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Tackling the Opioid Crisis by Understanding How Its Pieces Fit Together

A new report from RAND Corporation argues that progress against opioid drug abuse and addiction is best understood — and addressed — in the context of everything that comes with it through an ecosystem view.

Families who lost loved ones to fentanyl overdoses gathered in remembrance at Lincoln Veterans Memorial Park in Civic in Denver.
(Helen H. Richardson/TNS)
In Brief:
  •  Deaths from opioid overdoses have been rising for decades.
  •  The introduction of powerful synthetic opioids has increased the rate of opioid death levels so high they are a factor in decreasing life spans in the U.S.
  •  RAND researchers make the case that progress in addressing this crisis depends on taking interactions between the pieces of the opioid “ecosystem” into account.

  • How could a flower cause so much trouble? Drugs made from the opium poppy have been used as medicine, and abused, for 8,000 years. The properties that make them effective pain relievers can also produce an addictive state of euphoria.

    America’s first opioid crisis came in the aftermath of the Civil War. Wounded soldiers became addicted to the morphine injections and opium pills they received to lessen the pain of serious wounds, and this abuse spread. By one estimate, hundreds of thousands of Americans were addicted to these drugs by 1890.

    A century later, opioid crises came in waves. (“Opioid” is used to refer to drugs derived from the plant as well as synthetic drugs that mimic its properties.) Increases in opioid prescriptions in the late 1990s led to wave of overdose deaths. In 2010, deaths from heroin overdose began to rise.

    The next wave began in 2013, the Centers for Disease Control and Prevention (CDC) says. It was driven by overdoses of synthetic opioids, primarily fentanyl. These man-made drugs, intended to relieve severe pain from advanced cancer or surgery, can be 50 to 100 times stronger than natural opioids.

    This third wave continues to grip the nation. In addition to prescription misuse, drug dealers are manufacturing illicit fentanyl to sell in pill form or mix with heroin, cocaine, methamphetamine or other drugs. Drug overdoses took the lives of more than 107,000 Americans in 2022, according to the CDC, and more than 80,000 involved at least one opioid.
    A group of RAND researchers has offered a fresh look at this public health crisis. In a 600-page report aimed at policymakers, they make the case that progress depends on taking all the systems that it touches into account.

    An Opioid Ecosystem

    Last year, the National Center for Health Statistics (NCHS) reported that life expectancy in the U.S. had fallen to its lowest rate since 1996. The primary causes were COVID-19 and drug overdoses.

    Progress toward turning things around is not keeping pace with impacts on this scale, says Bradley Stein, co-editor of the report and a senior physician policy researcher at RAND. Conversations about response tend to focus on one aspect of the problem, he says, such as treatment, harm reduction or illegal supply. “We wanted to take a step back from those silos and think about it more holistically.”

    To accomplish this, RAND gathered a group of its experts who don’t normally work on opioids, but have expertise in areas including the education system, child welfare, workforce, criminal law, homeless services and emergency response. They were asked to examine how the opioid crisis affects their areas of focus and to look for missed opportunities to do something about it.

    This ecosystem view of the problem did reveal missed opportunities, Stein says, as well as the fact that policies that make sense in one system can have unintended consequences in another. For example, even minor drug charges can affect access to housing, employment or education opportunities, eroding stability essential to recovery and harming the families of those struggling with addiction.
    Opiod Ecyosystem.jpg
    Numerous systems play a role in dealing with the consequences of opioid abuse disorder, sometimes with problematic consequences for another system.
    (RAND Corporation)
    “The CDC has invested a good deal of money into having more precise information on fatal overdoses, but we don’t have the same type of information on the number of children who end up being involved in the foster-care system,” Stein observes.

    The RAND report encourages innovation at state and local levels, including implementing interventions on a time-limited basis and evaluating their outcomes, reconsideration of criminal penalties for possession and use and gaming exercises that look at cross-sector effects of policy.

    This requires data about what happens to people as they move from one part of the ecosystem to another. Massachusetts made it a priority to fill this gap, says Stein, and uncovered linkages that led to policy changes.

    A Data Warehouse

    In 2015, Massachusetts Gov. Charlie Baker established an Opioid Addiction Working Group. Members from government, medicine, education and law enforcement identified areas where missing data impaired response.

    With help from a law that addressed statutory barriers to data sharing, the state’s department of health created a “data warehouse” that could be used for cross-sector analysis. It draws on 28 data sets, from postmortem toxicology reports and prescription monitoring to homelessness and mental health services.

    Startling insights emerged. Opioid overdose deaths were 120 times higher for those with histories of incarceration and 23 times higher for those with a history of homelessness. Postpartum mothers known to have opioid use disorder (OUD) were 321 times more likely to die of overdoses than those without it.

    “Through data analysis, we were able to see who was dying, where and why, allowing the department to develop strategic investments,” said a department of health spokesperson.

    Opioid Solutions Center

    Funds are available that could help the public sector explore ways to get pieces of the opioid ecosystem working in sync. Opioid makers and distributors have faced a torrent of lawsuits from state and local governments seeking to recoup at least some of the more than $1 trillion that the opioid crisis is costing the U.S. each year. The largest settlement to date, between states, manufacturer Johnson & Johnson and three opioid distributors will bring $26 billion to eligible state and local entities over the next 18 years.

    The National Association of Counties (NACo) has established an Opioid Solutions Center to help counties make decisions about how they will use these funds. NACo is providing case studies, reports and briefs on strategies eligible for settlement funds.

    The intent is to give county officials a “what works” resource that gives a concise look at each strategy, what it addresses, and what it takes to do it well, says Ashleigh Holand, director of NACo’s Counties Futures Lab.

    NACo also worked with Johns Hopkins University to create how-to guides for planning principles the university developed for the use of settlement funds.

    “It's not just, ‘You should do this,’ but also ‘Here's how, and here's a good example and here's who you can talk to if you have questions’,” Holand says.

    Funding is available from the American Rescue Plan, the Bipartisan Infrastructure Law and the Inflation Reduction Act to address social determinants of health, social and environmental factors that affect well-being.

    Bolstering this health infrastructure could help foster coordination on opioid response between sectors such as education, health care and the workforce.
    Medical training isn't necessary to administer Narcan, a nasal spray can stop an opioid overdose and save a life. Some in the treatment world would like to see it in public vending machines, but not every community is comfortable with the "optics."
    (Rich Sugg/TNS)


    The stigma attached to drug use and other mental health problems is a barrier, Stein says. “Many of the issues we found related to stigma.”

    The opium crisis is a wicked, complex problem, he says, and it’s harder to sort out interconnections and unintended consequences than to focus on one piece of it. Still, some communities are beginning to bring stakeholders together and wrestle with this challenge. Stein and colleagues would like to see “system stewards” who help persons with OUD navigate transitions from one part of the ecosystem to another.

    “Some options are going to be far more acceptable in some communities rather than others,” Stein says, “But continuing to do the same thing over and over again is not going to result in the changes we need in the face of tens of thousands dying from overdose and the human toll the crisis is taking on families.”
    Carl Smith is a senior staff writer for Governing and covers a broad range of issues affecting states and localities. He can be reached at or on Twitter at @governingwriter.
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