The number of overdose deaths in the United States from the use of illicit drugs and the misuse of prescription drugs has risen to unprecedented levels. This crisis has worsened despite dozens of ongoing federal, state, local, and private sector efforts to prevent drug misuse and to treat substance use disorders.
Over 70,000 people died from drug overdoses in 2017, according to the Centers for Disease Control and Prevention. Drug overdoses are the leading cause of death due to injuries in the United States; since 2011, they have outnumbered deaths, respectively, by firearms, motor vehicle crashes, suicide, and homicide, according to the Drug Enforcement Administration (DEA).
The use of illicit drugs and the misuse of prescription drugs—and the ways they affect individuals, their families, and the communities in which they live—are important challenges facing our nation. The federal government spent nearly $30 billion dollars on drug control efforts in 2017, including efforts related to prevention, treatment, international counternarcotics activities, and law enforcement. These efforts often involve multiple agencies and issue areas such as health care, education, and social services—and they face a number of challenges.
Limiting prescription drug misuse and illicit drugs
Federal agencies have ongoing efforts to curb the misuse of prescription drugs, as well as the supply of illicit drugs.
The Centers for Medicare and Medicaid Services (CMS) provides guidance to Medicare Part D plan sponsors about monitoring beneficiaries who receive opioid prescriptions. However, CMS needs to improve its efforts. For example, CMS does not collect sufficient information to know the total number of at-risk beneficiaries receiving high doses of opioid prescriptions—information that would help CMS assess its progress toward reducing misuse.
Federal agencies are working to limit the domestic availability of illicit synthetic opioids. For example, federal agencies like the DEA collaborate with foreign governments and international organizations to help limit the production of illicit synthetic opioids. However, some of the strategies that federal agencies use do not include outcome-oriented performance measures. Without such measures, agencies cannot assess whether their efforts are helping limit the availability of illicit synthetic opioids.
The Departments of Defense (DOD), Homeland Security, Justice, and State carry out international counternarcotics activities in places such as Mexico and Colombia to disrupt the flow of illicit drugs and dismantle drug trafficking organizations. For example, the U.S. counternarcotics approach in Colombia includes disrupting drug trafficking, destroying coca crops, and supporting alternative livelihoods for coca farmers. However, the State Department has not comprehensively reviewed the benefits and limitations of this approach.
The U.S. Postal Service (USPS) and U.S. Customs and Border Protection (CBP) work with express consignment carriers like FedEx and DHL to inspect international express cargo and mail for illicit drugs entering the country. While express consignment carriers provide electronic advance data for inbound express cargo (allowing CBP to target its inspections), USPS is not required to provide similar information to CBP.
The National Guard counterdrug program supports federal, state, local, and tribal law enforcement organizations counterdrug activities. However, DOD lacks a strategy for this program, and needs to improve how it approves and funds these activities.
Measuring access to treatments
Opioids—both prescription and illicit—are currently the main driver of drug overdose deaths. One of the methods for treating opioid use disorder is medication-assisted treatment (MAT), which is a combination of behavioral therapy and medications like methadone and buprenorphine. The Department of Health and Human Services (HHS) has established a goal to expand access to MAT but needs to improve measurement of whether its efforts are successful or whether new approaches are needed.
Neonatal abstinence syndrome (NAS)—a condition causing withdrawal symptoms in newborns such as difficulties breathing and feeding—has also increased as a result of the opioid crisis. In May 2017, HHS published a strategy with key recommendations to help address some of the challenges related to treating NAS. However, HHS lacks a sound plan for implementing these recommendations, such as establishing priorities, stakeholder responsibilities, implementation timeframes, and methods for assessing progress.
Federal law requires governors of all states to provide assurances that their states have laws or programs that include policies and procedures to address the needs of infants affected by prenatal substance use. While HHS provides some guidance and technical assistance to implement this federal law, it needs to expand its assistance to help states better implement protections for children.
Curbing demand
In 2016, experts at a Comptroller General Forum identified several high-priority areas to help prevent illicit drug use and the misuse of prescription drugs. These include:
Supporting community coalitions made up of the health care, education, and law enforcement sectors that work in concert to prevent illicit drug use at the local level
Consolidating federal funding for multiple prevention programs into a single fund that addresses a range of unhealthy behaviors (including illicit drug use)
Increasing the use of prevention programs that have been proven to be effective
Supporting drug prevention efforts in primary-care settings—such as reimbursing providers for conducting preventative drug screenings
National drug control strategy
The Office of National Drug Control Policy is responsible for overseeing and coordinating the implementation of U.S. drug policy, including the development of the National Drug Control Strategy. The 2010 Strategy included seven goals related to reducing illicit drug use and prescription drug misuse, but the government made mixed progress on achieving those goals. The 2019 Strategy focuses on reducing the availability of illicit drugs, as well as prevention, treatment and recovery.
Drug Control: DOD Should Improve Its Oversight of the National Guard Counterdrug Program
GAO-19-27: Published: Jan 17, 2019. Publicly Released: Jan 17, 2019.
The National Guard counterdrug program has supported domestic law enforcement counterdrug activities for more than 30 years. In our review of the program, we found: DOD's strategy is out of date and doesn't reflect current drug threats. In 2014, the National Guard rescinded its guidance for states on how to operate and administer the program—and hasn't replaced it yet. DOD has funded state c...
Colombia: U.S. Counternarcotics Assistance Achieved Some Positive Results but State Needs to Review the Overall U.S. Approach
GAO-19-106: Published: Dec 12, 2018. Publicly Released: Dec 12, 2018.
The U.S. government has invested over $10 billion in counternarcotics and security efforts in Colombia since 1999. Security has improved but cocaine production has more than tripled from 2013 through 2017. The U.S. counternarcotics approach in Colombia includes disrupting drug trafficking, destroying coca crops, and supporting alternative livelihoods for coca farmers. We found the State Departmen...
Opioid Crisis: Status of Public Health Emergency Authorities
https://www.gao.gov/products/GAO-18-685R
GAO-18-685R: Published: Sep 26, 2018. Publicly Released: Oct 23, 2018.
Over 42,000 people died from opioid overdoses in 2016, according to the Department of Health and Human Services (HHS). Partly due to this, HHS declared the opioid crisis a public health emergency on October 26, 2017. This declaration allows HHS some leeway to conduct certain activities in response to the opioid crisis. For example, we found that HHS waived the public notice period for approval of...
VA Health Care: Progress Made Towards Improving Opioid Safety, but Further Efforts to Assess Progress and Reduce Risk Are Needed
GAO-18-380: Published: May 29, 2018. Publicly Released: May 29, 2018.
The VA has been working to address opioid safety for veterans and has made progress in reducing opioid prescriptions. For example, VA has started a program to educate providers on best practices related to pain management and the optimal use of opioids. However, we found that VA has not fully met all of its opioid safety goals. Its health care providers also are not consistently adhering to evide...
Prescription Opioids: Medicare Needs Better Information to Reduce the Risk of Harm to Beneficiaries
GAO-18-585T: Published: May 29, 2018. Publicly Released: May 29, 2018.
What can Medicare do to help address the nation's opioid crisis? We've previously found problems such as "doctor shopping" and questionable prescribing practices in Medicare's prescription drug benefits. 14.4 million people were prescribed at least one opioid through Medicare in 2016. While many opioids prescribed addressed legitimate need, others may have been overprescribed. This testimony rev...
Illicit Opioids: Office of National Drug Control Policy and Other Agencies Need to Better Assess Strategic Efforts
Federal agencies have documented specific strategies to combat illicit opioids. However, only one of the five strategies we reviewed included outcome, or results-oriented measures—largely due to agency perceptions that designing such measures posed challenges. Without specific outcome-oriented performance measures, federal agencies will not be able to truly assess whether their respective invest...
Illicit Opioids: While Greater Attention Given to Combating Synthetic Opioids, Agencies Need to Better Assess their Efforts
GAO-18-205: Published: Mar 29, 2018. Publicly Released: Apr 12, 2018.
Federal agencies collaborate with foreign governments, such as China, Mexico, and Canada, as well as with international organizations, to limit the production of illicit synthetic opioids. They do this by enhancing investigations, sharing information on emerging trends, helping to expand the regulation of illicit substances, and building capacity to thwart the distribution of illicit drugs. Feder...
GRAPHIC: INFOGRAPHIC: Stopping the Misuse of Fentanyl and Other Synthetic Opioids
Substance-Affected Infants: Additional Guidance Would Help States Better Implement Protections for Children
GAO-18-196: Published: Jan 19, 2018. Publicly Released: Feb 8, 2018.
All states reported adopting, to varying degrees, policies and procedures regarding health care providers notifying child protective services (CPS) about infants affected by opioids or other substances. Under the Child Abuse Prevention and Treatment Act (CAPTA), as amended, governors are required to provide assurances that the states have laws or programs that include policies and procedures to ad...
Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness of Efforts to Expand Access to Medication-Assisted Treatment
Over 52,000 people died of drug overdoses in 2015—and 63% of these involved opioids. For those who are addicted to or misuse opioids, medication-assisted treatment (MAT)—behavioral therapy combined with medication (such as buprenorphine)—can help. However, many people who need it don't have access to it. The Department of Health and Human Services implemented a number of efforts to improve...
Counternarcotics: Overview of U.S. Efforts in the Western Hemisphere
Most of the illicit drugs consumed in the United States come from other countries in the Western Hemisphere. For example, most of the heroin and cocaine reaching the U.S. market originates in Mexico and Colombia, respectively. Congress established the Western Hemisphere Drug Policy Commission in 2016 to evaluate the activities of U.S. counternarcotics programs in the region. We reviewed these act...
Preventing Drug Abuse: Low Participation by Pharmacies and Other Entities as Voluntary Collectors of Unused Prescription Drugs
GAO-18-25: Published: Oct 12, 2017. Publicly Released: Nov 13, 2017.
GAO-18-25 In 2015, 3.8 million Americans reported misusing prescriptions in the prior month, and deaths from prescription opioids have quadrupled since 1999. Most people get these drugs from friends or relatives, so providing secure and convenient ways for people to dispose of their unused drugs could help. A 2010 federal law authorized pharmacies and other entities to voluntarily maintain a pre...
Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm
GAO-18-15: Published: Oct 6, 2017. Publicly Released: Nov 6, 2017.
More than 14 million people received opioid prescriptions in 2016 through the Medicare drug benefit program, Part D. The Centers for Medicare & Medicaid Services delegate monitoring of these beneficiaries to the private organizations that implement the Medicare Part D benefit. These organizations follow CMS monitoring criteria. While these criteria identify beneficiaries at the greatest risk of...
PODCAST: Prescription Opioids
Newborn Health: Federal Action Needed to Address Neonatal Abstinence Syndrome
GAO-18-32: Published: Oct 4, 2017. Publicly Released: Oct 4, 2017.
The rising opioid epidemic has contributed to an increase in the number of babies born with neonatal abstinence syndrome—a withdrawal condition with symptoms including excessive crying and difficulty breathing. The Department of Health and Human Services identified key recommendations to help guide its efforts to prevent and treat this syndrome—such as providing medical education to healthcar...
Anti-Money Laundering: U.S. Efforts to Combat Narcotics-Related Money Laundering in the Western Hemisphere
GAO-17-684: Published: Aug 22, 2017. Publicly Released: Sep 7, 2017.
Transnational drug traffickers try to launder their money to make illicit proceeds appear legitimate. To help fight this, U.S. agencies and regulators monitor financial institutions' compliance with anti-money laundering requirements—including that they verify customers' identities and report suspicious transactions. Federal agencies also provide such things as training and equipment to suppor...
Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014
GAO-17-529: Published: Jun 22, 2017. Publicly Released: Jul 21, 2017.
Behavioral health conditions disproportionately affect low-income people. Some states expanded Medicaid to cover low-income adults, as authorized by the Affordable Care Act, so we examined how many people in this expansion group received behavioral health treatment. In four states—Iowa, New York, Washington, and West Virginia—we found that in 2014: Up to 1 in 3 Medicaid expansion enrollees r...
Drug-Free Communities Support Program: Agencies Have Strengthened Collaboration but Could Enhance Grantee Compliance and Performance Monitoring
The Office of National Drug Control Policy (ONDCP) and the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA) employ leading collaboration practices to administer the Drug Free Communities (DFC) Support Program and have funded a range of drug prevention activities. Both agencies have improved their collaboration since GAO last reported...
https://www.gao.gov/products/GAO-17-146SP
GAO-17-146SP: Published: Nov 14, 2016. Publicly Released: Nov 15, 2016.
Are there strategies to prevent illicit drug use? Over 47,000 people died of drug overdoses in the United States in 2014—more than any previous year on record—according to data from the Centers for Disease Control and Prevention. Preventing the use of illicit drugs (which includes the misuse of prescription drugs) is less expensive than treating addiction. We convened a diverse panel of educ...
VIDEO: Reflections on Addiction and Recovery (First of Two Video Testimonials)
VIDEO: Reflections on Addiction and Recovery (Second of Two Video Testimonials)
Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access
Overdoses of opioids such as heroin caused more than 28,000 deaths in the U.S. in 2014. Medication-assisted treatment (which combines medication with behavioral therapy) can reduce opioid addiction. We looked at factors that can affect patients' access to medication-assisted treatment such as: Federal laws: Laws are more restrictive when medications—e.g., methadone—are used to treat addictio...
Drug Enforcement Administration: Additional Actions Needed to Address Prior GAO Recommendations
GAO-16-737T: Published: Jun 22, 2016. Publicly Released: Jun 22, 2016.
In three reports issued during 2015, GAO made eleven recommendations to the Drug Enforcement Administration (DEA) related to administering the quota process for controlled substances, providing information and guidance to registrants, and complying with guidelines for overseeing confidential informants. As of June 2016, DEA had taken some actions to address these recommendations but had fully impl...
State Marijuana Legalization: DOJ Should Document Its Approach to Monitoring the Effects of Legalization
GAO-16-419T: Published: Apr 5, 2016. Publicly Released: Apr 5, 2016.
Officials from the Department of Justice's (DOJ) Office of the Deputy Attorney General (ODAG) reported monitoring the effects of state marijuana legalization relative to DOJ policy, generally in two ways. First, officials reported that U.S. Attorneys prosecute cases that threaten federal marijuana enforcement priorities (see fig. below) and consult with state officials about areas of federal conce...
PODCAST: State Marijuana Laws
Office of National Drug Control Policy: Office Could Better Identify Opportunities to Increase Program Coordination
The Office of National Drug Control Policy (ONDCP) and federal agencies have not made progress toward achieving most of the goals articulated in the 2010 National Drug Control Strategy (the Strategy), but are reported to be on track to implement most Strategy action items intended to support these goals. ONDCP established seven Strategy goals related to reducing illicit drug use and its consequenc...
Reflections on Addiction and Recovery (First of Two Video Testimonials)