Are Opioids Still a Problem?
• March 2022 •
From Juan Navarro, Executive Director
Los Angeles Centers for Alcohol and Drug Abuse
World AIDS Day in the Age of Anti-Retroviral Therapy (ART)
It’s getting worse, not better. There were over 100,000 drug overdose deaths in the United States during the year ending in April 2021 – an increase of 28% from 2020. And about 75% of these deaths were from opioid overdose.
Almost a decade ago, the raging abuse of prescription pain medications drove manufacturers, public policy makers, and law enforcement agencies to enact multiple measures to curtail the drug supply. Even so, the problem morphed into a deadly heroin epidemic, including heroin laced with drugs like fentanyl that simulate the effect of opiates and are powerful enough to kill with small amounts.
Then, COVID-19. The pandemic exacerbated the opioid overdose crisis, and as researchers work to examine this trend, the most likely reasons include: 1) a more dangerous drug supply, 2) disruption of treatment and recovery support services, with 3) social isolation and 4) increased levels of social and economic stress.
A comprehensive response has been needed to address America’s opioid crisis. For one thing, behavioral health treatment agencies have remained open throughout the pandemic to provide lifesaving recovery care. Business as usual changed considerably and treatment programs had to quickly pivot to fill new needs. This includes implementing universal precautions, temperature checks, and COVID testing, as well as using personal protective equipment (PPE) for patients and staff, and socially distanced or telehealth treatment sessions. Meanwhile, the rates of opioid overdose continue to rise.
Harm reduction strategies are another tool in our arsenal, including the distribution of naloxone, an opioid overdose reversal medication, to those most likely to witness an opioid overdose.
Other medications, specifically methadone and buprenorphine, have been recognized as effective in treating opioid use disorder (OUD) when combined with cognitive-behavioral treatment. The bad news is that only 20% of individuals with OUD receive specialty treatment and, among these, only a third receive the evidence-based medications of methadone or buprenorphine. Innovative interventions are vital to address this treatment gap, such as providing these medications at vital touchpoints, including emergency departments and the criminal justice system. Other promising models include post-overdose response teams and peer outreach.
The good news is that the government is actively funding community services agencies like L.A. CADA to deliver needed evidence-based OUD practices, medications, and treatment. It may not make us feel better about paying our taxes next month, but it’s definitely a positive trend.
Learn how: Cognitive Behavioral Therapy Works for OUD
“My name is Tom and I’m an addict. It started … Ok, not blaming grandma, but that’s where I first got Oxy. I had really bad stress headaches, so grandma she gave me a bottle of her pain pills. Said she didn’t like seeing me suffer. They worked, too. Got rid of my headaches, calmed me down. I actually loved them, especially good when drinking. But one time, grandma saw something on TV about pills and said she wasn’t going to give me any more. Then, I found out how easy Oxy is to buy at parties, from people at school, in my neighborhood, even at work. Me, I overdo everything and I just used too much. In the exact wrong place – at school. Or maybe the right place. They used that thing to revive me and that’s why I’m still alive. Dad made me go to treatment after that and it really wasn’t as bad as I thought. They weren’t a bunch of goodie-goods. The counselors are recovering addicts, and they have the stories! Examples of what would have happened to me if I kept using. So, I would say treatment really worked for me. I’m clean and sober.”
SPOTLIGHT – THE EVIDENCE IS IN:
The Recovery-Oriented Cascade of Care Model
Getting scientific progress out to the community through the science-to-practice pipeline is a persistent problem. Thankfully, we now have a model thanks to the HIV/AIDS field. It’s called the “Cascade of Care” framework.
Like HIV, opioid use disorder is a chronic, relapsing, often fatal disorder that typically requires long-term medication treatment to be effective. Like the achievement of HIV viral suppression, combating opioid overdose requires success along sequential stages — from screening and detection of OUD, to care linkage and medication initiation, through to long-term retention in treatment.
The Cascade of Care model was effectively used to address gaps in HIV care. It provides quality outcome measures at each stage along the cascade, targeting interventions to overcome barriers, and comparing the effectiveness of interventions across populations and settings.
To use the Cascade of Care model for OUD care, the treatment system must reorient itself to follow all patients who enter care for opioid use disorder, especially including those who discontinue medication treatment or stop appearing for appointments. Specific outcomes to track are:
- Diagnosis among those affected
- Linkage to care among those diagnosed
- Medication initiation among those entering care
- Retention for at least six months among those initiating medication
- Continuous abstinence among those retained
The Cascade of Care model for treatment programs can deploy peers to serve as a natural bridge to long-term use of community-based recovery services. The information obtained from Peer Navigators about individuals who “fall off” the cascade will be key for designing interventions and improving outcomes. Most importantly, this data can help us learn about critical barriers that currently undermine each stage of the Opioid Treatment Cascade. The same was initially true of barriers in the HIV/AIDS treatment field, yet substantial progress has been made under the cascade framework. For example, Motivational Interviewing and family engagement can improve success at each stage of the Cascade, especially long-term adherence to medication and retention in care.
Learn about: Barriers to OUD Treatment