Message from the Secretary, U.S. Department of Health and Human Services

The opioid misuse and overdose crisis touches everyone in the United States. In 2016, we lost more than 115 Americans to opioid overdose deaths each day, devastating families and communities across the country. Preliminary numbers in 2017 show that this number continues to increase with more than 131 opioid overdose deaths each day. The effects of the opioid crisis are cumulative and costly for our society—an estimated $504 billion a year in 2015—placing burdens on families, workplaces, the health care system, states, and communities.

Addressing the opioid crisis is a priority for this Administration, and the U.S. Department of Health and Human Services (HHS) is leading the public health-based approach to understanding the problem and taking action to fight it. HHS is tackling this crisis through our comprehensive five-point strategy focused on improving access to prevention, treatment, and recovery services; promoting use of overdose reversing drugs; strengthening our understanding of the epidemic through better public health surveillance; providing support for cutting-edge research on pain and addiction; and advancing better practices for pain management. Our efforts are collaborative—with all federal agencies and state and local partners working together to equip health care providers, communities, policymakers, law enforcement, and others with the information and tools they need to stem this growing epidemic.

HHS also brought a new level of awareness and commitment to the cause by declaring the opioid crisis a nationwide Public Health Emergency on October 26, 2017. Since 2017, HHS has disbursed more than $2 billion in grants to fight the opioid crisis, more than any previous year.

The Spotlight on Opioids document is another important step in our efforts to address the issue. This document assembles opioid-related information from Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health in one document and provides updated data on the prevalence of substance use, opioid misuse, opioid use disorders, opioid overdoses, and related harms. As the Secretary of the Department of Health and Human Services, I encourage you to use the information and findings in this document and join us in taking action on this vital issue and making our communities healthier and stronger.

• ALEX M. AZAR II
  Secretary
  U.S. Department of Health and Human Services

Foreword from the Assistant Secretary for Mental Health and Substance Use

After many years combating the opioid epidemic on the front lines of addiction psychiatry, I returned to the Substance Abuse and Mental Health Services Administration (SAMHSA) to do everything possible to ensure that American families and communities do not continue to lose their loved ones to opioids.

Now is the time to work together and apply what we know to end this epidemic once and for all. Medication-assisted treatment (MAT) combined with psychosocial therapies and community-based recovery supports is the gold standard for treating opioid addiction.

There is strong scientific evidence that this combination of therapeutic interventions is life-saving and can enable people to recover to healthy lives. SAMHSA is joining forces with agencies across HHS and the federal government to increase access to these evidence-based interventions—especially in communities hardest hit by the opioid crisis. We are (1) working with states and their communities to increase access to prevention, treatment and recovery support services for opioid use disorder; (2) supporting providers’ efforts to offer specialized treatment to pregnant and postpartum women with opioid use disorder and their opioid-exposed infants; (3) promoting early intervention and treatment as healthier alternatives to detaining people with opioid addiction in our criminal justice systems; (4) and facilitating the expansion of telemedicine to deliver MAT to people in need in rural communities and to enhance rural providers’ skills.

To help remove the societal stigma for those seeking addiction treatment, we have implemented new changes to the federal rules governing confidentiality and disclosures of substance use disorder patient records. Our workforce efforts include support for a variety of trainings and resources to prevent over prescribing and diversion of prescription medications and initiatives to increase the number of qualified health care providers who can offer treatment for opioid use disorder. In the crucial area of overdose prevention, we are increasing the distribution of naloxone and expanding training to first responders, prescribers, patients, employers, and family members on how to administer this live-saving antidote.

With the Office of the Surgeon General, SAMHSA has produced the Spotlight on Opioids—a document that offers practical information and guidance that individuals and systems can use to take action. I urge you to use it as a resource as you consider what you can do to help end this crisis and save lives. Inside and outside of government, at the national, state and local level, and in every community across this nation, we must join forces to turn the tide against the opioid crisis.

• ELINORE F. McCANCE-KATZ, M.D., Ph.D.
  Assistant Secretary for Mental Health and Substance Use
  Substance Abuse and Mental Health Services Administration

Preface from the Surgeon General, U.S. Department of Health and Human Services

My family and I are among the millions of Americans affected by substance use disorder. My younger brother has struggled with this disease, which started with untreated depression leading to opioid pain reliever misuse. Like many with co-occurring mental health and substance use disorder conditions, my brother has cycled in and out of incarceration. I tell my family’s story because far too many are facing the same worries for their loved ones. We all ask the same question: How can I contribute to ending the opioid crisis and helping those suffering with addiction?

The first step is understanding that opioid use disorder is a chronic but treatable brain disease, and not a moral failing or character flaw. Like many other chronic medical conditions, opioid use disorder is both treatable, and in many cases, preventable. It is also a disease that must be addressed with compassion. Unfortunately, stigma has prevented many sufferers and their families from speaking about their struggles and from seeking help. The way we as a society view and address opioid use disorder must change—individual lives and the health of our nation depend on it.

I believe that the best way to address the opioid crisis is to work towards achieving better health through better partnerships. Health advocates must involve businesses and law enforcement organizations—they have witnessed the negative effects of opioids and have a strong interest in helping end the epidemic. Educators and the faith-based community have unique touchpoints and resources that can be brought to bare for prevention and treatment efforts. We must listen to all communities affected by the opioid crisis—speaking with them versus at them, leveraging their strengths, and addressing their priorities. Through partnerships, we can address the overall health inequities and determinants of health that exist where we live, learn, work, and play. Together we can reduce the risks of opioid misuse, opioid use disorder, and related health consequences such as overdose and infectious disease transmission.

As Surgeon General, I care about the health and well-being of all Americans. My office worked with SAMHSA to create the Spotlight on Opioids so that people with a broad range of backgrounds can reference opioid-related information from Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health in one document. I hope that all readers use this document to determine specific actions they can take to mitigate the opioid crisis.

• JEROME M. ADAMS, M.D., M.P.H.
  Vice Admiral, U.S. Public Health Service
  Surgeon General

Introduction and Overview

All across the United States, individuals, families, communities, and health care providers are struggling to cope with the impacts of the opioid crisis. Opioid misuse and opioid use disorders have devastating effects. As we see all too often in cases of overdose deaths, lives end prematurely and tragically. Other serious consequences include neonatal abstinence syndrome and transmission of infectious diseases such as HIV and viral hepatitis, as well as compromised physical and mental health. Social consequences include loss of productivity, increased crime and violence, neglect of children, and expanded health care costs. However, it must be noted that there are certain populations who rely on prescription opioids and are taking them responsibly under the care of a trusted provider. These include, but are not limited to: individuals in hospice care; individuals who are undergoing cancer treatment; people who recently experienced a traumatic injury; or those with long-term disability and chronic pain.

In November 2016, the Office of the Surgeon General released Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (the Surgeon General’s Report).¹ This landmark publication provided the latest research-based information on substance misuse, substance use disorders, and their health impacts for the general public. It provided suggestions and recommendations for action that everyone can take to prevent substance misuse and reduce its consequences. The Surgeon General’s Report described a public health–based approach to substance misuse and substance use disorders. A public health approach recognizes that substance misuse and its consequences are the result of multiple interacting factors (individual, environmental, and societal) and requires that diverse stakeholders work in a coordinated way to address substance misuse across the community.

The Office of the Surgeon General and the Substance Abuse and Mental Health Services Administration (SAMHSA) developed this Spotlight on Opioids from the Surgeon General’s Report, in order to provide opioid-related information in one, easy-to-read document. Although Spotlight on Opioids does not include new scientific information, it provides the latest data on prevalence of substance use, opioid misuse, opioid use disorders, opioid overdoses, and related harms. This document sometimes discusses substance use disorders rather than opioid use disorder specifically. As indicated in the section “The Neurobiology of Substance Use, Misuse, and Addiction,” opioids and other substances have similar effects on the brain’s reward pathways. Additionally, it is common for people who misuse opioids to misuse other substances or to have multiple substance use disorders or co-occurring mental disorders. Therefore, the general principles related to substance use disorders often apply to opioid use disorder.

Opioids: The Current Landscape

Historically, opioids have been used as pain relievers. However, opioid misuse presents serious risks, including overdose and opioid use disorder. The use of illegal opioids such as heroin—a highly addictive drug that has no accepted medical use in the United States—and the misuse of prescription opioid pain relievers can have serious negative health effects. Fentanyl is a synthetic opioid medication that is used for severe pain management and is considerably more potent than heroin. Sometimes, prescription fentanyl is diverted for illicit purposes. But fentanyl and pharmacologically similar synthetic opioids are also illicitly manufactured and smuggled into the United States.²

These illicitly made synthetic opioids are driving the rapid increase in opioid overdose deaths in recent years.^3–5 Illicitly made fentanyl and other pharmacologically similar opioids are often mixed with illicit substances such as heroin. They can also be made into counterfeit prescription opioids or sedatives and sold on the street.

Neurobiology of Substance Use, Misuse, and Addiction

Figure 1

The Three Stages of the Addiction Cycle and the Brain Regions Associated With Them.

Severe substance use disorders (commonly called addictions) were once viewed largely as a moral failing or character flaw, but are now understood to be chronic diseases that are subject to relapse, and characterized by clinically significant impariments in health, social function, and voluntary control over substance use.²⁶ All addictive substances—including opioids—have powerful effects on the brain. They “hijack” the brain’s reward system by inducing feelings that motivate people to use those substances again and again, despite the risks for significant harms. With repeated exposure, progressive changes occur in the structure and function of the brain, compromising brain function and driving chronic misuse. These brain changes endure long after an individual stops using substances and may produce continued, periodic cravings for the substance that can lead to relapse for many years.^{27, 28}

Well-supported evidence suggests that the addiction process involves a three-stage cycle: (1) Binge/Intoxication, the stage at which an individual consumes an intoxicating substance and experiences its rewarding or pleasurable effects; (2) Withdrawal/Negative Affect, the stage at which an individual experiences a negative physical and emotional state in the absence of the substance; and (3) Preoccupation/Anticipation, the stage at which one seeks substances again after a period of abstinence. This cycle becomes more severe as a person continues substance use and as it produces dramatic changes in brain function that reduce a person’s ability to control his or her substance use. The three stages are linked to and feed on each other, but they also involve different brain regions: (1) the basal ganglia (binge/intoxication), (2) the extended amygdala (withdrawal/negative affect), and (3) the prefrontal cortex (preoccupation/anticipation).²⁹

Like other drugs, opioids affect the brain’s reward system. Opioids attach to opioid receptors in the brain, causing euphoria (the high), drowsiness, and slowed breathing, as well as reduced pain signaling (which is why they are frequently prescribed as pain relievers).

Opioid addiction typically involves a pattern of: (1) intense intoxication, (2) the development of tolerance, (3) escalation in use, and (4) withdrawal signs that include profound negative emotions and physical symptoms, such as bodily discomfort, pain, sweating, and intestinal distress. As use progresses, the opioid must be taken to avoid the severe negative effects that occur during withdrawal. With repeated exposure to opioids, stimuli associated with the pleasant effects of the substances (e.g., places, persons, moods, and paraphernalia) and with the negative mental and physical effects of withdrawal can trigger intense craving or preoccupation with use.

The Continuum of Care for Substance Misuse and Substance Use Disorders

Effective identification, intervention, and integration of prevention, treatment, and recovery services across health care systems is key to addressing substance misuse and its consequences, and it represents the most promising way to improve access to and quality of treatment. The continuum of care approach is a strategy to promote this integration by providing individuals an array of service options—including prevention, early intervention, treatment, and recovery support—based on need.

Evidence-Based Treatment: Components of Care

As discussed in the Surgeon General’s Report Chapter 4 (“Early Intervention, Treatment, and Management of Substance Use Disorders”), evidence-based treatment involves particular components of care. Table 1 (page 20) summarizes what people should look for in a treatment program.

Table 1

What People Should Look for in a Treatment Program.

All substance use disorder treatment programs are expected to individualize treatment using evidence-based clinical components. These components are clinical practices that research has shown to be effective in reducing substance use and improving health and functioning. These include behavioral therapies, medications, and recovery support services (RSS). Treatment programs that offer more of these evidence-based components have the greatest likelihood of producing better outcomes.

Medications and Medication-Assisted Treatment (MAT) for Opioid Use Disorders

Comprehensive MAT programs include behavioral therapies and psychosocial supports as well as medication. The FDA has approved medications for use in the management of opioid use disorder (see table below).

Methadone use in treatment of opioid use disorders can only be dispensed in a federally-regulated opioid treatment program (OTP). Buprenorphine and naltrexone can be dispensed in an OTP and also can be prescribed in medical care settings, such as primary care, and do not require an OTP. Use of these drugs is an individual decision for prescribers and their patients.

Key Term

Opioid Treatment Program (OTP): SAMHSA-certified program, usually comprising a facility, staff, administration, patients, and services, that engages in supervised assessment and treatment, using methadone, buprenorphine, or naltrexone, of individuals who have opioid use disorders. An OTP can exist in a number of settings, including but not limited to intensive outpatient, residential, and hospital settings. Services may include medically supervised withdrawal and/or maintenance treatment, along with various levels of medical, psychiatric, psychosocial, and other types of supportive care.

Those FDA-approved medications listed in Table 2 demonstrate “well-supported” evidence of safety and effectiveness for improving outcomes for individuals with opioid use disorders.^74,75 Only appropriately trained health care professionals should decide, in conjunction with the person in need of treatment, whether and which medication is needed as part of treatment, how the medication is provided in the context of other clinical services, and under what conditions the medication should be discontinued. MAT for patients with an opioid use disorder must be delivered for an adequate duration in order to be effective. Patients who receive MAT for fewer than 90 days have not shown improved outcomes.⁷⁶ One study suggested that individuals who receive MAT for fewer than 3 years are more likely to relapse than those who are in treatment for 3 or more years.⁷⁷

Table 2

Medications/Pharmacotherapies for Opioid Use Disorder (OUD).

In 2018, SAMHSA released Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. This Clinical Guide provides comprehensive, national guidance for optimal management of pregnant and parenting women with opioid use disorder and their infants.

It helps health care professionals and patients determine the most clinically appropriate action for a particular situation and informs individualized treatment decisions.

MAT for Pregnant Women

Long-term methadone maintenance treatment has demonstrated improved outcomes for individuals (including pregnant women) with opioid use disorders. Buprenorphine is associated with improved outcomes compared to placebo for individuals (including pregnant women) with opioid use disorders. The safety of naltrexone for pregnant women has not been established.

Key Term

Agonist: A chemical substance that binds to and activates certain receptors on cells, causing a biological response. Fentanyl and methadone are examples of opioid receptor agonists.

State agencies that oversee substance use disorder treatment programs use a variety of strategies to promote implementation of MAT, including education and training, financial incentives (e.g., linking funding to the provision of MAT), policy mandates, and support for infrastructure development.⁷⁸ Nevertheless, multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing medications; payment policies; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation.⁷⁸

The use of opioid agonist medications to treat opioid use disorders has always had its critics. Many people, including some policymakers, authorities in the criminal justice system, and treatment providers, have viewed maintenance treatments as “substituting one substance for another”⁷⁹ and have adhered instead to an abstinence-only philosophy that avoids the use of medications, especially those that activate opioid receptors. Such views are not scientifically supported; the research clearly demonstrates that opioid agonist therapy leads to better treatment outcomes compared to behavioral treatments alone. Moreover, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death. Decades of research have shown that the benefits of opioid agonist therapy greatly outweigh the risks associated with diversion.^80–82

MAT for Criminal Justice Populations

Upon release, incarcerated individuals will have lower tolerance to opioids. They are at high risk for overdose and death if they return to opioid use in the community. There is typically insufficient pre-release counseling and post-release follow-up provided to this population to reduce these risks. Research findings from randomized controlled trials indicate that people involved in the criminal justice system benefit from methadone maintenance (pre- and post-release) and extended-release naltrexone treatment.

Behavioral Therapies

These structured therapies help patients recognize the impact of their behaviors—such as dealing with stress or interacting in interpersonal relationships—on their substance use and ability to function in a healthy, safe, and productive manner. They can be provided in individual, group, and/or family sessions in virtually all treatment settings.^{72, 83} Behavioral therapies also teach and motivate patients to change their behaviors as a way to control their substance use disorders.⁷² Most studies support the use of individual counseling as an effective intervention for individuals with substance use disorders as part of MAT.^{75, 84} Group counseling should primarily be used only in conjunction with individual counseling or other forms of individual therapy.^{77, 79} Despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.^{84, 85}

Recovery Support Services (RSS)

RSS, provided by both substance use disorder treatment programs and community organizations, help to engage and support individuals in treatment and provide ongoing support after treatment. These supportive services are typically delivered by trained case managers, recovery coaches, and/or peers. Specific supports include help with navigating systems of care, removing barriers to recovery, staying engaged in the recovery process, and providing a social context for individuals to engage in community living without substance use.⁸⁶ Individuals who participate in substance use disorder treatment and RSS typically have better long-term recovery outcomes than individuals who receive either alone.⁸⁶ Furthermore, active recovery and social supports, both during and following treatment, are important to maintaining recovery.⁸⁶

Recovery: The Many Paths to Wellness

People can and do recover. Recovery from substance use disorders has had several definitions. Although specific elements of these definitions differ, all agree that recovery goes beyond the remission of symptoms to include a positive change in the whole person. In this regard, “abstinence,” though often necessary, is not always sufficient to define recovery. There are many paths to recovery. People will choose their pathway based on their cultural values, their psychological and behavioral needs, and the nature of their substance use disorder.

Successful recovery often involves making significant changes to one’s life to create a supportive environment that avoids substance use or misuse cues or triggers. Recovery can involve changing jobs or housing, finding new friends who are supportive of one’s recovery, and engaging in activities that do not involve substance use. This is why ongoing RSS in the community after completing treatment can be invaluable for helping individuals resist relapse and rebuild lives that may have been devastated by years of substance misuse.

RSS are not the same as treatment and have only recently been included as part of the health care system. The most well-known approach, mutual aid groups, link people in recovery and encourage mutual support while providing a new social setting in which former alcohol or drug users can engage with others in the absence of substance-related cues from their former life. Mutual aid groups are facilitated by peers, who share their lived experience in recovery. However, health care professionals have a key role in linking patients to these groups, and encouraging participation can have great benefit.⁸⁷

Recovery coaches, who offer individualized guidance, support, and sometimes case management, and recovery housing—substance-free living situations in which residents informally support each other as they navigate the challenges of drug- and alcohol-free living—have led to improved outcomes for participants.^88–92 Several other common RSS, including recovery community centers and recovery high schools, have not yet been rigorously evaluated.

Health Care Systems and Opioid Use Disorder

Services for the prevention and treatment of substance misuse and substance use disorders have traditionally been delivered separately from other mental health and general health care services. Because substance misuse has traditionally been seen as a social or criminal problem, prevention services were not typically considered a responsibility of health care systems; and people needing care for substance use disorders have had access to only a limited range of treatment options that were generally not covered by insurance.

Effective integration of prevention, treatment, and recovery services across health care systems is key to addressing opioid misuse and its consequences, and it represents the most promising way to improve access to and quality of treatment. When health care is not well integrated and coordinated across systems, too many patients fall through the cracks, leading to missed opportunities for prevention and early intervention, ineffecive referrals, incomplete treatment, high rates of hospital and emergency department readmissions, and individual tragedies (e.g., opioid overdoes) that could have been prevented.

The good news, however, is that a range of promising health care structures, technologies, and innovations are emerging, or are being refined and strengthened. These developments are helping to address challenges and facilitate integration. Is so doing, they are broadening the focus of interventions beyond just the treatment of severe substance use disorders to encompass the entire spectrum of prevention, treatment, and recovery.

Conclusion

The opioid overdose epidemic brings into sharp focus how myths and misconceptions about addiction have led to devastating consequences for individuals and communities. The evidence-based public health approach described in the Surgeon General’s Report offers a positive way forward to reducing the opioid crisis by addressing factors that contribute to the misuse and its consequences. By adopting this approach—which seeks to improve the health, safety, and well-being of the entire population—we have the opportunity as a nation to take effective steps to prevent and treat opioid misuse and opioid use disorder and reduce opioid overdose. A public health approach to the opioid crisis will also reduce other harmful consequences, such as infectious disease transmission and NAS. States that have had success in implementing the public health approach and slowing their overdose rates have emphasized the importance of partnerships. Given that too many individuals are dying every day from opioid overdose, shifting our attitudes and working together to widen access to prevention, treatment, and recovery services for opioid misuse and opioid use disorders are essential for saving lives.

The responsibility of addressing opioid misuse and opioid use disorders does not fall on one sector alone, and the health care system cannot address all of the major determinants of health related to substance misuse without the help of the wider community. Everyone has a role to play in changing the conversation around addiction, to improve the health, safety, and well-being of individuals and communities across our nation.

Below are suggestions for various key stakeholders.

Individuals and Families:

• Reach out, if you think you have a problem with opioid misuse or a substance use disorder.
• Be supportive (not judgmental) if a loved one has a problem.
• Carry naloxone and be trained on how to use it.
• Show support toward people in recovery.
• Parents, talk to your children about substance use.
• Understand pain. Many scientifically proven pain management options do not involve opioids. Talk to your health care provider about an individualized plan that is right for your pain.
• Be safe. Only take opioid medications as prescribed to you. Always store in a secure place. Dispose of unused medication properly.

Educators and Academic Institutions:

• Implement evidence-based prevention interventions.
• Provide treatment and recovery supports.
• Teach accurate, up-to-date scientific information about substance use disorders as medical conditions.
• Enhance training of health care professionals.

Health Care Professionals and Professional Associations:

• Address substance use-related health issues with the same sensitivity and care as any other chronic health condition.
• Support high-quality care for substance use disorders.
• Follow the gold standard for opioid addiction treatment.
• Follow the CDC Guideline for Prescribing Opioids for Chronic Pain.
• When opioids are prescribed, providers can assess for behavioral health risk factors to help inform treatment decisions, and collaborate with mental health providers.
• Check the PDMP before prescribing opioids.
• Refer to patients to opioid treatment providers when neccessary.
• Become qualified to prescribe buprenorphine for the treatment of opioid use disorder.

Health Care Systems:

• Promote universal, selective, and indicated prevention.
• Promote use of evidence-based treatments.
• Promote effective integration of prevention, treatment, and recovery support services.
• Work with payers to develop and implement comprehensive billing models.
• Implement health information technologies to promote efficiency, actionable information, and high-quality care.
• Create stronger connections across behavioral health providers and mainstream medical systems.
• Engage primary care providers as part of a comprehensive treatment solution.

Communities:

• Build awareness of substance use as a public health problem.
• Invest in evidence-based prevention interventions and recovery supports.
• Implement interventions to reduce harms associated with opioid misuse.

Private Sector—Industry and Commerce:

• Support youth substance use prevention.
• Continue to collaborate with the federal initiative to reduce prescription opioidand heroin-related overdose, death, and dependence.
• Reduce work-related injury risks and other working conditions that may increase the risk for substance misuse.
• Offer education, support and treatment benefits for workers affected by the opioid crisis.

Federal, State, Local, and Tribal Governments:

• Provide leadership, guidance, and vision in supporting a science-based approach to addressing substance use-related health issues.
• Collect and use data to guide local response to people and places at highest risk.
• Improve coordination between social service systems and the health care system to address the social and environmental factors that contribute to the risk for substance use disorders.
• Implement criminal justice reforms to transition to a less punitive and more health-focused approach.

Researchers:

• Conduct research that focuses on implementable, sustainable solutions to address high-priority substance use issues.
• Identify research gaps in understanding the complexity of opioids addiction and pain.
• Promote rigorous evaluation of programs and policies.

Key Federal Resources

• The Surgeon General’s Report
  https://addiction.surgeongeneral.gov/
• CDC Guideline for Prescribing Opioids for Chronic Pain
  https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
• MMWR Opioid Reports
  https://www.cdc.gov/mmwr/opioid_reports.html
• SGR Appendix B: Review Process for Prevention Programs
  https://addiction.surgeongeneral.gov/sites/default/files/appendices.pdf
• NIDA Opioid Risk Tool
  https://www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf
• NIDA Quick Screen
  https://www.drugabuse.gov/publications/resource-guide-screening-drug-use-in-general-medical-settings/nida-quick-screen
• CDC general resources
  https://www.cdc.gov/drugoverdose/prescribing/resources.html
• CDC resources related to People Who Inject Drugs (PWID)
  https://www.cdc.gov/pwid/index.html
• CDC’s Rx Awareness Campaign
  https://www.cdc.gov/rxawareness/index.html
• CDC Adverse Childhood Experiences page
  https://www.cdc.gov/violenceprevention/acestudy/index.html
• Preventing the Consequences of Opioid Overdose: Understanding the Naloxone Access Laws
  https://www.samhsa.gov/capt/sites/default/files/resources/naloxone-access-laws-tool.pdf
• The Surgeon General’s Advisory on Naloxone and Opioid Overdose
  https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html
• SAMHSA Opioid Overdose Prevention Toolkit
  https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA16-4742
• SAMHSA Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants
  https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054

References

1.

Office of the U.S. Surgeon General. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington D.C.: U.S. Department of Health and Human Services; 2016. [PubMed: 29388330]

2.

United States Drug Enforcement Administration. FAQ’s-Fentanyl and Fentanyl-Related Substances. 2018; https://www​.dea.gov/factsheets/fentanyl. Accessed June 28, 2018

3.

Wide-ranging online data for epidemiologic research (WONDER). Centers for Disease Control and Prevention, National Center for Health Statistics; http://wonder​.cdc.gov; 2016.

4.

Hedegaard H, Warner M, Minino AM. Drug Overdose Deaths in the United States, 1999–2016. NCHS Data Brief. 2017(294):1–8. [PubMed: 29319475]

5.

Jones CM, Einstein EB, Compton WM. Changes in Synthetic Opioid Involvement in Drug Overdose Deaths in the United States, 2010–2016. JAMA. 2018;319(17):1819–1821. [PMC free article: PMC6583033] [PubMed: 29715347]

6.

Center for Behavioral Health Statistics and Quality. 2017 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018.

7.

Ahmad F, Rossen L, Spencer M, Warner M, Sutton PJNCfHS. Provisional drug overdose death counts. 2017.

8.

Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445–1452. [PubMed: 28033313]

9.

Kochanek KD, Murphy S, Xu J, Arias E. Mortality in the United States, 2016. NCHS Data Brief. 2017(293):1–8. [PubMed: 29319473]

10.

U.S. National Library of Medicine. Neonatal abstinence syndrome. 2015; https://www​.nlm.nih.gov​/medlineplus/ency/article/007313.htm.

11.

Substance Abuse and Mental Health Services Administration. Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018.

12.

Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540–560. [PubMed: 22291123]

13.

Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004–2014. Pediatrics. 2018;141(4). [PMC free article: PMC5869343] [PubMed: 29572288]

14.

Floyd RL, Jack BW, Cefalo R, et al. The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures. Am J Obstet Gynecol. 2008;199(6 Suppl 2):S333–339. [PubMed: 19081427]

15.

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. 2016;65(1):1–49. [PubMed: 26987082]

16.

Jackson KA, Bohm MK, Brooks JT, et al. Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Persons Who Inject Drugs—Six Sites, 2005–2016. 2018;67(22):625. [PMC free article: PMC5991809] [PubMed: 29879096]

17.

Centers for Disease Control and Prevention. HIV in the United States: At a glance. 2017; https://www​.cdc.gov/hiv​/statistics/overview/ataglance.html.

18.

Increase in Hepatitis C infections linked to worsening opioid crisis; https://www​.cdc.gov/nchhstp​/newsroom/2017​/hepatitis-c-and-opioid-injection.html [press release]. Centers for Disease Control and Prevention, 2017

19.

Forster M, Gower AL, Borowsky IW, McMorris BJ. Associations between adverse childhood experiences, student-teacher relationships, and non-medical use of prescription medications among adolescents. Addictive behaviors. 2017;68:30–34. [PubMed: 28088740]

20.

Stein MD, Conti MT, Kenney S, et al. Adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder. Drug and alcohol dependence. 2017;179:325–329. [PMC free article: PMC5599365] [PubMed: 28841495]

21.

Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2018; Retrieved from https://www​.samhsa.gov/data/.

22.

Moran GE, Snyder CM, Noftsinger RF, et al. Implementing medication-assisted treatment for opioid use disorder in rural primary care: environmental scan, volume 2. tools and resources. Rockville, MD: Agency for Healthcare Research and Quality; October 2017.

23.

Guy GP, Jr., Zhang K, Bohm MK, et al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697–704. [PMC free article: PMC5726238] [PubMed: 28683056]

24.

Lynch FL, McCarty D, Mertens J, et al. Costs of care for persons with opioid dependence in commercial integrated health systems. Addict Sci Clin Pract. 2014;9:16. [PMC free article: PMC4142137] [PubMed: 25123823]

25.

Substance Abuse and Mental Health Services Administration. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2004.

26.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013.

27.

Hser YI, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotics addicts. Arch Gen Psychiatry. 2001;58(5):503–508. [PubMed: 11343531]

28.

Vaillant GE. The natural history of alcoholism revisited. Cambridge, MA: Harvard University Press; 1995.

29.

Koob GF, Le Moal M. Drug abuse: hedonic homeostatic dysregulation. Science. 1997;278(5335):52–58. [PubMed: 9311926]

30.

Dahl RE. Adolescent brain development: a period of vulnerabilities and opportunities. Keynote address. Ann N Y Acad Sci. 2004;1021:1–22. [PubMed: 15251869]

31.

Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. [PubMed: 15939837]

32.

Thornberry TP, & Krohn, M. D. Taking stock of delinquency: An overview of findings from contemporary longitudinal studies. New York, NY: Springer Science & Business Media; 2006.

33.

Botvin GJ, Griffin KW. Life skills training as a primary prevention approach for adolescent drug abuse and other problem behaviors. Int J Emerg Ment Health. 2002;4(1):41–47. [PubMed: 12014292]

34.

Flay BR, Graumlich S, Segawa E, Burns JL, Holliday MY. Effects of 2 prevention programs on high-risk behaviors among African American youth: a randomized trial. Arch Pediatr Adolesc Med. 2004;158(4):377–384. [PMC free article: PMC2386246] [PubMed: 15066879]

35.

Schweinhart LJ, Montie, J., Xiang, Z., Barnett, W. S., Belfield, C. R., & Nores, M.. Lifetime effects: The High/Scope Perry Preschool study through age 40. (Monographs of the High/Scope Educational Research Foundation, 14). Ypsilanti, MI: High/Scope Press; 2005.

36.

National Research Council (US) and Institute of Medicine (US). The National Academies Collection: Reports funded by National Institutes of Health. In: O’Connell ME, Boat T, Warner KE, eds. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington (DC): National Academies Press (US), National Academy of Sciences; 2009. [PubMed: 20662125]

37.

Bowman S, Engelman A, Koziol J, Mahoney L, Maxwell C, McKenzie M. The Rhode Island community responds to opioid overdose deaths. R I Med J (2013). 2014;97(10):34–37. [PubMed: 25271658]

38.

National Safety Council. Prescription drug community action kit: Public education and media. Washington, DC: National Safety Council; 2015.

39.

Substance Abuse and Mental Health Services Administration. National Recovery Month. n.d.; http://www​.recoverymonth.gov/. Accessed September, 2017.

40.

Centers for Disease Control and Prevention. Rx Awareness. 2017; https://www​.cdc.gov/rxawareness/index​.html. Accessed January 2, 2018.

41.

Washington State Institute for Public Policy. Benefit-cost results. 2016; http://www​.wsipp.wa.gov​/BenefitCost?topicId=.

42.

Centers for Medicare & Medicaid Services. Decision memo for screening and behavioral counseling interventions in primary care to reduce alcohol misuse (CAG-00427N). Washington DC: US Department of Health and Human Services; 2011.

43.

Centers for Medicare & Medicaid Services. Screening, brief intervention, and referral to treatment (SBIRT) services. (ICN 904084). Washington, DC: U.S. Department of Health and Human Services; 2015.

44.

Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and death rates from drug overdose. Pain Med. 2011;12(5):747–754. [PubMed: 21332934]

45.

Haffajee RL, Jena AB, Weiner SG. Mandatory use of prescription drug monitoring programs. JAMA. 2015;313(9):891–892. [PMC free article: PMC4465450] [PubMed: 25622279]

46.

Patrick SW, Fry CE, Jones TF, Buntin MB. Implementation Of Prescription Drug Monitoring Programs Associated With Reductions In Opioid-Related Death Rates. Health Affairs (Millwood). 2016;35(7):1324–1332. [PMC free article: PMC5155336] [PubMed: 27335101]

47.

Ettner SL, Huang D, Evans E, et al. Benefit-cost in the California treatment outcome project: does substance abuse treatment “pay for itself”? Health Serv Res. 2006;41(1):192–213. [PMC free article: PMC1681530] [PubMed: 16430607]

48.

McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695. [PubMed: 11015800]

49.

Garner BR, Scott CK, Dennis ML, Funk RR. The relationship between recovery and health-related quality of life. J Subst Abuse Treat. 2014;47(4):293–298. [PMC free article: PMC4138291] [PubMed: 25012552]

50.

Pasareanu AR, Opsal A, Vederhus JK, Kristensen O, Clausen T. Quality of life improved following in-patient substance use disorder treatment. Health Qual Life Outcomes. 2015;13:35. [PMC free article: PMC4364507] [PubMed: 25889576]

51.

Tracy EM, Laudet AB, Min MO, et al. Prospective patterns and correlates of quality of life among women in substance abuse treatment. Drug Alcohol Depend. 2012;124(3):242–249. [PMC free article: PMC3366154] [PubMed: 22333265]

52.

Baca CT, Yahne CE. Smoking cessation during substance abuse treatment: what you need to know. Journal of substance abuse treatment. 2009;36(2):205–219. [PubMed: 18715746]

53.

Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. Journal of consulting and clinical psychology. 2004;72(6):1144–1156. [PubMed: 15612860]

54.

Substance Abuse and Mental Health Services Administration. Behavioral health treatments and services. 2015; http://www​.samhsa.gov/treatment.

55.

Millette S, & Cort, B.. Treatment for substance use disorders – The continuum of care. In: National Partnership on Alcohol Misuse and Crime; 2013.

56.

Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11–24. [PMC free article: PMC3196788] [PubMed: 21981788]

57.

Substance Abuse and Mental Health Services Administration. Chapter 10. Addressing diverse populations in intensive outpatient treatment. Clinical issues in intensive outpatient treatment. Treatment improvement protocol (TIP) series, No. 47. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2006.

58.

Community-based opioid overdose prevention programs providing naloxone - United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(6):101–105. [PMC free article: PMC4378715] [PubMed: 22337174]

59.

Hawk KF, Vaca FE, D’Onofrio G. Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies. Yale J Biol Med. 2015;88(3):235–245. [PMC free article: PMC4553643] [PubMed: 26339206]

60.

Ingram M. The impact of syringe and needle exchange programs on drug use rates in the United States. (Master’s thesis). Vol 2018. Washington, DC: Georgetown University; 2014.

61.

Aspinall EJ, Nambiar D, Goldberg DJ, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. International Journal of Epidemiology. 2014;43(1):235–248. [PubMed: 24374889]

62.

Hunt N, Ashton, M., Lenton, S., Mitcheson, L., Nelles, B., & Stimson, G. A review of the evidence-base for harm reduction approaches to drug use. 2003; https://www​.hri.global​/files/2010/05/31/HIVTop50Documents11​.pdf. Accessed October, 2017.

63.

Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Review. 2006;25(6):611–624. [PubMed: 17132577]

64.

Prescription Drug Abuse Policy System. Naloxone Overdose Prevention Laws. http://pdaps​.org/datasets​/laws-regulating-administration-of-naloxone-1501695139. Accessed August, 2018.

65.

European Monitoring Centre for Drugs and Drug Addiction. Preventing fatal overdoses: A systematic review of the effectiveness of take-home naloxone. Luxembourg: EMCDDA Papers, Publications Office of the European Union; 2015.

66.

Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. [PMC free article: PMC4688551] [PubMed: 23372174]

67.

Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality. Am J Public Health. 2009;99(3):402–407. [PMC free article: PMC2661437] [PubMed: 19150908]

68.

Substance Abuse and Mental Health Services Administration. SAMHSA Opioid overdose prevention toolkit. (HHS Publication No. (SMA) 13-4742). Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

69.

The Network for Public Health Law. Legal interventions to reduce overdose mortality: Naloxone access and overdose Good Samaritan Laws. 2017; https://www​.networkforphl​.org/resources_collection​/2017/06/08​/396/resource_legal​_interventions_to_reduce​_overdose_mortality. Accessed March 12, 2018.

70.

World Health Organization. Clinical guidelines for withdrawal management and treatment of drug dependence in closed settings. 4, Withdrawal management. 2009; https://www​.ncbi.nlm​.nih.gov/books/NBK310652/. [PubMed: 26269862]

71.

American Society of Addiction Medicine. The ASAM standards of care for the addiction specialist physician. Chevy Chase, MD: American Society of Addiction Medicine; 2014.

72.

Center for Health Information and Analysis. Access to substance use disorder treatment in Massachusetts. (15-112-CHIA-01). Boston, MA: Center for Health Information and Analysis, Commonwealth of Massachusetts; 2015.

73.

Substance Abuse and Mental Health Services Administration. Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide. HHS Publication No. (SMA) 14-4892R. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.

74.

Lee J, Kresina TF, Campopiano M, Lubran R, Clark HW. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. Biomed Res Int. 2015;2015:137020. [PMC free article: PMC4299453] [PubMed: 25629034]

75.

Kleber HD, McIntyre JS. Practice Guideline for Treatment of Patients with Substance Use Disorders. Vol 122. Arlington, VA: American Psychiatric Association; 2006.

76.

National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Effective medical treatment of opiate addiction. JAMA. 1998;280(22):1936–1943. [PubMed: 9851480]

77.

Joseph H, Stancliff S, Langrod J. Methadone maintenance treatment (MMT): a review of historical and clinical issues. Mt Sinai J Med. 2000;67(5–6):347–364. [PubMed: 11064485]

78.

Rieckmann T, Kovas AE, Rutkowski BA. Adoption of medications in substance abuse treatment: priorities and strategies of single state authorities. J Psychoactive Drugs. 2010;Suppl 6:227–238. [PMC free article: PMC3640346] [PubMed: 21138199]

79.

National Institute on Drug Abuse. Principles of drug addiction treatment: A research-based guide. (NIH Publication No. 12–4180). Rockville, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2012.

80.

Krinsky CS, Lathrop SL, Brown P, Nolte KB. Drugs, detention, and death: a study of the mortality of recently released prisoners. The American journal of forensic medicine and pathology. 2009;30(1):6–9. [PubMed: 19237844]

81.

Gordon MS, Kinlock TW, Schwartz RP, O’Grady KE. A randomized clinical trial of methadone maintenance for prisoners: findings at 6 months post-release. Addiction. 2008;103(8):1333–1342. [PMC free article: PMC2582162] [PubMed: 18855822]

82.

Lee JD, Friedmann PD, Kinlock TW, et al. Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders. N Engl J Med. 2016;374(13):1232–1242. [PMC free article: PMC5454800] [PubMed: 27028913]

83.

National Quality Forum. Evidence-based treatment practices for substance use disorders: Workshop proceedings. (NQFWP-06-05). Washington, DC: National Quality Forum; 2005.

84.

McGovern MP, Carroll KM. Evidence-based practices for substance use disorders. The Psychiatric Clinics of North America. 2003;26(4):991–1010. [PMC free article: PMC3678283] [PubMed: 14711132]

85.

Substance Abuse and Mental Health Services Administration. Substance abuse treatment: Group therapy. Treatment improvement protocol (TIP) series, No. 41. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2005.

86.

Substance Abuse and Mental Health Services Administration. Recovery and recovery support. 2015; http://www​.samhsa.gov/recovery. Accessed September 13, 2017.

87.

Walitzer KS, Dermen KH, Barrick C. Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial. Addiction. 2009;104(3):391–401. [PMC free article: PMC2802221] [PubMed: 19207347]

88.

Douglas-Siegel JA, Ryan JP. The effect of recovery coaches for substance-involved mothers in child welfare: impact on juvenile delinquency. Journal of Substance Abuse Treatment. 2013;45(4):381–387. [PubMed: 23856594]

89.

Groh DR, Jason LA, Ferrari JR, Davis MI. Oxford House and Alcoholics Anonymous: The Impact of Two Mutual-help Models on Abstinence. Journal of Groups in Addiction & Recovery. 2009;4(1–2):23–31. [PMC free article: PMC2916198] [PubMed: 20689661]

90.

LePage JP, Garcia-Rea EA. Lifestyle coaching’s effect on 6-month follow-up in recently homeless substance dependent veterans: a randomized study. Psychiatric Rehabilitation Journal. 2012;35(5):396–402. [PubMed: 23116382]

91.

Polcin DL, Henderson DM. A clean and sober place to live: philosophy, structure, and purported therapeutic factors in sober living houses. Journal of Psychoactive Drugs. 2008;40(2):153–159. [PMC free article: PMC2556949] [PubMed: 18720664]

92.

Polcin DL, Korcha R, Bond J, Galloway G. Eighteen Month Outcomes for Clients Receiving Combined Outpatient Treatment and Sober Living Houses. Journal of Substance Use. 2010;15(5):352–366. [PMC free article: PMC3008818] [PubMed: 21197122]

Suggested citation:

U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Spotlight on Opioids. Washington, DC: HHS, September 2018.

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