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1、How Leveraging System Interactions Can Help Curb Addiction,Overdose,and Other HarmsAMERICASOPIOIDECOSYSTEMDionne Barnes-Proby|Jonathan P.Caulkins|Lois M.Davis|Michael DworskySusan M.Gates|Martin Y.Iguchi|Karen Chan OsillaRosalie Liccardo Pacula|Bryce Pardo|Tisamarie B.Sherry|Sierra SmuckerBRADLEY D.
2、STEIN|BEAU KILMER|JIRKA TAYLOR|MARY E.VAIANAEDITORSC O R P O R AT I O NFor more information on this publication,visit www.rand.org/t/RRA604-1.About RANDThe RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world sa
3、fer and more secure,healthier and more prosperous.RAND is nonprofit,nonpartisan,and committed to the public interest.To learn more about RAND,visit www.rand.org.Research IntegrityOur mission to help improve policy and decisionmaking through research and analysis is enabled through our core values of
4、 quality and objectivity and our unwavering commitment to the highest level of integrity and ethical behavior.To help ensure our research and analysis are rigorous,objective,and nonpartisan,we subject our research publications to a robust and exacting quality-assurance process;avoid both the appeara
5、nce and reality of financial and other conflicts of interest through staff training,project screening,and a policy of mandatory disclosure;and pursue transparency in our research engagements through our commitment to the open publication of our research findings and recommendations,disclosure of the
6、 source of funding of published research,and policies to ensure intellectual independence.For more information,visit www.rand.org/about/research-integrity.RANDs publications do not necessarily reflect the opinions of its research clients and sponsors.Published by the RAND Corporation,Santa Monica,Ca
7、lif.2023 RAND Corporation is a registered trademark.Library of Congress Cataloging-in-Publication Data is available for this publication.ISBN:978-1-9774-1066-5Limited Print and Electronic Distribution RightsThis publication and trademark(s)contained herein are protected by law.This representation of
8、 RAND intellectual property is provided for noncommercial use only.Unauthorized posting of this publication online is prohibited;linking directly to its webpage on rand.org is encouraged.Permission is required from RAND to reproduce,or reuse in another form,any of its research products for commercia
9、l purposes.For information on reprint and reuse permissions,please visit www.rand.org/pubs/permissions.iiiThis book is dedicated to our dear friend and colleague,Martin Iguchi.From his early work implementing the first methadone program in Camden County,New Jersey,to his pioneering work on contingen
10、cy management and his contributions to this volume,Martin was steadfast in his commitment to helping those most in need.He served as a mentor to several authors of this book,providing the insight,humor,and compassion that we all needed.Martin will be long remembered in the field and by the people he
11、 helped.He is missed by us all.Martin Y.Iguchi19552021vAbout This ReportIn 2018,the RAND Corporation initiated a comprehensive effortOpioids Unchartedto better understand the problems and responses to help stem the tide of opioid overdose and addiction.The first product from this initiative,a book t
12、itled The Future of Fentanyl and Other Synthetic Opioids,remains the most comprehensive document written about the ori-gins of this problem,the current situation,and possibilities for the future.The key message from this book was that decisionmakers in the United States must start thinking“outside t
13、he box”when considering solutions.Since that book was released in late 2019,limited progress has been made.The corona-virus disease 2019(COVID-19)pandemic pushed our problems with opioids and overdose deaths to the back burner,but they continue to boil over.Unfortunately,that book is just as relevan
14、t today as when it was published,and the recommendations and ideas discussed could still make a difference.The second product from the Opioids Uncharted initiative is a more holistic and far-reaching effort,focused on what we refer to as“Americas opioid ecosystem.”Viewing the opioid crisis as an eco
15、system requires adopting a comprehensive perspective.The book draws on the expertise of more than 15 RAND researchers in multiple areas,including drug policy,substance use treatment,health care,public health,criminal legal system,harm reduction,child welfare and other social services,education,and e
16、mployment.Understanding the nature of the opioid ecosystem is a necessary step for decisionmakers seeking to continue to address the crisis.To craft sound policies,they need to pay attention to multiple parts of the ecosystem at the same time.They also need reliable information to understand how pol
17、icies interact and what effects of the interaction are likely to be.Moving away from siloed thinking and adopting an ecosystem approach will not only help curb the opioid crisis.It should also help mitigate the harmful consequences of other drug problems.We dedicated project resources and communicat
18、ions expertise to ensure that our prod-ucts and dissemination activities are optimized for reaching our primary intended audi-ences:policymakers and other critical decisionmakers and influencers,including those in the public,private,and nonprofit sectors.This ambitious project will not be the last w
19、ord on Americas drug crisis,but it offers a unique perspective on how the country understands and responds to this grave public health challenge.FundingFunding for this venture was provided by gifts from RAND supporters and income from operations.We are especially grateful to the contribution made b
20、y Jack McCauley,whose support was critical in the late stages of the project.Americas Opioid EcosystemviAcknowledgmentsThis book would not have been possible without the vision of our former RAND President,Michael Rich.Michael encouraged us to think big about addressing Americas issues with opioids
21、and provided the guidance and support to make it happen.His leadership and invest-ment in RANDs Opioids Uncharted initiative led to this volume and to our book on The Future of Fentanyl and Other Synthetic Opioids.We are deeply indebted to Michael for every-thing he has done for this initiative,for
22、us personally,and for the larger RAND community.There would also be no book if it were not for our brilliant chapter authors.Many of these chapters could have been developed into separate books,and we were amazed by the authors abilities to crystallize the ecosystem interactions and key policy consi
23、derations for their respective chapters.We learned a tremendous amount from our colleagues during this process and are forever thankful for their wisdom(and patience!).We are especially grateful for the extremely detailed and useful comments we received on the full volume from Ricky Bluthenthal,Jona
24、than Caulkins,Beth McGinty,and Susan Sohler Everingham.We are also indebted to those who reviewed stand-alone chapters,including Mahshid Abir,Dionne Barnes-Proby,Ray Barishansky,Shawn Bushway,Magdalena Cerda,Rajeev Darolia,Carrie Fry,Rebecca Kilburn,Jane Liebschutz,Nipher Malika,Aili Malm,Harold Pol
25、lack,Lucy Schulson,and Melanie Zaber.We also thank Rosalie Liccardo Pacula and Priscillia Hunt for their early contributions to this volume and Julia Dilley for her insights on drug possession decriminalization in Oregon.All these reviewers made this a much stron-ger book,but the views presented her
26、e reflect only those of the chapter authors.Because parts of this book are rooted in two previous RAND publications,Considering Heroin-Assisted Treatment and Supervised Drug Consumption Sites in the United States and The Future of Fentanyl and Other Synthetic Opioids,we remain indebted to the more t
27、han 200 people who shared their experiences and opinions with us during interviews and focus groups for those projects.Last,but certainly not least,we have many other colleagues at RAND who offered guid-ance and support throughout this process.We owe a tremendous amount to Anita Chandra,Rick Eden,Su
28、san Gates,Jennifer Gould,Kimbria McCarty,Chris Nelson,Darleen Opfer,Jeanne Ringel,Dana Torres,Jason Ward,Chara Williams,and to Brian Dau,Blair Smith,Maria Vega,Emily Ward,and Pete Soriano,who provided editorial and design assistance.viiSummaryMotivationThe United States has long grappled with multip
29、le problems stemming from the use of alco-hol and other drugs,but the number of individuals overdosing and dying from drugs has grown exponentially since 1979;provisional estimates from the Centers for Disease Control and Prevention(CDC)suggest that more than 100,000 individuals died from drug-invol
30、ved overdoses between September 2021 and August 2022.Approximately 75 percent of the deaths involve opioids(mostly opioids that are illegally produced),and most death certificates for overdoses list multiple drugs.But the problems are broader and deeper than drug fatalities.Reliable data are lacking
31、 on the number of individuals actively using drugs and those with substance use disorders(SUDs).Although most people who use drugs do not run into problems with them or suffer from SUDs,depending on the substances involved,there can be myriad physical and mental health consequences associated with b
32、eing addicted to drugs.And it is not just those with SUDs who suffer.Their substance use and related behaviors can significantly affect their families,friends,employers,and wider communities.Having a loved one suffer from addiction can bring with it substantial psychological,physical,and financial c
33、osts.Opioids play an outsized role in Americas drug problems,but they also play a critically important role in medicine.Thus,they deserve special attention.The dynamics of Americas drug problem are also shifting,not only in the types of opioids being consumed but also in the populations most affecte
34、despecially in terms of race and ethnicity.Of course,our primary focus on opioids does not mean we can ignore the countrys issues with other drugs.To the contrary,the United States confronts multiple challenges,includ-ing long-standing problems related to alcohol and a dramatic rise in harms related
35、 to meth-amphetamine use.Correspondingly,some of the observations and suggestions made in this volume will be applicable to contexts other than opioids.Focusing on Americas Opioid EcosystemMany policies have been implemented to reduce opioid use,enhance effective treatment,and mitigate opioid-relate
36、d harms.But confronting the crisis is not just about better pain management or treatment for opioid use disorder.Many widely adopted policies target indi-viduals at highest risk for opioid misuse or opioid use disorder and focus on the role of the health care system in providing treatment for addict
37、ion and comorbid disorders.However,a broader swath of the population and many more governmental and nongovernmental sys-tems are affected by problems related to substance use.These systems interconnect,often in Americas Opioid Ecosystemviiiunexpected ways.As a result,policies targeting one part of t
38、he system can have unintended consequences on other parts,affecting systems that they were not intended to target.A lack of a systems perspective also contributes to missed opportunities that could promote positive change.This volume,which is arguably the most comprehensive analysis of opioids in 21
39、st cen-tury America,offers a broader view by considering the opioid crisis in the context of an eco-system.1 Its component parts,linked by individuals and organizations,interact both directly and indirectly.Recognizing the ecosystems major components and exploring how they doand do notinteract allow
40、s us to understand how one component of the ecosystem can have a major impact on opioid-related outcomes in other components identify new policy opportunities that require interacting with or reducing barriers among multiple components of the ecosystem.Multiple commissions,task forces,and research t
41、eams are working to reduce the harms associated with opioids.We applaud these efforts,acknowledging their important contribu-tions.By necessity,our report covers much of the same ground.However,we extend the prior work on several important dimensions.We consider,more explicitly and in greater detail
42、,the specific ways in which the opioid crisis affects systems that are less commonly considered,such as the child welfare and education systems;we also consider how policies in those sys-tems may affect systems more commonly considered,such as the health care,harm reduc-tion,criminal legal,and SUD t
43、reatment systems.We examine policies that would be imple-mented within systems that could have potential benefits in other systems;we also appraise policies that must be implemented across systems and offer ways to do so.Major TakeawaysA major contribution of this study is to identify opportunities
44、at the intersections of the ecosystems components and to highlight other cross-sector initiatives that could mitigate the harmful effects of opioids.We offer nine portfolios of action addressing issues that arose 1 Some have referred to this problem as the“opioid epidemic,”“opioid crisis,”or“overdos
45、e crisis,”noting that the rise in overdoses is not limited to opioids.Those preferring the latter term are correct to note increases in deaths involving drugs other than opioids,but the problems extend beyond fatalities.This volume uses opioid crisis because it covers more than overdoses,is not limi
46、ted to problems faced by people who use opioids,and signifies the unique role opioids play in American society.This is in no way meant to suggest that other drug problems should not be addressed or to downplay the medical benefits opioids pro-vide millions of people in the United States.Indeed,an im
47、portant aspect of the crisis is the barriers people confront when trying to obtain prescribed opioids to treat opioid use disorder and,increasingly,for chronic pain.(For sources on terminology,see Chapter One.)Summaryixacross many ecosystem components.These portfolios could help decisionmakers prior
48、itize and organize their efforts to address the opioid crisis.Just because an idea appears in the volume does not mean that it is a priority option,or even a good option,for every community.We recognize the complexities,challenges,and potential downsides of implementing these ideas.For some ideas,th
49、ere is a strong evidence base;others have potential and deserve consideration.That said,some of the ideas,if imple-mented,might not be as effective as envisioned or could have unintended consequences.We offer four major takeaways:1.Americas issues surrounding opioids are most appropriately viewed in
50、 the context of an ecosystem.Like a biological ecosystem,it is dynamic,and its components(such as medical care,criminal legal system,harm reduction,and others,as depicted in Figure S.1)interact both directly and indirectly.Understanding these interactions is challenging but essential for effective p
51、olicy-making.For example:a.Ecosystem components often focus on individuals,but their families also lie at the heart of the ecosystem.The family members,friends,and wider communities of those with SUDs can also suffer its harms.Family members who live with those with SUDs are often directly affected,
52、and these relatives interact with the eco-system components in a variety of ways,depending on the status and needs of the individual using drugs.Understanding these interactions can help us iden-tify ways in which families can be better supported.Acknowledging the harms families experience could fur
53、ther justify devoting time and resources to helping them,potentially reducing the overall burdens imposed by opioid use disorder.b.Each ecosystem component has its own mission,priorities,and funding,but poli-cies furthering those priorities may hamper the efforts of other system components.Furthermo
54、re,most of these components are designed to serve the broader popu-lation,not just people who use opioids,and that can leave the special needs of this group unmet.Lack of coordination and communication across ecosystem com-ponents poses a formidable challenge for many opioid-affected individuals and
55、 their families.In addition,decisions made in one component can ripple through the ecosystem;effects can be helpful,harmful,or unanticipated.To illustrate this point,we present the following three examples:i.Public housing policies that can exclude individuals misusing substances are intended to pro
56、tect other residents,but housing instability is a significant barrier to successful treatment and recovery.ii.Making drugs illegal increases their price and reduces their availability.But a criminal record makes it harder for an individual to get a job and access social services,and fear may discour
57、age individuals with opioid use disorder from identifying themselves and seeking help.Americas Opioid Ecosystemxiii.Child welfare policies regarding parental drug use are intended to keep chil-dren safe,but fear of losing a child may prevent a parent who uses drugs from seeking treatment.2.Current r
58、esponses to opioid problems are insufficientthe United States need to innovate.The increased prevalence of such illegally produced synthetic opioids as fentanyl has exacerbated the harms of drug useand particularly of overdoseand complicated the struggle with opioids.a.Increasing access to and use o
59、f high-quality treatment for SUDs remains the top priority,but it will not be enough to stem the tide of overdose deaths and addic-FIGURE S.1The Opioid EcosystemPerson who uses opioidsFamilyChild welfareIncome support andhomeless servicesFirst respondersEmploymentHarm reductionEducationSubstance use
60、disorder treatmentIllegal supply and supply controlCriminal legal systemMedical careSummaryxition.Even clients receiving high-quality treatment for opioid use disorder often cycle in and out of treatment,and those who return to using illegally produced opioids(and sometimes other drugs and counterfe
61、it pills)carry a heightened risk of overdose in an era of synthetic opioids.b.Because criminalization of drug possession and/or use creates barriers in many components of the ecosystem,jurisdictions could consider alternatives ranging from changing enforcement practices to changing laws.Each alterna
62、tive has pros and cons,and the consequences will likely differ depending on local conditions(e.g.,types of drug problems,service infrastructure,existing enforcement prac-tices).c.The federal government should make it easiernot harderfor states or localities to pilot,implement,and evaluate interventi
63、ons that are intended to help reduce overdose deaths.Because the nature and character of current issues with opioids differ substantially across communities,giving state and local decisionmakers the latitude to design and implement local services is essential to ensuring that they address local need
64、s and priorities.d.New approaches need not be permanent and should include objective evaluation.There is considerable uncertainty and hesitancy regarding the introduction of new interventions.To assuage possible concerns,decisionmakers could imple-ment sunset clauses to limit the duration of new pol
65、icies and make their exten-sion contingent on satisfactory evaluation results.e.Policy gaming exercises could stimulate leaders to consider new approaches and the complexities of how they would affect other ecosystem components.The games could be coordinated by government officials,nonprofit organiz
66、ations,and/or philanthropic foundations.3.Someone needs to take ownership of assisting people in their journey through the systems.a.Individuals with opioid use disorders often touch multiple components of the eco-system,but it is not always clear who is responsible for coordination among com-ponent
67、s or transition from one component to another.Is it the system compo-nent from which an individual is coming that is responsible for managing the transition,or is it the system component to which the individual is going?Who takes ownership of assisting people in their journey or transition through t
68、he systems?(Examples include individuals with opioid use disorder being released from incarceration and needing to obtain employment or engage in treatment in the community;individuals receiving services from first responders or in emer-gency rooms who do not transition to treatment;and children who
69、 are informally moved to a relatives home because of parental substance use not being referred to services they may need.)By making clear who is responsible at these junctures and providing the resources necessary to meet the commitment of the additional Americas Opioid Ecosystemxiiresponsibility,po
70、licymakers and stakeholders can diminish some of the discon-nects that hamper the provision of treatment and support.b.A broader perspective allows us to identify policy opportunities generated by the interactions of components across the ecosystem.For example,comprehensive case managers could help
71、people with opioid use disorder navigate the landscape of existing service providers;develop a plan for appropriate services;and establish linkages and relationships with corresponding agencies,among other actions.These case managers also could remain involved with individuals throughout periods whe
72、n more-traditional case managers are not involved,such as during an individuals incarceration,enabling managers to address needs proactively during high-risk periods,such as release from incarceration.Such a model would likely require new sources of funding,probably from state and local governments
73、or foundations;therefore,case managers would be involved with individuals when they are uninsured and not involved with social services.4.The United States is often flying blind,which makes it difficult to evaluate exist-ing interventions,invent new ones,or improve our understanding of ecosystem int
74、eractions.a.The United States urgently needs to improve the data infrastructure for under-standing people who use drugs,drug consumption,and drug markets.There is a lack of credible information about the number of people with opioid use disorder and/or those using illegally produced opioids,let alon
75、e those who supply ille-gal opioids.This hampers policymakers ability to allocate resources efficiently,monitor changes in drug markets,and conduct rigorous policy evaluations.The United States needs to step up efforts to learn more about the size and character-istics of this population and how they
76、 are changing.b.There is little information about what happens to individuals when they transition from one component of the ecosystem to another.This,coupled with the data gaps mentioned earlier,hampers our ability to know how different components of the ecosystem interact and how that interaction
77、affects individuals moving through the system.c.Unlike many prior public health challenges,the onset of the overdose crisis has not motivated substantial new surveillance efforts.The HIV/AIDS crisis prompted large-scale investments in new data and monitoring systems.The overdose crisis,which now kil
78、ls more than HIV/AIDS did at its peak,has not elicited a compa-rable investment in data infrastructure.d.Concrete opportunities for data improvements exist and could offer great value to policymakers and researchers alike.For instance,administrative data already being collected by law enforcement ag
79、encies could be made more available to researchers so that they can learn about drug markets,especially for fentanyl.Valuable discontinued programs,such as the Arrestee Drug Abuse Monitoring(ADAM)program,could be resurrected.New data-collection efforts,such as Summaryxiiiwastewater monitoring,could
80、be introduced to provide essential real-time data on trends and changes in drug consumption and to detect the emergence of new psychoactive substances.Understanding the nature of the opioid ecosystem is a necessary step for decisionmakers seeking to move forward.They need to pay attention to multipl
81、e parts of the ecosystem at the same time.And they need reliable information to understand how policies interact and what effects of the interaction are likely to be.Moving away from siloed thinking and adopting an ecosystem approach will help stem the current tide of addiction and overdose deaths.I
82、t also should help mitigate the harmful consequences of future drug problems.xvContentsAbout This Report.vSummary.viiFigures and Tables.xxiCHAPTER ONEIntroduction.1The National Context for U.S.Issues with Opioids.1Current Responses to U.S.Opioid Problems Are Insufficient.4Efforts to Address Opioids
83、Confront Both Old and New Challenges.5Taking an Ecosystem Approach to Addressing Opioids.10Approach and Structure of This Report.23Abbreviations.26References.26CHAPTER TWOPeople Who Use Opioids .35Beau Kilmer,Jirka Taylor,and Bryce PardoIntroduction.35How Many People Use Opioids in the United States
84、,and Which Opioids Are They Using?.37How Does the Rate of Opioid Prescriptions in the United States Compare with That of Other Developed Countries?.40What Share of People Who Use Opioids Transition to Opioid Use Disorder?.43How Many People Currently Suffer from Opioid Use Disorder?.44What Are the Ch
85、aracteristics of Those with Opioid Use Disorder and Those Who Receive Treatment?.46Who Is Dying from Opioid-Involved Overdoses and How Has This Changed?.50What Is the Scope of Other Health Harms Related to Opioid Use,Including Nonfatal Overdose?.62What Do We Know About the Families of Those with Opi
86、oid Use Disorder?.68How Many Arrests Can Be Linked to Opioids Each Year?.69For Those with Opioid Use Disorder Who Are Justice Involved,What Share of Their Arrests Are for Drug Law Violations Versus Other Crimes?.73Improving the Data Infrastructure for Describing People Who Use Opioids,Their Families
87、,and Drug Markets.74Additional Data.77Abbreviations.88References.89Americas Opioid EcosystemxvixviCHAPTER THREEFamily Members of Individuals with Opioid Use Disorder.101Rosalie Liccardo Pacula,Sierra Smucker,Jonathan P.Caulkins,Beau Kilmer,BradleyD.Stein,and Jirka TaylorIntroduction.101How Are Famil
88、ies Affected by Opioids?.102How Do Families Interact with the Opioid Ecosystem?.105Other Considerations and Policy Options.108References.112CHAPTER FOURSpecialty Treatment System for Opioid Use Disorders.119Bradley D.Stein,Martin Y.Iguchi,Karen Osilla,Jirka Taylor Overview.119Introduction.122System
89、Components and How They Interact with Opioids.124Key Interactions with Other Components of the Ecosystem.132Policy Opportunities and Considerations.145Abbreviations.147References.147CHAPTER FIVEMedical Care.167Tisamarie B.SherryOverview.167Introduction.171System Components and How They Interact with
90、 Opioids.171Key Interactions with Other Components of the Ecosystem.191Policy Opportunities and Considerations.196Abbreviations.200References.200CHAPTER SIXCriminal Legal System .219Beau KilmerOverview.219Introduction.222System Components and How They Interact with Opioids.223Key Interactions with O
91、ther Components of the Ecosystem.237Policy Opportunities and Considerations.254Abbreviations.260References.260ContentsxviixviiCHAPTER SEVENIllegal Supply and Supply Control .273Bryce Pardo,Beau Kilmer,and Jirka TaylorOverview.273Introduction.277System Components and How They Interact with Opioids.28
92、0Key Interactions with Other Components of the Ecosystem.296Policy Opportunities and Considerations.300Abbreviations.306References.306CHAPTER EIGHTHarm Reduction and Community-Initiated Interventions.317Martin Y.Iguchi,Jirka Taylor,Beau KilmerOverview.317Introduction.321System Components and How The
93、y Interact with Opioids .322Key Interactions with Other Components of the Ecosystem.338Policy Opportunities and Considerations.343Abbreviations.345References.345CHAPTER NINEFirst Responders.365Jirka TaylorOverview.365Introduction.368System Components and How They Interact with Opioids.370Key Interac
94、tions with Other Components of the Ecosystem.377Policy Opportunities and Considerations.384Abbreviations.387References.387CHAPTER TENChild Welfare.397Dionne Barnes-ProbyOverview.397Introduction.401System Components and How They Interact with Opioids.403Key Interactions with Other Components of the E
95、cosystem.409Policy Opportunities and Considerations.417Abbreviations.421References.421Americas Opioid EcosystemxviiixviiiCHAPTER ELEVENIncome Support and Homeless Services.429Lois M.DavisOverview.429Introduction.435System Components and How They Interact with Opioids.436Interactions with Other Compo
96、nents of the Ecosystem.445Policy Opportunities and Considerations.451Abbreviations.454References.454CHAPTER TWELVEEmployment.461Michael DworskyOverview.461Introduction.465System Components and How They Interact with Opioids.467Key Interactions with Other Components of the Ecosystem.492Policy Opportu
97、nities and Considerations.497Abbreviations.502References.502CHAPTER THIRTEENEducation.509Susan M.GatesOverview.509Introduction.512System Components and How They Interact with Opioids.512Key Interactions with Other Components of the Ecosystem.523Policy Opportunities and Considerations.528Abbreviation
98、s.531References.531CHAPTER FOURTEENSynthesis:A Strategy That Reflects the Ecosystem Perspective.541Cross-Sector Barriers to Change.542Nine Portfolios of Action.546Prioritizing Policy Considerations.568Key Takeaways.569Abbreviations.570References.570ContentsxixxixAPPENDIXESA.Overview of Synthesis Exh
99、ibits and Ideas.577B.Overview of Chapter-Level Considerations.589xxiFigures and TablesFigures S.1.The Opioid Ecosystem.x 1.1.The Opioid Ecosystem.13 1.2.The Opioid Ecosystem:Vignette 1.16 1.3.The Opioid Ecosystem:Vignette 2.18 1.4.The Opioid Ecosystem:Vignette 3.20 1.5.The Opioid Ecosystem:Vignette
100、4.21 1.6.The Opioid Ecosystem:Vignette 5.23 2.1.Total Prescription Opioid Consumption for G7 Countries:Defined Daily Doses per 1 Million Inhabitants,19642018.41 2.2.U.S.Opioid Prescribing Rates,2020.42 2.3.U.S.Opioid-Involved Overdose Deaths,20002020.51 2.4.U.S.Drug Overdose Deaths Involving Synthet
101、ic Opioids,20002020.52 2.5.U.S.Opioid-Involved Overdose Deaths,by Sex,20002020.53 2.6.U.S.Opioid-Involved Overdose Deaths,by Race/Ethnicity,20002020.55 2.7.U.S.Opioid-Involved Overdose Deaths,by Age Group,20002020.56 2.8.U.S.Opioid-Involved Overdose Deaths,by Educational Attainment,20002020.58 2.9.U
102、.S.Opioid-Involved Overdose Deaths,by Marital Status,20002020.59 2.10.U.S.Opioid-Involved Overdose Deaths,by CBSA Designation,20002020.60 2.11.U.S.Opioid-Involved Overdose Deaths,by Census Region,20002020.61 2.12.Mean Availability of Analgesic Opioids in OECD Countries,20112013 and 20142016.78 4.1.S
103、UD Treatment System and Its Interactions.125 5.1.The Medical Care System and Its Interactions.172 6.1.The Criminal Legal System and Its Interactions.223 6.2.Estimated Number of Sentenced Prisoners Under State Jurisdiction for Drug Offenses in 2010 and 2019,by Race/Ethnicity.234 6.3.State Policies Re
104、garding Law Enforcement Access to Prescription Drug Monitoring Program Data,20102017.239 6.4.Supplemental Nutrition Assistance Program Eligibility for Individuals Convicted of Drug Felonies.252 7.1.The Illegal Supply System and Its Interactions.278 7.2.Drug-Involved Deaths in the United States by Sy
105、nthetic Opioid Involvement,20002020.280 7.3.Source of Most Recent Misused Pain Reliever,by Opioid Use Disorder Status(2019 National Household Survey on Drug Use and Health).288 7.4.Price and Purity of Heroin.290 7.5.Drug Seizures Involving Heroin and Synthetic Opioids in Selected States,20122020.292
106、Americas Opioid EcosystemxxiixxiiTables 2.1.Number of People Using Opioids in the United States.38 2.2.Per Capita Opioid Use Disorder Rates,by Race/Ethnicity,for Three Groups with Highest Prevalence Rates.49 2.3.National Nonfatal and Fatal Opioid-Involved Overdose Counts and Rates per 100,000 Indivi
107、duals,2017.65 2.4.Comparing Heroin and Cocaine Mentions in NIBRS,2019 .71 2.5.Characteristics of Those with Self-Reported Past-Year Opioid Use Disorder in NSDUH,2019.79 2.6.Substance Use Treatment Admissions from TEDS,by Primary Drug,2018.81 2.7.Characteristics of Medicaid Enrollees with Opioid Use
108、Disorder.83 2.8.Other Adult Family Members in a Household.85 2.9.Number of Children in a Household.85 2.10.Marriage Status of People With or Without Opioid Dependence and With or Without Past-Year Heroin Use or Pain Reliever Misuse.86 2.11.Uniform Crime Reports Arrests for Drug Violations in the Uni
109、ted States,2019.87 6.1.Alcohol or Drug Treatment Among State and Federal Prisoners Who Met the Criteria for Substance Use Disorder,2016.236 6.2.Example Programs,Locations,and Model Activity,by Pathway.241 A.1.Overview of Synthesis Exhibits and Ideas.578 B.1.Overview of Chapter-Level Considerations.5
110、90 8.1.The Harm Reduction System and Its Interactions.322 8.2.Type of Drugs Injected as a Percentage of All Drugs Injected at an Unsanctioned Supervised Consumption Site in the United States.330 9.1.First Responder System and Its Interactions.371 10.1.Child Welfare Case Flow.404 10.2.The Child Welfa
111、re System and Its Interactions.405 10.3.Overdose Deaths and Foster Care Caseloads,20022016.406 11.1.Income Support and Homeless Services Interactions with Key Components of the Opioid Ecosystem.446 12.1.The Employment System and Its Interactions.468 12.2.Overview of Potential Causal Relationships Be
112、tween Employment,Opioids,and Other Factors.469 13.1.The Education System and Its Interactions.5131CHAPTER ONEIntroductionOpioids play an outsized role in Americas drug problems,but they also play an essential role in medicine.The purpose of this volume is to inform ongoing policy efforts to reduce o
113、pioid-related harms,with a special focus on how individuals,organizations,and systems interact with respect to opioids.We argue that the issues surrounding opioids are appropriately viewed as an ecosystem and,as in a biological ecosystem,parts of the ecosystem interact both directly and indirectly.T
114、his comprehensive view recognizes how decisions made in one part of the ecosystem can have a major effectsometimes helpful,sometimes harmful,and sometimes unanticipatedin other parts of the system.A broader perspective also allows us to identify policy opportu-nities generated by the interactions of
115、 components across the ecosystem.In the chapters that follow,we characterize the ecosystem,drawing on the knowledge of subject-matter experts,existing research,and some of our own analyses.In our concluding chapter,we identify barriers and opportunities that are common to many parts of the ecosys-te
116、m and offer suggestions for prioritizing policy considerations.We begin by sketching the broad contours of the countrys struggle with drugs,giving special attention to opioids.The National Context for U.S.Issues with OpioidsThe United States has long grappled with multiple problems stemming from the
117、 use of alco-hol and other drugs,but the number of people overdosing and dying from drugs has grown exponentially since 1979(Jalal et al.,2018).Recent estimates suggest that more than 100,000 individuals died from drug-involved overdoses between September 2021 and August 2022(Provisional data from t
118、he Centers for Disease Control and Prevention CDC,2023).1 But the harms run broader and deeper than drug fatalities.We lack reliable data on the number of individuals actively using drugs and the subset of them who meet the clinical 1 The estimated total excludes those who may have died from drug-in
119、volved violence or accidents or medical conditions attributable to or exacerbated by substance use.This total also excludes deaths exclusively attributable to alcohol poisoning.CDC reports that there are about 2,300 alco-hol poisoning deaths each year and roughly 100,000 deaths that are attributable
120、 to alcohol-related causes overall(CDC,2019).Americas Opioid Ecosystem2criteria for a substance use disorder(SUD).2 However,one recent estimate suggests that,in 2019,at least 20 million Americans had an SUD in the past year(Substance Abuse and Mental Health Services Administration SAMHSA,2020b).3 Th
121、ere are also myriad physical and mental health consequences associated with SUDs;their nature and severity vary with the drugs involved(Degenhardt et al.,2013;Mark et al.,2001;Nicosia et al.,2009).It is not just those with SUDs who suffer.Their substance useand behaviors related to that usecan impos
122、e mental,physical,and financial costs on their families,friends,employ-ers,and wider communities.For example,although not everyone with an SUD engages in criminal behavior to support their habits,some do,and those who are victimized can also suffer greatly.Borrowing money from friends and familysome
123、times with little prospect of repaymentis another burden.There are many types of opioids,and they play multiple roles in the lives of millions of Americans.4 Most prescription opioids are used to help control chronic or acute pain(Dahl-hamer et al.,2018).Methadone and buprenorphine are opioids that
124、are used primarily to treat opioid use disorder(OUD).5 Per capita prescription opioid rates increased dramatically in the 1990s as pharmaceuti-cal companies promoted opioids aggressively,and pain was even promoted as the“fifth vital sign.”Some pharmaceutical companiesincluding the Sackler-owned Purd
125、ue Pharmaceuti-cals,among othersalso pursued deceptive and illegal activities to increase sales across the country(see,e.g.,Keefe,2021).For example,executives of InSys Therapeutics were convicted of criminal racketeering charges for essentially bribing doctors to prescribe fentanyl(Lopez,2019).There
126、 have been efforts to reduce the number of opioid prescriptions,given the devas-tating consequences of oversupply.However,these efforts have inadvertently created barriers for some individuals who need the drugs for pain relief,even though most studies find that 2 SUD and alcohol use disorder are tw
127、o distinct diagnoses,according to the Diagnostic and Statistical Manual of Mental Disorders(DSM).Unless noted otherwise,when we use the term SUD,we refer to drugs other than alcohol and tobacco.3 For insights about the limitations of using National Survey of Drug Use and Health data to measure the n
128、umber of people with SUD,and especially for the use of heroin,see Caulkins et al.,2015;Reuter,Caulkins,and Midgette,2021;and Chapter 2 of this volume.4 Some have referred to this problem as the“opioid epidemic,”“opioid crisis,”or“overdose crisis,”noting that the rise in overdoses is not limited to o
129、pioids.Those preferring the latter term are correct to note increases in deaths involving drugs other than opioids,but the problems extend beyond fatalities.This volume uses opioid crisis because it covers more than overdoses,is not limited to problems faced by people who use opioids(PWUO),and signi
130、fies the unique role opioids play in American society.This is in no way meant to suggest that other drug problems should not be addressed or to downplay the medical benefits opi-oids provide millions of people in the United States.Indeed,an important aspect of the crisis is the barriers people confr
131、ont when trying to obtain prescribed opioids to treat opioid use disorder and,increasingly,for chronic pain(Zhang,Kilaru,et al.,2021;Zhang,Paice,et al.,2021;Lagisetty,Healy,et al.,2019).5 The 2023 Consolidated Appropriations Act(H.R.2617),which was signed by President Biden on Janu-ary 4,2023,change
132、d requirements related to prescribing buprenorphine.Introduction3the United States continues to lead the world in terms of total and per capita rates of opioid prescribing(further discussed in Chapter Two).Most people who use prescription opioidsfor prescribed purposes or notdo not expe-rience probl
133、ems because of their use(Higgins,Smith,and Matthews,2018;Volkow et al.,2019).This is partly because most people use them for short periods and infrequently.Indi-viduals who use the drugs for longer periods sometimes become physically dependent,mean-ing that“the body adapts to the drug,requiring more
134、 of it to achieve a certain effect(toler-ance)and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased(withdrawal)”(National Institute on Drug Abuse NIDA,2018b).Such dependence is not the same as addiction.Addiction is best characterized as compul-sive use despite harmf
135、ul consequences(NIDA,2020,p.4).People with opioid addiction are usually dependent on them(i.e.,they need larger doses to achieve the same effect and can suffer short-term health consequences from stopping use),but not everyone who is dependent is addicted.6 The risk of addiction from a short(e.g.,se
136、ven-day)prescription is minimal,and short-term prescriptions account for a substantial share of all opioid prescriptions.However,a large portion of pharmaceutical company sales and profits come from supplying people who use prescription opioids on an extended basis,and prolonged use greatly increase
137、s risks,not only of becoming physically dependent but also of sustained use,leading to addiction and/or the use of other opioids,such as heroin or illegally produced fentanyl.Similarly,most people who try heroin do not go on to experience a heroin use disorder(Anthony et al.,1994),in part because mo
138、st people never use it regularly.There are also some people who regularly use heroin for pleasure without negative consequences(see,e.g.,Kaplan,1983;and Hart,2021),but it is difficult to estimate the precise number(see Chap-ter Two).Nonetheless,for many,prolonged and regular heroin use results in ad
139、diction,which often creates great harms for themselves and others.The spread of illegally produced synthetic opioids,such as fentanyl,since 2014 has mas-sively exacerbated the harms from using illegal drugs,particularly overdose,and complicated the struggle with opioids.Although parts of the United
140、States had temporary minor out-breaks of illegally produced fentanyl in the past,those outbreaks utterly pale in comparison with the contemporary mass production and importation of these substances from China and Mexico(Pardo et al.,2019).Synthetic opioids are both more potent and less expensive tha
141、n heroin,giving wholesalers a strong financial incentive to mix them with heroin or put them in counterfeit pills or other drugs to cut costs and increase profits(Mars,Rosenblum,and Ciccarone,2019;Pardo et al.,2019).As a consequence,many individuals who believe that they are purchasing heroin or oth
142、er opioids are unknowingly using synthetic opioids and overdosing.Fentanyl is also carving out its own place in the market.In some locations,such as Massa-chusetts and New Hampshire in the United States and British Columbia in Canada,fentanyl 6 There is confusion about these terms.Formerly,those who
143、 were addicted to opioids were diagnosed with what was called“opioid dependence.”Americas Opioid Ecosystem4has largely replaced heroin(Scholl et al.,2019;Pardo et al.,2021;Shover et al.,2020),and there are growing reports of people specifically looking for fentanyl(Buresh et al.,2019;Gry-czynski et
144、al.,2019;Meier et al.,2020).There is a large market for illegally produced fentanyl powderthat is purchased separately from heroinin San Francisco(San Francisco Office of Economic and Workforce Development,2021),and there have been some reports that it is becoming harder for people who use drugs to
145、find heroin in some cities in the western part of the country(see,e.g.,Boiko-Weyrauch,2021;and McCormick,2022).7As noted,of the 100,000 drug-involved deaths in the United States between September 2021 and August 2022,roughly 75 percent involved opioids(CDC,2023).However,many of the deaths involve po
146、lysubstance use(Cicero,Ellis,and Kasper,2020;also see Chapter Two).In addition,focusing on drugs detected by the coroner or medical examiner tells only part of the story.The thoroughness and accuracy of these assessments may be questionable(Ruhm,2018;Slavova et al.,2019).More fundamentally,the subst
147、ance whose use escalated into SUD and triggered a cascade of events may or may not be the individuals drug of choice at the time of death.For example,many individuals who are using illegally produced opioids such as heroin or fentanyl today began their opioid use with nonmedical use of prescribed op
148、ioids(Jones,2013;Mars et al.,2014).Thus,manyand perhaps mostdeaths attributed to heroin or synthetic opioids may have their roots in prior prescription opioid use.Current Responses to U.S.Opioid Problems Are InsufficientNoteworthy efforts have been made to address the countrys drug problems.Access t
149、o qual-ity treatment,especially medications for OUD(MOUD),has been expanding(Mojtabai et al.,2019;Wen,Borders,and Cummings,2019),and more individuals with OUD have enteredand remained engaged intreatment(Saloner,McGinty,et al.,2018;Sharp et al.,2018).The majority of those with OUD did not receive tr
150、eatment in the previous year,and studies sug-gest that the share of those receiving MOUD could have ranged from roughly 14 percent to 28 percent in 2019(Krawczyk et al.,2022;Mauro et al.,2022).8 That gap does not stem solely from limited treatment access.Many people with OUD do not want or seek out
151、treatment.Naloxone,the overdose reversal drug,is also now more readily available(Lambdin et al.,2020),and an increasing number of police departments and other first responder agencies are training and equipping officers with it(North Carolina Harm Reduction Coalition,undated).Many states have facili
152、tated access through third-party prescribing laws,in which naloxone prescriptions can be written for individuals who have not been examined by the prescriber,7 The McCormick article quotes Dr.Ricky Bluthenthal as follows:“Whats happening is fentanyl is replac-ing heroin in most of the nations larges
153、t drug markets.As fentanyl has begun to replace heroin and become the only thing available,you have this increased mortality among African Americans.”8 We put more stock in the lower number because it is not purely based on the National Survey on Drug Use and Health.For more on this,see Chapter Two.
154、Introduction5and standing-order laws,in which naloxone can be distributed or dispensed from pharma-cies without patient-specific prescriptions(Smart et al.,2020).However,the vast majority of individuals filling opioid prescriptions that put them at higher risk of overdose do not fill naloxone prescr
155、iptions(Guy et al.,2021;Stein et al.,2021).Initiatives to reduce the supply of prescription opioids have been successful in reducing the amounts prescribed.Unfortunately,in some cases,restrictions have made it harder for patients to address their chronic pain(North Carolina Medical Board,2018;Lagise
156、tty,Healy,et al.,2019)and created new harms(see the box on opioid tapering and discontinuation).And despite reductions in the number of opioid prescriptions,the per capita prescription rate in the United States remains far higher than in any other high-income country(Organisation for Economic Co-ope
157、ration and Development,2019;see Chapter Two).Despite these efforts,we continue to see increases in opioid-involved overdose deaths(CDC,2021a),opioid-involved hospitalizations(Singh and Cleveland,2020),and medi-cal problems typically associated with injection drug use(Ronan and Herzig,2016;Collier,Do
158、shani,and Asher,2018).The absolute number of people receiving treatment for OUD is increasing,but as noted,most individuals with OUD are not accessing that treatment(SAMHSA,2018)and even fewer receive MOUD,the most effective treatment for many people(SAMHSA,undated).What is especially problematic fr
159、om a resource allocation and policy evaluation perspective is that we do not know how the share of those with OUD receiv-ing treatment is changing.A major barrier to assessing progress is lack of information.We lack reliable national estimates of the total number of people who use prescription opioi
160、ds(for nonprescribed pur-poses),heroin,and/or synthetic opioids(Kilmer and Caulkins,2014;Caulkins et al.,2015;Reuter,Caulkins,and Midgette,2021),let alone how many of them have OUD.There is also an urgent need for early-warning systems to detect synthetic opioid supply.The United States made major i
161、nvestments in surveillance and data collection in response to HIV/AIDS;a com-parable effort has not been made for opioids(Pardo et al.,2019;Frank,Humphreys,and Pol-lack,2021).In short,although expanding MOUD and naloxone is critical,MOUD and naloxone are not adequate or complete responses in the sen
162、se that even after having pushed those priori-ties,the rates of OUD and death are still very high and will remain so for years to come unless other approaches are developed and implemented(Humphreys et al.,2022).Efforts to Address Opioids Confront Both Old and New ChallengesChallenges surrounding su
163、bstance use are not new,and neither are the larger issues related to health outcomes and social determinants of health,such as health care access and qual-ity,education,and economic and community-level factors(including incarceration;CDC,2021b).In this section,we highlight a few old and new challeng
164、es to addressing problems Americas Opioid Ecosystem6Issues Surrounding Prescription Opioid Tapering and DiscontinuationBecause of efforts to decrease clinically unnecessary and potentially harmful opioid pre-scribing,a key consideration is the manner in which such reductions in opioid prescrib-ing a
165、re achieved and how to avoid negative unintended consequences for individuals with chronic pain.Health care providers,patients,and advocacy groups have voiced concerns that growing“opioid hesitancy”might result in inadequate access to pain treatment for individuals with severe,disabling pain for who
166、m other therapies have not been effective(Hoffman,2018;Kertesz,2017).There are also concerns that more-restrictive opioid pre-scribing policies might disproportionately harm patients from minority racial and ethnic groups,who are already less likely to receive opioids for pain and more likely to exp
167、erience discontinuation of long-term opioid treatment(Burgess et al.,2014;Gaither et al.,2018;Phan et al.,2021;Singhal,Tien,and Hsia,2016).Furthermore,there is limited but accumulating evidence on the ways in which indi-viduals with pain might experience harm as a result of more-restrictive opioid p
168、rescrib-ing practices,especially patients with chronic pain on long-term opioid therapy,who are at increased risk of adverse health outcomes if opioid therapy is abruptly discontinued or tapered too quickly(Agnoli et al.,2021;Demidenko et al.,2017;DiPrete et al.,2022;Mark and Parish,2019;Oliva et al
169、.,2020).A large study of individuals with commercial insurance or Medicare Advantage who were prescribed opioids between 2008 and 2017 found that dose tapering has become more common since 2016,including tapering at rates that exceed those recommended by CDC guidelines(Fenton et al.,2019).Similarly,
170、a study of Medicaid beneficiaries in Vermont who received chronic high-dose opioid analgesic therapy between 2013 and 2017 found that more than 50 percent of patients who discontinued opioid treatment did so suddenly.This study also highlighted the potential risks of rapid discontinuation:49 percent
171、 of patients who discontinued opioid treatment had an opioid-related emergency department or hospital visit,but the probability of these adverse events decreased by 7 percent with each additional week that dose tapering was extended(Mark and Parish,2019).A national study of patients receiving care f
172、rom the Veterans Health Administration found that all patients who were exposed to opioids had an increased risk of death because of overdose or suicide after stopping opioids and that the risk increased with the length of time an indi-vidual had been treated with opioids(Oliva et al.,2020).Concerns
173、 about such unintended consequences and harms have led to efforts to clarify and revise chronic pain management treatment guidelines(Dowell et al.,2022)and are important considerations in any efforts to reduce risks associated with opioid pain man-agement.This issue is discussed throughout this volu
174、me,particularly in Chapters Five,Seven,Twelve,and Fourteen.Introduction7related to opioids that appear in multiple parts of this volume:systemic racism,stigma and discrimination,and the coronavirus disease 2019(COVID-19)pandemic.RacismSystemic racism has plagued the United States for centuries,and d
175、eeply rooted racial and ethnic disparities affect many social determinants of health(Williams,Lawrence,and Davis,2019;Bluthenthal,2021,Volkow,2021).With respect to opioids,people of color and those living in communities with a larger percentage of people of color are less likely to receive the most-
176、effective treatments for OUD(Stahler and Mennis,2018;Stein et al.,2021;Lagisetty,Ross,et al.,2019;Volkow,2019).Black and/or Hispanic individuals who enter treatment for OUD are less likely than non-Hispanic White individuals to complete it(Saloner and L Cook,2013).In 2020,the U.S.federal government
177、published a report entitled The Opioid Crisis and the Black/African American Population:An Urgent Issue(SAMHSA,2020a).Noting the changing dynamics of the crisis,SAMHSA argued that“attention to this epidemic has focused pri-marily on White suburban and rural communities.Less attention has focused on
178、Black/Afri-can American communities which are similarly experiencing dramatic increases in opioid misuse and overdose deaths”(SAMHSA,2020a,p.3).9 Disparities in polysubstance deaths also deserve more attention,especially because the increase in deaths involving both syn-thetic opioids and cocaine di
179、sproportionately affect people of color(we further discuss this in Chapter Two;see also the box comparing the response to crack and opioids).Similarly,American Indians and Alaska Natives have seen disproportionately large increases in drug-related mortality,and there has been a comparative lack of a
180、ttention paid to the situation in tribal communities(Joshi,Weiser,and Warren-Mears,2018;Tipps et al.,2018).9 Changes in opioid-involved overdose deaths by race/ethnicity from 2000 to 2020 are documented in Chapter Two.A useful summary covering 19792015 is provided by Alexander,Kiang,and Barbieri,201
181、8,p.712:The opioid epidemic can be divided into three waves between 1979 and 2015.During the first wave,from 1979 to the mid-1990s,opioid mortality was higher for the black population,but rates of increase were similar for both populations and largely driven by heroin.During the second wave,from the
182、 mid-1990s to 2010,the opioid epidemic expanded quickly within the white population while opioid mortality remained stable in the black population.As a consequence,the racial gradient of risk reversed in 2000,and by 2010,the opioid mortality rate were sic over 2 times higher for whites than for blac
183、ks.During this period,the opioid epidemic was driven largely by non-heroin and non-methadone opioids(i.e.,prescription painkill-ers).Lastly,from about 2010 to 2015,the opioid mortality rate grew rapidly for both the black and white populations.Americas Opioid Ecosystem8Comparing the Responses to Cra
184、ck and OpioidsThe racial dynamics in how the country has addressed opioids versus crack cocaine have been widely discussed(see,e.g.,Gounder,2016;Szalavitz,2016;and Shachar et al.,2020).It has been argued that the countrys response to the crack cocaine tribulations of the 1980s and 1990swhich disprop
185、ortionately affected major cities and communities of colorwas highly aggressive and implemented primarily by ramping up criminal justice efforts.In contrast,the response to opioidswhich initially disproportionately affected White rural communitieshas been more focused on treatment and public health
186、approaches(Shachar et al.,2020).There is truth in this narrative,but it is incomplete.There is no denying that polic-ing intensified in response to the surge in violence that accompanied the spread of crack cocaine(this violence was often associated with crack markets and sellers,not so much with th
187、ose using crack),and the application of mandatory minimum sentences and other forms of determinant sentencing increased in the 1980s,infamously so for crack offenses.a These policies contributed to a large increase in incarceration,disproportionately of young Black men.Public health was not complete
188、ly absent from the scene:Insurance benefits for SUDs and specialty SUD treatment did expand(SAMHSA,2016).Public health interventions have played a much larger role in discussions of the 21st century opioid crisis,partially because escalation of prescription opioid use and its diver-sion were not in
189、any meaningful way linked to violent crime,and perhaps more impor-tantly,there were essentially no organized or high-level traffickers or distribution.Most of the diversion and sale of prescription opioids was by individuals with multiple prescrip-tions(i.e.,it was PWUO who were often supplying,not
190、multitiered international drug distribution networks).Furthermore,we have much better treatments for OUD than for cocaine use disorder.That has always been true,but the gap between OUD treatment in 2010 and cocaine treatment in 1985 is even wider than the gap between treatment capabili-ties for the
191、two drugs at any specific point in time.However,law enforcement is still playing a major role in the response:There are on the order of 200,000 to 300,000 arrests for opioid-specific offenses each year(i.e.,arrests for production,sales,and distribution and for simple possession)and multiple times th
192、at for arrests for crimes related to opioid use(e.g.,property crimes,which we discuss more in Chapter Two).There has also been an increase in charges related to drug-induced homi-cide laws,which apply additional sanctions on those who supply drugs to someone who overdoses and dies(Beletsky,2019;Heal
193、th in Justice Action Lab,undated).a It is widely reported that sentences for crack were more severe than those for powder cocaine,but the more accurate description is that a sentence of a given length could be triggered by smaller quan-tities of crack than powder cocaine.Introduction9Stigma and Disc
194、riminationLong-standing concerns regarding stigma and discrimination against PWUO and people who use other drugs also shape responses to the current crisis(Volkow,2020b).10 For exam-ple,a growing body of research suggests that stigmatizing labels,such as addict or substance abuser,can influence how
195、individuals,including medical professionals,perceive people with SUDs(Kelly and Westerhoff,2010;Ashford et al.,2019).Also,some clinicians simply do not want to provide MOUD(Kennedy-Hendricks et al.,2020),and,of clinicians who begin pre-scribing medication to treat opioid use disorder,most cease with
196、in a year(Cabreros et al.,2021).Research has also found that higher levels of stigmatized attitudes about people with OUD are strongly associated with lower rates of providing MOUD(Stone et al.,2021).Drug laws and some criminal legal interventions seek to reify social disapproval of drug use.The sti
197、gmatization of people who use and/or sell drugs is a feature,not a bug,of the cur-rent system,as it is for other forms of criminal activity.However,this is only one component.There is also considerable stigma associated with alcohol use disorder(Kilian et al.,2021).Although criminal justice agencies
198、 play an important role in preventing drug-related crimes,laws intended to reduce drug use and drug-related crime can create barriers to recov-ery,even though other criminal justice programs can increase uptake of treatment.Drug offense convictions entail much more than a criminal record;they can oc
199、casion additional sanctions,such as reduced access to or additional restrictions on public housing and nutri-tional support.Restrictions vary by state and locality(Polkey,2019).Some of these polices are well intentioned(e.g.,protecting public housing or shelter resi-dents from drug-related victimiza
200、tion),but there are trade-offs.Making it harder for those with SUDs to obtain shelter and other services makes it harder for them to stabilize their lives and engage in treatment.COVID-19 PandemicThe COVID-19 pandemic brought new challenges(Wang et al.,2021).It will take time before we really know h
201、ow the pandemic has affected opioid-related harms,but early reports show an increase in fatal overdoses(American Medical Association,2021;CDC,2021a),possibly from more people using alone,although also possibly from expanded fentanyl supply.Experts worry that individuals will face barriers in accessi
202、ng treatment because of concerns about contracting COVID-19(Volkow,2020a;Khatri and Perrone,2020).That said,to maintain access to treatment for OUD at a time when the pandemic reduced face-to-face treatment,10 We are not aware of any longitudinal data on the extent of stigma in the United States.The
203、 General Social Survey has asked questions on the topic in the past,but regrettably not in a way that would enable compari-sons over time.In a recent new effort,Shatterproof fielded a 2020 survey on addiction stigma to a nation-ally representative sample of nearly 8,000 individuals.In headline findi
204、ngs offered by the authors,three-quarters of respondents did not believe that individuals with SUDs were experiencing a chronic illness and nearly two-thirds of participants responded that they would not want a person with an SUD to marry into their family(Shatterproof and The Hartford,2021).America
205、s Opioid Ecosystem10the federal government and many state governments temporarily relaxed some of the restric-tions requiring in-person visits(Andraka-Christou et al.,2021;Pessar et al.,2021),potentially enabling many individuals to maintain access to MOUD(e.g.,via telehealth)(Cantor et al.,2021;Ngu
206、yen et al.,2021;SAMHSA,2021).The extent to which these changes will ultimately become permanent remains to be seen.Taking an Ecosystem Approach to Addressing OpioidsMultiple policies have been implemented to reduce opioid misuse,enhance effective treat-ment,and mitigate opioid-related harms(see,e.g.
207、,review by Schuler et al.,2020).But con-fronting the crisis is not just about better pain management or treatment for OUD.Many widely adopted policies target individuals at highest risk for opioid misuse or OUD and focus on the role of the health care system in providing treatment for addiction and
208、comorbid disorders.However,a broader swath of the population and many more governmental and nongovernmental systems are affected.These systems interconnect,sometimes in unex-pected ways.As a result,policies targeting one part of the system can have unintended conse-quences,affecting systems that the
209、y were not intended to target.Lack of a systems perspective also contributes to missed opportunities that could promote positive change.In this report,we offer a broader perspective by considering the opioid crisis in the con-text of an ecosystem.Its component parts,linked by individuals and organiz
210、ations,interact both directly and indirectly.Taking this comprehensive approach helps us identify new perspectives:The scope and persistence of the problem demands innovative new approaches,which require looking at the problem in a novel(or at least unconventional)way.contradictions:Policies designe
211、d to help in one arena can cause harm in others,coun-teracting each other and often wasting resources.synergies:Policies interact with each other in ways that can multiply their impacts.unintended consequences:Components of the opioid ecosystem interconnect,often in unexpected ways.As a result,polic
212、ies targeting one part of the system can have unin-tended consequences,affecting systems that they were not intended to target.transitions:Policies need to be designed so that the targets of interventions do not get lost between components as their situations evolve.the importance of families:Famili
213、es sometimes suffer because of a relatives substance use but also are key players in many components of the ecosystem.Building on Previous Efforts Multiple commissions,task forces,research teams,and other organizations and partnerships are working to reduce the harms associated with opioids(e.g.,Bar
214、ry,2018;Kertesz,2017;Kertesz and Gordon,2019;Commission on Combating Synthetic Opioid Trafficking,2022;Introduction11Humphreys et al.,2022).Our work builds on and extends this work.For example,Barry,2018,recognized that changes in the illegal market related to the introduction of fentanyl would crea
215、te challenges in multiple components of the opioid ecosystem,including criminal legal system,harm reduction,first responders,and SUD treatment.Furthermore,Kertesz and others have written about the potential dangers of focusing primarily on opioid prescrib-ing within the medical care system,underscor
216、ing the need for policymakers to consider how efforts to address such prescribing can both affect and be affected by other systems(Kertesz,2017;Kertesz and Gordon,2019).Several efforts have taken a broader view,exploring how social determinants of health create an environment that is likely to exace
217、rbate opioid misuse and overdose while rais-ing barriers to effective treatment.Researchers have also explored ways in which policies addressing some of these social determinants could improve the response to the opioid crisis in many dimensions of the system,including the specialty SUD treatment sy
218、stem,the crim-inal legal system,and community efforts at harm reduction(Park et al.,2020;Dasgupta,Beletsky,and Ciccarone,2018).Saloner and colleagues,among others,have examined the variety of opioid-related harms across multiple systems.In their work,they argued that con-sidering the crisis as a pub
219、lic health problem presents valuable opportunities across multiple elements of the overall system to implement policies addressing various aspects of the crisis(Saloner,McGinty,et al.,2018;Bingham,Cooper,and Hough,2016).11 We laud these previous and ongoing efforts and acknowledge their important co
220、ntribu-tions.However,we extend the prior work on several important dimensions.We consider,more explicitly and in greater detail,the specific ways in which the opioid crisis affects system components that are less commonly considered,such as the education system,employers,and the child welfare system
221、.We also consider how policies in those parts of the system may affect components that are more commonly considered,such as the health care system,criminal legal system,and SUD treatment system.We examine policies that would be imple-mented within systems that could have potential benefits in other
222、systems;we also appraise policies that must be implemented across systems and suggest ways to do so.The challenges associated with interactions across system components are not unique to opioids.Such concepts as coordination,redundancy,and unintended consequences are fun-damental issues in the field
223、s of public administration and business management.12 In the case 11 There is sometimes a tendency for discussions about drug policy to devolve into“criminal justice versus public health”debates.We find this framing too simplistic and not very helpful for promoting productive policy conversations.Th
224、ere are obvious tensions among various components of the ecosystem,but there are also some synergies,collaborations,and innovations that should be recognized.These debates can be more productive if the focus is on specific levers,agencies,and actions,and one goal of this report is to foster and info
225、rm these more specific discussions.12 Indeed,there have been numerous attempts to coordinate health services,and some look beyond tra-ditional medical care settings.One example is the Robert Wood Johnson Foundations Culture of Health Action Framework,which conceives of“a strengthened health care sys
226、tem in which medical care,public health,and social services interact to produce a more effective,equitable,higher-value whole that maxi-Americas Opioid Ecosystem12of opioids,some of the system-related questions are“bread and butter”health systems issues.For example,are those receiving treatment for
227、an OUD receiving nonmedical services(e.g.,housing)that will improve the probability of sustained recovery?But the systems questions around opioids become increasingly complex when one factors in profit-maximizing entitiesbe they pharmaceutical firms or illegal drug suppliersthat have an incentive to
228、 persuade people to use or misuse opioids.As noted earlier,there are some policies intended to protect potential victims of drug-related harms(e.g.,children,public housing residents,employers)that can also create challenges for PWUO or people who are in recovery.Policymakers often have to balance th
229、ese competing interests.Major Components of the EcosystemAt the core of the opioid ecosystem are the individuals who use opioids and their fami-lies;these are the topics of the next two chapters.We also explore the following ten major components of the opioid ecosystem,which are affected by and affe
230、ct such individuals(see Figure 1.1):1.Substance use disorder treatment covers services by providers who specialize in treating substance use disorders.These services include engaging individuals in treatment,providing effective treatment,retaining individuals in treatment for long enough for the tre
231、atment to be beneficial,supporting individuals in recovery,and facilitating reengagement with treatment among individuals in recovery who start using again.2.Medical care covers physical and mental health care beyond specialty substance use disorder treatment.It encompasses health care providers,hea
232、lth care delivery orga-nizations,insurers,pharmaceutical companies,medical training organizations,and various regulatory bodies.3.Criminal legal system includes local,state,and federal laws;law enforcement agen-cies;lawyers and courts;corrections agencies(including community supervision);and the pri
233、vate and nonprofit organizations that support these institutions(e.g.,drug-testing companies).4.Illegal supply and supply control is a broad component,encompassing drug traffick-ing organizations,“pill mills,”and people who use opioids but give or sell(some of)their prescription opioids to others.Su
234、pply control includes criminal justice agencies and regulatory agencies,such as the U.S.Food and Drug Administration.5.Harm reduction and community-initiated interventions include interventions to reduce risks and stigma associated with drug use,such as naloxone distribution pro-mizes health and wel
235、l-being for all”(Martin et al.,2016,p.1976).Our challenges with opioids,however,extend far beyond the health care system.Introduction13grams and syringe service programs,along with community coalitions to prevent and reduce the harms of drug use.6.First responders covers professionals who provide me
236、dical assistance in emergency situations,including drug overdoses.Our discussion addresses three main types of first responderslaw enforcement,fire and rescue,and emergency medical services.7.Child welfare covers public and private services designed to ensure that children are safe and protected fro
237、m abuse and neglect,ensure that they live in stable and perma-nent environments,and support child well-being.FIGURE 1.1The Opioid EcosystemPerson who uses opioidsFamilyChild welfareIncome support andhomeless servicesFirst respondersEmploymentHarm reductionEducationSubstance usedisorder treatmentIlle
238、gal supply and supply controlCriminal legal systemMedical careAmericas Opioid Ecosystem148.Income support and homeless services covers public support programs,largely focusing on Social Security Disability Insurance,Supplemental Security Income,wel-fare(Temporary Assistance for Needy Families),and a
239、gencies that provide services to people experiencing homelessness.9.Employment addresses the myriad ways in which labor markets affect and are,in turn,affected by opioids,including through the behaviors of both employees and employers.10.Education is affected by the opioid ecosystem in many ways.Alt
240、hough it is not an explicit goal of the education system to address the opioid crisis or opioid use,the opioid crisis touches the education system in a variety of direct and indirect ways through its effect on individuals and communities.The components we have identified are neither mutually exclusi
241、ve nor exhaustive.For example,substance use disorder treatment is just one part of the medical care system;how-ever,the issues surrounding the former are so central to the crisis that considering it a sepa-rate component of the ecosystem is justified.Similarly,the concept of illegal supply and how i
242、t is addressed are shaped by the criminal legal system.We do not identify separate components for social services or public health because they are covered by other parts of the ecosystem.Social services are addressed in the chapters on child welfare(Chapter Ten),income support and homeless services
243、(Chapter Eleven),employment(Chapter Twelve),and education(Chapter Thirteen).The traditional roles of public health agencies are addressed in the chapters on the specialty treatment system for opioid use disorders(Chapter Four),medical care(Chapter Five),and harm reduction and community-initiated int
244、erventions(Chapter Eight).Furthermore,surveillance is discussed in these chapters and in the chapters on the criminal legal system(Chapter Six)and illegal supply(Chapter Seven).The components in Figure 1.1 are not inherently of equal importance;importance depends on the outcomes being considered.For
245、 example,if one were focused on issues related to the supply of opioids,the medical care,substance use disorder treatment,criminal legal system,and illegal supply components would be more prominently featured.If one were more focused on reducing harms related to drug use,the harm reduction and commu
246、nity-initiated inter-ventions and first responders components deserve more attention.The box on the next page offers three specific examples of how thinking about opioids as an ecosystem can enhance policy analyses and improve lives.Humanizing the EcosystemThe opioid ecosystem is more than macro-lev
247、el interactions at the policy level;millions of people affected by opioids interact with many of the system components.Understanding these touchpoints can help identify barriers to effective interventions and policy opportunities.To help bring the ecosystem concept to life,we offer several vignettes
248、 that begin with a focus on individuals and then highlight the system components with which they interact.The Introduction15vignettes are fictitious and do not represent specific individuals or families;however,they are consistent with the experiences of many individuals in communities throughout th
249、e country.Chapter Two,which describes individuals who use opioids,sheds further light on how indi-viduals may find themselves in situations similar to those described in these vignettes.Each vignette is accompanied by a version of Figure 1.1 that highlights the dimensions of the ecosystem that play
250、the most active roles in the vignette.Three Examples of How Thinking About Opioids as an Ecosystem Could Make a DifferenceAcknowledging that family matters.OUD creates harms for those with that medical con-dition and can negatively affect family members and others close to the individual with OUD;ho
251、wever,most policies and programs neglect these other stakeholders.Indeed,most past economic studies of opioids have failed to account for this,largely because it is hard to quantify and collect data on the emotional,physical,financial,and mental health harms often associated with having a loved one
252、who has an SUD and the effects that this situ-ation can have on performance in school or productivity at work.Acknowledging these consequences would justify devoting time and resources to helping these families reduce the overall burdens imposed by OUD.Making it easier for those with OUD to move acr
253、oss system components to obtain services.Several steps can be taken to address the challenges that occur as individuals with OUD move across system components(e.g.,medical care,criminal justice,income support).At the juncture between components,it is unclear who is responsible for a suc-cessful tran
254、sition.In many cases,this means that no one is responsible.Although many system components use case managers,some of whom work across components(e.g.,treat-ment providers helping patients gain access to social services),too often individuals with OUD fall through the cracks between components.By cla
255、rifying who is responsible at these junctures and providing resources necessary to meet the commitment of the addi-tional responsibility,we can diminish some of the disconnects that hamper provision of treatment and support.Better understanding the far-reaching effects of changing drug laws and enfo
256、rce-ment strategies.There is a growing discussion about decriminalizing the possession and use of all drugs in the United States.In November 2020,Oregon voters passed an initiative to not only decriminalize all drugsincluding heroin and illegally produced fentanylbut also redirect funds from cannabi
257、s tax revenues to provide health assessments and other services to those cited for drug possession.Other jurisdictions(e.g.,Washington,Massachusetts)are discussing related measures.Now is the time to rigorously analyze the potential effects of these efforts.Better understanding how criminal laws and
258、 law enforce-ment actions affect the other components(e.g.,eligibility for some health services,treat-ment referrals)can lead to more-rigorous and-informative analyses,and hopefully better policies.Americas Opioid Ecosystem16Vignette 1:Becky and MikeBecky(age 30)and her son Mike(age 9)lived in one o
259、f the seven states that drop individu-als from Medicaid if they are imprisoned(Kaiser Family Foundation,2019).Becky became dependent on the opioid pain medication Vicodin after extensive dental surgery that was covered by Medicaid.Her dentist stopped writing prescriptions six weeks after the surgery
260、,but Becky started doctor shopping to obtain more opioid pain medications,and because pre-scribers were not required to check the Prescription Drug Monitoring Program in Beckys state,none of them realized that Becky was getting pain medications from multiple places.Beckys opioid misuse made her less
261、 productive at work,and she began stealing from her FIGURE 1.2The Opioid Ecosystem:Vignette 1Person who uses opioidsFamilyChild welfareIncome support andhomeless servicesFirst respondersEmploymentSubstance usedisorder treatmentIllegal supply and supply controlCriminal legal systemMedical careIntrodu
262、ction17coworkers to feed her increasingly expensive habit.Ultimately,she lost her job and began to sell pills to pay the rent,buy groceries,and cover the costs of her own opioid consumption.After running a red light while she was high,Becky was arrested for impaired driving.Because this was her firs
263、t offense,she was sentenced to probation and mandatory attendance at a 12-step program.However,compliance was not consistently enforced,and Becky stopped attending.Within a month,she was convicted a second time for possession with intent to distribute(she had prescription bottles obtained from other
264、 people,whose names were on the label).She was remanded to a drug court,which ordered her to counseling,but it did not provide an option for medication treatment for her opioid use disorder.13While in the drug court program,Becky was arrested,convicted for selling drugs,and sentenced to prison,where
265、 treatment for her opioid use disorder was not available.Beckys son Mike moved in with Beckys parents.Once she was released,Becky had nowhere to go and no source of income.She moved in with her parents but began to use drugs again.To finance her renewed use,Becky borrowed money from her parents unde
266、r false pretenses but failed to pay them back.Shortly thereafter,she overdosed on opioids.Her parents called 911,the paramedic was able to revive her with naloxone,and Becky survived.She was determined to get into treatment,but had no insurance coverage because she had been disenrolled from Medicaid
267、 when she was incarcerated.She had reapplied for Medicaid when she was released,but the process of being reinstated took time,and during that period without insurance,Becky was unable to get treatment.Furthermore,the drug convictions made it harder for her to obtain public income support or to find
268、a job.After more than three months of struggling,Beckys mom found her after an overdose.This time,the paramedic could not revive her.Vignette 2:JamesJames(age 55)worked in a refrigerator assembly plant in Ohio.He had a history of depres-sion,which was exacerbated by his heavy drinking.Toward the end
269、 of a shift,he caught his sleeve in a conveyor belt and severely injured his arm and shoulder.The physician to whom he was referred through workers compensation prescribed OxyContin to help him with pain while he was in physical therapy.After six weeks,James was sufficiently recovered that he resume
270、d work,although he still had chronic pain.He did not stop taking OxyContin because he enjoyed how it made him feel.As his bodys tolerance to the medication increased,he needed a stronger dose.After several months,he started to crush the prescribed pills and snort them.James then“traded down”to heroi
271、n;first smoking,then injecting.He was aware that injecting drugs was risky in terms of infection,disease transmission,and overdose,so he regularly visited syringe service programs to pick up sterile supplies.13 Efforts have been made to close this gap in many jurisdictions(see,e.g.,California Health
272、 Policy Strategies,2018).Americas Opioid Ecosystem18James continued to work in the factory,although he knew he was less productive(a phe-nomenon referred to as presenteeism).But he did not ask for help;he was not sure he had a“real”problem because he was working,and he knew that asking for treatment
273、 would brand him as a“junkie”among his managers and coworkers.Eventually,his poor performance cost him his job.He continued to inject heroin.Physical labor was now prohibitively painful,but there were no vocational programs to help him make a transition to less physically demanding employment.Withou
274、t a job,he could no longer afford his apartment.He lived in his car for a while,but it was stolen,so he lived on the street.Dealers in the area started to adulterate heroin with fentanyl.James unknowingly injected a mixed bag and ended up overdosing.He survived,but examination in the emergency FIGUR
275、E 1.3The Opioid Ecosystem:Vignette 2Person who uses opioidsFamilyIncome support andhomeless servicesEmploymentHarm reductionIllegal supply and supply controlMedical careIntroduction19department revealed that he had contracted infective endocarditis,a dangerous infection of one of the heart valves,fr
276、om injecting these substances.Treatment involved intravenous anti-biotics for six weeks,which was covered by Medicaid.With his endocarditis treated,James is back on the street.He continues to struggle with his opioid use disorder,drinks heavily,and has no available help for his mental health issues.
277、Vignette 3:LouieLouie(age 17)was a high-school student in California who worked as a waiter at a local res-taurant.He was a B-average student who was well liked by his classmates and teachers and very involved in school activities.He did not get in trouble other than one suspension when he and some
278、friends were caught drinking at a high school football game.After taking Perco-cet at a few parties over the course of his junior year,he discovered that his mom had a bottle of prescription opioids left over from a medical procedure performed the previous year.The dozen or so pills remaining in tha
279、t bottle lasted him a few weeks,and he really enjoyed the high.It was not interfering with his school or job,and no one suspected that he was using.Most youth who experiment with opioid analgesics do not proceed to misusing them,but this was not the case for Louie.He started buying pills regularly f
280、rom one of his coworkers and,after a few months,realized that he was feeling anxious and sometimes nauseous when he was not taking them.He started spending even more of his tips to buy pills.He knew that some of those pills were likely counterfeit,but they tended to be cheaper.As he ramped up his us
281、e over the next few months,his boss and parents noticed that he was acting differently and was generally less reliable.After a friend overdosed from a counterfeit pill that contained fentanyl,Louie admitted to his parents that he thought he had a problem and was scared of overdosing like his friend.
282、His parents acquired some naloxone to keep in the house and convinced him to see a doctor for treatment.As is all too common,his parents had a difficult time finding a doctor to pre-scribe buprenorphine to Louie because he was only 17,but after three months of searching,they finally found a physicia
283、n willing to treat him.Louis has been stable on buprenorphine for 18 months,graduated from high school,and started college.However,his college girlfriend keeps telling him that taking buprenorphine is“just trading one drug for another,”so his parents are afraid he might stop taking it and go back to
284、 using counterfeit pills.Americas Opioid Ecosystem20Vignette 4:Eleanor and ClareEleanor,a 38-year-old single mom,lives with her 15-year-old daughter Clare.Eleanor had a good job as a manager in a busy accountants office.She occasionally snorted heroin.Elea-nors new live-in boyfriend was more than an
285、 occasional heroin user,and Eleanor started to use it more frequently.Heroin was only a phone call away in the city where they lived.When her boyfriend left her,Eleanors drug consumption increased sharply.Like the millions of children living in the households in the United States where a parent is u
286、sing opioids for nonprescribed purposes(Bullinger and Wing,2019),Clare was neglected because of her moms substance use.She had been a good student,but now her schoolwork suffered.Her teachers saw the change and noticed that Eleanor no longer showed up for FIGURE 1.4The Opioid Ecosystem:Vignette 3Per
287、son who uses opioidsFamilyChild welfareEmploymentHarm reductionSubstance usedisorder treatmentIllegal supply and supply controlMedical careIntroduction21parent-teacher conferences.Clare had several close friends she hung out with,but now she was embarrassed to ask them to come over because she never
288、 knew what state her mom would be in.She felt increasingly isolated.Eleanors drug use spiraled out of control,and she began injecting even more than usual because the illegally produced fentanyl she started purchasing gave her a shorter high than heroin.Her elderly parents took Clare for a few month
289、s so Eleanor could enter an abstinence-based residential treatment facility.Clare was confused,and her grandparents really strug-gled to take care of her.Eleanor emerged from treatment,remained drug-free for a time,and Clare moved back in with her.But the stability did not last.As is common with tho
290、se completing treatment for opioid use disorder(NIDA,2018a),Eleanor started using drugs again and became prone to angry outbursts as she despaired about her addiction.Child Protective Services and Child Welfare became involved.The agency recommended temporary foster care.FIGURE 1.5The Opioid Ecosyst
291、em:Vignette 4Person who uses opioidsFamilyChild welfareEducationSubstance usedisorder treatmentIllegal supply and supply controlAmericas Opioid Ecosystem22Eleanor eventually got medication treatment for her opioid use disorder.She had occa-sional relapses,but she made Clares needs a priority and con
292、tinued with treatment.How-ever,she was unable to stay off drugs for long enough to meet the Child Welfare threshold.Ultimately,the agency recommended terminating Eleanors parental rights.Because Clare could not stay with her grandparents,she will remain in foster care until she is 18,unless she is a
293、dopted.Vignette 5:DougDoug(age 44)is an independent trucker.His wife Marie,a 42-year-old stay-at-home mother of two young children,has had opioid use disorder since shortly after a car accident,when she was prescribed opioids for chronic pain.Marie suffered four nonfatal overdoses over the prior two
294、 years,leading to multiple trips to the emergency department.During this time,Doug was anxious about Maries well-being and changed jobs to local driving instead of cross-country trips to avoid prolonged separation from his wife.After Maries second and third overdoses,the emergency department referre
295、d her to outpatient treatment.However,Marie stopped treatment in both instances after just a few weeks and unsuccessfully tried to hide this from Doug.Despite his understanding of substance use disorder,Doug could not help but feel frus-trated with the situation.Finally,after the fourth overdose,Mar
296、ie was referred to a residential treatment program.Doug supports Maries participation in residential treatment and tells Marie to put her health first.To care for the children while Marie is in treatment,Doug will have to survive without a paycheck.He tells Marie not to worry about the cost,although
297、 their insurance does not cover residential treatment and child care will be an issue;he assures her that they will figure it out,likely through a bank loan or by borrowing money from friends and family.Dougs parents,who live nearby,have offered to take care of the children so that Doug can resume w
298、ork and cover the mounting costs.However,Doug knows that this would require his elderly parents,who live on a fixed income,to undertake a major lifestyle change.Thus,he would prefer to avoid this scenario.The stress eats at Doug,and he takes it out on the kids by yelling atand sometimes hittingthem.
299、The stress at home has also affected the chil-dren at school:Both have struggled with schoolwork over the past two years,and the young-est has been having more behavior problems at both home and school.Introduction23Approach and Structure of This ReportOur work and that of other researchers suggests
300、 that policy discussions most commonly focus on individual system components,giving short shrift to interactions between the com-ponents and the policy options available(Saloner,McGinty,et al.,2018;Stein,2019;Park et al.,2020;Schuler et al.,2020).Much of this previous work has also largely focused o
301、n indi-viduals with OUD and not on their families.This report is intended to help fill this gap,and more importantly,to help improve outcomes related to opioid problems.The primary audience for this report is decisionmakers at the federal,state,and local levels.It should also be useful for foundatio
302、ns and philanthropic donors looking for opportu-FIGURE 1.6The Opioid Ecosystem:Vignette 5Person who uses opioidsFamilyChild welfareFirst respondersEducationSubstance usedisorder treatmentMedical careAmericas Opioid Ecosystem24nities to create change that have often been overlooked.Finally,we believe
303、 that this effort can help(1)researchers better understand the full consequences of policy changes with respect to opioids and other drugs and(2)members of the media identify the dynamics of interactions(or lack thereof)among parts of the system that deserve more attention and discussion.We dedicate
304、 a chapter to each of the components of the ecosystem presented in Figure 1.1.Chapter Two provides background information about PWUO,who constitute the demand side of the market.There is an extensive and growing body of literature on the epidemiol-ogy of opioid use and polysubstance use in the Unite
305、d States.We do not attempt to present a systematic review of this work.Instead,we draw on some of these studies and on secondary data analyses to address nine questions that provide context for understanding our current problems with opioids and how those problems have evolved.Chapter Three focuses
306、on the family members and loved ones of those who use opioids.This is an underexamined topic that is critical not only for understanding the full conse-quences of opioid consumption(both the harms and benefits)but also for identifying oppor-tunities for improving the lives of PWUO and those around t
307、hem.Chapters Four through Thirteen,which focus on the components of our ecosystem model,are written by RAND researchers with extensive experience in that particular domain.The chapters have a similar structure.The authors begin each chapter by describing the compo-nent and how it affects and is affe
308、cted by opioids.They then highlight the other ecosystem components with which it interacts and present policy considerations.In some cases,the policy change would influence processes or outcomes within the system components high-lighted in that chapter;in other cases,the changes could have their gre
309、atest impact in other parts of the ecosystem.Some of the policy considerations we offer are motivated by existing peer-reviewed research,but for many,there is little or no empirical evidence evaluating anticipated policy effects;they are ideas we believe could make a positive difference in somebut n
310、ot neces-sarily allcommunities.That is why we describe them as considerations as opposed to full-throated endorsements.14The final chapter,Chapter Fourteen,synthesizes the chapter-specific findings(with a spe-cial focus on barriers to progress),identifies common issues that affect multiple component
311、s of the ecosystem,and offers ideas for prioritizing policy considerations.These priorities likely will differ depending on whether ones perspective is federal,state,or local,and we highlight this issue in that chapter.We do not limit our discussion of policy considerations to those mentioned in the
312、 previ-ous chapters.Indeed,one of the advantages of producing this report is that it prompts one to assess the opioid policy landscape comprehensively and to think creatively about new ideas and missed opportunities involving multiple components.14 Appendix B lists all ideas discussed in these chapt
313、ers and where the change would likely occur(e.g.,at the federal,state,local,and/or nongovernmental level).Introduction25Throughout the report,we highlight extensive interactions between the various compo-nents.We note that“extensive”is a qualitative judgment rather than one based on a single formula
314、.Because the components interact in different ways on multiple dimensions(e.g.,flows of people,levels of government,timing and context of the interaction),it is difficult to apply a universal rule.The existence of more-extensive interactions is highlighted in a modi-fied ecosystem graphic at the beg
315、inning of each chapter.Our approach has limitations.First,the components displayed in Figure 1.1 are not the only ones affecting and affected by opioid use.(For example,we do not discuss the role of public transportation,which can play an important role in accessing treatment and other health servic
316、es Marsh,DAunno,and Smith,2000;Syed,Gerber,and Sharp,2013.)How-ever,to make the ecosystem concept tractable and most useful to decisionmakers,we selected those components that we believe offer the most potential for creating positive change.Second,our approach does not generate an exhaustive list of
317、 all options available to deci-sionmakers within each of the components.We focus primarily on policy considerations that could have the biggest impact on other components with respect to opioids and on those that require coordination and interaction across multiple components.Finally,it is beyond th
318、e scope of this report to conduct a cost-benefit analysis for policy opportunities.In fact,one of the advantages of our approach is that it will generate new ideas for which there as of yet may be little or no empirical evidence.We highlight this issue in the synthesis chapter,making it clear which
319、options have greater empirical support and which are new and may be worth piloting or deserving of additional analysis.We anticipate that most individuals will focus on the chapter(s)that are most germane to their own interests and experience;however,we recommend that readers review the next two cha
320、pters on PWUO and their families before reading the others.We have structured our dis-cussion to make it easy for readers to learn about the roles of other components.Thus,to the extent possible,each chapter is a stand-alone discussion of the opioid-related issues in that part of the ecosystem and o
321、f the components interactions with other parts of the system.In the service of that goal,we have allowed some duplication of material across chapters.This report is certainly not the final word on the opioid crisis.At its current pace,this evolving tragedy is expected to kill hundreds of thousands o
322、f people over the next five years and lead to addiction and burdens for millions more.However,we believe that focusing on the opioid ecosystem and the interactions of its components will enrich how policymakers,practitioners,and researchers understand this dynamic problem and enhance their choices a
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