Dear John,

Today, we have a special edition of Health Affairs Today with an essay from our recent opioid crisis theme issue advisers, Brendan Saloner from Brown University and Pooja Lagisetty from the University of Michigan.

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The Opioid Crisis Theme Issue – A Call to Policy Action

A lot can change in a year.

When planning started on the Insights About the Opioid Crisis theme issue last summer, drug overdose deaths were just beginning to decrease from their height during the COVID pandemic when they topped 100,000 people annually.

Though it was not apparent at the time, we can now see in 2024 overdose deaths dropped below 80,000 – their largest single year decrease since the start of the opioid epidemic.

The decline was driven by many factors, but policy undoubtedly played a role.

Notably, the Biden Administration expanded federal strategy to address the crisis on many fronts, including the first mentions of harm reduction as part of the national drug control strategy and modest federal funding for syringe services programs. 

The first months of the Trump Administration, however, has brought about a reversal of many of these policies.

In the last few weeks alone, we have seen the administration release an executive order that increases pressure on cities and states to arrest more people for drug possession and public sleeping while also ending federal support for syringe services programs and Housing First programs.

The recent CDC Director firing further adds to growing turmoil across federal agencies that are at the heart of both monitoring the quickly evolving drug crisis and also guiding federal response to the overdose crisis.

Cutting federal resources and leadership at this critical moment risks squandering a major public health success.

This month’s theme issue of Health Affairs provides an incredibly timely research update on the policies, programs, and trends shaping the opioid crisis. We urge you to read it in full, but here are some of our takeaways.

Innovations in the Opioid Crisis Have Been Hard Won

There is a full toolbox of lifesaving interventions to reduce overdose and treat opioid addiction, and there are many innovative programs to deliver these services.

In our overview article, we argue despite their promise, these models often do not achieve the scale required to make a public health difference.

The theme issue offers some examples of programs and services that could make a big difference – if only they could be scaled up.

This includes:

• Problem-solving courts in Indiana
• Patient navigators in California emergency departments
• An innovative program to use telehealth buprenorphine prescribing in Maryland jails, and
• New models to deliver methadone to patients in nursing homes.

Medicaid Has Demonstrated Incredible Flexibility and Growth

Numerous articles in the special issue highlight the centrality of Medicaid as a source of reimbursement and a key lever for policy change.

In recent years, Medicaid expansion has been a major driver of increased use of buprenorphine and more recent provisions under the SUPPORT Act have been instrumental in increasing the overall number of patients treated with methadone.

Though Medicaid is often tarred as inferior to other sources of insurance, two studies in the theme issue demonstrate that it achieves demonstrably better quality outcomes than Medicare and private insurance for opioid use disorder care.

One reason may be greater accountability standards creating pressure on providers, such as requirements to offer medications along the continuum of care which led to more residential treatment programs offering medications.

Disparities Remain an Overwhelming Concern

Disparities remain a central problem to tackle in the opioid crisis.

The growing role of illicit fentanyl in the drug supply coincides with surging overdose deaths among Black Americans. Geographic sorting in areas hard-hit by fentanyl is a major factor explaining the relatively fast rise in overdose deaths among Black Americans.

We see striking data illustrating Black, Hispanic, and Asian populations fall far below white Americans in their awareness, access, and use of naloxone – one of the most critical lifesaving tools in the overdose crisis.

Overdose deaths also are rising very rapidly among adolescents, yet adolescents in treatment are not receiving medications at adequate levels, and programs that serve them are less likely to offer medications.

Research Matters

The collective wisdom of epidemiology, economics, sociology, medicine, and many other fields has helped build a robust foundation for studying the opioid crisis, and increasingly the field is growing to encompass the expertise of people with lived experience.

This research enterprise – and the articles in this theme issue – owe a great deal to federal research investments made over the last twenty years.

This includes major funding initiatives by the NIH and huge expansions of data collection by the CDC, SAMHSA, and the DEA. Without these data, we would be unable to advance evidence-based policy.

We are clear-eyed about the peril in the current moment, but we hope the theme issue not only educates but also uplifts by not only highlighting successful interventions, but also by demonstrating how research is needed to drive innovation.

We are very encouraged by the ingenuity of our colleagues and the inspiring stories of courage contained within. Special thanks to the funders and editors of Health Affairs for making this a reality.

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Brendan Saloner, Brown University

Pooja Lagisetty, the University of Michigan

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