This post was originally published in WestEd’s Justice and Prevention Research Center newsletter.

The word crisis is often overused. However, when it comes to opioids, crisis is insufficient to describe the death and destruction they have caused throughout the United States. Data indicate that approximately 115 people die every day nationally from opioid overdose, totaling more than 400,000 deaths over the past 20 years. And it is estimated that more than 2 million people are currently living with an opioid-related substance use disorder. What can we do about this?

Jennifer Loeffler-CobiaWe turned to our resident expert, Jennifer Loeffler-Cobia, to understand more about the current opioid crisis and what we can do about it. Jennifer is the JPRC’s Director of Justice and Public Health Policy and Practice. She currently leads a project working with the Idaho Office of Drug Policy to better understand its prevention efforts (see JPRC’s April 2023 newsletter). She is also Adjunct Associate Professor at the University of Southern California’s Bovard College. Jennifer is author of the Opioid Response Planning Checklist and Evidence-Based Skills Assessment for Criminal Justice Organizations.

What are opioids? What is their history in this country?

Opioids are a class of drugs that include the illegal drugs such as heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone or morphine. The opium drug has been used to treat pain for centuries. Opium was originally used to treat soldiers during the Revolutionary and Civil Wars and has since evolved through science into drugs like morphine (a derivative of opium) that has been widely used to treat pain and suffering. In fact, the first opioid epidemic was believed to have occurred just after the Civil War as the demand for more pain killers increased. This led to the development of heroin in 1874 as an effective pain reliever alternative to treat minor ailments (e.g., common cold symptoms).

By the turn of the 19th century, however, modern medicine further evolved and introduced non-narcotic pain killers such as aspirin. More research was also being conducted that identified the addictive properties of morphine and heroin. This slowed the prescribing of opioids to treat pain. As prescribed medical use of opioids diminished, an unmet demand for them was soon filled by illegal vendors selling “street drugs.”

Toward the end of the 20th century, as life expectancy increased, medical interest in pain management for patients who were now living longer with chronic disease and pain also grew. This began a new focus of research that indicated that opioids were not as addictive as once thought. This research created the pathway to reintroduce opioids as effective pain killers, with marketing used to promote their use. During this time, pharmaceutical companies released drugs that were derivatives of opium such as OxyContin (i.e., oxycodone), and fentanyl (a synthetic opioid originally developed in the 1950s that is 50–100 times stronger than morphine) to treat pain. Pharmaceutical companies marketed these opioids heavily to physicians, indicating they were safe and nonaddictive.

Why has it become a national crisis as opposed to previous substance misuse crisis?

As we know now, the claim by pharmaceutical companies that opioids were nonaddictive was false. The increased marketing led to substantial usage, resulting in many lives lost to opioid overdoses during the past two decades. This marketing is at the crux of why pharmaceutical companies were sued and have, in many cases, agreed to settle by paying billions to state and local government jurisdictions for their role in the crisis.

The opioid epidemic has evolved in three waves. The first wave in the late 1990s was primarily due to increased prescribing of opioids for chronic pain. Receiving such a prescription lowered the stigma of using street drugs; the perception was that it was socially accepted to take a prescription versus using a “street drug.” This led to the second wave in the early 2000s.

As more education was being provided on the addictive properties of opioids, a prescription drug monitoring program was developed to monitor the number of opioids being prescribed by physicians. Although better monitoring of prescriptions may have led to a decrease in prescribed opioids, street drugs such as heroin became more prevalent to fill the demand. The third and current wave has been facilitated by the illegal manufacturing and sales of fentanyl. Because of fentanyl’s lethality, it currently contributes to more than half of U.S. substance misuse overdose deaths.

Who are the most prevalent users?

The opioid epidemic has no boundaries, and it has impacted urban, suburban, and rural communities, persons of all demographics and income levels, and people with mental illness or history of substance use disorder. Prevention and intervention efforts need to be multifaceted to address the broad impacts from the epidemic.

You have been a proponent of a systems approach to addressing the opioid crisis. What does that mean? 

Current approaches to preventing and reducing opioid misuse and overdose deaths tend to lack coordination and collaboration among the many organizations trying to address the crisis. For example, the criminal justice system charges opioid misusers and sentences offenders to serve time in jail or prison (i.e., a punitive approach). This may have a short-term effect on decreasing opioid misuse by limiting user access to opioids but may only serve to postpone future misuse as this approach in and of itself does not treat or address the root causes of misuse and/or addiction (e.g., mental health, chronic pain, trauma).

The healthcare system focuses on decreasing opioid misuse by implementing the prescription drug monitoring program. This approach decreases the dispensing of opioid prescriptions but does not prioritize providing alternative treatments for those suffering from addiction, chronic pain, or other conditions. Opioid users may then, in turn, end up purchasing synthetic opioids on the street (e.g., fentanyl), leading to increased fatalities for many users and, for others, continuing a cycle of opioid misuse, justice involvement, homelessness, addiction, and unemployment.

As each component in a system is focused on one element at a time, problems are passed to other points in the opioid intervention system but not actually resolved systemwide. A systems approach would allow organizations within an ecosystem (e.g., criminal justice, public health, housing, health care, substance misuse, mental health) to work together under a common mission to map out current resources, gaps, and duplications and develop systemwide policies and strategies to better align resources to reach system-level outcomes and not just focus at the specific agency or organization level.

What are the most important things that jurisdictions can do to address the opioid crisis?

A systems approach, as described above, is the most important thing that a jurisdiction can do to get a handle on the opioid problem. But such a systems approach requires good collaboration and coordination. These are terms that are too often tossed around when discussing how to solve any complex public health problem. However, there are challenges to those in an ecosystem embarking on implementing a true systems thinking approach.

For example, systems-based approaches can struggle due to lack of common language across organizations or to competition between agencies in the ecosystem; there can be little organizational buy-in (especially if the agency is forced to the table); there may be no real champion to ensure that the process is valued and followed; there may not be funding to support the work needed; there may be difficulty in building trusting relationships; and there is often a lack of training on how to do systems thinking properly.

To overcome these barriers, leaders in the ecosystem can invest in a process called “system mapping.” System mapping is used to identify where resources in the ecosystem intersect, the gaps in resources where funding could be shared, and trends that exist pertaining to relationships, feedback loops, and leaders. This process can assist an ecosystem by providing a simplified conceptual understanding of its complex system that, for collective action purposes, can get partners on the same page. Once the system mapping is completed, leaders should invest in assessing the current state of readiness to implement a systems thinking approach and use the results to develop a systemwide strategic plan that outlines shared resources that support developing policies and strategies to combat the epidemic at the system level—not at the organizational level.

What can the JPRC do?

The JPRC is positioned to support leaders within an ecosystem to assess readiness, plan, implement, and evaluate policies and strategies. We have developed the Opioid Response Planning Checklist – Systems Thinking Readiness (ORPC-STR) instrument that can be implemented to assess readiness and use the results for strategic planning, implementation, evaluation, and continuous quality improvement.

Our team has worked with opioid coalitions and taskforces across the country to help them use their own data and assessments to gain a better understanding of their current resources, challenges, and strategies for overcoming barriers. Our team has expertise not only in substance misuse prevention and intervention evidence-based practices, but also implementation readiness, system-thinking, policy development, evaluation, and continuous quality improvement. We stand ready to help jurisdictions tackling the opioid crisis. For more information, contact me at jloeffl@wested.org.

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