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?

Patient/Family Perspectives

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 2: Behavioral and Social Factors Preventing Opioid Initiation and Mitigating the Transition from Acute to Chronic Pain


The second panel emphasized the importance of prevention in addressing the opioid crisis. 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.  Risk and protective factors are common across substances of abuse as well as other adolescent risk behaviors (e.g., teen pregnancy, delinquency).  As a result, effective prevention programs targeting these risk and protective factors reduce the likelihood of not only opioid use but a number of other substance abuse and risk behavior problems.  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.  Injection drug use is a socially communicable behavior in which current injection users assist others in initiating injection use.  Identifying those who assist others in injection initiation and providing MAT addresses not only their injection drug use, but potentially prevents others from initiating injection drug use. 

Panelists also focused the initiation of opioid use via prescribing practices.  Opioid prescribing patterns in primary care, emergency departments (ED), and hospitals vary widely and are influenced by the healthcare systems and the local culture of providers in those systems.  Prescribing higher doses for longer durations, particularly to those with a history of substance abuse, mood disorders, or chronic pain conditions, increases the likelihood of transition from acute to persistent opioid use.  Recent technology advances now allow for automated monitoring of pill ingestion, providing a detailed pattern of acute opioid use that also may serve as a useful early warning sign of transition to persistent use.

System approaches such as those conducted in the Veterans Administration (VA) involving education, stepped care, risk mitigation and addiction treatment have reduced opioid prescribing.   Decision support systems assist providers in appropriate prescription practices.  Innovative methods to change prescribing behavior utilize social influences on providers, who may be asked to publicly commit to safe prescribing practices, justify the prescription in the electronic record, or compare their own prescribing practices with those of peers.  Panelists noted that survivorship bias also influences providers who see patients with uneventful follow-ups but seldom learn of patient overdose deaths.  Giving providers more complete data about the outcomes of their patients prescribed opioids may further reduce opioid overprescribing.  Panel discussion included the need for improved suicide risk screening among providers as well, especially since some proportion of opioid overdose deaths are intentional, not accidental.

Patient factors play a role in prescribing patterns and account for the wide variability among providers. Improved ability to predict an individual’s variability in pain and analgesia response could identify which patients are at risk for persistent opioid use and abuse.  Panelists also noted that changes in patient and provider beliefs and expectations are needed.  NSAIDs are as effective as opioids for pain relief in many cases, but because they do not have abuse liability (not a schedule 2 drug) and are available without prescription, NSAIDS are often perceived as being less effective.

Key Things We Know

  • A variety of effective substance abuse programs are available for communities to implement.
  • Injection drug use is facilitated by social networks, and strategic targeting of individuals in these networks may have broader impacts than on the individuals targeted.
  • In many cases, NSAIDs may be as effective as as opioids for pain management.
  • Simple interventions (e.g., peer comparison) have been shown to change prescribing behavior.
  • Systems level interventions such as those by the VA have been shown to reduce opioid prescribing behaviors.

Key Things We Need to Know

  • What implementation science strategies will facilitate the adoption of effective substance abuse prevention programs by communities, and encourage them to de-implement unproven programs?
  • What interventions targeting patients, providers, and healthcare systems will optimize acute opioid administration to minimize opioid use while adequately controlling pain?
  • How can we change the cultural expectations of our society regarding pain relief (relieve vs. manage or control (including self-management and self-control) and the misperception that NSAIDS and self-management approaches are inferior for pain treatment?
  • What patient, provider, and system differences are responsible for the wide variability in opioid prescribing, and can these differences be used to predict reliably opioid initiation and the transition from acute to persistent use?
  • Can technologies for the automated monitoring of medication adherence be used to identify early warning patterns of acute opioid use likely to develop into persistent use?