Literature Collection

The current opioid epidemic in the United States has been characterized as having three waves: prescription opioid use, followed by heroin use, and then use of synthetic opioids (e.g., fentanyl), with early waves affecting a population that was younger, less predominantly male, and more likely to be Caucasian and rural than in past opioid epidemics. A variety of recent data suggest that we have entered a fourth wave which can be characterized as a stimulant/opioid epidemic, with mental illness co-morbidities being more evident than in the past. Stimulant use has introduced new complexities in terms of behavioral consequences (e.g., neurological deficits, suicidal ideation, psychosis, hostility, violence), available treatments, and engagement into services. These compound existing issues in addressing the opioid epidemic in rural areas, including the low density of populations and the scarcity of behavioral health resources (e.g., fewer credentialed behavioral health professionals, particularly those able to prescribe Buprenorphine). Considerations for addressing this new wave are discussed, along with the drawbacks of a wave perspective and persistent concerns in confronting drug abuse such as stigma.

The last quarter century has seen a clear move internationally towards greater integration between healthcare service types - including across mental and physical health - as well as with social care. The drivers include growing population complexity and clinical need, and a recognition that the broader evidence base supports better outcomes and cost effectiveness through tackling social determinants of health in a more joined-up and preventative manner. Challenges have included a lack of granularity about which approaches work best at a local level, which data might support learning from these, and how we might disseminate this between often very different systems and populations. The next 25 years will see renewed efforts towards greater integrated and preventative community approaches. However, we still lack a consensus about inpatient provision and need to optimise this through clinically led learning and care models. Technology is at a point where we can have digital infrastructure that pulls large-scale population-level clinical effectiveness data. The opportunity is to anchor this as our key tool to grow and refine better care models, augmenting more traditional process and governance data-sets, and therein also leverage research findings into measured novel implementation in practice.