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Despite a recent decline in drug overdose deaths in the U.S., fatalities involving multiple substances—known as polysubstance overdoses—have been on the rise.

In 2022, more than half of the 69,893 people in the U.S. who died from a synthetic opioid overdose such as fentanyl also had a stimulant in their system, while alcohol-involved opioid overdose deaths increased by 40.8% between 2019 and 2020. New substances are increasingly in the drug supply, such as the animal tranquilizers xylazine and medetomidine. Across 20 states and the District of Columbia, the percentage of fentanyl-involved deaths where xylazine was present increased by 276% from January 2019 to June 2022. And this trend has been creeping up for some time—between 1999 and 2018, youth overdose deaths involving multiple substances rose faster than those involving opioids alone.

These deaths underscore the need for high-quality treatment for people with substance use disorders across all age groups. To help, policymakers can take the following steps.

1. Reduce barriers to FDA-approved medications

Even though medications for opioid use disorder (OUD) are the most effective treatment and reduce mortality, the three FDA-approved drugs—methadone, buprenorphine, and naltrexone—are not widely prescribed. The same is true of the FDA-approved medications for alcohol use disorder (AUD)—which include acamprosate, naltrexone, and disulfiram—despite their demonstrated effectiveness in reducing unhealthy alcohol use. In fact, in 2024, fewer than 20% of the 4.8 million patients with OUD and just 2.5% of the nearly 28 million people with AUD received any medication.

To increase access to medications, policymakers should remove any unnecessary barriers for prescribers and patients. For example, state regulations for buprenorphine and methadone should not be more stringent than federal requirements. States can accomplish this by removing counseling requirements to receive these medications, not requiring daily visits to receive methadone, and prohibiting providers from terminating care if patients continue to use opioids or other substances. State agencies can also prohibit Medicaid plans from imposing prior authorization on medications for substance use disorders, and state legislatures can prohibit private insurers from doing the same.

Poliymakers can also require Medicaid managed care organizations to cover all approved medications for AUD. While managed care plans cover the majority of Medicaid enrollees, less than half of the plans cover all of the FDA-approved drugs for AUD.

In addition, policymakers can ensure that providers are reimbursed appropriately for providing patient care. For example, a payment model used in Massachusetts uses a mix of block grants and Medicaid funds to fund office-based addiction treatment settings. And Michigan’s health home model pays providers a fixed rate per month to cover services to patients with a diagnosed alcohol, stimulant, or opioid use disorder.

2. Implement contingency management

There are no FDA-approved medications for stimulant use disorder, but contingency management—which the American Society of Addiction Medicine endorses as the standard of careis an effective, evidenced-based treatment that provides patients with monetary rewards for positive behavior changes, usually verified by negative urine drug screens. In fact, when used together, contingency management and medications for OUD are effective in improving treatment outcomes among people with co-occurring OUD and stimulant use. Although the Veterans Health Administration has used contingency management since 2011, the treatment has not been widely used in states.

States can fund contingency management treatment in several ways. For example, although Medicaid cannot traditionally be used to provide incentives, California, Montana, and Washington have used Section 1115 Medicaid demonstration waivers—which permit states to use Medicaid funds in ways that are otherwise not allowed—to pay for services. States have also used State Opioid Response Grants from the Substance Abuse and Mental Health Services Administration, as well as opioid settlement funds, to pay for treatment.

3. Increase the use of lifesaving strategies

Lifesaving strategies, including tools for overdose prevention, aim to protect people who use drugs from negative outcomes and connect them to other health resources. Increasing access to naloxone, the opioid overdose reversal drug, is an essential strategy that states should adopt. Policymakers can do so by supporting community-based organizations that offer programs such as bulk ordering of naloxone, training for first responders to administer and carry naloxone, and providing naloxone to patients leaving hospitals, prisons and jails, and all treatment settings. Establishing policies allowing naloxone in schools can also help curb polysubstance overdoses in youth populations.   

States should also expand access to drug checking equipment—which can include test strips that identify the presence of a single drug or advanced equipment that detects numerous substances—and remove legal barriers to their use and distribution. Drug checking equipment laws and regulations vary by state, and states can legalize the possession, distribution, and sale of all types of this equipment. They can also make fentanyl and xylazine test strips available to community organizations, first responders, and emergency departments through opioid settlement funds, state general funds, federal dollars, or a combination of these funding sources.

Policymakers should also tailor policies to help populations most at risk of overdose. For example, lesbian, gay, and bisexual individuals have been shown to use a higher number of substances compared with heterosexual adults. American Indian/Alaska Native and Black Americans are now more likely to experience an overdose death compared with White Americans. And people from rural communities often face barriers to care, such as long travel distances and limited provider networks.

Reducing overdose deaths and addressing polysubstance use remain bipartisan priorities throughout the country. Expanding access to proven treatments and adopting lifesaving strategies for substance use disorders can save lives.  

Rob Siebers works on The Pew Charitable Trusts’ substance use prevention and treatment initiative. 

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