America's Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms

Motivation

The United States has long grappled with multiple problems stemming from the use of alcohol 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-involved 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 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 being 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 costs.

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. The dynamics of America's drug problem are also shifting, not only in the types of opioids being consumed but also in the populations most affected—especially in terms of race and ethnicity.

Of course, our primary focus on opioids does not mean we can ignore the country's issues with other drugs. To the contrary, the United States confronts multiple challenges, including long-standing problems related to alcohol and a dramatic rise in harms related to methamphetamine use. Correspondingly, some of the observations and suggestions made will be applicable to contexts other than opioids.

Focusing on America's Opioid Ecosystem

Many policies have been implemented to reduce opioid use, enhance effective treatment, and mitigate opioid-related harms. But confronting the crisis is not just about better pain management or treatment for opioid use disorder. Many widely adopted policies target individuals at highest risk for opioid misuse or opioid use disorder and focus on the role of the health care system in providing treatment for addiction and comorbid disorders. However, a broader swath of the population and many more governmental and nongovernmental systems are affected by problems related to substance use. These systems interconnect, often in unexpected ways. As a result, policies targeting one part of the 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 study, which is arguably the most comprehensive analysis of opioids in 21st century America, offers a broader view by considering the opioid crisis in the context of an ecosystem.¹ Its component parts, linked by individuals and organizations, interact both directly and indirectly. Recognizing the ecosystem's major components and exploring how they do—and do not—interact allows 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 teams are working to reduce the harms associated with opioids. We applaud these efforts, acknowledging their important contributions. 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, 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 systems may affect systems more commonly considered, such as the health care, harm reduction, criminal legal, and SUD treatment systems. We examine policies that would be implemented 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 Takeaways

A major contribution of this study is to identify opportunities at the intersections of the ecosystem's 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 across many ecosystem components. These portfolios could help decisionmakers prioritize 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, there is a strong evidence base; others have potential and deserve consideration. That said, some of the ideas, if implemented, might not be as effective as envisioned or could have unintended consequences.

Two icons labeled “Person who uses opioids” and “Family” are in the center of the figure. Ten icons are arranged around them in a circle (clockwise from top): criminal legal system, illegal supply and supply control, harm reduction, first responders, child welfare, income support and homeless services, employment, education, substance use disorder treatment, and medical care.

We offer four major takeaways:

1. America's issues surrounding opioids are most appropriately viewed in 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 1) interact both directly and indirectly.

   Understanding these interactions is challenging but essential for effective policymaking. For example:

   1. 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, and these relatives interact with the ecosystem components in a variety of ways, depending on the status and needs of the individual using drugs. Understanding these interactions can help us identify ways in which families can be better supported. Acknowledging the harms families experience could further justify devoting time and resources to helping them, potentially reducing the overall burdens imposed by opioid use disorder.
   2. Each ecosystem component has its own mission, priorities, and funding, but policies furthering those priorities may hamper the efforts of other system components. Furthermore, most of these components are designed to serve the broader population, not just people who use opioids, and that can leave the special needs of this group unmet. Lack of coordination and communication across ecosystem components poses a formidable challenge for many opioid-affected individuals and 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:
      1. Public housing policies that can exclude individuals misusing substances are intended to protect other residents, but housing instability is a significant barrier to successful treatment and recovery.
      2. 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 discourage individuals with opioid use disorder from identifying themselves and seeking help.
      3. Child welfare policies regarding parental drug use are intended to keep children safe, but fear of losing a child may prevent a parent who uses drugs from seeking treatment.
2. Current responses to opioid problems are insufficient—the United States needs to innovate. The increased prevalence of such illegally produced synthetic opioids as fentanyl has exacerbated the harms of drug use—and particularly of overdose—and complicated the struggle with opioids.
   1. Increasing access to and use of high-quality treatment for SUDs remains the top priority, but it will not be enough to stem the tide of overdose deaths and addiction. 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 counterfeit pills) carry a heightened risk of overdose in an era of synthetic opioids.
   2. 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 alternative has pros and cons, and the consequences will likely differ depending on local conditions (e.g., types of drug problems, service infrastructure, existing enforcement practices).
   3. The federal government should make it easier—not harder—for states or localities to pilot, implement, and evaluate interventions 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 needs and priorities.
   4. 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 implement sunset clauses to limit the duration of new policies and make their extension contingent on satisfactory evaluation results.
   5. 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 organizations, and/or philanthropic foundations.
3. Someone needs to take ownership of assisting people in their journey through the systems.
   1. Individuals with opioid use disorders often touch multiple components of the ecosystem, but it is not always clear who is responsible for coordination among components or transition from one component to another. Is it the system component 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 the 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 emergency rooms who do not transition to treatment; and children who are informally moved to a relative's 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 responsibility, policymakers and stakeholders can diminish some of the disconnects that hamper the provision of treatment and support.
   2. 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 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 when more-traditional case managers are not involved, such as during an individual's 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 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 existing interventions, invent new ones, or improve our understanding of ecosystem interactions.
   1. The United States urgently needs to improve the data infrastructure for understanding 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 alone those who supply illegal 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 characteristics of this population and how they are changing.
   2. 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 affects individuals moving through the system.
   3. 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 kills more than HIV/AIDS did at its peak, has not elicited a comparable investment in data infrastructure.
   4. 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 agencies 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 wastewater monitoring, could 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 multiple 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. It also should help mitigate the harmful consequences of future drug problems.