Nation’s Response to the Substance Use Crisis

Introduction

Recently, I visited Western North Carolina to under­stand how Burke County, a community of 88,338 peo­ple, was responding to the opioid crisis. What I saw gave me hope for our country’s effort to save lives and beat this crisis.

My optimism comes at a time when it is predicted our country lost more than 105,372 people to overdoses in the past year, including 3,844 people in North Carolina.¹

During my training as a physician, I never imagined that our nation would be faced with decades of such an epidemic. As a primary care physician routinely working shifts in the emergency department, I often revived several overdose vic­tims each shift. Later, serving as a local health department director and then as West Virginia’s state health commis­sioner, it was heartbreaking each time I attended funerals for the people I knew who died from an overdose. I know how hard it can be for people to access the addiction ser­vices they need to live healthy and fulfilling lives. I also know just how difficult it is for communities and states to deliver these services.

The Opioid Crisis

President Biden has made beating the opioid crisis a key pillar of his Unity Agenda for the nation, aimed at solving big problems all states face, regardless of income, race or ethnic­ity, or geography. The White House Office of National Drug Control Policy (ONDCP) leads and coordinates the nation’s drug policy so that it improves the health and lives of the American people. ONDCP is responsible for the develop­ment and implementation of the President’s National Drug Control Strategy (NDCS) across 19 federal agencies and oversees the $44 billion budget to effectively address addic­tion and the overdose epidemic.² The NDCS addresses the two key drivers of this unprecedented crisis: untreated addiction and the drug trafficking profits that fuel it.

In the past decade, synthetic opioids like fentanyl have changed the landscape of drug trafficking as the world races to keep up with new and evolving substances that are more lethal than ever, more profitable, and easier to traffic in small quantities. Death quite literally can now arrive in your mailbox in the form of a counterfeit pill labeled as Xanax, Adderall, or others.

In 2022, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that 4% of US adults suffering from addiction needed treatment for opioid use disorder (OUD); 42.7% of these people did not think they needed treatment, and only a quarter received it.³ Of those who did receive some treatment, a full 30% did not receive medications for opioid use disorder (MOUD), which is the gold standard and greatly improves outcomes for patients with OUD.⁴

To turn this epidemic around, the President’s NDCS and historic investments across communities recognized the need to prioritize saving lives, including by supporting harm reduction actions like overdose reversal medication distri­bution, drug-checking test strips, and syringe-services pro­grams.² NDCS also emphasizes case-finding to identify more people with substance use disorder (SUD), thereby cascading more people into evidence-based treatment, and finally, supporting people in recovery, including by making more workplaces “recovery ready”.² These innovations can help save lives and effect lasting change by moving tens of millions of Americans with SUD into long-term recovery.

Prioritizing Saving Lives

Making opioid overdose reversal medications available everywhere people need them is central to keeping people alive until they can enter treatment. Our new White House Challenge to Save Lives from Overdose is calling on commu­nities and businesses, large and small, public and private to help make sure everyone who needs naloxone has it.⁵ We estimate doing this will help our country save around 27,000 lives per year.⁵

Additionally, we have taken unprecedented actions to expand access to treatment, including changing regulations to reduce bureaucratic barriers and allow more DEA-registered prescribers to treat patients using buprenorphine for OUD and making it easier for patients to begin treatment using telehealth by removing the X-waiver, which previously required prescribers to obtain an additional DEA registra­tion to prescribe buprenorphine.^6,7 This has expanded the workforce in opioid addiction treatment from approxi­mately “129,000 to 1.8 million” clinicians.^8,9 Methadone, another MOUD, is now more accessible to patients through telemedicine, mobile services, and take-home doses.¹⁰ The Administration has also made opioid overdose rever­sal medications such as naloxone more accessible by mak­ing them available over the counter at lower cost, and has helped more states, including North Carolina, purchase such medications for distribution in the community in order to reduce cost barriers. Just last year, SAMHSA awarded over $100 million to North Carolina through various federal grants.¹¹

Overdose reversal medications and treatment are also a priority in criminal justice settings, where as many as two-thirds of incarcerated persons have substance use disorder.¹² A scoping review of the literature estimated people reentering society were at 27 times greater risk of drug-related mortality during the first two weeks after release from incarceration.¹³ If all US jails and prisons provided MOUD and linkage to care upon release to those in need, we estimate that between 13,060 and 17,703 opioid overdose deaths may be prevented among people released from jails/ prisons in a given calendar year (ONDCP Unpublished Data based on National Vital Statistics System – Mortality Data [2022] via CDC WONDER). That policy effort could mean more than 13,000 people returning to their communities, entering recovery, rejoining the workforce, supporting fami­lies, and strengthening their communities. To address reen­try, the Federal government has allowed states to apply for Medicaid 1115 Reentry Demonstrations to allow Medicaid reimbursement for residential treatment, including in jails and prisons.^14,15 North Carolina has submitted an appli­cation, and if granted, the state will join 10 other states in being able to treat people in custody with opioid use dis­order up to 90 days before reentry to help them transition back into the community.

Recently, SAMHSA and the DEA clarified in rulemaking that carceral settings registered as a hospital or clinic with the DEA may offer methadone for opioid use disorder with­out becoming a certified opioid treatment program.¹⁰ This step will allow many people reentering society to actively contribute to their community as employees and taxpayers. At least one report has shown when MOUD is provided in a correctional facility and linkage is offered following reentry, fewer people die.¹⁶ Although there is scant research on employment outcomes for people who receive care during reentry, untreated addiction has myriad economic costs to society including lost productivity and costs associated with hospitalizations from OUD.¹⁶ Offering addiction treat­ment for reentry can also provide more healthy workers to help grow a local workforce.

Federal actions are only one part of the equation, though. State and local actions are critical for saving lives.

North Carolina: Leading by Example

President Biden has said time and time again that we are the United States of America and there is nothing we can­not do if we do it together. North Carolina exemplifies how one state can lead the nation out of this crisis by coming together.

For example, North Carolina secured $1.5 billion in opi­oid settlement funds, and 85% of these funds have been dedicated to local and county governments.¹⁷ The part­nership of so many officials and educators—spanning the Attorney General’s Office and the Department of Justice, the Department of Health and Human Services, the North Carolina Association of County Commissioners and the North Carolina League of Municipalities, the University of North Carolina’s Injury Prevention Center and UNC School of Public Health, and more—working together with urgency to save lives is commendable.

On my recent trip, I learned that North Carolina has not only expanded Medicaid, but also reimburses clinicians for SUD assessment at 120% of the Medicare rate using the Medicaid bonus payment to support the increase.¹⁸ This gives providers an incentive to accept Medicaid and assess Medicaid-insured patients with SUD, some of our most vul­nerable residents. To the extent North Carolina places these individuals in treatment with highly efficacious medica­tions for opioid use disorder, their chances of recovering will improve dramatically.

Making Progress

By the end of 2020, drug overdose deaths were increas­ing by as much as 30% per year. Beginning in 2021, the Biden-Harris Administration has invested $83 billion in expanding treatment across America. In 2022, the nation experienced a flattening in the overdose death curve; and by the end of 2023 we observed the first reduction in overdose deaths in five years.¹⁹ North Carolina’s investments in naloxone and treatment appear to be starting to pay off. In the 2017–2018 reporting year, the state distributed around 19,000 naloxone kits and reported 2,700 overdose rever­sals.²⁰ In the 2022–2023 reporting year, North Carolina distributed 109,400 kits and reported 16,700 overdose reversals.²⁰ Even prior to Medicaid expansion, managed care organizations had increased the number of people who received mental health and substance use disorder treat­ment services between 2018 and 2021 by 22.6%.²¹ The actions North Carolina and other states are taking to expand harm reduction and treatment services make the difference between life and death for many people.

However, more must be done. At the state level, North Carolina is well positioned to consider taking the following actions to help end the opioid crisis and further its role as a national leader:

1. North Carolina can work to expand a stronger treat­ment infrastructure, including in rural communities and in carceral settings.

By using funds from the Federal Health Resources and Services Administration (HRSA) to expand behavioral health care settings, the state can add more Certified Community Behavioral Health Clinics where they’re needed most. The state can embrace and expand telehealth treatment initia­tion and ensure more people can access OUD treatment and maximize the federal funding draw-down to bulk purchase and distribute naloxone and improve access to treatment in communities.

2. North Carolina can strengthen its businesses and sup­port people in recovery entering the workforce—and break the stigma against addiction in the process.

People in recovery are among the most dedicated and hardest-working team members, and I know this because we have several people in recovery on the White House staff. Business leaders can use our toolkit to become recovery-ready businesses, which will help their bottom lines and also strengthen their communities.²² By improving educa­tional and other programs addressing stigma against people with addiction, North Carolina can make sure people who want help are not afraid to ask for it and make it easier for people and their communities to heal from this crisis.

3. North Carolina can make sure that every penny of its settlement dollars goes to support the needs of the people and communities affected by this crisis.

Making sure people have access to naloxone is critical. Additionally, these dollars can be utilized to help expand the treatment and harm reduction infrastructure to make sure people affected by this crisis get the help they need—day or night, residential or outpatient. A model opioid litigation process act developed by the Legislative Analysis and Public Policy Association provides ideas to consider when develop­ing spending plans.²³

I applaud communities like Burke County for working to make effective use of these funds, including adding hospi­tal emergency room resources with better behavioral health accommodations.

Looking to the Future

With the recent decrease in overdose numbers, we are on the right track. However, more must be done, and American lives and America’s prosperity depend on it. If we expand treatment and harm reduction even more and support peo­ple in recovery, overdoses will go down, lives will be saved, and our families, communities, and country will be stronger than ever.

What I saw in North Carolina gives me hope that we’re moving in the right direction and that our goal is within reach. Working smartly, we can utilize and resource the best evidence-based practices. Working together, I know we can beat this crisis.

Disclosure of interests

The author serves in the White House Office of National Drug Control Policy. The statements in this article are the sole responsibility of the author and are published here for informa­tional purposes only.