Topic 6 Assessment

How Psychologists Can Impact the Opioid Epidemic

Ashley C. Yaugher Utah State University Extension

Shane W. Bench and Kimberly J. Meyers Utah State University

Maren Wright Voss Utah State University Extension

Professional psychologists have an important role in addressing the current United States opioid epidemic through community engagement, collaboration, clinical practice, education, and scholarly activity. We review the contemporary opioid epidemic, with a special emphasis on the impact of opioid addiction in rural communities. The Utah State University Health Extension: Advocacy, Research, and Teaching (HEART) Initiative, based in nine counties in Utah, including rural Carbon and Emery counties, is uniquely reviewed as an example of a local, rural opioid prevention and intervention program. We discuss the why and how of multisystem, collaborative efforts as critical to combatting the opioid epidemic, and we drill down to psychologists playing a leading role in multidisciplinary, community action teams, leveraging their expertise in education/training, scholarly research, and evidence-based approaches in preventing and treating substance use disorders and specifically opioid use disorders. Psychologists are well poised to make significant positive impacts in our communities, states, and nationally.

Public Significance Statement The United States is being devastated by an epidemic of opioid-related deaths. This article reviews existing data and literature and gives an example of a local opioid-focused initiative to combat the opioid crisis. We discuss how and why psychologists are well positioned to make positive impacts on this national crisis through collaborative and community-based efforts. Our review focuses on experiences in rural Carbon and Emery counties, Utah through a new Initiative model.

Keywords: opioid, addiction, psychologist, initiative, rural

The United States of America is currently in the throes of its second opioid epidemic, with the first peaking in the 1890s (Kolodny et al., 2015). In 2017, the United States lost more lives to drug overdose than automobile accidents, with over 70,000 deaths resulting from overdose (approximately 68% of overdose deaths involved opioids; Scholl, Seth, Kariisa, Wil- son, & Baldwin, 2019), and slightly over 37,000 deaths from automobile accidents (National Center for Statistics and Anal-

ysis, 2019). The number of deaths resulting from drug overdose nearly doubled from 2007 (36,010; 11.9 per 100,000) to 2017 (70,237; 21.7 per 100,000). Furthermore, opioid overdoses ac- counted for over two and half times as many deaths in 2017 (47,600; 14.9 per 100,000) than 2007 (18,516; 6.1 per 100,000; Hedegaard, Minino, & Warner, 2018). This is an equivalent of almost 20,000 additional lives lost each year in only a de- cade.

X ASHLEY C. YAUGHER received her MS and PhD in clinical psychol- ogy from Texas A&M University. She is currently Health & Wellness faculty at Utah State University Extension and is the HEART Initiative Coordinator. Professional interests include collaboration; internalizing and externalizing disorders; and Opioid Use Disorder prevention, treatment, and recovery.

SHANE W. BENCH received his MS and PhD in social psychology from Texas A&M University. He is an assistant professor at Utah State Univer- sity. He is interested in the function of emotions, boredom, perceptions of risk, the self, and perceptions of science.

KIMBERLY J. MEYERS received her MS and PhD in counseling psychol- ogy from the University of Utah. She is a staff psychologist at Utah State University’s Counseling and Psychological Services, serving

statewide campuses. Professional interests include substance use, inter- nalizing disorders, mindfulness, self-compassion, and interpersonal re- lationship issues.

MAREN WRIGHT VOSS received her MS in psychology from University of Texas Southwestern and ScD in health sciences from Towson University. She is currently a HEART initiative faculty member at Utah State Univer- sity Extension. Professional interests include pain education using evidence-based community workshops, Opioid Harm Reduction and Well- ness Training in Tribal and Rural Utah, and increasing the rural Substance Use Disorder workforce.

CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Ashley C. Yaugher, Utah State University Extension, 751 East 100 North, Suite 2300, Price, UT 84501. E-mail: ashley.yaugher@usu.edu

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Professional Psychology: Research and Practice © 2020 American Psychological Association 2020, Vol. 51, No. 1, 85–93 ISSN: 0735-7028 http://dx.doi.org/10.1037/pro0000287

85

Some states have been hit harder than others during this epi- demic. Specifically, West Virginia (17.2), Maryland (11.5), and Utah (10.8) had the highest rate of prescription opioid deaths in 2017 per 100,000 population (Scholl et al., 2019). There are many hypotheses regarding why the rates are higher in these states versus others. For example, in West Virginia and Maryland there is a high rate of overdose related to the increased availability of illicit Fentanyl (National Institute on Drug Abuse [NIDA], 2019a, 2019c). While overdose rates also increased in Utah as a result of synthetic opioids, the leading overdose death rate (approximately 70%) was due to prescription opioid pain medications (NIDA, 2019b). This is consistent with other rural areas such as Virginia, where polydrug overdoses occurred most often with prescribed medications rather than illicit drugs (i.e., combined with antide- pressants or benzodiazepines), further implicating the role of pre- scribing practice discrepancies (Wunsch, Nakamoto, Behonick, & Massello, 2009). Additionally, interconnected rural social net- works have been theorized to facilitate diversion, distribution, and access as high prescription rates create availability for illegal markets (Keyes, Cerdá, Brady, Havens, & Galea, 2014).

According to the 2017 National Survey on Drug Use and Health assessment of substance use and mental health indicators for individuals 12 years and older, approximately 20.3 million people reported experiencing a substance use disorder (SUD) in 2016 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). Over 14 million people surveyed reported having an alcohol use disorder, and over 8 million people reported an illicit substance use disorder (including 2 million with an opioid use disorder and over 4 million with marijuana use disorder; SAMHSA, 2019). Opioid Use Disorder (OUD) includes the mis- use of prescription pain medication as well as the illicit substance heroin and other related chemical compositions such as Fentanyl (American Psychiatric Association, 2013; SAMHSA, 2019). Fur- thermore, it is estimated that over 80% of people who use heroin, first misused an opioid prescription (Jones, 2013), which they may have obtained legally or from a loved one (SAMHSA, 2019). Almost 10 million people are estimated to have misused opioid prescriptions, and over 808,000 are estimated to have used heroin in the past year (SAMHSA, 2019). These numbers are concerning given the high mortality and morbidity related to OUD (Hser et al., 2017) and the limited number of individuals who receive treatment for SUD. In fact, only an estimated 11.1% of people who needed treatment reported receiving treatment in a facility specializing in SUD services (SAMHSA, 2019).

The severity of the opioid epidemic has resulted in a broad response from a variety of different agencies. In 2018, the U. S. Department of Health and Human Services (HHS) provided over $800 million dollars to support prevention, treatment, and recovery efforts as well as developed the HHS 5-Point Strategy to Combat the Opioid Crisis. The strategy emphasizes (1) Access: improved access to prevention, treatment, and recovery support services; (2) Data: strengthening public health data and timely reporting to understand how to stop this crisis; (3) Pain: increasing practice of evidence-based pain management to treat pain; (4) Overdose: improving distribution and availability of overdose-reversal drugs (e.g., Naloxone) that are lifesaving; and (5) Research: enhancing addiction and pain research in cutting-edge methods (HHS, 2018). The U.S. Department of Agriculture (USDA) built a Community Assessment Tool that maps opioid overdose statistics in each

county in the US (USDA, 2019). In addition, the National Heroin Task Force (NHTF, 2015) reviewed the literature on legal, public health, and public safety recommendations, and reported that ef- fective solutions to the opioid epidemic include comprehensive and collaborative efforts with key stakeholders in an effort to reduce opioid-related deaths, specifically related to heroin. Taking a step further, the NHTF recommended the sharing of positive recovery stories, the increase of prevention and treatment efforts, and overdose prevention and education, among other activities, to address this epidemic.

As mentioned, the overdose rate in Utah is much higher than the national average (HHS, 2018). Consistent with Mack, Jones, and Ballesteros (2017), Utah’s rural counties, namely Carbon and Emery counties in Southeast Utah, experience significantly higher rates of opioid overdose than Utah’s more populated urban or suburban coun- ties. Carbon and Emery Counties are home to approximately 30,900 people combined (USDA, 2019) and have the highest rate of opioid overdose deaths in the state at 54.4 deaths per 100,000, 10 times the national average (i.e., UT Department of Health “hot spots”; Utah Department of Health, 2019; see Table 1).

Interviews with family members of decedents from opioid over- doses in Utah found that 63% had been unemployed, 59% had a recent financial problem, and 49% had been diagnosed with a mental health condition prior to the overdose death (Porucznik, Johnson, Sauer, Crook, & Rolfs, 2011). In Utah, families have been impacted by the opioid epidemic as family disruption and separation are on the rise (Adoption and Foster Care Analysis and Reporting System, 2017). Furthermore, an increasing number of infants have been born with symptoms of neonatal opioid with- drawal syndrome or neonatal abstinence syndrome as a result of opioid use during fetal development (NIDA, 2015).

The opioid epidemic is complex and multifaceted and requires an equally multifaceted and comprehensive community-driven, public health response. This is particularly true in rural commu- nities who face limited resources and infrastructure (e.g., adequate health care and workforce; Rosenblatt, Andrilla, Catlin, & Larson, 2015). However, the strength of rural communities lies in their mutually supportive and collaborative spirit. Collaboration is a key ingredient to successful public and community health program- ming (Hearld, Alexander, Wolf, & Shi, 2019), and to address the opioid epidemic in Utah, a uniquely rural collaborative approach grounded in established and trusted relationships was needed. Building upon this, the rural communities of Carbon and Emery as well as seven other identified counties in Utah targeted the re- sources and community-action expertise of Utah State University’s (USU) land-grant Cooperative Extension offices, funded by the U.S. Department of Agriculture (USDA), to examine and imple- ment community-based strategies to end the opioid crisis.

USDA’s Cooperative Extension has traditionally supported ag- ricultural, animal, and food sciences, but in 2014, USDA intro- duced a new national Health and Wellness focus across the land- grant institutions. Combined with national support from organizations such as the Robert Wood Johnson Foundation, USU modified its Health and Wellness Extension model to address the opioid epidemic and specifically engaged nine counties in Utah where opioid overdose deaths were higher than the national aver- age (i.e., rural Carbon, Emery, and Tooele Counties; and urban Box Elder, Weber, Salt Lake, Utah, Davis, and Cache Counties; Centers for Disease Control and Prevention, 2018b).

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86 YAUGHER, BENCH, MEYERS, AND VOSS

The purpose of the HEART Initiative is to bring unique aca- demic resources into the community by partnering locally and nationally to address the opioid epidemic and other pressing public health issues. By doing so, the HEART initiative could maximize community-level partnership among county health departments, community coalitions, providers, and other key stakeholders, as well as coordinate strategic community solutions and on-the- ground efforts and produce measurable impacts on reducing Utah’s opioid epidemic. Using a participatory community-action framework, the HEART Initiative identified four opioid-related action items: (1) Prevention and education through collaborative partnerships; (2) Stigma reduction through education and promo- tion of recovery messages; (3) Strengthening community ties through connecting and engaging key stakeholders; and (4) Harm reduction promotion through education and evidence-based pro- gramming. Increasing prevention efforts and harm reduction ef- forts through education and collaborative community approaches is an evidence-based way to make a significant impact in commu- nities (Centers for Disease Control & Prevention, 2018a). The HEART community-developed objectives coincided with many elements of the U.S. Department of Health and Human Services (HHS, 2018) agency’s Five-Point Strategy to combat the opioid crisis (better overdose reversal drugs; better research; better data; better pain management; better access to SUD prevention, treat- ment, and recovery services).

The HEART Initiative is anchored by a multidisciplinary team that includes a psychologist along with specialists in public health, evaluation, emergency services, and health education, among oth- ers. They have built on existing rural and urban partnerships to swiftly bring new evidence-based resources and programming into local communities. Within the first year of the collaborative ini- tiative, HEART faculty had state-wide impact through publishing

dozens of opioid and wellness focused newspaper articles, fact sheets, and journal articles (i.e., 29 newspaper articles produced, 13 HEART features on websites, 6 peer-reviewed journal articles produced, 10 peer-reviewed fact sheets produced, and 11 other authored publications). HEART faculty were also successful in opioid-focused program implementation (i.e., 37 one-time educa- tional events such as health fairs, trainings, and seminars; 82 conferences and professional events were attended and/or sup- ported by HEART faculty input), distributing harm reduction education and Naloxone training (i.e., 426 Naloxone kits distrib- uted and several confirmed saves related to education on opioid overdose reversal), and bringing in millions of dollars in additional funding through collaborative partnerships (i.e., over $3.3 million; and $70,700 in internal funding acquired) to support local preven- tion and treatment programming.

The HEART Initiative created the readiness and resource infra- structure necessary to acquire a large federal Substance Abuse and Mental Health Services Administration (SAMHSA) partnership grant for Rural Opioid Technical Assistance funds. Under the leadership and collaboration with the USU Extension Health and Wellness Specialist, the HEART psychologist and other key part- ners coordinated a rural opioid summit for community members, partially funded by the SAMHSA grant. The community-wide summit held in rural Carbon County, Utah had attendance that exceeded planned capacity. The summit provided a space for rural health care professionals to earn opioid-focused continuing edu- cation credit and bring state-wide attention to opioid concerns from rural community members. Additionally, the summit focused on stigma reduction and provided culturally sensitive education materials, under the guidance of tribal liaisons. The SAMHSA funds have allowed expansion of programming to rural areas of the state, with limited access to other resources, development of edu-

Table 1 Carbon and Emery Demographic and Economic Information With State and National Comparison Data

Descriptor Carbon County Emery County Utah United States

Demographics Population 20,512 10,410 2,993,941 327,167,434 Substance use mortality rate per 100k 87.9 51.7 32.5 25.1 Opioid overdose mortality rate per 100k 69.1 42 23.5 16.4 Between the ages 15–64 62.1% 58.8% 64.1% 66.1% High School Diploma (25�) 89.7% 93.3% 91.8% 87.3% Bachelor’s or more (25�) 15.7% 15.0% 32.5% 30.9%

Race/Ethnicity White (non-Hispanic) 83.3% 91.4% 79% 61.5% Hispanic or Latino 13.2% 6.2% 13.7% 17.6% American Indian/Alaska Native 0.8% 0.7% 0.9% 0.7% African American 0.7% 0.1% 1.1% 12.3% Asian 0.4% 0.6% 2.2% 5.3% Native Hawaiian/Pacific Islander 0.2% 0.0% 0.9% 0.2%

Economy Median household income $46,994 $51,852 $65,325 $57,652 Poverty rate 16.2% 12.9% 11.0% 14.6% Unemployment rate 5.4% 4.4% 4.4% 6.6% Construction 4.8% 11.1% 6.3% 4.6% Mining and natural resources 7.7% 10.3% 1.2% 1.4% Manufacturing 3.8% 0.6% 9.2% 8.8% Trade, transportation, & utilities 23.0% 28.8% 19.4% 19.1%

Note. Data are from 2013 to 2017. Job types listed are employment with high accident-proneness. Data was retrieved from the U.S. Department of Agriculture on August 11, 2019 from the USDA Community Assessment Tool: https://opioidmisusetool.norc.org/.

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87PSYCHOLOGISTS AND THE OPIOID EPIDEMIC

cational materials in an online format, and continued collaboration with key stakeholders. Community members completed feedback questionnaires during this and other summits and overwhelmingly stated that they felt they now had additional tools to use to make an impact, including training on how to save a life with Naloxone. Community members have consistently expressed a continued need for a team-based, local model such as HEART (Listening Session Report, H. E. A. R. T., 2018). Additionally, community members have verbally reported at the HEART Initiative events and programming that they are noticing increased community awareness and literacy in just one year (July 2018 to July 2019). The addition of faculty with an opioid focus into rural counties has bolstered local efforts in supporting prevention capacity and opioid-monitoring programs, and initiated the collection of a dig- ital repository of personal opioid narratives. The HEART initiative is one example of a local response led by a psychologist aimed at lowering opioid overdose deaths, increasing public education, and advancing access to care.

How Psychologists Can Help

Psychologists are well positioned and trained to contribute to combatting the opioid epidemic. We identify three pillars of sup- port that psychologists are uniquely qualified to provide: Pillar 1, Psychologists as part of multidisciplinary teams or initiatives; Pillar 2, Psychologist as directly involved in treatment and patient management; and Pillar 3, Psychologists as engaged in educational and scholarly work exploring the etiology and prevention of future epidemics. Each of these pillars is connected to the implementation and assessment of evidence-based efforts that can impact and reduce the opioid epidemic.

Pillar 1: Multidisciplinary Teams: HEART an Opioid Collaborative in Utah

Psychologists are trained clinicians, researchers, and educators, but it is their collaborative leadership skills that stand out. While the HEART Initiative is far different than direct treatment or clinical consultation, psychologists contribute by making mean- ingful connections and following research to identify key partners needed to make large impacts (Fouad et al., 2009). For example, the clinical expertise of a psychologist on the HEART team has elevated collaboration with and sustained involvement from the Veterans Affairs (VA) health care of Salt Lake City. This has resulted in the VA piloting their alternative pain education and opioid monitoring program (PC-POP) in Carbon and Tooele coun- ties (Clinton-Lont, Kaye, & Martinson, 2016). Further examples include the HEART team psychologist developing and chairing the Carbon and Emery Opioid and Substance Use Coalition after an initial needs assessment. The group is then guided by the psychol- ogist in an evidence-based model to ensure positive impact (e.g., Strategic Prevention Framework; Peterson, et al., 2019). Further- more, the psychologist-led multidisciplinary team was able to reach deep into the community to facilitate an expanded reach of opioid prevention efforts. In fact, with the five-faculty team, HEART added 45 community coalitions to our network for local impacts.

Pillar 2: Evidence-Based Treatment

Substance Use Disorders (SUDs) encompass a wide range of behavioral, cognitive, and physiological symptoms that are orga- nized in the Diagnostic and Statistical Manual of Mental Disor- ders, 5th Edition (DSM–5) into 10 classes of substances (e.g., Alcohol; Cannabis; and Opioid-Related Disorders; American Psy- chiatric Association, 2013). An SUD occurs when, despite substance-related issues (i.e., impairment in home or work life), the individual continues using the substance (American Psychiatric Association, 2013). Diagnosis of an SUD is based on 11 criteria that describe the various clusters of symptoms (e.g., tolerance, withdrawal, craving, etc.; American Psychiatric Association, 2013).

Psychologists are essential in the treatment and prevention of SUDs, including OUD. In recent years, the focus of psychologists’ work in this area has been the research, development and imple- mentation of evidence-based treatments (EBTs). This is in recog- nition of the critical importance that ethical professionals only use treatments with demonstrated effectiveness supported by scientific evidence. Psychologists can play a significant role throughout the spectrum of prevention from primary prevention to secondary and tertiary prevention. The field of psychology has a history of being engaged in establishing best practices for prevention interventions that benefit both individuals and communities (American Psycho- logical Association [APA], 2014, 2019).

There are several evidence-based treatments for SUDs and OUDs, as well as for managing chronic pain disorders without the use of prescription opioids. In addition, psychologists are influen- tial in primary care, community mental health centers, substance use treatment facilities, and other health care settings in instituting best practices for OUD treatment that include these EBTs as well as educating treatment providers in their use. Within this domain, psychologists serve as educators to advocate for evidence-based Medication Assisted Treatment for OUD in many contexts (e.g., at center administration, governing boards, media, clientele, and other audiences) to ensure that these treatments are instituted in a comprehensive, safe, and effective manner.

Psychologists have a long history of treating SUDs in both individual and group therapy settings. As EBT’s have been ex- plored, many meta-analyses have consistently shown support for the use of cognitive behavioral therapy (CBT) in treating SUDs (Glasner-Edwards & Rawson, 2010; Herbeck, Hser, & Teruya, 2008; McGovern & Carroll, 2003; McHugh, Hearon, & Otto, 2010). The use of CBT in treating SUDs utilizes many of the same techniques that are used to treat other mental health disorders, such as depression and anxiety. The CBT approach helps the individual to explore thinking and behavioral patterns, as well as evaluate environmental influences, to alter the individual’s responses and reduce and eliminate the use of substances (McHugh et al., 2010). Part of the CBT approach for SUDs is to emphasize the importance of relapse prevention, which helps the individual to explore trig- gers for substance use, and to enhance skills for sobriety and coping with these triggers without the use of substances (Larimer, Palmer, & Marlatt, 1999). Relapse prevention strategies help to normalize the difficulties of making changes in substance use behavior, such as cravings, to help the individual maintain absti- nence (Larimer et al., 1999). For example, a randomized clinical trial conducted by Barry and colleagues (2019) found a higher

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88 YAUGHER, BENCH, MEYERS, AND VOSS

proportion of individuals in the CBT group maintained abstinence from nonprescribed opioids than those in the Methadone Drug Counseling group, and both groups reported reductions in pain. These findings support the use of CBT to help individuals with opioid use disorders achieve and maintain abstinence from opioids.

Another EBT for SUDs is the use of motivational enhancement therapy (MET). Such interventions arise from the motivational interviewing work of Miller and Rollnick and adapting interven- tions to an individual’s readiness for change based on the Prochaska and DiClemente’s Stages of Change Model (Miller, Benefield, & Tonigan, 1993; Prochaska & DiClemente, 1983). MET helps the individual to explore the pros and cons of contin- ued substance use, as well as the pros and cons of making changes to their use behavior. This technique helps the individual to ex- plore any ambivalence they have toward committing to behavioral changes, as well as provides them positive support as they take action to reduce their use of substances (Miller et al., 1993). One study found that 52% of veterans with chronic pain and SUD maintained abstinence from substances for over six months after participation in a MET intervention (Cummins & Tobian, 2018). The veterans reported that the MET intervention helped to gain insight into their use, increase their motivation to change, and increase abstinence (Cummins & Tobian, 2018).

Psychologists can also be helpful in the treatment of chronic pain, ultimately reducing the likelihood of an individual develop- ing OUD. Psychologists in primary care settings or working as part of a multidisciplinary team with physicians may directly impact pain and opioid management through patient education and treat- ment (Binswanger et al., 2018; Clinton-Lont et al., 2016). Specif- ically, evidence-based treatments for chronic pain are CBT for Pain, Mindfulness Based Stress Reduction, and Acceptance and Commitment Therapy. There are a number of other approaches for pain management including physical therapy, biofeedback, relax- ation therapy, meditation, and progressive muscle relaxation (see the pain management report by the American Society of Anesthe- siologists Task Force on Chronic Pain Management, 2010 for more information). Interestingly, many individuals seeking treatment for chronic pain are often under the care of physicians, but are not always referred for psychological care due to limited resources or other issues related to coverage, despite this being a recommen- dation by the CDC (Dowell, Haegerich, & Chou, 2016). Psychol- ogists can help individuals with chronic pain by providing educa- tion about pain, cognitive interventions to help reframe how the individual interprets their pain, as well as pain management skills (Coakley & Wihak, 2017).

A unique EBT used in the treatment of OUD is Medication Assisted Treatment (MAT). MAT is the combination of FDA- approved medications for the treatment of OUD and psychosocial/ behavioral therapy(ies). MAT requires the care of a qualified medical provider (i.e., DATA 2000 waiver physician, nurse prac- titioner, or physician assistant), who prescribes either an agonist medication (e.g., Buprenorphine or Methadone) to reduce with- drawal symptoms, or an antagonist medication (e.g., Naltrexone) to block the effects of opioids if used (Connery, 2015; Herbeck et al., 2008; McGovern & Carroll, 2003). Medication is paired with psychosocial/behavioral treatments (e.g., addiction counseling, contingency management, case management, recovery support ser- vices) to address co-occurring concerns (Dugosh et al., 2016; McGovern & Carroll, 2003; “Medical Experts,” 2019). MAT for

OUD are often met with resistance by patients and providers, particularly in rural areas, due to stigma and lack of understanding. This is fueled by lack of education and bias given the continued use of opioids in a controlled environment, and despite the strong evidence base for their use MAT interventions are not always covered by insurance (Center for Substance Abuse Treatment, 2005; Chou et al., 2016; SAMHSA, 2018; Williams & Bisaga, 2016). However, there are many pathways to recovery, and a patient-centered, multidisciplinary approach is recommended as the leading evidence-based treatment modality for individuals with SUD and OUD (HHS, 2019; SAMHSA, 2018). MAT for OUD continues to be demonstrated as an effective and efficacious treat- ment modality (Connery, 2015; for more specific recommenda- tions see SAMHSA, 2018 and HHS, 2019).

In a recent testimony, Dr. Arthur Evans, Chief Executive Officer of the APA, before the U.S. House of Representatives Committee on Oversight and Reform, stated that we need to expand care for a “whole person” approach (e.g., biological, social, interpersonal, and treatment aspects of addiction and recovery; “Medical Ex- perts,” 2019). Pain is a biopsychosocial phenomenon rather than strictly physical in nature, and psychologists are particularly useful in addressing pain from this model. The full spectrum of OUD and SUD supports need to be considered to reduce overdose deaths. One recommendation to address this is the Comprehensive Addic- tion Resources Emergency (CARE) Act as described by Evans (“Medical Experts,” 2019). He stated that “success in fighting the overdose epidemic will require enabling the delivery of an array of services spanning prevention, treatment, recovery, and supports. . . . ” (“Medical Experts,” 2019).” Evans further stated that evidence- based practices, such as the examples above, are integral in reduc- ing overdoses, OUDs, and implementing effective treatment, in addition to family therapy and stable housing to encompass the “whole person” (“Medical Experts,” 2019).

There are many available resources for practicing psychologists to gain further information on the treatment of OUD. In fact, the June 2019 APA Monitor on Psychology, (APA, 2019) published a review of the many ways psychologists can positively impact this crisis. Within this issue, authors suggest encouraging treatment seeking by reducing stigma, increasing prevention efforts, using evidence-based treatment, and advocating for improved policies and practices, among other important topics (APA, 2019). In addition to being aware of emerging data, assessment tools, and evidence-based treatments, it is important to maintain competency in our efforts as psychologists to respond to this opioid epidemic as it continues to progress and change (APA, 2018).

Pillar 3: Educational and Scholarly Work

Psychology is the scientific understanding of the mind and behavior. This places psychologists in a unique position to assist with eradicating the opioid epidemic, as—akin to many of the leading causes of mortality (e.g., alcohol consumption and tobacco use, poor nutrition, and limited physical activity; Mokdad, Marks, Stroup, & Gerberding, 2004)—the opioid epidemic is attributable to behaviors. Changing behavior, including health-related behav- ior, is not as easy as simply providing information, yet psycholo- gists possess an understanding of the factors that can contribute to behavior change (e.g., motives, cognitions, situations; Klein, Shep- perd, Suls, Rothman, & Croyle, 2015). This knowledge allows

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psychologists to research broad health-related behaviors (Klein et al., 2015), such as SUDs, and alternative pain management tech- niques. This area is currently in demand, with the National Insti- tute of Health launching an initiative in 2018, Helping to End Addiction Long-Term (HEAL). HEAL focuses on treatment re- search to address OUD and improve treatment through research (Collins, Koroshetz, & Volkow, 2018). HEAL seeks to enhance pain management strategies through better understanding of pain and nonpharmacological treatments, as well as research treatment for addiction to further illuminate effective treatment modalities (Collins et al., 2018). Additionally, psychologists studying animal models of behavior, a nontraditional role for psychology practitio- ners, can also illuminate relationships among neuronal effects of substance use, addiction, treatment, and recovery that we may not otherwise have access to (Smith et al., 2018).

Psychologists have emphasized expertise in the scientific method to be integral to the discipline (APA, 2013), and psychol- ogists are trained in research design, study assessment, critical thinking, and data analysis and interpretation. In fact, scientific inquiry skills are valued so greatly by psychologists that it is recommended for inclusion in introductory level psychology courses (APA, 2011). The scientific skills emphasized by psychol- ogists have a much broader value, with the National Science Board recently stating, “Appreciating the scientific process can be even more important than knowing scientific facts” (National Science Board, 2008, p. 16). Specific to the opioid epidemic, psychologists can include updated, relevant, and evidence-based information about opioids and the opioid crisis in their lectures, presentations, and outreach activities to provide much-needed education to the general public and other clientele served by psychologists.

In an introductory psychology course, the scientific method is often a critical teaching component and is an excellent time to teach about application of this method to combat the opioid and other public health crises in a positive manner. Indeed, one study supports a direct effect of scientific inquiry skills training in reducing positive perceptions of substances in teenagers. Sadrabad and Sohrabi (2011) found that Iranian high school students trained in critical thinking and scientific inquiry skills reported more negative attitudes toward substance abuse. The study had several limitations, including a small sample size (20 students in each condition), using a self-reported measure of attitudes, and not directly assessing behaviors related to substances. However, it showed encouraging results that future studies should seek to replicate and expand. Pending additional research support, this could demonstrate a direct impact on the opioid epidemic as a result of psychological education that emphasizes scientific in- quiry and critical thinking skills.

Psychologists contribute even more broadly through the appli- cation of scientific inquiry skills. For instance, the widespread acceptance of opioids as a long-term treatment for chronic non- cancer pain developed from the spread of misinterpreted and misrepresented scientific studies (Kolodny et al., 2015). Specifi- cally, the foundation for the current epidemic stemmed from the misinterpretation and overstatement of a small sample study (Portenoy & Foley, 1986) that provided low-quality scientific evidence that was used by pharmaceutical manufacturers in an invalid way to suggest that the long-term use of opioid pain relievers was safe (see Juurlink & Dhalla, 2012) and the risk of addiction was exceptionally low (e.g., Medina & Diamond, 1977).

As a result, prescribers are now being trained and building com- petencies in this area to continue to combat this misinformation, and psychologists can play a key role in integrated health care settings to educate providers on this information as well (Baird et al., 2014; McDaniel et al., 2014). Additionally, psychologists can aid the prevention of this type of misinformation in the future by contributing to interdisciplinary research teams.

The opioid crisis is a complex problem, with no single or simple solution, and will require not only scientific thinking and inquiry, but also a “whole person” and multidisciplinary approach (e.g., McDaniel et al., 2014). Through collaboration with public health agencies and scholars in other disciplines, psychologists can work to disseminate the knowledge of psychological principles to be integrated by experts in other disciplines, thus resulting in a more widespread use of critical thinking and seeking of evidence-based information.

Implications and Applications

Psychologists have numerous important roles to play in turning the tide of the opioid epidemic. This range of roles includes community engagement, involvement in multidisciplinary teams, clinical practice, and educational and scholarly work. First, psy- chologists can be effective team members within treatment set- tings, on initiatives, and in other collaborative efforts. For exam- ple, McDaniel and colleagues (2014) suggest that psychologists are important as multidisciplinary team members in addressing the “whole person” and are important in becoming involved in inte- grated or primary care with other disciplines. Psychologists, as part of a multidisciplinary team, are providing critical education on evidence-based practices, such as reducing stigma around contro- versial methods and encouraging communities to support mental health treatments that are effective. The Utah State University HEART initiative is a multidisciplinary and collaborative initiative model that exemplifies how psychologists can make changes from the local to the state and national level. Multidisciplinary teams are most effective when there is a cohesive team with good processes (e.g., a shared team vision, multiple meetings or interactions, and team member trust) that focus on quality of programming, and where team members feel connected with or learn with their group (Fay, Borrill, Amir, Haward, & West, 2006; Van Der Vegt & Bunderson, 2005).

We reviewed how psychologists can impact substance use and addiction, with a focus on OUD through clinical practice. Findings suggest the use of evidence-based treatments (EBTs) in the treat- ment of these substance use related disorders. Furthermore, there is support in psychology training programs to promote the under- standing and use of EBTs in clinical practice and train the next generation of psychologists to do the same (Fouad et al., 2009; Rodolfa et al., 2005). Specifically, practitioners and programs should strive to review current EBTs and provide the best treat- ment to clientele seeking support. Additionally, it is important for us to remember that the vast majority of individuals who need treatment services struggle to receive them and that our treatment models (face-to-face, online, group, etc.) should continue to evolve to provide EBTs to the individuals who need them most (Kazdin, 2017). Psychologists can work to develop and implement EBTs with a range of delivery models and educate patients, families, and

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communities about their effectiveness, whether it be in urban or rural settings.

Finally, psychology as a field is focused on the teaching and development of critical thinking and scientific inquiry skills. This supports the use of psychological teaching and study to continue improving critical thinking as well as the training of future psy- chologists and the general public in key competency areas (e.g., teaching, clinical practice, and critical thinking; Fouad et al., 2009). Providers in clinical practice may also find these skills useful to encourage the use of EBTs by colleagues, as a self- assessment of competency, and to encourage critical thinking in their clientele and the public that they serve. Psychologists should strive to join multidisciplinary research teams—contributing ex- pertise in behavior and motivation to understanding complex health behaviors—and work to disseminate findings to the general public in an accessible way (e.g., media outlets).

While we have made significant strides and continue to devote additional research to OUD and turning the tide of the contempo- rary opioid epidemic, more can be done. For example, mentorship in public health or community related initiatives may improve psychologists’ attitudes toward seeking careers in this area (Eby, Allen, Evans, Ng, & DuBois, 2008). Through these three pillars reviewed (i.e., multidisciplinary teams and collaborative initia- tives, clinical practice, and educational and scholarly work) and others, psychologists are well poised to make significant positive impacts in our communities, states, and nationally.

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Received April 26, 2019 Revision received November 21, 2019

Accepted November 22, 2019 �

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