HEALing the Opioid Crisis
The misuse of opioid in the U.S. is devastating lives and communities. The NIH’s HEAL initiative is trying to stop it.
By Linda Rath | Aug. 23, 2023
Opioids are responsible for close to 100,000 people dying in the U.S. in 2023, according to the Centers for Disease Control and Prevention (CDC). That’s five times the number of reported deaths from prescription opioids just two decades ago, and likely an underestimate. Experts say the aggressive marketing, distribution and prescribing of opioids in the late 1990s ignited the current epidemic of addiction and overdose deaths. The scale of the problem and the human and societal costs are unique to this country. The U.S. consumes 80% of the world’s opioids and 99% of hydrocodone (Vicodin), yet there is no evidence that the U.S. population has more pain than other countries’ or that opioids help reduce the population’s pain level.
The CDC responded to the crisis in 2016 by recommending severe curbs on opioid prescriptions, but patient advocates and pain experts argued that the recommendations had the unintended consequence of penalizing those who use opioids to control chronic pain by cutting them off, leading to greater pain and psychological distress. The CDC later revised its recommendation, limiting the use of opioids to the lowest possible dose for the shortest possible time. Alternatives, however, are still needed to halt or reverse the excessive use of these drugs.
To find effective and lasting solutions to this public health emergency, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-Term (HEAL) Initiative in 2018. The initiative brings together scientists, community members, the private sector and many branches of government.
It aims to:
Most of HEAL’s short-term goals focus on finding better ways to treat opioid use disorder (OUD), preventing or reversing opioid overdoses, and improving treatments for newborns exposed to opioids before birth. Researchers will also try to understand the biological and psychosocial drivers of chronic pain and identify better ways to treat them.
Here’s a closer look at some of these issues and what has been accomplished so far:
1. Treating Opioid Use Disorder (OUD)
Two million people in the U.S. have this disorder, and millions more misuse opioids, taking a higher dose for longer or using a different method than prescribed. The Food and Drug Administration (FDA) has approved three drugs, including the synthetic opioids methadone and buprenorphine, to treat the disorder, but not everyone responds to or sticks with treatment. The drugs also carry their own risks of misuse, dependence and overdose.
HEAL proposes reformulating existing drugs, repurposing drugs approved for other uses and creating new medications that target the brain’s reward pathways to reduce cravings. It’s also studying nondrug therapies such as mindfulness meditation and cognitive behavioral therapy.
The problem? Most people with OUD don’t have access to medical care, treatment or recovery support services. HEAL is testing ways to get treatment to people in emergency rooms, the legal system and other community settings. One study found that people in rural areas could benefit from telemedicine, if they were willing to use it. Telemedicine is also being used to teach pain coping skills to Indigenous Americans undergoing kidney dialysis in isolated communities. In general, a tremendous number of opioids are prescribed to dialysis patients.
Researchers are also studying how to make naloxone — a life-saving drug that reverses opioid overdose — more effective and readily available. Narcan, a nasal spray version of naloxone, is now sold over the counter. It’s simple to use and safe and effective for adults and kids of all ages.
2. Preventing Opioid Use Disorder.
Opioid misuse often starts in late adolescence or early adulthood. Overdose deaths among teens jumped 94% between 2019 and 2020. HEAL is studying ways to prevent addiction and overdose deaths in at-risk youth, including those who may be in foster care due to parental drug use. It’s also studying the connection between OUD, sleep and circadian rhythm disorders, and between opioid misuse and mental health — a link many teachers have noted since the COVID-19 pandemic.
3. Improving treatments for withdrawal in infants.
As many as 10% of newborns in communities hit hard by the opioid crisis are exposed to drugs before birth. These infants can have severe withdrawal symptoms, including excessive crying and trouble eating, sleeping and breathing. Like adults, they’re usually treated with methadone or, more commonly, buprenorphine, but there’s little data about the effect of these drugs on a growing infant’s brain. Scientists are actively seeking nondrug treatments for withdrawal symptoms in newborns. A bassinet pad that soothes babies using gentle vibrations has been fast-tracked for FDA approval.
Newborns who experience withdrawal may also have developmental delays and are at higher risk of substance misuse later in life. A long-term goal is to follow them for at least 10 years to see how they fare compared to kids not exposed to opioids.
4. Understanding chronic pain and improving pain management.
Most chronic pain starts as acute pain from an illness or injury. It’s a signal to your brain that something is wrong. But in some people, the warning doesn’t stop, like a smoke detector that keeps beeping after the fire is out. HEAL researchers are trying to understand the unique biologic and psychosocial characteristics that make some people more likely to develop chronic pain or perceive pain differently than others. Finding safer and more effective ways to relieve pain for diverse patients is also a top priority.
In addition to being highly addictive, opioids are generally ineffective at controlling chronic, non-cancer pain and are known to increase pain sensitivity over time. In a meta-analysis comparing opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), exercise and placebo for osteoarthritis (OA) pain, exercise came out on top, followed by NSAIDs. Opioids came in last.
Researchers are trying to understand the best way to treat many different types of chronic pain. That’s the focus of HEAL’s Pain Management Effectiveness Research Network, which will help support advanced clinical trials of both drug and nondrug options. Researchers will need to focus on recruiting diverse trial participants, since extreme disparities exist in pain management for Blacks and other people of color.
HEAL is focused on helping patients and doctors learn to manage pain safely and effectively. It does not address the root causes of opioid misuse and overdose. Those are societal problems that need to be dealt with on a societal level. They include:
Opioids are responsible for close to 100,000 people dying in the U.S. in 2023, according to the Centers for Disease Control and Prevention (CDC). That’s five times the number of reported deaths from prescription opioids just two decades ago, and likely an underestimate. Experts say the aggressive marketing, distribution and prescribing of opioids in the late 1990s ignited the current epidemic of addiction and overdose deaths. The scale of the problem and the human and societal costs are unique to this country. The U.S. consumes 80% of the world’s opioids and 99% of hydrocodone (Vicodin), yet there is no evidence that the U.S. population has more pain than other countries’ or that opioids help reduce the population’s pain level.
The CDC responded to the crisis in 2016 by recommending severe curbs on opioid prescriptions, but patient advocates and pain experts argued that the recommendations had the unintended consequence of penalizing those who use opioids to control chronic pain by cutting them off, leading to greater pain and psychological distress. The CDC later revised its recommendation, limiting the use of opioids to the lowest possible dose for the shortest possible time. Alternatives, however, are still needed to halt or reverse the excessive use of these drugs.
To find effective and lasting solutions to this public health emergency, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-Term (HEAL) Initiative in 2018. The initiative brings together scientists, community members, the private sector and many branches of government.
It aims to:
- Find better ways to prevent and treat opioid misuse, addiction and overdose
- Change the way pain is perceived and managed, including with non-drug therapies
- Ensure that treatment and other resources reach everyone who needs them.
Health care: One piece of the puzzle
Most of HEAL’s short-term goals focus on finding better ways to treat opioid use disorder (OUD), preventing or reversing opioid overdoses, and improving treatments for newborns exposed to opioids before birth. Researchers will also try to understand the biological and psychosocial drivers of chronic pain and identify better ways to treat them.Here’s a closer look at some of these issues and what has been accomplished so far:
1. Treating Opioid Use Disorder (OUD)
Two million people in the U.S. have this disorder, and millions more misuse opioids, taking a higher dose for longer or using a different method than prescribed. The Food and Drug Administration (FDA) has approved three drugs, including the synthetic opioids methadone and buprenorphine, to treat the disorder, but not everyone responds to or sticks with treatment. The drugs also carry their own risks of misuse, dependence and overdose.
HEAL proposes reformulating existing drugs, repurposing drugs approved for other uses and creating new medications that target the brain’s reward pathways to reduce cravings. It’s also studying nondrug therapies such as mindfulness meditation and cognitive behavioral therapy.
The problem? Most people with OUD don’t have access to medical care, treatment or recovery support services. HEAL is testing ways to get treatment to people in emergency rooms, the legal system and other community settings. One study found that people in rural areas could benefit from telemedicine, if they were willing to use it. Telemedicine is also being used to teach pain coping skills to Indigenous Americans undergoing kidney dialysis in isolated communities. In general, a tremendous number of opioids are prescribed to dialysis patients.
Researchers are also studying how to make naloxone — a life-saving drug that reverses opioid overdose — more effective and readily available. Narcan, a nasal spray version of naloxone, is now sold over the counter. It’s simple to use and safe and effective for adults and kids of all ages.
2. Preventing Opioid Use Disorder.
Opioid misuse often starts in late adolescence or early adulthood. Overdose deaths among teens jumped 94% between 2019 and 2020. HEAL is studying ways to prevent addiction and overdose deaths in at-risk youth, including those who may be in foster care due to parental drug use. It’s also studying the connection between OUD, sleep and circadian rhythm disorders, and between opioid misuse and mental health — a link many teachers have noted since the COVID-19 pandemic.
3. Improving treatments for withdrawal in infants.
As many as 10% of newborns in communities hit hard by the opioid crisis are exposed to drugs before birth. These infants can have severe withdrawal symptoms, including excessive crying and trouble eating, sleeping and breathing. Like adults, they’re usually treated with methadone or, more commonly, buprenorphine, but there’s little data about the effect of these drugs on a growing infant’s brain. Scientists are actively seeking nondrug treatments for withdrawal symptoms in newborns. A bassinet pad that soothes babies using gentle vibrations has been fast-tracked for FDA approval.
Newborns who experience withdrawal may also have developmental delays and are at higher risk of substance misuse later in life. A long-term goal is to follow them for at least 10 years to see how they fare compared to kids not exposed to opioids.
4. Understanding chronic pain and improving pain management.
Most chronic pain starts as acute pain from an illness or injury. It’s a signal to your brain that something is wrong. But in some people, the warning doesn’t stop, like a smoke detector that keeps beeping after the fire is out. HEAL researchers are trying to understand the unique biologic and psychosocial characteristics that make some people more likely to develop chronic pain or perceive pain differently than others. Finding safer and more effective ways to relieve pain for diverse patients is also a top priority.
In addition to being highly addictive, opioids are generally ineffective at controlling chronic, non-cancer pain and are known to increase pain sensitivity over time. In a meta-analysis comparing opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), exercise and placebo for osteoarthritis (OA) pain, exercise came out on top, followed by NSAIDs. Opioids came in last.
Researchers are trying to understand the best way to treat many different types of chronic pain. That’s the focus of HEAL’s Pain Management Effectiveness Research Network, which will help support advanced clinical trials of both drug and nondrug options. Researchers will need to focus on recruiting diverse trial participants, since extreme disparities exist in pain management for Blacks and other people of color.
Where society and public health intersect
HEAL is focused on helping patients and doctors learn to manage pain safely and effectively. It does not address the root causes of opioid misuse and overdose. Those are societal problems that need to be dealt with on a societal level. They include:
- Poverty
- Lack of safe housing
- Job loss and lack of opportunity
- A family or personal history of substance misuse
- Mental health issues
- Social isolation and lack of social support
- Traumatic experiences — one HEAL study found a link between certain life experiences and chronic low back pain
- Systemic racism in society and medicine