Combatting the Opioid Crisis With Evidence-Based Treatments

Opioid use disorder (OUD) is a chronic, relapsing brain disease characterized by compulsive drug seeking and use despite adverse life consequences.¹ It is estimated that over 6 million Americans suffer from this disease, with about 55 thousand opioid-related deaths and an estimated economic toll of about $4 trillion in 2024 alone.^2-4 While the United States (US) recently saw the largest ever 1-year decline (27%) in overdose deaths, we still have a long way to go in combatting this crisis. Annual overdose deaths are still above where they were prior to the COVID-19 pandemic, and the number of opioid overdose deaths in 2024 was comparable to all US casualties lost in the Vietnam War.^5,6

Fortunately, there are evidence-based treatments for OUD that have shown to have a significant impact on clinical, economic, and societal outcomes. However, there are many barriers to accessing treatment that make it difficult to see their potential effect at scale in combatting the opioid crisis.⁷

Evidence-Based Treatments for Opioid Use Disorder

There are 3 different medications with distinct mechanisms that are approved by the US Food and Drug Administration (FDA) for the treatment of OUD. These include methadone, buprenorphine, and naltrexone. Methadone is a full opioid agonist, which directly activates the opioid receptor. It is taken orally once a day and typically requires daily visits to an opioid treatment program. Buprenorphine is a partial opioid agonist, which has relatively lower opioid receptor activation compared to methadone, lessening the risk for euphoria or respiratory depression at higher doses. Uniquely, it can simultaneously block the binding and corresponding effect of other opioids. While this may be beneficial for reducing the negative consequence of patients coingesting illicit opioids, it also means buprenorphine can precipitate withdrawal if initiated in patients with opioids in their system. It is available in a daily oral formulation as well as a weekly or monthly subcutaneous injection. Naltrexone is an opioid receptor antagonist, which blocks the binding of opioids and is available as either a daily oral tablet or monthly intramuscular injection. Unlike methadone and buprenorphine, naltrexone does not activate the opioid receptor and has no potential for abuse. It does, however, require 7 to 10 days of abstinence from opioids prior to initiation given its ability to precipitate withdrawal. Methadone and buprenorphine are often viewed as the gold standard, as both medications have demonstrated evidence for reducing the risk of death in patients with OUD. They also have shown greater treatment retention compared to naltrexone.^7-9

The use of medications for OUD (MOUD) combined with psychosocial treatment is generally associated with the best clinical results. The therapeutic goals of psychosocial treatment are primarily to modify underlying processes that reinforce substance use behavior, encourage adherence to a treatment plan, and treat any concomitant psychiatric disorders that either complicate OUD or factor into return to substance use. While individuals with OUD may benefit from psychosocial treatment, a patient’s decision to decline this therapy should not prevent or delay use of MOUD, which alone has demonstrated efficacy.⁸

Barriers to Treatment for Opioid Use Disorder

Despite substantial evidence supporting OUD treatment, particularly MOUD, there are many barriers which continue to limit access across settings. One of the most significant challenges is overcoming stigma associated with individuals with substance use disorders, as well as the concept of treating something that many still view as a choice or a moral failing rather than a brain-related disease. Individuals with OUD often face judgment and discrimination, which can deter them from seeking help and lead to underutilization of evidence-based treatments. Separately, there continues to be a shortage of trained providers, especially in rural and underserved areas.^10,11 Many counties in the US do not have even a single MOUD provider, leaving large populations without local treatment options.¹²

Structural and policy-related barriers also play a significant role in access to treatment for OUD. Until recently, federal regulations required providers to obtain a special waiver, known as an X-waiver, to prescribe buprenorphine, which was thought to discourage provider participation. Although this requirement was eliminated in 2023, there has not been a significant increase in buprenorphine prescribing and utilization, as many had expected.^13-15 The fragmented nature of the US healthcare system further complicates continuity of care, particularly for individuals transitioning in and out of correctional settings. Upon release from jails or prisons, individuals with OUD often face gaps in treatment access, which drastically increases their risk for overdose and death.^16,17 Socioeconomic factors also create barriers: individuals experiencing homelessness or poverty may prioritize immediate needs over long-term health interventions and may lack transportation or the modes of communication necessary to stay engaged in treatment.^18,19

Intersection Between Opioid Crisis and Criminal Justice System

An estimated 15% of the 1.8 million individuals incarcerated in the US have OUD, placing a significant burden on the criminal justice system, including $52 billion of related costs in 2024.^4,20 The majority of individuals with OUD experience at least 1 episode of incarceration and nearly half of all fatal opioid overdoses occur in people with prior criminal justice involvement.^21,22 Individuals are at their highest risk for opioid overdose death during the period immediately following release from correctional settings.

In fact, a study found that following release from prison, individuals had 129 times greater risk of overdose death compared to the general population.²²

The Substance Abuse and Mental Health Services Administration, within the US Department of Health and Human Services, has previously stated that there is overwhelming evidence that medication-assisted treatment is an effective intervention in addressing OUD in criminal justice populations.²³ This is well supported by various studies, which have consistently found positive outcomes associated with MOUD treatment during incarceration, including reductions in recidivism, overdose, and death post-release.^24-27 Despite all of this, a recent study found that only 44% of jails had any form of MOUD available. Even more shockingly, of the jails that had MOUD available, only 13% actually offered it to anyone with OUD.²⁸ Given the clear intersection between the opioid crisis and criminal justice system, these findings highlight a missed opportunity for implementing evidence-based treatments and reducing the impact of this crisis on affected communities.

Where Do We Go From Here?

Meaningful progress in addressing the opioid crisis depends on getting more individuals with OUD engaged with evidence-based treatment. There are effective tools that can save lives, but far too many patients continue to face barriers to care. Further efforts are needed to reduce stigma, expand access to MOUD, and empower providers with adequate knowledge and training. With stronger collaboration and prioritization among healthcare providers, payers, the criminal justice system, and all levels of government, the existing evidence-based treatments for OUD have the potential to substantially reduce the burden of this ongoing public health emergency.

Dr Frost is the chief medical officer of Wayspring, a value-based care organization focusing on individuals with substance use disorders. He is board certified in both internal medicine and addiction medicine and is a Distinguished Fellow of the American Society of Addiction Medicine.

Dr Dawson serves as the chief medical officer of Ideal Option, a multi-state addiction treatment clinic based in Washington State specializing in the management of patients with substance use disorders. He is double board certified in emergency and addiction medicine.

References

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