The opioid epidemic has resulted in significant morbidity and mortality in the U.S.
Health systems, policymakers, payers, and public health have enacted numerous strategies
to reduce the harms of opioids, including opioid use disorder (OUD). Much of this
implementation has occurred before the development of OUD‒related comparative effectiveness
evidence, which would enable an understanding of the benefits and harms of different
approaches. This article from the American College of Preventive Medicine (ACPM) uses
a prevention framework to identify the current approaches and make recommendations
for addressing the opioid epidemic, encompassing strategies across a primordial, primary,
secondary, and tertiary prevention approach.
Key primordial prevention strategies include addressing social determinants of health
and reducing adverse childhood events. Key primary prevention strategies include supporting
the implementation of evidence-based prescribing guidelines, expanding school-based
prevention programs, and improving access to behavioral health supports. Key secondary
prevention strategies include expanding access to evidence-based medications for opioid
use disorder, especially for high-risk populations, including pregnant women, hospitalized
patients, and people transitioning out of carceral settings. Key tertiary prevention
strategies include the expansion of harm reduction services, including expanding naloxone
availability and syringe exchange programs.
The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in
which historical and current practices may be ineffective or causing harm. De-implementation
strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all
policies; eliminating barriers to medications for OUD, debunking the myth of detoxification
as a primary solo treatment for opioid use disorder; and destigmatizing care practices
and policies to better treat people with OUD.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Preventive MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
United Nations Office On Drugs & Crime. World drug report 2021. CrimRxiv. Published online June 24, 2021. https://doi.org/10.21428/cb6ab371.e39c4e60.
Centers for Disease Control and Prevention. 2019 Annual surveillance report of drug-related risks and outcomes - United States surveillance special report. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdf/pubs/2019-cdc-drug-surveillance-report.pdf. Published November 1, 2019. Accessed May 28, 2022.
- National U.S. time-trends in opioid use disorder hospitalizations and associated healthcare utilization and mortality.PLoS One. 2020; 15e0229174https://doi.org/10.1371/journal.pone.0229174
- Opioid-related deaths in Europe: strategies for a comprehensive approach to address a major public health concern.Int J Drug Policy. 2020; 76102616https://doi.org/10.1016/j.drugpo.2019.102616
- Understanding the epidemic: CDC’s response to the opioid overdose epidemic.Centers for Disease Control and Prevention, 2021 (Updated March 17. Accessed May 28, 2022)
- Opioid treatments for chronic pain.Agency for Healthcare Research and Quality, Rockville, MD2020https://doi.org/10.23970/AHRQEPCCER229 (. Published Mar 17)
- Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial.JAMA. 2018; 319: 872-882https://doi.org/10.1001/jama.2018.0899
- Consumption of prescription opioids for pain: a comparison of opioid use in the United States and other countries.Congressional Research Service, Washington, DC2021 (Published June 2. Accessed May 28, 2022)
- Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.Proc Natl Acad Sci U S A. 2015; 112: 15078-15083https://doi.org/10.1073/pnas.1518393112
- Drug companies’ liability for the opioid epidemic.N Engl J Med. 2017; 377: 2301-2305https://doi.org/10.1056/NEJMp1710756
- How FDA failures contributed to the opioid crisis.AMA J Ethics. 2020; 22: E743-E750https://doi.org/10.1001/amajethics.2020.743
- Increase in fatal drug overdoses across the United States driven by synthetic opioids before and during the COVID-19 pandemic.Centers for Disease Control and Prevention, Atlanta, GA2020 (Published December 17Accessed May 28, 2022)
- State-level and system-level opioid prescribing policies: the impact on provider practices and overdose deaths, a systematic review.J Opioid Manag. 2016; 12: 109-118https://doi.org/10.5055/jom.2016.0322
- Evidence for state, community and systems-level prevention strategies to address the opioid crisis.Drug Alcohol Depend. 2019; 204107563https://doi.org/10.1016/j.drugalcdep.2019.107563
- Prevention strategies.StatPearls. Pearls Publishing, Treasure Island, FL2022 (Accessed May 28, 2022)
- The opioid crisis and economic opportunity: geographic and economic trends.ASPE Research Brief, HHS, Washington, DCSeptember 11, 2018 (Published September 11, 2018. Accessed May 28, 2022)
- Socioeconomic risk factors for fatal opioid overdoses in the United States: findings from the Mortality Disparities in American Communities Study (MDAC).PLoS One. 2020; 15e0227966https://doi.org/10.1371/journal.pone.0227966
- Social vulnerabilities for substance use: stressors, socially toxic environments, and discrimination and racism.Neuropharmacology. 2021; 188108518https://doi.org/10.1016/j.neuropharm.2021.108518
- Food insecurity, chronic pain, and use of prescription opioids.SSM Popul Health. 2021; 14100768https://doi.org/10.1016/j.ssmph.2021.100768
- The role of physicians in addressing social determinants of health.JAMA. 2020; 323: 1551-1552https://doi.org/10.1001/jama.2020.1637
- The social determinants of death.HealthAffairs, Bethesda, MD2020 (Published June 3. Accessed May 28, 2022)
- Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.Am J Prev Med. 1998; 14: 245-258https://doi.org/10.1016/s0749-3797(98)00017-8
- Preventing adverse childhood experiences (ACEs): leveraging the best available evidence.National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA2019 (Accessed May 28, 2022)
John McConnell K, Kaufman MR, Grunditz JI, et al. Project nurture integrates care and services to improve outcomes for opioid-dependent mothers and their children. Health Aff (Millwood). 2020;39(4):595–602. https://doi.org/10.1377/hlthaff.2019.01574.
- Association of opioids prescribed to family members with opioid overdose among adolescents and young adults.JAMA Netw Open. 2020; 3e201018https://doi.org/10.1001/jamanetworkopen.2020.1018
- Evidence-based interventions for adolescent opioid use disorder what might work for high-risk Ohio counties?.Urban Institute, Washington, DC2018 (Published September. Accessed May 28, 2022)
- PROSPER delivery of universal preventive interventions with young adolescents: long-term effects on emerging adult substance misuse and associated risk behaviors.Psychol Med. 2017; 47: 2246-2259https://doi.org/10.1017/S0033291717000691
- Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review.JAMA Netw Open. 2019; 2e193365https://doi.org/10.1001/jamanetworkopen.2019.3365
- How people obtain the prescription pain relievers they misuse.Substance Abuse and Mental Health Services Administration, Rockville, MD2017 (Published January 12. Accessed May 28, 2022)
- CDC guideline for prescribing opioids for chronic pain - United States, 2016 [published correction appears in MMWR Recomm Rep. 2016;65(11):295].MMWR Recomm Rep. 2016; 65: 1-49https://doi.org/10.15585/mmwr.rr6501e1
- Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: a national systematic legal review.Drug Alcohol Depend. 2019; 194: 166-172https://doi.org/10.1016/j.drugalcdep.2018.09.022
- Safe practice recommendations for safer opioid prescribing: measures and clinical decision support.Partnerships for Health IT patient Safety, Agency for Healthcare Research and Quality, Rockville, MD2019 (Accessed May 28, 2022)
A comprehensive public health framework to address the opioid crisis. ASTHO. https://my.astho.org/opioids/home. Accessed May 28, 2022.
- Healthcare payer strategies to reduce the harms of opioids.Centers for Medicare & Medicaid Services, Baltimore, MD2017 (Published January. Accessed May 28, 2022)
- No shortcuts to safer opioid prescribing.N Engl J Med. 2019; 380: 2285-2287https://doi.org/10.1056/NEJMp1904190
- Indication-specific opioid prescribing for U.S. patients with Medicaid or private insurance, 2017.JAMA Netw Open. 2020; 3e204514https://doi.org/10.1001/jamanetworkopen.2020.4514
- Opioid prescribing by primary care providers: a cross-sectional analysis of nurse practitioner, physician assistant, and physician prescribing patterns.J Gen Intern Med. 2020; 35: 2584-2592https://doi.org/10.1007/s11606-020-05823-0
- Differences in opioid prescribing among generalist physicians, nurse practitioners, and physician assistants.Pain Med. 2020; 21: 76-83https://doi.org/10.1093/pm/pnz005
- Comparison of opioid prescribing by dentists in the United States and England.JAMA Netw Open. 2019; 2e194303https://doi.org/10.1001/jamanetworkopen.2019.4303
- Strategies to prevent opioid misuse, abuse, and diversion that may also reduce the associated costs.Am Health Drug Benefits. 2011; 4: 107-114
- Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized clinical trial.JAMA Intern Med. 2017; 177: 1265-1272https://doi.org/10.1001/jamainternmed.2017.2468
- Clinical decision support systems for the practice of evidence-based medicine.J Am Med Inform Assoc. 2001; 8: 527-534https://doi.org/10.1136/jamia.2001.0080527
- The effectiveness of prescription drug monitoring programs at reducing opioid-related harms and consequences: a systematic review.BMC Health Serv Res. 2019; 19: 784https://doi.org/10.1186/s12913-019-4642-8
- Systematic literature review of prescription drug monitoring programs.AMIA Annu Symp Proc. 2018; 2018 (Accessed May 28, 2022): 1478-1487
- Do more robust prescription drug monitoring programs reduce prescription opioid overdose?.Addiction. 2017; 112: 1773-1783https://doi.org/10.1111/add.13741
- Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates.Health Aff (Millwood). 2016; 35: 1324-1332https://doi.org/10.1377/hlthaff.2015.1496
- Interventions for postsurgical opioid prescribing: a systematic review.JAMA Surg. 2018; 153: 948-954https://doi.org/10.1001/jamasurg.2018.2730
- No refills: the durable impact of a multifaceted effort by surgical trainees to minimize the prescription of postoperative opioids.Surgery. 2019; 166: 758-763https://doi.org/10.1016/j.surg.2019.05.021
- Pain Management and the Opioid Epidemic.National Academies Press, 2017https://doi.org/10.17226/24781
- Tapering long-term opioid therapy in chronic noncancer pain: evidence and recommendations for everyday practice.Mayo Clin Proc. 2015; 90: 828-842https://doi.org/10.1016/j.mayocp.2015.04.003
- Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review.Ann Intern Med. 2017; 167: 181-191https://doi.org/10.7326/M17-0598
- Best practices, research gaps, and future priorities to support tapering patients on long-term opioid therapy for chronic non-cancer pain in outpatient settings.NAM Perspect. 2020; (2020:10.31478/202008c)https://doi.org/10.31478/202008c
- The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop.The National Academies Press, Washington, DC2019https://doi.org/10.17226/25406
- Alternatives to opioids for pain management in the emergency department decreases opioid usage and maintains patient satisfaction.Am J Emerg Med. 2019; 37: 38-44https://doi.org/10.1016/j.ajem.2018.04.043
- Noninvasive nonpharmacological treatment for chronic pain: a systematic review update.Agency for Healthcare Research and Quality, Rockville, MD2020 (Published April. Accessed May 28, 2022)
- Screening for unhealthy drug use: U.S. Preventive Services Task Force recommendation statement.JAMA. 2020; 323: 2301-2309https://doi.org/10.1001/jama.2020.8020
- Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependence: a systematic review and meta-analysis [published correction appears in JAMA Psychiatry. 2021;78(9):1044] [published correction appears in JAMA Psychiatry. 2022;79(5):516].JAMA Psychiatry. 2021; 78: 979-993https://doi.org/10.1001/jamapsychiatry.2021.0976
- Medications for Opioid Use Disorder Save Lives.The National Academies Press, Washington, DC2019https://doi.org/10.17226/25310
- Comparative effectiveness of different treatment pathways for opioid use disorder.JAMA Netw Open. 2020; 3e1920622https://doi.org/10.1001/jamanetworkopen.2019.20622
- Acceptability and efficacy of naltrexone for criminal justice-involved individuals with opioid use disorder: a systematic review and meta-analysis.Addiction. 2020; 115: 1413-1425https://doi.org/10.1111/add.14946
- Detoxification and substance abuse treatment. treatment improvement protocol (TIP) series, no. 45.Substance Abuse and Mental Health Services Administration, Rockville, MD2015 (https://store.samhsa.gov/product/TIP-45-Detoxification-and-Substance-Abuse-Treatment/SMA15-4131. Published October. Accessed May 28, 2022)
- National and state treatment need and capacity for opioid agonist medication-assisted treatment.Am J Public Health. 2015; 105: e55-e63https://doi.org/10.2105/AJPH.2015.302664
- Improving access to evidence-based medical treatment for opioid use disorder: strategies to address key barriers within the treatment system.NAM Perspect. 2020; (2020:10.31478/202004b)https://doi.org/10.31478/202004b
- Characteristics of U.S. counties with high opioid overdose mortality and low capacity to deliver medications for opioid use disorder.JAMA Netw Open. 2019; 2e196373https://doi.org/10.1001/jamanetworkopen.2019.6373
- Telemedicine-delivered treatment interventions for substance use disorders: a systematic review.J Subst Abuse Treat. 2019; 101: 38-49https://doi.org/10.1016/j.jsat.2019.03.007
- Changes in access to medication treatment during COVID-19 telehealth expansion and disparities in telehealth use for Medicare beneficiaries with opioid use disorder.Centers for Medicare & Medicaid Services, Baltimore, MDJanuary 2022 (Published January. Accessed May 28, 2022)
- Methadone in primary care - one small step for Congress, one giant leap for addiction treatment.N Engl J Med. 2018; 379: 7-8https://doi.org/10.1056/NEJMp1803982
- Managing opioid use disorder in primary care: PEER simplified guideline [published correction appears in Can Fam Physician. 2019;65(10):687] [published correction appears in Can Fam Physician. 2019;65(10):687].Can Fam Physician. 2019; 65 (Accessed May 28, 2022): 321-330
- Why buprenorphine is so successful in treating opiate addiction in France.Curr Psychiatry Rep. 2007; 9: 358-364https://doi.org/10.1007/s11920-007-0046-2
- Rapid adoption of low-threshold buprenorphine treatment at California emergency departments participating in the CA Bridge Program.Ann Emerg Med. 2021; 78: 759-772https://doi.org/10.1016/j.annemergmed.2021.05.024
- Implementation and evaluation of Missouri's Medication First treatment approach for opioid use disorder in publicly- funded substance use treatment programs.J Subst Abuse Treat. 2020; 108: 55-64https://doi.org/10.1016/j.jsat.2019.06.015
- Differences in availability and use of medications for opioid use disorder in residential treatment settings in the United States.JAMA Netw Open. 2020; 3e1920843https://doi.org/10.1001/jamanetworkopen.2019.20843
Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. Medication treatment for opioid use disorders in substance use treatment facilities. Health Aff (Millwood). 2019;38(1):14–23. https://doi.org/10.1377/hlthaff.2018.05162.
- Association between Medicaid expansion and rates of opioid-related hospital use.JAMA Intern Med. 2020; 180: 753-759https://doi.org/10.1001/jamainternmed.2020.0473
- Coverage of medications that treat opioid use disorder and opioids for pain management in marketplace plans, 2017.Med Care. 2018; 56: 505-509https://doi.org/10.1097/MLR.0000000000000918
Foundation. Opioid safety toolkit. California Health Care. https://www.chcf.org/resource/opioid-safety-toolkit/. Accessed May 28, 2022.
Opioid agonist therapy gap coverage program. Government of Alberta Canada. https://www.alberta.ca/opioid-agonist-therapy-gap-coverage-program.aspx#jumplinks-4. Updated December 1, 2021. Accessed May 28, 2022.
- Buprenorphine coverage in the Medicare Part D program for 2007 to 2018.JAMA. 2019; 321: 607-609https://doi.org/10.1001/jama.2018.20391
National Council for Behavioral Health, Vital Strategies. Medication-assisted treatment for opioid use disorder in jails and prisons: a planning & implementation toolkit. https://www.thenationalcouncil.org/wp-content/uploads/2022/02/MAT_in_Jails_Prisons_Toolkit_Final_12_Feb_20.pdf. Accessed May 28, 2022.
- Interventions for incarcerated adults with opioid use disorder in the United States: a systematic review with a focus on social determinants of health.PLoS One. 2020; 15e0227968https://doi.org/10.1371/journal.pone.0227968
- Does exposure to opioid substitution treatment at prison release reduce the risk of death? A prospective, observational study in England.Lancet. 2016; 388: 11https://doi.org/10.1016/S0140-6736(16)32247-4
- Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system.JAMA Psychiatry. 2018; 75: 405-407https://doi.org/10.1001/jamapsychiatry.2017.4614
- Public policy statement on treatment of opioid use disorder in correctional settings.American Society of Addiction Medicine, Chevy Chase, MD2020 (Published July 15. Accessed May 28, 2022)
- Public policy statement on access to medications for addiction treatment for persons under community correctional control.American Society of Addiction Medicine, Chevy Chase, MD2021 (Published January 20. Accessed May 28, 2022)
- Medication-assisted treatment for opioid use disorder in jails and prisons: a planning and implementation toolkit.National Council for Behavioral Health and Vital Strategies, Washington, DC2020 (Published January. Accessed May 28, 2022)
- The Substance Use Intervention Team: a preliminary analysis of a population-level strategy to address the opioid crisis at an academic health center.J Addict Med. 2019; 13: 460-463https://doi.org/10.1097/ADM.0000000000000520
- Effects of Housing First approaches on health and well-being of adults who are homeless or at risk of homelessness: systematic review and meta-analysis of randomised controlled trials.J Epidemiol Community Health. 2019; 73: 379-387https://doi.org/10.1136/jech-2018-210981
- Effectiveness of needle and syringe programmes in people who inject drugs - an overview of systematic reviews.BMC Public Health. 2017; 17: 309https://doi.org/10.1186/s12889-017-4210-2
- Supervised injection facilities and other supervised consumption sites: effectiveness and value final report.Institute for Clinical and Economic Review, Boston, MA2021 (Published January 8. Accessed May 28, 2022)
- Expanding access to naloxone: a review of distribution strategies.Penn LDI, Philadelphia, PA2019 (Published May 29. Accessed May 28, 2022)
- Evidence-based strategies for preventing opioid overdose: what’s working in the United States an introduction for public health, law enforcement, local organizations, and others striving to serve their community.Centers for Disease Control and Prevention, Atlanta, GA2018 (Accessed May 28, 2022)
- Intranasal naloxone administration by police first responders is associated with decreased opioid overdose deaths.Am J Emerg Med. 2015; 33: 1201-1204https://doi.org/10.1016/j.ajem.2015.05.022
- Opioid overdose prevention programs providing naloxone to laypersons - United States, 2014.MMWR Morb Mortal Wkly Rep. 2015; 64: 631-635
Opioid epidemic toolkit 2021. National Association of County and City Health Officials. https://www.naccho.org/programs/community-health/injury-and-violence/opioid-epidemic/local-health-departments-and-the-opioid-epidemic-a-toolkit. Accessed May 28, 2022.
Overdose Detection Mapping Application Program. http://www.odmap.org/#agency. Accessed October 9, 2021.
- American College of Preventive Medicine statement on prioritizing prevention in opioid research.AMA J Ethics. 2020; 22: E687-E694https://doi.org/10.1001/amajethics.2020.687
Hodge JG Jr, Gostin LO. Guiding industry settlements of opioid litigation. Am J Drug Alcohol Abuse. 2019;45(5):432–437. https://doi.org/10.1080/00952990.2019.1618320.
Article Info
Publication History
Published online: June 21, 2022
Identification
Copyright
© 2022 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.
