Stacey McKenna Statement for the Record, Hearing on “Combating the Opioid Epidemic”

February 25, 2025

Dear Chairman Scott, Ranking Member Gillibrand, and members of the Committee:

Thank you for your decision to hold the February 26, 2025 hearing on “Combating the Opioid Epidemic.” My name is Stacey McKenna, and I am a Resident Senior Fellow at the R Street Institute, a public policy research organization focused on promoting free markets and limited, effective government in a variety of areas, including integrated harm reduction. Harm reduction is a pragmatic approach that helps reduce the potential negative consequences of a range of behaviors, including substance use.^[1] At the R Street Institute, we recognize that even the best prevention and cessation efforts leave too many people behind.^[2] Therefore, we support harm reduction as a key component of comprehensive policy solutions to the ongoing overdose crisis.

For the past decade, the United States has witnessed an unprecedented drug overdose crisis, largely driven by the proliferation of illicitly manufactured fentanyl (IMF) and other potent synthetic opioids.^[3] At its peak in 2023, the epidemic took the lives of more than 111,000 people across the country.^[4] And although we have recently seen a much-needed decline in overdose fatalities—thanks in large part to the expansion of harm reduction programs—too many people still die of drug overdoses each year.^[5] Consequently, we are grateful to this committee for continuing to seek real policy solutions.

Aging, Opioid Use, and Overdose Risk
People of all ages consume substances for a variety of reasons, including treatment (prescribed or self-medicated) for physical pain, substance use disorder, social coping, experimentation, and more.^[6] In the United States, adults 65 and older are more likely than their younger counterparts to be prescribed opioids and to take them for extended periods of time.^[7] They are also more likely to be isolated from the community, social, and medical resources that can help prevent chaotic substance use and overdose.^[8]

Although opioids can be beneficial when taken as prescribed, they are not risk-free. Long-term use increases the likelihood people will develop tolerance—leading to a need for higher doses of the medication—as well as physical dependence and in rare cases, opioid use disorder.^[9] Too-high doses of any substance, whether intentional or unintentional, prescribed or illicit, can result in an overdose, characterized by a range of unpleasant and sometimes deadly effects.^[10] An overdose involving IMF or other opioids is life threatening due to changes in blood pressure and heart beat and severe respiratory depression.^[11] Individuals who are unable to afford their prescribed opioids or whose prescription is abruptly cut-off may turn to the illicit market, where the supply is much more dangerous and overdose risk skyrockets.^[12] 

In the United States, although media reporting and policy attention have focused on the overdose crisis’ impact on youth, opioid-related risks have been on the rise for older adults in recent years.^[13] In fact, from 2002 to 2014, “problematic opioid use” nearly doubled (from 1.1 percent to 2.0 percent) among adults 50 and older, and the estimated prevalence of opioid use disorder among individuals 65 and over tripled between 2013 and 2018.^[14] The proportion of older adults reporting heroin use also climbed from 2013 to 2015, and while prescription opioid use fell between 2013 and 2019, heavy and chronic use of medical opioids remains relatively high in this group.^[15] Furthermore, although overdose death rates are lowest among adults aged 65 and older, from 2021 to 2022, this group saw a 10 percent increase in overdose death rates, larger than among any other age group.^[16] 

In short, older Americans are not immune from this crisis, and they deserve access to life saving resources.

Smart Policy Can Improve Well-Being and Save Lives
Unfortunately, there are no silver bullets when it comes to mitigating the risks associated with opioid use. However, the right policies can help people stay safer, healthier, and improve their lives. Harm reduction and medications for opioid use disorder are among the most proven ways to mitigate the risks that opioids pose to individuals and communities.^[17] Their efficacy has been demonstrated over decades and across the United States’ varied geographic and socioeconomic landscapes.^[18] Therefore, policy should facilitate and expand access to these approaches, allowing communities to tailor them to specific needs without being overly prescriptive.

Medications for Opioid Use Disorder
One tried and true way to support the roughly one million adults aged 65 and older who have a substance use disorder is by expanding access to evidence-based treatments.^[19] Two FDA-approved medications for opioid use disorder—buprenorphine and methadone—reduce cravings and withdrawal symptoms, improve treatment retention, reduce illicit and chaotic drug use, and slash overdose risk compared to both no treatment and non-medication treatment.^[20] Not only do they improve outcomes for patients, they reduce criminal recidivism and yield lifetime savings ranging from $25,000 to $105,000 per person.^[21]

Unfortunately, neither of these medications is sufficiently accessible. Methadone is considered the gold standard medication for OUD, especially in an era dominated by IMF.^[22] However, it is among the most heavily regulated medications in the United States.^[23] People with OUD can only access methadone through opioid treatment programs (OTPs), specialized clinics that are controlled by both state and federal governments and sparsely distributed throughout the country.^[24] Despite some recent updates intended to improve methadone access, OTPs still frequently require patients to visit in-person up to 6 days per week to take their medication, submit to regular urine screenings, and more.^[25] These barriers disproportionately hurt patients living in low-income and rural areas.^[26] Methadone access would be dramatically improved by removing the monopoly that OTPs currently have on its distribution.^[27] For example the Modernizing Opioid Treatment Access Act would do just that by allowing addiction specialist physicians to prescribe and pharmacists to dispense it.^[28] 

Buprenorphine is another very safe and effective medication for OUD. And while we applaud recent work to reduce its overregulation by removing the so-called X-waiver, access barriers persist, largely due to prescriber and pharmacist hesitancy.^[29] Two ways to further reduce persistent barriers to buprenorphine would be to ensure that pharmacies are not subject to excessive law enforcement scrutiny for stocking and dispensing it and by making telehealth buprenorphine treatment guidelines permanent.^[30] 

Harm Reduction
Unfortunately, improving treatment options alone is not enough to fight the ongoing opioid overdose epidemic. Recovery from a substance use disorder is not linear, and people do relapse. Relapse can lead to overdose, especially for individuals who lost tolerance due to being engaged in abstinence-based treatment.^[31] In addition, not all people who use opioids have an opioid use disorder; yet, even individuals who consume substances recreationally, medically, or experimentally are at risk of overdosing if they accidentally take too much.^[32] For example, individuals taking high-dose opioid medications may forget they have taken their medication and take a second dose, or take other medications that also slow breathing and heartrate.^[33] 

Harm reduction interventions can help reduce overdose risk for any person who uses substances, even if that use is casual, medical, or a relapse. Such interventions are therefore an important part of efforts to combat the opioid overdose crisis among older adults.^[34] Indeed, several essential harm reduction interventions have expanded in recent years in the United States, and can be credited for at least part of the recent decline in overdose deaths.^[35] 

For example, improving access to the overdose reversal drug, naloxone, has enabled some communities to get the life-saving medication to their most vulnerable populations.^[36] One potentially beneficial move on the part of the federal government was when the Food and Drug Administration authorized the intranasal formulation of standard dose naloxone for over-the-counter use.^[37] However, cost and stocking continue to present a barrier, especially for older adults.^[38] Because Medicare does not cover over-the-counter medications, the price of naloxone may continue to present a barrier for some.^[39] The federal government could help ease this burden by allowing Medicare to cover some over-the-counter medications, and by incentivizing the approval of generics to ensure market competition to drive prices lower.^[40]

Another important harm reduction intervention that helps reduce overdose is the presence of harm reduction organizations such as syringe services programs in communities. While these programs—sometimes referred to as needle exchanges—originated as a way to reduce infectious disease transmission among people who inject drugs, they provide a comprehensive array of services that may be relevant to older adults who use opioids.^[41] First of all, harm reduction organizations are primary distributors of naloxone and drug checking equipment such as fentanyl test strips to people who might not be able to afford them otherwise.^[42] Secondly, they serve as key points of connection for people, providing case management and referrals to substance use disorder treatment.^[43] In fact, participants in syringe services programs are up to five times more likely than their counterparts who don’t use the programs to enter drug treatment, and three times as likely to stop using altogether.^[44] Because older people who use drugs may struggle more than their younger counterparts to establish and maintain connection, these types of services are especially important for older adults.^[45] 

Combatting the Opioid Overdose Crisis Among Older Adults
In sum, older Americans are not immune from the opioid overdose crisis that continues to take tens of thousands of lives annually in the United States. Evidence-based treatment and harm reduction are two effective and cost-effective tools to help these individuals stay safer and healthier, regardless of how or why they use opioids.

The examples provided above represent only a small sampling of the potential interventions available to communities and organizations seeking to reduce the risks associated with opioid use among older adults. Because many harm reduction policies and health regulations are enacted at the state level, perhaps the most important thing the federal government can do is to avoid interfering with successful efforts. Harm reduction is at its most effective when local communities can tailor programs to meet local needs.

Chairman Scott, Ranking Member Gillibrand, and members of the Committee, thank you again for holding this important hearing and for your consideration of my views. Should you have any questions or wish to have further discussion, please do not hesitate to contact me.

        Sincerely,

Stacey McKenna, PhD
/s/
Resident Senior Fellow, Integrated Harm Reduction
R Street Institute

See the original testimony below:

[1] Substance Abuse and Mental Health Services Administration, Harm Reduction Framework, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 2023. https://www.samhsa.gov/sites/default/files/harm-reduction-framework.pdf.

[2] Ibid.

[3] Daniel Ciccarone, “The Rise of Illicit Fentanyls, Stimulants and the Fourth Wave of the Opioid Overdose Crisis,” Current Opinions in Psychiatry, 34: 4 (July 1, 2021), pp. 344-350. https://pmc.ncbi.nlm.nih.gov/articles/PMC8154745.

[4] Centers for Disease Control and Prevention, “Provisional Drug Overdose Death Counts,” National Center for Health Statistics, Centers for Disease Control and Prevention, Feb. 12, 2025. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

[5] Ibid.

[6] Chelsea Boyd and Stacey McKenna, “Beyond Addiction: The Myriad Reasons People Use Drugs,” R Street Institute Explainer, June 23, 2023. https://www.rstreet.org/research/beyond-addiction-the-myriad-reasons-people-use-drugs.

[7] National Institute on Drug Abuse, 2020. https://nida.nih.gov/publications/drugfacts/substance-use-in-older-adults-drugfacts; Ramin Mojtabai, “National trends in long-term use of prescription opioids,” Pharmacoepidemiology and Drug Safety, 27: 5, Sept. 6, 2017, pp. 526-534. https://onlinelibrary-wiley-com.ez.lib.jjay.cuny.edu/doi/full/10.1002/pds.4278.

[8] Cassie Sun, “The unseen epidemic: opioid overdoses among older adults,” Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, August 20, 2024. https://www.feinberg.northwestern.edu/sites/ipham/news/The-unseen-epidemic-opioid-overdoses-among-older-adults.html.

[9] Stacey McKenna, “Drug Use 101: Physical Dependence and Withdrawal,” R Street Institute Explainer, Nov. 6, 2024. https://www.rstreet.org/research/drug-use-101-physical-dependence-and-withdrawal.

[10] Chelsea Boyd, “Drug Use 101: What is Overdose?” R Street Institute Explainer, Nov. 21, 2024. https://www.rstreet.org/research/drug-use-101-what-is-overdose.

[11] Ibid.

[12] Julia Dickson-Gomez et al., “The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis,” Substance Abuse Treatment, Prevention, and Policy, 17: 55 (Jul. 21, 2022). https://pmc.ncbi.nlm.nih.gov/articles/PMC9306091.

[13] Sun. https://www.feinberg.northwestern.edu/sites/ipham/news/The-unseen-epidemic-opioid-overdoses-among-older-adults.html.

[14] Carla Shoff et al., “Trends in Opioid Use Disorder Among Older Adults: Analyzing Medicare Data, 2013-2018,” American Journal of Preventive Medicine, 60: 6 (June 2021), pp. 850-855. https://www.ajpmonline.org/article/S0749-3797(21)00092-1/abstract; Substance Abuse and Mental Health Services Administration, “Opioid Misuse Increases Among Older Adults,” The CBHSQ Report, SAMHSA, July 25, 2017. https://www.samhsa.gov/data/sites/default/files/report_3186/Spotlight-3186.pdf.

[15] Andrew S. Huhn et al., “A hidden aspect of the U.S. opioid crisis: Rise in first-time treatment admissions for older adults with opioid use disorder,” Drug and Alcohol Dependence, 193 (Dec. 1, 2018), pp. 142-147. https://pubmed.ncbi.nlm.nih.gov/30384321; Morgan I. Bromley et al., “Burden of Chronic and Heavy Opioid Use Among Elderly Community Dwellers in the U.S.,” American Journal of Preventive Medicine, 3: 2 (April 2024).

[16] Merianne R. Spencer et al., “Drug Overdose Deaths in the United States, 2002-2022,” NCHS Data Brief No. 491, National Center for Health Statistics, Centers for Disease Control and Prevention, March 2024. https://www.cdc.gov/nchs/products/databriefs/db491.htm#:~:text=mortality data file.-,The rate of drug overdose deaths increased among middle-aged,and older (Figure 2).

[17] Don C. Des Jarlais, “Harm reduction in the USA: the research perspective and an archive to David Purchase,” Harm Reduction Journal, 14: 51 (July 26, 2017). https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0178-6; National Institute on Drug Abuse, “How effective are medications to treat opioid use disorder?” Medications to Treat Opioid Use Disorder Research Report, National Institute on Drug Abuse, 2018. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder.

[18] Ibid; Cameron Bushling et al., “Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data,” The Journal of Rural Health, 38: 3 (Sept. 19, 2021), pp. 620-629. https://onlinelibrary.wiley.com/doi/abs/10.1111/jrh.12623.

[19] National Institute on Drug Abuse, “Substance Use in Older Adults Drug Facts,” U.S. Department of Health and Human Services, July 2020. https://nida.nih.gov/publications/drugfacts/substance-use-in-older-adults-drugfacts

[20] Jessica Shortall, “What the…? Safer From Harm on Methadone,” Safer From Harm, March 7, 2024. https://www.saferfromharm.org/blog/what-the-safer-from-harm-on-methadone; Sarah E. Wakeman et al., “Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder,” JAMA Network Open, 3: 2 (Feb. 5, 2020). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032.  

[21] Michael Fairley et al., “Cost-effectiveness of Treatments for Opioid Use Disorder,” JAMA Psychiatry 78: 7 (March 31, 2021), pp. 767-777. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2778020.

[22] Nora Volkow, “To address the fentanyl crisis, greater access to methadone is needed,” Nora’s Blog, National Institute on Drug Abuse, July 29, 2024. https://nida.nih.gov/about-nida/noras-blog/2024/07/to-address-the-fentanyl-crisis-greater-access-to-methadone-is-needed.

[23] “How Can Patients Access Methadone in Other Countries?” Pew Trusts, accessed Feb. 22, 2025. https://www.pewtrusts.org/en/research-and-analysis/articles/2023/05/17/how-can-patients-access-methadone-in-other-countries#:~:text=Methadone is one of three,be available outside of OTPs; Volkow, https://nida.nih.gov/about-nida/noras-blog/2024/07/to-address-the-fentanyl-crisis-greater-access-to-methadone-is-needed.

[24] Ibid.

[25] Lev Facher, “Methadone treatment gets first major update in over 20 years,” STAT News, Feb. 1, 2024. https://www.statnews.com/2024/02/01/opioid-addiction-methadone-clinic-regulations.

[26] Ibid.

[27] Stacey McKenna, “Unshackled from OTPs, Methadone Can Still Be Safe and Effective,” R Street Institute Explainer, April 11, 2024. https://www.rstreet.org/research/unshackled-from-otps-methadone-can-still-be-safe-and-effective.

[28] Ibid; American Society of Addiction Medicine, “The Modernizing Opioid Treatment Access Act,” ASAM Explainer, accessed Feb. 24, 2025. https://downloads.asam.org/sitefinity-production-blobs/docs/default-source/advocacy/letters-and-comments/methadone-resources/30.06.23_motaa-explainer.pdf?sfvrsn=e08d098e_1.

[29] Stacey McKenna, “How Red Tape Limits Access to Medications for Opioid Use Disorder,” R Street Institute Explainer, Nov. 7, 2023. https://www.rstreet.org/research/how-red-tape-limits-access-to-medications-for-opioid-use-disorder;  Hannah L.F. Cooper et al., “Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky,” International Journal of Drug Policy, 85 (November 2020). https://pubmed.ncbi.nlm.nih.gov/32223985.    

[30] Cooper et al. https://pubmed.ncbi.nlm.nih.gov/32223985; “DEA and HHS delay implementation of buprenorphine final rule,” American Hospital Association, Feb. 14, 2025. https://www.aha.org/news/headline/2025-02-14-dea-and-hhs-delay-implementation-buprenorphine-final-rule.  

[31] Mallory Locklear, “Treating opioid disorder without meds more harmful than no treatment at all,” YaleNews, Dec. 19, 2023. https://news.yale.edu/2023/12/19/treating-opioid-disorder-without-meds-more-harmful-no-treatment-all; John Strang et al., “Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study,” British Medical Journal, 326: 7396 (May 3, 2003), pp. 959-960. https://pmc.ncbi.nlm.nih.gov/articles/PMC153851.

[32] Chelsea Boyd, “Drug Use 101: Substance Use Disorders,” R Street Institute Explainer, Oct. 24, 2024. https://www.rstreet.org/research/drug-use-101-substance-use-disorders.

[33] Sun. https://www.feinberg.northwestern.edu/sites/ipham/news/The-unseen-epidemic-opioid-overdoses-among-older-adults.html.

[34] Stacey McKenna, “Drug Use 101: Physical Dependence and Withdrawal,” R Street Institute Explainer, Nov. 6, 2024. https://www.rstreet.org/research/drug-use-101-physical-dependence-and-withdrawal; Stacy Mosel, “Harm Reduction Guide,” American Addiction Centers, Jan. 17, 2025. https://americanaddictioncenters.org/harm-reduction.

[35] Nabarun Dasgupta et al., “Are overdoses down and why?” Opioid Data Lab, University of North Carolina Chapel Hill, Sept. 18, 2024. https://opioiddatalab.ghost.io/are-overdoses-down-and-why; Moiz Bhai et al., “Impact of Fentanyl Test Strips as Harm Reduction for Drug-Related Mortality,” Medical Care Research and Review, (Feb. 12, 2025). https://pubmed.ncbi.nlm.nih.gov/39936554.

[36] Olivia K. Sugarman et al., “Achieving the Potential of Naloxone Saturation by Measuring Distribution,” JAMA Health Forum, 4: 10 (Oct. 27, 2023). https://jamanetwork.com/journals/jama-health-forum/fullarticle/2811061; Stacey McKenna, “Rural Harm Reduction: Spotlight on Cochise County, Arizona,” R Street Institute Explainer, Jan. 28, 2025. https://www.rstreet.org/research/rural-harm-reduction-spotlight-on-cochise-county-arizona.

[37] Dasgupta et al. https://opioiddatalab.ghost.io/are-overdoses-down-and-why; Stacey McKenna, “Assessing the State of Over-the-Counter Naloxone Access,” R Street Institute Analysis, July 22, 2024. https://www.rstreet.org/commentary/assessing-the-state-of-over-the-counter-naloxone-access.

[38] McKenna, “Assessing the State of Over-the-Counter Naloxone Access”; Stacey McKenna, “Part 1: Exploring Cost and Emerging Landscape of Naloxone Competition,” R Street Institute Analysis, July 22, 2024. https://www.rstreet.org/commentary/part-1-exploring-cost-and-the-emerging-landscape-of-naloxone-competition; Stacey McKenna, “Part 2: Assessing the Retail Availability of OTC Naloxone,” R Street Institute Analysis, Aug. 22, 2024. https://www.rstreet.org/commentary/part-2-assessing-the-retail-availability-of-otc-naloxone.  

[39] Centers for Medicare and Medicaid Services, “How Medicare Covers Self-Administered Drugs Given in Hospital Outpatient Settings,” Jun. 2020. https://www.medicare.gov/Pubs/pdf/11333-Outpatient-Self-Administered-Drugs.pdf.

[40] McKenna, “Assessing the State of Over-the-Counter Naloxone Access.” https://www.rstreet.org/commentary/assessing-the-state-of-over-the-counter-naloxone-access.

[41] “Syringe Services Programs,” Centers for Disease Control and Prevention, accessed Feb. 22, 2025. https://www.cdc.gov/syringe-services-programs/php/index.html.

[42] “Syringe Services Programs: A NACo Opioid Solutions Strategy Brief,” National Association of Counties, Jan. 23, 2023. https://www.naco.org/resource/syringe-services-programs-naco-opioid-solutions-strategy-brief# 

[43] “Syringe Services Programs,” Centers for Disease Control and Prevention, accessed Feb. 22, 2025. https://www.cdc.gov/syringe-services-programs/php/index.html.

[44] Ibid.

[45] Sun. https://www.feinberg.northwestern.edu/sites/ipham/news/The-unseen-epidemic-opioid-overdoses-among-older-adults.html.