Overdose Prevention Strategy
Overdose Prevention Strategy
Overdose Prevention Strategy
KEY POINTS
• The overdose crisis is largely driven by synthetic opioids, predominantly illicitly manufactured
fentanyl. Drug overdoses involving psychostimulants such as methamphetamine are also
increasing, both with and without synthetic opioid involvement.
• The public health burden of drug overdose expands far beyond the devastating impact of overdose
deaths to other consequences of substance use disorders (SUDs), including nonfatal overdose. The
human cost of this crisis also has a radiating impact on families, caregivers, and communities.
• Given the changing face of the crisis and escalating harms, including during the COVID-19
pandemic, the U.S. Department of Health and Human Services (HHS) is releasing a new,
comprehensive, resourced Overdose Prevention Strategy to strengthen our primary prevention
efforts and increase access to the full continuum of care and services for individuals with SUD and
their families.
• Experts across HHS came together to leverage the best evidence to prioritize four key target areas
for the strategy: primary prevention, harm reduction, evidence-based treatment, and recovery
support.
• The strategy embodies HHS’s reinvigorated efforts to strengthen prevention and treatment, as well
as its more recent commitment to robust harm reduction and recovery support services. The
strategy recognizes that addressing the overdose crisis requires a multifaceted and integrated
approach spanning public health, health care, human services, and many other sectors.
• The HHS Overdose Prevention Strategy reflects the Biden-Harris Administration principles of equity
for underserved populations and evidence-based policy by being more inclusive of all populations
affected. It also prioritizes translating research into equitable practice, and it identifies ways to
further our understanding of how to mitigate overdose harms.
INTRODUCTION
From 1999 through 2019, there were more than 840,000 drug overdose deaths in the United States.1 The
crisis has continually evolved and escalated, including during COVID-19, when an estimated 93,000 persons
lost their lives to drug overdose in 2020--approximately a 30% increase over the year prior.2 In response to the
devastating human toll of SUDs and overdose, HHS is redoubling its work and bringing the best science and
evidence to bear to respond to the crisis.
The history of substance use in the U.S. is long, complex, and characterized by changing patterns of use.
Overdose deaths have increased exponentially since at least 1980, driven by different substances at different
times.3 The overdose crisis of the twenty-first century began as primarily a prescription opioid crisis, but now
is more accurately characterized as a polysubstance overdose crisis, as depicted in Figure 1. The late 1990s
and first decade of the 2000s saw increased opioid prescriptions followed by increased overdose deaths from
Figure 1. Drug Overdose Death Rates, United States, Selected Drug Classes: 1999-2019
12.0
11.4
Age-adjusted deaths, per 100,000
10.0
8.0
6.0
5.0
4.9
4.4
4.0
3.6
2.0
0.8
0.0
Cocaine Heroin
Methadone Psychostimulants
Natural and semisynthetic opioids Synthetic opioids other than methadone
Source: National Center for Health Statistics, National Vital Statistics System, Mortality, 2019.
The public health burden of drug overdose expands far beyond the devastating impact of fatal overdoses.
Some estimates suggest that 20-30 non-fatal overdoses occur for every fatal overdose, and non-fatal overdose
can result in permanent disability.5 Emergency department visits and inpatient admissions involving drug
misuse have escalated substantially in the past decades. For instance, the rate of emergency department visits
involving nonmedical use of prescription drugs (primarily opioids) more than doubled from 214 visits per
100,000 people in 2004 to 458 in 2011; a large proportion of these visits involved at least one other drug (e.g.,
benzodiazepines, cocaine, or heroin).6 More recently, emergency department visits attributable to nonfatal
opioid overdose increased across six major U.S. health care systems by 10.5% in 2020 during COVID-19, as
compared to 2018 and 2019--despite a 14% decline in all-cause ED visits during the same period.7
The societal cost of this crisis is substantial and has a radiating impact on families, caregivers, and
communities. Studies estimating the total cost of the opioid crisis alone vary.8,9 Those that include the value
of lost lives (e.g., foregone labor, criminal justice costs, and noneconomic costs) in addition to health care costs
find annual costs on the order of half a trillion dollars.10
The overdose crisis does not look the same in every community or for every individual. Because of geographic
differences in the types of drugs most commonly consumed, communities see variation in the proportion of
overdoses and related harms attributed to any given drug.11 Methamphetamine use and related harms, for
example, has historically been more common in the West and Midwest, while overdoses involving synthetic
opioids were more concentrated in the Northeast.12 Between 2018 and 2019, however, the West experienced
In recent years there have been marked increases in overdose deaths among racial and ethnic minority
populations,16 who are also more likely to face barriers in accessing equitable treatment and recovery
services.17 Between 2012 and 2018, the annual percentage change in opioid overdose for African Americans
surpassed that for Whites in the U.S.18 The increases during this period were largest for older non-Hispanic
Black men and women (50 or older and 45 or older, respectively).19 The crisis is further complicated for
underserved populations by social determinants of health that contribute to chronic and acute life stresses
that interact with SUDs, as well as co-occurring mental and physical health conditions, that complicate SUD
treatment (e.g., complex chronic pain). Criminal history and socioeconomic status have been identified as
mechanisms underlying race/ethnic differences in receipt of SUD treatment. According to national data, the
odds of receiving specialty SUD treatment among Latinos with SUD, for example, were less than half of those
for Whites after adjusting for criminal history and socioeconomic status.20 The same study identified similar
Black-White disparities in SUD treatment. In another study of publicly funded SUD treatment programs, Black
and Hispanic people were less likely than Whites to complete treatment; these differences were also largely
explained by socioeconomic factors such as unemployment and housing instability.21
Additional complications of the current overdose crisis warrant urgent attention. Shifts in drug supply and use
patterns referenced above make surveillance, prevention, and treatment more complex.22 Another concern is
the separation of SUD care from other health services, harm reduction interventions, and recovery supports,
and the resulting lack of integrated care delivery.23,24 Finally, persistent stigma associated with drug use
inhibits effective prevention, treatment, and recovery for SUD.
HHS’s updated plan focuses on SUD-related issues across the lifespan and stages of drug use, and it was
constructed within the changing environment of the COVID-19 pandemic. Its components also reflect many of
the priorities outlined in the Biden-Harris Administration’s Statement of Drug Policy Priorities for Year One.25
Addressing the various components of the overdose crisis requires a multifaceted and integrated approach
involving agencies across HHS. In addition to continuing longstanding HHS efforts to support prevention and
treatment for the types of substance use that are heavily connected to overdose risk, the new strategy places
equal emphasis on HHS-wide efforts to expand accessible services and supports for those in or seeking
recovery, and also to intervene early to reduce the risk for harm among people who are actively using
substances.
The newly developed Overdose Prevention Strategy (“Strategy”) consists of four priority areas: (1) primary
prevention; (2) harm reduction; (3) evidence-based treatment; and (4) recovery support. In addition, the
Strategy is guided by the cross-cutting principles of enhancing equity; improving coordination, collaboration,
and integration across government and relevant service sectors; using the best available science to guide
actions, while identifying research gaps and needs; and reducing the stigma associated with substance use,
which has always been a significant barrier to progress.
GUIDING PRINCIPLES
Each priority area of the Strategy is underpinned by the following cross-cutting guiding principles.
Equity
The overdose crisis is characterized by stark disparities, in which rural populations, racial/ethnic minorities,
pregnant people and mothers, and other historically underserved groups face heightened overdose-related
harms and barriers to accessing treatment, services, and supports.26 In 2019, for example, Native Americans
and Alaska Natives had a higher drug overdose death rate than any other racial or ethnic group.27 The rate of
overdose deaths among non-Hispanic Black Americans more than tripled between 2010 and 2019, but Black
Americans are still less likely to receive SUD treatment than White Americans.28 Maximizing health equity for
disproportionately affected populations is therefore an essential component of each priority area, objective,
and activity. Strategy activities will include efforts to increase the availability of culturally competent care, to
address underlying social determinants of health that increase overdose risk, and to provide evidence-based
SUD treatment to heavily impacted urban and rural populations. This emphasis on equity is also consistent
with the Biden-Harris Administration’s commitment to achieving more equitable outcomes for underserved
and marginalized populations.29,30,31,32
Reducing Stigma
Stigma surrounding substance use discourages people with SUDs from seeking and accessing the services they
need, contributes to inadequate investment in and quality of care for people with SUDs, and fuels negative
attitudes towards people who use substances resulting in discrimination.47,48 Stigma can then become
embedded into laws and policies that hinder efforts to expand access to evidence-based treatment and harm
reduction services.49 Punitive policies towards pregnant women with SUDs--which are actually associated with
an increased risk of neonatal abstinence system, potentially by discouraging pregnant women from seeking
care--are an example of the counterproductive effects of stigma.50,51 HHS has worked over the past decade to
better understand the manifestations and impacts of stigma, notably through past collaborative work with the
National Academies of Sciences that describes stigma as “a dynamic multidimensional, multilevel phenomenon
that occurs at three levels of society--structural (laws, regulations, policies), public (attitudes, beliefs, and
behaviors of individuals and groups), and self-stigma (internalized negative stereotypes).”52 To address this,
activities in each priority area will include efforts to reduce false perceptions about SUD, related treatments
and people who use drugs, including through evidence-informed public awareness and education campaigns.
This priority area supports a tiered approach to prevention, including population-level strategies as well as
targeted interventions aimed at high-risk individuals. For example, the Substance Abuse and Mental Health
Administration (SAMHSA) Strategic Prevention Framework for Prescription Drugs program raises community
awareness and advances prescription drug misuse prevention activities and education to schools,
communities, parents, prescribers, and their patients. The Food and Drug Administration’s (FDA) regulatory
work includes updated requirements to warn Americans about the serious risks associated with
benzodiazepines, especially when combined with other medications such as opioid pain relievers, alcohol, or
illicit drugs, and consideration of mandatory prescriber education via the Opioid Analgesic Risk Evaluation and
Mitigation Strategy. Since adolescents exposed to substances are particularly vulnerable to developing a SUD,
the National Institute on Drug Abuse’s (NIDA’s) Adolescent Brain and Cognitive Development (ABCD) Study is
tracking the biological and behavioral development of nearly 12,000 adolescents into young adulthood and is
poised to produce detailed risk and protective factor profiles to improve SUD prevention.
Multidisciplinary prevention activities are necessary to address the biological, behavioral, social, and
environmental risk and protective factors that impact substance use and SUDs. Accordingly, prevention
activities in the Strategy not only engage health and human services providers directly--for instance, the
Centers for Medicare & Medicaid Services’ (CMS’s) Prescriber Outreach educates and provides outreach to
prescribers around best practices for prescribing opioids and about non-opioid pain management--but also
facilitate cross-sector collaboration on prevention by investing in data infrastructure. An example of this is the
Centers for Disease Control and Prevention’s (CDC’s) Preventing Adverse Childhood Experiences (ACEs): Data
to Action program, which is designed to build state-level surveillance infrastructure that ensures the capacity
to collect, analyze, and use ACEs data to inform ACEs prevention activities which can have lasting protective
effects against substance use and other health-risk behaviors. In addition, CDC’s Overdose Data to Action
(OD2A) initiative supports innovative and critical surveillance through the collection of comprehensive data on
nonfatal and fatal overdoses to inform prevention and response efforts.
The Strategy reflects HHS’s commitment to promoting harm reduction across its programs. It extends recent
notable HHS harm reduction efforts, such as the Substance Abuse and Mental Health Services Administration
(SAMHSA) and CDC’s April 2021 announcement that certain federal grant funds can be used to purchase
fentanyl test strips,63 which some people use to avoid or take additional precautions when using drugs
adulterated with fentanyl.64,65 HHS recognizes the need for additional work to mitigate the risks associated
with drug use, and therefore this priority area supports further expanding access to a broader array of harm
reduction interventions and better integrating harm reduction principles and practices into specialty SUD
treatment and general medical care.
Examples of activities within this priority area include the National Institute of Health’s (NIH’s) Comprehensive
HIV Services in syringe services program settings, which will support research to develop and test intervention
models for syringe services programs; SAMHSA’s Harm Reduction Grants, which will support community-based
overdose prevention programs, syringe services programs, and other harm reduction services; and CDC’s Rx
Awareness Campaign, which promotes awareness of the impacts of prescription opioid misuse and overdose
through storytelling, and emphasizes that support is available for people with OUD. Recent campaign
messaging has also focused on fentanyl as well as stigma around substance use disorder. FDA and NIH are also
collaborating to collect community and clinical input on utilizing fentanyl test strips.
In addition, despite rising overdoses involving stimulants, access to evidence-based treatments for stimulant
use disorder--especially contingency management--remains inadequate, and there are currently no approved
medications for the treatment of stimulant use disorders, or for the reversal of stimulant overdose. Although
evidence-based treatment exists, there is a lack of knowledge about how to implement them in communities
across the country.70 The evidence-based treatment priority area in the Strategy focuses on reducing barriers
to accessing effective treatments, using motivational and cultural enhancements to encourage people who
might be reluctant to seek treatment, advancing strategies to improve engagement and retention, and
continuing to develop new therapeutic approaches. A major opportunity to enhance access to evidence-based
treatment is the potential improvement of the integration of SUD treatment with primary care and specialty
mental health care.
Key examples of current work to advance this priority area include the Justice Community Opioid Innovation
Network (JCOIN) at NIH, which seeks to advance knowledge about optimal approaches to treat OUD in criminal
justice settings, and to sustain quality care after community reentry. Another example is the Health Resources
and Services Administration’s (HRSA’s) Rural Community Opioid Response Program, which brings more
evidence-based treatment to rural communities that often lack access to high quality treatment despite having
disproportionately high need. HHS also recently issued practice guidelines to reduce barriers to MOUD by
removing training, counseling, and other ancillary service requirements for health care providers to treat up to
30 people at a time.71 FDA and NIH are also collaborating on supporting development of treatments for
stimulant use disorder. CMS is working to advance care for mothers and infants with the Maternal Opioid
Misuse demonstration model that advances high-quality care for participating pregnant and postpartum
Medicaid beneficiaries with OUD through the provision of coordinated and integrated physical and behavioral
health care services. NIDA is seeking to identify and develop new treatments for stimulant use disorder
through both its Medications Development Program and its National Drug Abuse Treatment Clinical Trials
Network, including a recent study with promising findings on a potential combination medication treatment
option.72
Despite the promising evidence of many types of recovery support services, various challenges impede their
availability and uptake, and many recovery support services could benefit from additional study and evidence-
building.79 CMS has made efforts to address recovery through its Value in OUD Treatment Demonstration,
which consists of an alternative payment model that allows certain Medicare funds to be used for services that
are not typically covered in its programs, such as peer support services, recovery housing, job training, and
nutrition support.80 A lack of readily available information on evidence-based implementation of recovery
support services necessitates development and dissemination of resources. SAMHSA is promoting high-quality
implementation through the Peer Recovery Center of Excellence, which provides training and technical
assistance on topics such as clinical integration of peer support specialists and enhancing the capacity of
recovery community organizations.
Strengthening the recovery support services workforce is essential to promoting access and quality. HRSA’s
Behavioral Health Workforce Education and Training Program for Paraprofessionals is expanding the recovery
support services workforce by funding community-based training programs for peer support specialists and
other paraprofessionals working in behavioral health. Furthermore, there is an ongoing need for research to
inform the effective delivery of recovery support services. NIH supports a portfolio of research on topics
including peer support services, recovery housing, and recovery community centers through its Research
Networks for the Study of Recovery Support Services for Persons Treated with Medications for Opioid Use
Disorder grants.
CONCLUSION
The Overdose Prevention Strategy is an important step forward in HHS’s approach to addressing the evolving
overdose crisis. The activities included within each of the four objectives--primary prevention, harm reduction,
evidence-based treatment, and recovery support--represent a comprehensive set of efforts aimed at reducing
morbidity and mortality related to substance use and SUD. They represent a host of new activities undertaken
in this Administration, which HHS intends to build upon in the coming years.
SUGGESTED CITATION
Haffajee, RL, Sherry, TB, Dubenitz, JM, White, JO, Schwartz, D,
Stoller, B, Swenson-O’Brien, AJ, Manocchio, TM, Creedon, TB,
Bagalman, E. U.S. Department of Health and Human Services
Overdose Prevention Strategy (Issue Brief). Washington, DC:
Office of the Assistant Secretary for Planning and Evaluation, U.S.
Department of Health and Human Services. October 27, 2021.
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