Full Summary - Contributions of Social and Behavioral Research in Addressing the Opioid Crisis
March 6, 2018
The NIH Office of Behavioral and Social Sciences Research (OBSSR) convened this meeting in collaboration with National Institute on Drug Abuse (NIDA), the National Institute of Neurological Disorders and Stroke (NINDS), the National Center for Complementary and Integrative Health (NCCIH) and the National Institute on Minority Health and Health Disparities (NIMHD) as part of the NIH Cutting-Edge Science Meeting Series to End the Opioid Crisis. Participants included leaders and subject matter experts with diverse expertise in research and practice relevant to the opioid crisis.
The goals of the meeting were 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.
These 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
Opening Remarks: Day 1
Dr. Francis Collins, Director of NIH, and Dr. Nora Volkow, Director of NIDA, each opened the meeting by highlighting the severity of the crisis, noting the rapid rise in opioid overdose death, the need for greater availability and more individualized treatments for the over two million Americans with opioid use disorder (OUD), and the urgent need for non-addictive pain management for the over 25 million experiencing pain. They described NIH research initiatives based on discussions from prior meetings in this series, including innovative opioid addiction treatments, effective pain management strategies, and overdose reversal treatments. Drs. Collins and Volkow noted that as overdose deaths from prescription opioids plateaued, overdose deaths from heroin and synthetic opioids (e.g., fentanyl) have dramatically increased. They posed a number of key questions to the participants including: 1) Which social factors contributing to the opioid crisis present malleable social change targets?, 2) How can technologies and citizen science approaches be leveraged to address these factors?, 3) How can prescribing practices be modified to reduce the transition from acute to chronic opioid use without causing drug seeking elsewhere?, 4) Can we reliably predict which individuals will respond to psychosocial strategies of medication assisted therapy (MAT)?, and 5) How can social and behavioral interventions be integrated better into the clinical care of chronic pain?
Jessica Hulsey Nickel, President and CEO of the Addiction Policy Forum, described the personal stories of individuals and families affected by the opioid crisis. She outlined approaches of the Addiction Policy Forum including: development and support of a crisis line aimed at providing research-based information to individuals (similar to poison control information lines), provision of MAT information to treatment programs, dissemination of information through public service announcements, and incorporation of predictive models of opioid overdose into emergency departments. She recommended that people with OUD should be treated only at locations that offer MAT, that multiple forms of MAT should be offered, and that improvements in continuity of care for individuals with non-fatal overdoses are necessary to reduce the risk of future fatal overdoses. She stressed that solutions are needed to reduce the number of people who develop OUD and ensure the survival of those who develop the disorder.
Panel 1: Sociocultural and Socioeconomic Underpinnings of the Opioid Crisis in the United States
Panelist presentations and subsequent discussions highlighted a number of key underlying social factors contributing to the opioid epidemic and identified research priorities needed to better understand these factors. Many acknowledged OUD as a predominant “symptom” of economic and social despair, and that these factors are driving increases in suicide, medical complications from alcohol abuse, and death rates from other drugs such as benzodiazepines and amphetamines. Death rates from these causes (“deaths of despair”) are markedly higher among those without a college degree (i.e., working class) regardless of age group or gender, but Whites without a college degree are more affected than other racial/ethnic groups. Over decades, those without college degrees have experienced an erosion of social and economic stability. Economic opportunities for those without a college degree have decreased, family structures that provide social stability have declined, and the safety net to help those struggling has weakened. Decreased mobility and increased legal and regulatory restrictions on job-seeking (e.g., non-compete clauses, professional licensing) limit upward economic mobility. Globalization contributes to this economic environment, but other countries demonstrate lower rates of harm, indicating that policy changes in response to globalization are more consequential than globalization itself. Economic factors affecting the opioid crisis are the result of a long process that has eroded working-class life in the United States.
These economic and social factors have led to an increase in pain complaints, which U.S. residents report more often than residents of peer nations. 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. The higher rates of pain complaints, emotional distress, suicide, substance abuse, and drug overdoses in the U.S. relative to other developed countries suggest that while more needs to be learned regarding these differences, changes in current U.S. social and economic policies could impact these health issues. The panelists noted that policies to address these social and economic determinants need to be evidence-based to avoid unintended negative effects. For example, addressing OUD via criminal law enforcement increases stigma, which reduces help-seeking and decreases treatment availability for OUD and opioid overdoses. The criminal justice system lacks the necessary infrastructure to address OUD, and in many communities the police are the primary crisis support. Opioid overdose deaths of formerly incarcerated individuals are 50 times higher than the general population. Social and economic policy changes need to be grounded in current research on the social drivers of the opioid crisis, and a stronger network of program evaluation and sharing of best practices is needed by communities attempting to address the opioid crisis.
The panel also considered health system policy changes that could impact the opioid crisis. In 1995, France began allowing primary care providers to prescribe buprenorphine, an opioid partial agonist, without special training or license, resulting in a nearly four-fold reduction in opioid overdose deaths in five years. In the U.S., providers who prescribe opioids either cannot or will not prescribe drugs that could reduce overdose deaths and increase the availability of treatment for OUD. The panelists also noted that opioids are rarely effective for chronic pain and, at a population level, the harm of prescribing opioids for chronic pain greatly exceeds the benefits. Working collaboratively with chronic pain patients to gradually taper to a safer dose or to cessation of use would reduce OUD and opioid overdose deaths.
These 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. Low levels of dopamine D2 receptors increase vulnerability to substance use and abuse. Animal studies have shown that being in subordinate social relationships and experiencing environmental stressors such as crowded housing reduce D2 receptor levels in the brain. Vulnerability to addiction and effectiveness of treatment vary widely among individuals, and these individual variations are influenced by social factors.
Key Things We Know
- Comprehensively addressing the opioid crisis requires addressing the underlying social and economic contributors to the crisis that impact a range of substance abuse disorders and suicidal behavior.
- Those without a college degree (i.e., working class families) are particularly vulnerable to opioid overdose deaths and other deaths of despair, and should be the focus of social policies, prevention programs, and other efforts to address the opioid crisis and the suffering and despair they experience.
- Ensuring that providers who prescribe opioids are also able to prescribe opioid treatment and overdose rescue medications (e.g., buprenorphine, naloxone) would greatly reduce opioid overdose deaths and increase accessibility to MAT.
- The criminal justice system is ill-equipped to address the opioid crisis, and criminalization has the unintended effect of increasing stigma and decreasing treatment access for OUD.
- Social factors increase not only psychological and social vulnerability to substance abuse, but also biological vulnerability to substance abuse.
- Monitoring progress in addressing the opioid crisis will require a comprehensive set of indicators including opioid prescribing, OUD incidence, overdose deaths, and polysubstance abuse.
Key Things We Need to Know
- What are the social and economic policy differences that 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?
- What post-incarceration intervention approaches will reduce the high rates of overdose deaths among the formerly incarcerated?
- Given the limited benefits and considerable harms from opioid use for chronic pain, what strategies optimize the ability of providers and patients to work collaboratively to taper, and potentially cease, inappropriate opioid use while managing pain and discouraging drug seeking elsewhere?
- What changes in social and community systems lead to the greatest reductions in OUD and overdose deaths based on rapid program evaluation and dissemination of best practices?
- Are there additional biomarkers of vulnerability to substance abuse and how do various social factors contribute to these vulnerabilities?
Panel 3: Incorporating Nonpharmacologic Approaches in the Treatment of Opioid Abuse and Chronic Pain Management
The third panel addressed a variety of nonpharmacological treatments for opioid abuse and identified chronic pain as a key driver of the opioid crisis. In the 1980s and 1990s, effective intensive multidisciplinary pain management programs involving time-contingent opioid medication administration and tapering, graded activation and exercise, coping skills training, use of reinforcement principles to support behavior change, and family support and training were covered by some insurance and provided to chronic pain patients. These programs were effective in reducing opioid intake, improving functional outcomes, and reducing pain. They have been adapted and continue to be used in other countries, but U.S. healthcare shifted to opioids as the primary treatment for chronic pain.
Numerous randomized clinical trials have demonstrated the effectiveness of behavioral and cognitive-behavioral pain management programs for various chronic pain conditions. These trials have shown that these programs are often as effective as medications for chronic pain, and superior to medications for some functional outcomes without the abuse liability of opioids. In addition dependence and abuse liability, treatment of chronic pain via opioids often produces a vicious cycle in which, as a result of biological and behavioral mechanisms, opioid misuse results in increased pain which then increases the likelihood of opioid misuse and other significant physical side effects that may actually exacerbate pain. Despite considerable evidence for these nonpharmacologic chronic pain management programs, there is limited capacity and access to these programs. Digital delivery of these programs (e.g., telehealth, internet, mobile applications) holds promise for addressing limited access and capacity.
Although more effective than no treatment, the current therapeutic armamentarium of available treatments, both pharmacologic and nonpharmacologic, are only modestly effective for treating chronic pain. One key contributor to these modest mean effects is the wide variability of individual pain response. The experience of pain is a complex interaction of biological, psychological, and social factors, as well as prior experiences with pain and its management. The variability in individual experiences of pain requires an biopsychosocial approach that is tailored to the individual and engages the individual in actively self-managing their pain. Mindfulness approaches (i.e., training that facilitates greater attention and awareness of present moment experiences) are among the recent additions to the therapeutic armamentarium of chroni pain management programs. Mindfulness training has been shown to reduce pain intensity and interference, and to reduce opioid craving and misuse compared to support group controls.
Medication Assisted Treatment (MAT), the current primary treatment approach for opioid misuse, is underutilized. Panelists discussed the need for extending access and availability of MAT, particularly in emergency departments and correctional facilities. Panelists noted that providing MAT in outpatient settings also remains a challenge. Currently, there is a shortage of providers trained in managing OUD, and the few trained and licensed to do so are not providing treatment at capacity. Potential barriers to providing this treatment include Drug Enforcement Administration (DEA) scrutiny of medical records, low insurance reimbursement for associated services (e.g., urine drug screen), the effort involved in intensive patient monitoring (e.g., diversion), and the stigma associated with treating patients with OUD. A stratified system of risk management is necessary to identify individuals who can be treated by their current providers and those who must be referred elsewhere. Primary care providers often are limited by time and by a system that does not integrate general medical care, OUD treatment programs, and social services. The healthcare system is further stressed by continued reimbursement coverage for ineffective approaches while failing to reimburse adequately for approaches that have been found effective. System level changes are clearly needed to facilitate the implementation of effective strategies and programs, and identifying and deimplementing ineffective strategies.
Key Things We Know
- 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.
Key Things We Need to Know
- Given the variability in OUD and chronic pain treatment response, what treatment strategies work for whom?
- What combination and sequences of existing treatment strategies, and what additional strategies optimize treatment outcomes from OUD and for chronic pain?
- 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, and can digitally delivered treatments improve outcomes for some individuals?
- How can barriers to the implementation of current nonpharmacologic treatments for chronic pain and of MAT for OUD be addressed to increase access and availability of these treatments?
- How can individuals be encouraged and motivated to take a more active role in the management of chronic pain and OUD?
Opening Remarks: Day 2
The second day of the meeting opened with comments from Dr. David Shurtleff, Acting Director, NCCIH, and Dr. Eliseo Pérez-Stable, Director, NIMHD. Dr. Shurtleff discussed the need for treatment of pain to include sophisticated, integrated approaches that provide not only analgesia but also relief from the cognitive and emotional aspects of pain. Psychosocial approaches improve patients’ abilities to reframe and tolerate pain, but they require time to show significant effects. Advancing the science of pain treatment is important, but we need to generate solutions that are practical and realistic to administer.
Dr. Pérez-Stable noted the need for further research on determining the mechanisms that cause the burden of opioid deaths to fall more heavily on White and American Indian/Alaska Native populations than on Hispanic and Black populations. Although trends in premature mortality for minority populations have decreased because of improvements in cancer care, HIV treatment, and heart disease, deaths of despair have increased.
Panel 4: Prevention, Treatment and Recovery: Challenges and Barriers to Implementation
The fourth panel focused on implementation of prevention, treatment, and recovery in underserved settings and communities. OUD and overdose deaths are disproportionately higher in rural areas. 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 in rural areas. Travel barriers and heightened stigma foster isolation which, along with inadequate treatment availability, limit access to OUD treatment. Rural areas also have less access and availability of syringe service programs which not only reduce infectious disease transmission but also help injection drug users connect to critical medical and social services. Access to syringe service programs is beginning to improve as states permit localities to allow these programs.
Rural areas are quite diverse. Factors contributing to OUD and overdose deaths differ, and strategies to address OUD need to be adapted for the unique needs and circumstances of each rural region. Community engagement is critical, and rural communities must engage law enforcement, healthcare providers, and community organizations to develop a treatment system consistent with cultural norms and resource limitations. Relationships damaged during opioid misuse are often difficult to rebuild in small communities; therefore, rural community programs for OUD must provide supportive pathways for recovery.
American Indian and Alaska Native (AI/AN) nations and communities also experience disproportionately higher rates of OUD and overdose deaths. These AI/AN nations and communities often share similar characteristics as rural areas, but also have unique cultural, structural, and governance characteristics that need to be considered when addressing the opioid crisis. Substance abuse prevention programs developed with and for AI/AN nations have been shown to reduce substance abuse, including prescription drug misuse. Providing OUD treatment services in AI/AN nations and communities requires working collaboratively with tribal leaders and the community and healthcare resources available within their nations or communities to implement effective programs adapted to their unique needs.
Panelists discussed how race and class inequalities related to the opioid crisis are more complex than indicated by differing rates of opioid use and overdose deaths by race/ethnicity. Institutional inequalities contribute to the geography of opioid use. Ethnographic, community, and geographical information system approaches provide a more nuanced perspective of the mechanisms contributing to these inequalities. Opioid harm reduction and decriminalization strategies are most often provided in predominately White neighborhoods, and opioid treatment marketing predominately targets Whites. Buprenorphine is prescribed predominately to Whites, and the geographical areas with lower rates of buprenorphine prescribing have higher concentrations of methadone clinics, predominately in areas with larger minority populations. Identifying disparities in treatment access and quality will result in better translated and effective interventions tailored to the needs of particular communities. Comprehensively addressing the opioid crisis requires addressing how structural racism influences the opioid response and the types of programs and services available in diverse communities.
The criminal justice system is on the front lines of the opioid crisis. The system has experienced increased incarcerations, not only of those with OUD but also those with a broad range of mostly untreated substance abuse and mental health conditions. A criminal justice model has been applied where a population health model is more appropriate. The criminal justice system complicates recovery; felony conviction makes it difficult for people with OUD to acquire housing, licensing for jobs, or other social and economic gains that reduce the risk of relapse. Panelists involved in the criminal justice system described being overwhelmed by the numbers of untreated substance abuse and mental health disordered individuals in the system and the lack of public health guidance, tools, and resources to address the needs of these individuals. The criminal justice system often becomes the repository of flawed public policy. The opioid crisis has revealed the larger systemic weaknesses in healthcare, public health, and social policies. Policies are often enacted based on weak evidence of their effect on opioid use and overdoses. Policies addressing the opioid crisis and the broader mental health and substance abuse needs should be more evidence-based with a recognition that such policies may affect initiation vs. continued drug use differently.
Key Things We Know
- OUD and overdose deaths are disproportionately occurring in rural areas and among AI/AN populations.
- Although other racial and ethnic groups (e.g., Blacks, Hispanics) may not have disproportionately higher rates of OUD and overdose deaths, their access to treatment is much more limited and of poorer quality than for Whites.
- Substance abuse prevention programs adapted to the unique needs of these communities have been effective at reducing substance use and abuse, including prescription medication misuse.
- Stigma is a critical barrier to obtaining care, and stigmatization extends beyond communities and includes providers as well. Even some MAT providers encourage patients to attempt abstinence prematurely.
- 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.
Key Things We Need to Know
- 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?
- What are best practices for involving communities and adapting OUD prevention and treatment programs for various communities, and how does one balance the need for adaptation with the need not to dilute the core active ingredients of the interventions?
- 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 treating OUD and overdoses?
- 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 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?
- How can comparative policy research be conducted (e.g., time series trials) to provide policymakers with the evidence to develop effective economic, social, criminal justice, healthcare, and drug policies that reduce opioid use initiation, dependence, and overdose deaths, and what evidence would be most compelling to policymakers when considering policy options?
Panel 5: Effective Models of Integrated Approaches
Using examples of effective models of integrative care in the US and Canada, the final panel discussed ways to integrate OUD and chronic pain treatment approaches within different care systems. Increasing access to specialty addiction treatment may not be an effective solution due to capacity limits and the barriers to those with OUD seeking specialty treatment. Integrated behavioral health provides a model for providing more psychiatric or addiction treatment in the primary care setting. Providing addiction treatment in a primary care setting, however, presents several challenges. Panelists noted that such integrated approaches require more than training primary care providers to deliver MAT; provider and organizational readiness for these integrated approaches also must be addressed.
Implementation of MAT in primary care settings presents a number of other challenges. Many primary care providers do not have sufficient time to undergo extensive training or education in complex treatments that will help only a small portion of their patients. Even among those willing to provide addiction treatment, there is inadequate compensation for providing addiction treatment, and electronic medical record systems may not support the treatment. Nurses and other allied health professionals have taken over many of the administrative leadership duties in health care settings, yet often are not involved in discussions of changes that impact opportunities to provide addiction treatment. Panelists noted that retention in treatment the only agreed-upon outcome metric currently, and the penetrance of evidence-based care is variable. Implementation of integrated addiction services is a complex process that requires addressing capacity, competency, consistency, and compensation.
In addition to the primary care setting, the panelists discussed other examples of integrated programs that could be used as potential models for effective addiction treatment. The military health care setting has moved toward integrated therapies in the treatment of OUD; soldiers often have issues that include traumatic brain injury, post-traumatic stress disorder, and pain, and most soldiers have been receptive to integrative practices. Integrated treatment programs in British Columbia include integration not only within healthcare but also with the public health and social service systems. Their innovative approach includes supervised injection, expanded opportunities for peer workers, drug purity test methods, and identification of overdose risk environments. Mapping social-structural dynamics of patients in these various systems can help align the environment and care with the practical experiences of people who use drugs. Peer engagement in intervention delivery is a particularly untapped resource. People dealing with OUD are seldom represented when interventions are developed.
Key Things We Know
- 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.
- Structural factors challenging the implementation of integrated care include lower reimbursement levels for appropriate OUD treatments, electronic medical record systems not optimized for integrative care, and organizational readiness to adopt integrated care.
- Integrated care within the U.S. military provides one model for integrating mental health and substance abuse services within the primary healthcare system.
- Canadian models for integrated care extend beyond healthcare and integrate social and public health services with the healthcare system.
Key Things We Need Know
- How do the types of outcomes monitored by healthcare systems (e.g., more than retention in treatment or pain intensity ratings) data impact care and can a more complete perspective on patient and system outcomes impact the type of care provided?
- How have integrated care models that adequately address OUD and overdose deaths been implemented and what are the effective components to that implementation?
- What are the financial considerations of health care payers to integrated care models, and how can these considerations be addressed to provide adequate compensation for integrated services?
- Which models of integration are most appropriate for which types of healthcare and public health systems and settings?
Meeting Summary and Next Steps
This meeting on the Contributions of Social and Behavioral Research in Addressing the Opioid Crisis brought together experts with diverse perspectives on the broad and complex array of social and behavioral factors contributing to the opioid crisis. This meeting also provided insight into what can be applied immediately to address the crisis as well as what research questions need to be answered to improve our ability to address the crisis.
While many empirically-supported and effective social and behavioral strategies to address the opioid crisis are currently available, adoption of these effective strategies has been disappointing. The inability to implement effective programs in the context of this crisis is symptomatic of healthcare, public health, and social services systems in which resources are not aligned well with population health needs. The NIH will 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.
The meeting generated a number of research questions that, if answered relatively quickly, could improve our ability to address the opioid crisis. Observers from many of the NIH Institutes, Centers, and Offices attended this meeting, and these staff members will consider the input from meeting participants, prioritize research questions, and consider how best to stimulate research in these prioritized areas.