A government report published this year shows that, after five years of declining HIV infection rates, progress in reducing new infections has stalled. According to the report from the Centers for Disease Control and Prevention (C.D.C.), among those seeing a halt to the decline in new infections are people who inject drugs.
Public health experts have been concerned that the opioid crisis is driving new clusters of H.I.V. infections as a result of users sharing contaminated needles. This report underlines the urgent need for a national public health strategy for the opioid crisis — one that is comprehensive and effective in addressing interconnected epidemics.
Fueled largely by rising numbers of drug overdoses and suicides, life expectancy in the United States has fallen over the past three years. This decline in lifespan for Americans has not been seen for more than a century. In 2017, drug overdose deaths reached a record high, according to the C.D.C., and overdose is now the leading cause of death among Americans under age 50.
Reports show, on average, 131 Americans died from an opioid overdose every day in 2017, up from 115 in 2016 and 91 in 2015. Opioid addiction has extremely harmful effects on the health of individuals, their families, and communities. Opioid misuse has also been linked to an increase in the incidence of certain infectious diseases including a tripling in hepatitis C (H.C.V.) infections between 2010 and 2015.
In 2015, H.I.V. diagnoses due to opioid injection drug use increased for the first time in two decades. These trends indicate that efforts to reverse the toll of the H.I.V. and H.C.V. epidemics in America are being undermined by the opioid crisis. Furthermore, the economic toll of the opioid epidemic in the U.S. has exceeded $1 trillion since 2001, with an estimated additional $500 billion through 2020 if current usage trends persist.
The Administration has declared the opioid epidemic to be a national public health emergency. In October 2018, President Trump signed comprehensive bipartisan legislation to fight the opioid epidemic and before that, in March 2018, Congress passed legislation allocating $3.3 billion in funding for programs to combat this public health crisis in communities across the country. This amount, however, falls short of the tens of billions of dollars experts say is necessary to end the epidemic.
The U.S. Department of Health and Human Services (H.H.S.) has issued a five-point strategy to combat the opioid crisis and the President’s Commission on Combating Drug Addiction and the Opioid Crisis brought much-needed attention to the issue, producing a report with 56 policy recommendations. However, what is still missing is a national, coordinated strategy — a roadmap of prioritized actions with indicators to measure progress in reversing the toll that the opioid crisis is taking on the health of Americans, with sufficient financial resources to turn the tide on the epidemic now and in the years ahead.
Such a National Strategy to End the Opioid Epidemic could be modeled on the plan developed to reverse the H.I.V./A.I.D.S. epidemic in America. The National HIV/AIDS Strategy (N.H.A.S.), first released in 2010 and updated in 2015, includes a vision, goals, and indicators to measure progress in the fight against the disease. The Strategy includes the steps needed to meet these goals with a designated time frame, providing a clear roadmap for action.
In its development and implementation, the N.H.A.S. included input from a wide variety of stakeholders including community partners and Federal organizations. Additionally, the Presidential Advisory Council on H.I.V./A.I.D.S. (P.A.C.H.A.) monitors progress annually and makes recommendations to the President and the H.H.S. Secretary on achieving the National H.I.V./A.I.D.S. Strategy goals.
While H.I.V./A.I.D.S. persists as a significant public health problem in America, experts document clear signs of progress in fighting the H.I.V. epidemic from the time the N.H.A.S. was implemented.
The Strategy has changed the way the American people talk about H.I.V., prioritize and organize prevention and care services locally, and deliver clinical and non-clinical services that support people living with the disease. It is viewed as an important tool for having directed funds to more closely align with trends in the epidemic including targeting efforts to address the needs of vulnerable population groups.
Since the N.H.A.S. was implemented, there has been increased funding for H.I.V. treatment assistance, support for testing, and efforts to address health disparities related to the disease in communities across the country. The number of new H.I.V. cases decreased nearly five percent, from 41,985 new diagnoses in 2011 to 39,876 in 2015, while the percentage of persons living with diagnosed H.I.V. who are virally suppressed increased from 28 percent in 2010 to 49 percent in 2014. And earlier this year, the Administration announced a new plan to end the A.I.D.S. epidemic in America by leveraging critical scientific advances in H.I.V. prevention, diagnosis, treatment, and care with powerful data tools now available to reduce new H.I.V. infections in the United States by 75 percent in five years and by 90 percent by 2030. For the plan to be successful, it will require coordination of efforts across a broad range of stakeholders in the public and private sectors as well an ensuring access to affordable health care and shattering the stigma that has been associated with the disease.
Similarly, the development of a National Strategy to End the Opioid Epidemic would chart a five-year plan for our country’s response to this public health crisis. Using the National H.I.V./A.I.D.S. Strategy as a model, the vision and goals of an opioid strategy might be as follows:
Vision: The United States will become a place where new opioid use disorder and overdoses are rare, and when they occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, or socioeconomic circumstance, will have unfettered access to high-quality, life-extending treatment and care, free from stigma and discrimination.
Goal 1: Reduce opioid misuse.
Goal 2: Decrease drug overdose deaths.
Goal 3: Increase access to comprehensive treatment and care and improve health outcomes for people living with opioid use and other substance use disorders.
Goal 4: Reduce co-infections with H.I.V. and hepatitis C.
Goal 5: Reduce health disparities and health inequities in the opioid epidemic.
Goal 6: Achieve a more coordinated national response to the opioid crisis.
The opioid strategy would include clear indicators of progress and an annual report that measures outcomes. Without such a strategy in place, it will be difficult to determine whether current and future investments in addressing the opioid epidemic in the U.S. are effective and whether funding priorities should be adjusted.
Congress has played an important leadership role. In October 2018, the SUPPORT for Patients and Communities Act was passed by the U.S. Senate and U.S. House of Representatives. This legislation contained a section called the “National Milestones to Measure Success in Curtailing the Opioid Crisis,” which represents an important step towards establishing such a roadmap. This component of the larger bill establishes a process for the federal government to measure progress on key objectives each year and set tangible benchmarks for how the opioid crisis is being addressed. By focusing on measures to reduce overdose deaths, expand treatment availability, increase the number of individuals in sustained recovery, and decrease emergency room visits for overdoses, this important provision of the SUPPORT Act provides a blueprint for reducing the health-damaging impact of the opioid crisis and for saving lives. With new funding, the N.I.H. in partnership with S.A.M.S.H.A. has launched a $350 million HEALing Communities implementation research study that aims to reduce overdose deaths by 40 percent over three years in four states most affected by the epidemic. It will test a set of proven prevention and treatment interventions, coordinated care models, and evaluate new tools as well. The multi-year study will mobilize community partners, academic and public health organizations and other stakeholders to combat the epidemic in areas of these four states hit hardest by the opioid crisis and provide lessons for other communities across the country in the future.
What is needed now is for the Administration to put in place this kind of comprehensive national strategy of coordinated actions, milestones, and measurable indicators of progress across all federal agencies, with a timeline for achieving its goals. Research has shown that there are steps we can take to effectively address the opioid crisis. A National Strategy to End the Opioid Epidemic would issue a vision, goals and outcome measures to address this public health emergency in America. The Strategy would hold the federal government accountable, foster innovation, community engagement, and public/private sector partnerships, as well as mobilize all sectors of society to respond. This is the pathway to making real progress now and in the future. With 131 Americans dying every day from an opioid overdose, failure is not an option.