A national effort to reduce opioid-related overdose deaths has laid the groundwork for more widely available opioid use disorder treatment, safer prescribing practices, and community-based overdose education and naloxone distribution that can save lives, according to researchers who led Ohio's participation in the initiative.
Launched in 2019, the HEALing (Helping to End Addiction Long-Term) Communities Study (HCS) is the largest addiction prevention and treatment implementation study ever conducted. Researchers from the four participating states report today (June 16, 2024) in the New England Journal of Medicine and at the College on Problems of Drug Dependence (CPDD) annual meeting that the intervention did not result in a statistically significant reduction in opioid-related overdose death rates during the evaluation period.
The data-driven intervention deployed evidence-based practices in 67 communities across states hit hard by the opioid crisis: Kentucky, Massachusetts, New York and Ohio. Though the goal to significantly reduce opioid overdose deaths was not met, Ohio implemented 137 evidence-based practice strategies in nine counties in Ohio. These strategies, implemented in complicated settings - hospital emergency departments and jails, to name just two - was an accomplishment that will have enduring positive effects, researchers say.
"Implementing all of those evidence-based practices is the success," said Bridget Freisthler, professor of social work at The Ohio State University and Ohio's principal investigator for the HEALing Communities Study. "The practices are really about changing clinical care. The fact that many of those services are in place and are still working gives us some confidence that, going forward, these communities are going to be better prepared to address overdoses and overdose deaths. And hopefully they'll see reductions over time."
T. John Winhusen, the HCS co-principal investigator for Ohio and director of the University of Cincinnati Center for Addiction Research, led the national group of experts convened to develop the Opioid-Overdose Reduction Continuum of Care Approach (ORCCA), a compendium of evidence-based practice strategies that guided the selection of interventions to be implemented in HCS intervention communities.
ORCCA includes three "menus" of evidence-based practices: one devoted to overdose education and naloxone distribution, one focused on increasing exposure to medication for opioid use disorder, and a third focused on safer opioid prescribing.
"ORCCA was designed to be flexible enough to meet the needs of a given community while also ensuring that strategies known to reduce opioid-related overdose deaths would be selected for implementation," said Winhusen, also the Donald C. Harrison Endowed Chair in Medicine and professor and vice chair for addiction sciences in the Department of Psychiatry and Behavioral Neurosciences at UC.
The National Institutes of Health (NIH) launched the four-year, multisite HCS to test a set of interventions for reducing overdose deaths across health care, justice and behavioral health settings. Over 100,000 people die annually of a drug overdose - 75% of which involve an opioid, according to the Centers for Disease Control and Prevention. Numerous evidence-based practices have been proven to prevent or reverse opioid overdose, but are gravely underused due to numerous barriers, according to the National Institute on Drug Abuse (NIDA).
Between January 2020 and June 2022, intervention communities successfully implemented 615 evidence-based practice strategies to address opioid-related overdose deaths - but only 235 were implemented before the study period comparing outcomes in intervention and control communities began. The authors of the NEJM article noted the COVID-19 pandemic, a short timeframe for implementing the interventions, and increased prevalence of fentanyl in the illicit drug market may have diminished the mortality impact of the intervention.
The evidence-based practices compiled for the ORCCA covered a lot of ground and required a lot of coordination to launch.
"Some of the strategies were major undertakings," Winhusen said. "For example, working with a jail to start a buprenorphine treatment program is one strategy out of the 137 strategies implemented in Ohio. Another example was working with emergency departments to identify people with opioid use disorder, get them started on buprenorphine, and link them to ongoing buprenorphine treatment.
"Due to both COVID-19 and time constraints, only 38% of the strategies were implemented before the start of the comparison period so you're not going to see the full effects. It just wasn't enough time."
Freisthler co-led the charge to engage community coalitions and help them consult data to select interventions best suited to the areas they served. The team also developed communications campaigns addressing a range of topics - the stigma linked to opioid misuse and to taking medications to combat opioid addiction, and the necessity of adopting evidence-based practices - that were among written materials that will help sustain Ohio's participation in the initiative, all housed on an Ohio State HCS website.
"Communities have been at the forefront of addressing opioid use and overdoses for years. A success of Ohio's implementation is peer-to-peer learning and feedback about the evidence-based practice strategies. This effort moved the needle and what had been barriers to services in the past," she said. "It takes a coordinated effort, and some might need help and expertise, but really, that piece showed that communities can be an agent of change in this process."
The Ohio consortium brought together experts from Ohio State, UC and four other universities - Case Western Reserve University, Ohio University, University of Toledo and Wright State University - as well as the community organizations and leaders from state agencies.
Freisthler noted that ongoing engagement with the RecoveryOhio multi-agency initiative created by Gov. Mike DeWine was an enabling force behind many features of the HEALing Communities Study, including establishment of the State of Ohio Integrated Behavioral Health Dashboard of county statistics and trend data, as well as streamlined navigation of policy and communication challenges over the course of the study.
Many U.S. states have access to national opioid settlement funds specifically designated to address the opioid epidemic. Winhusen said that several free products developed from the Opioid-Overdose Reduction Continuum of Care Approach, including a practice guide and a guide for policymakers, are "perfect for communities that are trying to decide how to wisely invest their opioid settlement dollars."
"Back in 2019, the four states convened top experts to discuss the scientific literature in order to develop this," he said. "A great deal of time and effort went into reaching consensus on the strategies included in the ORCCA, and we would love to see communities use this resource to determine how best to invest their opioid settlement funds."
The HEALing Communities Study was supported and carried out in partnership between NIDA (see NIDA's HCS press release on the NEJM article) and the Substance Abuse and Mental Health Services Administration through the NIH HEAL Initiative.
A $65.9 million NIH award funding Ohio State's leadership of the Ohio portion of the study was housed in the university's College of Medicine. Additional sites funded to conduct implementation research within communities in their state were the University of Kentucky, Lexington; Boston Medical Center, Boston; and Columbia University, New York City. RTI International, based in North Carolina, received an award to serve as the study's data coordinating center.
