Inflection Point: Taking a Population Health Approach to the Opioid Crisis

Reacting to the 2008 financial crisis, Rahm Emanuel famously – and notoriously – stated: “You never want a serious crisis go to waste…it is an opportunity to do things you think you could not do before.”  With the opioid epidemic, we certainly have a serious crisis:  drug overdoses were the leading cause of accidental death in the United States in 2016, responsible for a staggering 64,000 deaths—with over 20,000 due to synthetic opioids.

Past health crises have spurred transformational change
Throughout our country’s history, epidemics have served as inflection points – moments in which health systems, policymakers, and the public have responded, if sometimes too slowly, to address tremendous human suffering and to meet urgent needs, while leaving a legacy of changed attitudes and improvements in infrastructure and services.

At the height of the polio epidemic in the U.S. in 1952, over 3,000 people died and 21,000 were paralyzed. But a strong response to the crisis turned the tide, leaving a legacy that includes a robust public health infrastructure for vaccinations, grassroots fundraising campaigns that revolutionized medical philanthropy, the rise of rehabilitation therapy, and the disability rights movement.

Similarly, the AIDS epidemic, which has resulted in nearly 700,000 deaths in the U.S., challenged bigotry, altered the patient-doctor relationship, and activated and empowered patients with other serious diseases, such as breast cancer and lymphoma.  It also led to enhancements in the health care delivery system, including the widespread adoption of needlestick precautions, the provision of high-tech care in home and outpatient settings, and coordination with community-based organizations to help provide supportive services.

The inadequate response and barriers to progress
While the potential to make similar advances exists now, progress in addressing underlying causes and building systems to stem the opioid epidemic has been devastatingly slow. Although the White House Commission has called for new initiatives and funding, the President supports deep cuts to Medicaid, which provides treatment to over a million Americans with substance use disorders. In addition, the administration’s return to harsher sentencing policies for low-level drug offenses threatens a repeat of failed approaches to curbing substance use that have disproportionately incarcerated black and brown populations.

A key barrier to progress is that our nation’s policies and programs – whether addressing eating habits, physical activity, smoking, or substance use –too often fail to take into account the web of underlying drivers of the health of populations. Opioid use too results from a complex interplay of forces – life stressors and hardships, social interactions, pain, medical practices, exposure to the substance, neurophysiologic susceptibility, and more.  In ignoring this complexity, we greatly underestimate the fight at hand.

A population health approach to turn the tide
To turn the tide on the opioid epidemic, an all-in population health approach is required. This would mean addressing root causes, working across sectors, eliminating inequalities in treatment access, and confronting and reducing racial bias and stigma.

We are starting to see a population health approach applied with success to the seemingly intractable obesity epidemic in children, which is slowly decelerating as multi-pronged efforts take hold to improve access to healthy and affordable food, change the built environment to encourage activity, and implement programs that educate and support families.

In the same vein, we can deploy the tools of population health science to address the opioid epidemic.  We should:

• Draw on principles of implementation science and payment reform to routinely screen for substance abuse and greatly expand access to effective treatment – in clinical settings, prisons, shelters – and facilitate low-threshold referrals from social service agencies, community- and faith-based organizations, and high schools and colleges.
• Apply communication science ideas to hone messages that diminish the deeply entrenched stigma associated with substance use, and use behavioral economics principles to develop policies that encourage people to make healthy choices the easy choices, such as carrying naloxone or accessing treatment.
• Use comparative effectiveness analysis and rapid cycle evaluation to rigorously and efficiently analyze which configurations of outreach, harm reduction, and treatment work best for whom.
• Implement evidence-based programs built on powerful knowledge about the first five years of life to prevent, or blunt, the impact of adverse childhood events, which otherwise make children vulnerable to substance abuse in later life.
• Leverage the burgeoning science of big data analysis—for example, by integrating electronic health records with criminal justice data—to rapidly detect and target resources to hotspots of need.

Such initiatives, focused at the individual, community, and policy levels, and drawing from an array of disciplines, will increase our chances of effectively preventing and treating substance use disorders, and, as with other epidemics in our country’s history, accelerate a much needed transformation of how we improve health more broadly.

Marc N. Gourevitch, MD, MPH, is Professor and founding Chair of the Department of Population Health at NYU Langone Health. His research seeks to leverage both healthcare delivery and policy- and community-level interventions to advance the health of populations.

Sue A. Kaplan, JD, is Research Associate Professor of Population Health at NYU Langone Health. Her work focuses on understanding the causes of health inequities and advancing community-based initiatives to improve population health.