The US overdose crisis: the next administration needs to move beyond criminalisation to a comprehensive public health approach
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2418 (Published 01 November 2024) Cite this as: BMJ 2024;387:q2418
- Magdalena Cerdá, professor and director,
- Noa Krawczyk, assistant professor and associate director
The opioid overdose crisis remains one of the most considerable public health threats in the United States, claiming over 100 000 lives annually in recent years.1 Despite this year’s 12% reduction in overdose deaths,1 the crisis persists, driven by the rise of synthetic opioids such as fentanyl and exacerbated by widening racial inequalities.2 This crisis is central to the 2024 US presidential election,3 with both candidates proposing to tackle it.45 Their positions emphasise criminalisation, tightened border controls, and expanded law enforcement efforts to reduce the supply of illicit opioids. However, to achieve sustained progress in overdose prevention, we need a comprehensive approach grounded in public health.
Interventions that are focused on cutting off supply, including using tightened surveillance and controls at the borders, can only provide a temporary reduction in drug availability,678 with suppliers quickly adapting by altering supply routes or substituting novel synthetics such as xylazine into illicit markets. Historically, punitive efforts to reduce drug related harms through tougher law enforcement, criminalisation, and incarceration have not had enduring success and often lead to human costs that disproportionately affect marginalised communities.9
Tackling the overdose crisis effectively requires policies that are informed by a public health approach, with a focus on reducing demand and mitigating the health risks associated with an increasingly toxic drug supply. Kamala Harris has acknowledged this in her election campaign, referring to the crisis as a public health concern. She rightly points to the efforts of the current Biden-Harris administration,10 which include federal funding of harm reduction11 and substantial expansion in the availability of naloxone.1213 However, the government’s response must go further to ensure a sustainable reduction in overdose deaths. This must include initiatives that are aimed at lowering the number of people engaged in risky drug use, preventing overdoses, and reducing fatal outcomes once someone has overdosed.14
Reduce the number of people engaged in risky drug use
Preventing risky drug use requires comprehensive prevention efforts, which should be prioritised by federal funding. These include community based interventions that focus on early intervention to prevent adverse childhood experiences,151617 and universal psychosocial interventions for children and young people in school settings.18192021 Policies and programmes that strengthen household financial security in low income communities—such as rental and home purchase assistance, housing eviction moratoria, and unemployment insurance—will also be important priorities to reduce initiation of risky drug use and misuse.222324
Prevent overdoses among people at risk
Investment in opioid use disorder treatment and harm reduction are important tools to prevent overdoses among people at risk. For people experiencing an opioid use disorder, the federal government can play a crucial role in expanding access to the evidence based treatments methadone and buprenorphine, which reduce the risk of overdose by more than 50%.25 These treatments fall under the oversight of federal agencies and could benefit from regulatory changes, such as ensuring that buprenorphine is permanently available via telehealth26 and allowing methadone to be prescribed in physician offices and dispensed in pharmacies, rather than restricting it to designated opioid treatment programmes.27 Ensuring treatment success must also involve increasing supportive services such as peer recovery programmes, housing assistance, and transportation, which can be funded and supported through federal programmes and policies.28
A comprehensive public health approach to overdose prevention must also include harm reduction services, which reduce the immediate risks for people who use drugs. Services such as syringe exchange programmes and overdose prevention centres with wraparound services—including connections to housing, nutrition, and treatment—have proved effective in reducing both the spread of infectious diseases and risk of overdose.29 Federal support is essential to remove the legal barriers that currently restrict funding for harm reduction services. For example, the prohibition against using federal funds to purchase syringes constrains the operation of syringe exchange programmes, while the federal prohibition on “maintaining drug-involved premises” (the so called “crack-house statute”) limits federal funding for and the operation of overdose prevention services, depending on how the law is interpreted.
Additionally, drug checking services that are based in accessible locations in the community, such as schools, libraries, and community health centres, could improve drug market surveillance and allow people using drugs to make safer choices.30 Federal funding for harm reduction initiatives would encourage local governments and non-profits to implement these effective measures at scale, thereby reducing overdoses in vulnerable communities.
Reduce fatal overdose outcomes
Expanding access to naloxone, a lifesaving overdose reversal drug, is an important component of any strategy to reduce drug related deaths.3132 Federal agencies can use regulatory authority and funding to ensure saturation of naloxone and drug checking equipment in housing facilities, correctional settings, and other spaces where overdoses are more likely to take place.
The federal government must also issue guidelines for private insurance plans to cover over-the-counter and prescription formulations of naloxone,33 making naloxone more affordable. Expanding access to naloxone through federal support and insurance coverage would lower the probability of fatal overdoses and save countless lives.
An evidence based approach
Although recent declines in overdose rates indicate progress, the widening racial inequalities in overdose rates signal the need for a more inclusive and sustained strategy. By moving beyond criminalisation and tightened border controls to adopt a comprehensive public health framework that includes prevention, treatment, and harm reduction, the next administration can make a lasting impact on one of the most urgent public health challenges facing families and communities in the US.
Footnotes
Competing interests: NK and MC receive fees for expert witness testimony in ongoing opioid litigation.
Provenance and peer review: Commissioned; not externally peer reviewed.