Expand Access to Medications for Opioid Use Disorder
Medications for opioid use disorder (MOUD) help stabilize brain chemistry, reduce or block the euphoric effects of opioids (the “high”), and relieve cravings, which in turn helps patients engage in other aspects of treatment such as counseling.1
The Food and Drug Administration (FDA) has approved three medications to treat opioid use disorder: methadone, buprenorphine, and naltrexone.
Decades of research have shown that MOUD reduces opioid use, overdose deaths, criminal activity, infectious disease transmission, and other adverse health and behavioral consequences.1 MOUD also improves social functioning, finding and maintaining employment, retention and adherence to treatment, and overall quality of life.2 Effective MOUD interventions are ones that address bio-psycho-social domains in addition to medication management and behavior change.
MOUD reduces mortality by
- A Massachusetts cohort study of 17,568 individuals initiated on MOUD following a non-fatal overdose between 2012 and 2014 found that individuals treated with buprenorphine and methadone had a 40% to 60% reduction in mortality.3
- A national cohort study of 40,885 individuals with opioid use disorder found a 76% reduction in overdose cases after 3 months and a 59% reduction at 12 months among the individuals who received buprenorphine or methadone.4 The study also found that individuals who received buprenorphine or methadone reported a 32% reduction in the emergency department and intensive care visits at 3 months and a 26% reduction at 12 months.
- A review of 19 studies on mortality among individuals receiving methadone (n = 122,885) or buprenorphine (n = 15,831) treatment found that MOUD was associated with a 61.9% reduction in all-cause mortality.5
- A randomized trial of 250 patients who received either extended-release naltrexone or a placebo found that the naltrexone group reported 90% confirmed weeks of abstinence compared to 35% among the control group.6 The naltrexone group also reported higher retention in treatment and lower drug cravings and relapses.
Comprehensive Opioid Addiction Treatment (COAT) Program, West Virginia University
Over the past decade, West Virginia has had the highest drug overdose mortality rate in the U.S. In response to the overdose crisis and a need for evidence-based care for patients, clinicians implemented a group-based model of medications for addiction treatment at the West Virginia University (WVU) academic medical center.
The Comprehensive Opioid Addiction Treatment (COAT) Program, which began in 2005, is an interdisciplinary, team approach to opioid use disorder treatment that includes group-based medication management followed by group therapy at the same medical visit. The program utilizes a multitude of psychotherapies including cognitive behavioral therapy (CBT), psychoeducation regarding the disease of addiction, relapse prevention, and 12-step facilitation programs.
A 2020 study of COAT found that 51% of patients reported more than a 1 year of continuous abstinence, with only 22% of patients with fewer than 91 days of abstinence.9
Increase Community Naloxone Distribution
Naloxone is a safe and effective medication that reverses an opioid overdose and saves lives.
Expanding naloxone availability is a step that communities can take to enhance public health and reduce overdose fatalities. Effective nationwide naloxone distribution programs provide training and distribute doses to first-responders, community-based organizations, public health departments, people who use drugs and their caregivers, employers, school systems, transportation partners, and jails and prison systems. States have also implemented co-prescribing of naloxone with opioid prescriptions.10,11
The numerous models of naloxone distribution programs fall into two main categories – active and passive distribution.
Reduction in Overdose Deaths with Maximum Distribution of Naloxone
Strategies provide proactive distribution of overdose education and naloxone to at-risk populations and key professionals and stakeholders. Examples include harm reduction programs handing out naloxone to at-risk clients, hospitals or emergency departments providing naloxone to patients admitted for substance use disorders (SUD), naloxone distribution to individuals released from prison and jail, and physicians co-prescribing naloxone with prescription opioid medications.
Passive distribution strategies focus on making naloxone available to those who seek it out on their own. Examples of passive distribution include making naloxone available at pharmacies without a prescription (referred to as a standing order) and in public areas such as restrooms and vending machines.
- A 2013 study of the Massachusetts Overdose Education and Naloxone Distribution Programs (OENDPs) found that opioid overdose death rates reduced by 11% in communities where OENDPs were implemented, compared with communities with no implementation.12
- A recent study using a decision-analytic model to analyze the cost-effectiveness of eight naloxone distribution strategies found that maximum distribution of naloxone to laypeople, police and firefighters, and paramedics could reduce overdose deaths by 21% compared to minimum distribution of naloxone.13
- A study found that 87% of naloxone rescue attempts were performed by people who use drugs, that the person performing the rescue was usually a friend of the person that overdosed, and that naloxone was successful in 98% of the rescue attempts.12
- According to a study conducted in Lorain County, OH, after police officers began carrying naloxone nasal spray, overdose deaths decreased by 18%.14
Project DAWN (Deaths Avoided with Naloxone), Ohio Department of Health
Due to the growing need for accessible community-based resources to prevent opioid overdoses, Ohio implemented Project DAWN (Deaths Avoided with Naloxone), a network of overdose education and naloxone distribution programs coordinated by the Ohio Department of Health and administered in partnership with local health departments, syringe service programs, community-based SUD and mental health providers, and community organizations.
Project DAWN provides free naloxone medication as well as training on how to use it at 117 sites across Ohio. Statewide distribution settings include health departments, syringe service programs (SSPs), community grassroots organizations, emergency departments, correctional facilities, leave-behind programs with emergency medical services (EMS), and street outreach. Several sites have set up an online mail-order service to ensure more Ohio residents have access to naloxone. Since 2014, Project DAWN has distributed 345,160 naloxone kits, trained nearly 239,800 people, and assisted with over 50,000 known overdose reversals.15 As of April 2022, Project DAWN has expanded to include 117 registered programs, spanning 310 sites across 73 Ohio counties.
Expand Access to Behavioral Therapies
Behavioral therapies are a key component of SUD treatment and focus on changing an individual's behaviors, emotions, and responses to certain situations.
These therapies also help individuals learn new coping and life skills to implement within their life rather than turning to unhealthy patterns of the past. While receiving treatment for SUD, it is essential that patients receive individualized and comprehensive care that addresses the biopsychosocial aspects of an individual's health, and is modified according to disease severity and co-occurring disorders.
There are several evidence-based behavioral therapies that are effective in treating SUDs, including cognitive behavioral therapy, contingency management, 12-step facilitation therapy, motivational enhancement therapy, therapeutic communities, as well as group and individual counseling.
- Research shows that CBT is effective for treating various SUDs, including alcohol, opioids, marijuana, cocaine, methamphetamine, and nicotine, and produces better patient outcomes when combined with MAT and other behavioral therapies.16-19
- Research on the effectiveness of CM dates back over 30 years and consistently shows that CM improves patient outcomes, including reducing substance use and increasing continuous abstinence, engagement and retention in treatment, medication adherence, and attendance in other behavioral therapies.20-22
- Research shows individuals who participate in mutual support groups more frequently are more likely to sustain abstinence for prolonged periods of up to 16 years, show higher levels of self-efficacy, and enhance social function.26
- Multiple studies have found that there is a correlation between length of treatment in therapeutic communities and sustained recovery. Findings also suggest that incorporating Therapeutic Communities in correctional facilities and facilitating participation in community-based Therapeutic Communities during reentry are effective in preventing relapse and increasing social connections.27
Aware Recovery Care
Aware Recovery Care is designed to be flexible and individualized. By prioritizing the specific needs of each client and meeting them in their home, rather than a group setting off-site or an office, the program bypasses common barriers that many people face when trying to access treatment. This includes a lack of transportation to and from appointments, difficulties with scheduling, and the social anxiety that is often associated with adopting new behaviors. If a client does not have their own home, appointments can be held at alternative locations, such as a friend’s house, a space made available by partnering organizations in the community, a walking path, and even in a client’s car. Clients whose schedules are difficult to navigate due to work and/or family care can make appointments at any time throughout the day, ensuring that treatment fits seamlessly into their lives. A 2016 study concluded that Aware Recovery Care had recovery rates six times higher than the national average.32
Expand Access to Syringe Service Programs
Syringe service programs (SSPs), also referred to as syringe exchange programs, are an effective public health approach for reducing human immunodeficiency virus (HIV), hepatitis C virus (HCV), and other infectious disease transmissions.
SSPs also promote linkages to SUD treatment and other medical services. Decades of research demonstrates syringe services programs are a key component to combating the opioid epidemic, preventing the spread of infections, saving costs, and controlling outbreaks in vulnerable communities without increasing crime or substance use, and while providing an opportunity to engage individuals in health care services.34-36
People who participate in SSPs are
more likely to enter SUD treatment programs
Syringe service programs are cost-effective and provide considerable cost-savings to communities. For example, the expansion of SSPs in New York City is associated with saving the city government $1,300-$3,000 per client in one year.37 In Scott County, Indiana opening an SSP saved Indiana taxpayers approximately $120 million in costs associated with averting additional people contracting HIV.37 Baltimore and Philadelphia have also shown an annual return on investment for SSPs of $62 million and $243 million, respectively.38
Syringe service programs are safe, effective, and provide access to a variety of services including:
- Sterile syringes and methods of safe disposal of used injection equipment;
- Education on safer injection practices and wound care;
- Overdose prevention resources such as naloxone (overdose reversal medication) and fentanyl test strips;
- Infectious disease vaccinations, testing, and care; and
- Linkages to SUD, behavioral health, and other medical care services.
- Research shows that people who participate in syringe service programs are three times more likely to stop or reduce injection drug use, and five times more likely to enter SUD treatment programs compared to people not participating in SSPs.38,39
- Syringe service programs can reduce HIV and HCV cases by at least 50%.38
- Naloxone provision through SSPs is attributed with a 30% reduction in overdose deaths.37
- Numerous studies have shown that syringe service programs do not increase in crime rates or substance use.40-42
Baltimore City Community Risk Reduction Services (CRRS)
In 1994, the spread of HIV among persons who inject drugs in Baltimore, Maryland was exploding. Looking for a solution to reduce infections and save lives, the Baltimore City Health Department launched its Community Risk Reduction Services (CRRS) program that delivers free and confidential quality prevention, harm reduction, and treatment services for infectious diseases and SUDs to communities within Baltimore City.
Program services are delivered by a mobile van in dozens of locations throughout the city every week, and include syringe exchanges, wound care, OB-GYN check-ups, naloxone distribution, and connections to SUD treatment. The program also implemented a “Staying Alive” program that provides overdose prevention and response training to at-risk Baltimore residents. By continuing to use this effective public health approach, this pioneering and effective program remains at the front line of public health after two and a half decades.
Distribute Fentanyl Test Strips
Fentanyl is a synthetic opioid 50 to 100 times more powerful than morphine that is typically prescribed to people with advanced stage cancer.43
SIn recent years, illegally manufactured fentanyl has entered the illicit drug market as a heroin alternative, and as an adulterant in the production of illicit drugs, including stimulants and counterfeit pills. The spread of fentanyl throughout the illicit drug market has drastically increased deaths from overdoses.
more likely to engage in safer behaviors
Fentanyl Test Strips (FTS) are an inexpensive and easy to use tool that can prevent overdose fatalities of people who use drugs. FTS are a relatively new technology that works much like a pregnancy test. An individual can mix a small amount of a drug with water, dip the FTS into the water, and within minutes know if fentanyl is present.
Communities can prevent accidental fentanyl overdose by distributing test strips to health departments and other agencies that frequently interact with people who use drugs. For example, it’s particularly important for communities to provide FTS kits to high-risk people returning to the community after a period of incarceration when their tolerance level for opioids has likely decreased. Importantly, recent administrative changes to many federal grants now allow state and local governments to use federal funds to purchase FTS.
- According to a 2018 study, a positive test result with a FTS was significantly associated with a positive change in overdose risk behavior. 45% used smaller amounts, 42% used slower, and 39% used with someone else present.44
- According to a 2019 study, people who use heroin are 5 times more likely to engage in safer drug use behaviors when an FTS strip indicates fentanyl.45
City of Alexandria, Virginia
In May 2021, the City of Alexandria Opioid Work Group launched a regional evidence-based harm reduction program in partnership with The Chris Atwood Foundation to distribute fentanyl test strips and to help support and (re-)engagement of individuals with SUD or in recovery. What started as a mail-order program now spans programs across the City of Alexandria.
The peer support specialists team also offers a wide range of services to help individuals with SUD or in recovery find and navigate resources such as housing, medical insurance, medications for addiction treatment, and other services. In addition, the team conducts direct outreach to individuals who have recently overdosed and provides naloxone and overdose response training to the Department of Community and Human Services staff and local organizations. The program also has a free order service that will mail fentanyl test strips and naloxone to residents and organizations across the city.
Ensure Support Group Access
Recovery support groups are free, peer-led services that create opportunities for people in recovery to share experiences, connect with others with lived experience, and learn skills in a safe and supportive environment.
Support groups help individuals navigate the early stages of recovery, learn how to manage their chronic illness, and create positive social connections to sober peers. It is important to ensure that there is a wide range of support groups and programs available that provide a structured, supportive, and culturally competent environment for people in recovery from a SUD.
increase in patient outcomes when participating in mutual support groups
- Engaging in 12-step facilitation (TSF) or mutual support groups (MSG), such as Alcoholics Anonymous (AA), has shown to increase patient outcomes by 10-20%.51
- TSF/MSGs have shown to be as effective as certain behavioral therapies in decreasing substance use but shows slightly higher rates of continuous abstinence. A study that compared the effectiveness of TSF/MSGs to other established treatments, such as cognitive-behavioral therapy (CBT) and motivational enhancement therapy (MET), found that 24% of the TSF/MSGs participants were continuously abstinent for the first year post-treatment compared to 15% of CBT and 14% MET participants.52 After three years, 36% of the TSF/MSG group reported abstinence and 24% of the CBT group and 27% of MET group reported abstinence. Another study found that abstinence rates among people who participated in TSF/MSGs were 60% higher than behavioral therapies alone.53
- A longitudinal study found that individuals who participate in both MSG and formal treatment were more likely to be abstinent at years 1 and 3 compared to those that received formal treatment only.54 Of those that received both MSG and formal treatment, 42% were abstinent at year 1 and 51% at year 3. Compared to the formal treatment group, 21% at year 1 and 26% at year 3.
- Research shows that individuals that attend MSGs within the first three months after treatment and who attend 90 meetings in 90 days have significantly better outcomes compared to those that attend less frequently.55
Types of Support Groups
Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)
Spiritual peer-led program that uses the twelve-step model, utilizes sponsors for support and guidance, teaches self-awareness, and encourages abstinence.
A behavioral change program and national support group network for people concerned about their drinking and who desire to make positive lifestyle changes.
Self-Management and Recovery Training (SMART)
Secular (non-religious) peer-to-peer support group. Meetings are open to the public and last anywhere from 1 to 1.5 hours. Science-based, utilizing cognitive behavior and rational emotive behavior techniques and tools.
Secular Organizations for Sobriety
A non-religious, sobriety-based group that welcomes anyone who is seeking sobriety from alcohol, drugs, or compulsive eating. An alternative to the 12-Step model of recovery and respect for recovery in any form, regardless of the path by which it is achieved.
Abstinence-based, worldwide network of individuals seeking to live in recovery from addiction to alcohol or to other non-medically indicated drugs.
This is a mindfulness-based addiction recovery community that practices and utilizes Buddhist philosophy as the foundation of the recovery process.
Christ-centered, 12-step recovery program for anyone struggling with hurt, pain, or addiction of any kind.
Recovery Community Organizations
Twenty-one million Americans are in recovery today from SUD, and as communities provide care for more individuals in need of addiction treatment, investing in the necessary recovery framework is critical.56
Recovery Community Organizations (RCOs)offer recovery-focused policy advocacy activities, carry out recovery-focused community education and outreach programs, and/or provide peer-based recovery support.57 RCOs bring together individuals in recovery, family members, professionals who work directly and indirectly with individuals with SUD, and other key members within the community. RCOs Many include a physical location where the recovery community can organize a “hub” for recovery and family support services. Services may include recovery coaching, life skills groups, employment training and assistance, support groups, education, legal aid, harm reduction services, and housing support. The main goal of an RCO is to create a network of resources, within and outside the recovery community, which will help to increase the quality of an individual's recovery.
Americans are in recovery from a substance use disorder
- In one study, individuals who participated in RCOs with peer-based recovery support services showed significantly improved recovery capital (the total resources that a person has available to find and sustain recovery), social functioning, and community engagement, as well as reduced negative health outcomes.58
- A study of 20 RCOs found that individuals who engaged in services within the RCO and took two assessments had low levels of substance use, low levels of emergency room visits, and an increase in their recovery capital.58
- Research shows that peer support services support treatment and health outcomes by reducing rates of relapse, increasing treatment retention and satisfaction, and improving relationships with providers and social networks.59 Peer support also improves individuals feelings of acceptance, self-esteem, self-efficacy, and community inclusion.60
Chicago Recovering Communities Coalition
CRCC is a peer-driven and peer-led organization whose mission is to increase visibility and resources for those in recovery and to end discrimination surrounding addiction recovery and mental illness. CRCC works to improve the neighborhood of Austin and the greater Chicago area by educating communities about addiction, recovery, and mental illness to increase public awareness and reduce stigma associated with addiction. The program also strives to unite the recovery community, which includes people in recovery, family members, friends, and allies, to put a face on recovery and provide support services. CRCC offers a variety of personalized recovery support services and trainings to help individuals and families. These resources include recovery education, peer coaching and mentoring, individual case management, spiritual coaching, life skills, and trauma support groups. Services tailored for youth are also available and focus on enhancing support networks, skills building, job readiness, mentoring, and wellness programs.