Drug Misuse: Sustained National Efforts Are Necessary for Prevention, Response, and Recovery

Drug misuse—the use of illicit drugs and the misuse of prescription drugs—has been a persistent and long-standing public health issue in the United States. Ongoing drug control efforts seek to address drug misuse through education and prevention, addiction treatment, and law enforcement and drug interdiction, as well as programs that serve populations affected by drug misuse. These efforts involve federal, state, local, and tribal governments as well as community groups and the private sector. In recent years, the federal government has spent billions of dollars and has enlisted more than a dozen agencies to address drug misuse and its effects.

This report provides information on (1) trends in drug misuse (2) costs and other effects of drug misuse on society and the economy, and (3) challenges the nation faces in addressing the drug crisis.

GAO analyzed nationally representative federal data on drug misuse and deaths from overdoses for 2002–2018 (the most recent available); reviewed selected empirical studies published from 2014–2019; and compared GAO's High-Risk list criteria to findings and recommendations in over 75 GAO reports issued from fiscal year 2015 through March 2020.

Nationally, since 2002, rates of drug misuse have increased, according to GAO's analysis of federal data. In 2018, the Substance Abuse and Mental Health Services Administration reported that an estimated 19 percent of the U.S. population (over 53 million people) misused or abused drugs, an increase from an estimated 14.7 percent in 2003. People across a broad range of demographic groups—including sex, race or ethnicity, education levels, employment status, and geographic categories—reported misusing drugs (see figure below).

The rates of drug overdose deaths have also generally increased nationally since the early 2000s. Over 716,000 people have died of a drug overdose since 2002, and in 2018 alone, over 67,000 people died as a result of a drug overdose, according to the Centers for Disease Control and Prevention. Although the number of drug overdose deaths in 2018 decreased compared to 2017, drug misuse in the United States continued to rise.

Rates of drug overdose deaths varied in counties across the nation in 2003 and 2017, the most recent year that county-level data were available (see figure below). In 2017, 43.2 percent of counties had estimates of more than 20 drug overdose deaths per 100,000 people, including 448 counties with rates that were significantly higher than this amount.

Note: CDC's National Center for Health Statistics used a statistical model to estimate rates of drug overdose deaths to account for counties where data were sparse because of small population size.

GAO work and other government and academic studies have found that the negative health and societal effects of drug misuse are widespread and costly—for example, the increased need for health care, human services, and special education; increased crime, childhood trauma, reduced workforce productivity; and loss of life.

The federal government is making progress in some areas, but a strategic, coordinated, and effective national response—with key sustained leadership from federal agencies—is needed. This report identifies opportunities to strengthen the federal government's efforts to address this persistent and increasing problem. These opportunities include addressing challenges in providing sustained leadership and strengthened coordination; the necessary capacity to address the crisis; and systems to measure, evaluate, and demonstrate progress. For example:

the Office of National Drug Control Policy should ensure future iterations of the National Drug Control Strategy include all statutorily required elements. Examples of statutorily required elements include a 5-year projection for the National Drug Control Program and budget priorities; a description of how each of the Strategy's long-range goals will be achieved, including estimates of needed federal resources; and performance evaluation plans for these goals, among other requirements;

the Office of National Drug Control Policy should ensure effective, sustained implementation of the 2020 Strategy and future strategies;

the Department of Health and Human Services should provide guidance to states for the safe care for infants born with prenatal drug exposure, who may be at risk for child abuse and neglect;

the Drug Enforcement Administration should take steps to better analyze and use drug transaction data to prevent diversion of prescription opioids to be sold illegally; and

the State Department should develop and implement a data management system for all Caribbean Basin Security Initiative activities to reduce illicit drug trafficking or track data trends across countries.

In GAO's March 2019 High-Risk report, GAO named drug misuse as an emerging issue requiring close attention. Based on 25 GAO products issued since that time and this update, GAO has determined that this issue is high risk. Moreover, the severe public health and economic effects of the Coronavirus Disease 2019 (COVID-19) pandemic could fuel some of the contributing factors of drug misuse, such as unemployment—highlighting the need to sustain and build upon ongoing efforts. However, maintaining sustained attention on preventing, responding to, and recovering from drug misuse will be challenging in the coming months, as many of the federal agencies responsible for addressing drug misuse are focused on addressing the pandemic. Therefore, GAO will include this issue in the 2021 High-Risk Series update and make the high-risk designation effective at that time.

Since fiscal year 2015, GAO has made over 80 recommendations to multiple agencies responsible for addressing the drug crisis; over 60 of these recommendations have yet to be implemented.

Drug misuse—the use of illicit drugs and the misuse of prescription  drugs—has been a long-standing and persistent problem in the United  States. It represents a serious risk to public health and has resulted in  significant loss of life and effects to society and the economy, including  billions of dollars in costs.

According to the Centers for Disease Control and Prevention (CDC), over  716,000 people have died as the result of a drug overdose since 2002,  and in 2018 alone, over 67,000 people died as a result of a drug  overdose. Although the number of drug overdose deaths in 2018  decreased compared to 2017, drug misuse in the United States continued  to rise. In 2018, the Substance Abuse and Mental Health Services  Administration (SAMHSA) reported that an estimated 19 percent of the  U.S. population (over 53 million people) misused or abused drugs, an  increase from an estimated 14.7 percent in 2003. Apart from overdose  deaths, drug misuse has contributed to a number of other problems, such  as the increased need for health care, human services, and special  education, as well as increased crime and childhood trauma, and reduced  workforce productivity. In October 2017, the Acting Secretary of the  Department of Health and Human Services (HHS) first declared the  opioid crisis a public health emergency and a declaration has been in  effect since that time.

Ongoing drug control efforts seek to address the drug crisis through  education and prevention, addiction treatment, and law enforcement and  drug interdiction—as well as programs that serve populations affected by  drug misuse. These efforts involve federal, state, local, and tribal  governments as well as community groups and the private sector. The  federal drug control budget for fiscal year 2019 was more than $36 billion  with broad involvement across more than a dozen federal agencies.

We have issued more than 90 reports on topics related to drug misuse,  including on its negative effects, federal efforts to enforce anti-drug laws,  and treatment programs. In recent years, our reports have examined drug  misuse prevention strategies for adolescents and young adults, access to  treatment for drug use disorders, ways to identify suspicious opioid  orders, and security at borders and ports of entry to address illicit drug  smuggling, among other related issues. Through this work we have  identified many persistent challenges that the federal government faces in  its efforts to address the crisis.

GAO Priority Recommendations  GAO’s priority recommendations on the topic  of drug misuse that have yet to be  implemented call for the Department of Health  and Human Services (HHS) to develop a plan  to assist babies born with neonatal abstinence  syndrome, a withdrawal condition in newborn  infants resulting from prenatal use of opioids  (GAO-18-32); and for the Department of  Veterans Affairs to employ key opioid risk  mitigation strategies when prescribing opioid  medication (GAO-18-380). HHS has also  implemented two priority recommendations  regarding expanding access to treatment  (GAO-18-44) and gathering information on the  number of Medicare beneficiaries at risk of  harm from opioids (GAO-18-15).

Since fiscal year 2015, we have made over 80 recommendations  regarding actions that, if taken, could help the federal government more  effectively address the drug crisis, with 28 recommendations made in the  last year (since March 2019). Although agencies largely agreed with the  recommendations and have taken some steps to address the  recommendations, more than 60 recommendations made since fiscal  year 2015 remain unaddressed, including two that we have previously  determined warrant special attention from management (see sidebar).  However, the current and past Administrations have also taken other  actions to stem drug misuse. For example, HHS has implemented  activities within the Medicaid and Medicare programs to reduce the risk of  opioid use disorders, overdoses, inappropriate prescribing, and drug  diversion, such as by improving information on opioid prescribing that  causes a risk of harm to patients.

In 1988, the Office of National Drug Control Policy (ONDCP) was  established by the Anti-Drug Abuse Act of 1988, to lead the national drug  control effort, among other things. Since fiscal year 1994, over $500  billion appropriated to federal agencies has been used to help address  the crisis, including for grant programs to support state and local efforts.  Examples of recent legislation to help address the drug crisis include the  Substance Use-Disorder Prevention that Promotes Opioid Recovery and  Treatment for Patients and Communities Act (SUPPORT Act), the  Comprehensive Addiction and Recovery Act of 2016, and the 21st  Century Cures Act. Congress has also held numerous congressional  hearings on drug misuse over the years to spotlight the problems  associated with drug misuse and provide oversight of federal drug control  efforts.

Even with these efforts, the devastating effects that drug misuse has on  families, communities, and society have continued, and drug overdoses  continue to be a leading cause of death in the United States. Further,  federal, state, and local efforts to address drug misuse through education  and prevention, law enforcement, and mental health initiatives have, at  times, been fragmented and inconsistent.

In our March 2019 High-Risk report, we named drug misuse as an  emerging issue requiring close attention. Based on our findings from a  body of work related to drug misuse—including 25 new GAO products  issued since our 2019 High-Risk report—we have determined that this  issue should be on our High-Risk List. The federal government is making  progress in some areas but the nation is at a critical juncture where a  strategic, coordinated, and effective national response—with key  sustained leadership from federal agencies—is needed. A High-Risk  designation is intended to help to spur such progress by shining a  spotlight on ways the federal government can lead the national effort,  such as by addressing our recommendations and focusing on using  federal funds efficiently to maximize results. Given the urgency of this  issue, we were prepared to make an out-of-cycle high-risk designation  this month. However, many of the federal, state, and local agencies  responsible for addressing drug misuse are currently fully engaged in the  nation’s efforts to respond to and recover from the Coronavirus Disease  2019 (COVID-19) pandemic. Recognizing the strain these agencies are  under as they address the ongoing public health and economic effects of  the coronavirus, we will include National Efforts to Prevent, Respond to,  and Recover from Drug Misuse in our 2021 High-Risk Series update and  make the designation effective at that time.

We prepared this report under the authority of the Comptroller General to  assist Congress with its oversight responsibilities. Specifically, this report  provides information on (1) trends in drug misuse in the United States, (2)  costs and other effects of drug misuse on society and the economy, and  (3) challenges the nation faces in addressing the long-standing drug  crisis. It also conveys factors we considered when making the  determination to add this issue to the High-Risk List.

To describe trends in drug misuse in the United States, we identified and  analyzed publicly available federal data on drug misuse and overdose  deaths nationwide, and by county.

For trends in drug misuse, we used data from SAMHSA’s National  Survey on Drug Use and Health. The National Survey on Drug Use  and Health is an annual survey of the civilian, non-institutionalized  population of the United States, aged 12 years or older and whose  results are designed to be representative of the nation as a whole and  for each of the 50 states and the District of Columbia.

For trends in drug overdose deaths, we used data from CDC’s  National Center for Health Statistics’ National Vital Statistics System.  The National Vital Statistics System is a public health data sharing  system by which the National Center for Health Statistics collects and  disseminates the nation’s official vital statistics including information  on drug overdose deaths occurring within the 50 states and the  District of Columbia.

Generally, we identified published data from the earliest common year  available across a range of variables (2002 for data from both the  National Survey on Drug Use and Health and the National Vital Statistics  System) and data from the most current year available (2018 for the  National Survey on Drug Use and Health and 2018 for National Vital  Statistics System). For trends in drug misuse among demographic  groups, we identified published data from the National Survey on Drug  Use and Health from the four most recent years of comparable data, 2015  through 2018. For some county-level data from the National Vital  Statistics System, 2003 was the earliest year for which comparable data  were available. When reporting on data from a single year, we used data  from the latest year available (2018 for the National Survey on Drug Use  and Health and 2017 for National Vital Statistics System). To assess the  reliability of data from both the National Survey on Drug Use and Health  and the National Vital Statistics System, we reviewed agency  documentation and interviewed relevant SAMHSA and CDC officials. We  determined these data are sufficiently reliable for the purposes of this  report.

To provide information on the costs and other effects of drug misuse, we  conducted a literature search of research studies on the effects and costs  of drug misuse on society and the economy. We considered studies that  met the following criteria: published by peer-reviewed academic sources  or government publications, published from 2014 through 2019, used  nationally representative data, and discussed the costs and other effects  of drug misuse on society or the economy. We selected 16 studies that  collectively covered a variety of illicit drugs as well as a broad range of  types of costs, such as health care, workforce productivity, criminal  justice, and education. We also conducted a detailed analysis of over 40  prior GAO reports published from fiscal year 2015 through the present  (October 2014 through March 2020, approximately 5.5 fiscal years) that  addressed the costs or other effects of drug misuse on society and the  economy. Selected studies and our prior work vary in the types of drug  misuse considered, the costs or other effects of drug misuse that are  examined, and the timeframe of analysis. Though all selected studies  were published between 2014 and 2019, the data used by each study  vary, including timeframes from 2002 through 2018, and do not represent  all research or findings related to drug misuse. The examples presented  provide an illustration of the effects of drug misuse.

To describe the challenges the nation faces in addressing the drug crisis,  we identified and reviewed prior GAO reports on a variety of drug-related  issues—such as prevention, enforcement, and treatment (see app. I).  This review focused on over 75 GAO reports that were published from  fiscal year 2015 through the present (October 2014 through March 2020,  approximately 5.5 fiscal years) but also included older reports with open  recommendations to federal agencies. To identify the reports, we  consulted with internal stakeholders and conducted key word searches of  a report database. For each of these products, we conducted a detailed  analysis of our findings, as well as any recommendations that have yet to  be implemented. We compared findings from our prior reports against the  criteria for determining government-wide high risks. To follow-up on our  prior work regarding ONDCP and the National Drug Control Strategy, we  reviewed the 2020 Strategy and four associated companion documents to  assess the extent to which the Strategy met selected statutory  requirements.

We conducted this performance audit from June 2019 to March 2020 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Background Designating Federal Programs as High Risk

Since the early 1990s, our high-risk program has focused attention on  government operations with greater vulnerabilities to fraud, waste, abuse,  and mismanagement, or that are in need of transformation to address  economy, efficiency, or effectiveness challenges.

To determine which federal government programs and functions should  be designated high risk, we use our guidance document, Determining  Performance and Accountability Challenges and High Risks. We  consider qualitative factors, such as whether the risk (1) involves public  health or safety, service delivery, national security, national defense,  economic growth, or privacy or citizens’ rights; or (2) could result in  significantly impaired service, program failure, injury or loss of life, or  significantly reduced economy, efficiency, or effectiveness. We also  consider the exposure to loss in monetary or other quantitative terms. At  a minimum, $1 billion must be at risk, in areas such as the value of major  assets being impaired; revenue sources not being realized; major agency  assets being lost, stolen, damaged, wasted, or underutilized; potential for,  or evidence of improper payments; and presence of contingencies or  potential liabilities.

Before making a high-risk designation, we also consider corrective  measures that are planned or under way to resolve a material control  weakness and the status and effectiveness of these actions.

We release a High-Risk Series report every two years at the start of each  new Congress. Our biennial reports detail progress made on previously  designated high-risk issues. We designate any new issue areas we  identify as high risk, based on the above criteria, in these reports or in  separate products outside of the two-year cycle. We make out-of-cycle  designations—as has been the case for seven other high-risk  designations we have made—to highlight urgent issues, help ensure  focused attention, and maximize the opportunity for the federal  government to take action.

The Office of National Drug Control Policy (ONDCP) was established by  the Anti-Drug Abuse Act of 1988 as a component of the Executive Office  of the President, and its Director is to assist the President in the  establishment of the policies, goals, objectives, and priorities for the  National Drug Control Program. In October 2018, the SUPPORT Act,  among other things, reauthorized ONDCP and amended its authorities.  ONDCP is responsible for (1) leading the national drug control effort, (2)  coordinating and overseeing the implementation of national drug control  policy, (3) assessing and certifying the adequacy of National Drug Control  Programs and the budget for those programs, and (4) evaluating the  effectiveness of national drug control policy efforts.

As part of these efforts, ONDCP is to coordinate with more than a dozen  federal agencies—known as National Drug Control Program agencies— that have responsibilities for activities including education and prevention,  treatment, and law enforcement and drug interdiction (see fig. 1).

Within these agencies, there may be components or offices that handle  specific aspects of drug control. Some examples include SAMHSA and  CDC within HHS, and the Drug Enforcement Administration (DEA) within  the Department of Justice.

Rates of Drug Misuse and Drug Overdose Deaths Have Generally Increased in the United States

Rates of drug misuse and drug overdose deaths have generally  increased in the United States. Nationally representative data show that  this increase in the estimated rate of drug misuse has occurred across  several demographic categories such as sex and education levels.  Nationally, the rate of drug overdose deaths decreased in 2018 after  increasing almost every year since 2002. Drug overdose death rates vary  by region and by different types of drugs.

Drug Misuse Has Increased in the United States and Affected People across a Range of Demographics

Drug misuse—the use of illicit drugs and the misuse of prescription  drugs—has generally increased in the United States since 2002.  According to SAMHSA, estimates of self-reported drug misuse among  people aged 12 or older increased from 14.9 percent in 2002 to 16.7  percent in 2014, and then further increased from 17.8 percent in 2015 to  19.4 percent in 2018 (see fig. 2).

The increase in estimated drug misuse from 2015 to 2018 by people aged  12 or older is evident in people across a broad range of demographic  groups, including sex, race or ethnicity, military veterans, income and  education levels, employment status, and geographic categories, with few  exceptions (see figures 3 through 5). Additionally, the estimated  percentage of drug misuse within certain demographic groups increased  for some years and decreased for others, in every year more than 10  percent of the people in every demographic group reported misusing  drugs.

The National Rate of Drug Overdose Deaths Increased between 2002 and 2018

The rate of drug overdose deaths in the United States increased between  2002 and 2018 (see fig. 6). For context, in 2002, there were 23,518 drug  overdose deaths, and in 2018, there were 67,367 drug overdose deaths,  according to CDC data. Furthermore, the rate of drug overdose deaths  increased more rapidly in recent years; the rate increased on average by  2 percent per year from 2006 through 2013, and by 14 percent per year  from 2013 through 2016; however, the rate decreased by 4.6 percent  between 2017 and 2018.

Regional Rates of Drug Overdose Deaths Varied Across the Nation

Rates of drug overdose deaths varied in counties across the nation in  2003 and 2017, the most recent year that county-level data were  available (see fig. 7). In 2017, there were some areas of the country with  high rates of drug overdose deaths. For example, in 2017, 1,354 counties  (43.2 percent of counties) had estimates of more than 20 drug overdose  deaths per 100,000 people, including 448 counties with rates that were  significantly higher than this amount.

Rates of Overdose Deaths Increased for Multiple Drug Types between 2002 and 2018

The rate of overdose deaths for different types of drugs increased  between 2002 and 2018. Rates of drug overdose deaths involving  synthetic opioids, natural and semi-synthetic opioids, methadone, heroin,  cocaine, benzodiazepines, psychostimulants, and antidepressants  generally increased between 2002 and 2018 (see fig. 8). It is important to  note that drug overdose deaths may involve more than one drug, and the  drugs most frequently involved in overdose deaths were often found in  combination with each other.

The most common drugs involved in overdose deaths vary in different  parts of the United States, according to data for each of the 10 HHS  public health regions (see fig. 9). Generally, in eastern regions, fentanyl  was the most common drug involved in overdose deaths in 2017, the  most recent year that data were available, whereas methamphetamine  was the most common drug involved in overdose deaths in western  regions. As previously discussed, many drug overdose deaths involve  more than one drug.

Negative Effects of Drug Misuse Are Widespread and Cost Billions

Past GAO work, as well as other selected government and academic  studies, have found that drug misuse results in high costs for society and  the economy. Such costs vary and include health care costs, criminal  justice costs, workplace productivity costs, education costs, human  services costs, and mortality costs. Figure 10 below includes examples of  costs and other effects of drug misuse in these areas. These costs are  born by federal, state, and local governments; private businesses and  nonprofit organizations; employers; families, and individuals who misuse  drugs.

While selected studies we reviewed provided estimates for some of the  costs of drug misuse, one study also indicated it is difficult to precisely  quantify these costs. For example, concepts such as the quality of life or  the pain and suffering of family members are difficult to fully capture or  quantify.

Challenges Impede National Efforts to Prevent, Respond to, and Recover from the Drug Crisis

Our recent work on the topic of drug misuse and its effects has  highlighted challenges the federal government faces that impede national  efforts to address the drug crisis. We categorized these challenges as  related to sustained leadership and strengthened coordination; capacity  to address the crisis; and measurement, evaluation, and demonstration of  progress. In the course of our work on the topic of drug misuse, we have  identified many actions that if taken could help to address challenges in  each of these areas, and have made specific recommendations to federal  agencies about these actions.

While over 25 of these recommendations have been implemented by  National Drug Control Program agencies since fiscal year 2015, over 60  of our recommendations to at least 10 federal agencies—including  recommendations that have received our highest priority designation— have not yet been implemented as of February 2020. The information  below describes our findings and how agencies’ inaction on our  recommendations has contributed to the federal government’s lack of  progress in addressing the drug crisis.

Sustained leadership and strengthened coordination. Making  progress in high-risk areas requires demonstrated, strong, and sustained  commitment and coordination, which we have found to be a challenge  facing the federal government’s drug control efforts. Our work has  identified the need for ONDCP to improve its efforts to lead and  coordinate the national effort to address drug misuse and for agency  leaders to engage in more effective coordination across the government  and with stakeholders. ONDCP has a responsibility to coordinate and  oversee the implementation of the national drug control policy across the  federal government, and the National Drug Control Program agencies  also have important roles and responsibilities that involve reducing drug  misuse and mitigating its effects.

ONDCP’s responsibility to develop the National Drug Control Strategy  offers the office an important opportunity to help prioritize, coordinate, and  measure key efforts to address the drug crisis. Our work has shown that  ONDCP can improve its efforts to develop a National Drug Control  Strategy that meets statutory requirements and effectively coordinates  national efforts to address drug misuse. In 2017 and 2018, ONDCP  lacked a statutorily required National Drug Control Strategy, and we  recently reported that the 2019 National Drug Control Strategy did not  fully comply with the law. In December 2019, we recommended that  ONDCP develop and document key planning elements to help ONDCP  structure its ongoing efforts and to better position the agency to meet  these requirements for future iterations of the National Drug Control  Strategy.

ONDCP subsequently issued the 2020 National Drug Control Strategy on  February 3, 2020. We reviewed this Strategy and found that it made  progress in addressing several statutory requirements. For example:

The 2020 National Drug Control Strategy includes 17 annual  quantifiable and measurable objectives and specific targets, such as  reducing overdose deaths by 15 percent by 2022, whereas we found  that the 2019 National Drug Control Strategy did not contain such  annual targets.

The 2020 Strategy also includes a description of how each of the  Strategy’s long-range goals was determined, including required  consultations and data used to inform the determination, and a list of  anticipated challenges to achieving the Strategy’s goals, such as  limitations in existing data systems that provide little insight into  emerging patterns of drug misuse, and planned actions to address  them.

However, the 2020 Strategy fell short in meeting other requirements. For  example, the 2020 Strategy does not include a list of each National Drug  Control Program agencies’ activities and the role of each activity in  achieving the Strategy’s long-range goals, as required by law. The  federal government invests billions of dollars each year in programs  spanning over a dozen agencies, and therefore the development and  implementation of a comprehensive Strategy is critical to guiding and  ensuring the effectiveness of federal activities to address drug misuse. In  December 2019, we recommended that ONDCP routinely implement an  approach to meet the requirements for future Strategy iterations, and  ONDCP agreed.

ONDCP is uniquely situated to promote coordination across federal  agencies. For example, the National Drug Control Strategy is required to  include a description of how each of the Strategy’s long-range goals will  be achieved, including a list of each existing or new coordinating  mechanism to achieve each goal and a description of ONDCP’s role in  facilitating achievement of each goal. The 2020 Strategy partially  addressed these required elements. By including these descriptions in  future iterations of the Strategy and effectively implementing them,  ONDCP has the potential to strengthen coordination and provide  sustained leadership.

ONDCP has previously used its unique position to help implement some  of our recommendations aimed at improving coordination across federal  agencies in their efforts to prevent and respond to drug misuse. For  example, ONDCP implemented our recommendation to assess the extent  of overlap and potential for duplication across federal programs engaged  in drug abuse prevention and treatment activities and to identify  opportunities for increased coordination as well as developed  performance metrics and reporting data regarding field-based  coordination to prevent drug trafficking. We have also reported on the  lack of available treatment programs for pregnant women and newborns  with neonatal abstinence syndrome as well as gaps in research related to  the treatment of prenatal opioid use. As of February 2020, ONDCP  implemented our recommendation to document the process the agency  uses to identify gaps and action items to track federal activities related to  prenatal opioid use and neonatal abstinence syndrome. Sustaining and  building on these coordination efforts will help maximize opportunities,  leverage resources, and better position ONDCP to identify opportunities  for increased efficiencies in preventing and treating drug misuse.

National Drug Control Program agencies also have a responsibility to  coordinate their efforts, and we have reported that gaps in agency  coordination have hindered national drug control efforts. For example, the  Department of Homeland Security (DHS), the U.S. Postal Service  (USPS), and U.S. Customs and Border Protection (CBP) each have  important roles in enforcing certain data-sharing and enforcement  requirements of the Synthetics Trafficking and Overdose Prevention Act  of 2018 (STOP Act). The STOP Act requires DHS to promulgate  regulations detailing additional USPS responsibilities—beyond those  included in the Act—related to sharing advance electronic data with CBP  that can be used to identify shipments at high risk of transporting illegal  drugs by October 24, 2019. However, as of November 2019, DHS had  not drafted these regulations, and therefore USPS’s and CBP’s  responsibilities for sharing advance electronic data—a key tool that could  help stop the flow of illicit drugs into the United States—remain unclear.  As we reported in December 2019, DHS does not have a plan for drafting  these regulations, and therefore we recommended that DHS develop a  timeline to do so; DHS agreed with this recommendation.

It is also important for the federal government to coordinate among  different levels of government and across issue areas, including with  state, local, and tribal agencies, as well as with community groups and  organizations in the private sector working to address the drug crisis.  Our prior work has also found ways in which coordination between federal  efforts to address drug misuse and those of local governments and other  stakeholders could be more effective. In January 2018, we reported that  states cited the need for additional guidance, training, and technical  assistance from HHS to address the needs of infants born with prenatal  drug exposure. HHS disagreed with our recommendation to provide such  guidance regarding the safe care for substance-affected infants, and has  not implemented the recommendation. HHS stated that it had already  clarified guidance in this area and believed that states needed flexibility to  meet the program requirements in the context of each state’s program.  We found that states continued to report issues with the guidance, and  that the clarifications did not address an ongoing challenge regarding the  program requirements. We continue to believe our recommendation is  warranted. As of February 2020, HHS continues to disagree with us and  with the states. Without adequate supports and services to ensure their  safety, these vulnerable infants may be at risk for child abuse and  neglect.

We have also recently recommended in January 2020 that DEA should,  in consultation with industry stakeholders—such as drug distributors— identify solutions to address the limitations of the ARCOS Enhanced  Lookup Buyer Statistic Tool, to ensure industry stakeholders have the  most useful information possible to assist them in identifying and  reporting suspicious opioid orders to DEA. DEA agreed with our  recommendation, and is starting to assess how to address this  recommendation. These limitations, including a lack of appropriately  detailed data, may limit the usefulness of the tool in assisting distributors  in determining whether an order is suspicious.

In addition, we have previously reported in 2019 that coordination across  private health plans, health-care prescribers, pharmacists, and at-risk  beneficiaries could contribute to the success of Medicare drug monitoring  programs, which are designed to identify beneficiaries at risk of opioid  misuse. We also have ongoing work on how federal departments and  agencies coordinate their drug prevention efforts in schools as well as on  how effectively federal agencies coordinated their counter-drug activities  with Mexico.

Capacity to address the crisis. We have identified ongoing challenges  related to the nation’s capacity to address the drug crisis. Sufficient  capacity and efficient use of that capacity are key components for making  progress in high-risk areas; they are necessary for federal, state, and  local agencies to achieve strategic goals in addressing drug misuse, such  as implementing the National Drug Control Strategy. In our work  designating high-risk government programs and functions, we define  capacity as having the people and resources sufficient to address the  risk.

Our prior work has found that the nation faces insufficient capacity to  successfully address persistent, troubling trends in drug misuse, including  the lack of treatment options. In addition, the nation’s existing capacity  may be plagued by inefficiencies and gaps in information about what  resources are most effective in addressing drug misuse. These capacity  challenges permeate every level of government and affect the nation’s  key social services and health care programs. As a result, effectively  addressing the drug crisis requires harnessing capacity across agencies  within the federal government as well as coordinating with state and local  governments and community-based nongovernment organizations.

The availability of treatment for substance use disorders has not kept  pace with needs, and the federal government has faced barriers to  increasing treatment capacity. For example, we have reported on  barriers to increasing access to evidence-based treatment for opioid use  disorder, and federal efforts to address these barriers. Such barriers to  treatment include a lack of Medicaid coverage for treatment medications  in some states, delays that can be caused by the need for prior  authorizations for some treatment medications, and the unwillingness of  some health care providers to obtain the federal waiver required to  prescribe some treatment medications. We have also reported that,  according to officials at the Veterans Health Administration (VHA), many  veterans lack access to residential substance use treatment programs  because of high demand relative to capacity.

Developing and maintaining sufficient capacity to address the drug crisis  also requires that federal agencies use existing resources—such as  data—effectively. For example, we have recently reported in January  2020 that DEA should be more proactive in using the data it already  collects from DEA registrants to identify problematic drug transaction  patterns. According to DEA officials, one analysis that they conduct on a  quarterly basis involves using a computer algorithm when comparing  large volumes of drugs purchased in a given geographic area to the  area’s population data. However, DEA did not report conducting active  and recurring monitoring of transactions using algorithms to detect and  flag transactions that indicate potential diversion, either on a real-time or  near real-time basis, to help identify questionable patterns in the data or  unusual patterns of drug distribution on a more routine basis. Such  analyses could be used to proactively support or generate leads for  investigations of potential drug diversion.

Registrants already report data on controlled-substance transactions to  the DEA. DEA could use these data to identify trends in distribution or  purchases of drugs in a given geographic area. DEA could also look for  and compare unusual patterns in drug order activity in different locations  to identify potential issues that warrant further investigation. Further, DEA  has not established a way to manage all of the data it collects and  maintains.

DEA agreed with three of our four recommendations to better manage  and use the data it collects. DEA neither agreed nor disagreed with the  fourth recommendation. However, DEA has not yet implemented any of  the recommendations. By implementing these recommendations, DEA  could ensure that important data assets are formally managed and fully  utilized to inform investigations and prevent diversion of prescription  opioids to be sold illegally. Overall, federal efforts to address the drug  crisis could make better use of available data to assist in identifying  emerging patterns of misuse, allowing the government to respond more  quickly to evolving trends.

Beyond specific capacity challenges that we have identified, in December  2019 we reported on challenges federal agencies face in assessing the  resources they will need to achieve the goals of the National Drug Control  Strategy. ONDCP is required to issue drug control funding guidance to  the heads of departments and agencies with responsibilities under the  National Drug Control Program by July 1 of each year, and such funding  guidance must address funding priorities developed in the National Drug  Control Strategy. Since ONDCP did not issue a Strategy in 2017 or  2018, ONDCP could neither provide funding guidance to National Drug  Control Program agencies based on the Strategy, nor could it review and  certify budget requests of these agencies to determine if they are  adequate to meet the goals of the Strategy, in accordance with and as  required by law. Without a National Drug Control Strategy in 2017 or  2018, ONDCP used other sources—such as policy priorities identified in  the President’s Budget from fiscal year 2018—to identify drug policy  priorities and develop funding guidance.

ONDCP issued a National Drug Control Strategy in 2019 and 2020, but  neither Strategy included a 5-year projection for program and budget  priorities, as required by law. In December 2019, we recommended that  ONDCP develop and document key planning elements to help ONDCP  structure its ongoing efforts and to better position the agency to meet  these requirements for future iterations of the National Drug Control  Strategy.

We also found that the 2020 National Drug Control Strategy does not  include estimates of federal funding or other resources needed to achieve  each of ONDCP’s long-range goals. The 2020 Strategy includes a plan  to expand treatment of substance use disorders that identifies unmet needs for substance use disorder treatment and a strategy for closing the  gap between available and needed treatment. The plan also describes  the roles and responsibilities of relevant National Drug Control Program  agencies for implementing the plan. However, the plan does not identify  resources required to enable National Drug Control Program agencies to  implement the plan or resources required to eliminate the treatment gap,  as required by law. The National Drug Control Strategy is important for  assessing the nation’s capacity to address drug misuse through both the  development of federal funding estimates and the certification of agency  budget requests that aim to meet the goals of the Strategy.

Additionally, we have ongoing work on the federal government’s capacity  to address the drug crisis. For example, we are studying gaps in the  capacity of the health care system to treat substance use disorders, and  examining how grantees use funding from selected SAMHSA grant  programs to increase access to substance use disorder treatment. We  are also studying school-based drug prevention programs and the effects  of drug misuse on the workforce. This work will examine challenges that  states and local educational entities face in serving the needs of  communities affected by the drug crisis. We also have planned work  examining the effectiveness of federal funding to combat the ongoing  opioid crisis.

Measurement, evaluation, and demonstration of progress. The  federal government faces challenges related to measuring, evaluating,  and demonstrating progress towards addressing the crisis. We have  reported that key data needed to measure and evaluate progress towards  strategic goals are not reliable or are not collected and reported. We have  also found that some agencies lack plans or metrics to measure the  effectiveness of specific programs to address the drug crisis and to  demonstrate that these programs are making progress towards stated  national goals, including reducing drug overdose deaths and expanding  access to addiction treatment. Successfully addressing drug misuse  requires ongoing measurement and evaluation of efforts towards stated  goals and the ability to share and use performance information to make  midcourse changes and corrections where needed.

Regarding challenges related to data, we have identified gaps in the  availability and reliability of data for measuring progress. ONDCP and  other federal, state, and local government officials have identified  challenges with the timeliness, accuracy, and accessibility of data from  law enforcement and public health sources related to both fatal and non- fatal overdose cases. In March 2018, we recommended that ONDCP  lead a review on ways to improve overdose data; ONDCP did not indicate  whether it agreed with our recommendation. Additionally, in December  2019, we found that ONDCP’s Drug Control Data Dashboard did not  include all of the data required by the SUPPORT Act, such as data  sufficient to show the extent of the unmet need for substance use  disorder treatment. We recommended that ONDCP establish the  planning elements to ensure that these data were included in the Data  Dashboard, and ONDCP disagreed with our recommendation. Having  accessible and reliable data, including data on drug overdoses will help  ONDCP and other agencies better measure the scope and nature of the  drug crisis.

We also found in 2019 that the State Department cannot ensure the  reliability of its program monitoring data for its Caribbean Basin Security  Initiative, which seeks to reduce illicit drug trafficking. The State  Department agreed with the recommendation to ensure the development  and implementation of a data management system for centrally collecting  reliable program monitoring data for all Caribbean Basin Security Initiative  activities, but has not yet implemented it. Without this action, there may  be discrepancies in how Caribbean Basin Security Initiative program  performance data is defined and collected, and the State Department  cannot report comprehensively or accurately on the Initiative’s activities to  reduce illicit drug trafficking or track data trends across countries.

While ONDCP is responsible for evaluating the effectiveness of national  drug control policy efforts across the government, we found that ONDCP  has not developed performance evaluation plans for the goals in the 2020  National Drug Control Strategy. Some of the long-range goals listed in the  2020 Strategy include expanding access to evidence-based treatment,  reducing the availability of illicit drugs in the United States, and decreasing the over-prescribing of opioid medications. However, the 2020  National Drug Control Strategy does not include performance evaluation  plans to measure progress against each of the Strategy’s long-range  goals, as required by law. These performance evaluation plans are  required by statute to include (1) specific performance measures for each  National Drug Control Program agency, (2) annual and—to the extent  practicable—quarterly objectives and targets for each measure, and (3)  an estimate of federal funding and other resources necessary to achieve  each performance objective and target. Without effective long-term  plans that clearly articulate goals and objectives and without specific  measures to track performance, federal agencies cannot fully assess  whether taxpayer dollars are invested in ways that will achieve desired  outcomes such as reducing access to illicit drugs and expanding  treatment for substance use disorders.

Additionally, National Drug Control Program agencies are responsible for  evaluating their progress toward achieving the goals of the National Drug  Control Strategy, and in some cases have improved how to measure  this progress. For example, although the federal government continues to  face barriers to increasing access to treatment for substance use  disorders, HHS has recently implemented our recommendation to  establish performance measures with targets to expand access to  medication-assisted treatment (MAT) for opioid use disorders. As of  March 2020, HHS has established such performance measures with  targets to increase the number of prescriptions for MAT medications and  to increase treatment capacity, as measured by the number of providers  authorized to treat patients using MAT. Monitoring progress against these  targets will help HHS determine whether its efforts to expand treatment  are successful or whether new approaches are needed.

We have also identified challenges regarding how federal agencies  demonstrate the progress of specific programs toward addressing the  drug crisis. We reported in 2018 on DEA’s 360 Strategy—which aims to  coordinate DEA enforcement, diversion control, and demand reduction  efforts—as well as on ONDCP’s Heroin Response Strategy under its High  Intensity Drug Trafficking Areas program. We found that neither DEA’s  360 Strategy nor ONDCP’s Heroin Response Strategy included outcome- oriented performance measures for its activities and goals, respectively.  DEA disagreed with and has not yet implemented our recommendation to  establish these types of performance measures for its activities. ONDCP  neither agreed nor disagreed with our recommendation to establish  outcome-oriented performance measures for the goals of the Heroin  Response Strategy, and has not yet implemented the recommendation.  Without these measures, it is unclear the extent to which DEA or ONDCP  can accurately and fully gauge their efforts and their overall effectiveness  in combatting heroin and opioid use and reducing overdose deaths.

Additionally, we have found that DEA does not have outcome-oriented  goals and performance targets for its use of data in opioid diversion  activities, making DEA likely not able to adequately assess whether its  investments and efforts are helping to limit the availability of and better  respond to the opioid prescription diversion threat. DEA neither agreed  nor disagreed with our recommendation to establish these outcome- oriented goals and related performance targets for its opioid diversion  activities, and has not implemented this recommendation.

We have also reported that the Department of State has not established  performance indicators for its Caribbean Basin Security Initiative to  facilitate performance evaluation across agencies, countries, and  activities, inhibiting the assessment of the program’s progress to reduce  illicit drug trafficking. The State Department agreed with our  recommendation to develop and implement a data management system  for centrally collecting reliable program monitoring data. The State  Department has not yet implemented this recommendation. Without  robust assessments of how specific programs help to achieve the goals of  the National Drug Control Strategy, federal agencies may be unable to  demonstrate progress in addressing the drug crisis, and may be unable to  make any needed adjustments to their strategies.

Illicit drug use and misuse of prescription drugs is a long-standing  national problem that will continue to evolve. The terrible effects of drug  misuse on families and communities have persisted over decades,  despite ongoing federal, state, and local efforts. Federal agencies and  Congress can and must work to ensure that available resources are  coordinated effectively to mitigate and respond to the drug misuse crisis.

Maintaining sustained attention on preventing, responding to, and  recovering from drug misuse will be challenging in the coming months as  many of the federal agencies responsible for addressing drug misuse are  currently focused on addressing the COVID-19 pandemic. However, the  severe public health and economic effects of the pandemic could fuel  some of the contributing factors of drug misuse, such as unemployment— highlighting the need to sustain drug misuse prevention, response, and  recovery efforts. Addressing these challenges will require sustained  leadership and strengthened coordination; the necessary capacity to  address the crisis; and the systems to measure, evaluate, and  demonstrate progress. The more than 60 related GAO recommendations  that have yet to be implemented are an indication of how federal agencies  may begin addressing these challenges. For example:

ONDCP should ensure future iterations of the National Drug Control  Strategy include all statutorily required elements. Examples of  statutorily required elements include a 5-year projection for the  National Drug Control Program and budget priorities; a description of  how each of the Strategy’s long-range goals will be achieved,  including a list of each National Drug Control Program agency’s  activities, and the role of each activity in achieving these goals, and  estimates of federal funding or other resources needed to achieve  these goals; performance evaluation plans for each year covered by  the Strategy for each long-range goal for each National Drug Control  Program agency; and resources required to enable National Drug  Control Program agencies to implement the plan to expand treatment  of substance use disorders and eliminate the treatment gap;

ONDCP should take steps to ensure effective, sustained  implementation of the 2020 National Drug Control Strategy and future  strategies;

HHS should provide guidance to states for the safe care for infants  born with prenatal drug exposure, who may be at risk for child abuse  and neglect;

DEA should take steps to better analyze and use drug transaction  data to identify suspicious opioid orders and prevent diversion of  prescription opioids to be sold illegally; and  the State Department should develop and implement a data  management system for all Caribbean Basin Security Initiative  activities to reduce illicit drug trafficking or track data trends across  countries.

Through our ongoing and planned work, we will continue to review the  effects of drug misuse, the federal response, and opportunities for  improvement.

We provided draft report excerpts regarding our analysis of the 2020  National Drug Control Strategy to the Office of National Drug Control  Policy for review and comment. ONDCP officials stated that they plan to  address the statutory requirements that we identified as missing in  additional documents, including the Fiscal Year 2021 Budget and  Performance Summary. We will review and assess any additional  materials that ONDCP publishes in response to the requirements for the  2020 National Drug Control Strategy. Findings regarding other programs  and activities are drawn from past GAO work and our follow-up work on  our recommendations; the related content was previously provided to the  respective agencies for review as part of the original work.

We are sending copies of this report to the appropriate congressional  committees, the Director of the Office of National Drug Control Policy, and  other interested parties. In addition, the report is available at no charge on  the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  Triana McNeil at (202) 512-8777 or McNeilT@gao.gov, Mary Denigan- Macauley at (202) 512-7114 or DeniganMacauleyM@gao.gov, or  Jacqueline M. Nowicki at (617) 788-0580 or NowickiJ@gao.gov.

Contact points for our Offices of Congressional Relations and Public  Affairs may be found on the last page of this report. GAO staff who made  key contributions to this report are listed in appendix II.

Appendix I: List of Selected Related GAO Reports

International Mail: Stakeholders' Views on Possible Changes to Inbound  Mail Regarding Customs Fees and Opioid Detection Efforts. GAO-20- 340R. Washington, D.C.: February 27, 2020.

Medicaid: States' Changes to Payment Rates for Substance Use Disorder  Services. GAO-20-260. Washington, D.C.: January 30, 2020.

Drug Control: Actions Needed to Ensure Usefulness of Data on  Suspicious Opioid Orders. GAO-20-118. Washington, D.C.: January 29,  2020.

Opioid Use Disorder: Barriers to Medicaid Beneficiaries’ Access to  Treatment Medications. GAO-20-233. Washington, D.C.: January 24,  2020.

Social Security Disability: Action Needed to Help Agency Staff  Understand and Follow Policies Related to Prescription Opioid Misuse.  GAO-20-120. Washington, D.C.: January 9, 2020.

Countering Illicit Finance and Trade: U.S. Efforts to Combat Trade-Based  Money Laundering. GAO-20-314R. Washington, D.C.: December 30,  2019.

Drug Control: The Office of National Drug Control Policy Should Develop  Key Planning Elements to Meet Statutory Requirements. GAO-20-124.  Washington, D.C.: December 18, 2019.

International Mail: Progress Made in Using Electronic Data to Detect  Illegal Opioid Shipments, but Additional Steps Remain. GAO-20-229R.  Washington, D.C.: December 18, 2019.

Counternarcotics: Treasury Reports Some Results from Designating Drug  Kingpins, but Should Improve Information on Agencies’ Expenditures.  GAO-20-112. Washington, D.C.: December 16, 2019.

Mental Health and Substance Use: State and Federal Oversight of  Compliance with Parity Requirements Varies. GAO-20-150. Washington,  D.C.: December 13, 2019.

Veterans Health Care: Services for Substance Use Disorders, and Efforts  to Address Access Issues in Rural Areas. GAO-20-35. Washington, D.C.:  December 2, 2019.

Coast Guard: Assessing Deployable Specialized Forces' Workforce  Needs Could Improve Efficiency and Reduce Potential Overlap or Gaps  in Capabilities. GAO-20-33. Washington, D.C.: November 21, 2019.

Substance Use Disorder: Prevalence of Recovery Homes, and Selected  States’ Investigations and Oversight. GAO-20-214T. Washington, D.C.:  October 24, 2019.

Medicaid: Opioid Use Disorder Services for Pregnant and Postpartum  Women, and Children. GAO-20-40. Washington, D.C.: October 24, 2019.

U.S. Assistance to Central America: Department of State Should  Establish a Comprehensive Plan to Assess Progress Toward Prosperity,  Governance, and Security. GAO-19-590. Washington, D.C.: September  26, 2019.

Science & Tech Spotlight: Opioid Vaccines. GAO-19-706SP. Washington,  D.C.: September 16, 2019.

U.S. Assistance to Mexico: State and USAID Allocated over $700 Million  to Support Criminal Justice, Border Security, and Related Efforts from  Fiscal Year 2014 through 2018. GAO-19-647. Washington, D.C.:  September 10, 2019.

Prescription Opioids: Patient Options for Safe and Effective Disposal of  Unused Opioids. GAO-19-650. Washington, D.C.: September 3, 2019.

Land Ports of Entry: CBP Should Update Policies and Enhance Analysis  of Inspections. GAO-19-658. Washington, D.C.: August 6, 2019.

Drug Control: Certain DOD and DHS Joint Task Forces Should Enhance  Their Performance Measures to Better Assess Counterdrug Activities.  GAO-19-441. Washington, D.C.: July 9, 2019.

VA Mental Health: VHA Improved Certain Prescribing Practices, but  Needs to Strengthen Treatment Plan Oversight. GAO-19-465.  Washington, D.C.: June 17, 2019.

Health Centers: Trends in Revenue and Grants Supported by the  Community Health Center Fund. GAO-19-496. Washington, D.C.: May  30, 2019.

Prescription Opioids: Voluntary Medicare Drug Management Programs to  Control Misuse. GAO-19-446. Washington, D.C.: May 20, 2019.

Drug Policy: Assessing Treatment Expansion Efforts and Drug Control  Strategies and Programs. GAO-19-535T. Washington, D.C.: May 9, 2019.

Drug Policy: Preliminary Observations on the 2019 National Drug Control  Strategy. GAO-19-370T. Washington, D.C.: March 7, 2019.

Behavioral Health: Research on Health Care Costs of Untreated  Conditions is Limited. GAO-19-274. Washington, D.C.: February 28,  2019.

Security Assistance: U.S. Agencies Should Establish a Mechanism to  Assess Caribbean Basin Security Initiative Progress. GAO-19-201.  Washington, D.C.: February 27, 2019.

Drug Control: DOD Should Improve Its Oversight of the National Guard  Counterdrug Program.GAO-19-27. Washington, D.C.: January 17, 2019.

Colombia: U.S. Counternarcotics Assistance Achieved Some Positive  Results but State Needs to Review the Overall U.S. Approach.  GAO-19-106. Washington, D.C.: December 12, 2018.

Illegal Marijuana: Opportunities Exist to Improve Oversight of State and  Local Eradication Efforts. GAO-19-9. Washington, D.C.: November 14,  2018.

Opioid Crisis: Status of Public Health Emergency Authorities.  GAO-18-685R. Washington, D.C.: September 26, 2018.

Adolescent and Young Adult Substance Use: Federal Grants for  Prevention, Treatment, and Recovery Services and for Research.  GAO-18-606. Washington, D.C.: September 4, 2018.

Foster Care: Additional Actions Could Help HHS Better Support States’  Use of Private Providers to Recruit and Retain Foster Families.  GAO-18-376. Washington, D.C.: May 30, 2018.

VA Health Care: Progress Made Towards Improving Opioid Safety, but  Further Efforts to Assess Progress and Reduce Risk Are Needed.  GAO-18-380. Washington, D.C.: May 29, 2018.

Prescription Opioids: Medicare Needs Better Information to Reduce the  Risk of Harm to Beneficiaries. GAO-18-585T. Washington, D.C.: May 29,  2018.

Illicit Opioids: Office of National Drug Control Policy and Other Agencies  Need to Better Assess Strategic Efforts. GAO-18-569T. Washington,  D.C.: May 17, 2018.

Substance Use Disorder: Information on Recovery Housing Prevalence,  Selected States’ Oversight, and Funding. GAO-18-315. Washington,  D.C.: March 22, 2018.

Illicit Opioids: While Greater Attention Given to Combating Synthetic  Opioids, Agencies Need to Better Assess their Efforts. GAO-18-205.  Washington, D.C.: March 29, 2018.

Substance-Affected Infants: Additional Guidance Would Help States  Better Implement Protections for Children. GAO-18-196. Washington,  D.C.: January 19, 2018.

Prescription Opioids: Medicare Should Expand Oversight Efforts to  Reduce the Risk of Harm. GAO-18-336T. Washington, D.C.: January 17,  2018.

Preventing Drug Abuse: Low Participation by Pharmacies and Other  Entities as Voluntary Collectors of Unused Prescription Drugs.  GAO-18-25. Washington, D.C.: October 12, 2017.

Border Patrol: Issues Related to Agent Deployment Strategy and  Immigration Checkpoints. GAO-18-50. Washington, D.C.: November 8,  2017.

Prescription Opioids: Medicare Needs to Expand Oversight Efforts to  Reduce the Risk of Harm. GAO-18-15. Washington, D.C.: October 6,  2017.

Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness  of Efforts to Expand Access to Medication-Assisted Treatment.  GAO-18-44. Washington, D.C.: October 31, 2017.

Counternarcotics: Overview of U.S. Efforts in the Western Hemisphere.  GAO-18-10. Washington, D.C.: October 13, 2017.

Newborn Health: Federal Action Needed to Address Neonatal Abstinence  Syndrome. GAO-18-32. Washington, D.C.: October 4, 2017.

Anti-Money Laundering: U.S. Efforts to Combat Narcotics-Related Money  Laundering in the Western Hemisphere. GAO-17-684. Washington, D.C.:  August 22, 2017.

Nonviolent Drug Convictions: Stakeholders’ Views on Potential Actions to  Address Collateral Consequences. GAO-17-691. Washington, D.C.:  September 7, 2017.

Medicaid: States Fund Services for Adults in Institutions for Mental  Disease Using a Variety of Strategies. GAO-17-652. Washington, D.C.:  August 9, 2017.

International Mail Security: Costs and Benefits of Using Electronic Data to  Screen Mail Need to Be Assessed. GAO-17-606. Washington, D.C.:  August 2, 2017.

Drug Control Policy: Information on Status of Federal Efforts and Key  Issues for Preventing Illicit Drug Use. GAO-17-766T. Washington, D.C.:  July 26, 2017.

Medicaid Expansion: Behavioral Health Treatment Use in Selected States  in 2014. GAO-17-529. Washington, D.C.: June 22, 2017.

Border Security: Additional Actions Could Strengthen DHS Efforts to  Address Subterranean, Aerial, and Maritime Smuggling. GAO-17-474.  Washington, D.C.: May 1, 2017.

VA Health Care: Actions Needed to Ensure Medical Facilities’ Controlled  Substance Programs Meet Requirements. GAO-17-442T. Washington,  D.C.: February 27, 2017.

VA Health Care: Actions Needed to Ensure Medical Facility Controlled  Substance Inspection Programs Meet Agency Requirements.  GAO-17-242. Washington, D.C.: February 15, 2017.

Drug Free Communities Support Program: Agencies Have Strengthened  Collaboration but Could Enhance Grantee Compliance and Performance  Monitoring. GAO-17-120. Washington, D.C.: February 7, 2017.

Highlights of a Forum: Preventing Illicit Drug Use. GAO-17-146SP.  Washington, D.C.: November 14, 2016.

Opioid Addiction: Laws, Regulations, and Other Factors Can Affect  Medication-Assisted Treatment Access. GAO-16-833. Washington, D.C.:  September 27, 2016.

Drug Enforcement Administration: Additional Actions Needed to Address  Prior GAO Recommendations. GAO-16-737T. Washington, D.C.: June  22, 2016.

Controlled Substances: DEA Should Take Additional Actions to Reduce  Risks in Monitoring the Continued Eligibility of Its Registrants.  GAO-16-310. Washington, D.C.: May 26, 2016.

Office of National Drug Control Policy: Progress toward Some National  Drug Control Strategy Goals, but None Have Been Fully Achieved.  GAO-16-660T. Washington, D.C.: May 17, 2016.

Veterans Justice Outreach Program: VA Could Improve Management by  Establishing Performance Measures and Fully Assessing Risks.  GAO-16-393. Washington, D.C.: April 28, 2016.

State Marijuana Legalization: DOJ Should Document Its Approach to  Monitoring the Effects of Legalization. GAO-16-419T. Washington, D.C.:  April 5, 2016.

DOD and VA Health Care: Actions Needed to Help Ensure Appropriate  Medication Continuation and Prescribing Practices. GAO-16-158.  Washington, D.C.: January 5, 2016.

State Marijuana Legalization: DOJ Should Document Its Approach to  Monitoring the Effects of Legalization. GAO-16-1. Washington, D.C.:  December 30, 2015.

Office of National Drug Control Policy: Lack of Progress on Achieving  National Strategy Goals. GAO-16-257T. Washington, D.C.: December 2,  2015.

Drug Control: Additional Performance Information Is Needed to Oversee  the National Guard’s State Counterdrug Program. GAO-16-133.  Washington, D.C.: October 21, 2015.

Medicaid: Additional Reporting May Help CMS Oversee Prescription-Drug  Fraud Controls. GAO-15-390. Washington, D.C.: July 8, 2015.

Prescription Drugs: More DEA Information about Registrants’ Controlled  Substances Roles Could Improve Their Understanding and Help Ensure  Access. GAO-15-471. Washington, D.C.: June 25, 2015.

Behavioral Health: Options for Low-Income Adults to Receive Treatment  in Selected States. GAO-15-449. Washington, D.C.: June 19, 2015.

Drug-Impaired Driving: Additional Support Needed for Public Awareness  Initiatives. GAO-15-293. Washington, D.C.: February 24, 2015.

Prenatal Drug Use and Newborn Health: Federal Efforts Need Better  Planning and Coordination. GAO-15-203. Washington, D.C.: February 10,  2015.

Medicare Program Integrity: CMS Pursues Many Practices to Address  Prescription Drug Fraud, Waste, and Abuse. GAO-15-66. Washington,  D.C.: October 24, 2014.

Office of National Drug Control Policy: Office Could Better Identify  Opportunities to Increase Program Coordination. GAO-13-333.  Washington, D.C.: March 26, 2013.

Drug Control: Initial Review of the National Strategy and Drug Abuse  Prevention and Treatment Programs. GAO-12-744R. Washington, D.C.:  July 6, 2012.

Prescription Pain Reliever Abuse: Agencies Have Begun Coordinating  Education Efforts, but Need to Assess Effectiveness. GAO-12-115.  Washington, D.C.: December 22, 2011.

Adult Drug Courts: Studies Show Courts Reduce Recidivism, but DOJ  Could Enhance Future Performance Measure Revision Efforts.  GAO-12-53. Washington, D.C.: December 9, 2011.

Drug Control: U.S. Assistance Has Helped Mexican Counternarcotics  Efforts, but Tons of Illicit Drugs Continue to Flow into the United States.  GAO-07-1018. Washington, D.C.: August 17, 2007.

Adult Drug Courts: Evidence Indicates Recidivism Reductions and Mixed  Results for Other Outcomes. GAO-05-219. Washington, D.C.: February  28, 2005.

Prescription Drugs: OxyContin Abuse and Diversion and Efforts to  Address the Problem. GAO-04-110. Washington, D.C.: December 19,  2003.

Drug Courts: Better DOJ Data Collection and Evaluation Efforts Needed  to Measure Impact of Drug Court Programs. GAO-02-434. Washington,  D.C.: April 18, 2002.

Drug Abuse: Efforts under Way to Determine Treatment Outcomes.   T-HEHS-00-60. Washington, D.C.: February 17, 2000.

Emerging Drug Problems: Despite Changes in Detection and Response  Capability, Concerns Remain. HEHS-98-130. Washington, D.C.: July 20,  1998.

Drug Courts: Overview of Growth, Characteristics, and Results. GGD-97- 106. Washington, D.C.: July 31, 1997.

Drug Control: Reauthorization of the Office of National Drug Control  Policy. T-GGD-97-97. Washington, D.C.: May 1, 1997.

Confronting the Drug Problem: Debate Persists on Enforcement and  Alternative Approaches. GGD-93-82. Washington, D.C.: July 1, 1993.

War on Drugs: Federal Assistance to State and Local Drug Enforcement.  GGD-93-86. Washington, D.C.: April 29, 1993.

Drug Control: Coordination of Intelligence Activities.GGD-93-83BR.  Washington, D.C.: April 2, 1993.

Drug Abuse Prevention: Federal Efforts to Identify Exemplary Programs  Need Stronger Design. PEMD-91-15. Washington, D.C.: August 22,  1991.

VA Health Care: Inadequate Controls over Addictive Drugs. HRD-91-101.  Washington, D.C.: June 6, 1991.

The War on Drugs: Arrests Burdening Local Criminal Justice Systems.  GGD-91-40. Washington, D.C.: April 3, 1991.

Drug Treatment: Targeting Aid to States Using Urban Population as  Indicator of Drug Use. HRD-91-17. Washington, D.C.: November 27,  1990.

Controlling Drug Abuse: A Status Report. GGD-88-39. Washington, D.C.:  March 1, 1988.

Drug Abuse Prevention: Further Efforts Needed To Identify Programs  That Work. HRD-88-26. Washington, D.C.: December 4, 1987.

Comprehensive Approach Needed To Help Control Prescription Drug  Abuse. GGD-83-2. Washington, D.C.: October 29, 1982.

Action Needed To Improve Management and Effectiveness of Drug  Abuse Treatment. HRD-80-32 Washington, D.C.: April 14, 1980.

Identifying and Eliminating Sources of Dangerous Drugs: Efforts Being  Made, but Not Enough. B-175425. Washington, D.C.: Jun 7, 1974.

United States Efforts to Increase International Cooperation in Controlling  Narcotics Trafficking. B-176625. Washington, D.C.: October 4, 1972.

Efforts to Prevent Dangerous Drugs from Illicitly Reaching the Public. B- 175425. Washington, D.C.: April 17, 1972.

Appendix II: GAO Contacts and Staff Acknowledgments

Triana McNeil at (202) 512-8777 or McNeilT@gao.gov; Mary Denigan- Macauley at (202) 512-7114 or DeniganMacauleyM@gao.gov; or  Jacqueline M. Nowicki at (617) 788-0580 or NowickiJ@gao.gov.

In addition to the contacts named above, Alana Finley (Assistant  Director), Bill Keller (Assistant Director), Will Simerl (Assistant Director),  Meghan Squires (Analyst-in-Charge), James Bennett, Ben Bolitzer,  Breanne Cave, Billy Commons, Holly Dye, Wendy Dye, Brian Egger,  Kaitlin Farquharson, Sally Gilley, Sarah Gilliland, Mara McMillen, Amanda  Miller, Sean Miskell, Jan Montgomery, Dae Park, Bill Reinsberg, Emily  Wilson Schwark, Herbie Tinsley, and Sirin Yaemsiri made key  contributions to this report. Key contributors to the prior work discussed in  this report are listed in each respective product.

Drug misuse—using illicit drugs or misusing prescription drugs—is a serious public health issue in the United States. National rates of drug misuse rose from 15% in 2003 to 19% in 2018.

We are adding drug misuse to our High Risk List in 2021 to encourage progress. Our High Risk List covers areas in need of transformation, or at high risk from fraud, waste, abuse, and mismanagement.

Federal agencies may struggle to focus on drug misuse during the COVID-19 pandemic. Yet the pandemic could fuel contributing factors of misuse—such as unemployment—stressing the long-term need to sustain and build upon ongoing efforts.