Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

Abstract

Importance: In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs).

Objective: To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo.

Design, setting, and participants: This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic.

Exposure: Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years.

Main outcomes and measures: Projected reduction in number of OODs under different combinations and durations of sustainment of interventions.

Results: Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained.

Conclusions and relevance: In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Trial registration: ClinicalTrials.gov NCT04111939.

Figure 1.. Opioid Policy Model Schematic Showing Transition Between Different Health States

The state-level Opioid Policy Model consists of 4 categories of health states representing subpopulations at different stages of opioid use: (1) prescription opioid misuse, (2) illicit opioid use, (3) opioid use disorder (OUD), and (4) in recovery. Individuals can enter the model over time with either prescription opioid misuse or illicit opioid use and may subsequently develop OUD. Those with OUD can transition to the in-recovery state, starting the recovery process typically through treatment initiation. Individuals in recovery remain at risk of relapse, returning to the OUD state. We assume that those who are no longer receiving medications for opioid use disorder (MOUD) must relapse before receiving MOUDs again. All individuals in the model who are actively using opioids have a risk of opioid overdose death that depends on their health state, and all individuals have a background mortality risk from other (ie, nonopioid-related) causes (transition not shown in figure for simplicity). Deaths (from opioid overdose or from other causes) are possible from all states.

Figure 2.. Estimated Percentage Reduction in Annual Opioid Overdose Deaths After 2 Years of Implementation of Evidence-Based Practice Interventions in Kentucky, Massachusetts, New York, and Ohio Compared With the Status Quo

For each state and the intervention combinations, columns represent the scenarios of increasing medications for opioid use disorder (MOUD) initiation (a plausible 2-fold increase and an aspirational 5-fold increase) and rows represent the 6-month retention of MOUDs (base case retention of 32% for buprenorphine and 52% for methadone; and high retention observed in randomized clinical trials [RCTs] at 46% for buprenorphine and 74% for methadone). The first set of columns shows the estimated percentage reduction of implementing of MOUD-related interventions. The second set of columns add overdose education and naloxone distribution, which translates to a 10% mortality rate reduction. The third set of columns adds an increase in safe opioid prescribing that translates to a 50% reduction in new prescription opioid misuse.

Figure 3.. Temporal Trends in Estimated Opioid Overdose Deaths Under the Status Quo and With the Implementation of Interventions, With and Without Sustainment for Different Durations

The selected intervention consists of 2-fold increase in medications for opioid use disorder, medications for opioid use disorder retention at the level observed in clinical trials (6-month retention of 46% for buprenorphine and 74% for methadone), overdose education and naloxone distribution that translate to a 10% mortality rate reduction, and increase in safe opioid prescribing that translates to a 50% reduction in new prescription opioid misuse.

Figure 4.. Estimated Reduction in Annual Opioid Overdose Deaths in Each State, With and Without Sustainment of the Intervention Relative to the Status Quo

The selected intervention consists of 2-fold increase in medications for opioid use disorder (MOUD) initiation rates, MOUD retention at the level observed in clinical trials (6-month retention of 46% for buprenorphine and 74% for methadone), overdose education and naloxone distribution that translate to a 10% mortality rate reduction, and an increase in safe opioid prescribing that translates to a 50% reduction in new prescription opioid misuse.