Throwback Article Review: Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic, 2018

An article that has never been far from my mind, and frequently on my presentations slides and reference lists, is Allison Pitt, Dr. Keith Humphrey, and Dr. Margaret Brandeau's Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic in the American Journal of Public Health, 2018. This article came out when I was championing Maryland's Center for Harm Reduction Services, and it helped me show that harm reduction is part of a comprehensive response to the overdose crisis and will save lives in the short and long-term. Now, almost five years later, what are we still learning from this modeling exercise?

"Notably, none of the policies substantially reduces opioid-related deaths. Increasing naloxone availability resulted in the greatest number of addiction deaths averted among the 11 interventions, representing a 4% reduction."

Pitt et al.'s model evaluated the 5 and 10 year impact of 11 public health interventions on overdose deaths. I'll note Victoria Pless, MPH, PMP et al. published a great piece summarizing contemporary public policy interventions to reduce overdose risk, including the centering of health equity, and ASTHO issued recommendations for state and territorial health agencies in a "policy playbook".

In 2018, however, authors considered these supply reduction strategies:

1. Reducing opioid prescribing for acute pain
2. Limiting refills for opioid prescriptions
3. Transitioning people from opioid treatment for pain
4. Rescheduling opioids under the Controlled Substances Act
5. Opioid disposal programs
6. Prescription Monitoring Programs
7. Tamper-resistant and abuse-deterrent formulations of opioids

and these harm reduction strategies:

1. Expanding medication for opioid use disorders, increasing enrollment
2. Increasing psychosocial treatment availability
3. Increasing naloxone availability
4. Expanding syringe service programs

Without any of these interventions, the model predicted 510,000 people would die of opioid overdose between 2016-2025. Unfortunately, during that time, the total number of overdose deaths (all drugs), despite all our efforts, is just over 580,000. Starting in 2021, deaths top 100,000 people every 12 months and that trend continues today. The situation also grows increasingly complex as it involves drugs other than opioids, so the same interventions measured here may not be as relevant if they don't adapt. I would say that harm reduction programs are the most adaptable compared to other interventions on this list; therefore, worth the investment as a primary response to ever- evolving drug-related health crises. In summary, an overemphasis on supply reduction and devaluing of harm reduction over the last ten years has made the crisis worse.

One of the key takeaways of the research is that no single intervention will end the overdose crisis. We need a comprehensive approach. "The model projected that combining the reduced acute, transitioning, and chronic pain prescribing, excess opioid disposal, MOUD, needle exchange, naloxone availability, and psychosocial treatment interventions would reduce 10-year addiction deaths by 59?000 (11%)."

After 5 years, the model predicted naloxone access to have the most significant impact on overdose deaths, reducing it by 4%, followed by expanding enrollment in medications for opioid use disorder treatment programs at 2%. Supply reduction strategies were less effective, as people switch from using a safe supply of prescription opioids to unregulated ones.

"Although PMPs reduce prescription opioid deaths, our model suggests that the detrimental effect on heroin use and resulting deaths may outweigh this benefit for the period of time modeled here."

At 10 years, harm reduction strategies remain consistently growing in impact, continuing to save lives as long as they are implemented. Supply reduction strategies, however, particularly drug rescheduling, opioid reformulation, and prescription monitoring, increase predicted heroin deaths, while decreasing deaths related to prescription medications. Drug rescheduling was predicted to increase heroin deaths 45% in the first five years, and by 8% after 10 years. This has likely been exacerbated in reality by fentanyl in the drug supply (FYI Office of National Drug Control Policy continues to include scheduling as a pillar of a federal response to emerging substances.)

I find this study extremely valuable, however, in giving us a snapshot of what might work and might not as we make critical decisions to allocate overdose response resources. The authors attempted to determine threshold magnitudes that each intervention would have to be implemented at to maximize impact - we are not even close. We need naloxone in abundance among people who use drugs, medications for opioid use disorder to be easier to get than fentanyl (#liberatemethadone), and to triple the number of syringe service programs.

Thanks for reading. I would love to hear your thoughts, there is a lot more in this article than I have space to discuss here! and how you think the predictions have held up in real time ??