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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to a health podocy. I'm your host, Rob Lott. Friends, it is an exciting month here at Health Affairs as this month's issue just released is a full theme issue dedicated entirely to research and policy insights all about the ongoing opioid epidemic. It's really chock full of path breaking empirical research articles, perspectives, and policy proposals for addressing opioid misuse and addiction, and which we hope will contribute to an urgent national dialogue around evidence based strategies, best practices, and lessons learned over the course of this crisis. And so I'm delighted to speak today with Doctor.
Rob Lott:Brendan Saloner, one of the authors of the overview papers published in this issue. A big, thoughtful, deep look at how far we've come and where we're going. Doctor. Saloner is a professor of health services, policy, practice at the Brown University School of Public Health. He served as an external expert advisor to this theme issue as well.
Rob Lott:And his paper, is titled Scaling Up Treatment and Harm Reduction Programs to Reach More People Who Would Benefit. The paper's other author, by the way, is the University of Michigan's Doctor. Puja Lajesedi. And we're grateful for both Doctor. Saloner's and Doctor.
Rob Lott:Lajeseti's guidance in the development of this issue over the course of a year. I can't wait to hear from Doctor. Saloner about why this way of looking at the opioid crisis is so promising and timely. Doctor. Saloner, welcome to A Health Odyssey.
Brendan Saloner:Thanks for having me.
Rob Lott:So let's just dive right in and maybe start with some background. I think most of our readers have a sense of what you mean when you refer to the opioid crisis. But we've been talking about that for quite some time and folks might have some trouble articulating where it starts, where it might end, and what it really encompasses. And so maybe you can just kind of give us an equal starting point here. What do you mean exactly when you refer to the opioid crisis?
Brendan Saloner:Yeah. So the opioid crisis is one of the most significant public health emergencies that has ever happened in the history of The United States, and we're in the third decade of it. So if you go back to the early two thousands, public health experts were sounding the alarm bells about a rise in deaths related to prescription opioids. The numbers then continued to go up. And around 2010, something important happened, which is that, there was a shift in the opioids that were involved in overdose deaths, and a lot more people were dying of deaths involving heroin.
Brendan Saloner:So there was a shift from the legally prescribed to the illicit drug, economy. And then around 2013 to 2014, depending on where you're looking at in the country, a a new thing, came into it came into effect, and that was fentanyl, illicitly manufactured fentanyl. Fentanyl is a, legally prescribable, very potent prescription opioid, but it's also a a drug that can be readily synthesized, and it can be made basically in clandestine labs. And so fentanyl, hit the streets, and what we saw is that the overdose curve just hockey sticked. So we saw overdose mortality rising and rising.
Brendan Saloner:And going into the COVID pandemic, it just rose even further to the height years of the, overdose crisis around 2021 and 2022 when deaths were, peaking one hundred thousand Americans a year. It's kind of hard to believe that we have seen those numbers. Starting in 2023, numbers have started to, come down, but we are still looking at, mortality numbers that are just so far out of the norm of what we've seen in this country in the past and put The United States, unfortunately, in very bad shape internationally. And just one final thing, these overdose numbers are so significant that even before the pandemic, they were, very much contributing to a reversal in American life expectancy. So they really are one of the largest public health challenges our country has ever confronted.
Rob Lott:Would you say that the worst is over? You said sort of the numbers have come down, and that's certainly promising. Is it too early to tell if we're on the right track, or do you think questions remain as to sort of whether or not that those trends are gonna continue?
Brendan Saloner:I'm a vigilant optimist. So I I really believe that it's possible that we can build on what we've seen and continue to see reductions in those numbers. But I also am very, awake to the possibility that our overdose crisis, could just, you know, basically boomerang back to where it's been. Or there's new trends on the horizon such as an increase in deaths involving opioids in combination with stimulants like methamphetamine, and we really need to understand how to get ahold of that problem. So this is a very shape shifting crisis, and I I I would caution that we're very far from being out of the woods.
Rob Lott:Okay. Fair enough. I I wanna maybe set the stage for digging a little deeper into your article. One of the areas you point to is sort of the gold standard for opioid use disorder treatment, which is a sort of medication like buprenorphine and methadone. Can you say just how effective are those?
Rob Lott:And of the people who could benefit from that kind of treatment, how many typically are getting that treatment?
Brendan Saloner:It's a great question. And, you know, the way I look at it is that these medications, which, more than have the, the risk of dying of an overdose compared to treatment without medication, are some of the most effective tools that we have. In fact, they're probably some of the most effective, medications we have for any chronic condition. So they're they are a true kind of silver lining in this situation because getting people started on medication can dramatically improve their outcomes and actually save their lives. The problem is that many people don't get medications, and the reason why is that many people don't get treatment at all.
Brendan Saloner:So recent data would tell us that only about one in three people with an opioid use disorder is getting any kind of treatment. You know, one positive is that we've seen over the last, let's say, twenty years, more people being willing to get treated and being able to get treated with medications. But, certainly, the problem is that a lot of people who could benefit from medication treatment are not getting that treatment.
Rob Lott:Okay. I wanna circle back to maybe some of the underlying reasons behind that. But before we do, I wanna ask sort of the same question to one of the other sort of categories that you point to in your paper, which is harm reduction strategies. In In that case, we're talking about things like syringe exchange and naloxone. What do we know about their effectiveness, and how widespread are are their use?
Brendan Saloner:Yeah. We actually know quite a lot about their effectiveness. So syringe services programs, which is kind of the the term of art for needle exchange programs or syringe exchange, programs like that which provide people with sterile syringes and other, you know, drug use supplies, have a dramatic effect in terms of reducing the transmission of HIV, hepatitis C, and other infectious diseases. And we've seen, example after example of when, these programs have, come into communities and helped slow or stop the spread of those very, devastating, diseases. And then also unfortunate examples of when those, programs have been shut down and the the diseases have come right back.
Brendan Saloner:And then naloxone is a really important antidote to an opioid involved overdose because what it does is it essentially, reverses the respiratory suppression that can be so lethal to people who are, experiencing an overdose. You know? And then there's other harm reduction approaches like overdose, prevention sites, which just have a toehold in The United States, And we we know internationally and from, some experiences in New York City that that is also an important model for keeping people safe if they are using drugs. So taken together, what we call harm reduction, that package of interventions is really important and lifesaving.
Rob Lott:Great. And I wanna just take a moment here to sort of maybe ask you to weigh in on the counterargument we often hear about some harm reduction strategies, which is that they perhaps encourage risky behavior that someone knowing that, you know, there's naloxone there might be more willing to engage in in that risky behavior. What is sort of the, the response or, the evidence based interpretation of that response?
Brendan Saloner:Yeah. It's it's it's a totally fair and good question. I think the reality is that we've never seen evidence to suggest that the harm reduction tools that I'm talking about encourage or promote, drug use. The kind of folks who take advantage of harm reduction pro programs are often people who, have, a pretty serious opioid use problem, and what harm reduction is doing is helping them to stay alive another day, and importantly, helping them to stay alive another day so that they might be able to access treatment and other resources. And we know from the research that doing things like engaging with the syringe services program is often a stepping stone toward that important goal of getting started on treatment and ultimately moving toward abstinence.
Brendan Saloner:So I don't think of these as being sort of opposing strategies. I think they're actually quite complementary.
Rob Lott:Fair enough. And I'll put a little plug in for some of the other articles in our theme issue that look at exactly those sort of stages of kind of connecting people to to treatment following initial interaction with harm reduction interventions. So let's talk a little bit about your paper. It really does revolve around this idea or this concept of scale. And I'd love it if you can describe why you see that as potentially a a sort of very powerful and useful framework for how we approach this crisis going forward.
Brendan Saloner:Thanks for the question. Yeah. Puja, Lajesedi, and I, wanted to approach, the question of where we are, in the overdose crisis with a somewhat fresh lens. And I think that one of our real goals was to say, well, look. We're at a place where we have so many really novel and interesting and effective interventions.
Brendan Saloner:You know, we have mobile vehicles now that can provide methadone. We have naloxone that can be provided through vending machines in the mail. We have street outreach workers. We have ambulances that are equipped with buprenorphine. And we look at those things, and we say, well, why are these great programs not, the standard of care?
Brendan Saloner:Why is it so hard to get these programs out to where they're needed the most? And I think the concept of scale became very important to us. And we look at it almost like you would think about the production function of effective interventions. So if you wanna look at it that way, take the people, the money, the medication, the physical space, all of the inputs that go into getting, services to people. And let's ask the question of why those inputs are not effectively working to provide resources at a level great enough to make a sustained impact on the national trend.
Brendan Saloner:Now I think that they have been making a really important difference in the background, but it's been something that's been very hard to feel, to perceive for the public. And I think that that makes it just less palpable. We look at the concept of scale as being sort of the complement or the mirror image to what we talk about as access to care, but I think it gets a little bit more at the root of what's going on. So, you know, if I could use an analogy, let's say that, this is a little bit silly, but let's say that you have a sandwich truck that you really like. Okay?
Brendan Saloner:And there's something really great about that sandwich, but, you know, your your friends in other towns don't have access to that same sandwich truck. Now you might want wonder, well, how can we get them access to that sandwich? And I think that's a totally valid question. But I think the important flip side is what would it take to create a model of production so that more people could benefit from that delicious sandwich? And I think there, we have to look at all the different factors that go into making sandwiches.
Brendan Saloner:Now making sandwiches is fairly easy compared to getting effective interventions to people who need them when they're at risk of overdose. But I think many of the same lessons are the same. You need, investors and resources. You need to have the right kind of people with the right know how, and you need to have regulations that support the scale up of sandwiches or, in this case, of effective treatments and services for people with, opioid use disorder.
Rob Lott:Wow. Well, as someone who has traveled great distances for a really good sandwich, I appreciate that analogy and support the widespread scallop of really good sandwiches in our society. And I appreciate what that's telling us about the sort of theory behind access and expansion of, you know, treatment and harm reduction programs. In just a moment, I wanna ask you a little more about some of those obstacles in practice. But first, let's take a quick break.
Rob Lott:Welcome back. I'm here with Doctor. Brendan Saloner, talking about the challenges and opportunities around scaling up treatment and harm reduction programs. And you you provided us a great sort of framework when thinking about the sort of complement between access and scale. I'm wondering if we can dig in in sort of practical terms to what those challenges are to scale.
Rob Lott:And I know your paper, sort of starts with the technical challenges. Can you tell us a little bit about some of those?
Brendan Saloner:Yes. So the technical challenges are what we enumerate as all of the things that need to be, overcome in order to basically make this resource or program more widely available. And we enumerate three. Of course, there could be more than three, but the one of them is program complexity. So how challenging is it to actually take this, model or or program and and replicate it in a different setting?
Brendan Saloner:And sometimes it is quite complicated because it involves a particular group of people with a lot of know how or it takes, many different professionals working together, like supporting a client who needs housing and treatment and employment support and, you know, help with, criminal legal system involvement. So that could be one reason why it's difficult to scale models. I think that's true in health care in general that many effective models are hard to scale, but I think it's a particularly can be important care where so much depends on unique, ingredients in the specific environment in the local context. The second issue, which, comes as no surprise to people who have been looking at this issue, is just the financial constraints. So for the longest time, substance use, services were really marginalized and, not given the attention and resources that they needed.
Brendan Saloner:They were not part of mainstream health care. Now there's been a movement to try to move these interventions and tools to the mainstream. But the problem is that many of the legacy, problems from the funding structure, from even getting programs to work in the world of, insurance reimbursement, that's been taking a long time, and we're not anywhere close to where we need to be even when we compare it to, say, mental health care. So getting to a place where those financial constraints is really, overcomeable is a is a key challenge. And, you know, we give the example in our paper of, federal grants that were allocated to states, and they were meant to be spent very quickly.
Brendan Saloner:And, actually, the states had a real hard time spending the money because they even lacked the financial capacity and infrastructure to spend those resources quickly. So that seems like sort of a paradox, but I look at it like if you have a major, rain falling on wet soil a lot or on dry soil rather, a lot of that water is just gonna run off. You need to have, a really good root system in the soil that can absorb resources and use them, and I think that's been a key challenge. And then the final one is regulatory burdens. So we just know that, there's a lot of ways in which substance use treatment and, in particular, opioid use disorder treatment with medications, is just overburdened with regulations.
Brendan Saloner:Getting a a methadone program established takes, overcoming a whole patchwork of federal and state and often local regulations. It's very, burdensome to the clinic, and oftentimes, the decision is made just to not go forward and open the program. So overcoming those regulatory burdens makes scaling really difficult. So those three together, we identified as sort of the the crux of the technical scaling problem.
Rob Lott:Okay. Great. And now your paper also makes a distinction between those technical challenges and sociocultural obstacles to scaling as well. Can you say a little bit about what makes that them different and, you know, sort of how we should think about them in a different light?
Brendan Saloner:Sure. So technical scaling is is how we solve the production function problem. You know? How do you actually get the inputs to produce the output that you, hope for? Think I the other piece of it is making sure that there is a receptive and, supportive community and target population that wants those, resources.
Brendan Saloner:And there, I think we really need to lean in and understand why have some of these very well intentioned programs and interventions foundered. And for that, we've looked at, three primary factors. One of them is just what we call lack of demand. And this is the reality that only about one in ten people with an opioid use disorder say that they want treatment in in a survey. Of course, our contention is that many more people would be interested in services if they were more, let's say, friendly, accessible, you know, culturally tailored.
Brendan Saloner:So part of it is just overcoming that, lack that mismatch problem between what people want and what they can have. But I think it's also important to to look a little bit more at, the variety of different tools that we might need to use to, encourage or heavily incentivize people to make access, make use of those, treatment programs. I think the other one that we point to is broadly community opposition to programs. And here, the the talking point is often about stigma. Stigma is so real, and it's so important.
Brendan Saloner:But we also, wanted to a a little bit maybe encourage our readers to think beyond just stigma at some of the reasons why communities may be resistant to having new interventions and and services. I I think that some communities feel understandably pretty overburdened by having a lot of services located in their area. They don't feel like they've necessarily been consulted. And I think that that can be a real reason why, the the programs do not, have the staying power, and the durability that we'd hope to see. And then finally, this is sort of the elephant in the room, but the shifting politics, you know, at a national level about what is considered legitimate or acceptable.
Brendan Saloner:And, you know, here we point to the fact that our current, secretary of health and human services, Robert f Kennedy junior, is a person himself in long term recovery from a heroin addiction. And, he has his own particular viewpoints about, what acceptable recovery is. I would say that he is, maybe tepid on medications and believes a lot in things like, what he calls natural recovery. But the reality is that he speaks for a fairly broad coalition of people who want to conceptualize recovery as more than just medications. And I think it's important to figure out whether there's a space to, build on different kinds of enthusiasms that people might have for recovery to to to open up the tent a little bit.
Brendan Saloner:So that's, that's a question that we really just try to pose in our piece. Not that we have an answer for it, but we think that all of these factors have to be brought together to understand the the social and the cultural challenges with scaling.
Rob Lott:Great. Wow. Well, a lot of challenges there. You've just outlined and appreciate that that's sort of the the first step to moving forward. I want to circle back to your self identification as a vigilant optimist, think was the term, and wonder if maybe we can close by thinking about maybe listeners who hear all this and appreciate and sort of can really latch on to this framework around scale, but then want to sort of say, you know, what do we do now?
Rob Lott:And so I'm wondering if you could point to areas where you potentially see maybe the most fruitful policy changes that could be made over the next few years in this context to have a tangible impact both on access and scale.
Brendan Saloner:Well, one of the reasons why I I would say I'm vigilant is because I see and perceive a lot of fatigue around this issue. I think there's a desire to sort of close the book on this even though it's not a solved problem and to say, well, you know, we're seeing numbers come down. Let's move on. And I think that we do need to not succumb to a kind of, a sense that either the problem is solved or that the problem can't be solved. I think that both of those sentiments are understandable.
Brendan Saloner:And one of the points that we make is that there actually are examples of how the scaling problem has been overcome. They're just not as widely celebrated as we think they should be. So a good example is naloxone access. A few years ago, was very hard to get naloxone into the hands of people at risk of overdose. Now, from what what we can see in the world is that many more people are able to get ahold of naloxone to use it for themselves and for their friends, and that that is making a real difference.
Brendan Saloner:So being able to tell those success stories and having the data to, really back up why these programs matter is important for the movement. But I also think it's important to start thinking a little bit differently about kind of the new coalition that we would need to build to transcend, the challenging politics around this issue. And so in our paper, we call for thinking a little bit more about a kind of a cross political coalition of people would include those in recovery, people from the business community, faith leaders, labor groups, this self help movement, and many more, to come together and try to figure out where there's alignment in, interests and priorities. Because I think that policymakers have tried to sort of steer around this the socially contentious aspects of it, but that has not proven very successful. And so it's time to have a more direct engagement with the difference different communities that have a real stake in this issue.
Brendan Saloner:And then in turn, I think those communities will be more supportive of solutions.
Rob Lott:Well, a great note to end on. Always good advice to take the direct approach when all else fails. Doctor. Saloner, thank you so much for taking the time to chat with us today, really appreciate it.
Brendan Saloner:It's been great to be with you.
Rob Lott:Thank you as well to you and Doctor. Lajesetti for your, again, ongoing support of this theme issue. It's been, a really, important project and we're grateful for the work you've put into it over the last year, year plus.
Brendan Saloner:It's been our pleasure. Thank you so much.
Rob Lott:And to our listeners, thanks for tuning in. If you enjoyed this episode, please, leave a review, share it with a friend, and, of course, tune in next week. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.