Solving the unrelenting opioid crisis has become a pressing national priority. As evidence, the President’s Commission on Combating Drug Addiction and the Opioid Crisis recently urged President Trump to declare “a national emergency under either the Public Health Service Act or the Stafford Act.” Critical to future progress will be leveraging the full resources of the community—in partnership with health professionals—to prevent misuse, addiction, and death.
Evidence-Based Prevention of Addictive Behaviors
National experience demonstrates that prevention initiatives have contributed to past or ongoing reductions in cocaine use, underage drinking, and youth cigarette smoking. The exhaustive global report Prevention of Addictive Behaviours describes theories of addiction prevention, applies strength-of-evidence ratings to high-quality studies (including randomized trials, meta-analyses, and Cochrane reviews), and ranks universal and selective interventions (for average- or high-risk populations) for various settings and substances.
One oft-cited study, from Communities That Care (CTC), tailored evidence-based interventions to families and school-aged youth, including training to reduce risk factors, such as delinquency, and boost protective factors, such as decision-making skills for problem solving and resisting peer pressure. Involving more than 4000 youth (in grade 5 at the beginning of the study) in 7 states, this study matched 12 pairs of small towns, randomly assigning one from each pair to the intervention. By grade 12, those in intervention towns were 18% more likely to avoid delinquent behavior and 31% more likely to abstain from gateway drug use (alcohol, cigarettes, or marijuana) than their counterparts in matched control towns.
Such studies not only provide the foundation for addiction prevention recommendations by the White House Office of National Drug Control Policy National Drug Control Strategy (2016), the Office of the Surgeon General, and the National Institute on Drug Abuse but also inform the ongoing work of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, established in March 2017. Meanwhile, organizations are encouraging prevention strategies in communities nationwide. The Center for Substance Abuse Prevention of the Substance Abuse and Mental Health Services Administration (SAMHSA) supports implementing effective prevention practices, focusing on their fidelity and sustainability. The Community Anti-Drug Coalitions of America (CADCA) promotes drug-free communities via youth education and training.a The National Association of State Alcohol and Substance Abuse Directors fosters prevention and treatment through every state. Yet, to date, such prevention practices have currently reached only about 10% of youth.
Prevention of Addictive Behaviors: Opioids
Identifying evidence-based preventive measures for opioids remains a work-in-progress that will require more documentation of how prevention strategies can best ameliorate the current crisis. For example, although the Iowa Strengthening Families Program showed that brief universal interventions in adolescents implemented by community-university partners reduced self-reported prescription opioid misuse and lifetime prescription drug misuse overall, generalizability of these results awaits replication in additional populations.
Developing stronger prevention measures also requires recognizing specific challenges of opioids. The 33 000 opioid-related deaths in 2015 arose from misuse of illegal drugs (including heroin or illicitly manufactured synthetic opioids such as fentanyl), legal prescription drugs, or multiple additional substances. The average age of initiation was about 25 years, and median age of overdose death ranged from 35 years to 44 years. Of those misusing heroin, 75% to 83% reported starting with a prescription drug. Of those misusing prescription opioid painkillers, 41% to 57% obtained them from friends or relatives. In 2015, 91.8 million (37.8%) US adults reported using prescription opioids, 11.5 million (4.7%) misused them, and 1.9 million (0.8%) had use disorders. Misuse and use disorders were most common among those who were uninsured or unemployed, were low-income individuals, or had behavioral health problems.
These data highlight the urgent need to address addiction broadly—and opioids in particular—and to reduce access to both illegal and legal drugs. Prevention can encompass a continuum of activities. This ranges from educational efforts that frame the crisis as a medical issue (as opposed to solely a criminal justice issue) to multifaceted policies and practices that can complement treatment. Across the country, multisector coalitions (including, for example, patients, families, educators, health leaders, law enforcement officials, and policy makers) are tailoring opioid-specific interventions to their own communities. Online toolkits from CADCA and from SAMHSA document case studies of some of these efforts in areas hardest hit by the crisis.
Current community-level interventions can include public education, clinician-patient partnerships, and community-based medication disposal programs.
Public Education. Major national momentum to teach lay bystanders to reverse overdoses with naloxone has now reached 50 states and the District of Columbia, aided in 40 by Good Samaritan laws providing liability protections. A systematic review of 19 studies showed increased knowledge and administration rates, as well as some early evidence of decreased deaths in Massachusetts and in North Carolina. Such education can also raise public understanding of harm reduction through syringe service programs and catalyze collaborations with criminal justice officials committed to expanding their role beyond traditional law enforcement.
Other efforts include the New York State health education curriculum, which now requires information about opioids as part of an overall prevention strategy. Heightened community-wide dialogue emphasizing use of nonstigmatizing language could change societal perceptions about people with addiction and lend support to the estimated 25 million in recovery nationally.
Clinician-Patient Partnerships. Before starting opioids for medical reasons, patients are increasingly asked to partner with clinicians to disclose risk factors (such as a family history of substance use disorders) and reach explicit understanding, sometimes contractual, about goals and expectations. Despite recent declines, per capita opioid prescriptions remain high, having tripled between 1999 and 2015.
Community-Based Medication Disposal Programs. Collection sites and “drop boxes” for unused prescription opioids have arisen in sites including hospitals, fire departments, and pharmacies. For example, Walgreens’ safe medication disposal kiosks populate over 500 stores across 43 states, and the Drug Enforcement Agency’s National Prescription Drug Take-Back Days involve over 5000 collection sites. Further evaluation awaits.
Prevention always constitutes a hard sell: it lacks the glamor of treatment, can entail years of implementation, and when successful, is usually invisible. The first major federal addiction legislation in 40 years, the 2016 Comprehensive Addiction and Recovery Act, authorized education campaigns but did not appropriate funds for them. Furthermore, although the 2016 21st Century Cures Act authorized nearly a billion dollars to state and territories and noted universal prevention strategies as a priority, to date they have been underemphasized and largely overlooked.
Considerable efforts notwithstanding, the national burden of opioid-related suffering remains unacceptable. Accelerating action in research, evaluation, and practice of effective community-based prevention could bring a measure of relief for a nation in need.
a The author serves on the Board of Directors of CADCA
About the author: Howard K. Koh, MD, MPH, is the Harvey V. Fineberg professor of the practice of public health leadership at the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School. He is also the former Massachusetts commissioner of public health and the 14th assistant secretary for health for the US Department of Health and Human Services. A quadruple-boarded physician, Dr Koh has published more than 250 articles in the medical and public health literature, earned more than 70 awards for interdisciplinary achievements in public health, and has received 5 honorary doctorate degrees. (Image: Harvard T.H. Chan School of Public Health)
About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.