September 2, 2025 • 26 mins
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Health Affairs' Rob Lott interviews Brendan Saloner of Brown University about his recent paper exploring how scaling up opioid treatment and harm reduction programs could reach more people.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:00):
Hello, and welcome to a health podocy. I'm your host,
(00:04):
Rob Lott. Friends, it is anexciting month here at Health
Affairs as this month's issuejust released is a full theme
issue dedicated entirely toresearch and policy insights all
(00:25):
about the ongoing opioidepidemic. It's really chock full
of path breaking empiricalresearch articles, perspectives,
and policy proposals foraddressing opioid misuse and
addiction, and which we hopewill contribute to an urgent
national dialogue aroundevidence based strategies, best
(00:46):
practices, and lessons learnedover the course of this crisis.
And so I'm delighted to speaktoday with Doctor.
Brendan Saloner, one of theauthors of the overview papers
published in this issue. A big,thoughtful, deep look at how far
we've come and where we'regoing. Doctor. Saloner is a
(01:06):
professor of health services,policy, practice at the Brown
University School of PublicHealth. He served as an external
expert advisor to this themeissue as well.
And his paper, is titled ScalingUp Treatment and Harm Reduction
Programs to Reach More PeopleWho Would Benefit. The paper's
(01:29):
other author, by the way, is theUniversity of Michigan's Doctor.
Puja Lajesedi. And we'regrateful for both Doctor.
Saloner's and Doctor.
Lajeseti's guidance in thedevelopment of this issue over
the course of a year. I can'twait to hear from Doctor.
Saloner about why this way oflooking at the opioid crisis is
(01:53):
so promising and timely. Doctor.Saloner, welcome to A Health
Odyssey.
Brendan Saloner (01:58):
Thanks for having me.
Rob Lott (02:00):
So let's just dive right in and maybe start with
some background. I think most ofour readers have a sense of what
you mean when you refer to theopioid crisis. But we've been
talking about that for quitesome time and folks might have
some trouble articulating whereit starts, where it might end,
(02:22):
and what it really encompasses.And so maybe you can just kind
of give us an equal startingpoint here. What do you mean
exactly when you refer to theopioid crisis?
Brendan Saloner (02:35):
Yeah. So the opioid crisis is one of the most
significant public healthemergencies that has ever
happened in the history of TheUnited States, and we're in the
third decade of it. So if you goback to the early two thousands,
public health experts weresounding the alarm bells about a
rise in deaths related toprescription opioids. The
(02:55):
numbers then continued to go up.And around 2010, something
important happened, which isthat, there was a shift in the
opioids that were involved inoverdose deaths, and a lot more
people were dying of deathsinvolving heroin.
So there was a shift from thelegally prescribed to the
illicit drug, economy. And thenaround 2013 to 2014, depending
(03:17):
on where you're looking at inthe country, a a new thing, came
into it came into effect, andthat was fentanyl, illicitly
manufactured fentanyl. Fentanylis a, legally prescribable, very
potent prescription opioid, butit's also a a drug that can be
readily synthesized, and it canbe made basically in clandestine
(03:39):
labs. And so fentanyl, hit thestreets, and what we saw is that
the overdose curve just hockeysticked. So we saw overdose
mortality rising and rising.
And going into the COVIDpandemic, it just rose even
further to the height years ofthe, overdose crisis around 2021
and 2022 when deaths were,peaking one hundred thousand
(04:02):
Americans a year. It's kind ofhard to believe that we have
seen those numbers. Starting in2023, numbers have started to,
come down, but we are stilllooking at, mortality numbers
that are just so far out of thenorm of what we've seen in this
country in the past and put TheUnited States, unfortunately, in
very bad shape internationally.And just one final thing, these
(04:25):
overdose numbers are sosignificant that even before the
pandemic, they were, very muchcontributing to a reversal in
American life expectancy. Sothey really are one of the
largest public health challengesour country has ever confronted.
Rob Lott (04:39):
Would you say that the worst is over? You said sort of
the numbers have come down, andthat's certainly promising. Is
it too early to tell if we're onthe right track, or do you think
questions remain as to sort ofwhether or not that those trends
are gonna continue?
Brendan Saloner (04:58):
I'm a vigilant optimist. So I I really believe
that it's possible that we canbuild on what we've seen and
continue to see reductions inthose numbers. But I also am
very, awake to the possibilitythat our overdose crisis, could
just, you know, basicallyboomerang back to where it's
(05:19):
been. Or there's new trends onthe horizon such as an increase
in deaths involving opioids incombination with stimulants like
methamphetamine, and we reallyneed to understand how to get
ahold of that problem. So thisis a very shape shifting crisis,
and I I I would caution thatwe're very far from being out of
the woods.
Rob Lott (05:39):
Okay. Fair enough. I I wanna maybe set the stage for
digging a little deeper intoyour article. One of the areas
you point to is sort of the goldstandard for opioid use disorder
treatment, which is a sort ofmedication like buprenorphine
and methadone. Can you say justhow effective are those?
(06:01):
And of the people who couldbenefit from that kind of
treatment, how many typicallyare getting that treatment?
Brendan Saloner (06:10):
It's a great question. And, you know, the way
I look at it is that thesemedications, which, more than
have the, the risk of dying ofan overdose compared to
treatment without medication,are some of the most effective
tools that we have. In fact,they're probably some of the
most effective, medications wehave for any chronic condition.
So they're they are a true kindof silver lining in this
(06:33):
situation because getting peoplestarted on medication can
dramatically improve theiroutcomes and actually save their
lives. The problem is that manypeople don't get medications,
and the reason why is that manypeople don't get treatment at
all.
So recent data would tell usthat only about one in three
people with an opioid usedisorder is getting any kind of
treatment. You know, onepositive is that we've seen over
(06:57):
the last, let's say, twentyyears, more people being willing
to get treated and being able toget treated with medications.
But, certainly, the problem isthat a lot of people who could
benefit from medicationtreatment are not getting that
treatment.
Rob Lott (07:13):
Okay. I wanna circle back to maybe some of the
underlying reasons behind that.But before we do, I wanna ask
sort of the same question to oneof the other sort of categories
that you point to in your paper,which is harm reduction
strategies. In In that case,we're talking about things like
syringe exchange and naloxone.What do we know about their
(07:35):
effectiveness, and howwidespread are are their use?
Brendan Saloner (07:39):
Yeah. We actually know quite a lot about
their effectiveness. So syringeservices programs, which is kind
of the the term of art forneedle exchange programs or
syringe exchange, programs likethat which provide people with
sterile syringes and other, youknow, drug use supplies, have a
dramatic effect in terms ofreducing the transmission of
(08:02):
HIV, hepatitis C, and otherinfectious diseases. And we've
seen, example after example ofwhen, these programs have, come
into communities and helped slowor stop the spread of those
very, devastating, diseases. Andthen also unfortunate examples
of when those, programs havebeen shut down and the the
(08:23):
diseases have come right back.
And then naloxone is a reallyimportant antidote to an opioid
involved overdose because whatit does is it essentially,
reverses the respiratorysuppression that can be so
lethal to people who are,experiencing an overdose. You
know? And then there's otherharm reduction approaches like
(08:45):
overdose, prevention sites,which just have a toehold in The
United States, And we we knowinternationally and from, some
experiences in New York Citythat that is also an important
model for keeping people safe ifthey are using drugs. So taken
together, what we call harmreduction, that package of
interventions is reallyimportant and lifesaving.
Rob Lott (09:07):
Great. And I wanna just take a moment here to sort
of maybe ask you to weigh in onthe counterargument we often
hear about some harm reductionstrategies, which is that they
perhaps encourage risky behaviorthat someone knowing that, you
know, there's naloxone theremight be more willing to engage
(09:28):
in in that risky behavior. Whatis sort of the, the response or,
the evidence basedinterpretation of that response?
Brendan Saloner (09:38):
Yeah. It's it's it's a totally fair and good
question. I think the reality isthat we've never seen evidence
to suggest that the harmreduction tools that I'm talking
about encourage or promote, druguse. The kind of folks who take
advantage of harm reduction proprograms are often people who,
have, a pretty serious opioiduse problem, and what harm
(10:00):
reduction is doing is helpingthem to stay alive another day,
and importantly, helping them tostay alive another day so that
they might be able to accesstreatment and other resources.
And we know from the researchthat doing things like engaging
with the syringe servicesprogram is often a stepping
stone toward that important goalof getting started on treatment
and ultimately moving towardabstinence.
(10:22):
So I don't think of these asbeing sort of opposing
strategies. I think they'reactually quite complementary.
Rob Lott (10:28):
Fair enough. And I'll put a little plug in for some of
the other articles in our themeissue that look at exactly those
sort of stages of kind ofconnecting people to to
treatment following initialinteraction with harm reduction
interventions. So let's talk alittle bit about your paper. It
really does revolve around thisidea or this concept of scale.
(10:51):
And I'd love it if you candescribe why you see that as
potentially a a sort of verypowerful and useful framework
for how we approach this crisisgoing forward.
Brendan Saloner (11:05):
Thanks for the question. Yeah. Puja, Lajesedi,
and I, wanted to approach, thequestion of where we are, in the
overdose crisis with a somewhatfresh lens. And I think that one
of our real goals was to say,well, look. We're at a place
where we have so many reallynovel and interesting and
effective interventions.
(11:26):
You know, we have mobilevehicles now that can provide
methadone. We have naloxone thatcan be provided through vending
machines in the mail. We havestreet outreach workers. We have
ambulances that are equippedwith buprenorphine. And we look
at those things, and we say,well, why are these great
programs not, the standard ofcare?
Why is it so hard to get theseprograms out to where they're
(11:49):
needed the most? And I think theconcept of scale became very
important to us. And we look atit almost like you would think
about the production function ofeffective interventions. So if
you wanna look at it that way,take the people, the money, the
medication, the physical space,all of the inputs that go into
getting, services to people. Andlet's ask the question of why
(12:13):
those inputs are not effectivelyworking to provide resources at
a level great enough to make asustained impact on the national
trend.
Now I think that they have beenmaking a really important
difference in the background,but it's been something that's
been very hard to feel, toperceive for the public. And I
think that that makes it justless palpable. We look at the
(12:36):
concept of scale as being sortof the complement or the mirror
image to what we talk about asaccess to care, but I think it
gets a little bit more at theroot of what's going on. So, you
know, if I could use an analogy,let's say that, this is a little
bit silly, but let's say thatyou have a sandwich truck that
you really like. Okay?
And there's something reallygreat about that sandwich, but,
(12:58):
you know, your your friends inother towns don't have access to
that same sandwich truck. Nowyou might want wonder, well, how
can we get them access to thatsandwich? And I think that's a
totally valid question. But Ithink the important flip side is
what would it take to create amodel of production so that more
people could benefit from thatdelicious sandwich? And I think
there, we have to look at allthe different factors that go
(13:20):
into making sandwiches.
Now making sandwiches is fairlyeasy compared to getting
effective interventions topeople who need them when
they're at risk of overdose. ButI think many of the same lessons
are the same. You need,investors and resources. You
need to have the right kind ofpeople with the right know how,
and you need to have regulationsthat support the scale up of
(13:43):
sandwiches or, in this case, ofeffective treatments and
services for people with, opioiduse disorder.
Rob Lott (13:50):
Wow. Well, as someone who has traveled great distances
for a really good sandwich, Iappreciate that analogy and
support the widespread scallopof really good sandwiches in our
society. And I appreciate whatthat's telling us about the sort
(14:11):
of theory behind access andexpansion of, you know,
treatment and harm reductionprograms. In just a moment, I
wanna ask you a little moreabout some of those obstacles in
practice. But first, let's takea quick break.
(15:23):
Welcome back. I'm here withDoctor. Brendan Saloner, talking
about the challenges andopportunities around scaling up
treatment and harm reductionprograms. And you you provided
us a great sort of frameworkwhen thinking about the sort of
complement between access andscale. I'm wondering if we can
(15:45):
dig in in sort of practicalterms to what those challenges
are to scale.
And I know your paper, sort ofstarts with the technical
challenges. Can you tell us alittle bit about some of those?
Brendan Saloner (15:59):
Yes. So the technical challenges are what we
enumerate as all of the thingsthat need to be, overcome in
order to basically make thisresource or program more widely
available. And we enumeratethree. Of course, there could be
more than three, but the one ofthem is program complexity. So
(16:19):
how challenging is it toactually take this, model or or
program and and replicate it ina different setting?
And sometimes it is quitecomplicated because it involves
a particular group of peoplewith a lot of know how or it
takes, many differentprofessionals working together,
like supporting a client whoneeds housing and treatment and
(16:43):
employment support and, youknow, help with, criminal legal
system involvement. So thatcould be one reason why it's
difficult to scale models. Ithink that's true in health care
in general that many effectivemodels are hard to scale, but I
think it's a particularly can beimportant care where so much
depends on unique, ingredientsin the specific environment in
(17:04):
the local context. The secondissue, which, comes as no
surprise to people who have beenlooking at this issue, is just
the financial constraints. Sofor the longest time, substance
use, services were reallymarginalized and, not given the
attention and resources thatthey needed.
They were not part of mainstreamhealth care. Now there's been a
(17:26):
movement to try to move theseinterventions and tools to the
mainstream. But the problem isthat many of the legacy,
problems from the fundingstructure, from even getting
programs to work in the worldof, insurance reimbursement,
that's been taking a long time,and we're not anywhere close to
where we need to be even when wecompare it to, say, mental
(17:47):
health care. So getting to aplace where those financial
constraints is really,overcomeable is a is a key
challenge. And, you know, wegive the example in our paper
of, federal grants that wereallocated to states, and they
were meant to be spent veryquickly.
And, actually, the states had areal hard time spending the
money because they even lackedthe financial capacity and
(18:09):
infrastructure to spend thoseresources quickly. So that seems
like sort of a paradox, but Ilook at it like if you have a
major, rain falling on wet soila lot or on dry soil rather, a
lot of that water is just gonnarun off. You need to have, a
really good root system in thesoil that can absorb resources
and use them, and I think that'sbeen a key challenge. And then
(18:30):
the final one is regulatoryburdens. So we just know that,
there's a lot of ways in whichsubstance use treatment and, in
particular, opioid use disordertreatment with medications, is
just overburdened withregulations.
Getting a a methadone programestablished takes, overcoming a
(18:50):
whole patchwork of federal andstate and often local
regulations. It's very,burdensome to the clinic, and
oftentimes, the decision is madejust to not go forward and open
the program. So overcoming thoseregulatory burdens makes scaling
really difficult. So those threetogether, we identified as sort
of the the crux of the technicalscaling problem.
Rob Lott (19:12):
Okay. Great. And now your paper also makes a
distinction between thosetechnical challenges and
sociocultural obstacles toscaling as well. Can you say a
little bit about what makes thatthem different and, you know,
sort of how we should thinkabout them in a different light?
Brendan Saloner (19:30):
Sure. So technical scaling is is how we
solve the production functionproblem. You know? How do you
actually get the inputs toproduce the output that you,
hope for? Think I the otherpiece of it is making sure that
there is a receptive and,supportive community and target
population that wants those,resources.
(19:50):
And there, I think we reallyneed to lean in and understand
why have some of these very wellintentioned programs and
interventions foundered. And forthat, we've looked at, three
primary factors. One of them isjust what we call lack of
demand. And this is the realitythat only about one in ten
people with an opioid usedisorder say that they want
(20:11):
treatment in in a survey. Ofcourse, our contention is that
many more people would beinterested in services if they
were more, let's say, friendly,accessible, you know, culturally
tailored.
So part of it is just overcomingthat, lack that mismatch problem
(20:32):
between what people want andwhat they can have. But I think
it's also important to to look alittle bit more at, the variety
of different tools that we mightneed to use to, encourage or
heavily incentivize people tomake access, make use of those,
treatment programs. I think theother one that we point to is
(20:53):
broadly community opposition toprograms. And here, the the
talking point is often aboutstigma. Stigma is so real, and
it's so important.
But we also, wanted to a alittle bit maybe encourage our
readers to think beyond juststigma at some of the reasons
why communities may be resistantto having new interventions and
(21:17):
and services. I I think thatsome communities feel
understandably prettyoverburdened by having a lot of
services located in their area.They don't feel like they've
necessarily been consulted. AndI think that that can be a real
reason why, the the programs donot, have the staying power, and
the durability that we'd hope tosee. And then finally, this is
(21:39):
sort of the elephant in theroom, but the shifting politics,
you know, at a national levelabout what is considered
legitimate or acceptable.
And, you know, here we point tothe fact that our current,
secretary of health and humanservices, Robert f Kennedy
junior, is a person himself inlong term recovery from a heroin
addiction. And, he has his ownparticular viewpoints about,
(22:02):
what acceptable recovery is. Iwould say that he is, maybe
tepid on medications andbelieves a lot in things like,
what he calls natural recovery.But the reality is that he
speaks for a fairly broadcoalition of people who want to
conceptualize recovery as morethan just medications. And I
think it's important to figureout whether there's a space to,
(22:24):
build on different kinds ofenthusiasms that people might
have for recovery to to to openup the tent a little bit.
So that's, that's a questionthat we really just try to pose
in our piece. Not that we havean answer for it, but we think
that all of these factors haveto be brought together to
understand the the social andthe cultural challenges with
(22:46):
scaling.
Rob Lott (22:48):
Great. Wow. Well, a lot of challenges there. You've
just outlined and appreciatethat that's sort of the the
first step to moving forward. Iwant to circle back to your self
identification as a vigilantoptimist, think was the term,
and wonder if maybe we can closeby thinking about maybe
(23:09):
listeners who hear all this andappreciate and sort of can
really latch on to thisframework around scale, but then
want to sort of say, you know,what do we do now?
And so I'm wondering if youcould point to areas where you
potentially see maybe the mostfruitful policy changes that
(23:30):
could be made over the next fewyears in this context to have a
tangible impact both on accessand scale.
Brendan Saloner (23:40):
Well, one of the reasons why I I would say
I'm vigilant is because I seeand perceive a lot of fatigue
around this issue. I thinkthere's a desire to sort of
close the book on this eventhough it's not a solved problem
and to say, well, you know,we're seeing numbers come down.
Let's move on. And I think thatwe do need to not succumb to a
(24:01):
kind of, a sense that either theproblem is solved or that the
problem can't be solved. I thinkthat both of those sentiments
are understandable.
And one of the points that wemake is that there actually are
examples of how the scalingproblem has been overcome.
They're just not as widelycelebrated as we think they
should be. So a good example isnaloxone access. A few years
(24:23):
ago, was very hard to getnaloxone into the hands of
people at risk of overdose. Now,from what what we can see in the
world is that many more peopleare able to get ahold of
naloxone to use it forthemselves and for their
friends, and that that is makinga real difference.
So being able to tell thosesuccess stories and having the
data to, really back up whythese programs matter is
(24:46):
important for the movement. ButI also think it's important to
start thinking a little bitdifferently about kind of the
new coalition that we would needto build to transcend, the
challenging politics around thisissue. And so in our paper, we
call for thinking a little bitmore about a kind of a cross
(25:06):
political coalition of peoplewould include those in recovery,
people from the businesscommunity, faith leaders, labor
groups, this self help movement,and many more, to come together
and try to figure out wherethere's alignment in, interests
and priorities. Because I thinkthat policymakers have tried to
sort of steer around this thesocially contentious aspects of
(25:29):
it, but that has not proven verysuccessful. And so it's time to
have a more direct engagementwith the difference different
communities that have a realstake in this issue.
And then in turn, I think thosecommunities will be more
supportive of solutions.
Rob Lott (25:46):
Well, a great note to end on. Always good advice to
take the direct approach whenall else fails. Doctor. Saloner,
thank you so much for taking thetime to chat with us today,
really appreciate it.
Brendan Saloner (25:59):
It's been great to be with you.
Rob Lott (26:01):
Thank you as well to you and Doctor. Lajesetti for
your, again, ongoing support ofthis theme issue. It's been, a
really, important project andwe're grateful for the work
you've put into it over the lastyear, year plus.
Brendan Saloner (26:18):
It's been our pleasure. Thank you so much.
Rob Lott (26:20):
And to our listeners, thanks for tuning in. If you
enjoyed this episode, please,leave a review, share it with a
friend, and, of course, tune innext week. Thanks for listening.
If you enjoyed today's episode,I hope you'll tell a friend
about a health policy.
Hello, and welcome to a health podocy. I'm your host,
(00:04):
Rob Lott. Friends, it is anexciting month here at Health
Affairs as this month's issuejust released is a full theme
issue dedicated entirely toresearch and policy insights all
(00:25):
about the ongoing opioidepidemic. It's really chock full
of path breaking empiricalresearch articles, perspectives,
and policy proposals foraddressing opioid misuse and
addiction, and which we hopewill contribute to an urgent
national dialogue aroundevidence based strategies, best
(00:46):
practices, and lessons learnedover the course of this crisis.
And so I'm delighted to speaktoday with Doctor.
Brendan Saloner, one of theauthors of the overview papers
published in this issue. A big,thoughtful, deep look at how far
we've come and where we'regoing. Doctor. Saloner is a
(01:06):
professor of health services,policy, practice at the Brown
University School of PublicHealth. He served as an external
expert advisor to this themeissue as well.
And his paper, is titled ScalingUp Treatment and Harm Reduction
Programs to Reach More PeopleWho Would Benefit. The paper's
(01:29):
other author, by the way, is theUniversity of Michigan's Doctor.
Puja Lajesedi. And we'regrateful for both Doctor.
Saloner's and Doctor.
Lajeseti's guidance in thedevelopment of this issue over
the course of a year. I can'twait to hear from Doctor.
Saloner about why this way oflooking at the opioid crisis is
(01:53):
so promising and timely. Doctor.Saloner, welcome to A Health
Odyssey.
Brendan Saloner (01:58):
Thanks for having me.
Rob Lott (02:00):
So let's just dive right in and maybe start with
some background. I think most ofour readers have a sense of what
you mean when you refer to theopioid crisis. But we've been
talking about that for quitesome time and folks might have
some trouble articulating whereit starts, where it might end,
(02:22):
and what it really encompasses.And so maybe you can just kind
of give us an equal startingpoint here. What do you mean
exactly when you refer to theopioid crisis?
Brendan Saloner (02:35):
Yeah. So the opioid crisis is one of the most
significant public healthemergencies that has ever
happened in the history of TheUnited States, and we're in the
third decade of it. So if you goback to the early two thousands,
public health experts weresounding the alarm bells about a
rise in deaths related toprescription opioids. The
(02:55):
numbers then continued to go up.And around 2010, something
important happened, which isthat, there was a shift in the
opioids that were involved inoverdose deaths, and a lot more
people were dying of deathsinvolving heroin.
So there was a shift from thelegally prescribed to the
illicit drug, economy. And thenaround 2013 to 2014, depending
(03:17):
on where you're looking at inthe country, a a new thing, came
into it came into effect, andthat was fentanyl, illicitly
manufactured fentanyl. Fentanylis a, legally prescribable, very
potent prescription opioid, butit's also a a drug that can be
readily synthesized, and it canbe made basically in clandestine
(03:39):
labs. And so fentanyl, hit thestreets, and what we saw is that
the overdose curve just hockeysticked. So we saw overdose
mortality rising and rising.
And going into the COVIDpandemic, it just rose even
further to the height years ofthe, overdose crisis around 2021
and 2022 when deaths were,peaking one hundred thousand
(04:02):
Americans a year. It's kind ofhard to believe that we have
seen those numbers. Starting in2023, numbers have started to,
come down, but we are stilllooking at, mortality numbers
that are just so far out of thenorm of what we've seen in this
country in the past and put TheUnited States, unfortunately, in
very bad shape internationally.And just one final thing, these
(04:25):
overdose numbers are sosignificant that even before the
pandemic, they were, very muchcontributing to a reversal in
American life expectancy. Sothey really are one of the
largest public health challengesour country has ever confronted.
Rob Lott (04:39):
Would you say that the worst is over? You said sort of
the numbers have come down, andthat's certainly promising. Is
it too early to tell if we're onthe right track, or do you think
questions remain as to sort ofwhether or not that those trends
are gonna continue?
Brendan Saloner (04:58):
I'm a vigilant optimist. So I I really believe
that it's possible that we canbuild on what we've seen and
continue to see reductions inthose numbers. But I also am
very, awake to the possibilitythat our overdose crisis, could
just, you know, basicallyboomerang back to where it's
(05:19):
been. Or there's new trends onthe horizon such as an increase
in deaths involving opioids incombination with stimulants like
methamphetamine, and we reallyneed to understand how to get
ahold of that problem. So thisis a very shape shifting crisis,
and I I I would caution thatwe're very far from being out of
the woods.
Rob Lott (05:39):
Okay. Fair enough. I I wanna maybe set the stage for
digging a little deeper intoyour article. One of the areas
you point to is sort of the goldstandard for opioid use disorder
treatment, which is a sort ofmedication like buprenorphine
and methadone. Can you say justhow effective are those?
(06:01):
And of the people who couldbenefit from that kind of
treatment, how many typicallyare getting that treatment?
Brendan Saloner (06:10):
It's a great question. And, you know, the way
I look at it is that thesemedications, which, more than
have the, the risk of dying ofan overdose compared to
treatment without medication,are some of the most effective
tools that we have. In fact,they're probably some of the
most effective, medications wehave for any chronic condition.
So they're they are a true kindof silver lining in this
(06:33):
situation because getting peoplestarted on medication can
dramatically improve theiroutcomes and actually save their
lives. The problem is that manypeople don't get medications,
and the reason why is that manypeople don't get treatment at
all.
So recent data would tell usthat only about one in three
people with an opioid usedisorder is getting any kind of
treatment. You know, onepositive is that we've seen over
(06:57):
the last, let's say, twentyyears, more people being willing
to get treated and being able toget treated with medications.
But, certainly, the problem isthat a lot of people who could
benefit from medicationtreatment are not getting that
treatment.
Rob Lott (07:13):
Okay. I wanna circle back to maybe some of the
underlying reasons behind that.But before we do, I wanna ask
sort of the same question to oneof the other sort of categories
that you point to in your paper,which is harm reduction
strategies. In In that case,we're talking about things like
syringe exchange and naloxone.What do we know about their
(07:35):
effectiveness, and howwidespread are are their use?
Brendan Saloner (07:39):
Yeah. We actually know quite a lot about
their effectiveness. So syringeservices programs, which is kind
of the the term of art forneedle exchange programs or
syringe exchange, programs likethat which provide people with
sterile syringes and other, youknow, drug use supplies, have a
dramatic effect in terms ofreducing the transmission of
(08:02):
HIV, hepatitis C, and otherinfectious diseases. And we've
seen, example after example ofwhen, these programs have, come
into communities and helped slowor stop the spread of those
very, devastating, diseases. Andthen also unfortunate examples
of when those, programs havebeen shut down and the the
(08:23):
diseases have come right back.
And then naloxone is a reallyimportant antidote to an opioid
involved overdose because whatit does is it essentially,
reverses the respiratorysuppression that can be so
lethal to people who are,experiencing an overdose. You
know? And then there's otherharm reduction approaches like
(08:45):
overdose, prevention sites,which just have a toehold in The
United States, And we we knowinternationally and from, some
experiences in New York Citythat that is also an important
model for keeping people safe ifthey are using drugs. So taken
together, what we call harmreduction, that package of
interventions is reallyimportant and lifesaving.
Rob Lott (09:07):
Great. And I wanna just take a moment here to sort
of maybe ask you to weigh in onthe counterargument we often
hear about some harm reductionstrategies, which is that they
perhaps encourage risky behaviorthat someone knowing that, you
know, there's naloxone theremight be more willing to engage
(09:28):
in in that risky behavior. Whatis sort of the, the response or,
the evidence basedinterpretation of that response?
Brendan Saloner (09:38):
Yeah. It's it's it's a totally fair and good
question. I think the reality isthat we've never seen evidence
to suggest that the harmreduction tools that I'm talking
about encourage or promote, druguse. The kind of folks who take
advantage of harm reduction proprograms are often people who,
have, a pretty serious opioiduse problem, and what harm
(10:00):
reduction is doing is helpingthem to stay alive another day,
and importantly, helping them tostay alive another day so that
they might be able to accesstreatment and other resources.
And we know from the researchthat doing things like engaging
with the syringe servicesprogram is often a stepping
stone toward that important goalof getting started on treatment
and ultimately moving towardabstinence.
(10:22):
So I don't think of these asbeing sort of opposing
strategies. I think they'reactually quite complementary.
Rob Lott (10:28):
Fair enough. And I'll put a little plug in for some of
the other articles in our themeissue that look at exactly those
sort of stages of kind ofconnecting people to to
treatment following initialinteraction with harm reduction
interventions. So let's talk alittle bit about your paper. It
really does revolve around thisidea or this concept of scale.
(10:51):
And I'd love it if you candescribe why you see that as
potentially a a sort of verypowerful and useful framework
for how we approach this crisisgoing forward.
Brendan Saloner (11:05):
Thanks for the question. Yeah. Puja, Lajesedi,
and I, wanted to approach, thequestion of where we are, in the
overdose crisis with a somewhatfresh lens. And I think that one
of our real goals was to say,well, look. We're at a place
where we have so many reallynovel and interesting and
effective interventions.
(11:26):
You know, we have mobilevehicles now that can provide
methadone. We have naloxone thatcan be provided through vending
machines in the mail. We havestreet outreach workers. We have
ambulances that are equippedwith buprenorphine. And we look
at those things, and we say,well, why are these great
programs not, the standard ofcare?
Why is it so hard to get theseprograms out to where they're
(11:49):
needed the most? And I think theconcept of scale became very
important to us. And we look atit almost like you would think
about the production function ofeffective interventions. So if
you wanna look at it that way,take the people, the money, the
medication, the physical space,all of the inputs that go into
getting, services to people. Andlet's ask the question of why
(12:13):
those inputs are not effectivelyworking to provide resources at
a level great enough to make asustained impact on the national
trend.
Now I think that they have beenmaking a really important
difference in the background,but it's been something that's
been very hard to feel, toperceive for the public. And I
think that that makes it justless palpable. We look at the
(12:36):
concept of scale as being sortof the complement or the mirror
image to what we talk about asaccess to care, but I think it
gets a little bit more at theroot of what's going on. So, you
know, if I could use an analogy,let's say that, this is a little
bit silly, but let's say thatyou have a sandwich truck that
you really like. Okay?
And there's something reallygreat about that sandwich, but,
(12:58):
you know, your your friends inother towns don't have access to
that same sandwich truck. Nowyou might want wonder, well, how
can we get them access to thatsandwich? And I think that's a
totally valid question. But Ithink the important flip side is
what would it take to create amodel of production so that more
people could benefit from thatdelicious sandwich? And I think
there, we have to look at allthe different factors that go
(13:20):
into making sandwiches.
Now making sandwiches is fairlyeasy compared to getting
effective interventions topeople who need them when
they're at risk of overdose. ButI think many of the same lessons
are the same. You need,investors and resources. You
need to have the right kind ofpeople with the right know how,
and you need to have regulationsthat support the scale up of
(13:43):
sandwiches or, in this case, ofeffective treatments and
services for people with, opioiduse disorder.
Rob Lott (13:50):
Wow. Well, as someone who has traveled great distances
for a really good sandwich, Iappreciate that analogy and
support the widespread scallopof really good sandwiches in our
society. And I appreciate whatthat's telling us about the sort
(14:11):
of theory behind access andexpansion of, you know,
treatment and harm reductionprograms. In just a moment, I
wanna ask you a little moreabout some of those obstacles in
practice. But first, let's takea quick break.
(15:23):
Welcome back. I'm here withDoctor. Brendan Saloner, talking
about the challenges andopportunities around scaling up
treatment and harm reductionprograms. And you you provided
us a great sort of frameworkwhen thinking about the sort of
complement between access andscale. I'm wondering if we can
(15:45):
dig in in sort of practicalterms to what those challenges
are to scale.
And I know your paper, sort ofstarts with the technical
challenges. Can you tell us alittle bit about some of those?
Brendan Saloner (15:59):
Yes. So the technical challenges are what we
enumerate as all of the thingsthat need to be, overcome in
order to basically make thisresource or program more widely
available. And we enumeratethree. Of course, there could be
more than three, but the one ofthem is program complexity. So
(16:19):
how challenging is it toactually take this, model or or
program and and replicate it ina different setting?
And sometimes it is quitecomplicated because it involves
a particular group of peoplewith a lot of know how or it
takes, many differentprofessionals working together,
like supporting a client whoneeds housing and treatment and
(16:43):
employment support and, youknow, help with, criminal legal
system involvement. So thatcould be one reason why it's
difficult to scale models. Ithink that's true in health care
in general that many effectivemodels are hard to scale, but I
think it's a particularly can beimportant care where so much
depends on unique, ingredientsin the specific environment in
(17:04):
the local context. The secondissue, which, comes as no
surprise to people who have beenlooking at this issue, is just
the financial constraints. Sofor the longest time, substance
use, services were reallymarginalized and, not given the
attention and resources thatthey needed.
They were not part of mainstreamhealth care. Now there's been a
(17:26):
movement to try to move theseinterventions and tools to the
mainstream. But the problem isthat many of the legacy,
problems from the fundingstructure, from even getting
programs to work in the worldof, insurance reimbursement,
that's been taking a long time,and we're not anywhere close to
where we need to be even when wecompare it to, say, mental
(17:47):
health care. So getting to aplace where those financial
constraints is really,overcomeable is a is a key
challenge. And, you know, wegive the example in our paper
of, federal grants that wereallocated to states, and they
were meant to be spent veryquickly.
And, actually, the states had areal hard time spending the
money because they even lackedthe financial capacity and
(18:09):
infrastructure to spend thoseresources quickly. So that seems
like sort of a paradox, but Ilook at it like if you have a
major, rain falling on wet soila lot or on dry soil rather, a
lot of that water is just gonnarun off. You need to have, a
really good root system in thesoil that can absorb resources
and use them, and I think that'sbeen a key challenge. And then
(18:30):
the final one is regulatoryburdens. So we just know that,
there's a lot of ways in whichsubstance use treatment and, in
particular, opioid use disordertreatment with medications, is
just overburdened withregulations.
Getting a a methadone programestablished takes, overcoming a
(18:50):
whole patchwork of federal andstate and often local
regulations. It's very,burdensome to the clinic, and
oftentimes, the decision is madejust to not go forward and open
the program. So overcoming thoseregulatory burdens makes scaling
really difficult. So those threetogether, we identified as sort
of the the crux of the technicalscaling problem.
Rob Lott (19:12):
Okay. Great. And now your paper also makes a
distinction between thosetechnical challenges and
sociocultural obstacles toscaling as well. Can you say a
little bit about what makes thatthem different and, you know,
sort of how we should thinkabout them in a different light?
Brendan Saloner (19:30):
Sure. So technical scaling is is how we
solve the production functionproblem. You know? How do you
actually get the inputs toproduce the output that you,
hope for? Think I the otherpiece of it is making sure that
there is a receptive and,supportive community and target
population that wants those,resources.
(19:50):
And there, I think we reallyneed to lean in and understand
why have some of these very wellintentioned programs and
interventions foundered. And forthat, we've looked at, three
primary factors. One of them isjust what we call lack of
demand. And this is the realitythat only about one in ten
people with an opioid usedisorder say that they want
(20:11):
treatment in in a survey. Ofcourse, our contention is that
many more people would beinterested in services if they
were more, let's say, friendly,accessible, you know, culturally
tailored.
So part of it is just overcomingthat, lack that mismatch problem
(20:32):
between what people want andwhat they can have. But I think
it's also important to to look alittle bit more at, the variety
of different tools that we mightneed to use to, encourage or
heavily incentivize people tomake access, make use of those,
treatment programs. I think theother one that we point to is
(20:53):
broadly community opposition toprograms. And here, the the
talking point is often aboutstigma. Stigma is so real, and
it's so important.
But we also, wanted to a alittle bit maybe encourage our
readers to think beyond juststigma at some of the reasons
why communities may be resistantto having new interventions and
(21:17):
and services. I I think thatsome communities feel
understandably prettyoverburdened by having a lot of
services located in their area.They don't feel like they've
necessarily been consulted. AndI think that that can be a real
reason why, the the programs donot, have the staying power, and
the durability that we'd hope tosee. And then finally, this is
(21:39):
sort of the elephant in theroom, but the shifting politics,
you know, at a national levelabout what is considered
legitimate or acceptable.
And, you know, here we point tothe fact that our current,
secretary of health and humanservices, Robert f Kennedy
junior, is a person himself inlong term recovery from a heroin
addiction. And, he has his ownparticular viewpoints about,
(22:02):
what acceptable recovery is. Iwould say that he is, maybe
tepid on medications andbelieves a lot in things like,
what he calls natural recovery.But the reality is that he
speaks for a fairly broadcoalition of people who want to
conceptualize recovery as morethan just medications. And I
think it's important to figureout whether there's a space to,
(22:24):
build on different kinds ofenthusiasms that people might
have for recovery to to to openup the tent a little bit.
So that's, that's a questionthat we really just try to pose
in our piece. Not that we havean answer for it, but we think
that all of these factors haveto be brought together to
understand the the social andthe cultural challenges with
(22:46):
scaling.
Rob Lott (22:48):
Great. Wow. Well, a lot of challenges there. You've
just outlined and appreciatethat that's sort of the the
first step to moving forward. Iwant to circle back to your self
identification as a vigilantoptimist, think was the term,
and wonder if maybe we can closeby thinking about maybe
(23:09):
listeners who hear all this andappreciate and sort of can
really latch on to thisframework around scale, but then
want to sort of say, you know,what do we do now?
And so I'm wondering if youcould point to areas where you
potentially see maybe the mostfruitful policy changes that
(23:30):
could be made over the next fewyears in this context to have a
tangible impact both on accessand scale.
Brendan Saloner (23:40):
Well, one of the reasons why I I would say
I'm vigilant is because I seeand perceive a lot of fatigue
around this issue. I thinkthere's a desire to sort of
close the book on this eventhough it's not a solved problem
and to say, well, you know,we're seeing numbers come down.
Let's move on. And I think thatwe do need to not succumb to a
(24:01):
kind of, a sense that either theproblem is solved or that the
problem can't be solved. I thinkthat both of those sentiments
are understandable.
And one of the points that wemake is that there actually are
examples of how the scalingproblem has been overcome.
They're just not as widelycelebrated as we think they
should be. So a good example isnaloxone access. A few years
(24:23):
ago, was very hard to getnaloxone into the hands of
people at risk of overdose. Now,from what what we can see in the
world is that many more peopleare able to get ahold of
naloxone to use it forthemselves and for their
friends, and that that is makinga real difference.
So being able to tell thosesuccess stories and having the
data to, really back up whythese programs matter is
(24:46):
important for the movement. ButI also think it's important to
start thinking a little bitdifferently about kind of the
new coalition that we would needto build to transcend, the
challenging politics around thisissue. And so in our paper, we
call for thinking a little bitmore about a kind of a cross
(25:06):
political coalition of peoplewould include those in recovery,
people from the businesscommunity, faith leaders, labor
groups, this self help movement,and many more, to come together
and try to figure out wherethere's alignment in, interests
and priorities. Because I thinkthat policymakers have tried to
sort of steer around this thesocially contentious aspects of
(25:29):
it, but that has not proven verysuccessful. And so it's time to
have a more direct engagementwith the difference different
communities that have a realstake in this issue.
And then in turn, I think thosecommunities will be more
supportive of solutions.
Rob Lott (25:46):
Well, a great note to end on. Always good advice to
take the direct approach whenall else fails. Doctor. Saloner,
thank you so much for taking thetime to chat with us today,
really appreciate it.
Brendan Saloner (25:59):
It's been great to be with you.
Rob Lott (26:01):
Thank you as well to you and Doctor. Lajesetti for
your, again, ongoing support ofthis theme issue. It's been, a
really, important project andwe're grateful for the work
you've put into it over the lastyear, year plus.
Brendan Saloner (26:18):
It's been our pleasure. Thank you so much.
Rob Lott (26:20):
And to our listeners, thanks for tuning in. If you
enjoyed this episode, please,leave a review, share it with a
friend, and, of course, tune innext week. Thanks for listening.
If you enjoyed today's episode,I hope you'll tell a friend
about a health policy.
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