Executive Summary - Contributions of Social and Behavioral Research in Addressing the Opioid Crisis
As part of a government-wide effort to address the opioid crisis, the NIH has initiated a public-private collaborative research initiative on (1) new and innovative medications and biologics to treat opioid addiction and to prevent or reverse overdose; (2) safe, effective, and non-addictive strategies to manage chronic pain; and (3) neurobiology of chronic pain.
Cognizant of the social and behavioral influences of opioid problem, the NIH sought to complement these prior efforts and brought together innovative experts from academia, government, and public health for a cutting-edge science meeting to identify and pursue promising opportunities for addressing the social and behavioral contributors to the opioid crisis.
This meeting, held March 5 and 6, 2018, sought to 1) specify key actionable social and behavioral science findings that can be brought to bear immediately to address the opioid crisis, and 2) identify critical short-term (as well as potential mid-term and longer-term) research priorities that have the potential to improve the opioid crisis response.
The discussions were organized in five panels:
- Panel 1: Sociocultural and socioeconomic underpinnings of the crisis
- Panel 2: Behavioral and social factors preventing opioid initiation and mitigating the transition from acute to chronic opioid use
- Panel 3: Incorporating nonpharmacologic approaches in the treatment of opioid abuse and chronic pain management
- Panel 4: Challenges and barriers to implementing prevention and treatment strategies
- Panel 5: Effective models of integrated approaches
- Economic and social factors affecting the opioid crisis are the result of a long process that has eroded working-class life in the United States.
- The opioid crisis could be described more accurately as a crisis of unaddressed suffering and polysubstance abuse, of which opioids currently are the predominant substances of abuse.
- Policies to address these social and economic determinants need to be evidence-based to avoid unintended negative effects.
- The social and economic factors that influence OUD, opioid overdose, and related “deaths of despair” affect not only social and psychological mechanisms but also biological mechanisms of substance abuse.
- Numerous substance abuse prevention programs applicable to a variety of contexts (e.g., schools, communities) have been found effective, yet unevaluated programs continue to be used in some communities. Weak adoption by communities of these effective programs is a critical public health concern.
- Social networks are an important component of opioid use prevention, and these social networks are particularly important for disrupting the initiation of injection drug use.
- Opioid prescribing patterns vary widely and are influenced by the healthcare systems and the local culture of providers in those systems. Various provider and system interventions have been shown to change prescribing behavior.
- Effective nonpharmacological treatment strategies and programs for chronic pain have been available for decades; however, despite being as or more effective than opioids for treating chronic pain with no abuse liability, there is limited access to these programs in the U.S. healthcare system.
- There is limited access to MAT and considerable barriers to implementation of MAT in outpatient care settings.
- Individuals with OUD and chronic pain benefit from comprehensive approaches that address medical and social needs, but the link between such treatment, social services, and general medical care is frequently weak.
- OUD and overdose deaths are disproportionately occurring in rural areas and among AI/AN populations where socioeconomic factors such as lower education rates, fewer opportunities for employment, lower infrastructure investment, and higher rates of poverty contribute to higher rates of OUD.
- Opioid harm reduction and decriminalization strategies are most often provided in predominately White neighborhoods, and opioid treatment marketing predominately targets Whites.
- Stigma is a critical barrier to obtaining care, and stigmatization extends beyond communities and includes providers as well.
- The criminal justice system is overwhelmed by the number of untreated mental health and substance abuse problems, including OUD, and does not have the guidance, tools, or resources necessary to address these needs.
- Collaborative care and related models for integrating behavioral health and addiction treatment within the primary healthcare setting increases treatment accessibility and improves outcomes, but there continue to be significant barriers to implementing these integrative healthcare models, including lower reimbursement levels for appropriate OUD treatments, electronic medical record systems not optimized for integrative care, and organizational readiness to adopt integrated care.
- U.S. Military and Canadian models for integrated care link mental health and substance abuse services within the primary healthcare system and extend beyond healthcare to integrate social and public health services with the healthcare system.
Possible Next Steps
- Collaborate and coordinate with other entities charged with practice implementation to disseminate proven strategies and interventions, and address key implementation barriers based on current implementation science research findings.
- Convene NIH Institutes, Centers, and Office meeting participants to prioritize research questions and consider how best to stimulate research in these prioritized areas. Among the research questions to consider based on the input from the meeting:
- Given the variability in OUD and chronic pain treatment response, what treatment strategies work for whom?
- Which treatment strategies in which dosages and durations facilitate maintenance of initial treatment effects?
- Digital technologies can increase access and reach of OUD and chronic pain treatments, but which components of these treatments can be automated or delivered digitally without compromising effectiveness?
- What interventions targeting patients, providers, and healthcare systems will optimize acute opioid administration to minimize opioid use while adequately controlling pain?
- What can be learned from addressing stigma in the alcohol and HIV/AIDS fields that can be applied to reducing stigma from OUD and encouraging treatment seeking of those with OUD, especially in communities with heightened levels of addiction stigma?
- Which multilevel strategies reduce the disparities in OUD, not only of OUD incidence, but also providing more equitable availability of best practices for preventing and treating OUD and overdoses?
- What programs and policies effectively divert OUD individuals from the criminal justice system to the public health system and minimize the social and economic repercussions of a felony conviction that can contribute to relapse?
- What combination of programs and resources will give criminal justice systems the tools they need to address the large number of OUD and other substance abuse and mental health disordered individuals in the system?
- What post-incarceration intervention approaches will reduce the high rates of overdose deaths among the formerly incarcerated?
- What social and economic policy differences result in higher rates of OUD and overdose deaths in the U.S. than in peer countries, and do changes in these policies result in eventual reductions in OUD and overdose deaths?
- Which models of integration are most appropriate for which types of healthcare and public health systems and settings?