An Equitable Response to the Ongoing Opioid Crisis

  • Date: Oct 26 2021
  • Policy Number: 202113

Key Words: Opioid pain relievers, Overdose, Substance Abuse, Painkillers

APHA Policy Statement 20154 (Prevention and Intervention Strategies to Decrease Misuse of Prescription Pain Medication) recognized the public health priority of minimizing the risk of nonmedical use of prescription opioids by emphasizing supply reduction–oriented measures. Collectively, these evidence-informed intervention strategies were expected to produce measurable positive outcomes. While millions of dollars have been expended on evidenced-based programs and treatments, the United States continues to experience an opioid crisis. Although prescription opioid–related deaths have decreased, mortality related to synthetic opioids has increased by more than 15%. The nature of the opioid crisis has shifted. Emphasis must now shift to addressing a more dangerous landscape of increased use of potent synthetic opioids, polysubstance use, and growth in stimulant overdose deaths (with or without opioid involvement). A public health response must address these emergent trends. Although efforts to reduce opioid-related morbidity and mortality primarily driven by prescribed opioids continue, there is still a need to address the increasing number of opioid-related fatal and nonfatal overdoses.

Relationship to Existing APHA Policy Statements
This policy statement is an update to APHA Policy Statements 20154 (Prevention and Intervention Strategies to Decrease Misuse of Prescription Pain Medication) and 202012 (A Public Health Approach to Protecting Workers from Opioid Use Disorder and Overdose Related to Occupational Exposure, Injury, and Stress).

Problem Statement
The focus of this policy is to update APHA Policy Statement 20154 (Prevention and Intervention Strategies to Decrease Misuse of Prescription Pain Medication) in response to the continuing public health opioid crisis. This requires examination of the impact of recent policy, practice, and secondary and tertiary prevention and intervention strategies. Therefore, this policy will not focus on primary prevention per se; rather, it will specifically address the drivers of the current crisis such as drug overdoses, primarily driven by opioids, which continue to be the leading cause of injury-related deaths in the United States. More than 70% of drug overdose deaths in 2019 involved an opioid.[1] Initially, prescribed opioids were the primary contributors to opioid-related deaths. From 2010 to 2012, as the number of deaths related to prescription opioids stabilized but remained high, mortality rates associated with heroin began to increase. In 2013, synthetic opioids, such as fentanyl and illicitly manufactured fentanyl, were responsible for most opioid-related deaths. The most recent mortality data (from June 2019 through May 2020) indicate a surge in opioid deaths primarily driven by synthetic opioids. During the same time, overdose deaths involving cocaine also increased by 26.5%, which was likely linked to co-use and contamination of cocaine with illicitly manufactured fentanyl or heroin.[2] The increase in fatal opioid overdoses has been accompanied by increases in nonfatal opioid overdoses. In 2017, the most recent year for which population-level estimates of nonfatal overdoses can be generated, there were 305,623 opioid-involved overdoses, a 3.1% increase from 2016.[3] Nonfatal opioid overdoses increased 9.7% from 2018 to 2019. This increase occurred among both females (7.1%) and males (10.7%), across all age groups, and among people living in both urban (13.6%) and rural (10.1%) counties. Injection of opioids has been associated with increases in hepatitis C virus (HCV), HIV, and infective endocarditis.[4,5]

In 2019, 10.1 million U.S. residents (3.7% of the population) reported nonmedical use of an opioid. Of those, the majority reported misusing prescription opioids. About 750,000 used heroin, and half of those individuals also used prescription opioids.[6] Efforts to reduce nonmedical use of prescribed opioids resulted in a decline in people initiating prescription opioid use from 425,000 in 2015 to 239,000 in 2019. This number remained steady from 2016 to 2019.[6] Opioid use disorder (OUD) peaked in 2015, with 2.4 million people experiencing OUD. The prevalence of OUD declined to 1.6 million people between 2016 and 2019.[6] In 2019, 2.8% of 12- to 17-year-olds and 5.5% of 18- to 25-year-olds reported nonmedical use of prescription opioids.[6] In 2019, 31% of 12th graders believed that it would be fairly or very easy to get prescription opioids.[7] More than half of 12th graders who report nonmedical prescription opioid use obtain these medications from relatives or friends, with or without their knowledge, and 28.4% divert their own prescription for nonmedical use.[7]

The most affected age group is individuals 18–25 years old, 0.9% of whom had OUD in 2019. Notably, in that same year, 0.4% of adolescents 12 to 17 years of age already had been diagnosed with OUD.[6] It is estimated 850 adolescents initiate nonmedical prescription opioid use each day.[6] The number of new initiates is especially disconcerting given that individuals most often initiate nonmedical prescription opioid use before transitioning to, or supplementing with, heroin or fentanyl, which drastically increases risk for fatal overdose.[8]

There are existing socioeconomic disparities associated with opioid misuse and related harms. A systematic review showed that 34 of 37 studies published from 2000 to 2018 identified at least one socioeconomic factor related to opioid overdose. The included studies revealed that socioeconomic marginalization in the forms of neighborhood-level poverty rates or median household income, county-level unemployment rates, neighborhood-level educational attainment, neighborhood-level dilapidated housing structures, and population-level criminal justice system involvement was were associated with higher rates of opioid overdose.[9] Vulnerable and historically marginalized populations are disproportionately affected; however, we continue to struggle to develop evidence through surveillance data to fully articulate the true impact on many vulnerable populations such LGBTQI (lesbian, gay, bisexual, transgender, queer, questioning, intersexed) and incarcerated individuals.[10] It is especially troubling that Black Americans and historically marginalized groups experience disparities in access to treatment.[11] Opioid use among pregnant and breastfeeding people has paralleled the opioid crisis in the general population. Risks associated with opioid use during pregnancy include neonatal abstinence syndrome[12] and increases in pregnancy-associated deaths. Women across all age groups are disproportionately prescribed opioid medications,[13] and the states with the highest rates of opioid prescriptions also have the highest rates of neonatal abstinence syndrome.[14] Of particular concern is the fact that punitive approaches toward pregnant women with substance use disorder cause the greatest harm to Black women and women of color.[15] From 2017 to 2018, overdose death rates increased among individuals 65 years or older, non-Hispanic Blacks, and Hispanics. While American Indian and Alaska Native (AI/AN) populations had the second highest opioid overdose rate among U.S. racial/ethnic groups (following non-Hispanic Whites) in 2018 (14.2 deaths per 100,000 population),[16] only 40% of AI/ANs in specialty OUD care receive opioid agonist medication treatments and 22% of specialty treatment facilities serving AI/ANs offer opioid agonist treatment (OAT).[17]

Over the past five years, the U.S. response to the crisis has evolved, with more emphasis on demand-oriented interventions, harm reduction, and treatment. Medication for opioid use disorder (MOUD) is the most effective evidence-based treatment for moderate to severe OUD. MOUD pharmacotherapies reduce opioid use and OUD remission, improve treatment retention, and reduce overdose mortality. Yet, access to integrated MOUD treatment with OAT medications in medical care remains limited.[19] Identified barriers to increased uptake of MOUD include stigma, lack of provider education, and the restrictive MOUD regulatory environment.[20] Individuals living in rural communities also have significant barriers to MOUD access, including (1) lack of clinics/providers providing MOUD, (2) accessibility barriers related to travel and cost to receive MOUD, (3) negative provider attitudes about addiction treatment, and (4) time constraints of providers.[21] Despite efforts to reduce opioid-related morbidity and mortality, there continues to be an increase in the number of opioid-related fatal and nonfatal overdoses, which disproportionately impact vulnerable and marginalized populations.[9] Existing surveillance systems fail to provide meaningful real-time data and contribute significantly to gaps in our ability to address limited access to treatment and services for vulnerable and marginalized populations.[22] Therefore, APHA calls for policy actions that address these barriers and foster equitable access to the full continuum of prevention, intervention services, and evidence-based care, including the following:

  1. Enhance and improve prevention and treatment programs and policies with special attention to vulnerable and marginalized populations through improved community- and school-based programming; access to syringe service programs (SSPs); screening, brief intervention, and referral to treatment (SBIRT); and interprofessional coalitions. 
  2. Minimize harm to the public through expanded access to MOUD and overdose prevention, establishment of safe consumption sites, distribution of fentanyl testing strips, and population and workforce education and training.
  3. Expand monitoring of patterns of opioid use and related public health and safety outcomes through improving real-time access to data, monitoring and evaluating access to and quality of treatment services, improving and enhancing surveillance tools to strengthen appropriate data utilization by prescribers and public health professionals, and evaluating the cost-effectiveness of interventions.

Evidence-Based Strategies to Address the Problem
Research on and analysis of the gap in access to evidence-based care has evolved. In 2018, the National Academy of Medicine and the Aspen Institute launched the Action Collaborative on Countering the U.S. Opioid Crisis. The collaborative works across public, private, and nonprofit sectors to conduct research on gaps in and barriers to implementation of evidence-based OUD responses to improve outcomes. In mid-2020, the group published strategies to address specific institutional, regulatory, financial, and other barriers and identified actions Congress, federal agencies, the states, public and private payers, and treatment systems can take to respond to the national opioid crisis.[20] The collaborative’s work is ongoing and provides a roadmap for the evidence-based strategies identified below.

Enhance and improve prevention and treatment programs and policies: Adolescents and young adults are at heightened risk of nonmedical prescription opioid use. Strategies to address this issue begin with an assessment of readiness and community needs. Community- and school-based prevention programs can be improved to include a stronger focus on OUD among adolescents and young adults. These programs should be culturally sensitive and adapted to the needs of disproportionately affected vulnerable and marginalized populations. A community needs assessment calculator and methodology called CAST (Calculating for an Adequate System Tool) can determine estimates for community needs, specifically with respect to for community and social correlates to behavioral health.[23] CAST can help public health leaders across the continuum of care prioritize resource allocation to the determined highest-risk target populations.[23] Results from CAST assessments could be utilized to target prevention strategies that directly address initiation of use in these populations. 

Enhancing tertiary prevention for people who inject drugs, which includes access to syringe and needle service programs, will mitigate the risk of blood-borne infections such as HIV and HCV.[24] Absence of these programs leads to undetected outbreaks,[25] whereas access to them (e.g., in Philadelphia, Baltimore, and Scott County, Indiana) substantially reduces injection drug use risk behaviors and rates of new HCV and HIV infections. SSPs also have the potential to reduce overdose deaths when they include referrals and increased access to MOUD pharmacotherapies (e.g., OAT) and harm reduction strategies (e.g., distribution of naloxone and fentanyl testing strips).[18] As of 2019, 32 states had laws explicitly authorizing SSPs.[24]

SBIRT is a comprehensive and integrated public health approach that aims to address harmful substance use in patients. SBIRT efforts have primarily focused on alcohol consumption, but an increasing number of studies are examining its impact on substance use. Brief interventions have been shown to reduce patients’ risk of overdose.[26] In June 2020, the U.S. Preventive Services Task Force recommended primary care screening for unhealthy drug use in adults 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or are available by referral.[26] A large cohort study of 17,575 patient groups showed that there was a statistically significant pre- to post-SBIRT decrease for every measure of substance use disorder, with a 75.8% decrease in the prevalence of illicit drug use. Prenatal and postnatal reductions in the risk of adverse outcomes (e.g., birth complications, low birth weight, neonatal opioid withdrawal syndrome, and overdose mortality in pregnant and breastfeeding women and their infants) are needed. The American College of Obstetricians and Gynecologists recommends early and universal screening, brief interventions, and treatment referrals for opioid agonist medications for mother and child (if the child presents with neonatal opioid withdrawal syndrome).[27]

Use of interprofessional coalitions that include people who use drugs, people in recovery, advocates/allies, service providers, and academics to implement collaborative solutions to reduce risks at state, municipal, and tribal levels is imperative.[28] Shifting efforts to focus on increasing access to pharmacotherapies, overdose prevention initiatives, and harm reduction strategies reduces risks.[18] Additional efforts include creating low-threshold access to drug treatment programs such as telemedicine, which has been shown to strengthen engagement and retention in treatment.[29] In state programs with strong interprofessional coalitions, early-stage intervention has been shown to reduce risks among those with substance use disorders who are in states of emergency.[28] An interprofessional coalition in Connecticut identified barriers to care for communities at risk, including active users needing access to harm reduction services and people in treatment needing access to their medications. Increasing interprofessional coalitions is effective in identifying community needs ahead of official initiatives and assisting in scoping the target populations.[28]

Minimize harm to the public: Since 2015, the need to reduce the treatment gap has become apparent. Efforts have focused on expanding treatment access to AI/ANs and non-Hispanic Black Americans and increasing access in primary care services, rural underserved areas, and correctional settings.[16,18] These efforts must continue and be enhanced to improve access to high-quality, evidence-based treatment that integrates MOUD services within medical care.[19] Furthermore, supporting state and federal efforts to ensure universal access to naloxone and training in its use (e.g., standing orders and emergency personnel) has been shown to produce significant reductions in overdose deaths.[30] 

Safe consumption sites (SCSs) are an evidence-based, cost-effective[31] intervention implemented in 11 countries of the world to address the growing effects of illicitly manufactured fentanyl on mortality and morbidity related to addiction.[32] The United States does not have sanctioned SCSs. SCSs provide a place for people to safely use substances and access sterile supplies under observed conditions with safe disposal of paraphernalia. Evaluations of these sites have shown that they improve the health of people who use them by reducing infectious disease risks, overdose mortality,[33] and level of substance use and enhancing engagement with and linkage to medical and social care.[34,35] 

As illicitly manufactured fentanyl became a driver of overdose fatalities, fentanyl testing strips became a growing grassroots effort to identify fentanyl in substances and encourage changes in substance use behaviors. Around 92% of people who use substances are interested in using fentanyl testing strips to determine whether substances contain fentanyl. According to one study, 43% of people who used substances changed their behavior when they had a positive test result, including using a smaller amount and snorting instead of injecting drugs.[36] This study also showed that 77% of people who used substances indicated perceived safety after using fentanyl testing strips.

Negative and stigmatizing attitudes of providers result in undertreatment of patients with substance use disorders. Manifestations of stigma include inadequate treatment of pain in people with substance use disorders, particularly people of color.[37] The use of stigmatizing language and the belief that substance use disorders are a moral failing or a matter of personal choice also influence provider bias. A lack of empathy leads to reticence among patients to share information about their substance use with providers.

People who use substances, their family, and community members are essential to overdose prevention and harm reduction. Providing training in and access to harm reduction kits that include naloxone increases the possibilities of survival for people who overdose. Training community and family members helps reduce stigma and improves outcomes related to harm reduction.[38] Discriminatory practices include overuse of incarceration for drug possession or use, particularly among people of color, and use of stigmatized language.[11] Stigma is generated by society’s long-held view that substance dependence is a moral failing. This produces internalized shame, real and perceived, that prevents people from seeking harm reduction, treatment, and recovery services. Stigma on the part of individuals, providers, and communities can be reduced through educational programs, media campaigns, advocacy, and peer support.[39] Interventions that change perceptions regarding substance use and people who use substances have the potential to save lives by making harm reduction strategies more acceptable within communities and reducing internal shame and stigma that prevent substance users from seeking help. While the evidence on internalized stigma leading to decreased substance use disorders is still pending, there is substantial evidence that training of providers with respect to stigma leads to decreased internalized shame and increased peer support.[39]  

Most U.S. states have implemented a prescription drug monitoring program (PDMP) to track dispensing of controlled substances, help prescribers monitor dosing, reduce the harms of drug interactions, and identify patients with multiple prescribers and/or pharmacies.[40] PDMPs can serve as an important primary prevention tool in reducing initiation of prescription opioids and monitoring dosages. Evaluations of PDMPs have shown reduced dispensing of higher-schedule opioids and lower rates of multiple prescribers.[41] There have been decreases in opioid use in states implementing PDMPs, especially among Medicare beneficiaries. PDMPs can be effective in decreasing initiation of substance use disorders.[41]

Expanded monitoring of patterns of opioid use and related public health and safety outcomes: Data collection in real time is key to reducing overdose deaths and identifying gaps in treatment admissions. Public health laboratories are uniquely qualified to test nonfatal overdose samples. By adding queries to existing surveillance programs, public health professionals and policymakers can act promptly to address needs.[42]

Data collection can be improved to reduce overdose deaths and identify gaps in treatment admissions.[42] Existing surveillance systems focused on vulnerable populations can include overdose tracking. States that have incorporated drug overdose fatality surveillance (e.g., Kentucky) have improved the accuracy of their data to drive targeted interventions designed to reduce mortality from substance use disorders.[42] 

PDMPs are critical tools in conducting surveillance of opioid and other prescription medications that can be addictive and/or have unintended outcomes. Improving PDMP functionality can increase utility and build appropriate primary prevention and intervention capacity. There is also a need to address restrictions and fund research on data sharing programs and tools to improve access to data on overdose mortality and other opioid-related health outcomes.[20]

The benefits of various opioid responses include lives saved, diseases averted, treatment accessed, medications administered, and quality of life improved, all of which directly or indirectly lead to cost savings. The anticipated benefits or cost-effectiveness of each strategy can be identified and compared via dynamic compartmental modeling.[43]

Opposing Arguments/Evidence
Arguments opposing evidence-based strategies often focus on the potential for bias and for increasing disparities. The following opposing arguments address the strategies presented above. 

Enhance and improve prevention and treatment programs and policies: The establishment of needle service programs requires legislative action by people elected to represent their constituents. Stigma toward people with OUD is prevalent and not geographically uniform. In this context, distribution of needle service programs may reflect the prevailing local political views rather than needs of individual communities, resulting in uneven distribution and an increase in the disparity of health outcomes.[44] Hagemeier et al. studied the relationship between state-specific syringe policies and pharmacists’ nonprescription syringe dispensing behaviors in a three-state region (North Carolina, Tennessee, and Virginia). State laws governing dispensing/selling syringes without a prescription varied among the states. Patients in Tennessee are unable to purchase syringes without a prescription unless they have “proof of medical need,” a stipulation subject to interpretation by a pharmacist. In North Carolina, pharmacists can sell syringes to anyone without a prescription, but the statute states that drug paraphernalia may not be sold or distributed if they are known to be used for illicit drug use.[45] That study described challenges of SSPs in three states in which they are legal; in 2021, SSPs remained illegal in 11 states.

There is evidence against the effectiveness of SBIRT or brief interventions in at least two populations. Among incarcerated individuals, studies demonstrate no statistically significant differences in outcomes between those who received SBIRT and those who did not after control for baseline differences. Effective implementation of SBIRT requires readiness for change, including an assessment of underlying biases and stigma.[46] In a systematic review and meta-analysis of studies evaluating brief alcohol interventions among military and veteran populations, Doherty et al. concluded that existing versions of these interventions do not seem to be effective in reducing alcohol use in military populations.[47]

Minimize harm to the public: Barriers to access and overdose prevention represent significant opposing arguments in that they demonstrate the limitations of existing evidence-based strategies. People receiving methadone for OUD in low-income neighborhoods have been shown to experience barriers to access and retention associated with mental illness, family responsibilities, and use severity.[48] When people with OUD receive prescriptions, they may not fill them. Morgan et al. reported that in a group of 264 individuals who received a prescription for buprenorphine or naltrexone, only 70% filled the prescription within 30 days.[49] Although harm reduction strategies are available, not all communities adopt and support universal access. Uzwiak et al. conducted qualitative interviews with the next of kin of people who died of overdoses and concluded that existing health disparities and structural barriers to care increase a person’s risk of overdose.[50]

Evidence of the value of safe consumption sites is overshadowed by the challenges associated with developing them. Establishing effective safe consumption sites requires alignment of goals among public health, the public, and the legal/criminal justice system. Arguments opposing safe consumption sites include the following: (1) public funds should be spent on addiction treatment, (2) heroin and other opioids are illegal, and (3) safe consumption sites support drug use.[51]

Fentanyl test strips can detect only the analogues for which they were developed. Test strips may lack the sensitivity for detecting some fentanyl analogues. Thus, a negative result does not necessarily mean that fentanyl or another substance is not present.[52]

Increased knowledge about bias and substance use disorder does not guarantee equitable care and can increase disparities in outcomes. One study collected data over a seven-year period[53] on a broad variety of knowledge translation activities designed to decrease stigma about opioid use during pregnancy. The activities addressed addiction, harm reduction, the impact of provider bias, types of substance use, judgments of pregnant women, and women’s experiences. The authors found persistent biases against women with OUD and ambivalence toward evidence-based recommendations. They concluded that, to translate knowledge to practice, there has to be a better understanding of how knowledge is learned and how beliefs are changed.[53] 

The challenge of community harm reduction training is addressing the needs of a diverse group of people with OUD in the context of a community with which they may share only geography.[54] Studies have identified several interrelated challenges to implementing harm reduction services in nonurban communities: (1) limited understanding of harm reduction; (2) community-level social stigma toward people with OUD and the organizations providing support; (3) data reporting, aggregation, and interpretation leading to inaccurate perceptions of local patterns and health consequences; and (4) a “prosecutorial mindset.”[54]

Structural stigma in health care is rooted in the culture of broadly defined institutions, affecting rules, policies, procedures, and practices of professionals and decision makers. Although outward signs of structural stigma can be removed, the culture of stigma is perpetuated through social stigma. Members of the stigmatized group may experience self-stigma as they internalize the attitudes toward them.[55] 

It is not clear whether education is sufficient to reduce stigmatizing attitudes toward people with OUD. The literature on education to address mental illness stigma is mixed. Some evidence suggests that a better understanding of psychiatric illness is associated with a lower likelihood of endorsing stigma and discrimination. Other evidence does not correlate better understanding with improvements in proxies of public stigma.[56] 

Although use of PDMPs has decreased prescriptions for opioids, they have done nothing to decrease the need for opioids among those with OUD. The historical association between heroin use and nonmedical use of opioids is well established.[57] National Vital Statistics System Multiple Cause of Death mortality data on annual overdose deaths from 2003 to 2016 showed an estimated increase in heroin deaths of 0.9 per 100,000 in a six-month period (relative to control data).[57] 

Expanded monitoring of patterns of opioid use and related public health and safety outcomes: The context of data collection can have adverse consequences for people with OUD. For example, in response to the opioid crisis, states implemented a range of policies to address the growing problem of neonatal abstinence syndrome. Many of these policies either mandated reporting or made reporting an option. The effect of state-level policies was studied, and the results showed that punitive prenatal substance abuse policies did not reduce neonatal abstinence syndrome or maternal narcotic exposure at birth; also, there was evidence that such policies may deter women from seeking treatment during pregnancy.[58]

Furthermore, the consequences of screening women for opioid use during pregnancy with the option of reporting are disproportionately borne by women of color. Terplan and Minkoff reported that Black women are more likely to be screened for substance use. With positive screens, Black women and poor women are more likely to be reported to social services.[59] In addition, legislative responses to substance use during pregnancy, often with a sole focus on protecting the unborn child, can result in maternal detention or incarceration, subsequent loss of prenatal care, and separation from the infant.[59]

Evidence supporting reduced opioid prescribing following PMDP implementation is mixed. Among 16 studies investigating the association between PDMP implementation and provider prescribing behaviors, 11 reported a reduction in different prescribing outcomes after implementation.[60] PDMPs may influence provider prescribing and patient care. Some providers may be reluctant to prescribe opioids when appropriate. Others may stop prescribing opioids to patients who have long histories of inappropriately prescribed medications resulting in withdrawal.[61]

State and federal laws have been passed to criminalize opioid use and mandate reporting of opioid prescriptions in state PDMPs as responses to the crisis. In some states, law enforcement can access PDMPs during investigations of controlled substance distribution, often without establishing cause for prior judicial approval.[62] Access to prescription records in PDMPs denies patients their reasonable expectation of privacy in their relationships with providers and pharmacists. Furthermore, access to records without cause violates protections afforded under the Fourth Amendment. Protecting public health should not be used as the rationale for violating patient privacy.[62] 

Action Steps
APHA urges the following steps.

Enhance and improve prevention and treatment programs and policies with special attention to vulnerable and marginalized populations:

  • State and local health departments, health systems, social service agencies, and tribal leaders and/or councils should develop and implement culturally sensitive assessments of OUD continuum of care and service needs at the community level. These groups and individuals can leverage existing federal and state resources.
  • State and local health departments, tribal leaders and/or councils, and community agencies should implement comprehensive SSPs for people who inject drugs to mitigate the risk of blood-borne infections (HIV and HCV) at the community level.
  • State and local health departments, health systems and social service agencies, licensing boards, and tribal leaders and/or councils should increase dissemination and utilization of the Substance Abuse and Mental Health Services Administration national guidelines established for prescribers and providers on the use of SBIRT and medications for OUD.
  • State and local health departments, health systems, social service agencies, grassroot initiatives, and tribal leaders and/or councils should establish and maintain coordinated multidisciplinary coalitions composed of stakeholders including state and local health departments, tribal leaders and/or councils, hospital systems, medical examiners/coroners, law enforcement and judiciary officials, social service organizations, and affected community members.

Minimize harm to the public:

  • Federal, state, and private insurers should leverage existing funding streams for state and local health departments, health and criminal justice systems, medical and licensing boards, social service agencies, and tribal leaders and/or councils to improve equitable access to comprehensive, integrated MOUD treatment and overdose prevention.
  • State and local health departments, health systems, medical and licensing boards, social service agencies, and tribal leaders and/or councils should obtain funding for, develop, implement, and evaluate education and workforce training curricula directed toward harm reduction strategies that address provider bias, PDMP use, use of fentanyl testing strips, access to safe consumption sites, SSPs, and community-wide overdose education.

Expand monitoring of patterns of opioid use and related public health and safety outcomes:

  • Federal, state, and local health agencies such as the Centers for Disease Control and Prevention (CDC) should fund and implement a nationally embedded surveillance system in health systems, emergency medical services, and treatment centers to provide state and local health departments as well as tribal leaders and councils data to monitor quality assurance, cost-effectiveness, and policy development.
  • Federal, state, and local health agencies such as the CDC should coordinate multidisciplinary collaborations with communities and local stakeholders including health departments, public health laboratories, hospital and health care representatives, medical examiners/coroners, law enforcement and judiciary officials, social service organizations, and affected community members.
  • Federal, state, and local health agencies such as the CDC should improve and integrate surveillance systems across federal and state entities to provide real-time data on opioid prescribing and dispensing, fatal and nonfatal incidences of overdose, and incidence of neonatal opioid withdrawal syndrome.
  • Federal, state, and local health agencies such as the CDC and the Centers for Medicare & Medicaid Services should create and monitor national quality standards and measures for OUD treatment and promotion of evidence-based practice through funding, reimbursement, and technical assistance.

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