FACING ADDICTION 

IN AMERICA

The Surgeon General’s

Spotlight on Opioids

U.S. Department of Health & Human Services
SUGGESTED CITATION

U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, 

Facing Addiction in America: The Surgeon General’s Spotlight on Opioids.

Washington, DC: HHS, September 2018.

FOR MORE INFORMATION

For more information about the Surgeon General’s Spotlight on Opioids or to download copies, 

visit Addiction.SurgeonGeneral.gov.

Use of trade names and specific programs are for identification only and do not constitute 

endorsement by the U.S. Department of Health and Human Services.

Facing Addiction in America

The Surgeon General’s 

Spotlight on Opioids
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 1

Message from the Secretary, 

U.S. Department of Health and Human Services

T

he opioid misuse and overdose crisis touches everyone in the United States. 

In 2016, we lost more than 115 Americans to opioid overdose deaths each 

day, devastating families and communities across the country. Preliminary 

numbers in 2017 show that this number continues to increase with more than 131 

opioid overdose deaths each day. The effects of the opioid crisis are cumulative 

and costly for our society—an estimated $504 billion a year in 2015—placing 

burdens on families, workplaces, the health care system, states, and communities. 

Addressing the opioid crisis is a priority for this Administration, and the U.S. 

Department of Health and Human Services (HHS) is leading the public health-based approach to 

understanding the problem and taking action to fight it. HHS is tackling this crisis through our 

comprehensive five-point strategy focused on improving access to prevention, treatment, and 

recovery services; promoting use of overdose reversing drugs; strengthening our understanding 

of the epidemic through better public health surveillance; providing support for cutting-edge 

research on pain and addiction; and advancing better practices for pain management. Our efforts are 

collaborative—with all federal agencies and state and local partners working together to equip health 

care providers, communities, policymakers, law enforcement, and others with the information and 

tools they need to stem this growing epidemic. 

HHS also brought a new level of awareness and commitment to the cause by declaring the opioid 

crisis a nationwide Public Health Emergency on October 26, 2017. Since 2017, HHS has disbursed more 

than $2 billion in grants to fight the opioid crisis, more than any previous year. 

The Spotlight on Opioids document is another important step in our efforts to address the issue. This 

document assembles opioid-related information from Facing Addiction in America: The Surgeon 

General’s Report on Alcohol, Drugs, and Health in one document and provides updated data on 

the prevalence of substance use, opioid misuse, opioid use disorders, opioid overdoses, and related 

harms. As the Secretary of the Department of Health and Human Services, I encourage you to use the 

information and findings in this document and join us in taking action on this vital issue and making 

our communities healthier and stronger.

ALEX M. AZAR II

Secretary 

U.S. Department of Health and Human Services
PAGE 2 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Foreword from the Assistant Secretary for 

Mental Health and Substance Use

A

fter many years combating the opioid epidemic on the front lines of addiction 

psychiatry, I returned to the Substance Abuse and Mental Health Services 

Administration (SAMHSA) to do everything possible to ensure that American 

families and communities do not continue to lose their loved ones to opioids. 

Now is the time to work together and apply what we know to end this epidemic 

once and for all. Medication-assisted treatment (MAT) combined with psychosocial 

therapies and community-based recovery supports is the gold standard for 

 treating opioid addiction. 

There is strong scientific evidence that this combination of therapeutic interventions is life-saving 

and can enable people to recover to healthy lives. SAMHSA is joining forces with agencies across HHS 

and the federal government to increase access to these evidence-based interventions—especially in 

communities hardest hit by the opioid crisis. We are (1) working with states and their communities 

to increase access to prevention, treatment and recovery support services for opioid use disorder; (2) 

supporting providers’ efforts to offer specialized treatment to pregnant and postpartum women with 

opioid use disorder and their opioid-exposed infants; (3) promoting early intervention and treatment 

as healthier alternatives to detaining people with opioid addiction in our criminal justice systems; (4) 

and facilitating the expansion of telemedicine to deliver MAT to people in need in rural communities 

and to enhance rural providers’ skills. 

To help remove the societal stigma for those seeking addiction treatment, we have implemented 

new changes to the federal rules governing confidentiality and disclosures of substance use disorder 

patient records. Our workforce efforts include support for a variety of trainings and resources to 

prevent over prescribing and diversion of prescription medications and initiatives to increase the 

number of qualified health care providers who can offer treatment for opioid use disorder. In the 

crucial area of overdose prevention, we are increasing the distribution of naloxone and expanding 

training to first responders, prescribers, patients, employers, and family members on how to 

administer this live-saving antidote. 

With the Office of the Surgeon General, SAMHSA has produced the Spotlight on Opioids—a document 

that offers practical information and guidance that individuals and systems can use to take action. I 

urge you to use it as a resource as you consider what you can do to help end this crisis and save lives. 

Inside and outside of government, at the national, state and local level, and in every community across 

this nation, we must join forces to turn the tide against the opioid crisis. 

ELINORE F. McCANCE-KATZ, M.D., Ph.D.

Assistant Secretary for Mental Health and Substance Use

Substance Abuse and Mental Health Services Administration
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 3

Preface from the Surgeon General, 

U.S. Department of Health and Human Services 

My family and I are among the millions of Americans affected by substance 

use disorder. My younger brother has struggled with this disease, 

which started with untreated depression leading to opioid pain reliever 

misuse. Like many with co-occurring mental health and substance use disorder 

conditions, my brother has cycled in and out of incarceration. I tell my family’s 

story because far too many are facing the same worries for their loved ones. We 

all ask the same question: How can I contribute to ending the opioid crisis and 

helping those suffering with addiction? 

The first step is understanding that opioid use disorder is a chronic but treatable brain disease, and 

not a moral failing or character flaw. Like many other chronic medical conditions, opioid use disorder 

is both treatable, and in many cases, preventable. It is also a disease that must be addressed with 

compassion. Unfortunately, stigma has prevented many sufferers and their families from speaking 

about their struggles and from seeking help. The way we as a society view and address opioid use 

disorder must change—individual lives and the health of our nation depend on it. 

I believe that the best way to address the opioid crisis is to work towards achieving better health 

through better partnerships. Health advocates must involve businesses and law enforcement 

organizations—they have witnessed the negative effects of opioids and have a strong interest in 

helping end the epidemic. Educators and the faith-based community have unique touchpoints 

and resources that can be brought to bare for prevention and treatment efforts. We must listen to 

all communities affected by the opioid crisis—speaking with them versus at them, leveraging their 

strengths, and addressing their priorities. Through partnerships, we can address the overall health 

inequities and determinants of health that exist where we live, learn, work, and play. Together we 

can reduce the risks of opioid misuse, opioid use disorder, and related health consequences such as 

overdose and infectious disease transmission. 

As Surgeon General, I care about the health and well-being of all Americans. My office worked with 

SAMHSA to create the Spotlight on Opioids so that people with a broad range of backgrounds can 

reference opioid-related information from Facing Addiction in America: The Surgeon General’s 

Report on Alcohol, Drugs, and Health in one document. I hope that all readers use this document to 

determine specific actions they can take to mitigate the opioid crisis. 

JEROME M. ADAMS, M.D., M.P.H.

Vice Admiral, U.S. Public Health Service

Surgeon General
PAGE 4 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Introduction

and Overview

A

ll across the United States, individuals, 

families, communities, and health care 

providers are struggling to cope with the 

impacts of the opioid crisis. Opioid misuse and 

opioid use disorders have devastating effects. 

As we see all too often in cases of overdose 

deaths, lives end prematurely and tragically. 

Other serious consequences include neonatal 

abstinence syndrome and transmission of 

infectious diseases such as HIV and viral 

hepatitis, as well as compromised physical and 

mental health. Social consequences include loss 

of productivity, increased crime and violence, 

neglect of children, and expanded health care 

costs. However, it must be noted that there are 

certain populations who rely on prescription 

opioids and are taking them responsibly under 

the care of a trusted provider. These include, 

but are not limited to: individuals in hospice 

care; individuals who are undergoing cancer 

treatment; people who recently experienced 

a traumatic injury; or those with long-term 

disability and chronic pain.

In November 2016, the Office of the Surgeon 

General released Facing Addiction in America: 

The Surgeon General’s Report on Alcohol, Drugs, 

and Health (the Surgeon General’s Report).1

This landmark publication provided the latest 

research-based information on substance 

misuse, substance use disorders, and their health 

impacts for the general public. It provided 

suggestions and recommendations for action 

that everyone can take to prevent substance 

misuse and reduce its consequences. The 

Surgeon General’s Report described a public 

health–based approach to substance misuse 

and substance use disorders. A public health 

approach recognizes that substance misuse 

and its consequences are the result of multiple 

interacting factors (individual, environmental, 

and societal) and requires that diverse 

stakeholders work in a coordinated way to 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 5

Opioid: Natural or synthetic chemicals that interact 

with opioid receptors on nerve cells in the body 

and brain, and reduce the intensity of pain signals 

and feelings of pain. This class of drugs that include 

the illegal drug heroin, synthetic opioids such as 

fentanyl, and pain medications available legally 

by prescription, such as oxycodone, hydrocodone, 

codeine, morphine, and many others. Opioid pain 

medications are generally safe when taken for a short 

time and as prescribed by a health care professional, 

but because they produce euphoria in addition to 

pain relief, they can be misused. 

Substance Misuse: The use of any substance in 

a manner, situation, amount, or frequency that can 

cause harm to users or to those around them.

Prescription opioid (or opioid pain reliever) 

misuse: Use of an opioid pain reliever in any way 

not directed by a health care professional. 

Substance Use Disorder: Occurs when the 

recurrent use of alcohol and/or drugs causes clinically 

and functionally significant impairment, such as 

health problems, disability, and failure to meet major 

responsibilities at work, school, or home. According 

to the Diagnostic and Statistical Manual of Mental 

Disorders (DSM)-5, a diagnosis of substance use 

disorder is based on evidence of impaired control, 

social impairment, risky use, and pharmacological 

criteria.

Opioid Use Disorder: A disorder characterized 

by loss of control of opioid use, risky opioid 

use, impaired social functioning, tolerance, and 

withdrawal.

address substance misuse across the community. KEY TERMS

The Office of the Surgeon General and the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) developed this 

Spotlight on Opioids from the Surgeon General’s 

Report, in order to provide opioid-related 

information in one, easy-to-read document. 

Although Spotlight on Opioids does not include 

new scientific information, it provides the latest 

data on prevalence of substance use, opioid 

misuse, opioid use disorders, opioid overdoses, 

and related harms. This document sometimes 

discusses substance use disorders rather than 

opioid use disorder specifically. As indicated in 

the section “The Neurobiology of Substance 

Use, Misuse, and Addiction,” opioids and other 

substances have similar effects on the brain’s 

reward pathways. Additionally, it is common 

for people who misuse opioids to misuse other 

substances or to have multiple substance use 

disorders or co-occurring mental disorders. 

Therefore, the general principles related to 

substance use disorders often apply to opioid 

use disorder.
PAGE 6 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Opioids: 

The Current 

Landscape

To obtain a copy of Facing Addiction in 

America: The Surgeon General’s Report 

on Alcohol, Drugs, and Health, please 

visit https://addiction.surgeongeneral.

gov. Please refer to that Report for 

more in-depth discussion of the topics 

presented here.

Historically, opioids have been used as 

pain relievers. However, opioid misuse 

presents serious risks, including overdose 

and opioid use disorder. The use of illegal 

opioids such as heroin—a highly addictive 

drug that has no accepted medical use in the 

United States—and the misuse of prescription 

opioid pain relievers can have serious negative 

health effects. Fentanyl is a synthetic opioid 

medication that is used for severe pain 

management and is considerably more potent 

than heroin. Sometimes, prescription fentanyl 

is diverted for illicit purposes. But fentanyl and 

pharmacologically similar synthetic opioids are 

also illicitly manufactured and smuggled into 

the United States.2

PREVALENCE OF OPIOID MISUSE 

AND OPIOID USE DISORDER 

Based on data from SAMHSA’s National Survey on 

Drug Use and Health, in 2017, 11.1 million people 

aged 12 and older had misused prescription pain 

relievers in the past year.6 Repeated use of 

opioids greatly increases the risk of developing 

an opioid use disorder. 

In 2017, about 1.7 million people aged 12 and 

older had a prescription pain reliever use disorder 

in the past year. In 2017, 953,000 people received 

treatment for the misuse of opioid pain relievers.6

Heroin use is also a concern. In 2017, about 

886,000 people aged 12 or older reported having 

used heroin in the past year.6 During that same 

time period, about 652,000 people aged 12 or 

These illicitly made synthetic opioids are driving 

the rapid increase in opioid overdose deaths in 

recent years.3-5 Illicitly made fentanyl and other 

pharmacologically similar opioids are often mixed 

with illicit substances such as heroin. They can 

also be made into counterfeit prescription 

opioids or sedatives and sold on the street. 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 7

older were estimated to have a heroin use 

disorder. 

Specialty treatment is defined as receiving 

treatment at a substance use rehabilitation facility 

(inpatient or outpatient), hospital (inpatient 

services only), and/or mental health center. Only 

54.9 percent of those aged 12 and older with 

heroin use disorder received treatment for illicit 

drug use at a specialty treatment facility.6 Only 

28.6 percent of those aged 12 and older with an 

opioid use disorder in the past year received 

treatment for illicit drug use at a specialty 

treatment facility.6

OPIOID OVERDOSE DEATHS 

Opioids can depress critical areas in the 

brain that control breathing, heart rate, and 

body temperature and cause them to stop 

functioning. Opioids were involved in 42,249 

deaths in 2016—more than 115 deaths every 

day, on average. According to preliminary 

estimates from the Centers for Disease Control 

and Prevention (CDC), 47,872 people died from 

an opioid overdose in 2017. 7 Opioid overdose 

deaths were five times higher in 2016 than in 

1999. The majority of these opioid overdose 

deaths were unintentional.3,4

The opioid crisis is being driven by three trends: 

(1) an increase of prescription opioid overdose 

deaths since 1999; (2) the four-fold increase in 

heroin overdoses since 2010; and (3) the tripling 

death rate for synthetic opioids like fentanyl 

since 2013. As a result, the number of people 

dying from opioid overdoses has increased 

dramatically.8 In fact, the average life expectancy 

in the United States decreased for the second 

year in a row in 2016, falling by about 1.2 

months, in part due to opioid overdose deaths.9

NEONATAL ABSTINENCE 

SYNDROME (NAS) 

Newborns may experience NAS, a withdrawal 

syndrome following exposure to drugs while 

in the mother’s womb.10 NAS, also known as 

neonatal opioid withdrawal syndrome, is an 

expected and treatable condition following 

repeated substance exposure in utero, which 

may have long-term health consequences for 

the infant.11 NAS signs include neurological 

excitability, gastrointestinal dysfunction, and 

autonomic dysfunction.12 Newborns with NAS 

are more likely than other babies to have low 

birthweight and respiratory complications. The 

incidence of NAS has increased dramatically 

in the last decade along with increased opioid 

misuse.13 These data suggest the need to 

develop and test measures to reduce the 

impacts of prenatal exposure to opioids (e.g., 

skin to skin care, and rooming in). Healthcare 

providers should discuss possible risks 

associated with opioid use during pregnancy 

to both the mother and fetus.14 Given that 

prescription opioid pain relievers are at times 

deemed clinically appropriate during pregnancy 

and there may be medical consequences 

when an individual with an opioid use 

disorder discontinues opioids abruptly, the 

CDC Guideline for Prescribing Opioids for 

Chronic Pain includes information specific to 

implications for pregnant women in particular.15 

SAMHSA’s Clinical Guidance for Treating 

Pregnant and Parenting Women With Opioid 

Use Disorder and Their Infants also provides 

guidance for the management of pregnant and 

parenting women with opioid use disorder and 

their infants. 

INFECTIOUS DISEASE 

TRANSMISSION 

Injection drug use (including injection of 

prescription opioid medications and illicit 

opioids such as heroin) is integrally linked 
PAGE 8 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

for full clinical assessment and comprehensive 

treatment services that are matched to an 

individual’s needs. Prevention, screening, 

early intervention, and treatment—including 

medication-assisted treatment, which combines 

medication with behavioral therapies and 

psychosocial supports—are discussed in this 

report.

ACCESS TO TREATMENT

Despite the fact that effective treatments for 

opioid use disorder do exist, only about one 

in four people (28.6 percent) with this disorder 

received specialty treatment for illicit drug 

use in the past year.6 This “treatment gap” is 

not unique to opioid use disorder. Only about 

12.2 percent of adults who need treatment for 

a substance use disorder receive any type of 

specialty treatment.6,21 Additionally, 45.5 percent 

of people with a substance use disorder also 

have a mental disorder, yet only about half (51.0 

percent) receive treatment for either disorder 

and only a small minority receive treatment for 

both.21

Many factors contribute to this “treatment 

gap.” For far too long, too many in our country 

have viewed addiction as a moral failing rather 

than a disease. This stigma has made people 

with substance use disorders less likely to seek 

help. Other contributing factors include the 

inability to access or afford care and a lack of 

screening for substance misuse and substance 

use disorders in general health care settings. 

Furthermore, 39.7 percent of individuals who 

know they have an alcohol or drug problem 

are not ready to stop using. Others simply feel 

they do not have a problem, do not have a need 

for treatment, or believe they can handle the 

problem without treatment.6

Integrating substance use disorder services, 

as well as screening for early risk factors for 

with transmission of HIV, viral hepatitis, other 

blood-borne diseases (e.g., endocarditis, a 

life threatening heart valve infection), and 

bacterial infections, including antibiotic 

resistant organisms (e.g., Methicillinresistant Staphylococcus aureus or MRSA).16 

Approximately, one in 10 new HIV diagnoses 

occur among people who inject drugs. The CDC 

has observed a steady decline in HIV diagnoses 

attributable to injection drug use since the mid1990s, but progress may be slowing.17 Reported 

rates of acute hepatitis C virus (HCV) infection 

have also increased significantly.18 The opioid 

crisis is helping to fuel these increases as well as 

rising health care costs associated with treating 

these conditions.

IMPORTANCE OF PREVENTION, 

SCREENING, EARLY INTERVENTION, 

AND TREATMENT 

The risk of death and other significant 

consequences of opioid misuse highlight the 

importance of prevention, screening, and 

treatment for substance use disorders. Evidencebased interventions to prevent substance use, 

misuse and addiction target risk factors and 

enhance protective factors. Such interventions 

need to begin early in life to delay or prevent 

initiation of substance use and continue 

throughout the lifespan. For example, childhood 

trauma like adverse childhood experiences 

(ACEs) have been repeatedly linked to substance 

misuse.19, 20 Primary prevention can also begin 

in the healthcare setting with prescribers 

using effective strategies to reduce overdoses 

involving prescription opioids such as safe 

prescribing practices. Currently, few primary 

care providers screen for or treat substance use 

disorders. Additionally, it is common for people 

who misuse opioids to misuse other substances 

or to have multiple substance use disorders, 

childhood trauma, or co-occurring physical 

and mental disorders. This highlights the need 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 9

substance use disorders, into mainstream health 

care and ensuring all Americans have access to 

those services has the power to substantially 

improve outcomes for individuals and reverse 

the opioid crisis. These actions may reduce 

overall health care costs for individuals and their 

families, reduce health disparities among highrisk groups, and reduce costs for health care 

systems and communities.

Despite the promise that integration offers for 

the prevention and treatment of substance use 

disorders, challenges remain. Specifically: 

• The substance use disorder treatment 

system is underprepared to support care 

coordination; 

• The primary care system has been slow 

to implement medication-assisted 

treatment (MAT) as well as prevention, early 

identification, and other evidence-based 

recommendations; 

• The existing health care workforce is already 

understaffed and often lacks the necessary 

training and education to address substance 

use disorders; and 

• The need to protect patient confidentiality 

creates hurdles for sharing of information.

Additionally, some ingrained attitudes must 

change. For example, as is discussed later in this 

report, the use of some medications for opioid 

use disorder (methadone and buprenorphine) 

remains surrounded by misconceptions and 

prejudices that have hindered their delivery. 

However, the federal government is currently 

collaborating with key stakeholders to address 

the challenges discussed above. HHS has invested 

$2 billion in opioid-specific funding for states, 

which encompasses the State Targeted Response 

(STR) to the Opioid Crisis and the State Opioid 

Response (SOR) grant programs administered by 

SAMHSA to support a comprehensive array of 

prevention, treatment, and recovery services. This 

includes funding to expand provider capacity 

and increase patient access to evidence-based 

treatment for opioid use disorder.

The Health Resources and Services 

Administration (HRSA) has invested funds to 

support community health centers in 

implementing and advancing evidence-based 

strategies, including expanded MAT services, 

expansion of mental health and substance use 

disorder services focusing on treatment, 

prevention and awareness of opioid misuse, and 

the integration of substance use disorder services 

into primary care. Since January 2017, over 200 

health centers have been engaged in a HRSAfunded technical assistance opportunity through 

the Opioid Addiction Treatment Extension for 

Community Healthcare Outcomes project, a 

virtual, national technical assistance effort to 

enhance health center capacity to treat substance 

misuse. HRSA is also providing funds to train the 

primary care and behavioral health workforce in 

opioid addiction. 

The National Institutes of Health (NIH), in 

collaboration with other federal agencies, is 

developing a study as part of the Helping to End 

Addiction Long-term (HEAL) Initiative called the 

HEALing Communities Study. This 

comprehensive study will test the 

implementation of an integrated set of addiction 

prevention and treatment approaches across 

healthcare, behavioral health, justice systems, 

state and local governments, and community 

organizations to prevent and treat opioid misuse 

and opioid use disorder. 

The Agency for Healthcare Research and Quality 

(AHRQ) in investing in research grants to discover 

how to best support primary care practices and 

rural communities in delivering MAT for opioid 

use disorders. AHRQ has release a report that 
PAGE 10 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

in the long and often difficult task of maintaining 

recovery after treatment. Transformations in the 

health care landscape are supporting integration 

of substance use disorder treatment with general 

health care in ways that will better address the 

needs of the millions of people with substance 

use disorders. Technology-based interventions 

offer many potential advantages and can 

increase access to care in underserved areas and 

settings. Use of health information technology 

is expanding to support greater communication 

and collaboration among providers, fostering 

better-integrated and collaborative care, while 

at the same time protecting patient privacy. 

Together, these changes are leading to a new 

landscape of care for alcohol and drug misuse 

problems in America, and to new hope for 

millions of people. 

The over-prescription of powerful opioid pain 

relievers was associated with a rapid escalation 

of use and misuse of these substances. The good 

news is that a decrease in the amount of opioid 

pain relievers prescribed has been reported.20

However, the amount of opioids prescribed in 

2015 remained approximately three times higher 

than in 1999 and varied substantially across the 

country.23

Progress has been made regarding the 

prescribing of buprenorphine and naltrexoneextended release (XR)—medications that, with 

psychosocial supports, are part of evidencebased medication-assisted treatment for 

opioid use disorder. Individuals receiving 

buprenorphine with counseling have 

significantly lower total health care costs than 

individuals receiving little or no treatment for 

their opioid use disorder ($13,578 compared to 

$31,055).24 Buprenorphine may be prescribed by 

qualifying health care professionals who have 

met the statutory requirements for a waiver in 

accordance with the Controlled Substances Act 

includes links and descriptions to nearly 250 tools

and resources available for health care 

professionals, patients, and communities to help 

implement MAT in primary care settings.22

The Centers for Medicare and Medicaid Services 

(CMS) is now offering a more flexible, streamlined 

approach to accelerate states’ ability to respond 

to the national opioid crisis through section 1115 

demonstrations announced in November 2017. 

The Medicare program is focused on prescription 

opioid safety, access to MAT, and non-opioid 

alternatives for pain management. 

The HHS Center for Faith-Based and 

Neighborhood Partnerships created the Opioid 

Epidemic Practical Toolkitto equip local 

communities—lay persons, faith groups, nonprofits, and health care providers—with practical 

steps to bring hope and healing to the millions 

suffering the consequences of opioid misuse.

REASONS FOR OPTIMISM

Despite the challenges, this is a time of great 

hope and opportunity. Research on alcohol and 

drug use and addiction has led to an increase 

of knowledge and to one clear conclusion: 

Addiction to alcohol or drugs is a chronic but 

treatable brain disease that requires medical 

intervention, not moral judgment. Additionally, 

policies and programs have been developed 

that are effective in preventing alcohol and 

drug misuse, and reducing its negative effects. 

Addressing risk and protective factors for 

individuals and communities can help prevent 

opioid misuse. Evidence-based treatments—

both medications and behavioral therapies—can 

save lives and restore people’s health, wellbeing, and functioning, as well as reduce the 

spread of infectious diseases and lessen other 

consequences. Support services such as mutual 

aid groups, recovery housing, and recovery 

coaches are increasingly available to help people 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 11

(21 U.S.C. 823(g)(2)(D)(iii)).25 Naltrexone-XR can be

precsribed by any licensed clinician who has 

prescribing authority. Although there is no 

limit to the number of patients a prescriber can 

treat with naltrexone-XR, qualifying physicians 

can request to treat up to 275 patients with 

buprenorphine, subject to renewal and 

reporting requirements. Raising the number 

of patients that qualifying physicians can treat 

with buprenorphine (“the cap”) may increase 

access to this medication, though this may not 

be the primary barrier to accessing treatment. 

Broader efforts to ensure appropriate training 

for more health care professionals continue. 

Nurse practitioners and physician assistants can 

prescribe naltrexone-XR without limitations and, 

if they qualify, can also prescribe buprenorphine. 

Currently, 44,968 physicians and 8,825 nurse 

practitioners and physician assistants, are 

approved to prescribe buprenorphine (as of 

September 8, 2018). 
PAGE 12 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Neurobiology 

of Substance 

Use, Misuse, 

and Addiction

Figure 1: The Three Stages of the 

Addiction Cycle and the Brain 

Regions Associated With Them

Relapse: The return to drug use after a significant 

period of abstinence.

KEY TERMS

S

evere substance use disorders (commonly 

called addictions) were once viewed largely 

as a moral failing or character flaw, but are 

now understood to be chronic diseases that are 

subject to relapse, and characterized by clinically 

significant impariments in health, social function, 

and voluntary control over substance use.26 All 

addictive substances—including opioids—have 

powerful effects on the brain. They “hijack” the 

brain’s reward system by inducing feelings that 

motivate people to use those substances again 

and again, despite the risks for significant harms. 

With repeated exposure, progressive changes 

occur in the structure and function of the brain, 

compromising brain function and driving 

chronic misuse. These brain changes endure 

long after an individual stops using substances 

and may produce continued, periodic cravings 

for the substance that can lead to relapse for 

many years.27, 28

Well-supported evidence suggests that the 

addiction process involves a three-stage cycle: 

(1) Binge/Intoxication, the stage at which an 

individual consumes an intoxicating substance 

and experiences its rewarding or pleasurable 

effects; (2) Withdrawal/Negative Affect, the 

stage at which an individual experiences a 

negative physical and emotional state in the 

absence of the substance; and (3) Preoccupation/

Anticipation, the stage at which one seeks 

substances again after a period of abstinence. 

This cycle becomes more severe as a person 

continues substance use and as it produces 

dramatic changes in brain function that 

reduce a person’s ability to control his or her 

substance use. The three stages are linked to 

and feed on each other, but they also involve 

different brain regions: (1) the basal ganglia 

(binge/intoxication), (2) the extended amygdala 

(withdrawal/negative affect), and (3) the 

prefrontal cortex (preoccupation/anticipation).29
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 13

Dependence: A state in which an individual only 

functions normally in the presence of a substance, 

experiencing physical disturbance when the 

substance is removed. A person can be dependent 

on a substance without being addicted, but 

dependence sometimes leads to addiction.

Addiction: Common name for a severe substance 

use disorder, associated with compulsive or 

uncontrolled use of one or more substances. 

Addiction is a chronic brain disease that has the 

potential for both recurrence (relapse) and recovery. 

Tolerance: Alteration of the body’s responsiveness 

to alcohol or a drug such that higher doses are 

required to produce the same effect achieved 

during initial use. 

Withdrawal: A set of symptoms and signs that are 

experienced when discontinuing use of a substance 

to which a person has become dependent or 

addicted, which can include negative emotions 

such as stress, anxiety, or depression, as well as 

physical effects such as nausea, vomiting, muscle 

aches, and cramping, among others. Withdrawal 

symptoms often lead a person to use the substance 

again.

KEY TERMS Like other drugs, opioids affect the brain’s 

reward system. Opioids attach to opioid 

receptors in the brain, causing euphoria (the 

high), drowsiness, and slowed breathing, as well 

as reduced pain signaling (which is why they are 

frequently prescribed as pain relievers). 

Opioid addiction typically involves a pattern 

of: (1) intense intoxication, (2) the development 

of tolerance, (3) escalation in use, and (4) 

withdrawal signs that include profound negative 

emotions and physical symptoms, such as 

bodily discomfort, pain, sweating, and intestinal 

distress. As use progresses, the opioid must 

be taken to avoid the severe negative effects 

that occur during withdrawal. With repeated 

exposure to opioids, stimuli associated with 

the pleasant effects of the substances (e.g., 

places, persons, moods, and paraphernalia) and 

with the negative mental and physical effects 

of withdrawal can trigger intense craving or 

preoccupation with use.
PAGE 14 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

The 

Continuum 

of Care for 

Substance 

Misuse and 

Substance 

Use Disorders

E

ffective identification, intervention, and 

integration of prevention, treatment, 

and recovery services across health care 

systems is key to addressing substance misuse 

and its consequences, and it represents the 

most promising way to improve access to 

and quality of treatment. The continuum of 

care approach is a strategy to promote this 

integration by providing individuals an array of 

service options—including prevention, early 

intervention, treatment, and recovery support—

based on need.

PREVENTION

Substance misuse can put individual users and 

others around them at risk of harm, whether or 

not they have a disorder. Also, early initiation of 

substance use, substance misuse, and substance 

use disorders are associated with a variety of 

negative consequences, including deteriorating 

relationships, poor school performance, loss 

of employment, diminished mental health, 

and increases in sickness and death (e.g., 

motor vehicle crashes, poisoning, violence, or 

accidents).30-32 It is therefore critical to prevent 

the full spectrum of substance misuse problems 

in addition to treating those with substance 

use disorders. Although there are exceptions, 

most risk and protective factors associated 

with substance use also predict other problems 

affecting youth, including delinquency, 

psychiatric conditions, violence, and school 

dropout. Therefore, programs and policies 

addressing those common or overlapping 

predictors of problems have the potential to 

simultaneously prevent substance misuse as well 

as other undesired outcomes.33-35

Evidence-based interventions to prevent 

substance use, misuse, and addiction, target 

risk factors and enhance protective factors. For 

example, effective school-based strategies that 

combine substance use prevention and health 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 15

education curricula, link students to youth 

friendly mental and behavioral health providers 

in the community, and increase protective 

factors such as parent engagement and school 

connectedness can prevent the initiation of drug 

use. 

The Institute of Medicine (IOM), now known 

as the National Academy of Medicine, has 

described three categories of prevention 

interventions: universal, selective, and 

indicated.36 With respect to substance use 

interventions, universal interventions are 

aimed at all members of a given population 

(for instance, population-level strategies); 

selective interventions are aimed at a subgroup 

determined to be at high-risk for substance 

use (for instance, justice-involved youth); 

and indicated interventions are targeted to 

individuals who are already using substances 

but have not developed a substance use 

disorder. Schools and communities are 

encouraged to use a combination of these three 

types of preventive interventions based on their 

needs. Further research is needed to determine 

the best mix of prevention interventions. 

Evidence-based prevention interventions, 

carried out before the need for treatment, are 

critical because they can prevent initiation of 

substance use, delay early use, and stop the 

progression from use to problematic use or to a 

substance use disorder. The good news is that 

there is strong scientific evidence supporting 

the effectiveness of prevention programs and 

policies. The Surgeon General’s Report identified 

42 prevention programs that met criteria for 

inclusion based on an extensive review of 

published research studies. These are described 

in the Surgeon General’s Report Appendix B

(“Evidence-Based Prevention Programs and 

Policies”). In addition, education campaigns 

target the overall public to improve general 

understanding about addiction, community 

health and safety risks, and how to access 

available treatment services.37-39 An example is 

CDC’s Rx Awareness Campaign, which aims to 

increase awareness that prescription opioids can 

be addictive and dangerous.40

The Surgeon General’s Report also discusses 

the economics of prevention. Evidence-based 

prevention interventions can decrease costs 

related to substance use-related crime, lost 

work productivity, and health care. Research has 

found that for every dollar spent on prevention 

programs, the program returns between $0.62 

and $64.18 in reduced costs.41 Most of the 

rigorous research on the effectiveness and 

population impact of prevention policies and 

programs has addressed alcohol rather than 

opioids. Nevertheless, prevention is critical to 

addressing the opioid crisis.

SCREENING AND EARLY 

INTERVENTION

Given the impact of opioid misuse on public 

health and the increased risk for long-term 

medical consequences, including opioid use 

disorders and overdose, it is critical to prevent 

misuse from starting and to identify those who 

have already begun to misuse these substances 

and intervene early. Health care professionals 

Risk factors: Factors that increase the likelihood 

of beginning substance use, of regular and harmful 

use, and of other behavioral health problems 

associated with use. 

Protective factors: Factors that directly decrease 

the likelihood of substance use and behavioral 

health problems or reduce the impact of risk factors 

on behavioral health problems. 

Evidence-based interventions: Refers to 

programs and policies that are supported by 

research and proven to be effective.

KEY TERMS
PAGE 16 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

regarding when to start opioids for chronic 

pain, how to select the appropriate dosage, 

and how to assess risks and address harms from 

opioid use. This guideline can help providers 

reduce opioid misuse and related harms among 

those with chronic pain and is intended for use 

by primary care providers in caring for patients 

aged 18 and older outside of cancer, palliative, 

or end-of-life care. To help encourage uptake 

and use of the guideline, CDC has developed a 

suite of translational materials (e.g., fact sheets, 

training modules, videos, mobile apps, etc.)

for clinicians and patients. Additionally, it is 

crucial to improve access to non-opioid pain 

management options, and more research is 

needed in this important area.

As part of prevention, it is important to 

develop better pain management strategies. 

In March 2016, the National Pain Strategy: 

A Comprehensive Population HealthLevel Strategy for Pain was released. 

The report addresses the current pain 

management environment and describes 

strategies and objectives to improve pain 

management, including improving access 

to non-pharmacologic and non-opioid pain 

management options. More research is needed 

in this important area.

Research has documented the effects of 

prescription drug monitoring programs (PDMPs) 

on misuse of prescription medications.44 PDMPs 

are state-controlled electronic databases that 

track controlled substance prescriptions within 

a state and provide prescribing and patient 

behavior information to prescribers and other 

authorities who are granted access to the 

information. Findings have been mixed.45 

However, studies have shown that certain 

characteristics of PDMPs enhance their impact. 

For example, specific PDMP policies, such 

as mandated use and timely reporting, are 

can offer prevention advice, screen patients for 

substance misuse and substance use disorders, 

as well as risk factors for substance use such 

as childhood trauma and ACEs, and provide 

early interventions in the form of motivational 

approaches.42, 43

Primary care has a central role in this process, 

because it is the site for most preventive and 

ongoing clinical care for patients and the hub 

for specialty care. The U.S. Preventive Services 

Task Force (USPSTF) recommends that clinicians 

screen adults aged 18 years or older for alcohol 

misuse and provide persons engaged in risk 

or hazardous drinking with brief behavioral 

counseling interventions to reduce alcohol 

misuse.42 This approach is called Screening, Brief 

Intervention and Referral to Treatment or SBIRT 

for adult alcohol use. While the evidence rating 

from USPSTF for screening and intervention for 

illicit substance use remains “I” for insufficient 

evidence, asking about alcohol use may present 

a natural opportunity to ask about other 

substance use—including opioids. 

To curb the rise in opioid overdose deaths, CDC 

recommends screening for substance use and 

substance use disorders before and during the 

course of opioid prescribing for chronic pain, 

combined with patient education.15 The National 

Institute on Drug Abuse’s (NIDA) Opioid Risk Tool 

and the NIDA Quick Screen are available to help 

practitioners screen for substance use in general 

medical settings. 

Prevention strategies specifically targeting 

prescriber behavior have also been developed. 

In March 2016, the CDC Guideline for 

Prescribing Opioids for Chronic Pain was 

released.15 The guideline informs health care 

professionals about the consequences and 

risks of using opioids to treat chronic pain and 

provides research-based recommendations 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 17

associated with reductions in opioid overdose 

mortality.46 PDMPs serve many purposes beyond 

preventing inappropriate prescribing—they 

can be leveraged as a clinical decision support, 

a public health surveillance tool, and have 

utility to the public safety sector, especially 

as interstate and intrastate interoperability 

improve.

TREATMENT AND MANAGEMENT 

OF OPIOID USE DISORDERS

Substance use disorder treatment is designed 

to help individuals stop or reduce harmful 

substance misuse, improve their health and 

social function, and manage their risk for relapse. 

In this regard, substance use disorder treatment 

is effective and has a positive economic impact. 

Research shows that treatment improves 

individuals’ productivity,47 health,47, 48 and overall 

quality of life.49-51 Incorporating treatment 

for multiple substance use disorders could 

also be beneficial. For example, integrating 

tobacco cessation programs into substance 

use disorder treatment does not jeopardize 

treatment outcomes, and is associated with a 25 

percent increase in the likelihood of maintaining 

long-term abstinence from alcohol and drug 

misuse.52, 53 Consequently, substance use 

disorders can be identified quickly and reliably 

in many medical and social settings, including 

primary care. In contrast, severe, complex, and 

chronic substance use disorders often require 

specialty substance use disorder treatment and 

continued post-treatment support to achieve 

full remission and recovery. 

Substance use disorder treatment: A service 

or set of services that may include medication, 

counseling, and other supportive services designed 

to enable an individual to reduce or eliminate 

alcohol and/or other drug use, address associated 

physical or mental health problems, and restore the 

patient to maximum functional ability.54

KEY TERM

TREATMENT PLANNING.

Among the first steps involved in substance 

use disorder treatment are assessment and 

diagnosis. The diagnosis of substance use 

disorders is based primarily on the results of 

a clinical interview, and several assessment 

instruments are available. The diagnosis of a 

substance use disorder is made by a trained 

professional based on 11 symptoms defined 

in the Fifth Edition of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM-5). 

Conducting a clinical assessment is essential to 

understanding the nature and severity of the 

patient’s health and social problems that may 

have led to or resulted from their substance use. 

This assessment is important in determining 

the intensity of care that will be recommended 

and the composition of the treatment plan.55

After a formal assessment, the information is 

discussed with the patient to jointly develop 

a personalized treatment plan designed to 

address the patient’s needs.55, 56 The treatment 

plan and goals should be person-centered 

and include strength-based approaches, or 

ones that draw upon an individual’s strengths, 

resources, potential, and ability to recover, to 

keep the patient engaged in care. As mentioned 

previously, co-occurring mental health 

conditions are common among individuals with 

substance use disorder. Therefore, individualized 

treatment plans should consider these 

conditions and ensure that co-occurring mental 

health conditions are addressed. Tailoring 

treatment to the patient’s specific needs 

increases the likelihood of successful treatment 

engagement and retention, and research 

shows that those who participate more fully 

in treatment typically have better outcomes.57 

Throughout treatment, individuals should be 

periodically reassessed to determine response to 

treatment and to make any needed adjustments 

to the treatment plan.
PAGE 18 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

drug in which bystanders can take action 

to reverse the overdose and prevent 

death.59 However, the introduction of illicitly 

manufactured fentanyl and other highly potent 

synthetic opioids to the drug supply makes 

immediate access to naloxone (and perhaps 

multiple administrations) crucial to effective 

overdose death prevention. 

The rising number of deaths from opioid 

overdose has led to increasing public health 

efforts to make naloxone available to at-risk 

individuals and their families, as well as to 

emergency medical technicians, police officers, 

other first responders, or community members 

through community-based opioid overdose 

prevention programs. Although regulations 

vary by state, most states have passed laws 

expanding access to naloxone without a patientspecific prescription.64 The distribution of takehome doses of naloxone, along with education 

and training, for those actively using opioids 

and their peers and family members have the 

potential to help decrease opioid overdoserelated deaths.65, 66 Research demonstrates that 

naloxone does not increase the prevalence 

or frequency of opioid use.67 SAMHSA has 

develped an Opioid Overdose Prevention Toolkit 

for community members, first responders, 

prescribers, patients and families, and those 

recovering from opioid overdose.68 Good 

Samaritan Laws exist in most states. In the event 

of an overdose, these types of laws may protect 

the victim and/or the person seeking medical 

help for the vctim from drug possession 

charges.69 Given that most people overdose 

Antagonist: A chemical substance that binds to 

and blocks the activation of certain receptors on 

cells, preventing a biological response. Naloxone 

and naltrexone are examples of opioid receptor 

antagonists.

KEY TERM

HARM REDUCTION STRATEGIES.

Strategies to reduce the harms associated with 

opioid misuse and opioid use disorder have 

been developed as a way to engage people 

in treatment and to help preserve the life and 

health of those who are not ready to participate 

in treatment. Strategies include outreach and 

education programs, syringe services programs 

(sometimes called needle/syringe exchange 

programs), overdose prevention education, and 

access to naloxone to reverse potentially lethal 

opioid overdose.58, 59 The goal of syringe services 

programs is to prevent transmission of infectious 

agents and other harms by giving individuals 

who inject drugs sterile equipment and other 

support services at little or no cost and linking 

them to medical and mental health services, 

including substance use disorder treatment 

programs, as well as social services such as 

housing assistance and case management.60 

Evaluation studies have clearly shown that 

syringe services programs are effective in 

reducing HIV and HCV transmission and do 

not increase rates of community drug use.61

They help individuals engage in treatment to 

reduce, manage, and stop their substance use 

when appropriate. Harm reduction programs 

provide public health-oriented, cost-effective, 

and often cost-saving services to prevent and 

reduce substance use-related risks among 

those actively using substances, and substantial 

evidence supports their effectiveness. 59, 62, 63

NALOXONE.

Naloxone is an opioid antagonist medication 

approved by the U.S. Food and Drug 

Administration (FDA) to reverse opioid overdose. 

Naloxone is available in injectable and nasal 

spray forms. It works by displacing opioids from 

receptors in the brain, thereby interrupting and 

blocking their effects on breathing and heart 

rate. Typically, there is a 1- to 3-hour window of 

opportunity after an individual has taken the 
THE SURGEON GENERAL’S REPORT ON ALCOHOL, DRUGS, AND HEALTH: SPOTLIGHT ON OPIOIDS PAGE 19

EVIDENCE-BASED TREATMENT: 

COMPONENTS OF CARE

As discussed in the Surgeon General’s Report

Chapter 4 (“Early Intervention, Treatment, and 

Management of Substance Use Disorders”), 

evidence-based treatment involves particular 

components of care. Table 1 (page 20)

summarizes what people should look for in a 

treatment program.

All substance use disorder treatment programs 

are expected to individualize treatment using 

evidence-based clinical components. These 

components are clinical practices that research 

has shown to be effective in reducing substance 

use and improving health and functioning. 

These include behavioral therapies, medications, 

and recovery support services (RSS). Treatment 

programs that offer more of these evidencebased components have the greatest likelihood 

of producing better outcomes.

at home or outside of a medical setting, the 

Surgeon General released a public health 

advisory on community use of naloxone to 

reduce deaths from opioid overdose.

WITHDRAWAL MANAGEMENT. 

Withdrawal management, often called 

“detoxification” or medically supervised 

withdrawal, includes interventions aimed 

at managing the significant physical and 

emotional distressthat occurs after a person 

stops using opioids.70 When clinicians follow 

evidence-based standards of care,71 withdrawal 

management is highly effective in preventing 

immediate and serious medical consequences 

associated with discontinuing substance 

use.72 However, it is not an effective therapy 

for any substance use disorder by itself and 

should always be followed by evidence-based 

treatment, such as injectable naltrexone for 

opioid use disorder.73 

Because withdrawal management reduces 

much of an individual’s acquired tolerance 

to opioids, any return to use increases the 

risk of overdose and even death. Therefore, 

a person with opioid use disorder who 

undergoes medical withdrawal should be 

offered injectable naltrexone to protect him 

or her in case of relapse to opioid use.73 It is 

critically important for health care providers 

to facilitate engagement into the appropriate 

intensity of treatment.72 Medically supervised 

withdrawal is not indicated for pregnant 

women who use or misuse opioids. Medically 

supervised withdrawal is associated with a 

high rate of return to substance use, which 

puts both the pregnant woman and the fetus 

at risk.11 Medication-assisted treatment with 

buprenorphine or methadone for pregnant 

women with opioid use disorder has been 

shown to improve outcomes and should be 

offered.15
PAGE 20 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Table 1: What People Should Look for in a Treatment Program

COMPONENTS OF CARE

Personalized diagnosis, assessment, and treatment planning—one size does 

not fit all, and treatments should be tailored to you and your family.

Long-term disease management—addiction is a chronic disease of the brain 

with the potential for both recovery and recurrence. Long-term outpatient 

care is the key to recovery.

Access to FDA-approved medications.

Effective behavioral interventions delivered by trained professionals.

Coordinated care for other/co-occurring diseases and disorders.

Recovery support services—such as mutual aid groups, peer support 

specialists, and community services that can provide continuing emotional 

and practical support for recovery.
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 21

Table 2: Medications/Pharmacotherapies for Opioid Use Disorder (OUD)

NOTE: Adapted from Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A 

Brief Guide (SMA14-4892R).73

MEDICATIONS AND MEDICATIONASSISTED TREATMENT (MAT) FOR 

OPIOID USE DISORDERS.

Comprehensive MAT programs include 

behavioral therapies and psychosocial supports 

as well as medication. The FDA has approved 

medications for use in the management of 

opioid use disorder (see table below). 

Methadone use in treatment of opioid use 

disorders can only be dispensed in a federallyregulated opioid treatment program (OTP). 

Buprenorphine and naltrexone can be dispensed 

in an OTP and also can be prescribed in medical 

care settings, such as primary care, and do not 

require an OTP. Use of these drugs is an individual 

decision for prescribers and their patients.

Medication Frequency of 

Administration

Route of 

Administration

Who May Prescribe 

or Dispense

Naltrexone Monthly

Intramuscular 

injection into the 

gluteal muscle 

by a physician or 

other health care 

professional

Any individual who is licensed 

to prescribe medicines (e.g., 

physician, physician assistant, 

or nurse practitioner) may 

prescribe and/or order 

administration by qualified 

staff.

Medication Frequency of 

Administration

Route of 

Administration

Who May Prescribe 

or Dispense

Methadone Daily

Orally as liquid 

concentrate, tablet, 

or oral solution of 

diskette or powder

SAMHSA-certified outpatient 

OTPs dispense methadone for 

daily administration either 

onsite or, for stable patients, at 

home.

Buprenorphine

Daily for tablet or

 film (also alternative 

dosing regimens)

Oral tablet or film 

dissolved under the 

tongue

Physicians, nurse 

practitioners, and physician 

assistants with a federal 

waiver. Prescribers must 

complete special training to 

qualify for the federal waiver 

to prescribe buprenorphine, 

but any pharmacy can fill 

the prescription. OTPs can 

prescribe buprenorphine 

within the rules that regulate 

these facilities.

Every 6 months Subdermal implant

Monthly

Injection

(for moderate to 

severe OUD)
PAGE 22 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

In 2018, SAMHSA released Clinical Guidance for 

Treating Pregnant and Parenting Women With 

Opioid Use Disorder and Their Infants. This Clinical 

Guide provides comprehensive, national guidance 

for optimal management of pregnant and parenting 

women with opioid use disorder and their infants. 

It helps health care professionals and patients 

determine the most clinically appropriate action 

for a particular situation and informs individualized 

treatment decisions.

MAT FOR PREGNANT WOMEN

Long-term methadone maintenance 

treatment has demonstrated improved 

outcomes for individuals (including 

pregnant women) with opioid use 

disorders.Buprenorphine is associated with 

improved outcomes compared to placebo 

for individuals (including pregnant women) 

with opioid use disorders.The safety of 

naltrexone for pregnant women has not 

been established.

Opioid Treatment Program (OTP): SAMHSAcertified program, usually comprising a facility, staff, 

administration, patients, and services, that engages 

in supervised assessment and treatment, using 

methadone, buprenorphine, or naltrexone, of individuals 

who have opioid use disorders. An OTP can exist in a 

number of settings, including but not limited to intensive 

outpatient, residential, and hospital settings. Services 

may include medically supervised withdrawal and/or 

maintenance treatment, along with various levels of 

medical, psychiatric, psychosocial, and other types of 

supportive care.

KEY TERM

Those FDA-approved medications listed in Table 

2 demonstrate “well-supported” evidence of 

safety and effectiveness for improving outcomes 

for individuals with opioid use disorders.74, 

75 Only appropriately trained health care 

professionals should decide, in conjunction 

with the person in need of treatment, whether 

and which medication is needed as part of 

treatment, how the medication is provided in 

the context of other clinical services, and under 

what conditions the medication should be 

discontinued. MAT for patients with an opioid 

use disorder must be delivered for an adequate 

duration in order to be effective. Patients 

who receive MAT for fewer than 90 days have 

not shown improved outcomes.76 One study 

suggested that individuals who receive MAT 

for fewer than 3 years are more likely to relapse 

than those who are in treatment for 3 or more 

years.77
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 23

MAT FOR CRIMINAL JUSTICE 

POPULATIONS 

Upon release, incarcerated individuals will 

have lower tolerance to opioids. They are 

at high risk for overdose and death if they 

return to opioid use in the community. 

There is typically insufficient pre-release 

counseling and post-release follow-up 

provided to this population to reduce these 

risks.Research findings from randomized 

controlled trials indicate that people 

involved in the criminal justice system 

benefit from methadone maintenance 

(pre- and post-release) and extendedrelease naltrexone treatment.

State agencies that oversee substance use 

disorder treatment programs use a variety of 

strategies to promote implementation of MAT, 

including education and training, financial 

incentives (e.g., linking funding to the provision 

of MAT), policy mandates, and support for 

infrastructure development.78 Nevertheless, 

multiple factors create barriers to widespread 

use of MAT. These include provider, public, and 

client attitudes and beliefs about MAT; lack 

of an appropriate infrastructure for providing 

medications; payment policies; need for staff 

training and development; and legislation, 

policies, and regulations that limit MAT 

implementation.78

The use of opioid agonist medications to treat 

opioid use disorders has always had its critics. 

Many people, including some policymakers, 

authorities in the criminal justice system, and 

treatment providers, have viewed maintenance 

treatments as “substituting one substance for 

another”79 and have adhered instead to an 

abstinence-only philosophy that avoids the use 

of medications, especially those that activate 

opioid receptors. Such views are not scientifically 

supported; the research clearly demonstrates 

that opioid agonist therapy leads to better 

treatment outcomes compared to behavioral 

treatments alone. Moreover, withholding 

medications greatly increases the risk of relapse 

to illicit opioid use and overdose death. Decades 

of research have shown that the benefits of 

opioid agonist therapy greatly outweigh the 

risks associated with diversion.80-82

Agonist: A chemical substance that binds to 

and activates certain receptors on cells, causing a 

biological response. Fentanyl and methadone are 

examples of opioid receptor agonists. 

KEY TERM

BEHAVIORAL THERAPIES. 

These structured therapies help patients 

recognize the impact of their behaviors—

such as dealing with stress or interacting in 

interpersonal relationships—on their substance 

use and ability to function in a healthy, safe, 

and productive manner. They can be provided 

in individual, group, and/or family sessions in 

virtually all treatment settings.72, 83 Behavioral 

therapies also teach and motivate patients to 

change their behaviors as a way to control their 

substance use disorders.72 Most studies support 

the use of individual counseling as an effective 

intervention for individuals with substance use 

disorders as part of MAT.75, 84 Group counseling 

should primarily be used only in conjunction 

with individual counselingor other forms of 

individual therapy.77, 79 Despite decades of 

research, it cannot be concluded that general 

group counseling is reliably effective in reducing 

substance use or related problems.84, 85
PAGE 24 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

RECOVERY SUPPORT SERVICES (RSS). 

RSS, provided by both substance use 

disorder treatment programs and community 

organizations, help to engage and support 

individuals in treatment and provide ongoing 

support after treatment. These supportive 

services are typically delivered by trained case 

managers, recovery coaches, and/or peers. 

Specific supports include help with navigating 

systems of care, removing barriers to recovery, 

staying engaged in the recovery process, and 

providing a social context for individuals to 

engage in community living without substance 

use.86 Individuals who participate in substance 

use disorder treatment and RSS typically 

have better long-term recovery outcomes 

than individuals who receive either alone.86

Furthermore, active recovery and social 

supports, both during and following treatment, 

are important to maintaining recovery.86
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 25

Recovery: 

The Many 

Paths to 

Wellness

P

eople can and do recover. Recovery from 

substance use disorders has had several 

definitions. Although specific elements of 

these definitions differ, all agree that recovery 

goes beyond the remission of symptoms to 

include a positive change in the whole person. 

In this regard, “abstinence,” though often 

necessary, is not always sufficient to define 

recovery. There are many paths to recovery. 

People will choose their pathway based on 

their cultural values, their psychological and 

behavioral needs, and the nature of their 

substance use disorder. 

Successful recovery often involves making 

significant changes to one’s life to create a 

supportive environment that avoids substance 

use or misuse cues or triggers. Recovery can 

involve changing jobs or housing, finding new 

friends who are supportive of one’s recovery, 

and engaging in activities that do not involve 

substance use. This is why ongoing RSS in the 

community after completing treatment can be 

invaluable for helping individuals resist relapse 

and rebuild lives that may have been devastated 

by years of substance misuse. 

RSS are not the same as treatment and have 

only recently been included as part of the health 

care system. The most well-known approach, 

mutual aid groups, link people in recovery and 

encourage mutual support while providing 

a new social setting in which former alcohol 

or drug users can engage with others in the 

absence of substance-related cues from their 

former life. Mutual aid groups are facilitated 

by peers, who share their lived experience in 

recovery. However, health care professionals 

have a key role in linking patients to these 

groups, and encouraging participation can have 

great benefit.87
PAGE 26 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Recovery coaches, who offer individualized 

guidance, support, and sometimes case 

management, and recovery housing—

substance-free living situations in which 

residents informally support each other as they 

navigate the challenges of drug- and alcoholfree living—have led to improved outcomes 

for participants.88-92 Several other common 

RSS, including recovery community centers 

and recovery high schools, have not yet been 

rigorously evaluated. 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 27

Health Care 

Systems and 

Opioid Use 

Disorder

S

ervices for the prevention and treatment 

of substance misuse and substance use 

disorders have traditionally been delivered 

separately from other mental health and general 

health care services. Because substance misuse 

has traditionally been seen as a social or criminal 

problem, prevention services were not typically 

considered a responsibility of health care 

systems; and people needing care for substance 

use disorders have had access to only a limited 

range of treatment options that were generally 

not covered by insurance. 

Effective integration of prevention, treatment, 

and recovery services across health care 

systems is key to addressing opioid misuse and 

its consequences, and it represents the most 

promising way to improve access to and quality 

of treatment. When health care is not well 

integrated and coordinated across systems, too 

many patients fall through the cracks, leading to 

missed opportunities for prevention and early 

intervention, ineffecive referrals, incomplete 

treatment, high rates of hospital and emergency 

department readmissions, and individual 

tragedies (e.g., opioid overdoes) that could have 

been prevented. 

The good news, however, is that a range of 

promising health care structures, technologies, 

and innovations are emerging, or are being 

refined and strengthened. These developments 

are helping to address challenges and facilitate 

integration. Is so doing, they are broadening the 

focus of interventions beyond just the treatment 

of severe substance use disorders to encompass 

the entire spectrum of prevention, treatment, 

and recovery. 
PAGE 28 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Conclusion

T

he opioid overdose epidemic brings into 

sharp focus how myths and misconceptions 

about addiction have led to devastating 

consequences for individuals and communities. 

The evidence-based public health approach 

described in the Surgeon General’s Report offers 

a positive way forward to reducing the opioid 

crisis by addressing factors that contribute to 

the misuse and its consequences. By adopting 

this approach—which seeks to improve the 

health, safety, and well-being of the entire 

population—we have the opportunity as a 

nation to take effective steps to prevent and 

treat opioid misuse and opioid use disorder 

and reduce opioid overdose. A public health 

approach to the opioid crisis will also reduce 

other harmful consequences, such as infectious 

disease transmission and NAS. States that have 

had success in implementing the public health 

approach and slowing their overdose rates have 

emphasized the importance of partnerships. 

Given that too many individuals are dying 

every day from opioid overdose, shifting our 

attitudes and working together to widen access 

to prevention, treatment, and recovery services 

for opioid misuse and opioid use disorders are 

essential for saving lives.

The responsibility of addressing opioid misuse 

and opioid use disorders does not fall on one 

sector alone, and the health care system cannot 

address all of the major determinants of health 

related to substance misuse without the help 

of the wider community. Everyone has a role 

to play in changing the conversation around 

addiction, to improve the health, safety, and 

well-being of individuals and communities 

across our nation. 
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 29

Below are suggestions for various key 

stakeholders.

Individuals and Families:

• Reach out, if you think you have a problem 

with opioid misuse or a substance use 

disorder.

• Be supportive (not judgmental) if a loved 

one has a problem. 

• Carry naloxone and be trained on how to 

use it.

• Show support toward people in recovery. 

• Parents, talk to your children about 

substance use.

• Understand pain.  Many scientifically proven 

pain management options do not involve 

opioids.  Talk to your health care provider 

about an individualized plan that is right for 

your pain.

• Be safe. Only take opioid medications as 

prescribed to you.  Always store in a secure 

place.  Dispose of unused medication 

properly.

Educators and Academic Institutions:

• Implement evidence-based prevention 

interventions.

• Provide treatment and recovery supports.

• Teach accurate, up-to-date scientific 

information about substance use disorders 

as medical conditions.

• Enhance training of health care 

professionals. 

Health Care Professionals and Professional 

Associations:

• Address substance use-related health issues 

with the same sensitivity and care as any 

other chronic health condition.

• Support high-quality care for substance use 

disorders.

• Follow the gold standard for opioid 

addiction treatment.

• Follow the CDC Guideline for Prescribing 

Opioids for Chronic Pain.

• When opioids are prescribed, providers 

can assess for behavioral health risk factors 

to help inform treatment decisions, and 

collaborate with mental health providers.

• Check the PDMP before prescribing opioids.

• Refer to patients to opioid treatment 

providers when neccessary.

• Become qualified to prescribe 

buprenorphine for the treatment of opioid 

use disorder.

Health Care Systems:

• Promote universal, selective, and indicated 

prevention.

• Promote use of evidence-based treatments.

• Promote effective integration of prevention, 

treatment, and recovery support services.

• Work with payers to develop and implement 

comprehensive billing models.

• Implement health information technologies 

to promote efficiency, actionable 

information, and high-quality care.

• Create stronger connections across 

behavioral health providers and mainstream 

medical systems.

• Engage primary care providers as part of a 

comprehensive treatment solution.
PAGE 30 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

Communities:

• Build awareness of substance use as a public 

health problem.

• Invest in evidence-based prevention 

interventions and recovery supports. 

• Implement interventions to reduce harms 

associated with opioid misuse.

Private Sector—Industry and Commerce: 

• Support youth substance use prevention.

• Continue to collaborate with the federal 

initiative to reduce prescription opioidand heroin-related overdose, death, and 

dependence.

• Reduce work-related injury risks and other 

working conditions that may increase the 

risk for substance misuse. 

• Offer education, support and treatment 

benefits for workers affected by the opioid 

crisis.

Federal, State, Local, and Tribal Governments:

• Provide leadership, guidance, and vision in 

supporting a science-based approach to 

addressing substance use-related health 

issues.

• Collect and use data to guide local response 

to people and places at highest risk.

• Improve coordination between social service 

systems and the health care system to 

address the social and environmental factors 

that contribute to the risk for substance use 

disorders.

• Implement criminal justice reforms to 

transition to a less punitive and more healthfocused approach.

Researchers:

• Conduct research that focuses on 

implementable, sustainable solutions to 

address high-priority substance use issues.

• Identify research gaps in understanding the 

complexity of opioids addiction and pain.

• Promote rigorous evaluation of programs 

and policies.
FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS PAGE 31

Key Federal Resources

The Surgeon General’s Report

https://addiction.surgeongeneral.gov/

CDC Guideline for Prescribing Opioids for 

Chronic Pain

https://www.cdc.gov/mmwr/volumes/65/rr/

rr6501e1.htm

MMWR Opioid Reports

https://www.cdc.gov/mmwr/opioid_reports.

html

SGR Appendix B: Review Process for Prevention 

Programs

https://addiction.surgeongeneral.gov/sites/

default/files/appendices.pdf

NIDA Opioid Risk Tool

https://www.drugabuse.gov/sites/default/files/

files/OpioidRiskTool.pdf

NIDA Quick Screen

https://www.drugabuse.gov/publications/

resource-guide-screening-drug-use-in-generalmedical-settings/nida-quick-screen

CDC general resources

https://www.cdc.gov/drugoverdose/prescribing/

resources.html

CDC resources related to People Who Inject 

Drugs (PWID)

https://www.cdc.gov/pwid/index.html

CDC’s Rx Awareness Campaign

https://www.cdc.gov/rxawareness/index.html

CDC Adverse Childhood Experiences page

https://www.cdc.gov/violenceprevention/

acestudy/index.html

Preventing the Consequences of Opioid 

Overdose: Understanding the Naloxone Access 

Laws

https://www.samhsa.gov/capt/sites/default/files/

resources/naloxone-access-laws-tool.pdf

The Surgeon General’s Advisory on Naloxone 

and Opioid Overdose

https://www.surgeongeneral.gov/priorities/

opioid-overdose-prevention/naloxone-advisory.

html

SAMHSA Opioid Overdose Prevention Toolkit

https://store.samhsa.gov/product/OpioidOverdose-Prevention-Toolkit/SMA16-4742

SAMHSA Clinical Guidance for Treating Pregnant 

and Parenting Women with Opioid Use Disorder 

and Their Infants

https://store.samhsa.gov/product/ClinicalGuidance-for-Treating-Pregnant-and-ParentingWomen-With-Opioid-Use-Disorder-and-TheirInfants/SMA18-5054
PAGE 32 FACING ADDICTION IN AMERICA: THE SURGEON GENERAL’S SPOTLIGHT ON OPIOIDS

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