Many strategies can be funded using settlement funds. For example, the North Carolina Memorandum of Agreement’s Exhibit A lists 12 potential strategies that local governments can support with their funds. Additionally, there are dozens of additional strategies listed in the Exhibit B document of the NC MOA. Of the 12 strategies outlined in Exhibit A, our team examined the current literature on 5 strategies we felt most NC communities would select as their abatement strategies. As of July 23rd, 2024, 77 out of 100 NC counties are reporting funding for Exhibit A strategies.
Frequency of Strategies Across NC
- Recovery Support: ~58% of counties are funding this strategy
- Naloxone Distribution: ~56% of counties are funding this strategy
- Post Overdose Response: ~42% of counties are funding this strategy
- Evidence-Based Addiction Treatment: ~39% of counties are funding this strategy
- Criminal Justice Diversion Programs: ~13% of counties are funding this strategy
For a full breakdown of NC county local spending plans, visit ncopioidsettlement.org
Our Approach
We aimed to examine the literature, extract useful policy implications and results, and share our methodology for developing our summaries. Below, you’ll find our executive summaries for each abatement strategy, our extraction and coding methods, and our bibliographies.
Evidence-based treatments for opioid addiction are often categorized into two principal groups: medications and behavioral therapies. Three specific medications have received FDA approval: methadone, buprenorphine, and naltrexone, where:
- Methadone: A long-acting opioid agonist that reduces cravings and withdrawal symptoms
- Buprenorphine: A partial opioid agonist that blunts the effects of opioids, diminishes cravings, and helps with withdrawal.
- Naltrexone: An opioid antagonist that blocks the effects of opioids, preventing the sensation of euphoria[1].
Behavioral therapies encompass methods such as contingency management, cognitive-behavioral therapy, and family therapy.
- Contingency management (CM) is an evidence-based psychosocial therapy that uses positive reinforcement to treat substance use disorders (SUDs). It’s based on operant conditioning principles, which suggest that reinforced behaviors are more likely to happen again.
- Cognitive Behavioral Therapy is based on the idea that psychological problems can be caused by faulty thinking and unhelpful behaviors, and it uses theory and skill-based dialogue to help people change. CBT has been shown to be effective for a range of issues, including depression, anxiety, eating disorders, and substance use disorders.
- Family Therapy: Addresses family dynamics and improves family involvement and support, which can be helpful for recovery.
Medication-assisted treatments (MAT) integrate these medications and behavioral therapies to offer a comprehensive treatment strategy for opioid use disorders (OUD). MATs not only reduce overdose and death rates for OUD substantially[2], but also can save $25,000 to $105,000 per person lifetime in comparison to no treatment[3].
Though most of these treatments are proved to be highly effective, a vast majority of patients who are dependent on opioids do not receive any treatment[4]. Factors influencing this include:
- Low insurance coverage for health plans
- Low capacity at treatment centers
- Slow adoption and diffusion for opioid treatments within health care facilities
- Low awareness and willingness to pay for addiction treatments
- Stigma
The expansion of health plan coverage for Medication-Assisted Treatments (MATs) is essential. These treatments, particularly methadone and buprenorphine, have demonstrated improved outcomes for individuals and pregnant women[5]. The Affordable Care Act (ACA) has broadened public insurance coverage, enhancing access to treatments by increasing the number of patients covered. This expansion has led to a rise in treatment admissions and reduced the financial burden on state and local governments. Therefore, it is advisable for policies to also focus on expanding private insurance coverage for Opioid Use Disorder (OUD) treatments, following the ACA’s successful outcomes[6]. Expanding insurance coverage would likely increase the number of MAT facilities and providers in the market and support organizations in adopting and diffusing new treatments[7].
Secondly, a significant gap exists between the availability of Medication-Assisted Treatment (MAT) providers/Opioid Treatment Programs (OTPs) and the demand from patients. Strategies to increase accessibility are crucial[8]. State governments could offer additional subsidies to facilitate the provision of these treatments, as cost often presents a significant barrier to market entry[9]. Furthermore, training more physicians in OUD specialty treatments could be beneficial[10] and relaxing patient limits for waivered physicians—those authorized to treat OUD patients outside of OTPs—could serve as a cost-effective alternative to opening new facilities[11].
Thirdly, the adoption and diffusion of OUD treatments have been slow, particularly for naltrexone, which have seen low adoption rates.[12] Policy initiatives should support larger centers and hospital-based programs to facilitate the adoption and diffusion of these treatments. Additionally, encouraging private funding for early adoption is advisable, as privately funded centers tend to have significantly higher adoption rates compared to publicly funded centers.[13]
Fourthly, many patients are either unaware of these treatments, reluctant to pay for them, or skeptical about their effectiveness.
Finally, some clinicians may harbor negative attitudes towards this population, which could lead to a reluctance to prescribe opioid antagonists, provide appropriate treatments, and instill reluctance in the individuals seeking treatment to approach the clinical community for assistance (fear their problem will not be understood or treated fairly). To address this, it is crucial continually emphasize clinician training. Regulations should promote access to comprehensive training programs and advocate for the development of patient-centered care systems[14].
Recommended Readings
- Information about Medications for Opioid Use Disorder (MOUD) | FDA
- Medications for Substance Use Disorders | SAMHSA
- Evidence-Based Treatment | HHS
- Evidence-Based Treatments for Opioid Use Disorder | APA
Recommended Resource
The ncopioidsettlement.org team (CORE-NC) has compiled a variety of useful resources for better understanding Evidence-Based Addiction Treatment
Recovery support encompasses methods such as peer recovery and recovery housing. Peer recovery is a widely utilized approach, often facilitated by a peer recovery specialist who either currently has or has previously experienced OUD or similar issues. In this model, patients voluntarily form peer support groups to share their experiences and insights on OUD and to develop strategies for overcoming related challenges.[1] This approach is frequently combined with other addiction treatments and can serve as a complementary method to enhance the overall effectiveness of treatment.
The peer recovery strategy has several advantages:
- Improve treatment engagement and adherence
- Improve OUD-related knowledge for patients
- Reduce hospitalization and ED visits
- Reduce recidivism in substance use
- Reduce stigma[2]
Access to recovery support services for OUD patients should be facilitated through enhanced community support. Comprehensive interventions, which potentially could be more effective than MATs alone, should be a focal point of policy efforts. Policy should concentrate on:
- Educational efforts on OUD: the government and the community should provide more programs to increase social awareness of OUD and reduce stigma from other people.
- Promoting research on the effectiveness of recovery support services and heterogeneous effects on different socioeconomics, racial, gender, regional, and generational groups of people.
- Outreach to marginalized groups of people and incorporate targeted services (such as language and cultural support).
- Include more peer recovery services within emergency department and have a better transition from ED visits to aftercare and then back to the society[3].
Recommended Readings
Recommended Resource
The ncopioidsettlement.org team (CORE-NC) has compiled a variety of useful resources for better understanding Recovery Support Services
A post-overdose response team offers medical care, educational resources, and psychological support to individuals who have survived non-fatal drug overdoses. The primary goal of this team is to prevent future overdoses and facilitate connections for survivors with appropriate tools, treatments, and supportive programs.
A recent study indicates that interventions and outreach programs following opioid overdoses can effectively reduce subsequent overdose incidents, decrease long-term opioid-related fatality rates, and lessen the demand for emergency medical services (EMS) responses.[1] Another recent study shows that these programs can be cost-saving to local communities[2]. In response to the increasing incidence of opioid misuse and overdose cases in the U.S., it is crucial for policymakers and communities to consider these programs and implement them in the following ways:
- Effective structuring and allow variability for these programs[3].
- Enhance education in opioid overdose response and possibly use digital platforms to disseminate the information[4].
- Enhance EMS engagement in post-overdose interventions and standardize protocols in EDs for post-overdose care[5].
- Promote collaboration between law enforcement, health providers, and communities in post-overdose outreach[6].
- Strengthen these programs by regular trainings on overdose response staff to improve knowledge and attitudes and use of pre- and post-training assessments for effectiveness for more feedback[7].
- Integration of peer recovery in interventions and emphasis on Naloxone training and distribution within these programs[8].
- Inclusion of social services within these programs as they possibly reduce fatal overdoses[9].
Recommended Readings
Recommended Resource
The ncopioidsettlement.org team (CORE-NC) has compiled a variety of useful resources for better understanding Post-Overdose Response
Criminal justice diversion programs support individuals involved in the justice system with medication-assisted treatments, counseling and behavioral therapies, healthcare services, recovery support and so forth. The goal is not only to address the legal consequences of opioid use, but also the medical, psychological, and social factors that contribute to addiction.
Studies have shown that treatments for opioid use disorder (OUD) is associated with
- Significant reductions in the costs of crime[1]
- Reduce heroin use, overdose deaths post-incarceration, and risk behaviors in prison[2]
- Reduce re-incarceration/recidivism rates and post-release opioid use[3]
Policy could focus on:
- Facilitate expansion of MAT to serve opioid-dependent criminal justice populations and broaden access to MAT in correctional settings[4]
- Provide better linkages to community pharmacotherapy and increase collaboration with community MAT providers in community correctional settings[5]
- Provide sustained treatments, continue to monitor post-release individuals, and incorporate a continuum of MAT and overdose prevention treatment before, during , and after incarceration[6]
- Address inadequate knowledge and negative attitudes about MAT to increase its adoption in criminal justice settings and improve education efforts directed at both drug court personnel and policy makers about evidence-based treatment approaches[7]
- Establish effective screening and protocol-led treatment with MAT[8]
Recommended Readings
- Justice Involved Supports | NC DHHS
- Criminal Justice Diversion Programs In the News | Daily Tar Heel
Recommended Resource
The ncopioidsettlement.org team (CORE-NC) has compiled a variety of useful resources for better understanding Criminal Justice Diversion Programs
Naloxone, also marketed under the brand name Narcan, is a potent opioid antagonist known for its quick onset of action, which typically occurs within 2 to 10 minutes, varying with the mode of administration. It can be delivered intravenously, intramuscularly, or as a nasal spray. The intravenous route typically results in the fastest response. The nasal spray variant has become widely favored for its simplicity, making it accessible to individuals without medical training. This rapid effectiveness is essential for counteracting the severe, potentially fatal consequences of an opioid overdose, such as respiratory depression.
Research indicates that distributing naloxone can decrease overdose mortality and reduce the incidence of adverse events.[1]. However, the availability of naloxone in pharmacies varies by state, with some states having limited access[2]. Additionally, not all states have legal mandates in place that effectively facilitate the distribution of naloxone[3]. In some states, despite an adequate supply of naloxone, the medication remains relatively expensive, with an average cash price of $132.49[4].
Numerous studies have demonstrated that naloxone is cost-effective. For instance, Cherrier et al. (2022) found that the incremental cost-utility ratio for naloxone ranged from $111 to $58,738 per quality-adjusted life-year (QALY) gained[5]. Additionally, Acharya et al. (2020) reported an incremental cost-effectiveness ratio (ICER) of $56,699 per QALY, while Coffin & Sullivan (2013) estimated the ICER at $14,000 per QALY[6]. Given a willingness-to-pay (WTP) threshold of $100,000, naloxone distribution is deemed cost-effective and its broader implementation is advocated in most scenarios.
Therefore, policies should attempt to:
- Implement the naloxone coprescription mandate and naloxone access laws[7]
- Increase provision of naloxone by community programs[8]
- Invest in overdose education in teaching laypersons how to prevent overdoses as well as how to respond to them[9]
- Increase availability of naloxone in pharmacies and lower the costs[10]
- Prioritize naloxone prescription for patients on higher opioid doses or with a history of opioid-related ED visits for better resource allocation[11]
- Broaden the access of take-home naloxone[12]
Recommended Readings
- Naloxone Distribution Project | HCS
- Expanding Access to Naloxone: A Review of Distribution Strategies | Penn LDI
- Naloxone to Reverse Opioid Overdose | NACo
Recommended Resource
The ncopioidsettlement.org team (CORE-NC) has compiled a variety of useful resources for better understanding Naloxone Distribution