The bipartisan spending agreement Congress passed earlier this year includes about $800 million to fight opioid addiction and increase access to treatment and recovery services. This appropriation — up from $150 million in the last budget — builds on an additional $485 million in grants to states provided for in the 21st Century Cures Act.
How the government decides to spend this money could be a turning point in the opioid epidemic or mark a missed opportunity to address the crisis that’s killing tens of thousands of Americans each year.
The opioid epidemic is one of the few issues today that elected leaders on both sides of the aisle are urgently working to address. As important as that bipartisan cooperation is, it’s equally essential that policymakers rely on scientific evidence — not anecdote, status quo, or political belief — as they decide which programs to fund. There are a number of approaches to treating opiate addictions, some of which are evidence-based and some of which are not.
Last fall, at the suggestion of the White House Office of National Drug Control Policy, we worked with J-PAL North America, a research center at MIT, to review the evidence on several promising interventions and synthesize the results in a policy brief. Here’s what we found.
Medication-assisted treatment. The current standard of care for opioid use disorders is medication-assisted treatment, a combination of behavioral therapy and medication, usually methadone or buprenorphine. Medication-assisted treatment is safe and effective, especially when used in conjunction with psychosocial and medical support. It helps people stay in treatment and reduces the misuse of opioids. The evidence further suggests that it decreases the risk of contracting HIV and dying prematurely. However, there are significant barriers to the use of medication-assisted treatment: it is heavily regulated, often difficult to access, frequently under-dosed, requires long-term use, and is subject to considerable stigma.
Health and social service wrap-arounds. Several programs designed to address the social and health-related harms associated with opioid use disorders have generated net savings by lowering health and criminal justice costs below the costs of the programs themselves. That makes such programs especially attractive options for policymakers and the taxpayers they serve. For example, a number of randomized evaluations show that supportive housing for homeless individuals with substance use or mental health disorders reduces incarceration rates and prison time, and also lowers emergency department visits and inpatient hospital spending. In many cases, the financial savings generated by these improved outcomes generally offset or exceed the costs of the housing programs.
Similarly, programs to provide intravenous drug users (a growing population as heroin use continues to skyrocket) with access to clean, safe needles have been associated with reduced HIV transmission, and so can save money by lowering HIV treatment costs.
Education and prevention. A creative program from Massachusetts Attorney General Maura Healey’s office dedicated $700,000 in awards to schools around the state to scale up evidence-based educational programs to prevent opioid addiction. Funding for the program came from settlements with CVS Pharmacy and Walgreens over improper dispensing of controlled substances, particularly opioids.
Other ideas. A number of other innovative programs that have not yet been rigorously evaluated are worthy of further study, ideally through randomized controlled trials. These include
- Emergency departments providing peer counselors to help get patients into treatment
- Pre-arrest diversion to treatment for individuals at risk of overdose who turn themselves into the police
- Medical, behavioral, and social services for mothers with opioid use disorders and their babies.
These programs could serve a great unmet need. It would be very valuable to figure out which ones work, which work best, and why.
When possible, policymakers should set aside funds to evaluate the impacts of their programs. For example, the Louisville Metro Department of Corrections is partnering with J-PAL North America to test in a randomized controlled trial the impact of immediately linking opioid-addicted inmates to treatment upon release from jail. Major philanthropic organizations have also dedicated funding to evaluating programs targeting the opioid crisis — such as the Laura and John Arnold Foundation, which recently committed to supporting rigorous evaluations of opioid addiction treatment strategies.
As governments and philanthropists collaborate to learn what’s working to fight opioid addiction, establishing an infrastructure to share knowledge across local, state, and federal agencies will accelerate their collective work. It would also set a precedent for cooperation to use an evidence-driven approach to tackle many of our nation’s other pressing problems.
Some of this work is already being done by organizations such as the Pew-MacArthur Results First Initiative and the National Governors Association’s Center for Best Practices. Expanding the evidence on what works in the real world should be a priority. Public agencies can contribute to these efforts by integrating existing administrative data and making it easier to access these resources for research. Agencies can also design rigorous evaluations in conjunction with program roll-outs, and partner with researchers to independently evaluate their efforts.
Investing in such collaborations now offers the opportunity to truly understand what works and will provide guidance on how best to allocate limited public funds to address the growing public health crisis of opioid misuse.
Mireille Jacobson is a health economist at the University of California, Irvine, who is currently working with several states and localities to develop and test effective ways to address the opioid epidemic. Anna Spier is a senior policy associate at J-PAL North America, a research center at MIT that aims to reduce poverty by ensuring that policy is informed by scientific evidence.