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.
Drug misuseâ€”the use of illicit drugs and the misuse of prescription drugsâ€”has been a long-standing and persistent problem in the United States. National rates of drug misuse have increased over the past two decades and represent a serious risk to public health. This has resulted in significant loss of life and harmful effects to society and the economy, including billions of dollars in costs. The federal drug control budget for FY 2019 was over $36 billion, and it funded the efforts of over a dozen federal agencies that are working on prevention, treatment, international counternarcotics, and law enforcement activities.
Because of the devastating effects of this issue, National Efforts to Prevent, Respond to, and Recover from Drug Misuse will be added to the High Risk List in 2021. (This has been considered a High Risk area since March 2020 but it was not added to the High Risk List immediately because the federal governmentâ€™s efforts were focused on the COVID-19 pandemic.)
Federal agencies could begin addressing the issues related to drug misuse by implementing some outstanding recommendations, available for download (XLSX file and CSV file). Addressing the nationâ€™s drug misuse challenges will require a comprehensive national strategy, limiting the supply of drugs, increasing access to treatments, and curbing demand.
National 2018 Estimates on Drug Misuse
Note: Large and small metro counties are in metropolitan statistical areas and have a population of 1 million or more and fewer than 1 million, respectively. Metropolitan statistical areas have at least one urbanized area, and include adjacent counties with a high degree of social and economic integration with the urbanized area. All other counties are non-metro counties.
National Drug Control Strategy
The Office of National Drug Control Policy (ONDCP) is responsible for developing the National Drug Control Strategy, which helps prioritize, coordinate, and measure key efforts to address the drug crisis. But ONDCP could improve its efforts to effectively coordinate national efforts to address drug misuse.
In 2017 and 2018, ONDCP lacked a statutorily required National Drug Control Strategy, and the 2019 National Drug Control Strategy did not fully comply with the law. The 2020 National Drug Control Strategy made progress in addressing several statutory requirements, but fell short in meeting other requirements. For example, it did not include a list of drug misuse activities that federal agencies are undertaking, and the role of each activity in achieving long-term goals.
Limiting prescription drug misuse and illicit drugs
Federal agencies could improve their efforts to curb the misuse of prescription drugs, as well as the supply of illicit drugs, in a number of ways.
- The Drug Enforcement Administration (DEA) collects industry-reported data on the sale and purchase of controlled substances and prescription drugs, including opioids. The data supports DEAâ€™s investigations into whether drugs have been diverted to the illegal marketplace. DEAâ€™s systems do not provide real-time analysis, but more robust analysis is possible. For example, DEA could use computer algorithms to proactively identify patterns and trends in drug distributionâ€”e.g., to see when unusual volumes of drugs are disposed of vs. sold.
- Federal agencies are working to limit the domestic availability of illicit synthetic opioids. For example, federal agencies 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 for these activities 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, Homeland Security, Justice, and State carry out international counternarcotics activities 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 Synthetics Trafficking and Overdose Prevention Act (STOP Act) of 2018 requires the U.S. Postal Service to provide data on international mail shipments to U.S. Customs and Border Protection (CBP). CBP then uses this dataâ€”e.g., the recipientâ€™s address and description of contentsâ€”to target mail for inspection to find opioids. While the Postal Service and CBP have made progress implementing the actâ€™s requirements, the Department of Homeland Security has yet to issue regulations to clarify the Postal Serviceâ€™s responsibilities in providing this data.
- The Department of Veterans Affairs (VA) has been working to address opioid safety for veterans, and has made progress with reducing opioid prescriptions. For example, VA has initiated a program to educate providers on best practices related to pain management and optimal opioid use. However, VA has not fully met all of its opioid safety goals, especially those related to opioid risk mitigation strategies (such as annual urine drug screenings).
Increasing access to treatments
The federal government could further support improved access to treatments that can assist with drug misuse.
- Medicaid is one of the largest sources of coverage for individuals undergoing medication-assisted treatment (MAT), which combines medications like methadone and buprenorphine with behavioral therapy to treat opioid use disorders. The Department of Health and Human Services (HHS) has identified expanding access to MAT as important for reducing opioid use disorders and overdoses, and has taken action to increase access. However, some state and federal policies restrict Medicaid beneficiaries' access to MAT medications.
- Veterans coping with the stresses of deployment or with readjusting to civilian life are at particular risk for drug and alcohol addiction. Veterans living in rural areas use the VAâ€™s substance use disorder treatment services at the same rate as those in urban areas, but their access to these services is sometimes more limited. Providing treatment in rural areas poses challenges, such as a shortage of specialized providers and lack of transportation. VA is taking steps to address these challenges.
- Neonatal abstinence syndrome (NAS)â€”a condition causing withdrawal symptoms in newborns such as difficulties breathing and feedingâ€”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 the 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.
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.
- Supporting community coalitions made up of the health care, education, and law enforcement sectors that work together 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 settingsâ€”such as reimbursing providers for conducting preventative drug screenings
GAO-20-337: Published: May 21, 2020. Publicly Released: Jun 22, 2020.
The Department of Labor has awarded grants to help states address the opioid crisis through training and employment services. State officials told us that job seekers who are in recovery may have additional challenges with finding employment, in part, due to employersâ€™ concerns about potential criminal histories, relapse, and social stigma. To help meet the training and employment needs of thos...
GAO-20-474: Published: Mar 26, 2020. Publicly Released: Mar 26, 2020.
Drug misuseâ€”using illicit drugs or misusing prescription drugsâ€”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 a...
GAO-20-118: Published: Jan 29, 2020. Publicly Released: Jan 29, 2020.
The Drug Enforcement Administration collects industry-reported data on the sale and purchase of controlled substances and prescription drugs, including opioids. The data supports DEAâ€™s investigations into whether drugs have been diverted to the illegal marketplace. DEAâ€™s systems donâ€™t provide real-time analysis, but more robust analysis is possible. For example, DEA could use computer algor...
GAO-20-233: Published: Jan 24, 2020. Publicly Released: Jan 24, 2020.
Nearly 2 million Americans misused or were addicted to opioids in 2018. Medication-assisted treatmentâ€”which combines medications such as buprenorphine with behavioral therapyâ€”can effectively treat opioid use disorders and overdoses. Medicaid is one of the largest sources of coverage for individuals undergoing medication-assisted treatment. The Department of Health and Human Services has worke...
GAO-20-124: Published: Dec 18, 2019. Publicly Released: Dec 18, 2019.
The Office of National Drug Control Policy (ONDCP) oversees and coordinates federal drug policy. In 2018, new legislation reauthorized ONDCP and imposed a number of new requirements. We found that ONDCP met some of the new requirements. For instance, ONDCP designated officials for two new coordinator positions. However, ONDCP does not have key planning elements needed to ensure it can meet other...
GAO-20-35: Published: Dec 2, 2019. Publicly Released: Dec 2, 2019.
Veterans coping with the stresses of deployment or with readjusting to civilian life are at particular risk for drug and alcohol addiction. The VA pays for addiction treatment. We looked at these treatment services and veteransâ€™ access to them. Overall, veterans living in rural areas use VAâ€™s addiction treatment services at the same rate as those in urban areas. But providing treatment servic...
GAO-19-274: Published: Feb 28, 2019. Publicly Released: Apr 1, 2019.
Nearly 40 million American adults have untreated substance use disorders or mental health conditions, such as depression. According to a national survey, many of them don't think they need treatment, and others say it's hard to get care. Left untreated, these behavioral health conditions can cause other health complications, such as drug overdosesâ€”which can raise health care costs. But how much...
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...
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.Â Feder...
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...
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 syndromeâ€”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 syndromeâ€”such as providing medical education to healthcar...
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 2014â€”more than any previous year on recordâ€”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...