Progress and Challenges: The Community Burden of Opioids in the U.S.

According to the Centers for Disease Control, the number of deaths caused by drug overdose in the U.S. has decreased by nearly 20% since July 2023. This welcome change has sparked new lines of research into the factors behind it and has prompted some experts to declare victory over the country’s longstanding opioid epidemic.

Despite this growing optimism, Cleveland Clinic psychiatrist David Streem, MD, argues that the recent discussion surrounding opioids has missed two equally salient points: first, drug overdose remains a major preventable cause of death; and second, the sequelae of addiction and nonfatal drug overdose continue to exact a heavy financial toll on society and the U.S. healthcare system.

In a recent editorial published in Becker’s Behavioral Health, Dr. Streem explains that the prime directive when managing patients who inject drugs has long been to keep the person alive. For the last two decades, clinicians have focused their efforts on harm-reduction initiatives, including naloxone distribution, fentanyl test strips, supervised injection facilities (SIFs), syringe- and needle-access programs (SNAPs) and better access to medications for opioid use disorder (OUD).

However, the success of these interventions is being threatened by several new trends, Dr. Streem says, including the increasing popularity of xylazine, a nonopioid veterinary sedative; nitazenes, a class of dangerous synthetic opioids; and the dissociative anesthetic ketamine – all of which can greatly increase the risk of overdose.

Supply-side challenges

Although opioids have been the dominant culprit in U.S. overdose deaths for decades, he notes that nonopioid drugs are appearing with increasing frequency in fatal overdose reports. Leading the trend are psychostimulants (e.g. methamphetamine) and cocaine.

“Although cocaine trafficking into the U.S. has been a [serious problem] for the last 40 years, the appearance of cocaine adulterated with fentanyl is a new and disturbing phenomenon,” writes Dr. Streem, Medical Director of Cleveland Clinic’s Alcohol and Drug Recovery Center.

Weighing treatment options

Although studies show naloxone distribution to be one of the most consistently effective tools for reducing the risk of fatal opioid overdose, Dr. Streem notes several significant limitations to the future utility of this approach.

“The replacement of heroin for fentanyl in the illicit opioid supply has potentially reduced the effectiveness of naloxone as a rescue agent,” he says. “The increased affinity of fentanyl for the mu opioid receptor paired with the lipid solubility of the drug means that higher concentrations of naloxone may be required. In addition, the use of high-dose fentanyl raises the risk of chest wall rigidity, also known as wooden chest syndrome – a rare and potentially fatal complication that can occur without warning.”

Although fentanyl test strips may reduce the risk of overdose in people who inject drugs, Dr. Streem cautions that more evidence is needed to confirm their efficacy. “Furthermore, the impact of test strips in those who inject drugs is likely to wane as the level of fentanyl in the illicit opioid supply grows,” he adds.

Research suggests that SIFs may reduce the risk of overdose in the immediate vicinity of the facility. Unfortunately, efforts to open new SIFs often encounter resistance from local and federal regulators, which may mitigate the success of this approach, he says.

Dr. Streem asserts that there is little reason to believe that SNAPs can reduce the risk of opioid overdose death (OOD), but he notes that such programs may encourage people who inject drugs to seek substance abuse treatment.

He also stresses that there is strong evidence to support the use of methadone, buprenorphine and naltrexone to treat OUD. Research shows these medications may have a significant impact on treatment adherence and retention, positive drug tests, and other endpoints associated with OOD.

“Would the further elimination of state-based restrictions and barriers to the use of medications for OUD lead to further reductions in opioid overdose deaths?” Dr. Streem writes. “The totality of the evidence suggests the answer is ‘yes,’ but realize that the factors affecting overdose risk are complex in each state. How interventions are implemented matters. The more interventions that focus on helping people who inject drugs, the more impactful the results.”