Guest Blog: Here’s What a Massive New NIH Addiction Study Found

Discouragingly, an ambitious study recently reported in the New England Journal of Medicine did not prove evidence-based interventions like distributing naloxone (Narcan) and providing access to medication-assisted treatments (MATs) significantly curbed opioid deaths. Likely reasons for these findings start with the opioid epidemic as a moving target. False dichotomy either/or thinking is another issue, as both prevention and harm reduction are crucial to saving lives. Trying to end or delay use is also an unacknowledged but viable strategy.

Child and adolescent psychiatrist Sarah Vinson, M.D., Chair, Morehouse School of Medicine’s Department of Psychiatry & Behavioral Sciences, said, “The opioid crisis is driven by many factors that cannot be easily factored into any study, such as despair, poverty, genes, gene expression linked to secondhand drug or trauma exposure, housing, mental illness, involvement in the criminal legal system, other social determinants, and global drug manufacturing, distribution and selling entrepreneurship. Bottom line is primary prevention of drug use is underutilized and very poorly funded.”

Dr. Vinson noted the age of first use of a substance is key. “It is clear substance use disorders starting in 10-year-olds or teens need very different interventions and treatments than SUDs in physician addicts in their 30s.”

The National Institutes of Health (NIH) awarded $344 million to fund the HEALing Communities study. The focus was on overdose education, naloxone distribution, and medications treating opioid use disorder (OUD). This historic effort, launched in April 2018, was touted to reduce opioid deaths by 40 percent, boost addiction medicine, and create an infrastructure to coordinate responses to OUD.

Sadly, the study found rates of opioid-related overdose deaths did not differ compared to the control group. However, much was learned in this program implementing evidence-based treatment approaches, coalitions, and health system delivery building. While the headline now is failure of harm reduction, the data will continue to be evaluated, interventions modified/eliminated, and more positive findings reported. Still, I think longer-term implementation could have created better results.

Naloxone distribution and encouraging medication-assisted treatments are life-saving. They are often the last resort compared to prevention or interventions. Said National Institute on Drug Abuse (NIDA) director Nora Volkow, M.D., “This study brought researchers, providers, and communities together to break down barriers and promote the use of evidence-based strategies that we know are effective.” She added, “It’s clear we need to continue developing new tools and approaches for addressing the overdose crisis…”

Why did communities implementing public health strategies not see a statistically significant reduction in opioid overdose deaths?

The opioid overdose crisis: A moving target. The opioid crisis is a moving target, quickly making public health approaches obsolete. For example, counterfeit fentanyl-containing pills and heroin, cocaine, and methamphetamine, as well as xylazine combined with lab-made fentanyl, escalated death rates. Consequently, a death rescue strategy built for heroin overdoses, with patients treated with low doses of naloxone delivered intranasally in the community, was behind the curve once fentanyl dominated the former heroin user market. Fentanyl is uniquely dangerous, addicting, and anhedonia-inducing alone, challenging harm-reduction efforts.

Harm reduction doesn’t equal prevention or cure. Addiction is a chronic, relapsing, long-term disease, often ending with premature death. Harm reduction is important but not a cure, as more than 20 percent of all opioid overdose decedents received naloxone but died anyway. NIDA has funded new treatment development and research on overdose, psychedelics, brain neuromodulation, neurosurgery, immunological treatment, and vaccines. Focusing on at least five years of methadone treatment makes harm reduction and treatment sense.

Looking back. When tobacco use peaked in the mid-1960s, more than 40 percent of adults in the U.S. smoked cigarettes. Stigmatizing cigarette smokers was an important means of ending the tobacco epidemic. The tobacco smoking epidemic was reversed not by new treatments for nicotine use disorders, but public anti-smoking campaigns, legislation, and hefty taxation. Anti-tobacco campaigns made tobacco dangerous and changed social norms.

Imagine if the tobacco harm reduction approach had persisted. In that case, we might still have tobacco addiction deniers, smoking at work and in restaurants, and cheap cigarettes everywhere.

We must reduce stigma to get folks into treatment and ensure they aren’t ostracized. Inadvertently, we stopped raising the alarm about the dangers of drugs when what we need to do is stigmatize the drugs themselves.

An either-or dichotomy: MATs or prevention. Billions of federal dollars have been spent saving many lives from overdose. The current fentanyl death crisis is a speedballing and poly-drug zombie era. Nowadays, prevention is unrelated to stopping physicians from writing too many opioid prescriptions. We need new prevention ideas, targets, and tactics. I remember Dr. Dave Smith’s terse but effective motto: “Speed Kills,” and the anti-use impact of Len Bias’s and John Belushi’s deaths.

With support, Anne Milgram’s “One Pill Can Kill” could be an effective preventive message. Programs like the Office of National Drug Control Policy’s Drug-Free Communities, which have proven success reducing youth substance use, should be part of community evidence-based solutions.

There has been almost no new investment in stopping or delaying drug use in the first place—the most cost-effective way to reduce the number of new people entering pathways leading to overdose and death.

Many teens today choose not to use alcohol, cannabis, and other drugs. We need to support teens with prevention initiatives, in addition to providing overdose reversal, MAT treatment, and years-long continuation of addiction treatment.

We have decades of experience evaluating and treating physicians and other health providers with OUDs and SUDs. At the five-year follow-up, 80 percent of these resource-rich patients are in recovery and at work. I wish such treatment were available to everyone who wanted it.

In his book The New Addiction Treatment, David Patterson Silver Wolf reported patients refusing treatment and others repeatedly treated with the same treatment. In his paper, relapsing OUD was blamed on the patient—rather than the limited treatments available.

While not finding the reduced deaths expected, this harm reduction study facilitated remarkable community engagement, best practices and treatment system building. More good news from the study will likely come in the future. Strategies focusing exclusively on people already using drugs—rather than also investing in stopping or delaying use among youth and young adults—may explain the ever-changing continuous drug death tragedy in the U.S.