After a severe car accident that required several surgeries, Sarah Sartori’s doctors prescribed her oxycodone, an addictive opioid, to manage her pain. The drug not only relieved the pain of her injuries but also soothed the psychological trauma that her accident caused. She quickly became addicted, using far more than prescribed. “I viewed myself as someone who would never have this problem,” Sartori, 43, said. “That made it really difficult to seek treatment.”
Eventually, her misuse of the drug became so severe that she asked her husband for help. At the time, they lived in Arizona. “We got really lucky,” she said. “We happened to be about an hour away from one of the best treatment programs that I could have gone to.”
In the residential program she checked into, she received a range of treatments. Doctors prescribed her medication for opioid use disorder, including a combination of the drugs buprenorphine and naloxone to relieve cravings and withdrawal symptoms when she arrived, and a long-acting, injectable form of the opioid blocker naltrexone for maintenance after she checked out. She also received counseling and behavioral therapy, including forms specifically tailored to post-traumatic stress disorder, which she suffered from her car accident. The experience was the beginning of a path to long-term recovery.
Sartori’s story represents the success of several proven approaches to treating opioid use disorder. In March, Congress passed a Biden administration proposal that made new funding available in an effort to dramatically expand the use of such approaches. The American Rescue Plan, a $1.9 trillion federal response to the COVID-19 pandemic, increases block grants to state and local governments by $3 billion to address substance use disorder and mental illness, with additional funding for behavioral health services. When combined with $4 billion for those services in the prior relief package and the billions from settlements with prescription opioid manufacturers, it raises federal spending for opioid treatment by around 25 percent.
A Crucial Moment
The move comes at a crucial moment in the opioid crisis, as preliminary reporting from the Centers for Disease Control and Prevention shows that more than 87,000 people died from drug overdoses in the year leading up to September 2020, a 12-month record. Around 70 percent of those involved misuse of opioids like prescription painkillers, fentanyl, and heroin.
But opioid policy experts like Richard Frank, a professor of health economics at Harvard Medical School, warn that the flood of cash also presents challenges. While it represents a once-in-a-generation opportunity to improve America’s response to substance use disorder, it also requires that the country spend carefully on approaches that research has proven to be effective. Because federal guidelines cannot account for the diverse values, health care infrastructure, and resources across American communities, that means that discretion over spending will fall largely to a patchwork of state and local policymakers.
“We have a very heterogeneous country,” Frank said. “In some places, there is a lack of treatment resources, particularly in some rural states. There are values that differ. There is a reluctance to use some medications for opioid use disorder. Certainly in the case of methadone, that's true. You also have dramatically different health care and financial resources.”
Compounding the disparities in local resources are ideologies that have nothing to do with science, Frank said. That can include strong commitments to detox-only programs or abstinence-only approaches, which may not align with the evidence on what works to treat opioid use disorder. Because of this, there is a risk that policymakers will spend this taxpayer money on ineffective care.
In recognition of these challenges, advocates and foundations are working to promote solutions that use public funding to save the most lives possible. Frank recently led a coalition of experts from different fields in producing a report, published by the Legal Action Center, that compiles a menu of proven interventions for opioid use disorder, along with their costs to communities.
The report recommends a few things known to work. First is prescribing the three major medications for opioid use disorder: methadone, buprenorphine, and long-acting, injectable naltrexone. Evidence shows that, depending on a variety of circumstances, some patients benefit most from treatment through residential programs and psychosocial approaches like cognitive behavioral therapy, peer support, and case management along with medication. Together, these are the methods that helped Sartori find her way to lasting recovery.
Another important step is taking advantage of contact with patients in health care, criminal justice, and correctional settings to identify opioid use disorder and initiate treatment. Finally, the report recommends using harm-reduction methods that include the drug naloxone for overdose reversal, as well as syringe exchange programs that can help reduce disease transmission from intravenous drug use and offer an onramp to long-term treatment.
The authors explain how a state’s unique politics, finances, and infrastructure may make some packages of programs more practical than others. “What our report is trying to point out is that regardless of what your budget is, regardless of what your ideology is, there are things that work to get people better,” Frank said.
What our report is trying to point out is that regardless of what your budget is, regardless of what your ideology is, there are things that work to get people better.Richard Frank professor of health economics at Harvard Medical School
A $50 Million Investment
Among the other funders working to ensure dollars are most effectively spent, Bloomberg Philanthropies is taking measures to jumpstart state actions and spending, with a $50 million investment aimed at reducing opioid overdose deaths and creating state models that other funders and policymakers can follow.
“States have been receiving funding from the federal government,” said Jessica Leighton, who oversees the Bloomberg Philanthropies Opioid Initiative. “But we found that states often needed additional expertise and capacity to use that funding. Our support is intended to provide technical assistance and embed staff in two high-burden states to help develop protocols, programs and policies.”
Recently, the Bloomberg School of Public Health at Johns Hopkins University also led a group of more than 50 organizations in drafting a set of principles for effectively using opioid settlement funds on strategies that will save lives. Those principles, Leighton said, will also be useful for states seeking guidance on how to spend dollars flowing to them through the American Rescue Plan. One important principle it includes is “Use evidence to guide spending,” the big-picture version of the specific guidance in the Legal Action Center’s report.
Sartori hopes that states will take that guidance. She has been in recovery from opioid use for seven years, and today, she is a vice president of marketing at Shatterproof, a nonprofit organization that advocates for better access to addiction treatment based on science.
“There is really no standardized way to find high-quality addiction treatment in America right now,” she said. With new money flowing to states for treating opioid use disorder, she wants others to be able to access the kind care she received. Shatterproof has developed a set of national principles of care, guidelines the organization proposes so that new funding will support measures like routine screenings for opioid use disorder, fast access to treatment, medication, and broad-ranging recovery support services.
“The most meaningful work that we're doing is our advocacy to make sure that, in every state, substance use disorder is treated the same way as any other disease, that people have access to doctors, and that people have access to medicine,” Sartori said. “That work is absolutely critical.”