Opioids: Four ways to reduce harm, overdose and death
The epidemic of substance use disorder continues to ravage the United States—as nearly 108,000 Americans died due to overdose in 2021, according provisional data from the Centers for Disease Control and Prevention. More than 40 million Americans over 12 years old reportedly needed treatment for a substance use disorder in 2020, yet only 2.7 million people received treatment at a specialty facility, a national survey shows.
While overdose deaths climb, there are changes in the drug supply that have made it increasingly unpredictable, says Chin Hwa (Gina) Dahlem, Ph.D., FNP-C, FAANP, a nurse practitioner and overdose prevention expert at University of Michigan Health.
"We don't know what other substances are mixed with the drug itself or if multiple drugs are used at the time of overdose," Dahlem said. "Thus, as fentanyl is found in majority of the overdoses, it is vital that people who use drugs and their social networks are given the training and access to overdose prevention resources."
While curbing the scourge of opioids is a massive undertaking requiring action from governments, health care providers, industry leaders, and communities, there are viable steps to make improvements now. Here, three providers with expertise in substance use care discuss ways to reduce harm, overdose and death due to opioid and illicit drug use.
1. Naloxone: increase distribution, access and training
The primary way to reduce overdose deaths is simple: get naloxone into people's hands. Commonly known by the brand name Narcan, naloxone is a reversal agent that can restore normal breathing and save the life of a person who is experiencing an opioid overdose.
Over the last decade, naloxone has been made more available for individuals, health care providers and first responders. In fact, one national study found that overdose deaths dropped by 14% in states that enacted laws to make naloxone more accessible.
"The gold-standard model of overdose death prevention is direct distribution of naloxone at the point of care," said Keith Kocher, M.D., M.P.H., an emergency physician at U-M and the program director of the Michigan Emergency Department Improvement Collaborative, which has distributed 4,800 naloxone rescue kits to 22 emergency departments across the state.
"Rather than relying on a prescription or hope that a patient can get naloxone at a standing order pharmacy, we should try to achieve a standard in which providers and other outlets can give it seamlessly at the point of care."
Kocher recently published two studies: the first found that nationally, fewer than 10% of patients are prescribed naloxone after visiting the emergency department for an opioid overdose. The second found that only 54% of Michigan pharmacies participate in the naloxone standing order, which allows in-state pharmacies to dispense naloxone without a written prescription.
"Those just represent additional barriers; they may work at times, but they're still barriers," Kocher said. "The emergency department should be a key access point for naloxone for those at risk of future overdose. However, similar efforts are happening elsewhere, including at a local library where anyone can get naloxone for free from specially designed kiosks."
It's important that naloxone distribution and access are not only increased for people who are using opioids but also for the public. Naloxone is a medication where it is very unlikely that the person in need of the medicine is in a condition where they are administering it to themselves.
Overdoses happen in public spaces, parking lots and libraries, in bathrooms, gas stations and homes. And more than one in three overdoses occur while a bystander is present, where family members, friends or individuals in communities can take action to prevent deaths.
"This is why we have legislation in Michigan to protect individuals when they administer naloxone in good faith to someone who appears to be having an overdose," said Dahlem, who has trained scores of local police, fire and medical first responder organizations in administering the medication.
"We need to continue to expand naloxone distribution to family, friends and others, so we can get naloxone into the hands of those who will be able to administer it. The more we continue our efforts to expand naloxone access and training through pharmacies, hospitals and community distribution programs, the better prepared we will be to prevent overdose deaths across the nation."
2. Decrease stigma: increase education and perspective
Part of the success around naloxone distribution, access and training is the—albeit slow—reduction in stigma surrounding the overdose reversal agent. Years ago, much more controversy surrounded the medication.
When Dahlem worked at a homeless shelter as a nurse practitioner in 2013, they did not have any naloxone, nor were any of the staff trained to use it. Several clients at the shelter overdosed at that time.
"At that point, we didn't even think about distributing naloxone, we just wanted to have it at the clinic to respond to an overdose situation," Dahlem said.
"Then, our director brought up training the staff, since they are there seven days a week. With the passing of legislation requiring first responders to be equipped and trained to administer naloxone, the Washtenaw County Sheriff's Office reached out to me. We trained the law enforcement officials, and they have reversed hundreds of overdoses since then."
Dahlem has trained school nurses, factory workers, students, librarians and thousands of others. Some of these public places now offer naloxone for use as part of emergency response kits.
"I think making training around naloxone a civic duty like CPR training would be very helpful, and there are people who advocate for making sure this training is part of basic life support training," said Eve Losman, M.D., MHSA, a U-M Health emergency physician and department representative for quality improvement initiatives related to pain management, safe opioid prescribing and care of patients with substance use disorders.
Beyond showing people how to use naloxone, Dahlem says, this kind of education is vitally important to provide perspective towards addiction and destigmatize substance use in communities.
"You need to change the culture, which takes time," she said. "It starts with one person being educated, changing and having influence on others. As a provider, I didn't receive substance use disorder education when I was going to school. Now, there are efforts to increase training for providers and students in all the health professions, so that we can learn more about this disease."
People with substance use disorder are not defined by their addiction. They are people struggling with a disease. For those in health care as well as members of the public, Kocher says, reducing stigma requires making a choice about how you view and interact with people.
"You have to make a choice about the language you use and in your interactions with people, families and patients in your daily work," he said. "Doing so intentionally and positioning yourself with an open perspective about how people struggle, relapse and recover with this disease will set an example. People will begin to notice and adopt a more effective way to care for these patients."
3. Encouraging safer use, guide to recovery
A key aspect to harm reduction, Dahlem says, is understanding that you must meet people where they are and encourage any positive change.
"The fact that the person who is actively using drugs then comes to our clinic is a positive change," she said. "The person who decides to reduce their drug use, seek sterile syringes and needles, or access social services are other examples of positive change."
Recovery is an ongoing process which looks different for each person, and there are multiple pathways.
"When you talk with people who use drugs, they will say they are in recovery even if they have not used for over 20 years because they realize addiction is a chronic disease," she said. "The whole philosophy of care is to treat patients with compassion and dignity and not mistreat or judge them for using substances."
This guide to recovery involves several steps. For providers, offering buprenorphine, a drug designed to reduce dependence on opioids without causing a high of its own, to those going through withdrawal can help patients manage discomfort and work towards recovery.
In the 2021 study on naloxone in the emergency department, Kocher and researchers also found that just one in 12 patients in the 30 days after a visit for an opioid overdose were prescribed buprenorphine. Meanwhile, they compared that to nearly half of patients with severe allergic reactions who were prescribed epinephrine (an EpiPen) at the time of discharge from the emergency department.
"A diabetic patient wouldn't be shamed for coming in having run out of their insulin," Losman said.
"An asthmatic patient wouldn't be shamed for running out of albuterol, and we wouldn't have any concerns about giving them refills. We want everybody in the house of medicine to allow people to access care that they need without pushing them away. These people coming to the emergency department asking for help with a substance use disorder are being courageous. This is a stigmatized disease and many of these patients have had negative experiences with healthcare workers in the past, which adds to the challenge."
As part of a recently announced national drug control strategy, the Biden administration is focusing its effort on expanding access to buprenorphine, a medication used to treat opioid use disorder.
Over the past three years, the emergency department collaborative in Michigan has led trainings for providers across the state to teach them about using buprenorphine, an evidence-based and lifesaving intervention, to care for patients with opioid use disorders.
"To have people in our own discipline tell us that this is our lane, this is our wheelhouse, is very powerful," Losman said.
"This training by our colleagues normalizes this form of harm reduction within the practice of emergency medicine. In addition, hearing from colleagues in emergency departments across the country describe how patients benefit from medication for opioid use disorder and how this has shifted the perception of this disease among their staff is heartening."
Another way to help reduce the harm of opioids is to encourage safer use of substances for individuals who are not yet ready to enter recovery, Losman says. This includes offering naloxone kits, fentanyl testing strips and syringe service programs, as well as reminding individuals to avoid using alone.
"We want to engage patients and partner with them to be as safe as possible given their current life situation," she said. "By doing this consistently, not only do we save lives, but we also open the door to partnering with them if and when they are ready to contemplate entering recovery."
The opioid crisis is fueling a rise in hepatitis C infections and thousands of HIV infections each year, according to the CDC. Syringe service programs are an effective component of community-based prevention that more often lead substance users to enter treatment.
"We need to do whatever we can to provide the resources people need to prevent complications from drug use," Dahlem said. "By providing sterile syringes and other supplies, we can reduce threats of these infectious diseases from spreading," Dahlem said.
4. Conscious prescribing and safe disposal practices
At its peak in 2012, more than 255 million opioid prescriptions were dispensed at a rate of over 81 prescriptions per 100 persons. While prescribing rates have continued to decrease, Kocher says, there is more work to be done for preventing exposure to opioids.
"We need to fully appreciate the risks of prescribing opioids for standard indications of pain control and be sure we're adequately weighing the benefits and considering alternatives," he said.
Several states have laws in place surrounding safety and education for opioid prescription practices. A 2018 Michigan law prohibits a licensed prescriber treating patients for acute pain from prescribing more than a seven-day supply of an opioid in a one-week period.
These prescribing practices, Losman says, also must be accompanied by education of patients and families on the risks and dangers of the medications.
"It does not take a long time to talk with patients about the potential harms of opioids, and I've had a fair number of patients who decide to try Tylenol first," she said. "I think people are worried, appropriately so, and some have a family history of addiction and don't feel like taking a chance."
To reduce the number of people who overdose from prescription opioids, the CDC developed a guideline for prescribing opioids for chronic pain. The guidelines focus on determining when to initiate opioids, selection of medication and dosage, and assessing risk and harms of use.
For Michigan providers, the U-M Injury Prevention Center offers this safer prescribing toolkit as a just-in-time resource for clinicians; the online toolkit also contains extensive resources for patients and their families on a variety of topics. In addition, the Opioid Prescribing Engagement Network has resources to help providers appropriately prescribe opioids, and the Michigan Opioid Collaborative offers "at-the-elbow" support for primary care providers who need expert consultation regarding managing complex pain and opioid use disorder situations.
Reducing the number of opioids prescribed limits the number of leftover drugs that may circulate in communities. When a person has remaining opioids they are no longer using, there are several ways to dispose of them safely.
Many communities participate in drug take back days with specific drop-off locations. On top of that, pharmacies and police departments across the country have on-site prescription drug drop-off programs.
Overdose deaths dipped slightly in 2018 but shot up dramatically in 2020 during the COVID-19 pandemic. All the interventions and programs designed to improve substance use care, the experts say, will take time to have a lasting effect—but the work is worthwhile and has the potential to save many lives.
"The four methods proposed here are not just good ideas; they have been studied and are proven to work," Dahlem. "We can save lives and give people an opportunity to join the 23 million others living in recovery. Remember, dead people do not recover."