseh E, Pike CA, Oruche UM. Individualized approach to primary prevention of substance use disorder: Age-related risks. Subst Abuse Treat Prev Policy. 2020; 15(1): 58. doi:10.1186/s13011-020-00300-7. October 2021 ISSUE BRIEF 13 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71, 72. 73. 74. 75. 76. 77. Prochaska JO, Johnson S, Lee P. The Transtheoretical Model of behavior change. In Shumaker SA, Ockene JK, Riekert KA (Eds.). The handbook of health behavior change. 2009: 59-83. Bushling C, Walton MT, Conner KL, Liu G, Hoven A, Joseph J, Taylor A. Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data. Journal of Rural Health. 2021. doi:10.1111/jrh.12623. National Institute on Drug Abuse. Syringe Services Programs. https://www.drugabuse.gov/drug-topics/syringe- services-programs. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2020 National Survey on Drug Use and Health. *This estimate includes both drug use disorders and alcohol use disorders. Volkow ND, Blanco C. Interventions to address the opioid crisis--modeling predictions and consequences of inaction. JAMA Netw Open. 2021; 4(2): e2037385. doi:10.1001/jamanetworkopen.2020.37385. Federal Grantees May Now Use Funds to Purchase Fentanyl Test Strips. April 7, 2021. Retrieved from https://www.cdc.gov/media/releases/2021/p0407-Fentanyl-Test-Strips.html. Goldman JE, Waye KM, Periera KA, et al. Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study. Harm Reduct J. 2019: 16, 3. doi:10.1186/s12954-018-0276-0. Krieger MS, Goedel WC, Buxton JA, et al. Use of rapid fentanyl test strips among young adults who use drugs. Int J Drug Policy. 2018; 61: 52-58. doi:10.1016/j.drugpo.2018.09.009. National Institute on Drug Abuse. Effective Treatments for Opioid Addiction. November 1, 2016. Retrieved from https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2020 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. 2020 National Survey on Drug Use and Health. Volkow ND, Blanco C. Interventions to address the opioid crisis-modeling predictions and consequences of inaction. JAMA Netw Open. 2021; 4(2): e2037385. doi:10.1001/jamanetworkopen.2020.37385. Haffajee RL, Heins S. State and Community Efforts to Address Stimulant Use. May 2021. Retrieved from https://aspe.hhs.gov/sites/default/files/private/aspe-files/265576/stimuse.pdf. Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. 86 FR 22439. Retrieved from https://www.federalregister.gov/documents/2021/04/28/2021-08961/practice-guidelines-for-the- administration-of-buprenorphine-for-treating-opioid-use-disorder. National Institute on Drug Abuse. Combination treatment for methamphetamine use disorder shows promise in NIH study. January 13, 2021. Retrieved from https://www.nih.gov/news-events/news-releases/combination-treatment- methamphetamine-use-disorder-shows-promise-nih- study#:~:text=Combination%20treatment%20for%20methamphetamine%20use%20disorder%20shows%20promise% 20iIn%20NIH%20study,- AddThis%20Sharing%20Buttons&text=A%20combination%20o0f%20two%20medications,controlled%20Phase%20I11% 20clinical%2Otrial. Substance Abuse and Mental Health Services Administration. Recovery and Recovery Support. Updated April 23, 2020. Retrieved from https://www.samhsa.gov/find-help/recovery. Hennessy EA. Recovery capital: A systematic review of the literature. Addiction Research and Theory. 2017 Sep 3; 25(5): 349-60. doi:10.1080/16066359.2017.1297990. Substance Abuse and Mental Health Services Administration. Recovery and Recovery Support. Updated April 23, 2020. Retrieved from https://www.samhsa.gov/find-help/recovery. Reif S, Braude L, Lyman DR, Dougherty RH, Daniels AS, Ghose SS, Salim O, Delphin-Rittmon ME. Peer recovery support for individuals with substance use disorders: Assessing the evidence. Psychiatr Serv. 2014 Jul; 65(7): 853-61. doi:10.1176/appi.ps.201400047. Davidson L, Rowe M, DiLeo P, Bellamy C, Delphin-Rittmon M. Recovery-Oriented Systems of Care: A Perspective on the Past, Present, and Future. Alcohol Res. 2021 Jul 22; 41(1): 09. doi:10.35946/arcr.v41.1.09. October 2021 ISSUE BRIEF 14 78. US Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. November 2016. Retrieved from https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf. 79. US Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health. November 2016. Retrieved from https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf. 80. Center for Medicare and Medicaid Innovation. Value in Opioid Use Disorder Treatment Demonstration Program Request for Applications (RFA). November 12, 2020. Retrieved from https://innovation.cms.gov/media/document/vit-rfa. October 2021 ISSUE BRIEF 15 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Assistant Secretary for Planning and Evaluation 200 Independence Avenue SW, Mailstop 447D Washington, D.C. 20201 For more ASPE briefs and other publications, visit: aspe.hhs.gov/reports ie ial ABOUT THE AUTHORS Rebecca L. Haffajee, JD, PhD, MPH, Acting Assistant Secretary of Planning and Evaluation, Alicia J. Swenson-O' Brien, MSW, MPA, and Teresa M. Manocchio work in the Immediate Office of ASPE. Tisamarie B. Sherry, MD, PhD, Erin Bagalman, MSW, Joel M. Dubenitz, PhD, Daniel Schwartz, BS, Bethany Stoller, MPH, and Timothy B. Creedon, PhD, work in the Office of Behavioral Health, Disability, and Aging Policy in ASPE. Jessica O. White, MPP works in the Office of Science and Data Policy in ASPE. SUGGESTED CITATION Haffajee, RL, Sherry, TB, Dubenitz, JM, White, JO, Schwartz, D, Stoller, B, Swenson-O' Brien, AJ, Manocchio, TM, Creedon, TB, Bagalman, E. U.S. Department of Health and Human Services Overdose Prevention Strategy (Issue Brief). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. October 27, 2021. COPYRIGHT INFORMATION All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated. Subscribe to ASPE mailing list to receive email updates on new publications: aspe.hhs.gov/join-mailing-list For general questions or general information about ASPE: aspe.hhs.gov/about October 2021 ISSUE BRIEF 16