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The Overdose Crisis

Our country is experiencing an overdose crisis. There were an estimated 107,543 drug overdose deaths in the United States in 2023, reflecting a decrease of 3% from the 111,029 deaths estimated in 2022. While overdose deaths affect all groups in the United States, they disproportionately impact racial minorities, including Black and Native American people.¹ Approximately 70% (74,702) of these deaths were associated with fentanyl, a synthetic opioid.

However, the number of overdose deaths associated with psychostimulants (i.e. methamphetamine) and cocaine increased in 2023 to an estimated 66,169 deaths. According to the Centers for Disease Control and Prevention, many fatal overdoses involve multiple street drugs so the number of deaths attributed to specific substances does not “equal the total number of drug overdose deaths.”² In many cases, more than one drug is implicated in an overdose, referred to as polysubstance overdose.

There is growing concern among providers that the mixing of stimulants and fentanyl, often without the knowledge of the user, is fueling a new wave of overdose deaths in the U.S.³ Teens and young adults are at particular risk of negative outcomes associated with early drug abuse as it correlates with substance abuse problems later in life. Teen drug fatalities more than doubled in recent years, largely due to opioids, but they slightly decreased by the end of 2023.⁴

As a general trend, overdose deaths due to opioids have increased 500% among 15- to 24-year-olds since 1999.⁵ Greater education on prevention and treatment in places where young people live and learn can play a role in reducing initial use, overdose, and death. As such, schools can play a unique role in promoting education on prevention and treatment for substance use disorders among this population.

Treating Overdose and Substance Use Disorder (SUD)

Lifesaving medication for opioid overdose

Naloxone (brand name Narcan) is a lifesaving medication that reverses the effects of opioids and functions as an overdose antidote. It is available over-the-counter (OTC) and can be administered as a nasal spray to prevent death in a person experiencing overdose. However, the distribution of naloxone is insufficient, especially in rural areas and minority communities. Unfortunately, there are no overdose reversal medications for stimulants like there are for opioids.

Medications for opioid use disorder (OUD)

The Drug Enforcement Agency (DEA) classifies drugs into five schedules depending on the drug’s acceptable medical use and its abuse or dependency potential. For example, Schedule I drugs have a high potential for abuse and the potential to create severe psychological and/ or physical dependence, whereas Schedule V drugs represent the least potential for abuse.

There are 3 Food and Drug Administration (FDA)-approved medications used to treat OUD. These medications for opioid-use disorder (MOUD) lower the risk for fatal overdose and help patients recover:

• Methadone – a long-acting synthetic opioid that does not cause euphoria and reduces withdrawal symptoms and cravings. Only available in regulated clinics. Classified as a Schedule II drug.⁶
• Buprenorphine – partially blocks the effects of opioids while reducing withdrawal symptoms and cravings. Available as a daily tablet or monthly injection. Classified as a Schedule III drug.⁶
• Naltrexone – fully blocks the effects of opioids to prevent the feeling of euphoria. Available as a daily pill or monthly injection. Naltrexone is not a controlled substance.

Despite the availability of treatment options, access is still an issue. In 2022, only 25% of adults with OUD received MOUD.⁸ Physicians report barriers to treating OUD including minimal experience and lack of access to addiction specialists^.9 Even if prescribed, many pharmacies do not stock buprenorphine out of fear that their dispensing patterns may be viewed negatively by pharmaceutical distributors and regulatory bodies. Methadone can only be dispensed from certified opioid treatment program (OTP) centers and requires daily visits. Many counties do not have an OTP, forcing patients to travel long distances for treatment.

Treatment of stimulant-use disorders

Contingency management (CM) is the most effective treatment and current standard of care for stimulant-use disorders. CM is a behavioral therapy in which patients are rewarded for positive behavioral change. Most often, this involves monetary-based reinforcements for negative drug tests. Studies have found that CM is twice as effective as other psychosocial interventions, such as counseling, cognitive behavioral therapy, and motivational interviewing, for treatment of stimulant-use disorder.

However, there are numerous barriers that limit more widespread uptake of CM. These include concerns about the potential for fraud and abuse in CM programs, restrictions on funding, and stigma related to this treatment method.¹⁰

Policy opportunities

Health systems and policymakers must act to address the overdose crisis and access issues for SUD treatments. We recommend several approaches:

Expand access to naloxone, a lifesaving medication that treats opioid overdose.

• Increase prescriptions for at-risk patients: Policies should aim to encourage more consistent prescribing by physicians for both overdose prevention (naloxone) and medications that treat underlying OUD for at-risk individuals (e.g. those with OUDs or receiving care post-overdose). To increase access, pharmacists should have authority to prescribe and dispense naloxone to a t-risk individuals.
• Support programs that provide free or low-cost naloxone: Address cost barriers to both over the counter and prescription naloxone by supporting programs that provide naloxone at low-cost to addiction medicine clinics and hospitals
• Bolster availability in variety of settings: Ensure that naloxone is available and can be utilized in medical settings, including ambulatory clinics. Promote policies that increase access in community settings, including minority and under-served rural and urban communities and increase understanding of the medication among key stakeholders like at-risk patients and caregivers. Additionally, allow schools to possess and administer naloxone. 
• Ensure immunity from criminal and civil liability: Offer prescribers, dispensers, and laypersons immunity from civil liability, criminal liability, and professional disciplinary actions for prescribing or administering naloxone.

Increase access to buprenorphine and other evidence-based treatments for OUD.

• Distinguish between buprenorphine and other opioids: Ensure consistent and clear messaging around the importance of increasing buprenorphine access and its distinction from other opioids, specifically communicating that there are not quotas or caps on how much buprenorphine pharmacies can stock. Support research and re-evaluation as to whether the placement of all buprenorphine products in Schedule III11 is appropriate.
• Increase dispensing locations: Promote policies that expand locations where buprenorphine prescriptions can be filled (e.g. community behavioral health centers, federally qualified health centers) and streamline pharmacy drug safety programs to prescribe and administer injectable forms of buprenorphine.
• Reduce barriers to accessing MOUDs: Address high drug pricing of extended release buprenorphine and naltrexone. Facilitate telehealth access to buprenorphine by removing in-person requirements for treatment.
• Increase access to methadone: Align federal and state regulations to allow DEA-licensed providers to dispense up to three-days’ worth of methadone in appropriate circumstances and support research to evaluate access to methadone outside of OTPs.

 Expand access to contingency management for stimulant-use disorders

• Address concerns about the potential for fraud and abuse in CM programs by developing guidance on effective safeguards and best practices (i.e., within the Anti-Kickback Statute and Beneficiary Inducement Civil Monetary Penalties Law).
• Address restrictions on funding CM programs by removing ineffective and unnecessary limits to federally funded programs.

Promote education on prevention and evidence-based treatments for SUD

• Support education and training for prescribers on how to treat patients with SUD: Ensure single, federal training standards and promote broadly with providers while ensuring that educational requirements are not unnecessarily burdensome. Also support free education and training that reduces stigma and fear of prescribing, particularly for primary care providers. Support policies that increase the number, diversity, and language capabilities of the health workforce.
• Ensure that educational opportunities are equitable: Promote policies that aim to improve education and access to treatment for minority and underserved populations.
• Promote education on prevention and treatment of SUDs in schools: Support evidence-based prevention programs in schools, including training programs for staff and school districts. Ensure sustainable Medicaid funding for services delivered in schools and permit school districts to directly bill state Medicaid programs for substance use services delivered in schools.

- Advancing public policies to support substance use disorder treatment and recovery