Expanding treatment for the opioids crisis is critical to saving lives, but isn’t enough

Drug overdose deaths have soared during the COVID-19 pandemic, with an estimated 99,106 in the 12-months ending March 2021. Strong evidence shows medication is effective in treating opioid use disorder (OUD) and reducing overdose deaths. Scaling up medication treatment up in U.S. communities could reduce overdose deaths by 40 percent.

Yet in a recent study funded by the Bloomberg Overdose Initiative, we found that medication treatment for OUD is in critically short supply across the United States. In our new study of county-level opioid use disorder treatment needs and capacity in six states and Washington, D.C., — which was supported through funding from Bloomberg Philanthropies — we found the need for treatment far outpaces availability. In fact, even if the treatment capacity were doubled in counties we examined, it would only meet 7 to 28 percent of the need.

Federal and state policymakers can take steps to expand access to opioid use disorder treatment in communities across the U.S., which I describe below. But expanding the current system of treatment options won’t be enough to eliminate overdose deaths. Redirecting federal and state resources away from the criminalization of opioid use disorder and toward a health-centered approach would create a more effective, accessible and non-punitive treatment system. 

The federal government and states have taken modest steps to increase the treatment supply. In June 2021, the Drug Enforcement Administration lifted a ban on new methadone vans run by existing opioid treatment programs, which may increase access to methadone treatment, particularly in underserved urban and rural areas, especially if combined with expanded “take-home” dosing. 

Federal policymakers have also relaxed some restrictions on treatment, such as in the SUPPORT Act of 2018 and during the COVID-19 pandemic; but many restrictions on treatment remain, keeping life-saving services from the people who need them. 

A much more vigorous expansion of the treatment supply is needed to meet the demand, including medication treatment in in-person and telehealthcare in health centers, office visits to primary and specialty health care providers, schools, addiction treatment programs, hospitals, pharmacies and prisons and jails. A rapid expansion of buprenorphine treatment in France starting in 1995 resulted in about half of people with opioid use disorder in treatment and a 79 percent decrease in overdose deaths in France within four years.  

To expand access to medication treatment, state and federal government officials, together with Congress, could respond to the opioid crisis with far greater urgency by ending moratoriums and restrictions on new opioid treatment programs providing methadone treatment, making pandemic-related treatment flexibilities permanent (such as in Medicaid), removing the remaining restrictions on mobile methadone treatment vans, abolishing the x-waiver constraining buprenorphine treatment and ensuring that pharmacies stock buprenorphine. 

Expanding the current system of treatment options will help, but is still insufficient. To be effective, treatment must be accessible, safe and non-punitive. Transforming our treatment system to one that offers comprehensive care with harm reduction, low threshold treatment, long-term recovery supports and a robust social safety net will require refocusing federal and state resources away from the criminalization of substance use disorder and toward a health-centered approach. Fear of arrest causes people to use drugs in a more unsafe manner, which has made the most recent opioid epidemic more deadly and dangerous. 

In the short term, federal and state policymakers could take the following three immediate steps to decrease overdose deaths:

• Massively expand access to naloxone, the drug that reverses opioid overdose, by addressing supply shortages and high prices of naloxone through policies such as the Food and Drug Administration’s elimination of generic naloxone’s prescription requirement and the implementation of regulations limiting the price of new higher-dose brand name naloxone treatments;  
• Establish reimbursement and payment incentives for health care professionals to provide proven, cost-effective harm reduction services, such as syringe access; promulgate education on overdose prevention and provide naloxone, fentanyl test strips and other harm reduction as essential health benefits. And; 
• Expand health-led, locally-focused behavioral health crisis interventions, such as the new Medicaid-funded community-based mobile crisis intervention services, to help individuals experiencing mental health or substance use disorder crises. Adding harm reduction and social services as part of these crisis services is evidence-based and may be cost-effective.

In the long term, federal and state policymakers could prioritize the following three critical investments to decrease overdose deaths and improve people’s well-being:  

• Provide funding to community organizations to conduct their own community needs assessments. These would identify treatment and social service needs related to substance use, raise up community assets and strengths as well as challenges and engage with and respond to the perspectives and lived experiences of people who use substances; 
• Train substance use care providers in culturally informed practices. Approaches to treatment and how medications for OUD treatment are integrated into care vary for different populations. Policymakers could implement payment reforms to incentivize culturally and linguistically appropriate care for specific communities, taking into account the unique challenges they face. This can include expanding the workforce to include community members with lived experience of substance use as community health care workers and counselors. And;
• Increase Medicaid reimbursement rates for substance use services, which may currently impede access to care for many adults with low incomes.

Expanding treatment supply is the first step toward creating a system that works for patients. But fully addressing the overdose crisis will take a broader transformation of care — engaging communities and reframing substance use, not as a criminal justice issue, but as a health care issue. 

Treating opioid use disorder with a criminal justice approach has failed all communities and has led to significant harm for families and communities of color. Reframing federal and state responses to this crisis as a health issue and partnering with communities to implement the solutions they need is the best chance to make a difference.  

Lisa Clemans-Cope is a senior fellow at the Urban Institute’s Health Policy Center in Washington D.C.