In 2021, the United States set a grim record:
For the first time, more than 100,000 people lost their lives to drug overdoses. Substance misuse experts say the Covid-19 pandemic accelerated the opioid crisis. Lockdowns isolated people from support systems, impeded access to treatment, and increased depression and despair. At the same time, the illicit opioid market took a dangerous turn, shifting from products such as heroin to fentanyl, a potent synthetic opioid with even more deadly consequences.
“The pandemic has compounded many existing problems, including mental health crises. Meanwhile, we’ve seen a near-total transition of the illicit opioid supply to fentanyl, which is highly potent and often fatal,” said Sharon Walsh, PhD, director of the Center on Drug and Alcohol Research at the University of Kentucky. And while telehealth access improved during the pandemic, some people had more trouble accessing pharmacological treatments. “While there were some silver linings to the pandemic, such as policy changes to allow telehealth options for initiating buprenorphine treatment, all in all, we’re losing right now as fatal overdoses are rising,” Walsh said. Recent data show that overdose deaths are rising most quickly among people of color and particularly in low-income communities (Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Vol. 71, No. 29, 2022opens in new window).
But an ambitious federal initiative aims to turn the tide of the opioid epidemic. The National Institutes of Health (NIH) launched its Helping to End Addiction Long-term Initiative® (or NIH HEAL Initiative®) in 2018 to support science-based solutions to the opioid crisis. As of July 2022, NIH had invested $2 billion in HEAL, funding some 600 research projects nationwide.
Those projects include new cognitive behavioral therapy-based interventions for pain, behavioral interventions to complement pharmacological treatments, efforts to improve access to treatments in justice settings and communities, and research to understand how prenatal opioid exposure affects child development.
Psychologists are involved in many of the projects being done under the HEAL Initiative, applying their skills to a variety of efforts to reduce opioid deaths and lessen the impacts of opioid use disorder on individuals, families, and communities.
HEAL is designed to tackle the parallel problems of chronic pain and addiction, said Tisha Wiley, PhD, a psychologist and associate director for justice systems in the Services Research Branch at the National Institute on Drug Abuse (NIDA). “It covers the entire swath of science, from basic biomarkers to new therapeutics to getting evidence-based tools for prevention and treatment into practice,” she said. “What makes this effort different is that we’re really thinking about that whole continuum from prevention to harm reduction to treatment and recovery. We’re not going to make any progress if we don’t put that whole picture together.”
Improving opioid treatment
One major effort within HEAL targets opioid use disorder within the criminal justice setting. Research shows that 51.7% of people with prescription opioid use disorder, and 76.8% of those with heroin use in the past year, report contact with the criminal justice system. And justice involvement increases as the level of opioid use increases (Winkelman, T. N. A., et al., JAMA Network Open, Vol. 1, No. 3, 2018opens in new window).
Some criminal justice settings offer opioid treatments, but access to treatment services in jails and prisons varies widely. “You shouldn’t have to go to jail to get treatment. But jails and prisons are the largest mental health and substance use treatment providers in the country,” said Wiley, NIDA’s lead for the HEAL-supported Justice Community Opioid Innovation Network (JCOIN).
The average jail stay for people who misuse opioids is less than 30 days, Wiley noted, so treatment continuity is often a problem as people move from justice settings back into their home communities. JCOIN addresses gaps in treatment, with an emphasis on creating partnerships between justice systems and community-based treatment providers. The project includes a dozen research hubs, each working in multiple communities.
“The goal of the network is to ensure that everyone involved in the justice system has access to evidence-based opioid use disorder treatment,” said Rosemarie Martin, PhD, an experimental psychologist at Brown University and a principal investigator of JCOIN who oversees projects in Rhode Island, Philadelphia, and North Carolina.
The gold standard for treatment includes FDA-approved medications, including methadone, buprenorphine, or naltrexone to prevent drug cravings and/or block the effects of other opioids, alongside psychotherapy. Groups such as the American Society of Addiction Medicine recommend medications be made available to all patients (Crotty, K., et al., Journal of Addiction Medicine, Vol. 14, No. 2, 2020opens in new window). It has been established that medications for opioid use disorder can reduce both overdose deaths and recidivism, Wiley said. But methadone and buprenorphine are highly regulated medications, which can make it challenging to establish treatment programs that deliver them in justice settings. JCOIN is studying how best to implement those services to support justice-involved people with opioid use disorder in large-scale clinical trials.
Coordinating care between justice settings and communities presents many challenges. What happens if a person receives methadone treatment in jail, for instance, but is unable to access treatment when they’re released back to their community? How can probation officers and community providers work together to support the people they serve? “We’re taking a systems-change approach, starting with community partners,” Martin said. Local leaders are in the best position to determine their priorities, whether that’s increasing treatment capacity, improving communication between community providers and justice systems, or providing timely data so that community leaders can assess what’s working and what isn’t. “We’re focusing on helping leadership implement changes with the best science, to make sustainable changes that become part of their operations after we’re no longer involved,” Martin said.
The large-scale approach will allow researchers to collect data about what works within these settings, Martin said. “As a network, we’re more than the sum of our parts.”
Helping communities heal
Community input is also a key element in another large-scale HEAL project, the HEALing Communities Study, which is testing the integration of prevention, overdose education, and expansion of medications for opioid use disorder in 67 communities in Kentucky, Massachusetts, New York, and Ohio that have been hit especially hard by the opioid crisis. The goal is ambitious: to reduce overdose deaths by 40% over 3 years. The researchers hope to establish best practices for implementing prevention and treatment strategies that can be replicated nationwide.
“Communities know their strengths, resources, gaps, and vulnerabilities better than anyone else. This study is all about providing them with data and support so that they can make data-driven decisions,” says Redonna Chandler, PhD, a licensed psychologist and director of the HEALing Communities Study at NIDA. “We’ve found there are a lot of great things happening in communities, but they’re often happening in silos. We’re developing a multipronged approach across multiple sectors and helping them implement these practices in ways they can sustain beyond the life of this study.”
Each of the 67 communities was randomly assigned to receive the intervention immediately or in a second wave as a wait-listed control. The investigators present the communities with a menu of evidence-based practices that fall into three categories: overdose education and distribution of naloxone, a drug that can reverse opioid overdoses; expansion of medications for opioid use disorder, including efforts to improve accessibility and treatment retention; and educating health care providers about safer prescribing and dispensing practices for pain relievers.
“Unfortunately, because of the way our health care system is designed, and because of long-standing stigma against people who have substance use disorders and treatments for these disorders, there’s been a failure in terms of treating this as any other medical condition,” said Walsh, principal investigator of the HEALing Communities Study in Kentucky. “It’s been a challenge to get communities to take up those practices that we know are most effective.”
Like JCOIN, this study is all about getting evidence-based tools into the population. Each of the four states is using a common protocol in their communities, and the practices are designed so that communities can maintain them long term even after the study ends. “It’s a very structured decision-making process. And at the end of the process, each community has determined which interventions from our list they will deploy and in what agencies,” Walsh said.
The investigators completed the Wave 1 interventions and launched the intervention in the Wave 2 communities in the summer of 2022. They will be reviewing data to better understand what’s working and what gaps remain, and how best to ramp up efforts to save lives in other communities. “The need is greater than ever. But we know a lot about what works,” Walsh said.
Opioid exposure and neurodevelopment
HEAL extends beyond intervention and implementation research. Another large initiative explores the developmental effects of prenatal opioid exposure. Modeled on the NIH’s long-running Adolescent Brain Cognitive Development (ABCD) Study, the HEALthy Brain and Child Development Study (HBCD) will follow a cohort of 7,500 pregnant people and their babies through childhood, collecting biospecimens, imaging data, medical and family history, and information on social, emotional, and cognitive development.
While the study is not focused strictly on opioid exposure, the researchers plan to oversample for pregnant people who have used opioids and other substances to paint a clearer picture of the effects of prenatal and postnatal exposures. “Most of the information available [on opioid use in pregnancy] comes from very limited studies,” said Michelle Freund, PhD, project director for the HBCD Study at NIDA. HBCD is notable both for the magnitude of participants and the range of data that researchers will collect, including neuroimaging data for every child. “The HEAL Initiative has allowed us to take on a study that no single institute at the NIH would be able to do on its own,” she said.
The longitudinal study has the power to answer important questions not only about opioid exposure but about neurodevelopment more broadly, said Lauren Wakschlag, PhD, director of the Institute for Innovations in Developmental Sciences at Northwestern University and joint lead for her university’s HBCD study site. Her team is engaging members of the community as partners in study design to ensure an equitable approach that represents the lived experiences of diverse families, she said. Recent advances in biosensors and brain-based imaging also mean the study will be able to learn things that weren’t possible even a decade ago. One example is the use of what she calls “lullaby MRI,” a technique to look at infants’ brain growth, without anesthesia, while the baby sleeps.
The effort will provide a rich set of data that will be made available to the research and broader community through regular public releases. “Our ultimate goal is to conduct developmental follow-up of these children until they overlap with the age at which the ABCD study was initiated. By harmonizing the two studies, we can chart a path from the prenatal period through emergent adulthood to understand why some children do well under adverse circumstances and some do not—and ultimately, translate that to prevention efforts,” Wakschlag said.
Psychology’s role in HEAL (and HEALing)
Beyond these large-scale studies, the HEAL Initiative supports numerous other projects that touch on the opioid crisis in a variety of ways. Katie Witkiewitz, PhD, a professor of psychology at the University of New Mexico, is part of a team studying interventions to address risky opioid use in people who also live with chronic pain—a population thought to make up as many as 40% to 60% of people with opioid use disorder. The Integrative Management of chronic Pain and OUD for Whole Recovery (IMPOWR) study aims to treat both issues at the same time, rather than treat pain and substance use as separate problems.
In a pilot study of veterans, Witkiewitz and colleagues found that acceptance and commitment therapy combined with mindfulness-based relapse prevention helped participants pay attention to their pain response, make room for negative sensations without choosing harmful strategies to control them, and pursue personally valued activities (The Journal of Pain, Vol. 21, No. 7–8, 2020opens in new window). They’re now conducting a larger study to assess the technique in veterans and others. “We’re trying to provide a holistic intervention that gets at the core causes and conditions that lead to both chronic pain and opioid use disorder,” she said.
[Read more: Use the free APA substance use disorders curriculum]
In another psychologist-led study, Jessica Magidson, PhD, an associate professor of psychology at the University of Maryland, has support from HEAL to evaluate an intervention that employs peer recovery coaches to help individuals stay in treatment for opioid use disorder. These individuals with lived experience of opioid use are trained to deliver a structured, evidence-based approach that uses behavioral activation to help people with opioid use disorder identify meaningful behaviors and address barriers to staying in treatment. The intervention was originally designed to be led by peers and community health workers in international settings where access to psychologists and psychiatrists is limited, but Magidson has adapted the peer-delivered behavioral activation intervention for use in medically underserved communities in the United States (PLOS ONE, Vol. 15, No. 1, 2020opens in new window).
“Workforce shortages are also pervasive in the United States, and peers may play an essential role in expanding access to psychosocial support alongside medication treatment for opioid use disorder,” Magidson said. In the HEAL-funded pilot study currently under review, she found that 89% of participants in the peer intervention remained in methadone treatment at 3 months, compared with 60% in usual care. Magidson is now launching a larger trial to evaluate the intervention and has separate HEAL funding to test how the intervention may reduce stigma. “Our team is demonstrating how peers, through shared lived experience, may shift the many layers of stigma people face when seeking services for opioid use disorder,” she said.
Psychologist Sean Young, PhD, a professor at the University of California, Irvine, and executive director of the University of California Institute for Prediction Technology, is also evaluating the power of peers through an online community intervention. He and his colleagues originally developed a social media mentorship program to increase health behaviors among other populations affected by stigma, such as people living with HIV. With HEAL support, Young and his colleagues adapted the program to engage patients who use opioids to reduce risk factors for opioid misuse (Heliyon, Vol. 6, No. 3, 2020opens in new window). He’s also testing whether the intervention can increase uptake and adherence of medications for opioid use disorder. “We’re underutilizing behavioral science and psychology methods in public health,” Young said. “We can take these ideas and lessons from psychology and apply them to have a much bigger positive impact.”
Young isn’t the only psychologist to see a need for more psychological science in efforts to address the opioid epidemic. “We need as many brilliant psychologists working on this as possible,” Witkiewitz said. She thinks the tide is turning. “There’s now a lot of attention and a lot of money being thrown at the problem. And a lot of people who previously weren’t doing work on opioids or pain are moving into the area,” she said.
One important part of their role is to help chip away at the stigma that continues to stand in the way of prevention, harm reduction, and treatment efforts. “Both chronic pain and opioid use disorder have tremendous stigma associated with them. In my conversations with our partners with lived experience, one of the most devastating parts has been hearing how poorly they’ve been treated by the health care system,” Witkiewitz said. “We need to be thinking about the biases and discrimination we might bring into our interactions as psychologists or researchers. And we need to do everything that we can do to reduce stigma and to reduce barriers for people who genuinely need help.”
