On January 13 the Congressional Budget Office (CBO) released a report analyzing three policy approaches to the opioid-involved overdose crisis, along with their likely budgetary effects: supply reduction, demand reduction and harm reduction. The agency was right to not include too much on supply reduction, and wrong in pretty much everything it included about harm reduction.
The report evaluates only one strategy for supply reduction: Interdict the supply of illicit opioids. Fentanyl seizures, basically. Authors acknowledge that any benefits (usually reductions in use or perceived “crime,” more so than reductions in overdose) tend to be short-term.
Of the six strategies the report covers in total, four are considered forms of demand reduction. Three of those are related to treatment: Broaden opioid use disorder (OUD) Medicaid coverage, expand access to OUD telehealth services and expand treatment access for people in the criminal-legal system.
The fourth is to invest in prescription drug monitoring programs, which the CBO previously considered a strategy for supply reduction but is now apparently one of the best-evidenced strategies for demand reduction. The CBO argues that funding and expanding PDMP will decrease the availability of opioid analgesics prescriptions for new patients, which will result in fewer new cases of OUD, which will reduce the rate of overdose deaths. Almost as an afterthought, the agency notes that “benefits of improving PDMP are offset by some amount of substitution from prescription opioids to illegal opioids (such as heroin and illicitly manufactured fentanyl),” but that PDMP only do this “unintentionally.”
The authors used two criteria when selecting which strategies to include in the report: whether they have “considerable Congressional interest, as reflected in legislative actions and proposals,” and whether their outcomes—successful or not—are evidenced by at least six peer-reviewed papers; three correlational studies and three controlled trials or other quasi-experimental design.
CBO confirmed to Filter that the agency could not find six qualifying papers about the effectiveness or ineffectiveness of SSP.
Even without touching safe supply or overdose prevention centers or any research conducted outside the United States, there is more than one harm reduction strategy that meets those criteria. But the only one the CBO saw fit to include was “access to opioid overdose reversal medications.”
The report states that evidence for the efficacy of syringe service programs (SSP) is insufficient to meet CBO’s standards, but that the limited evidence that does exist is “mixed.” It cites a COVID-19 pandemic-era study arguing that SSP were responsible for increasing overdose deaths in counties that recently authorized them.
CBO confirmed to Filter that the agency is saying it was unable to find six qualifying papers about the effectiveness or ineffectiveness of SSP.
Peer-reviewed journals are as rife with junk science as any other part of the internet, so the evidence for the effectiveness of anything can be mixed if you want it to be. By the same token, you can take something like, say, nalmefene—a naloxone-alternative with an extremely mixed public opinion and almost no evidence base to speak of—and imply it’s the best-evidenced harm reduction tool of all.
Opioid-overdose reversal medications made it into the report based on evidence supporting the efficacy of naloxone access. And while naloxone is what the CBO discusses primarily, the agency also presents this strategy as applying equally to nalmefene, which “works similarly to naloxone and has stronger and more durable effects.” This is true, but less accurate than saying nalmefene works very differently than naloxone and is unnecessarily potent, to the point of increasing overdose risk rather than reducing it.
While SSP are briefly discussed later in the report, as a sort of honorable mention included due to public interest despite the CBO’s apparent failure to find evidence for or against them, they are not discussed in the context of naloxone access at all. There’s a single line referencing SSP as one of the types of organizations that participate in overdose education and naloxone distribution (OEND), and that line is what should have been the focus of a report that will influence how funds are allocated.
The report perpetuates a lot of myths besides just syringe programs increasing drug use.
Instead of SSP and OEND, the report focuses overwhelmingly on naloxone access via pharmacies, a strategy irrelevant to the overdose crisis at scale because the people best-positioned to respond to overdose don’t buy it from pharmacies. Much of the data cited are a decade old. The section as a whole is oddly skewed toward issues like out-of-pocket costs, the need to expand naloxone access laws and how the switch from prescription-status to over-the-counter will likely increase availability, which in addition to focusing on entirely the wrong thing lends the report a vague time-capsule quality like the authors have become trapped somewhere in late 2023.
The report perpetuates a lot of other myths and mischaracterizations besides just SSP increasing drug use. It presents fentanyl overdose as requiring higher doses of naloxone. It refers to naloxone itself as a medication that “blocks the effects of opioids,” language more associated with opioid vaccines or naltrexone (Vivitrol). After naloxone and nalmefene, naltrexone is the third opioid antagonist for which the CBO could endorse misleading research here, which it does.
“Naltrexone requires prior detoxification, so it is not used for initial treatment,” the report states. “Once detoxification is complete, naltrexone is about as effective as buprenorphine.”
This is a false premise. It comes from a National Institute on Drug Abuse study in which 28 percent of participants randomly assigned naltrexone were not able to complete the detox process, compared to 6 percent of participants assigned bupe, and this is the gist of most naltrexone research: If you look at the data without the substantial portion of people who found the onboarding process so unbearable they were unable to get on the medication at all, it works fine.
The outcome of that study was not that the naltrexone patients went off and detoxed, and then successfully started their medication, and then experienced the same results as the bupe patients. The outcome was that six months later—which is really not long enough to draw conclusions about overdose risk reduction for any MOUD, but especially naltrexone—more of the naltrexone patients were using unregulated opioids compared to the bupe patients. But if you take just the patients who did manage to get on naltrexone and compare them to the larger number of patients who managed to get on bupe, you could say the two medications were about equally effective.
Image (cropped) via Congressional Budget Office