Grading the Progress of National Initiatives on the Opioid Crisis

An update on the progress of national initiatives to address the opioid crisis.

by Mark S. Gold M.D. – Addiction Outlook
  • Key points:
  • In 2016, drug experts mapped out solutions to the opioid epidemic.
  • Several major initiatives subsequently were proposed and implemented.
  • Many changes have had profound influences, reducing the impact of opioid use and saving lives.

In their 2016 New England Journal of Medicine article on opioids, Nora Volkow, M.D., director of the National Institute on Drug Abuse (NIDA) and A. Thomas McLellan, Ph.D., who served as deputy director of the White House Office of National Drug Control Policy during the Obama administration, reported on what was needed to combat the opioid epidemic.

They focused initially on opioid prescribing for pain. Pain experts resisted restrictions on opioids since they were the treatment of choice and addiction was only 3% to 8% for chronic pain and lower for acute pain. Pain patients develop a physical dependence on opioids, but few become addicts.

Volkow and McLellan were prescient in their statements/predictions nearly a decade ago. They acknowledged the need for opioids for managing chronic pain for some but pointed to overprescriptions in the 1990s and 2000s as a major driver of the opioid crisis. They discussed naloxone (Narcan) saving lives by reversing opioid overdoses. They advocated expanding access to medication-assisted treatment (methadone, buprenorphine) to treat opioid addiction, calling it an evidence-based strategy for reducing illicit drug use and deaths. They noted state prescription drug monitoring programs (PDMPs) could be enhanced to track prescribing patterns and minimize diversion.

Volkow and McLellan called for research to develop effective non-opioid pain treatments and reduce reliance on opioids. They also addressed stigma associated with pain management and addiction treatment, urging the medical community and policymakers to view these issues through an evidence-based lens rather than a cloud of blame/moral failure. Most of all, they called for integrating scientific advances into policy and practice and improving training for providers of pain management and addiction treatment.

Here’s my “report card” on how we’re doing, based on the major recommendations from these experts in 2016.

Balancing Pain Management and Developing New Pain Treatment with Addiction Prevention. Grade: C+

Real progress was made in preventing opioid addiction and overdose deaths. However, many chronic pain patients report inadequate relief now due to stricter prescribing practices, sometimes resulting in untreated/undertreated pain. This is a problem without easy answers. Dr. Volkow has emphasized an urgent need for non-opioid-based medications bypassing the brain’s reward pathways, reducing abuse potential. NIH’s Helping to End Addiction Long-term (HEAL) Initiative researched non-opioid pain medications and therapies. There are promising candidates, such as cebranopadol, suzetrigine (FDA approved 1/30/25), LEVI-04, and others in the pipeline. However, progress remains slow, and chronic pain patients face limited options.

Curbing Overprescription/Misuse. Grade: A-

Opioid prescribing rates nearly halved, from 81.3 prescriptions per 100 people in 2012 to 43.3 in 2023. Medical, pharmacy, and health professional education reversed years of over-prescription. All states have PDMPs to track opioid prescriptions, reducing over-prescription and diversion. Some overcorrections in prescribing (or rather, not prescribing) opioids led to some patients seeking illicit drugs (heroin or fentanyl), contributing to the overdose crisis.

Expanding Opioid Pain Prescription Guidelines. Grade: A-

The CDC says opioid prescriptions in the United States peaked in 2012, with a rate of 81.3 prescriptions per 100 persons. By 2023, this rate nearly halved to 43.3 prescriptions per 100. This major reduction reflects efforts to address the opioid epidemic through updated prescribing guidelines and increased awareness of opioid risks. The CDC Guidelines for Prescribing Opioids for Chronic Pain (2016) recommended limiting opioid prescriptions for chronic pain outside active cancer treatment, palliative care, and end-of-life care, emphasizing using the lowest effective dose of opioids and restricting opioid prescriptions for acute pain to three to seven days. However, some health care providers remain hesitant to prescribe any opioids, ever.

The SUPPORT Act (2018) required electronic prescribing for controlled substances under Medicare and imposed new requirements for education and monitoring. Medicare Part D Opioid Policies (2019) implemented stricter safety edits at the pharmacy level for high-dose opioid prescriptions and introduced limits on opioid-naive pain patients, such as a maximum of seven days for acute pain.

Naloxone and Medication-Assisted Treatment (MAT). Grade: B+

Naloxone (Narcan) is widely available now, and over-the-counter sales were approved, as has the longer-acting antagonist nalmefene. However, fentanyl, the predominant opioid abused today, is very strong and challenging naloxone reversal protocols. Nalmefene may help.

Access to MAT (buprenorphine, methadone) improved. Patients with OUDs can start on buprenorphine without having to see a physician in person. On the downside, existing treatments are old, and the best outcomes are with the oldest OUD treatment, methadone. Methadone should be available for prescription by office and clinic-based physicians. Without detox and residential care options, patients with polysubstance, alcohol, meth, or cocaine use disorders and psychiatric dual disorders have been difficult to treat .

Stigma. Grade: B

NIDA has led national efforts to destigmatize substance use disorders (SUDs), especially OUDs. Expanding federal and state reimbursement for buprenorphine and methadone, and expanding the number of OUD prescribers, have succeeded somewhat. Classification of addiction as a disease, working with ASAM, and supporting destigmatizing language have helped. However, stigma persists, discouraging patients from seeking care.

Chronic pain patients still report feeling judged. AA, NA, and other mutual help groups are ubiquitous and destigmatizing. Yet, social network fellowships have been underutilized. One 2016 national survey revealed three-quarters of primary care physicians were unwilling to have a person with opioid use disorder marry into their family, and two-thirds viewed people with OUD as dangerous. It is not clear this has changed.

Science-Driven Policy. Grade: A-

Federal and state policies increasingly rely on evidence-based recommendations, such as funding research in non-opioid treatments. This is a huge accomplishment.

Developing totally new approaches has lagged, but innovation and invention can be like that sometimes. Broadly and equitably supporting MATs has helped people with OUD access evidence-based treatments. In the absence of a cure, we have made limited progress in developing and implementing effective non-opioid therapies. However, the doctors’ original focus on leveraging science to guide policy, improve treatments, and address root causes of the opioid epidemic was spot on, saving lives.

Policy Initiatives Impacted Opioid Prescribing and Pain Management Shifts. Grade: B-

Balancing effective pain management with risks of opioid use remains challenging. Patients with pain are treated with a combination of alternative strategies and therapies, with mixed outcomes. In states where it is legal, cannabis is increasingly used as an alternative treatment for chronic pain—even though evidence of its efficacy is mixed and cannabis use disorders may emerge. Complementary and alternative treatments like acupuncture, chiropractic care, massage therapy, and yoga are gaining popularity. Alternative therapies can’t provide the same level of relief as opioids. Those with complex or severe pain feel marginalized by policies restricting opioids. Non-pharmacological therapies like physical therapy, acupuncture, or CBT may be expensive, time-intensive, or uncovered by insurance. Many patients report inadequate relief, difficulty accessing specialized therapies, and frustration with the healthcare system.

New Hope in the Lab

Yale researchers identified alternative compounds with therapeutic potential chemicals extracted from the cannabis plant. A recent study showed that certain cannabinoids reduced the activity of a protein central to pain signaling in the peripheral nervous system. The protein, Nav1.8, enables repetitive firing of those neurons, a key process in transmitting pain signals. Blocking Nav1.8, and muting its activity, has shown promise in reducing pain in clinical studies. Cannabigerol in particular has the potential to provide effective pain relief without opioid risks.

Summary

In the opioid death crisis, the first phase was dominated by prescription pain medication abuse. Volkow and McLellan outlined changes necessary to reverse the epidemic. While tremendous progress has been made in this decade, more needs to be done as users first switched from pain medications to heroin, then fentanyl, adding xylazine, and now speedballing or polydrug use. The investment in prevention efforts, such as the DEA’s “One Pill Can Kill”, should be expanded.

Source: https://www.psychologytoday.com/us/blog/addiction-outlook/202501/opioid-crisis-grading-the-progress-of-national-initiatives

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