Every year the President’s Office of National Drug Control Policy (ONDCP), informally referred to as the “Drug Czar’s office,” releases a national drug control strategy announcing priorities for the administration. For decades, this report has emphasized interdiction and law enforcement-based approaches for combatting addiction. However, in the 2022 version published on April 21, 2022, the term “harm reduction”—strategic principles for reducing adverse effects of drug use that does not rely on law and punishment or total abstinence as a requisite goal—is mentioned 195 times. For context, the term has never been mentioned in the national drug control strategy to date. While the Obama White House may have taken incremental steps toward allowing for harm reduction principles and strategies in national efforts, the Biden administration has abruptly leapt ahead of long-held conventional wisdom about what is possible at the federal level. The 2022 report should be championed as indicating the dawn of a new age of drug control policy.
The irony should not be lost on us that President Joe Biden was a central figure in the tough on crime era of the 1980s and is now presiding over the most progressive genuflection of the ONDCP since its inception. More than a reflection of any singular individual, this moment in history likely suggests that two generations of failed drug war policies are no longer sustainable. The nation’s awakening to systemic racism, mass incarceration, and skyrocketing rates of overdose mortality despite many billions in dollars of federal and state spending have heralded a reconsideration of decades’ worth of drug strategies.
Supply And Demand
In general, there are two broad categories of approaches to reducing drug use: supply-side interventions and demand-side interventions. Supply side, as it sounds, includes efforts to reduce the availability of drugs. This includes access and cost. The hope is that by making drugs scarce and more expensive that fewer people, especially young people, will be inclined to use them. This philosophy is reflected in the director of the ONDCP often being recruited from the armed forces or law enforcement. More promising in theory than reality, supply-side interventions tend to be extremely expensive and yet mainly exert evolutionary pressures on the drug trade. Consider national prohibition of alcohol in the early 20th century and the incredible innovation that flourished under its draconian laws. While supply-side efforts are crucial to stemming unbridled advertising and importation of illegal drugs, they are very limited for actually helping people already addicted to particular substances. Hence, the need for demand side interventions.
Unlike supply-side efforts, which make phenomenal talking points on the campaign trail, demand-side interventions are evidence-based but, for many, a bit counter-intuitive. Allowing access to sterile syringes, for example, does not actually increase injection drug use, rather it reduces the spread of infectious disease. Providing naloxone, the overdose-reversal medication, does not cause risky behavior, it saves lives. Keeping patients in treatment for opioid use disorder, even when they are using other drugs such as cocaine, leads to better outcomes, not clinical destabilization. However, viewed through a lens overly colored by law enforcement and top-down control, these efforts threaten the status quo dating to the early 1970s. For people addicted to drugs, the best way to reduce drug use is to offer high-quality, evidence-based treatment—the central pillar of demand-side interventions. And for the first time in US history, the director of the ONDCP is a physician.
Unlike Western peer nations, the US is an outlier in our approaches to addiction treatment. At the intersection of privatized health insurance markets, ideological dogma about abstinence-only recovery, and widespread workforce shortages, addiction treatment has been marginalized to the periphery outside of mainstream health care settings. Unlike other areas of health care, treatment funding largely derives from block grants from the Substance Abuse and Mental Health Services Administration (SAMHSA) disbursed through state agencies. The modal care episode for opioid addiction in the US involves group therapy and 12-step-based ideology pressuring participants to commit to total abstinence and disavow their former selves. In contradistinction, the evidence base for what leads to less drug use, fewer opioid-involved overdose deaths, and lower mortality rates for patients with opioid use disorder hinges on two things: medication initiation and medication retention. Every day a patient with opioid use disorder is on a medication such as buprenorphine or methadone, their risk of death drops by about 66–80 percent. When such a patient stops medication-based treatment, their risk of death shoots up six-fold. Yet, only one in three treatment episodes for opioid use disorder involves a Food and Drug Administration-approved medication. The status quo has been failing our patients for too long.
The Mental Health Parity and Addiction Equity Act, passed in 2008, was intended to address many of these problems: unaccountable care for addiction treatment that is often subjected to discounted reimbursement rates or all-together non-reimbursable by insurance plans. While Medicaid expansion under the Affordable Care Act has successfully enrolled tens of millions of otherwise uninsured individuals, disproportionately with substance use disorders, and resultantly expanded coverage for addiction treatment, it has done little to actually improve the quality of care delivered to these covered lives. Concerted action is greatly needed by the Department of Labor and states’ attorneys general to confront bad actors and hold insurance plans accountable for flagrant parity violations that have mostly gone unchecked for the past decade.
The 2022 ONDCP national drug control strategy lays out seven bold objectives to achieve by 2025. Chief among them is an effort focused on treatment in the US: “Treatment admissions for the populations most at risk of overdose death is increased by 100 percent by 2025.” With three-quarters of overdose deaths now involving synthetic drugs such as fentanyl, this objective clearly refers to users of opioids as well as psychostimulants that may be adulterated with fentanyl-related compounds. While federal US health agencies have long maintained that around two million individuals are addicted to opioids, recent analyses with more rigorous methodologies suggest the true number is closer to seven million. To help millions of individuals successfully enter treatment, we need to make treatment easier to access than drug dealers. This is a time for innovation.
Providing evidence-based care is of the utmost importance; however, we additionally need to track these investments in addiction treatment and monitor how patients, especially those on the margins, manage to navigate treatment systems and successfully progress to recovery. Unlike many other fields in medicine, most notably HIV/AIDS, we lack the data collection and reporting systems to even know what is happening in the US. Investment in our data collection, reporting, and monitoring efforts is requisite to know what is happening on the ground. While SAMHSA has required states to report on levels of need and outcomes from block grant funding, there is no standardized framework for assessing treatment outcomes across geographies and populations. The opioid use disorder Cascade of Care, now widely promoted by the National Institutes of Health and the Centers for Disease Control and Prevention, holds great promise as a public health framework for organizing such efforts. The Cascade hinges on the two key stages of treatment medication initiation and retention. Primary to both, patients must first engage in specialty services to be connected with care settings that even have the ability to initiate medication use.
And here is the rub: Harm reduction services such as syringe exchange programs, naloxone distribution efforts, and drug testing initiatives are not reimbursable by insurance plans. The very services, evidence-based services, that engage persons at greatest risk of overdose death are not covered by insurance plans, not billable for reimbursement, and remain invisible to administrative data such as the health care evaluation data information system (HEDIS). State and county health agencies may, at the aggregate level, have a sense of how many people are receiving particular services, but there is currently no way to link at the individual level which drug users receive which services and who does or does not ever enter treatment. While confidentiality is a laudable virtue for protecting individuals’ data, it should not impede our nation’s ability to respond to a crisis that has killed nearly one million Americans and is the leading cause of death for those younger than 50 years of age.
Innovation in both treatment delivery systems and data infrastructure are therefore necessary to respond to the addiction crisis and monitor which efforts are best succeeding for which populations. Stemming from regulatory reform under the COVID-19 public health emergency, we now have a much greater sense of what is possible: Allowing for emergency licensure across state lines, expanding access to life-saving medications such as buprenorphine with remote clinical encounters, monthly take-home doses of methadone for stable patients, and the recent invention of long-acting injectable medications, offer many new avenues for connecting people in need with high-quality care. These reforms should be permanently codified and promoted to achieve the lofty goal of increasing treatment admissions by 100 percent. Additionally, we should invest in monitoring and public health surveillance efforts to track who gains access to these life-saving services and combat ever-persistent disparities in access.
For 50 years, we have operated under the delusion that responding to drug use and addiction with punitive measures would improve outcomes. Instead, we have witnessed the destruction of communities, ever-increasing mortality and morbidity, and skyrocketing overdose rates despite massive spending. The pivot to harm reduction and person-centered care is long overdue. The ONDCP guides the nation’s response to drugs and drug policy, and the 2022 national drug control strategy is a clear departure from prior efforts. With millions of lives on the line, this is both a relief and a challenge. Health and law enforcement authorities should recognize this moment for what it is and recalibrate longstanding outdated approaches to better incorporate what we have learned over these decades. Scaling access to evidence-based services is crucial to reducing dangerous drug use and overdose deaths. Fortunately, the nation’s leading office is now focused on reducing harm rather than filling prisons.
Dr. Williams receives compensation as fees, equity, and travel expenses from Ophelia Health, Inc., where he serves as chief medical officer.