THE PRESIDENT’S COMMISSION

ON COMBATING DRUG 

ADDICTION AND THE OPIOID 

CRISIS

Roster of Commissioners

Governor Chris Christie, Chairman

Governor Charlie Baker

Governor Roy Cooper

Congressman Patrick J. Kennedy

Professor Bertha Madras, Ph.D.

Florida Attorney General Pam Bondi
Table of Contents

Chairman’s Letter............................................................................................ 5

Summary of Recommendations.................................................................................................... 12

The Drug Addiction and Opioid Crisis......................................................................................... 19

Origins of the Current Crisis..................................................................................................... 19

Magnitude and Demographics .................................................................................................. 23

Newly Emerging Threats .......................................................................................................... 26

Pathways to Opioid Use Disorder (Including Heroin) from Prescription Opioids................... 27

Health, Financial, and Social Consequences............................................................................. 29

Drug Overdose Deaths.............................................................................................................. 31

Substance Use Treatment Availability...................................................................................... 32

Systems Approach to Solutions ................................................................................................ 35

Federal Funding and Programs..................................................................................................... 37

Streamlining Federal Funding for Opioids and Consideration of State Administrators........... 37

Funding Effective Opioid-Related Programs............................................................................ 38

Opioid Addiction Prevention ........................................................................................................ 40

Evidence-based Prevention Programs....................................................................................... 42

SBIRT as a School Prevention Strategy................................................................................ 43

Mass Media Public Education Campaigns................................................................................ 44

Media Campaign Focusing on Opioids................................................................................. 46

Opioid Prescription Practices.................................................................................................... 48

Improving upon the CDC Guideline for Prescribing Opioids for Chronic Pain and 

Provider/Prescriber Education............................................................................................... 48

Enhancing Prescription Drug Monitoring Programs (PDMP) .............................................. 53

Prescription Take-Back Programs and Drug Disposal.......................................................... 55

Pain Level as an HHS Evaluation Criteria ................................................................................ 56

Reimbursement for Non-Opioid Pain Treatments .................................................................... 57

Reducing and Addressing the Availability of Illicit Opioids.................................................... 58

Improving Data Collection and Analytics............................................................................. 58

Disrupting the Illicit Fentanyl Supply ................................................................................... 61

Interdiction and Detection Challenges .................................................................................. 63

Protecting First Responders from Harmful Effects Resulting from Exposure to Fentanyl and 

other Synthetic Opioids......................................................................................................... 65
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Opioid Addiction Treatment, Overdose Reversal, and Recovery................................................. 67

Drug Addiction Treatment Services.......................................................................................... 67

Increase Screenings and Referrals to Treatment through CMS Quality Measures............... 67

Evidence-based Improvements to Treatment ........................................................................ 68

Insurance and Reimbursement Barriers to Accessing MAT ................................................. 69

Enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA)........................ 71

MAT in the Criminal Justice System .................................................................................... 72

Drug Courts and Diversion Programs ................................................................................... 73

Addiction Services Workforce and Training Needs.............................................................. 74

Response to Overdose ............................................................................................................... 77

Expanded Access and Administration of Naloxone .............................................................. 77

Overdose to Treatment and Recovery ................................................................................... 79

Recovery Support Services ....................................................................................................... 80

Impact on Families and Children........................................................................................... 80

Supporting Collegiate Recovery and Changing the Culture on College Campuses.............. 81

Employment Opportunities for Americans in Recovery ....................................................... 83

Support Recovery Housing.................................................................................................... 84

Research & Development ............................................................................................................. 86

New Pain, Overdose, and MAT Medications ........................................................................... 86

Medical Technology Devices.................................................................................................... 88

FDA Post-Market Research and Surveillance Programs .......................................................... 89

Conclusion .................................................................................................................................... 90

Current Federal Programs and Funding Landscape...................................................................... 93

Overview ................................................................................................................................... 93

FY 2018 Funding Specific to America’s Opioid Crisis............................................................ 93

The Comprehensive Addiction and Recovery Act (CARA) ................................................. 96

21st Century Cures Act .......................................................................................................... 96

FY 2018 Consolidated Federal Drug Control Budget............................................................... 97

Prevention.............................................................................................................................. 97

Treatment and Recovery........................................................................................................ 98

Domestic Law Enforcement ................................................................................................ 101

Interdiction........................................................................................................................... 102

International Efforts............................................................................................................. 103
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Charter, President’s Commission on Combating Drug Addiction and the Opioid Crisis.......... 107

Appendices.................................................................................................................................. 110

Appendix 1. Acronyms .......................................................................................................... 110

Appendix 2. History of Opiate Use and Abuse...................................................................... 113

Appendix 3. Interim Report, President’s Commission on Combatting Drug Addiction and the 

Opioid Crisis........................................................................................................................... 115

Appendix 4. Fentanyl Safety Recommendations for First Responders.................................. 125

References................................................................................................................................... 126
ON COMB AT IN G DRUG ADDIC TION AND THE OPIOID CRISIS

Governor Chris Christie

Chairman

Governor Charlie Baker

Florida Attorney General Pam Bondi

Governor Roy Cooper

Congressman Patrick J. Kennedy Professor Bertha Madras, Ph.D.

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November 1, 2017

The Honorable Donald J. Trump

President of the United States

The White House

1600 Pennsylvania Avenue NW

Washington, DC 20500

Dear President Trump, 

On behalf of the President’s Commission on Combating Drug Addiction and the Opioid 

Crisis, we thank you for entrusting us with the responsibility of developing recommendations to 

combat the addiction crisis that is rampantly impacting our country. 

Your speech in the East Room of the White House, along with the remarks of the First 

Lady, made it clear to the country that fighting this epidemic is a top priority of your 

Administration. On behalf of the Commission, we thank you for your leadership on this issue and 

on the clarity of your call to action.

When you declared the opioid crisis a national public health emergency under federal law 

on October 26, 2017, you acknowledged this crisis as one of epic proportion, impacting nearly 

every community across all 50 states. You signaled to the country that the force of the federal 

government should and will mobilize to reverse the rising tide of overdose deaths. You gave the 

millions of Americans fighting addiction hope that we can overcome this crisis, and we are 

prepared to win the fight.

Mr. President, as you acknowledged when you addressed the nation last week, the reason 

behind the urgent recommendations presented to you today by this Commission is that the leading 

cause of unintentional death in the United States is now drug overdose deaths. 

Our people are dying. More than 175 lives lost every day. If a terrorist organization was 

killing 175 Americans a day on American soil, what would we do to stop them? We would do 

anything and everything. We must do the same to stop the dying caused from within. I know you 

will. 

Without comprehensive action, including your national public health emergency, the death 

count will continue to rise. I know that is unacceptable to you. I know you will win this fight for 

the people who elected you. 
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You’ve met hundreds of parents who have buried their children, so these numbers are no 

longer simply statistics. Instead, they represent the injured student-athlete who becomes addicted 

after first prescription, ending her academic and athletic career, the newborn infant who is red and 

screaming from withdrawal pain, the grandparents using their retirement savings to raise young 

kids when the parents can’t, the mom who just buried her only son, and the addict who cycles in 

and out of jail, simply because without access to treatment he is unable to stay sober and meet the 

terms of his parole. 

It is time we all say what we know is true: addiction is a disease. However, we do not treat 

addiction in this country like we treat other diseases. Neither government nor the private sector 

has committed the support necessary for research, prevention, and treatment like we do for other 

diseases. 

The recommendations herein, and the interim recommendations submitted by the 

Commission in July, are designed to address this national priority. These recommendations will 

help doctors, addiction treatment providers, parents, schools, patients, faith-based leaders, law 

enforcement, insurers, the medical industry, and researchers fight opioid abuse and misuse by 

reducing federal barriers and increasing support to effective programs and innovation. 

Obviously, many of the recommendations that follow will require appropriations from 

Congress into the Public Health Emergency Fund, for block grants to states and to DOJ for 

enforcement and judicial improvements. It is not the Commission’s charge to quantify the amount 

of these resources, so we do not do so in this report.

You have made fighting the opioid epidemic a national priority, Mr. President. And, the 

country is ready to follow your lead. Now, we urge Congress to do their constitutionally delegated 

duty and appropriate sufficient funds (as soon as possible) to implement the Commission's 

recommendations. 175 Americans are dying a day. Congress must act.

Here is what your Administration has already done:

• You acted to remove one of the biggest federal barriers to treatment by announcing the 

launch of a new policy to overcome the restrictive, decades-old federal rule that prevents 

states from providing more access to care at treatment facilities with more than 16 beds. 

This action will take people in crisis off waiting lists where they are at risk of losing their 

battle to their disease and put them into a treatment bed and on the path to recovery. We 

urge all Governors to apply to CMS for a waiver. This policy will – without any doubt –

save lives. Governors across this nation thank you for listening to our call for help.

• In the interim report, the Commission also called for prescriber education and enhanced 

access to medication-assisted treatment for those already suffering from addiction. You 

acknowledged the need for these recommendations and directed all federally employed 

prescribers to receive special training to fight this epidemic. This is a bold step by you to 

deal with this issue.

• We recommended that the Department of Justice, which has already acted forcefully to 

stop the flow of illicit synthetic drugs into this country through the U.S. Postal Service, 

continue its efforts. The aggressive enforcement action being taken by your Administration 

is critical in our efforts to reduce the rise of overdose deaths in this country.
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• National Institutes of Health (NIH) Director Dr. Francis Collins has been partnering with 

pharmaceutical companies to develop non-addictive painkillers and new treatments for 

addiction and overdose. The Commission worked with Dr. Collins to convene a meeting 

with industry leadership to discuss innovative ways to combat the opioid crisis. The 

Commission also held a public meeting to highlight the progress and innovation occurring 

today resulting from the NIH’s work. This type of scientific progress is a positive step to 

help free the next generation from the widespread suffering addiction is causing today.

Our interim recommendations called for more data sharing among state-based prescription 

drug monitoring programs and recognized the need to address patient privacy regulations that 

make it difficult for health providers to access information and make informed healthcare decisions 

for someone who has a substance use disorder. We recommended that all law enforcement officers 

across the country be equipped with life-saving naloxone.

Finally, we recommended full enforcement of the Mental Health Parity and Addiction 

Equity Act to ensure that health plans cannot provide less favorable benefits for mental health and 

substance use diagnoses than physical health ailments. You will see further recommendations in 

our final report regarding the Parity Act and calling for the Department of Labor to have enhanced 

penalty and enforcement powers directly against insurers failing those who depend on them for 

life-saving treatment. 

All the interim recommendations remain extremely relevant today and are critical tools to 

reduce ever increasing overdose deaths plaguing our citizens. The Commission is grateful the 

Administration has begun the hard work of implementing these initiatives. We urge you to 

implement the others as soon as possible.

Today, the Commission, as one its most urgent recommendations among the more than 50 

provided in the final report, is calling for an expansive national multi-media campaign to fight this 

national health emergency. 

This campaign, including aggressive television and social media outreach, must focus on 

telling our children of the dangers of these drugs and addiction, and on removing stigma as a barrier 

to treatment by emphasizing that addiction is not a moral failing, but rather a chronic brain disease 

with evidence-based treatment options. People need to be aware of the health risks associated with 

opioid use, and they must stop being afraid or ashamed of seeking help when facing their addiction.

Today, only 10.6% of youth and adults who need treatment for a substance use disorder 

receive that treatment. This is unacceptable. Too many people who could be helped are falling 

through the cracks and losing their lives as a result.

Many states, including my State of New Jersey, have undertaken this media strategy with 

significant positive results. However, having a nation-wide campaign will serve to reinforce the 

message and ensure, for example, that youth and young adults no longer believe that experimenting 

with pills from a doctor is safer than experimenting with illegal substances from a drug dealer.

As part of its prevention recommendations, the Commission also calls for better educating 

middle school, high school, and college students with the help of trained professionals such as 

nurses and counselors who can assess at-risk kids. Children have not escaped the consequences of 
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addiction and our efforts to reduce overdose deaths must start early. Mrs. Trump’s dedication and 

leadership in helping our nation’s children will make this a top priority and help save innocent 

young lives. 

One of the most important recommendations in this final report is getting federal funding 

support more quickly and effectively to state governments, who are on the front lines of fighting 

this addiction battle every day. Bureaucracy, departmental silos, and red tape must not be accepted 

as the norm when dealing with funding to combat this epidemic. Saving time and resources, in 

this instance, will literally save lives.

Accordingly, we are urging Congress and the Administration to block grant federal 

funding for opioid-related and SUD-related activities to the states. There are multiple federal 

agencies and multiple grants within those agencies that cause states a significant administrative 

burden from an application and reporting perspective. Money is being wasted and accountability 

for results is not as intense as it should be. Block granting them would allow more resources to be 

spent on administering life-saving programs. This was a request to the Commission by nearly every 

Governor, regardless of party, across the country. And as a Commission that has three governors 

as members, all of whom know the frustration of jumping through multiple hoops to receive the 

funding we need to help our constituents in this fight, we wholeheartedly agree. 

Throughout the comprehensive recommendations of its final report, the Commission also 

identifies the need to focus on, deploy and assess evidence-based programs that can be funded 

through these proposed block grants. Many of the recommendations acknowledge a need for better 

data analysis and accountability to ensure that any critical dollars are spent on what works best to 

fight this disease. 

From its review of the federal budget aimed at addressing the opioid epidemic, the 

Commission identified a disturbing trend in federal health care reimbursement policies that 

incentivizes the wide-spread prescribing of opioids and limits access to other non-addictive 

treatments for pain, as well as addiction treatment and medication-assisted treatment.

First, individuals with acute or chronic pain must have access to non-opioid pain 

management options. Everything from physical therapy, to non-opioid medications, should be 

easily accessible as an alternative to opioids. The Commission heard from many innovative life 

sciences firms with new and promising products to treat patients’ pain in non-addictive, safer ways; 

but they have trouble competing with cheap, generic opioids that are so widely used. We should 

incentivize insurers and the government to pay for non-opioid treatments for pain beginning right 

in the operating room and at every treatment step along the way.

In some cases, non-addictive pain medications are bundled in federal reimbursement 

policies so that hospitals and doctors are essentially not covered to prescribe non-opioid pain 

management alternatives. These types of policies, which the federal government can fix, are a 

significant deterrent to turning the tide on the health crisis we are facing. We urge you to order 

HHS to fix it.

Second, as a condition of full reimbursement of hospitals, CMS requires that hospitals 

randomly survey discharged patients. HHS previously included pain question response 
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information in calculations of incentive payment, but in 2017 thankfully abandoned this practice. 

However, all pain survey questions were not withdrawn from the surveys. The Commission 

recommends that CMS remove pain questions entirely when assessing consumers so that providers 

won’t ever use opioids inappropriately to raise their survey scores. We urge you to order HHS to 

do this immediately.

The expectation of eliminating a patient’s pain as an indication of successful treatment, 

and seeing pain as the fifth vital sign, which has been stated by some medical professionals as 

unique to the United States, was cited as a core cause of the culture of overprescribing in this 

country that led to the current health crisis. This must end immediately.

The Department of Labor must be given the real authority to regulate the health insurance 

industry. The health insurers are not following the federal law requiring parity in the 

reimbursement for mental health and addiction. They must be held responsible. The Secretary of 

Labor testified he needs the ability to fine violators and to individually investigate insurers not just 

employers. We agree with Secretary Acosta. If we do not get Congress to give him these tools, 

we will be failing our mission as badly as health insurance companies are failing their subscribers 

on this issue today leading to deaths. 

Also contributing to this problem is the fact that HHS/CMS, the Indian Health Service, 

Tricare, and the VA still have reimbursement barriers to substance abuse treatment, including 

limiting access to certain FDA-approved medication-assisted treatment, counseling, and 

inpatient/residential treatment. 

It’s imperative that federal treatment providers lead the way to treating addiction as a 

disease and remove these barriers. Each of these primary care providers employed by the abovementioned federal health systems should screen for SUDs and, directly or through referral, provide 

treatment within 24-to-48 hours. Each physician employee should be able to prescribe 

buprenorphine (if that is the most appropriate treatment for the patient) in primary care settings. 

As President, you can make this happen immediately. We urge you to do so.

A good example of this federal leadership occurred when Department of Veterans Affairs 

Secretary Shulkin, in response to the Commission’s interim report release, immediately launched 

eight best practices for pain management in the VA health-care system. These guidelines included 

everything from alternatives and complimentary care, counseling and patient monitoring to peer 

education for front-line providers, informed consent of patients and naloxone distribution for 

Veterans on long-term opioid therapy. I had the opportunity to visit with doctors and patients at 

the Louis Stokes Northeast Ohio VA Healthcare System and witnessed first-hand the positive 

results of a hospital that has embraced a different continuum of care for pain management. The 

VA doctors, which included behavioral health specialists, acknowledge and treat those with 

addiction in the full complement of ways the medical community would tackle other chronic 

diseases. Let’s use these VA practices as an example for our entire healthcare system. 

As you will see in the Commission’s recommendations, the Federal Government has a 

number of avenues through which it can ensure that individuals with addiction disorders get the 

help they need; including changing CMS reimbursement policies, enforcing parity laws against 

non-compliant insurers, promoting access to rural communities through such tools as telemedicine, 
10

and incenting a larger treatment workforce to address the broad scope of the crisis. 

For individuals with a substance use disorder, ensuring life-saving access to affordable 

health care benefits is an essential tool in fighting the opioid epidemic. Look at Indiana as an 

example. After Indiana used an insurance access program to rapidly respond to a rural, opioidrelated health crisis, the Indiana Department of Health reported that such a program opened the 

door to life changing medical treatment. 

We are recommending that a drug court be established in every one of the 93 federal district 

courts in America. It is working in our states and can work in our federal system to help treat those 

who need it and lower the federal prison population. For many people, being arrested and sent to 

a drug court is what saved their lives, allowed them to get treatment, and gave them a second 

chance. 

Drug Courts are known to be significantly more effective than incarceration, but 44% of 

U.S. Counties do not have an adult drug court. DOJ should urge states to establish state drug courts 

in every county. When individuals violate the terms of probation or parole with substance use, they 

need to be diverted to drug court, rather than back to incarceration. Further, drug courts need to 

embrace the use of medication-assisted treatment for their populations, as it clearly improves 

outcomes. The criminal justice system should accept that medication, when clinically appropriate, 

can lead to lasting recovery; abstinence-only sobriety is not the only path to recovery. 

Lastly, the Commission’s recommendations identify multiple ways to reduce the supply of 

licit and illicit opioids and enhanced enforcement strategies. Recognizing the growing threat of 

synthetic opioids such as fentanyl, the Commission recommends enhanced penalties for trafficking 

of fentanyl and fentanyl analogues and calls for additional technologies and drug detection 

methods to expand efforts to intercept fentanyl before entering the country. 

To help protect first responders, who are also on the front lines fighting this epidemic 

responding to overdoses sometimes multiple times a day, the Commission recommends the White 

House develop a national outreach strategy coordinating with Governors for the release and 

adoption of the Office of Homeland Security National Security Council’s new Fentanyl Safety 

Recommendations for First Responders. The Commission thanks White House Homeland Security 

Advisor Tom Bossert for his support and hard work already on this initiative.

Many other thoughtful, vital recommendations are included herein. These 

recommendations were informed by expert testimony provided during the Commission’s public 

meetings, which included treatment providers and experts, pharmaceutical innovators and insurers. 

They also were informed by thousands of written submissions accepted by the Commission as part 

of its public process. 

The Commission acknowledges that there is an active movement to promote the use of 

marijuana as an alternative medication for chronic pain and as a treatment for opioid addiction. 

Recent research out of the NIH’s National Institute on Drug Abuse found that marijuana use led 

to a 2 1⁄2 times greater chance that the marijuana user would become an opioid user and abuser. 

The Commission found this very disturbing. There is a lack of sophisticated outcome data on dose, 

potency, and abuse potential for marijuana. This mirrors the lack of data in the 1990’s and early 
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2000’s when opioid prescribing multiplied across health care settings and led to the current 

epidemic of abuse, misuse and addiction. The Commission urges that the same mistake is not made 

with the uninformed rush to put another drug legally on the market in the midst of an overdose 

epidemic. 

The Commission extends our sincere gratitude to all of the individuals, organizations, 

families, companies, state officials, federal agency staff, and clinical professionals who provided 

personal stories, creative solutions, and thoughtful input to the Commission. The Commission 

members received thousands of letters, took hundreds of phone calls and meetings, and heard 

testimony from prominent organizations including non-profits, professional societies, 

pharmaceutical companies, health insurance providers, and most importantly, individuals and 

families that have been in the throes of addiction. These letters, conversations, and meetings were 

the impetus for the vast majority of recommendations made in this report. 

The Commission is confident that, if enacted quickly, these recommendations will 

strengthen the federal government, state, and local response to this crisis. But it will take all 

invested parties to step up and play a role: the federal executive branch, Congress, states, the 

pharmaceutical industry, doctors, pharmacists, academia, and insurers. The responsibility is all of 

ours. We must come together for the collective good and acknowledge that this disease requires 

a coordinated and comprehensive attack from all of us. 

The time to wait is over. The time for talk is passed. 175 deaths a day can no longer be 

tolerated. We know that you will not stand by; we believe you will force action. 

Along with my fellow Commission members, and the thousands of people who contributed to this 

report by sharing their stories and ideas for solutions, I look forward to seeing these policy changes 

implemented. Thank you again for the opportunity to serve, and most of all thank you for your 

commitment to addressing this vital national public health emergency. 

Sincerely, 

Governor Chris Christie 

Governor of New Jersey

Chairman, President’s Commission on Combating 

Drug Addiction and the Opioid Crisis
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Summary of Recommendations

Federal Funding and Programs

1. The Commission urges Congress and the Administration to block grant federal funding for 

opioid-related and SUD-related activities to the states, where the battle is happening every day. 

There are multiple federal agencies and multiple grants within those agencies that cause states 

a significant administrative burden from an application and reporting perspective. Creating 

uniform block grants would allow more resources to be spent on administering life-saving 

programs. This was a request to the Commission by nearly every Governor, regardless of party, 

across the country. 

2. The Commission believes that ONDCP must establish a coordinated system for tracking all 

federally-funded initiatives, through support from HHS and DOJ. If we are to invest in 

combating this epidemic, we must invest in only those programs that achieve quantifiable goals 

and metrics. We are operating blindly today; ONDCP must establish a system of tracking and 

accountability. 

3. To achieve accountability in federal programs, the Commission recommends that ONDCP 

review is a component of every federal program and that necessary funding is provided for 

implementation. Cooperation by federal agencies and the states must be mandated.

Opioid Addiction Prevention

4. The Commission recommends that Department of Education (DOE) collaborate with states on 

student assessment programs such as Screening, Brief Intervention and Referral to Treatment 

(SBIRT). SBIRT is a program that uses a screening tool by trained staff to identify at-risk 

youth who may need treatment. This should be deployed for adolescents in middle school, high 

school and college levels. This is a significant prevention tool. 

5. The Commission recommends the Administration fund and collaborate with private sector and 

non-profit partners to design and implement a wide-reaching, national multi-platform media 

campaign addressing the hazards of substance use, the danger of opioids, and stigma. A similar 

mass media/educational campaign was launched during the AIDs public health crisis. 

Prescribing Guidelines, Regulations, Education

6. The Commission recommends HHS, the Department of Labor (DOL), VA/DOD, FDA, and 

ONDCP work with stakeholders to develop model statutes, regulations, and policies that 

ensure informed patient consent prior to an opioid prescription for chronic pain. Patients need 

to understand the risks, benefits and alternatives to taking opioids. This is not the standard 

today.

7. The Commission recommends that HHS coordinate the development of a national curriculum 

and standard of care for opioid prescribers. An updated set of guidelines for prescription pain 

medications should be established by an expert committee composed of various specialty 
13

practices to supplement the CDC guideline that are specifically targeted to primary care 

physicians. 

8. The Commission recommends that federal agencies work to collect participation data. Data on 

prescribing patterns should be matched with participation in continuing medical education data 

to determine program effectiveness and such analytics shared with clinicians and stakeholders 

such as state licensing boards. 

9. The Commission recommends that the Administration develop a model training program to be 

disseminated to all levels of medical education (including all prescribers) on screening for 

substance use and mental health status to identify at risk patients. 

10. The Commission recommends the Administration work with Congress to amend the 

Controlled Substances Act to allow the DEA to require that all prescribers desiring to be 

relicensed to prescribe opioids show participation in an approved continuing medical education 

program on opioid prescribing.

11. The Commission recommends that HHS, DOJ/DEA, ONDCP, and pharmacy associations train 

pharmacists on best practices to evaluate legitimacy of opioid prescriptions, and not penalize 

pharmacists for denying inappropriate prescriptions.

PDMP Enhancements

12. The Commission recommends the Administration's support of the Prescription Drug 

Monitoring (PDMP) Act to mandate states that receive grant funds to comply with PDMP 

requirements, including data sharing. This Act directs DOJ to fund the establishment and 

maintenance of a data-sharing hub.

13. The Commission recommends federal agencies mandate PDMP checks, and consider 

amending requirements under the Emergency Medical Treatment and Labor Act (EMTALA), 

which requires hospitals to screen and stabilize patients in an emergency department, 

regardless of insurance status or ability to pay.

14. The Commission recommends that PDMP data integration with electronic health records, 

overdose episodes, and SUD-related decision support tools for providers is necessary to 

increase effectiveness.

15. The Commission recommends ONDCP and DEA increase electronic prescribing to prevent 

diversion and forgery. The DEA should revise regulations regarding electronic prescribing for 

controlled substances.

16. The Commission recommends that the Federal Government work with states to remove legal 

barriers and ensure PDMPs incorporate available overdose/naloxone deployment data, 

including the Department of Transportation’s (DOT) Emergency Medical Technician (EMT) 

overdose database. It is necessary to have overdose data/naloxone deployment data in the 

PDMP to allow users of the PDMP to assist patients.
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Supply Reduction and Enforcement Strategies

17. The Commission recommends community-based stakeholders utilize Take Back Day to inform 

the public about drug screening and treatment services. The Commission encourages more 

hospitals/clinics and retail pharmacies to become year-round authorized collectors and explore 

the use of drug deactivation bags.

18. The Commission recommends that CMS remove pain survey questions entirely on patient 

satisfaction surveys, so that providers are never incentivized for offering opioids to raise their 

survey score. ONDCP and HHS should establish a policy to prevent hospital administrators 

from using patient ratings from CMS surveys improperly.

19. The Commission recommends CMS review and modify rate-setting policies that discourage 

the use of non-opioid treatments for pain, such as certain bundled payments that make 

alternative treatment options cost prohibitive for hospitals and doctors, particularly those 

options for treating immediate post-surgical pain.

20. The Commission recommends a federal effort to strengthen data collection activities enabling 

real-time surveillance of the opioid crisis at the national, state, local, and tribal levels.

21. The Commission recommends the Federal Government work with the states to develop and 

implement standardized rigorous drug testing procedures, forensic methods, and use of 

appropriate toxicology instrumentation in the investigation of drug-related deaths. We do not 

have sufficiently accurate and systematic data from medical examiners around the country to 

determine overdose deaths, both in their cause and the actual number of deaths.

22. The Commission recommends reinstituting the Arrestee Drug Abuse Monitoring (ADAM) 

program and the Drug Abuse Warning Network (DAWN) to improve data collection and 

provide resources for other promising surveillance systems.

23. The Commission recommends the enhancement of federal sentencing penalties for the 

trafficking of fentanyl and fentanyl analogues.

24. The Commission recommends that federal law enforcement agencies expressly target Drug 

Trafficking Organizations and other individuals who produce and sell counterfeit pills, 

including through the internet.

25. The Commission recommends that the Administration work with Congress to amend the law 

to give the DEA the authority to regulate the use of pill presses/tableting machines with 

requirements for the maintenance of records, inspections for verifying location and stated use, 

and security provisions.

26. The Commission recommends U.S. Customs and Border Protection (CBP) and the U.S. Postal 

Inspection Service (USPIS) use additional technologies and drug detection canines to expand 

efforts to intercept fentanyl (and other synthetic opioids) in envelopes and packages at 

international mail processing distribution centers.

27. The Commission recommends Congress and the Federal Government use advanced electronic 

data on international shipments from high-risk areas to identify international suppliers and their 

U.S.-based distributors.
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28. The Commission recommends support of the Synthetics Trafficking and Overdose Prevention 

(STOP) Act and recommends the Federal Government work with the international community 

to implement the STOP Act in accordance with international laws and treaties.

29. The Commission recommends a coordinated federal/DEA effort to prevent, monitor and detect 

the diversion of prescription opioids, including licit fentanyl, for illicit distribution or use.

30. The Commission recommends the White House develop a national outreach plan for the 

Fentanyl Safety Recommendations for First Responders. Federal departments and agencies 

should partner with Governors and state fusion centers to develop and standardize data 

collection, analytics, and information-sharing related to first responder opioid-intoxication 

incidents.

Opioid Addiction Treatment, Overdose Reversal, and Recovery

31. The Commission recommends HHS, CMS, Substance Abuse and Mental Health Services 

Administration, the VA, and other federal agencies incorporate quality measures that address 

addiction screenings and treatment referrals. There is a great need to ensure that health care 

providers are screening for SUDs and know how to appropriately counsel, or refer a patient. 

HHS should review the scientific evidence on the latest OUD and SUD treatment options and 

collaborate with the U.S. Preventive Services Task Force (USPSTF) on provider 

recommendations.

32. The Commission recommends the adoption of process, outcome, and prognostic measures of 

treatment services as presented by the National Outcome Measurement and the American 

Society of Addiction Medicine (ASAM). Addiction is a chronic relapsing disease of the brain 

which affects multiple aspects of a person's life. Providers, practitioners, and funders often face 

challenges in helping individuals achieve positive long-term outcomes without relapse.

33. The Commission recommends HHS/CMS, the Indian Health Service (IHS), Tricare, the DEA, 

and the VA remove reimbursement and policy barriers to SUD treatment, including those, such 

as patient limits, that limit access to any forms of FDA-approved medication-assisted treatment 

(MAT), counseling, inpatient/residential treatment, and other treatment modalities, particularly 

fail-first protocols and frequent prior authorizations. All primary care providers employed by 

the above-mentioned health systems should screen for alcohol and drug use and, directly or 

through referral, provide treatment within 24 to 48 hours.

34. The Commission recommends HHS review and modify rate-setting (including policies that 

indirectly impact reimbursement) to better cover the true costs of providing SUD treatment, 

including inpatient psychiatric facility rates and outpatient provider rates.

35. Because the Department of Labor (DOL) regulates health care coverage provided by many 

large employers, the Commission recommends that Congress provide DOL increased authority 

to levy monetary penalties on insurers and funders, and permit DOL to launch investigations 

of health insurers independently for parity violations. 

36. The Commission recommends that federal and state regulators should use a standardized tool 

that requires health plans to document and disclose their compliance strategies for nonquantitative treatment limitations (NQTL) parity. NQTLs include stringent prior authorization 
16

and medical necessity requirements. HHS, in consultation with DOL and Treasury, should 

review clinical guidelines and standards to support NQTL parity requirements. Private sector 

insurers, including employers, should review rate-setting strategies and revise rates when 

necessary to increase their network of addiction treatment professionals.

37. The Commission recommends the National Institute on Corrections (NIC), the Bureau of 

Justice Assistance (BJA), the Substance Abuse and Mental Health Services Administration 

(SAMHSA), and other national, state, local, and tribal stakeholders use medication-assisted 

treatment (MAT) with pre-trial detainees and continuing treatment upon release.

38. The Commission recommends DOJ broadly establish federal drug courts within the federal 

district court system in all 93 federal judicial districts. States, local units of government, and 

Indian tribal governments should apply for drug court grants established by 34 U.S.C. § 10611.

Individuals with an SUD who violate probation terms with substance use should be diverted 

into drug court, rather than prison. 

39. The Commission recommends the Federal Government partner with appropriate hospital and 

recovery organizations to expand the use of recovery coaches, especially in hard-hit areas. 

Insurance companies, federal health systems, and state payers should expand programs for 

hospital and primary case-based SUD treatment and referral services. Recovery coach 

programs have been extraordinarily effective in states that have them to help direct patients in 

crisis to appropriate treatment. Addiction and recovery specialists can also work with patients 

through technology and telemedicine, to expand their reach to underserved areas.

40. The Commission recommends the Health Resources and Services Administration (HRSA) 

prioritize addiction treatment knowledge across all health disciplines. Adequate resources are 

needed to recruit and increase the number of addiction-trained psychiatrists and other 

physicians, nurses, psychologists, social workers, physician assistants, and community health 

workers and facilitate deployment in needed regions and facilities.

41. The Commission recommends that federal agencies revise regulations and reimbursement 

policies to allow for SUD treatment via telemedicine.

42. The Commission recommends further use of the National Health Service Corp to supply 

needed health care workers to states and localities with higher than average opioid use and 

abuse.

43. The Commission recommends the National Highway Traffic Safety Administration (NHTSA) 

review its National Emergency Medical Services (EMS) Scope of Practice Model with respect 

to naloxone, and disseminate best practices for states that may need statutory or regulatory 

changes to allow Emergency Medical Technicians (EMT) to administer naloxone, including 

higher doses to account for the rising number of fentanyl overdoses.

44. The Commission recommends HHS implement naloxone co-prescribing pilot programs to 

confirm initial research and identify best practices. ONDCP should, in coordination with HHS, 

disseminate a summary of existing research on co-prescribing to stakeholders.

45. The Commission recommends HHS develop new guidance for Emergency Medical Treatment 

and Labor Act (EMTALA) compliance with regard to treating and stabilizing SUD patients 

and provide resources to incentivize hospitals to hire appropriate staff for their emergency 

rooms.
17

46. The Commission recommends that HHS implement guidelines and reimbursement policies for 

Recovery Support Services, including peer-to-peer programs, jobs and life skills training, 

supportive housing, and recovery housing.

47. The Commission recommends that HHS, the Substance Abuse and Mental Health Services 

Administration (SAMHSA), and the Administration on Children, Youth and Families (ACYF) 

should disseminate best practices for states regarding interventions and strategies to keep 

families together, when it can be done safely (e.g., using a relative for kinship care). These 

practices should include utilizing comprehensive family centered approaches and should 

ensure families have access to drug screening, substance use treatment, and parental support. 

Further, federal agencies should research promising models for pregnant and post-partum 

women with SUDs and their newborns, including screenings, treatment interventions, 

supportive housing, non-pharmacologic interventions for children born with neonatal 

abstinence syndrome, medication-assisted treatment (MAT) and other recovery supports.

48. The Commission recommends ONDCP, the Substance Abuse and Mental Health Services 

Administration (SAMHSA), and the Department of Education (DOE) identify successful 

college recovery programs, including "sober housing" on college campuses, and provide 

support and technical assistance to increase the number and capacity of high-quality programs 

to help students in recovery.

49. The Commission recommends that ONDCP, federal partners, including DOL, large employers, 

employee assistance programs, and recovery support organizations develop best practices on 

SUDs and the workplace. Employers need information for addressing employee alcohol and 

drug use, ensure that employees are able to seek help for SUDs through employee assistance 

programs or other means, supporting health and wellness, including SUD recovery, for 

employees, and hiring those in recovery.

50. The Commission recommends that ONDCP work with the DOJ, DOL, the National Alliance 

for Model State Drug Laws, the National Conference of State Legislatures, and other 

stakeholders to develop model state legislation/regulation for states to decouple felony 

convictions and eligibility for business/occupational licenses, where appropriate.

51. The Commission recommends that ONDCP, federal agencies, the National Alliance for 

Recovery Residents (NARR), the National Association of State Alcohol and Drug Abuse 

Directors (NASADAD), and housing stakeholders should work collaboratively to develop 

quality standards and best practices for recovery residences, including model state and local 

policies. These partners should identify barriers (such as zoning restrictions and discrimination 

against MAT patients) and develop strategies to address these issues.

Research and Development

52. The Commission recommends federal agencies, including HHS (National Institutes of Health, 

CDC, CMS, FDA, and the Substance Abuse and Mental Health Services Administration), DOJ, 

the Department of Defense (DOD), the VA, and ONDCP, should engage in a comprehensive 

review of existing research programs and establish goals for pain management and addiction 

research (both prevention and treatment).
18

53. The Commission recommends Congress and the Federal Government provide additional 

resources to the National Institute on Drug Abuse (NIDA), the National Institute of Mental 

Health (NIMH), and National Institute on Alcohol Abuse and Alcoholism (NIAAA) to fund 

the research areas cited above. NIDA should continue research in concert with the

pharmaceutical industry to develop and test innovative medications for SUDs and OUDs, 

including long-acting injectables, more potent opioid antagonists to reverse overdose, drugs 

used for detoxification, and opioid vaccines.

54. The Commission recommends further research of Technology-Assisted Monitoring and 

Treatment for high-risk patients and SUD patients. CMS, FDA, and the United States 

Preventative Services Task Force (USPSTF) should implement a fast-track review process for 

any new evidence-based technology supporting SUD prevention and treatments.

55. The Commission recommends that commercial insurers and CMS fast-track creation of 

Healthcare Common Procedure Coding System (HCPCS) codes for FDA-approved 

technology-based treatments, digital interventions, and biomarker-based interventions. NIH 

should develop a means to evaluate behavior modification apps for effectiveness.

56. The Commission recommends that the FDA establish guidelines for post-market surveillance 

related to diversion, addiction, and other adverse consequences of controlled substances.
19

The Drug Addiction and Opioid Crisis 

The primary goal of the President’s Commission on Combatting Drug Addiction and the Opioid 

Crisis is to develop an effective set of recommendations for the President to combat the opioid 

crisis and drug addiction in our nation. Many of the recommendations that follow will require 

appropriations from Congress into the Public Health Emergency Fund, for block grants to states 

and to DOJ for enforcement and judicial improvements. It is not the Commission’s charge to 

quantify the amount of these resources, so we do not do so in this report.

The Commission urges Congress to respond to the President’s declaration of a Public Health 

Emergency and fulfill their constitutionally delegated duty and appropriate sufficient funds to 

implement the Commission’s recommendations. 175 Americans are dying every day. Congress 

must act. Notwithstanding this core mission, it is vital to address the influences that transformed 

the United States into the world leader of opioid prescribing, opioid addiction, and opioid overdose 

deaths. 

Origins of the Current Crisis

The Current Crisis. In the mid- to late-19th century, the first national opioid crisis occurred; a 

detailed history is provided in Appendix 2. During this time, opioid use rose dramatically, fueled 

by physicians’ unrestrained opioid prescriptions (morphine, laudanum, paregoric, codeine, and 

heroin) for pain or other ailments, and by liberal use of opioid-based treatments for injuries and 

diseases impacting Civil War combatants and veterans (see Appendix 2). In parallel with the 

current crisis, this nation-wide crisis extended across socio-economic statuses, and reached urban 

and rural areas. This first epidemic was eventually contained and reversed by physicians, 

pharmacists, medical education, and voluntary restraint, combined with federal regulations and 

law enforcement.

After the first crisis subsided, medical education emphasized the hazards of improper opioid 

prescribing, and by doing so, created a cultural mindset against the dangers of opioids. However, 

over 30 years ago, a sequence of events eroded fears of opioids, and the medical community once 

again relapsed into liberal use of medicinal opioids. 

Triggered by excessive prescribing of opioids since 1999, the current crisis is being fueled by 

several factors that did not exist in the 19th century: the advent of large scale production and 

distribution of pure, potent, orally effective and addictive opioids; the widespread availability of 

inexpensive and purer illicit heroin; the influx of highly potent fentanyl/fentanyl analogs; the 

transition of prescription opioid misusers into use of heroin and fentanyl; and the production of 

illicit opioid pills containing deadly fentanyl(s) made by authentic pill presses. Prescription opioids 

now affect a wide age range, families both well-off and financially disadvantaged, urban and rural, 

and all ethnic and racial groups.

Historical precedent demonstrated that this crisis can be fought with effective medical education, 

voluntary or involuntary changes in prescribing practices, and a strong regulatory and enforcement 

environment. The recommendations of the Commission are grounded in this reality, and benefit 

from modern systematic epidemiological and large data analytics, evidence-based treatments, and 

medications to assist in recovery or rescue of an overdose crisis. 
20

Contributors to the Current Crisis. A widely held and supportable view is that the modern opioid 

crisis originated within the healthcare system and have been influenced by several factors:

• Unsubstantiated claims: One early catalyst can be traced to a single letter to the Editor of the 

New England Journal of Medicine published in 1980, that was then cited by over 600 

subsequent articles.1,2 With the headline “Addiction Rare in Patients Treated with Narcotics,”

the flawed conclusion of the five-sentence letter was based on scrutiny of records of 

hospitalized patients administered an opioid. It offered no information on opioid dose, number 

of doses, the duration of opioid treatment, whether opioids were consumed after hospital 

discharge, or long-term follow-up, nor a description of criteria used to designate opioid 

addiction. Six years later, another problematic study concluded that “opioid maintenance 

therapy can be a safe, salutary and more humane alternative to the options of surgery or no 

treatment in those patients with intractable non-malignant pain and no history of drug abuse.”

3

High quality evidence demonstrating that opioids can be used safely for chronic non-terminal 

pain did not exist at that time. These reports eroded the historical evidence (see Appendix 2) 

of iatrogenic addiction and aversion to opioids, with the poor-quality evidence that was 

unfortunately accepted by federal agencies and other oversight organizations.

• Pain patient advocacy: Advocacy for pain management and/or the use of opioids4,5,6by pain 

patients was promoted, not only by patients, but also by some physicians. One notable 

physician stated: “make pain ‘visible’... ensure patients a place in the communications loop... 

assess patient satisfaction; and work with narcotics control authorities to encourage therapeutic 

opiate use... therapeutic use of opiate analgesics rarely results in addiction.”7

• The opioid pharmaceutical manufacturing and supply chain industry: One 

pharmaceutical company sponsored over 20,000 educational events for physicians and others 

on managing pain with opioids, claiming their potential for addiction was low.8 Yet, warning 

signs of the addictive potential of oxycodone and similar opioids long predated this period: in 

1963, Bloomquist wrote that dihydrohydroxycodeinone (oxycodone, Percodan®), “although a 

useful analgesic retains addiction potential comparable to that of morphine. This fact should 

be considered when it is prescribed. Because of increasing numbers of addicts to this drug in 

the State of California, the California Medical Association Committee on Dangerous Drugs 

and the House of Delegates has recommended that oxycodone-containing drugs be returned to 

the triplicate prescription list as they were originally in 1949.” This recommendation failed to 

pass the legislature.9 Similar warnings followed. 

Aggressive promotion of an oxycodone brand from 1997-2002 led to a 10-fold rise in 

prescriptions to treat moderate to severe noncancer pain, and increases in prescribing of other 

opioids. Subsequently, the highest strengths permissible was increased for opioid-tolerant 

patients, likely contributing to its misuse. Extended-release (ER) formulations and delayed 

absorption were marketed as reducing abuse liability, but crushing the pills allowed users to

snort or inject the drugs.

10,11 There are now at least five marketed opioids that carry abusedeterrent labeling. It has been hypothesized that the marked rise in heroin and other illicit 

synthetic opioids is, in part, associated with unintended consequences of reformulation of 

OxyContin, and a reduced supply and greater expense of prescription opioids.12,13

To this day, the opioid pharmaceutical industry influences the nation’s response to the crisis.14

For example, during the comment phase of the guideline developed by the Centers for Disease 

Control and Prevention (CDC) for pain management, opposition to the guideline was more 
21

common among organizations with funding from opioid manufacturers than those without 

funding from the life sciences industry.15

• Rogue pharmacies and unethical physician prescribing: The key contributors of the large

number of diverted opioids were unrestrained distributors, rogue pharmacies, unethical 

physicians, and patients whose opioid medications were diverted, or other patients who sold 

and profited from legitimately prescribed opioids.16

• Pain as the ‘fifth vital sign’: The phrase, “pain as the ‘fifth vital sign,’” was initially promoted 

by the American Pain Society in 1995, to elevate awareness of pain treatment among healthcare 

professionals; “Vital Signs are taken seriously. If pain were assessed with the same zeal as 

other vital signs are, it would have a much better chance of being treated properly. We need to 

train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured 

and treated.”17

The Veteran’s Administration (VA)18 and then the Joint Commission on Accreditation of 

Healthcare Organizations (the Joint Commission) designated pain as a ‘fifth vital sign.’

19,20

The Joint Commission accredits and certifies health care organizations. Certification has 

implications for objective assessment of clinical excellence, and for contracting and 

reimbursement. The Joint Commission’s standards for pain assessment in 2000 “were a bold 

attempt to address widespread underassessment and undertreatment of pain,”21 even though 

the health care community was not advocating for a regulatory approach to pain management.22

The standards raised concerns that requiring all patients to be screened for the presence of pain 

and raising pain treatment to patients’ rights issue could lead to overreliance on opioids. 

The Joint Commission received sponsorship for developing educational materials from an 

opioid pharmaceutical company, one of over 20,000 pain-related educational programs 

through direct sponsorship or financial grants. It was “unaware that the science behind their 

claims and the advice of experts in the field were erroneous.”23 This designation set in motion 

a growing compulsion to detect and treat pain, especially to prescribe opioids beyond 

traditional boundaries of treating acute, postoperative, procedural pain and end-of-life care. 

The surge in opioid supply escalated into opioid-related misuse, diversion, use disorder, and 

overdose deaths. Administrators, regulatory bodies, and insurers collectively pressured 

physicians to address patient satisfaction with aggressive pain management.24 However, the 

concept that iatrogenic addiction was rare and that long-acting opioids were less addictive had 

been widely repeated, and studies refuting these claims were not published until years later. 

The Joint Commission has since eliminated the requirement that pain be assessed in all 

patients, except for patients receiving behavioral health care and established much stricter 

processes to review any corporate sponsorship of educational programs. In 2016, the Joint 

Commission began to revise its pain standards,25 which will go into effect in January 2018.

• Inadequate oversight by the Food and Drug Administration (FDA): The FDA is the sole 

federal authority responsible for protecting public health by assuring the safety, efficacy, and 

security of human drugs, biological products, and medical devices. It approves medications to 

diagnose, treat, and mitigate illnesses, after assessing their safety and efficacy. It safeguards 

the nation’s medications by setting standards for proper prescribing of approved drugs and 

post-approval surveillance. The FDA provided inadequate regulatory oversight. Even when 

overdose deaths mounted and when evidence for safe use in chronic care was substantially 

lacking, prior to 2001, the FDA accepted claims that newly formulated opioids were not 
22

addictive, did not impose clinical trials of sufficient duration to detect addiction, or rigorous 

post-approval surveillance of adverse events, such as addiction. 

The FDA also failed to assess the risks associated with deliberate diversion and misuse of 

opioids, risks that conceivably outweighed the intended benefits for patients if used as directed. 

They accepted the pharmaceutical industry’s claim that iatrogenic addiction was “very rare” 

and that the delayed absorption of OxyContin reduced the abuse liability of the drug.26 By 

2001, the FDA removed these unsubstantiated claims from OxyContin’s labeling. In March 

2016, the FDA requested from the National Academies of Sciences, Engineering, and 

Medicine (NASEM) and received on July 13, 2017, a summary of the current status of science 

regarding prescription opioid abuse and misuse, and the role of opioids in pain management.27 

The current FDA Commissioner has stated a strong commitment to using the regulatory 

authority of the FDA to mitigate the adverse consequences of opioid use.28

• Reimbursement for prescription opioids by health care insurers: Sales of prescription 

opioids in the U.S. nearly quadrupled from 1999 to 2014,29 largely paid for by insurance 

carriers. It is estimated that 1 out of 5 patients with non-cancer pain or pain-related diagnoses 

are prescribed opioids in office-based settings.30 From 2007 to 2012, the rate of opioid 

prescribing steadily increased amongst specialists more likely to manage acute and chronic 

pain (pain medicine [49%], surgery [37%], physical medicine/rehabilitation [36%]). Insurance 

carriers, including Medicare Part D plans, did not serve as a stop-gap to the huge influx of 

opioid prescriptions.

• Medical education: Medical education has been deficient in pain management, opioid 

prescribing, screening for, and treating addictions.31 During the 1990’s, the pain movement 

should have alerted medical education institutions and creators of continuing medical 

education courses to address this issue. In some medical schools and some specialties, it 

remains inadequate to this day.32 One strategy promoted 10 years ago to stratify patients’ risk 

for opioid misuse and overdose was the screening of patients for substance use disorders 

(SUDs), especially pain patients.33 Implementation of Screening, Brief Interventions, and 

Referral to Treatment (SBIRT) in healthcare systems was incentivized with billing codes.34

SBIRT was mainstreamed into health care reform, but has yet to be incorporated nationally 

into medical curricula, or applied as routine care. Nor do core curricula necessarily address 

addictions, treatment options, or stress the need to screen for substance use and mental health.

• Lack of patient education: Patients and their families are not often fully informed regarding

whether their prescriptions are opioids, the risks of opioid addiction or overdose, control and 

diversion, dose escalation, or use with alcohol or benzodiazepines. 

• Public demand evolves into reimbursement and physician quality ratings pegged to 

patient satisfaction scores: Today, the use of opioids for chronic non-cancer pain remains 

controversial for the same reasons their use declined and was avoided at the turn of the 20th

century: the potential for misuse and addiction, insufficient high-quality evidence of efficacy 

with long-term use, poor functional outcomes, overdose and death. 

Yet, a strong public demand for opioids continues to pressure clinicians to prescribe opioids 

persists. As an example, a recent survey of Emergency Department (ED) physicians indicated 

that 71% reported a perceived pressure to prescribe opioid analgesics to avoid administrative 

and regulatory criticism. Uniformly, they voiced concern about excessive emphasis on patient 

satisfaction scores by reimbursement entities as a means of evaluating their patient 
23

management. The physician requirement to address pain as the "fifth vital sign" persists,35 and 

reimbursement metrics based on patient satisfaction may have inadvertently created an 

environment conducive to exploitation by prescription opioid abusers.36 There are legitimate 

circumstances for which opioids are an appropriate therapy. But many current institutional and 

societal issues continue to pressure physicians to prescribe opioids when they are not clinically 

appropriate. 

Prior to this year, poor patient satisfaction with pain care could lead to reduced hospital 

reimbursement by Medicare through Value-Based Purchasing (VBP). There are often higher 

costs or no specific reimbursements for alternative pain management strategies, alternative 

pain intervention strategies, or spending time to educate patients about the risks of opioids. 

Further, failing to provide adequate pain relief can be grounds for malpractice claims or 

medical board action.

• Lack of foresight of unintended consequences: As prescription drugs came under tighter 

scrutiny and access became more limited (via abuse-deterrent formulations and more cautious 

prescribing), market forces responded by providing less expensive and more accessible illicit 

opioids. Increases in overdose death numbers due to prescription opioids have transitioned to 

overdoses largely due to heroin and, increasingly, fentanyl.37 Locally, this trend may have been

driven, in part, by tightening controls on prescription opioids. Physicians curtailed opioid 

prescriptions without guidelines on tapering and without determination of whether patients had 

developed an opioid use disorder (OUD), and if so, how to respond.38

The availability of cheaper heroin also drove prescription opioid misusers to illicit opioids.

Black market heroin is currently much less expensive than diverted prescription opioids, and 

fentanyl is even much less expensive per dose than heroin. Predictable from the economics of 

the two drug categories, the prescription drug overdose problem has decreased, but not the 

overall number of opioid-related deaths. 

• Treatment services insufficient to meet demand and to provide medication-assisted 

treatment (MAT): As OUDs increased dramatically over the past 15 years, quality treatment 

services and the associated workforce did not expand in response to the growing crisis.

• Lack of national prevention strategies: Prevention strategies focusing on specific illicit 

drugs for vulnerable populations - adolescents, college age youth, pregnant women, 

unemployed men, and other - and for influencers, (parents, families) don’t exist or have not 

been tested adequately.

Magnitude and Demographics

National statistics on prescription opioid misuse and use disorder, 2016.39 Weighted National 

Survey on Drug Use and Health (NSDUH) estimates suggested that, in 2016, 91.8 million (34.1%) 

or more than one-third of U.S. civilian, noninstitutionalized adults used prescription opioids; 11.5

million (4.3%) misused them. In 2015, 1.6 million (0.7%) had an OUD. Among adults with 

prescription opioid use, 12.2% reported misuse and 15.1% of misusers reported a prescription 

OUD.

40 The most commonly reported motivation for misuse was to relieve physical pain (63.6%). 

Misuse and use disorders were most commonly reported in adults who were uninsured, were 
24

unemployed, had low income, or had behavioral health problems. Among adults with misuse, 

62.2% reported using opioids without a prescription, and 40.6% obtained prescription opioids for 

free from friends or relatives for their most recent episode of misuse. The results suggest a need to 

improve access to evidence-based pain management and to decrease excessive prescribing that 

may leave unused opioids available for potential misuse.41

The NSDUH estimates that 3.4 million people aged 12 or older in 2016 were current misusers of 

pain relievers (1.2% of the population aged 12 or older).42 In 2016, an estimated 239,000 

adolescents aged 12 to 17 were current misusers of pain relievers (1.0% of adolescents) and 

631,000 young adults aged 18 to 25 misused pain relievers in the past month (1.8% of young 

adults). Among adults aged 26 or older, 2.5 million are estimated to be current misusers of pain 

reliever (1.2%). Upwards of 1.8 million Americans harbor an OUD involving prescription opioids 

or 0.7% of people aged 12 or older. Among adolescents aged 12 to 17, 152,000 (0.6%) had a pain 

reliever use disorder in the past year, and 291,000 young adults aged 18 to 25 (0.8%) and 

1.3 million adults aged 26 or older in 2016 (0.6%) had a pain reliever use disorder in the past year. 

These small percentages do not convey the massive personal and public health burden created by 

misuse of opioids. 

National statistics on heroin use and use disorder, 2016.43 The addictive and illegal opioid heroin 

has no accepted medical use in the United States. Past 30 day users of heroin (475,000) among 

people aged 12 or older or 0.2% of the population is probably an underestimate because NSDUH 

surveys households and does not capture heroin users in homeless shelters or transient populations 

with no fixed address, and the incarcerated. Despite its dangers heroin use continues to escalate 

and reflects changes in heroin use by adults aged 26 or older and, to a lesser extent, among young 

adults aged 18 to 25. Less than 0.1% of adolescents aged 12 to 17 were current or past year heroin 

users (3,000 and 13,000, respectively) and these numbers remained relatively stable. Among 

young adults aged 18 to 25, 0.3% were current heroin users (88,000) and this number rose since 

2002. For past year and at minimum, 630,000 individuals have a heroin use disorder (HUD).

17

Among adults 26 and older 0.2% were current heroin users (383,000), a rise since 2015. About 

626,000 people aged 12 or older reported an HUD (0.2%), an increase since 2002 to 2011. Less 

than 0.1% of adolescents aged 12 to 17 (1,000) had an HUD in the past year, but this rate was 

many times higher among 18-25-year-olds (152,000; 0.4%). Approximately 473,000 adults aged 

26 or older had an HUD (0.2%) 

Substance use disorder treatment needs, 2016.44 For NSDUH, people are defined as needing 

substance use treatment if they had an SUD in the past year or if they received substance use 

treatment at a specialty facility in the past year. In 2016, 10.6% of people aged 12 or older 

(2.3 million people) who needed substance use treatment received treatment at a specialty facility 

in the past year. Among people in specific age groups needing substance use treatment, 8.2% of

adolescents aged 12 to 17, 7.2% of young adults aged 18 to 25, and 12.1% of adults aged 26 or 

older received substance use treatment at a specialty facility in the past year. These percentages 

represent 89,000 adolescents, 383,000 young adults, and 1.8 million adults aged 26 or older who 

needed substance use treatment and received treatment at a specialty facility in the past year. Prior 

to 2016, NSDUH reported on the reasons people in need in treatment did not receive it. 

Approximately 90% self-reported they did not feel the need for treatment and did not seek it.

Special Populations. The Commission recognizes that, although many of the recommendations 

included in this report are generic for the population as a whole, subpopulations exist within our 

nation that conceivably require increased outreach, access to services, and more tailored or 
25

intensive services. These special populations can be viewed from the perspective of race or 

ethnicity, residential location and population density, gender, age45, mental46 and physical health 

status (e.g. HIV-AIDS), income, employment, socio-economic status, education, veterans,

47,48

involvement in the criminal justice system (juveniles, parolees, incarcerated), family status 

(fetus49, children of substance-using parents or other family members, pregnant women, living 

alone), healthcare insurance sources, behavioral health indicators50 (other SUDs or history), type 

of opioid use (heroin/fentanyl, prescription opioid nonmedical or medical use, or combined use), 

and others. 

According to the 2016 NSDUH, more males (4.8%) than females (3.8%) misused prescription 

opioid medications.51 Young adults aged 18 to 25 years old had the largest proportion of misusers. 

In comparison to the national average for past year misuse of pain relievers by those 12 years and 

older, misuse was most common among Americans with two or more races (6.5%), American 

Indian or Alaska Natives (3.9%), Native Hawaiian or other Pacific Islanders (4.2%), and Hispanics 

(4.2%). The rate of non-medical use of prescription opioid medications was lowest among Asians 

(1.8%).

Scrutiny of the NSDUH and other data sources can reveal which populations are at highest risk. A 

recent study using 2010-2013 NSDUH data52 revealed the prevalence of OUDs was highest among 

whites (72.29%), with lower prevalence among blacks (9.23%), Hispanics 13.82%, and others 

4.66%. Other factors overrepresented among those reporting OUDs were adults aged 18–34 

(55.95%), males (57.39%), low income (<$50,000; 67.12%), residents of large metropolitan areas 

(49.99%), with fewer privately insured persons (40.97%). Compared with whites, adolescents 

were overrepresented among mixed-race persons and Hispanics. In contrast, Native Americans 

included a higher proportion of older adults aged≥50.

53 Among mixed-race persons, the proportion 

of females was higher than males. The vast majority of blacks (83.78%), Native Americans 

(88.98%), and Hispanics (76.44%) were in the lowest income group. A high proportion of blacks, 

Native Hawaiians/Pacific Islanders/Asian Americans, and Hispanics resided in large metropolitan 

areas. A high proportion of native-Americans lived in nonmetropolitan areas. All non-white 

groups, except for Native Hawaiians/Pacific Islanders/Asian Americans, had higher proportions 

of public insurance than whites. 

Among persons with OUD, the majority (80.09%) had another SUD, 28.74% had major 

depression, 53.02% had nicotine dependence, 40.93% had alcohol use disorder (AUD), and

43.22% had ≥1 other drug use disorder (cannabis 22.32%, tranquilizer 13.99%, cocaine 15.25%, 

stimulant 9.28%, hallucinogen 5.25%, sedative 3.51%, inhalant 2.22%), which was more prevalent 

among whites (83.39%) than Hispanics (72.04%). Major depressive episode was also common 

(28.74%). Most people with OUD report no use of OUD treatment, with only 26.19% using any 

alcohol or drug use treatment, 19.44% using opioid-specific treatment. Adolescents, the uninsured, 

blacks, Native Hawaiians/Pacific Islanders/Asian Americans, persons with prescription opioids

only, and persons without depression episodes especially underutilized opioid-specific treatment. 

The treatment rate for adolescents among blacks with OUD was very low, unless they were 

involved with the criminal justice system. Among alcohol/drug use treatment users, self-help 

group and outpatient rehabilitation treatment were commonly used services. 

Adolescent-onset OUD indicates a high risk for severe OUD. Low treatment rates, conceivably 

related to inadequate MAT data for adolescents, places this population at particular susceptibility. 

Native Hawaiians/Pacific Islanders/Asian Americans with OUD had the lowest prevalence of 

using alcohol/drug treatment (4.91%) or opioid-specific treatment (1.24%). Cultural-related 
26

stigma toward addiction and a lack of culturally congruent addiction providers are unique barriers 

to seeking treatment. Residents in rural areas have relatively high rates of opioid overdoses, but 

they face substantial barriers to OUD treatment, including a shortage of mental/behavioral health 

providers.

Newly Emerging Threats

New Psychoactive Substances. The term “new psychoactive substances” (NPS) can be defined as 

individual drugs in pure form or in complex preparations that are not scheduled under the Single 

Convention on Narcotic Drugs (1961) or the Convention on Psychotropic Substances (1971). NPS 

may be categorized by chemical structure, by psychoactive properties, by biological targets, or by 

source (plant, synthetic, or combined). The emergence of NPS that target opioid sites in the body 

is challenging public health and drug policies globally. Their novelty, ambiguous legal status, 

ability to evade toxicological tests, swift adaptation to legal restrictions, global internet marketing, 

and scant public knowledge of their adverse effects are among the key drivers of this 21st century 

phenomenon. 

The designation “new” is not necessarily limited to newly-designed compounds with no historical 

precedent, but may also include compounds modified from substances previously used. The 

majority are chemical analogs of drugs in restricted categories and may elicit effects similar to the 

parent drug, or a more amplified response. Others may evoke unique or complex sensations 

because of their hybrid structures, or because several compounds with differing pharmacological 

profiles are combined and sold as a unit. Although synthetic cathinone analogs and synthetic 

cannabinoids occupy a major share of this market, synthetic opioids, especially fentanyl analogs,

are by far the most problematic substances because they are emerging as a leading cause of opioid 

overdose deaths in the United States.54

Drivers of NPS. The rapid expansion of NPS in the past decade is fueled by a convergence of the 

information revolution, vague legal status, uncertain detectability, and financial incentives 

combined with guileful marketing. 

The internet is a “global neural network” that can be exploited to disseminate promotion and 

distribution of these drugs instantly. The venues are chat rooms, blogs, instant messaging sites, 

social networking, or multimedia sites. At minimal cost, descriptions of new drugs, their positive 

psychoactive effects, doses, synthetic routes, and purchasing sites are accessible world-wide on 

computers or mobile devices such as smart phones or smart watches. Many of the marketing sites 

are impervious to legal sanctions, as it takes time to deliberate the evidence and move newly 

emerging drugs into a legally restrictive zone, especially internationally. 

Imperfect international agreements and a gradual dissolution of international resolve to attenuate 

drug use compromise effective solutions to this unique problem. Often, substances that imitate 

controlled drugs are unscheduled, unregulated, and not under the auspices of international law. 

Their nebulous legal status is an incentive for entrepreneurs to introduce new drugs quickly into 

the global market. 

The allure of NPS is magnified by current limitations in detecting them. Identifying these drugs 

for forensic, workplace, legal, and policy purposes is constrained by a lack of reference materials 

and the need for sophisticated detection methods which are not routinely available (e.g., mass 
27

spectroscopy). The chemical structures of NPS are designed to keep one step ahead of federal and 

international laws that restrict distribution and sale of specific chemicals. The Drug Enforcement 

Administration (DEA) has emergency powers to temporarily schedule a drug for 36 months, a time 

frame to accumulate evidence for/against long-term drug scheduling. 

New Psychoactive Opioids. Novel opioid receptor agonists, some of which are much more potent 

than morphine, are of particular public health concern, as they can be mixed with or substituted 

for heroin, and are more likely to be deadly.55 As these novel opioids emerge, emergency 

responders, medical professionals, law enforcement personnel, death investigators, medical 

examiners, toxicologists, and prosecutors face the challenge of treating and investigating 

intoxications and deaths from novel compounds whose identities are often unknown and for which 

analytical standards do not exist. 

In 2013, the rapid ascent of the potent opioid agonist fentanyl compelled a rethinking of public 

health and regulatory approaches to the opioid crisis.56 Fentanyl and fentanyl analogs, including 

carfentanil, are becoming a major contributor to opioid overdose fatalities in specific states, 

especially in the eastern half of the nation.

57 Many have been identified, with some fentanyl 

analogs found as contaminants of other drugs, e.g. furanyl fentanyl has been identified as a 

contaminant in crack cocaine.58,59,60,61,62 As many do not cross-react in routine assays, a simple 

analytic device to identify whether a street drug is unknowingly contaminated with fentanyl 

analogs may yield a false negative and a false sense of security.

Other opioid NPS compounds include U-50488, desomorphine, tapentadol, salvinorin A, and its 

analog herkinorin.63 ‘Krokodil,’ the street name for a homemade cheap heroin substitute in Russia, 

is synthesized from codeine, iodine, and red phosphorus, with esomorphine claimed as the end 

product. A total of 54 morphinans were detected after detailed chemical analysis, highlighting the 

possibility that additional morphinans may contribute to the psychotropic effects of krokodil.64

Pathways to Opioid Use Disorder (Including Heroin) from Prescription 

Opioids

Prior History of Prescription Opioid Misusers Who Seek Treatment. In 2016, 91.8 million 

people (ages 12 or older) in the United States use pain relievers in the past year.

65 Of these, 11.5

million people reported misuse of pain relievers.

In an analysis of more than 4,400 patients entering drug treatment for opioid abuse, of individuals 

initially exposed to opioids through a physician's prescription to treat pain, 94.6% had used a 

psychoactive substance non-medically prior to or coincident with their opioid prescription.

Alcohol (92.9%), nicotine and/or tobacco (89.5%), and marijuana (87.4%) were used by nearly all 

patients prior to, or coincident with, their first opioid prescription. If one excludes these drugs, 

70.1% (n=2,913) still reported some psychoactive drug use of licit or illicit stimulants (77.8%), 

benzodiazepines (59.8%) or hallucinogens (55.2%).66 Similar findings were observed in a study 

restricted to women.67 The findings are consistent with concerns that persons with prior use of 

addictive substances are at considerably higher risk for prescription opioid misuse, with addiction 

to one substance alone uncommon.

68 It highlights the need for clinicians to screen patients for prior 

drug use histories and judicious monitoring of and intervention with these at-risk patients prior to 

or during opioid prescribing. There is abundant evidence is that increased risk of iatrogenic 
28

addiction or nonmedical use of prescription drugs overlaps consistently with problematic drinking, 

marijuana use, and other forms of substance use or a history of substance use or use disorder. 

Prescription Opioids and Transition to Prescription OUD. Understanding the risks factors that 

drive transition to an OUD are critical for developing effective policies to attenuate the process.69,70

The specific opioid, the dose, number of doses, duration, route of administration, formulation, ER, 

or immediate-release (IR) can influence misuse and progression to addiction. Some opioids 

engender greater likability or abuse liability than others. In patients dependent on heroin, 

oxycodone was ranked highest of several opioids, while buprenorphine scored lowest.71 Overall, 

the risk of transition from medical use for pain relief to dependence is especially high for opioids, 

especially with longer use, and high doses. 

One study found that the probability of long-term prescription opioid use increased markedly in 

the initial period of therapy, especially after five days or one month.72 One causative factor of 

addiction is the development of rapid tolerance which can progress to OUD, without careful

tapering. 

In a small study of a single population, patients self-reported five common pathways to OUD: (1) 

inadequately controlled pain; (2) initial exposure to opioids during acute pain, which triggered a 

unique positive response; (3) relief from emotional distress; (4) relapse to a prior opioid addiction 

triggered by prescription opioids; and (5) misuse of prescription opioids solely for psychoactive 

purposes.73 This survey highlights the need for prescribing clinicians to screen patients for prior 

history of substance use.

Prescription Opioids and Heroin Use Disorder. The vast majority of patients who use 

prescription opioids, either short or long term, do not progress to misuse and are unlikely to 

transition to heroin use. If transition occurs, the reverse (heroin to prescription opioids) is rare, as 

heroin is less expensive, more euphoric by the intravenous route, and more accessible. 

Overprescribing is still considered a driver of increases in opioid-related consequences, addiction, 

overdose, and infections, as it sustains nonmedical use of prescription opioids.74,75 However, 

heroin initiation occurs in a relatively small subgroup of nonmedical users of prescription 

opioids,76,77,78 but nonmedical use is a key risk for conversion to heroin use.79,80 Although the 

percent of annual conversions from the large number of prescription opioid users to new heroin 

users is low, approximately 80% of heroin users are estimated to have transitioned from misuse of 

prescription opioids in recent years.

81,82

Transition to heroin use among young prescription opioid users was predicted by prescription 

OUD, use of prescription opioids at an early age, and recreational use for psychoactive purposes. 

More specifically, a nationally representative sample of U.S. adolescents (2004-2011 NSDUH; n 

= 223,534; aged 12-21 years), showed that a prior history of nonmedical use of prescription opioids 

was strongly associated with heroin initiation, with the highest risk being nonmedical use of 

prescription opioids at ages 10-12 years, regardless of race/ethnicity or income group.83 Moreover, 

because the peak period of heroin initiation occurs later, efforts to prevent heroin use may be most 

effective if they focus on young people who already initiated nonmedical use of prescription 

opioids.

An association between policies related to curtailing prescription opioids and heroin use or 

overdose mortality has yet to be definitively shown. Research has not yet shown whether 

restrictions on prescribing increased heroin use among those who had already initiated heroin. Yet, 
29

past year heroin use among nonmedical opioid users has increased dramatically among young 

adults and emerging adults during the past six years.

84

In one study of people in treatment, more persons (33.3%) in 2015 were experimenting with heroin 

as their first opioid exposure compared with 10 years prior (8.7%), although they may differ from 

the general population of opioid users.

85 In the same period, their endorsement of oxycodone and 

hydrocodone misuse declined. As supply side interventions reduce accessibility to commonly 

prescribed opioids, some initiates replace prescription opioids with heroin. Imprecise heroin 

dosing in users without a history of opioid use may contribute to overdose fatalities in novices.

Fentanyl and analogues may be too strong for all but the most tolerant opioid users. Nearly half of 

patients entering treatment for OUD reported first exposure to opioids through a physician’s 

prescription for pain management,86 but these estimates may need revision in view of currently 

high availability of heroin and fentanyl.

Heroin Use. Heroin use also increased during the same period that witnessed a rise in prescription 

opioid misuse. Data from the 2001-2002 and 2012-2013 National Epidemiologic Survey on 

Alcohol and Related Conditions-I and–III (NESARC) showed prevalence of heroin use increased 

five-fold and use disorder tripled in the United States during the period between the two surveys.87

The rise was greater among whites, unmarried respondents, males, young users, those with lower 

educational achievement, and those living in poverty. Prior exposure to nonmedical prescription 

opioids increased among white heroin users, reinforcing concerns and other reports that 

prescription opioid misusers were transitioning to heroin use.Evidence is accumulating that heroin 

is increasingly being used without prior to exposure to prescription opioids.88

Health, Financial, and Social Consequences

General Consequences of Opioid Misuse and Use Disorder. Heroin and other illicit opioids 

confer a high risk for medical consequences.89 Nonmedical users of prescription pain relievers are 

40 times more likely than the general population to use heroin or other injection drugs. Opioid 

addiction is a chronic difficult-to-treat disorder characterized by frequent relapses. Crude mortality 

rates and the risks of death of opioid users are substantially higher than the general population 

worldwide, although sample and country-level variables impact the extent and causes of mortality. 

Elevated causes of mortality among opioid users include overdose, traumatic and suicide deaths, 

and HIV-related mortality. Treatment, HIV-negative serostatus, and lower levels of injecting are 

protective factors against premature death.90

Powerful environmental factors can shape the course of heroin addiction. A study found that of 

the heroin-dependent soldiers who returned to the United States after the Vietnam War, only 12% 

were still drug dependent three years later.91 Although more than half of the returning soldiers tried 

narcotics again, only a minority of them became re-addicted. These results illustrate that powerful 

environmental factors may influence the course of heroin addiction.92

Stable abstinence is less than 30% after 10-30 years, and even if abstinent, use of other drugs 

including alcohol is frequent.93,94 Family, social support, and employment are associated with 

improved recovery rates, whereas a history of sexual or physical abuse and comorbid mental 

disorders correlate with persistent opioid use.95,96,97
30

A five-year abstinent period is associated with an increase in likelihood of stable abstinence. 

Mortality is 6-20 times higher than that of the general population, with deaths depending on 

country of origin. In the United States, the primary cause of mortality is overdose deaths.98

Medical Consequences. Opioid users are less healthy from the perspective of physical and mental 

health than drug users who do not use opioids.99 They are also substantial users of medical services 

at higher costs than non-users and require chronic medical, psychiatric, and addiction care. Those 

using non-prescribed opioids differ from persons using opioids as prescribed, with more severe

drug problems, as manifested by higher intravenous drug use and behavior that puts them at higher 

risk for HIV and Hepatitis C. 

Opioid users have higher numbers of ED visits, more inpatient hospital stays, along with almost 

double the inpatient costs compared to their non-opioid using counterparts. Current data out of 

North Carolina indicates both a record number of overdose patients visiting EDs and that half, 

49% of overdose survivors seen in the ED, do not have insurance.

Opioid users also have a higher mean number of outpatient medical visits and higher associated 

costs over the same time period. Their self-reported health status is lower, and they have a higher 

number of chronic medical comorbidities than their non-opioid using counterparts. They were also 

more likely to have been prescribed medication for psychological/emotional problems in their 

lifetime and to have a mental illness diagnosis.100 Patients using opioids are more likely to be 

taking two or more illicit or non-prescribed drugs, to be taking non-prescribed benzodiazepines, 

and to report intravenous drug use. Compared to patients using opioids only as prescribed, those 

using any non-prescribed opioids were more likely to have been homeless, have more serious drug 

problems than those using opioids only as prescribed, engage in intravenous drug use, and have a 

higher HIV risk-taking score. Non-prescribed opioid users also had more problem alcohol use 

relative to their prescribed opioid user counterparts. 

Infections and infectious diseases. Although overdose contributes most to drug-associated 

mortality, infections stemming from intravenous drug use are another major cause of death or an 

illness requiring hospitalization.101,102,103 Injecting drug users are at risk for acquiring hepatitis C 

virus (HCV) and HIV, as well as invasive bacterial infections, including endocarditis.104,105

Brain Toxicity. Brain toxicity is a common finding for specific drugs of abuse.106,107,108,109

Diagnostic imaging, especially magnetic resonance imaging (MRI) can detect a range of brain 

abnormalities associated with heroin use, including neurovascular complications related to 

inadequate blood supply such as stroke. A rare form of leukoencephalopathy has also been shown 

in people inhaling heroin vapors. 

Children at risk. Children are at high risk in opioid-using environments. Pregnant women who 

continue to use opioids throughout the gestational period are likely to deliver a newborn with 

neonatal abstinence syndrome (NAS). The incidence of NAS is increasing in the United States, 

and carries an enormous burden in terms of hospital days and costs.110 In comparing infants with 

a diagnosis of NAS with non-NAS infants between 2003 and 2012, NAS admissions increased 

more than fourfold, resulting in a surge in annual costs from $61 million and 67,869 hospital days 

in 2003 to nearly $316 million and 291,168 hospital days in 2012. For an infant affected by NAS, 

the hospital stay was nearly 3.5 times as long (16.57 hospital days compared with 4.98 for a nonNAS patient) and the costs more than three times greater ($16,893 compared to $5,610 for a nonaffected infant).111
31

Children living in homes with drug abusers have numerous challenges, including the potential for 

exposure to drug production, chemicals, or equipment, neglect because the caregiver is using, 

abusive behavior towards the child,

112 risk of removal from their family, and/or exposure to the 

criminal sale or distribution of drugs.113,114

Labor Force. The Labor Force Participation Rate has declined since 2007, primarily due to an 

aging population and effects of the Great Recession. However, a recent Brookings Institution study 

examining the implications of the opioid crisis on the labor force suggests that the increase in 

opioid prescriptions could account for much of the decline in the labor force participation of “prime 

age men” (ages 25-54) during this same time.115 The Bureau of Labor Statistics Time-Use Survey 

finds that 44% of prime age men not in the labor force acknowledged taking pain medications the 

previous day. The Brookings study found similar results (47% took pain medication the day 

before), however, nearly two-thirds of those men indicated it was prescription pain medication. 

Thus, on any given day, 31% of prime age men not in the labor force take prescription pain 

medication, most likely opioid based. These percentages are likely lower than the actual proportion 

of men who consume pain medication, due to the sigma and legal risk associated with narcotics.

Financial, Educational, Workplace, and Criminal Justice System. Prescription opioid overdose, 

abuse, and dependence carry high costs. In 2013, it was estimated that the total economic burden 

was $78.5 billion (in 2013 dollars).

116 Approximately one-third of the costs of the prescription 

opioid crisis are attributable to health care, and one-fourth of costs are borne by the public sector. 

Using data from various sources, the "monetized burden" of prescription opioid overdose, abuse,

and dependence was estimated from a societal perspective, including direct healthcare costs, costs 

related to loss productivity, and costs to the criminal justice system. Total spending for health care 

and substance abuse was over $28 billion, most of which ($26 billion) was covered by insurance. 

In nonfatal cases, costs for lost productivity, including reduced productivity for incarcerated 

individuals, were estimated at about $20 billion. Fatal overdose costs related to healthcare and lost 

productivity were estimated at $21.5 billion. Approximately 25% of the economic burden was 

borne by public sector (Medicaid, Medicare, and veterans' programs) and other government 

sources for substance abuse treatment. Criminal justice-related costs were estimated at $7.7 billion 

expended by state and local governments in addition to lost tax revenue. The total estimated 

economic burden for prescription opioid abuse, addiction, and overdose death and heroin addiction 

would be approximately $111 billion (in 2013 dollars). Many costs are inestimable, including the 

social impact on opioid-dependent people, and the suffering of family members as witnesses to 

addiction or to fatal overdose.

Drug Overdose Deaths

The crisis in opioid overdose deaths has reached epidemic proportions in the United States (33,091 

in 2015), and currently exceeds all other drug-related deaths or traffic fatalities. These data from 

the CDC are expected to rise even higher for 2016.117 The risk of overdose resides primarily, but 

not exclusively, among those harboring a medical diagnosis of an OUD.

118 Of six risk markers 

(sex, age, race, psychiatric disorders, SUDs, urban/rural residence), SUDs have the strongest 

association with drug overdose death, followed by psychiatric disorders, white race, 35-44 year 

age group, and male sex.119 Opioid-related death rates are higher among those who had recently 

been released from prison, those who doctor-shop and receive opioid prescriptions from multiple 
32

pharmacies, and those who consume prescription opioids in combination with other scheduled 

medications, particularly benzodiazepines. From 1999 onwards, overdose deaths due to 

prescription opioids rose incrementally and consistently outpaced annual heroin death rates. 

Heroin overdose deaths remained relatively low from 1999 onwards, and then escalated 4-fold 

from 2010-2015. Data from death certificates in 2015 revealed a disproportionate rise from the

previous year in deaths attributable to fentanyl/analogs (72.2%) and heroin (20.6%), with 

prescription opioid-related deaths rising minimally (2.6%). 

The overall death rate was higher for prescription opioids, but the most recent data show minimal 

increases in deaths involving prescription overdoses, while an increasing proportion now involves 

synthetic opioids, mainly fentanyl. Clearly, contamination of the heroin supply with fentanyl is 

currently driving recent increases in opioid-related overdose deaths. Reports from individual states 

in 2016 and 2017 confirm this emerging trend, as heroin and/or fentanyl currently account for 

more than 50% of the overdose deaths in specific states.120

Substance Use Treatment Availability

Among the many consequences of opioid misuse is the increasing need for SUD treatment 

services. SUD treatment facilities, particularly those providing MAT-enhanced opioid treatment 

programs (OTP), are uncommon in rural areas, as are physicians who can provide MAT from their 

offices.

Across all U.S. counties, 38% did not have a treatment facility for SUD in 2016 (Table 1).121 Ten 

percent of large central metro counties did not have an SUD treatment facility. The data show that 

progressively larger proportions of counties did not have SUD treatment facilities as the level of 

urbanization decreased. Among the most rural counties, 55% did not have a substance use 

treatment facility. Figure 1 below shows counties that did not have an SUD treatment facility as 

of 2014 by level of urbanization, and it is clear that the vast majority of counties is rural.

Table 1. Treatment Facilities for Substance Use Disorder by Level of Urbanization, 2016

Total

No 

Treatment 

Facilities 

for 

Substance 

Use 

Disorder 

(SUD)

No SUD 

Treatment 

Facilities 

with 

Opioid 

Treatment 

Programs

No SUD 

Treatment 

Facilities 

that 

accept 

Medicaid

Total

No 

Treatment 

Facilities 

for SUD

No SUD 

Treatment 

Facilities 

with 

Opioid 

Treatment 

Programs

No SUD 

Treatment 

Facilities 

that 

accept 

Medicaid

Large Central Metro 68 7 8 7 100% 10% 12% 10%

Large Fringe Metro 368 88 259 104 100% 24% 70% 28%

Medium Metro 373 100 242 116 100% 27% 65% 31%

Small Metro 358 100 267 121 100% 28% 75% 34%

Micropolitan (non-metro) 641 157 586 204 100% 24% 91% 32%

Non-core (non-metro) 1,333 728 1,321 800 100% 55% 99% 60%

United States 3,141 1,180 2,683 1,352 100% 38% 85% 43%

Level of Urbanization

Number of Counties Percent of Counties in Level of Urbanization
33

Figure 1. Counties with No Treatment Facilities for Substance Use Disorder by Level of Urbanization

Furthermore, 85% of all U.S. counties have no OTPs that provide MAT for people diagnosed with 

an OUD (Table 1). These facilities are concentrated in large central metropolitan areas, where 

88% of these counties have at least one treatment facility offering OTP (only 12% of these central 

metropolitan counties do not have OTP facilities). For other metropolitan counties, 65 to 75% do 

not have OTP facilities, but among rural counties, almost all (91 to 99%) lack an OTP facility. 

Figure 2 shows counties that did not have an OTP facility as of January 2016; as with SUD 

treatment facilities generally, the vast majority of these are rural counties. Many large fringe and 

medium metropolitan counties appear as doughnut-shaped areas around core locations where OTP 

facilities are located, but many rural counties are located far from OTP facilities.

Data were also obtained on the locations of physicians that can dispense buprenorphine from their 

offices.122 Physicians can provide MAT for OUD treatment in settings other than OTP facilities, 

including dispensing buprenorphine from their offices. To prescribe or dispense buprenorphine for 

OUD treatment, qualified physicians must receive waivers from the DEA under the terms of the 

Drug Addiction Treatment Act of 2000 (DATA 2000). As of February 2016, 47% of counties 

nationwide did not have a waived physician (Table 2). However, when classifying the county 

locations of waived physicians according to level of urbanization, the rural-urban disparities 

become clear. None of the large central metro counties, and 72% of the most rural counties, did 

not have a waived physician (Figure 3). The vast majority of counties without buprenorphinewaived doctors are rural. However, it is worth noting that the number of patients a physician can 

treat with buprenorphine is capped; so, having a waived physician within a geographic area is not 

necessarily indicative of sufficient access for county or city residents.
34

Figure 2. Counties with No Opioid Treatment Program Facilities by Level of Urbanization

While utilization of SUD treatment services in both rural and urban areas is challenged by many 

factors, the nature of these challenges varies. For example, findings from focus groups of 

counselors in rural areas noted a dearth of good facilities, poor access due to clients living far away 

from treatment centers, reliance on friends or family for transportation, and a need for basic 

medical and dental services. These factors were not mentioned by urban counselors.123 A recent 

study of SUD treatment facilities that accept Medicaid also found that rural residents are less likely 

to have such a facility.124

Table 2. Physicians Waived to Dispense Buprenorphine by Level of Urbanization, 2016

Total No Waived 

Doctors

1-5 Waived 

Doctors

More than 

5 Waived 

Doctors

Total No Waived 

Doctors

1-5 Waived 

Doctors

More than 

5 Waived 

Doctors

Large Central Metro 68 0 0 68 100% 0% 0% 100%

Large Fringe Metro 368 86 107 175 100% 23% 29% 48%

Medium Metro 373 107 86 180 100% 29% 23% 48%

Small Metro 358 113 103 142 100% 32% 29% 40%

Micropolitan (non-metro) 641 219 332 90 100% 34% 52% 14%

Non-core (non-metro) 1,333 964 340 29 100% 72% 26% 2%

United States 3,141 1,489 968 684 100% 47% 31% 22%

Level of Urbanization

Number of Counties Percent of Counties in Level of Urbanization
35

Figure 3. Counties with No Physicians with Buprenorphine Waivers by Level of Urbanization, 2016

Systems Approach to Solutions

There has never been a time more 

appropriate or opportune to develop 

effective and cost-effective policies for 

addressing substance use and disorders in 

our nation. A systems approach can 

facilitate development of recommendations 

and solutions to this dynamic and evershifting challenge. This report addresses 

solutions to each of the core components of 

the crisis, a trajectory which begins with 

drug supply, attitudes towards drug use and 

knowledge of opioids, risk factors for 

misusing, and progresses to addiction, 

transition to heroin/fentanyl, situational 

factors in overdose, rescue, treatment, 

relapse prevention, recovery support, and continuum of care (Figure 4). Over the past decade, large 

databases have accumulated to inform policies and associated budgets.

The most urgent goals and readily quantifiable achievements will be a reduction in overdose 

episodes and deaths, increased entry into and adherence to high quality treatment, and a reduction 

Figure 4. Opioid Crisis-Intervention Stages
36

in prescribed opioids. More complex models are needed to address whether prescribing policies 

result in time-dependent reductions in prescription opioid diversion or increase heroin/fentanyl 

use, who is at risk for transitioning to heroin or fentanyl, the incidence and prevalence of OUD, 

and others. The opioid epidemic defies standard medical and legal models for addressing addiction 

and trafficking. Limited data exists to track the crisis and identify weaknesses in current responses 

(e.g. prescribing practices, treatment availability, individuals at risk), but is held in different 

databases across a multitude of public and private organizations, and significant proportion is not 

in real-time. 

Building a secure data foundation that promotes cross-entity collaboration while protecting privacy 

is a challenging but necessary step to save lives, expand treatment options, and effectively prevent 

further spread of this deadly epidemic. The data exists but resides in agency silos, or in the private 

sector providing analytics for specific industries (e.g. pharmaceutical or healthcare insurers), 

making it difficult to act upon the information. The Federal Government should create an 

integrated data environment that brings together publicly available data with agencyspecific data to help address this epidemic. Often, the same data viewed through a different lens 

can support multiple parts of the problem. For example, doctors can use prescription drug 

monitoring programs (PDMPs) to check patient records, while law enforcement can use PDMPs 

to identify prolific opioid prescribers and public health agencies can use it to identify and intervene 

in a potential victim pool before overdoses occur – different, but all valuable uses of the same data.

This kind of effort would not require a new data warehouse or standardization initiative; the 

integrated data environment can immediately integrate existing data sources. 
37

Federal Funding and Programs

On page 93 of the report, there is a full breakdown of federal funding sources for drug-related 

activities, including interdiction, prevention, and treatment. As shown in that section, the federal 

funding landscape is complex, exists in silos, potentially duplicative, and supports hundreds of on 

the ground programs.

Streamlining Federal Funding for Opioids and Consideration of State 

Administrators

One of the first activities the Commission Chair undertook was a series of calls with Governors’ 

Offices in nearly all 50 states. A number of themes emerged from those calls that are reflected in 

this report and the recommendations. Regarding funding, many Governors and senior staff 

members expressed concern at how addiction and opioid-related funding coming from the Federal 

Government was fragmented; provided by many different agencies and funding sources which 

each had their own application requirements, reporting mechanisms, and preferred outcomes. 

It is clear that each federal agency has goals related to reducing drug use and misuse and provides 

funding for such activities. However, from the vantage points of states, this funding is not well 

coordinated, and applying for funding from the many different agencies, is a tremendous 

administrative burden for states. 

The SAMHSA block grants provide a formula-based grant to states for treatment activities; if 

additional funding opportunities could be rolled into the SAMHSA block grant, or combined to 

form larger block grants that required one application and one set of reporting requirements, that 

would free up state resources to focus on implementation activities, rather than paperwork. 

Some states have identified a State Administrator to coordinate opioid and addiction activities. 

Others may use their Single State Authorities for substance abuse services to serve as an effective 

point of contact or liaison regarding most federally-supported demand reduction efforts in a state—

although they may not always have up-to-date information on Department of Health and Human 

Services (HHS) or Department of Justice (DOJ) discretionary grant activities not directly involving 

the state. Regardless of the single entity that is identified by the state, the Federal Government 

should have a comparable single entity point of contact to help track activities related to 

discretionary grants with a demand reduction focus.

The Office of National Drug Control Policy’s (ONDCP) core function is to develop and coordinate 

the implementation of national drug policy, but it does not have appropriate staff or organizational 

units to track federally supported demand reduction funding and activities at the program or grant 

level (versus the overarching policy level). The tasks of making and tracking grant awards fall 

squarely within the responsibility of the Departments and agencies that manage grant programs, 

including HHS’s Regional Offices and the more recently established Substance Abuse and Mental 

Health Services Administration (SAMHSA) Regional Directors stationed in these offices. It 

therefore would seem reasonable for HHS to support ONDCP in this function by serving as an 

intermediary with Single State Authorities in the 50 states, the District of Columbia, and the 

territories. By so leveraging HHS and SAMHSA regional infrastructure, ONDCP could maintain 

timely accounting and ongoing awareness of the current allocation of federal demand reduction 

funding and the coordination of federally supported initiations, their contribution to activities 
38

funded at the state and local level, duplication or inefficiencies that may need to be addressed, and 

timely scrutiny the program effectiveness of federally-or-state-funded programs. This would assist 

ONDCP to become aware of promising practices emerging at the state level.

1. The Commission urges Congress and the Administration to block grant federal funding 

for opioid-related and SUD-related activities to the states, where the battle is happening 

every day. There are multiple federal agencies and multiple grants within those agencies 

that cause states a significant administrative burden from an application and reporting 

perspective. Creating uniform block grants would allow more resources to be spent on 

administering life-saving programs. This was a request to the Commission by nearly 

every Governor, regardless of party, across the country.

2. The Commission believes that ONDCP must establish a coordinated system for tracking 

all federally-funded initiatives, through support from HHS and DOJ. If we are to invest 

in combating this epidemic, we must invest in only those programs that achieve 

quantifiable goals and metrics. We are operating blindly today; ONDCP must establish 

a system of tracking and accountability.

Funding Effective Opioid-Related Programs

As stewards of taxpayer dollars, the Federal Government must ensure that programs demonstrate 

effectiveness in achieving the desired policy outcomes. While various assessments have 

demonstrated that treating and preventing substance use are effective in reducing the costs 

associated with health care, the workplace, and criminal justice system, these costs-benefit 

analyses were done at the system, not program, level.

At the program level, the Federal Government has a long history of undertaking a variety of efforts, 

varyingly referred to as strategic planning, performance management, program evaluation, or 

performance budgeting, to inform management decisions for program and policy officials. These 

efforts have contributed to significant investments being made in the development of an evidence 

base for effective programs. However, comparing the effectiveness of programs has proven more 

elusive, and looking at system-wide cost effectiveness is rare. Research studies in addition to 

private and public-sector analyses may be of value to Federal efforts to develop and implement 

cost-benefit evaluations. For example, the Washington State Institute for Public Policy maintains 

a list of available, evidence-based public policy options and ranks them by return on investment.125

While not a complete list, such ranked lists provide policymakers with a better understanding of 

the likelihood of which, of the many policy options available, are most likely to produce more 

benefits at lower costs.

Given the substantial challenges of the heroin and prescription opioid epidemic, it is critically 

important that the Federal Government maximize the impact of its response by supporting the most 

effective programs and policies to reduce the number of individuals affected by OUDs and end the 

nation’s opioid epidemic. A thorough review of programs and policy options would assist the 

Director of ONDCP in making recommendations on how to best allocate scarce federal resources 

to achieve the objectives of the National Drug Control Strategy. 
39

3. To achieve accountability in federal programs, the Commission recommends that 

ONDCP review is a component of every federal program and that necessary funding is 

provided for implementation. Cooperation by federal agencies and the states must be 

mandated. 
40

Opioid Addiction Prevention 

It is important to consider that the national crisis is not only about prescription or illicit opioids. 

We are focusing on this class of substances, but prevention efforts need to be broader because the 

removal of one substance conceivably will be replaced with another. 

To address the opioid and addiction epidemic, it is vital to make substance use and misuse 

prevention a much higher priority and stop the pipeline into addiction. In the first Commission 

meeting, General Arthur Dean, speaking on behalf of Community Anti-Drug Coalitions of 

America, expressed the strong belief that prevention has been underutilized, relative to its 

importance and cost-effectiveness in preventing or reducing drug use and misuse and the related 

human and societal costs. The American Society of Addiction Medicine (ASAM) and the 

Addiction Policy Forum both recommended the launch of a national public education campaign, 

similar to the one developed for the AIDS epidemic in the 1980s, to raise awareness that addiction 

is not a moral failing, but rather a chronic brain disease, and that evidence-based treatment is 

available. 

A generalized prevention campaign should address use of illicit drugs with abuse potential, as they 

can progress to addiction. Addiction is the most prevalent and costliest of neuropsychiatric 

disorders and the leading cause of premature, preventable deaths and disability in the United 

States. Of the ~2 million annual deaths in the United States, one-quarter are attributable to the 

consequences of tobacco, alcohol, opioids, and other drugs. Drugs impact every sector of society 

– individuals, families, communities, healthcare systems, educational environment, workplace, 

traffic safety, and the criminal justice system. Studies investigating the effects of drugs in the brain, 

body, and on behavior has yielded a vast base of information over the past twenty years, relevant 

and indeed critical information for public education. These research discoveries have outsized 

power and potential to heighten awareness and promote prevention, but their impact has been 

limited by discontinuities in translating research into effective prevention messages and 

broadcasting them widely. The current opioid crisis dramatically illustrates an unfulfilled need for 

expanded educational outreach to new generations of youth, their parents and the general 

population. Youth are more susceptible to addiction and are a key target cohort for prevention. The

vast majority of users fall into 16-34 age category, a peak period for pregnancy, parenting, and for 

adverse consequences of drugs: addiction, underemployment, health issues, accidents, and trauma. 

It is well recognized that use rates are inversely correlated with perception of risk, yet effective 

state-of-the-art, credible, compelling, and comprehensible information on the risks and adverse 

health consequences of drugs has not been mounted to reverse these trends.

The National Institute on Drug Abuse’s (NIDA) Drug Facts Chat Day website 

(http://drugfactsweek.drugabuse.gov/chat/) offers some insights into young people’s curiosity for 

accurate information about drugs and the lack of accessibility to information. Teenagers from 

around the nation are offered a day-long session to ask NIDA staff their personal question about 

drugs. A sampling of questions is listed below:

• What is in drugs that make it so addictive?

• What should you do if a parent is doing drugs?

• Do drugs kill brain cells?

• Is drinking worse than smoking?
41

During this nation’s worst drug crisis, there is no more opportune time to launch a national 

prevention campaign that highlights the hazards of substance use, but also focuses on the opioid 

crisis: (1) to educate the public on risks and consequences of drug use in general, with emphasis 

on opioids; (2) to focus on the vulnerable - adolescents, college age students, pregnant women, 

those harboring a psychiatric disorder, and the elderly - and highlight the detrimental effects of 

opioids; (3) to convey to parents their critical role in determining their children’s use of drugs; (4) 

to show parents how to engage in crucial conversations with children about drugs; (5) to dispel 

common myths and misinformation on drugs; (6) to educate families on warning signs in family 

members and on reducing environmental risks for children; (7) to advance the concept of addiction 

as a treatable brain disease; and (8) to tailor messages to specific populations and communities in 

need. Many sources of information exist from government agencies (e.g. NIDA, SAMHSA, 

National Institute on Alcohol Abuse and Alcoholism [NIAAA], DEA) or on websites of non- and 

for-profit private organizations. The reach of these websites is limited, and their impact and value 

undetermined. Creative strategies are needed to engage much larger populations, with 

accountability on effectiveness.

Notably, recent surveys indicate that parents can be key contributors to a child’s use or non-use of 

drugs. Youth alcohol or marijuana use was 5-7-fold lower if parents took a strong stance against 

use, compared with parents whose views were ambivalent. Systematic reviews have reinforced 

this conclusion.126,127 Yet, parental knowledge is limited, as illustrated by examples from a recent 

survey: 

a) Nine of ten parents do not think that teens spending time on social networking sites like 

Facebook are likelier to drink or use drugs. Yet, teens who spend time on a social 

networking site in a typical day are much likelier to use tobacco, alcohol, and other drugs 

than teens who don’t spend time on a social networking site in a typical day; 128

b) When asked, “do you consider it necessary to take steps to keep your child from having 

access to prescriptions for painkillers such as Oxycontin, Vicodin or Percocet in your 

home?,” 57% of parents with prescription pain killers in their home did not consider it 

necessary to prevent their child from accessing the prescriptions,129 even though more than 

50% of people who misuse prescription pain killers obtained them for free from friends 

and family.130 Yet, the 2016 national survey indicates that parental attitudes are critical in 

determining youth drug use.131

c) One-third of parents surveyed reported that it was “very likely” or “somewhat likely” that 

their teen would “try drugs (including marijuana or prescription drugs without a 

prescription to get high) at some point in the future.” Yet, if parents are perceived to 

disapprove of marijuana use, use among youth is approximately 9 times lower. 132

Parents have been under-represented in prevention programs, even though evidence is robust that 

parent-based prevention programs can play a pivotal role in delaying the onset and use of alcohol 

and other drugs, an influence that persists during adolescent development. Furthermore, universal 

prevention programs are enhanced with inclusion of parent-based components.133 In a systematic 

review of studies which combined student- and parent-based programs to prevent or reduce 

adolescent alcohol, tobacco or marijuana use, effectiveness was shown in the majority of studies.

In summary, there is a compelling need to integrate evidence-based prevention programs in large 

scale outreach programs within schools. With tools for teachers and parents to enhance youth 

knowledge of the dangers of drug use, early intervention strategies can be implemented for 
42

children with environmental and individual risk factors (trauma, foster care, adverse childhood 

experiences [ACEs], and developmental disorders).

Evidence-based Prevention Programs

Substance abuse prevention is a process which requires a shift in behavior, culture, and community 

norms. An investment in prevention requires meaningful outcome measures planned in 

coordination with the program. Demonstrated evidence of program effectiveness can include 

delaying the age of initiation of substance use, decreasing the number of new or current users, 

decreasing the frequency of use, reducing the adverse consequences of use (e.g. effect on school 

grades, employment, and others), decreasing use among contacts,134 and duration of effect. When 

evidence-based programs are selected for specific populations and implemented with fidelity, they 

can be effective. Prevention programs need to be tested for scalability, fidelity, and sustainability 

after research champions are no longer present to drive programs. Prevention is most successful 

when messages are consistent, culturally-appropriate, repeated at home, reinforced in schools, 

workplaces, and community organizations, and delivered by influential adults and peers. 

NASEM has described three categories of prevention interventions: universal, selective, and 

indicated. These interventions have been researched based on targeted populations and risk factors 

(e.g. schools, parents, or youth). Risk and protective factors are influential at different times during 

development, and they relate to changes that occur over the course of development. Risk factors 

can interrupt developmental patterns and it is therefore important to implement programs designed 

for early developmental periods by building on the strengths of the child or caregiver. Intervening 

early in childhood can alter the life course trajectory in a positive direction.135

Below is a description of the three categories of prevention interventions that target several risk 

factors and increase protective factors:

• Universal interventions attempt to reduce specific health problems across all people in a 

particular population by reducing a variety of risk factors and promoting a broad range of 

protective factors. Examples of universal programs include:

o Good Behavior Game136

o Nurse Family Partnership137,138

o Life Skills Training (LST)139

o Strengthening Families Program 10-14140

o Communities that Care141

• Selective interventions are delivered to particular communities, families, or children who, due 

to their exposure to risk factors, are at increased risk of substance misuse problems. Selective 

interventions may include families living in poverty, the children of depressed or substance 

using parents, and children who have difficulties with social skills or may have experienced 

trauma. Examples of selective programs include:

o Coping Power142

o Focus on Families143
43

• Indicated interventions are directed to those who are already involved in a risky behavior, such 

as substance misuse, or are beginning to have problems, but who have not yet developed an 

SUD. Examples of individual intervention programs include:

o Project Toward No Drug Abuse

o BASICS

o Keepin’ it Real

School programs implementing environmental approaches targeting children focus on building a 

repertoire of positive competencies, including in the areas of academics, self-regulation, and social 

skills. Teachers can focus on interventions in the classroom for those who may need support with 

self-regulation and social skills. Increasing the capacity of teachers by training them in classroom 

management strategies (e.g. establishing clear rules and rewards for compliance, teaching 

interactively, and promoting cooperative learning) provides them with the skills for managing 

behaviors and teaching children self-regulation.144 Risk and protective factors can be influenced 

by the choice of programs and policies at multiple levels, including federal, state, community, 

family, school, and the individual.

One advantage of a properly implemented universal prevention intervention is that it is likely to 

reach most or all the population (e.g. school-based interventions are likely to reach all students). 

Targeted (selective and indicated) approaches provide more intensive services to those who are 

reached. It is prudent for communities to provide a mix of universal, selective, and indicated 

preventive interventions.145

SBIRT as a School Prevention Strategy

SBIRT is an evidence-based systematic method to screen for problematic use of all substances 

and, depending on a cumulative score, follow up with a brief intervention or referral to specialty 

treatment. The service was catapulted more widely into healthcare systems following a report from 

the Federal Government demonstrating effectiveness in reducing substance use,146 and the advent 

of billing codes to reimburse for these services.147 Although traditionally developed for clinical 

care, SBIRT services have been increasingly offered in high schools and universities. School 

nurses and counselors are uniquely positioned to discuss substance use among young people. 

In 2016, Massachusetts passed a bill enabling appropriately trained staff to reinforce prevention, 

screen for substance use, provide counseling and make referrals as necessary to all adolescents, 

including students in upper elementary grades. Adolescent SBIRT focuses on prevention, early 

detection, risk assessment, brief counseling and referral intervention that can be utilized in the 

school setting. Use of a validated screening tool (CRAFFT) focused on adolescents has enabled 

school nurses and counselors to detect risk for substance use-related problems and to address them 

at an early stage in adolescents. The bill requires all public-school districts in Massachusetts to 

screen seventh and 10th graders for potential drug use, and is viewed as a way to interrupt the 

potential use of drugs, including opioids, at an early stage. The screenings do not involve drug 

tests, but rather a screener (school nurse or psychologist trained in conversations on drug use with

youth) to determine through a conversation/questionnaire if the student is engaged in risky 

substance use. The intent is to identify students who need help and to try to motivate them into 

treatment. Students or parents can opt out of the screening and parents are not immediately notified 

of the screening results to protect students’ privacy. Parents are notified only in severe cases of 

addiction. 
44

Previous research showed that 14.8% of adolescents had positive results on the CRAFFT screen. 

Prevalence rates differed significantly across practices after adjusting for demographic factors. 

The highest positive rates on the CRAFFT screen were at school-based health centers (29.5%) and 

the rural family practice (24.2%), the middle rate was at the adolescent clinic (16.6%), and lowest 

rates were at the health maintenance organization (14.1%) and pediatric clinic (8.0%). Sick visits 

had the highest rate (23.2%). Well-child care visits had a significantly lower rate (11.4%). 

Statistical modeling estimated that 11.3% of all patients had problematic use, 7.1% reported abuse, 

and 3.2% had an SUD. Substance abuse screening should occur whenever feasible, and not only 

at well-child care visits.148 Recently the State of New Mexico has begun a program for universal 

screening,149 the State of New York has initiated SBIRT trials,150 and calls for universal screening 

using validated SBIRT screening tools are increasing.151

Ohio State University developed an SBIRT course with the goal of making SBIRT accessible for 

use on college and university campuses nationwide. To meet this goal, the Higher Education 

Center for Alcohol Drug Misuse Prevention and Recovery developed ScreenU, a web-based 

program that allows SBIRT to be implemented with college students either independently or 

together with a campus professional. ScreenU identifies students who are misusing alcohol or 

prescription drugs and provides feedback and strategies to reduce their risk for experiencing 

negative consequences from their use.

4. The Commission recommends that Department of Education (DOE) collaborate with 

states on student assessment programs such as Screening, Brief Intervention and 

Referral to Treatment (SBIRT). SBIRT is a program that uses a screening tool by trained 

staff to identify at-risk youth who may need treatment. This should be deployed for 

adolescents in middle school, high school and college levels. This is a significant 

prevention tool.

Mass Media Public Education Campaigns

Mass-media campaigns are one of the primary universal prevention strategies for delivering 

educational messages on health promotion to youth and adults. A review of the literature provides 

an overview of the lessons learned from research on mass-media campaigns. The literature is quite 

clear that mass media campaigns can increase awareness of messages but are not always successful 

in changing attitudes, beliefs, or behaviors.152 Mass-media campaigns tend to work best when they 

are well-targeted and supported by comprehensive community-based efforts that coordinate 

clinical, regulatory, economic, and social strategies. In addition, funding for local prevention 

interventions that prevent initiation of a behavior and treatment programs that promote abstinence 

and recovery are important.

In addition to policies and strategies that help create environments that are less conducive to 

substance use, mass media campaigns can focus on either directly influencing individual level 

predictors or influencing an individual’s behavior through targeting others within youths’ social 

environment. The former strategy looks to increase knowledge about a particular drug, its negative 

health effects, self-efficacy in declining or stopping use, beliefs about the drug, and social norms 

about licit and illicit drug use. The latter includes messages which discourage young people from 

pressuring friends to use.153
45

Regardless of the approach, for a mass-media campaign to be effective, it is critical to develop 

coherent, credible, evidence based-messages that are grounded in behavioral science.154 This is 

critical to counteract the meta-messaging that drug use in society is pervasive and normal.155 

Media messaging also must strategically target populations with culturally appropriate messages, 

take advantage of multiple media platforms, and have sufficient resources to provide broad 

exposure over a significant period of time to ensure an effect. Branding the campaign also has been 

shown to enhance the impact of public health messaging as has integrating a media literacy 

component that helps train youth and young adults to critically view messages about substance 

use, be they within television shows, movies, or advertising.

The literature is very limited on mass-media campaigns focusing on prescription opioids, and even 

less on heroin and other opioids. There is a more robust literature on lessons learned from massmedia prevention campaigns on alcohol and tobacco, which have been incorporated.

ONDCP’s earlier paid advertising campaign, the National Youth Anti-Drug Media Campaign,

targeted young people aged 9 to 18 years, their parents, and other influential adults. It used a 

combination of television, radio advertising, other media, and community programming with the 

goals to educate and enable youth to reject illegal drugs, prevent youth from initiating use of drugs, 

especially marijuana and inhalants, and convince occasional users of marijuana and other drugs to 

stop using. A comprehensive evaluation of the campaign156 found substantial evidence that the 

campaign favorably impacted parents on measures such as thinking about and talking with their 

children about drugs, doing fun activities with their children, and beliefs about monitoring their 

children, but found little favorable direct effects of the campaign on youth. The evaluation found 

there were significant delayed unfavorable effects of exposure to the campaign on social norms 

and perceptions of use by youth; greater exposure was associated with weaker anti-drug norms. 

Additionally, greater exposure may have led to higher rates of initiation of marijuana use. Also, 

there was no evidence found to suggest that higher exposure to the campaign had any impact on 

quitting or reducing use.

Governor Otter shared with the Commission Chair the successes of the Idaho Meth Project, a 

large-scale prevention program founded in 2005 with the aim to reduce methamphetamine use 

through a comprehensive approach including public services messages, public policy approaches, 

community outreach, and in-school lessons. The Meth Project reports that 94% of teens that are 

aware of the anti-meth campaign ads say they make them less likely to try or use meth, and that 

Idaho has experienced a 56% decline in teen meth use since the campaign began in 2007. In a 

pooled analysis of sites, including from Colorado, Georgia, Hawaii, Idaho, Montana and 

Wyoming, no evidence was found of change in past month use among subjects aged 12-17.157 

However, there was evidence of reduction in past year use among this age group. In Idaho, this 

initiative was re-branded in 2016 as the Idaho Prevention Project to include opioids and 

prescription drugs.

Another study evaluated the impact of the SENsation seeking TARgeting approach (SENTAR) 

focusing on anti-heroin public service announcements (PSAs) on processing, affect, and antiheroin attitudes in a sample of 200 young adults.158 Building on previous work,159 this study 

recruited subjects from communications courses at a large Midwestern University exposing them 

to 30-second anti-heroin PSAs selected from a larger pool of PSAs produced by the Partnership 

for a Drug Free America. It utilized data from the 5-year television-based media campaign using 

public service announcements targeting messages. They found that high-sensation seekers’ anti-
46

heroin attitudes were largely influenced by narrative and sensory processes and low sensation 

seekers’ anti-heroin attitudes were relatively unaffected by anti-heroin ads.

A national education campaign focused on opioids could be modelled after The Real Cost, an 

existing award-winning youth tobacco prevention campaign from the FDA. The Real Cost seeks 

to educate at-risk teens about the harmful effects of tobacco use with the goal of preventing youth 

who are open to using tobacco from trying it and reducing the number of youth who move from 

experimenting with tobacco to regular use. It was launched nationally in February 2014 across 

multiple media platforms including TV, radio, print, web, social media, and out-of-home sites, like 

billboards. Initial campaign advertising focused on reaching the nearly 10 million youth ages 12-

17 in the United States who are either open to trying smoking or are already experimenting with 

cigarettes. Results from the first evaluation published in 2015 indicated that 9 out of 10 youth 

reported seeing The Real Cost ads seven months after the campaign launch and that the campaign 

positively affected tobacco-related risk perceptions and beliefs after 15 months. Further, from 

2014-2016, the campaign was associated with a 30% decrease in the risk of smoking initiation 

which translates into preventing an estimated 350,000 youths aged 11-18 from smoking.160

Media Campaign Focusing on Opioids

A national prevention strategy with a comprehensive public health mass media campaign 

supported by evidence-based prevention programs is timely and essential. The goals would 

include: (a) universal drug prevention messages, as current or past SUDs predispose individuals 

to misusing opioids, and polysubstance use disorders are common; (b) youth-directed messages,

as they are more susceptible to addiction and other adverse consequences; (c) prevention messages 

specific to opioids, to include patient and family education on what opioids are, the hazards of 

opioids, safeguarding of prescription medications, and disposing of unused pills; (d) the common 

hazards of illicit and prescription opioids; and (e) availability of treatment resources. Media 

campaigns are commonly used to deliver preventive health messages and to shape healthy 

behaviors and attitudes. There are several successful state, local government and grassroots media 

campaigns aimed at providing drug-related public education or assistance in locating appropriate 

help for children. During the first Commission meeting on June 16, 2017, the Commission heard 

about one such campaign from the Partnership for Drug-Free Kids, who have worked with national 

and local media partners, as well as private sector partners like Google and Facebook, to run public 

service announcements that inform parents on available help for their loved ones. Similarly, 

Commission Chairman Governor Christie has implemented a media campaign in New Jersey 

around opioid addiction and a help hotline and website.

A comprehensive public health mass media campaign should be conceived carefully, pilot tested 

on target audiences, quantitative goals established, and outcomes measured that are matched to 

goals. Initially, accurate, anonymous, and actionable national data can be collected by probing the 

internet about the opioid crisis and, more broadly, youth attitudes towards drugs. Data analytical 

industries are capable of uncovering the extent, locations, spread, who are most affected by specific 

drugs being used, and how they are obtained by surveying the web in real-time with keywords.161

These probes can also identify treatment barriers, including shame, stigma, mistrust, cost, service 

availability, service preference, treatment avoidance, perceptions of service quality, and denial of 

service. Probes and interactive dashboards can scientifically test the potential success of public 

health video and other multi-media messaging on anti-drug campaigns, and shifts in sentiments, 

opinions, to provide continuous real-time survey data.
47

Since use of specific drugs is initiated in different age ranges, the campaign would need to be 

shaped according to various demographics. For example, alcohol, tobacco, marijuana, and 

inhalant use begins, on average, in early adolescence; the use of cocaine, methamphetamine, and 

hallucinogens in the later teen years; the misuse of prescription drugs (e.g., stimulants, 

tranquilizers, barbiturates, and pain relievers) and illicit opioids typically begins in early 

adulthood. 

There is an unmet need to launch a portfolio of comprehensible, compelling, and universal 

information to educate our nation on drug-related vulnerabilities of youth and other populations. 

Audiences would include teens, parents, people with psychiatric disorders, older adults, and 

pregnant women. Information would be created for television and for the internet, with a portfolio 

of animated, visual, interactive, narrated material, or videos, with minimal text, and pop-ups to 

counter misinformation on drug. This form of communication has the advantage of fidelity, 

interactivity, feedback, and sustainability.162 It can be dispersed on social networking sites, 

accessible via computers, iPad, smartphones or smartwatches. The internet is rapidly evolving as 

the most important medium for teens, where teen beliefs and perceptions are shaped, strengthened,

and shared. Web-based digital, interactive, narrated, and animated materials should focus on: (a) 

the hazards of opioid use; (b) the risks of adolescent drug use; (c) the risks of opioid use during 

pregnancy; (d) the crucial role of parents in protecting children; (e) counter common myths and 

misinformation on drugs; and (f) educating youth and parents on signs of an emerging SUD. As 

mentioned above, parents can be major influencers on a child’s use or non-use of drugs, as drug 

use is considerably lower among youth if parents deliver strong, clear messages disapproving of 

drug use, are involved with their children’s school work, set clear limits on children’s behavior by 

monitoring their time, friends, and supervising activities, and communicate and connect effectively 

with their children.

The media campaign’s messaging will need to be amplified and extended by the integrative efforts 

of evidence-based prevention programs at the local level, many of which receive support from the 

Federal Government. To achieve the desired ultimate outcome — reduction in drug use — the 

campaign needs the support of locally implemented evidence-based prevention programming. The 

campaign’s messaging needs to be integrated closely with local efforts and amplified by them. 

Local partners could include community coalitions, such as ONDCP’s Drug-Free Community 

grantees, schools, hospitals, law enforcement, businesses, religious institutions, and local 

government. In this way, strong anti-drug abuse messages tightly focused on targeted audiences 

would serve to raise awareness of the problem and solutions to it and improve anti-drug attitudes, 

beliefs and intentions, driving parents, adult influencers and youth to the local evidence-based 

prevention resources available to achieve the desired behavioral outcomes.

Although the funding level for the recommended campaign has not yet been determined, the initial 

funding request in FY 1998 for the National Youth Anti-Drug Media Campaign was $200 million 

per year. Those entities receiving campaign funds to air/print its messages were required to match 

the funds received, thus doubling the purchasing power of the federal funds. The Commission 

believes that a coordinated media campaign that can be rolled out nationally with a consistent 

message about the dangers of both illicit and prescription drugs, including opioids could 

effectively educate youth, parents, pregnant women, remove stigma associated with the disease of 

addiction, and reduce drug use and misuse.

5. The Commission recommends the Administration fund and collaborate with private 

sector and non-profit partners to design and implement a wide-reaching, national multi-
48

platform media campaign addressing the hazards of substance use, the danger of opioids, 

and stigma. A similar mass media/educational campaign was launched during the AIDs 

public health crisis.

Opioid Prescription Practices

More than 20 years ago, a growing compulsion to detect and treat pain set in motion the prescribing 

of opioids beyond traditional boundaries of treating acute, postoperative, and procedural pain and 

end-of-life care. The surge in opioid supply escalated into opioid-related misuse, diversion, use 

disorder, overdose deaths, and the advent of deadly fentanyl analogs. One of the areas which can 

have the greatest impact in the opioid crisis is reducing the rate of new addictions. This can be 

partly accomplished by aiming to prescribe opioids to appropriately indicated patients, and that 

prescription durations and doses match the clinical reason for which the drug is prescribed. Some 

states have set firm limits on the maximum number of days of prescribed opioids at initial 

encounters, irrespective of pain condition.

Improving upon the CDC Guideline for Prescribing Opioids for Chronic Pain and 

Provider/Prescriber Education

In March of 2016, the CDC developed and published a guideline for prescribing opioid pain 

medications for adults 18 years of age and older in primary care settings.

163 This guideline is

“intended to improve the communication between provider and patient about the risks and benefits 

of opioid therapy for chronic pain, improve treatment safety and effectiveness of pain treatment, 

and reduce the risks associated with long-term opioid therapy, including OUD and overdose.” The 

guideline focuses on three key areas: 1) determining when to initiate or continue opioids for 

chronic pain; 2) opioid selection, dosage, duration, follow-up and discontinuation; and 3) assessing 

risk and addressing harms of opioid use. Prescriptions by primary care clinicians account for nearly 

half of all dispensed opioid prescriptions, and the growth in prescribing rates among these 

clinicians have been above average. More importantly, use of prescription opioids for more than 

90 days increases the risk of progression towards addiction.164 A CDC “Morbidity and Mortality 

Weekly Report” published in July 2017 found that while prescriptions for opioid medications have 

decreased since 2010, substantial variation in opioid prescribing was observed at the county-level 

across the U.S.,165 demonstrating “the need for better application of guidance and standards around 

opioid prescribing practices.”

In the first Commission meeting, the Commission heard from various medical societies about the 

need to promote expanded implementation of the CDC opioid prescribing guideline. However, 

while many professional organizations encourage use of the CDC guideline, it is important to note 

the Commission received a substantial amount of correspondence from patients who currently use 

opioid medications for legitimate medical reasons and are worried about the guideline being too 

restrictive for their physicians to properly treat them. Clinicians have added their concerns about 

the CDC guideline, including the time required to discuss alternative forms of pain control, the 

difficulty in obtaining reimbursement for alternatives, how to address opioid tapering, and 

concerns with the prescribing guideline for specific forms of pain. Furthermore, it is important to 

point out that the CDC guideline is intended for primary care clinicians, who are treating patients 
49

for chronic pain in outpatient settings, and more latitude in decision making should be given to 

physicians that have specialized training in pain management. The Commission also recognizes 

that the CDC guideline may not include specific recommendations regarding patient education and 

informed consent.166 Patients are often ill-informed about the risks of taking opioid analgesics and, 

therefore, are not able to balance the potential benefits of opioid analgesics with the associated 

risks.

While progress has been made in training prescribers and fostering the adoption of prescribing 

guidelines such as the CDC guideline, the Commission has learned that not all states have adopted 

the guideline, not all physicians are aware of them, and sound opioid prescribing guidelines are far 

from universally followed. For example, while the CDC guideline, as well as guidelines from the 

VA and the Department of Defense (DOD), recommend clinicians use baseline and periodic urine 

testing as part of a comprehensive plan to ensure the safe and effective use of opioid therapies, not 

all states have placed sufficient emphasis upon the utility of medication screenings. In the current 

crisis, drug testing not only allows providers to assess proper use of prescribed medications in 

individual patients, but it would also be part of a broader solution in fighting the opioid crisis, as 

it can provide a snapshot of controlled prescription drugs and illicit drugs available in a 

community.

Consequently, the Commission recommended in the interim report that medical education and 

prescriber education initiatives in proper opioid prescribing and risks of developing an SUD be 

mandated (Appendix 3). 

Stakeholders important to the adoption of prescribing guidelines include public and private payers, 

medical and dental schools, physician and pharmacy groups, insurers, and health care associations. 

Medical associations have developed courses for proper opioid prescribing practices, with support 

from federal grants and made them available online for free.167,168,169,170 Federal agencies have also 

compiled lists of courses in compliance with the CDC guideline.

171,172 It is imperative that all DEA 

registrants prescribing scheduled drugs develop proficiency in pain management and opioid 

prescribing. In recognizing that OUD is associated with or preceded by other SUDs, training on 

diagnosis and office-based treatment of addictions should also be implemented for all stages of 

professional activity, including medical school, residency, practicing clinicians, and all others 

legally permitted to prescribe scheduled drugs.

Given that the practice of medicine, including prescribing, is regulated primarily at the state level, 

strategies for ensuring that prescribers are better informed and that patients are educated about the 

relative risks and benefits of opioid analgesics should incorporate state governments. Many states 

have acted to improve the safety of opioid prescribing. In July 2016, for example, 45 state 

governors signed the Compact to Fight Opioid Addiction173 under which signatories agreed to 

update prescribing guidelines, require pain management continuing education for prescribers, 

improve monitoring of providers prescribing opioids, and increase access to treatment and 

recovery support services through state healthcare programs.174 In March 2016, Massachusetts 

passed legislation175 limiting opioid analgesic prescriptions to a seven-day supply for first-time 

adult users and for minors, mandating continuing medical education (CME) credits for effective 

pain management, and requiring prescribers to check the state PDMP before writing a prescription 

for a Schedule II or Schedule III narcotic. 

Since January 2012, the State of Washington has required written treatment plans for use of opioid 

analgesics and a written agreement between patients and prescribers outlining patient 

responsibilities, including: taking the medications as prescribed; providing biological samples for 
50

toxicology testing; releasing the agreement for treatment to local EDs, urgent care facilities, and 

pharmacies; authorizing the prescriber to notify authorities if there is reason to believe the patient 

has engaged in illegal activities; and, acknowledging that it is the patient's responsibility to 

safeguard all medications and keep them in a secure location.176

A recent survey in Massachusetts found that 50% of respondents felt that painkillers are prescribed 

too often or in larger doses than necessary; 47% felt that getting painkillers from those who save 

them is too easy. Only 36% of respondents who had been prescribed an opioid were informed of 

the addiction potential by their prescriber either before or while they were taking the medication.177

In 2014, 4.4 million prescriptions for Schedule II or Schedule III opioids were written for 

Massachusetts residents, resulting in the dispensation of 240 million pills or tablets.178 Together, 

these data point to the need to explore prescriber and patient education as a component of any 

strategy to address the current opioid epidemic. A review of the curricula at the four medical 

schools in Massachusetts revealed that, although they taught components of addiction medicine, 

no uniform standard existed to ensure that all students were taught prevention and management 

strategies for prescription drug misuse. 

To fill this gap, Commission member Governor Baker and the Massachusetts Secretary of Health 

and Human Services invited the deans of the state’s four medical schools to convene to develop a 

common educational strategy for teaching safe and effective opioid-prescribing practices. With 

leadership from the Department of Public Health and Massachusetts Medical Society, the deans 

formed the Medical Education Working Group in 2015. This group reviewed the relevant literature 

and current standards for treating SUDs and defined 10 core competencies for the prevention and 

management of prescription drug misuse. The medical schools have incorporated these 

competencies into their curricula and have committed to assessing students’ competence in these 

areas. The members of the Medical Education Working Group have agreed to continue to work 

together on key next steps, including connecting these competencies to those for residents, 

equipping inter-professional teams to address prescription drug misuse, and developing materials 

in pain management and opioid misuse for practicing physicians. This first-in-the-nation 

partnership has yielded cross-institutional competencies that aim to address a public health 

emergency in real time.

The following themes emerged from a literature review and from national and local standards for 

treating SUDs. The core competencies are meant to enhance medical student training in primary, 

secondary, and tertiary prevention strategies for prescription drug misuse and to provide students 

with a strong foundation in prevention, identifying SUDs, and referring patients to appropriate 

treatment. These competencies are designed to serve as a vital bridge between undergraduate 

medical education and residency training. 

1. Evaluate a patient’s pain using age, gender, and culturally appropriate evidence-based 

methodologies. 

2. Evaluate a patient’s risk for SUDs by using age, gender, and culturally appropriate 

evidence-based communication skills and assessment methodologies, supplemented by 

relevant available patient information, including but not limited to health records, 

prescription dispensing records (e.g., the Prescription Drug Monitoring Program), drug 

urine screenings, and screenings for commonly co-occurring psychiatric disorders 

(especially depression, anxiety disorders, and posttraumatic stress disorder). 

3. Identify and describe potential pharmacological and nonpharmacological treatment 

options, including opioid and nonopioid pharmacological treatments for acute and chronic 
51

pain management, along with patient communication and education regarding the risks and 

benefits associated with each of these available treatment options. 

• Secondary prevention domain: Treating patients at risk for SUDs (engaging patients in 

safe, informed, and patient-centered treatment planning) 

4. Describe SUD treatment options, including MAT, as well as demonstrate the ability to 

appropriately refer patients to addiction medicine specialists and treatment programs for 

both relapse prevention and co-occurring psychiatric disorders. 

5. Prepare evidence-based and patient-centered pain management and SUD treatment plans 

for patients with acute and chronic pain with special attention to safe prescribing and 

recognizing patients displaying signs of aberrant prescription use behaviors. 

6. Demonstrate the foundational skills in patient-centered counseling and behavior change in 

the context of a patient encounter, consistent with evidence-based techniques. 

• Tertiary prevention domain: Managing SUDs as chronic diseases (eliminating stigma 

and building awareness of social determinants) 

7. Recognize the risk factors for, and signs of, opioid overdose and demonstrate the correct 

use of naloxone rescue. 

8. Recognize SUDs as a chronic disease by effectively applying a chronic disease model in 

the ongoing assessment and management of the patient. 

9. Recognize their own and societal stigmatization and biases against individuals with SUDs

and associated evidence-based MAT

10. Identify and incorporate relevant data regarding social determinants of health into 

treatment planning for SUDs.

Integrating the core competencies for the prevention and management of prescription drug misuse 

with any related competencies for residents is critical to ensuring that medical students are required 

to maintain and expand these skills as they enter residency training. Furthermore, the group 

recognized the need to expand inter-professional education opportunities designed to better equip 

collaborative teams for primary, secondary, and tertiary prevention of OUDs. As other 

practitioners, including nurses, pharmacists, dentists, and mental health providers, among others, 

also contribute to the provision of care, they too must demonstrate competence in this area. Finally, 

the group recognized the need for continuing medical education materials for current prescribers.

The level of urgency is greater than ever to develop creative solutions based on exploiting modern 

data mining and communication proficiencies. A more rational approach is to develop detailed and 

specific guidance for clinicians treating specific manifestations of pain. With modern data 

analytical techniques capable of interrogating vast prescribing databases, it is feasible to identify 

current patterns of opioid prescribing for specific conditions, recommend changes in practice 

patterns based on specific pain sources and medical specialties, and create active programs to 

educate practitioners on these recommendations. Combined with data from PDMPs, a simple 

electronic printout conceivably can assist in guiding a physician’s decision on prescribing opioids 

or alternatives for pain management. Decisions on pain management can be fortified with 

additional information on a patient’s physical and mental health status, as the complex causes of 

pain can arise from a confluence of biological, psychological, and social factors.

To advance this goal, providers need to be informed about suitable prescribing practices for 

opioids, a class of drugs which confer benefit, as well as high risk. Pharmacoepidemiology 
52

research can facilitate improvements to the CDC guideline by initially defining existing patterns 

of opioid use and then developing condition-specific guidelines on optimal opioid dosing.179,180

To create a more useful foundation for interventions to reduce improper use of prescription 

opioids, much more needs to be known of existing patterns of prescription for specific conditions, 

including diagnosis, drug choice, dose, amount prescribed, and physician and patient 

characteristics. This work would draw on the extensive experience of pharmacoepidemiological 

analysis,181 as well as extensive population-based datasets from both the public and private 

sector.182 These studies will help to define which specific problems of opioid overuse are most 

prevalent in which settings in order to better focus public and private interventions on the areas of 

greatest need, in terms of clinical conditions, provider types, patient characteristics, and practice 

settings. The second and more important goal is to develop condition-specific guidelines on 

optimal opioid dosing. While CDC and other groups have set forth general guidelines on the 

principles of pain management, and some states have established uniform limits on the maximum 

number of tablets or capsules that can be prescribed for a first opioid prescription, clinicians need 

more detailed and specific guidance on drug choice, dose, and quantity to be dispensed in treating 

specific common conditions. Data analytics can build on the overall guidance documents prepared 

for pain management in general by: (a) reviewing the entire existing literature on evidence 

concerning condition-specific pain therapy, including recommended agents, doses, and quantities; 

(b) convening several expert clinician panels to generate condition-specific guidelines for 

managing the most common indications for pain medications; and (c) transforming that 

information into concise, clinically relevant, and actionable recommendations that can be

disseminated to practitioners.

Pharmacists are under pressure to continue filling prescriptions from irresponsible providers. A 

recent study of Wisconsin pharmacists found that a not insignificant minority did not understand 

what is legitimate practice under federal and state laws about evaluating the legitimacy of a 

controlled substance prescription – also known as corresponding responsibility. Further, 36% of

these pharmacists considered extended prescribing of opioids to be a violation of law or 

unacceptable medical practice. In the current crisis, it is critical that all pharmacists and pharmacy 

programs have the training necessary to responsibly dispense these medications while also not 

dispensing these powerful medications when the prescription is not legitimate or if it will harm the 

patient.183

6. The Commission recommends HHS, the Department of Labor (DOL), VA/DOD, FDA, 

and ONDCP work with stakeholders to develop model statutes, regulations, and policies 

that ensure informed patient consent prior to an opioid prescription for chronic pain. 

Patients need to understand the risks, benefits and alternatives to taking opioids. This is 

not the standard today.

7. The Commission recommends that HHS coordinate the development of a national 

curriculum and standard of care for opioid prescribers. An updated set of guidelines for 

prescription pain medications should be established by an expert committee composed of 

various specialty practices to supplement the CDC guideline that are specifically targeted 

to primary care physicians.

8. The Commission recommends that federal agencies work to collect participation data. 

Data on prescribing patterns should be matched with participation in continuing medical 
53

education data to determine program effectiveness and such analytics shared with 

clinicians and stakeholders such as state licensing boards.

9. The Commission recommends that the Administration develop a model training program 

to be disseminated to all levels of medical education (including all prescribers) on 

screening for substance use and mental health status to identify at risk patients.

10. The Commission recommends the Administration work with Congress to amend the 

Controlled Substances Act to allow the DEA to require that all prescribers desiring to be 

relicensed to prescribe opioids show participation in an approved continuing medical 

education program on opioid prescribing.

11. The Commission recommends that HHS, DOJ/DEA, ONDCP, and pharmacy 

associations train pharmacists on best practices to evaluate legitimacy of opioid 

prescriptions, and not penalize pharmacists for denying inappropriate prescriptions.

Enhancing Prescription Drug Monitoring Programs (PDMP) 

State-based PDMPs are electronic databases that give prescribers and many pharmacists access to 

critical information regarding a patient’s controlled substance prescription history, and which can 

help health professionals identify patients who may be misusing prescription opioids or other 

prescription drugs and who may be at risk for abuse or misuse. PDMPs are sometimes used by 

professional licensing boards to identify clinicians with patterns of inappropriate prescribing and 

dispensing. In most states, law enforcement may use them to investigate cases of controlled 

substance diversion. In the interim report, the Commission recommended that federal funding and 

technical support be provided to states to enhance data sharing among PDMPs to better track 

patient-specific prescription data and support regional law enforcement in cases of controlled 

substance diversion (Appendix 3). The commission believes the additional recommendations 

outlined below will further enhance the effectiveness and uptake of PDMPs across the nation.

Today, 49 states and the District of Columbia currently have legislation authorizing the operation 

of PDMPs in their jurisdictions. However, except in states with mandated PDMP use, providers 

who see patients and prescribe opioids, or have patients affected by opioids, don’t routinely 

register for or use PDMPs. The national median PDMP registration rate among licensed 

prescribers is only 35%, per a report in the Journal of the American Medical Association published 

in 2015. Furthermore, a study by the Johns Hopkins Bloomberg School of Public Health found 

that patient history was not checked via a PDMP database by the prescriber in 86% of prescriptions 

for opioids written in 2015.

The Federal Government should leverage mechanisms to facilitate PDMP use. Congress should 

pass and the President should sign the Prescription Drug Monitoring (PDMP) Act of 2017, which 

would mandate the creation and use of PDMPs by states who receive federal funding to fight the 

opioid crisis. This Act would impose strict PDMP requirements, such as a 24-hour reporting 

requirement after dispensing a controlled substance, further centralize prescribing data, and would 

help to facilitate data sharing across the states.

12. The Commission recommends the Administration's support of the Prescription Drug 

Monitoring (PDMP) Act to mandate states that receive grant funds to comply with PDMP 
54

requirements, including data sharing. This Act directs DOJ to fund the establishment 

and maintenance of a data-sharing hub.

13. The Commission recommends federal agencies mandate PDMP checks, and consider

amending requirements under the Emergency Medical Treatment and Labor Act 

(EMTALA), which requires hospitals to screen and stabilize patients in an emergency 

department, regardless of insurance status or ability to pay.

Providers often resist using PDMPs because these systems are not well integrated into the 

electronic health records (EHR) systems they currently use in practice, and for other reasons, 

including inadequate training on the use and complexity of some PDMP software programs. The 

Heller School at Brandeis University recommends simplifying the method of access to PDMPs for 

providers by integrating PDMP data into health information exchanges, increasing the likelihood 

that prescription history information will be used in clinical decision-making. Furthermore, many 

EHR systems also integrate electronic prescribing of controlled substances (EPCS). The American 

Medical Association (AMA) and the American College of Physicians both recommend EPCS as 

one of the top tactics to combat opioid abuse, as eliminating paper prescriptions will improve 

accuracy, reduce diversion and fraud, as well as improve data quality to PDMPs. However, only 

the States of Maine and New York have mandated the use of electronic prescribing for controlled 

substances (Minnesota has mandated e-prescribing since 2011, but no enforcement mechanism 

exists), and these states are using Medicaid reimbursement rates to incentivize providers to use 

EPCS. Other states have followed suit; Virginia passed legislation mandating statewide EPCS to 

take effect in 2020. More recently, Commission member Governor Cooper signed the Strengthen 

Opioid Misuse Prevention (STOP) Act which, as of July 1, 2017, requires electronic prescribing 

of certain schedule II and III controlled substances, including opioid medications, in North 

Carolina. Practitioner ability to electronically prescribe controlled substances in the United States

is currently governed by an interim final rule, which would benefit from a revision so practitioners 

can take advantage of modern technology that would make registration and use of this service 

easier.

Practitioners are also hesitant to use PDMPs because they often do not know what to do when they 

identify patients with a potential SUD. Physicians and other health professionals often do not have 

adequate training in SUDs to assess patients and may need coaching on how to effectively address 

the issue of a potential SUD. This is especially relevant if the PDMP indicates a high-risk patient 

requiring tapering, alternatives for pain management, and specialty treatment for OUD. Inadequate 

patient support or treatment may compromise the value of the PDMP,184 and promote a transition 

to illicit opioids if prescription opioids are eliminated. In addition, providers are typically pressed 

for time and often complain that if a patient is flagged by a PDMP they are either ill-equipped to 

screen for an SUD and/or unable to make a successful referral to specialty SUD treatment 

programs. ASAM strongly recommends that prescribers be trained in engagement strategies that 

result in linking patients to treatment when indicated. Integrated decision support tools, such as 

the screening tools used in SBIRT interventions, could also help practitioners make a quick 

determination about the likelihood of a SUD and to recommend appropriate specialty care or an 

appropriate specialty treatment provider at which to obtain an assessment. 

There are a number of new and innovative tools for providers to determine which patients are at 

risk of adverse effects from prescription opioids, including accidental overdose or development of 

an SUD. Some are used at the provider level and some analytic tools are used at the payer level to 

flag certain patients for follow-up or interventions.
55

14. The Commission recommends that PDMP data integration with electronic health 

records, overdose episodes, and SUD-related decision support tools for providers is 

necessary to increase effectiveness.

15. The Commission recommends ONDCP and DEA increase electronic prescribing to 

prevent diversion and forgery. The DEA should revise regulations regarding electronic 

prescribing for controlled substances.

Organizations such as the Association of State and Territorial Health Officials (ASTHO) and 

Palantir recommend that multiple data sources should be integrated, accessible, and up-to-date in 

PDMPs to rapidly predict and detect outbreak “hot spots” and disease clusters for both public 

health and law enforcement purposes.185 Medical providers would benefit from knowing if patients 

overdosed so they can adjust their treatment, but currently those records do not flow back to 

primary care from emergency rooms or emergency responders because, in many medical settings,

the differing EHR systems are not sufficiently interoperable. Patient privacy laws, while wellmeaning, can also hinder the ability to share this information between medical providers. However, 

the Department of Transportation (DOT) maintains a database of EMT responses for overdoses 

that could inform PDMPs about patients’ level of risk and provide better decision-making tools 

for the prescriber.

16. The Commission recommends that the Federal Government work with states to remove 

legal barriers and ensure PDMPs incorporate available overdose/naloxone deployment 

data, including the Department of Transportation’s (DOT) Emergency Medical 

Technician (EMT) overdose database. It is necessary to have overdose data/naloxone 

deployment data in the PDMP to allow users of the PDMP to assist patients.

Prescription Take-Back Programs and Drug Disposal

The National Prescription Drug Take Back Day, organized by the DEA with state and local 

partners, provides communities a safe and convenient way to dispose of their unneeded 

prescription drugs, while educating the public about the dangers for the public of abuse and misuse. 

Providers wrote nearly a quarter of a billion opioid prescriptions in 2013. This is enough for every 

American adult to have a bottle of prescription opioids.186 Many misusers of prescription drugs 

have indicated they received prescriptions from their family and friends’ medicine cabinets.187

DEA’s Take Back Day, which is held twice a year, provides an opportunity for communities to 

dispose of their unneeded prescriptions. In addition, these events are often community driven and 

offers the public a venue to host community health fairs and provide information about drug 

screening and treatment services. Offering drug screening and treatment information and resources 

during Take Back events encourages friends and family of loved ones with a substance abuse 

problem to obtain information and support on a convenient walk in basis. There is also a need to 

leverage resources by collaborating with other health professionals that offer comprehensive health 

and substance use services.

States have also established year-round take-back programs in partnership with community 

stakeholders and local law enforcement agencies. North Carolina’s ‘Operation Medicine Drop’ is 
56

the largest take-back program in the U.S., and has collected nearly 89.2 million pills at more than 

2000 events since 2010.

There is an opportunity to increase efforts by encouraging hospitals/clinics with onsite pharmacies 

and retail pharmacies to become authorized collectors. Authorized collectors provide a year-round 

opportunity for the public to properly dispose of their unused prescriptions. Onsite and retail 

pharmacies have a tremendous opportunity to aid in increasing collection rates by considering 

incentivizing the public to drop off their unneeded prescriptions by offering store rebates. 

In addition, the Federal Government supported the development of drug deactivation bags to allow 

the safe disposal of old prescription opioids. Drug deactivation bags would be particularly useful 

in rural areas where an authorized collector may not be nearby. The use of such bags would 

complement Take Back Day events and give consumers more options. Furthermore, the Federal 

Government could explore a potential partnership with onsite and retail pharmacies to fund and 

include a drug deactivation bag with opioid prescriptions. This would provide an opportune 

moment at the time of drug dispensing to educate the patient on and encourage safe drug disposal.

17. The Commission recommends community-based stakeholders utilize Take Back Day to 

inform the public about drug screening and treatment services. The Commission 

encourages more hospitals/clinics and retail pharmacies to become year-round 

authorized collectors and explore the use of drug deactivation bags.

Pain Level as an HHS Evaluation Criteria

As a condition of full reimbursement of hospitals, the Centers for Medicare and Medicaid Services 

(CMS) requires that hospitals randomly survey discharged inpatients using the post-hospitalization 

survey the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

188

 

While hospitals must survey only a small percent of patients and response rates are not high 

(~18%), some elect to also use email to survey every patient and use these responses to improve 

their own internal processes. This information is reported as part of the program for hospital 

ratings, ‘Hospital Compare,’189 which offers a public data tool for prospective patients. The tool 

allows comparison of hospitals across the US on these and other metrics related to patient outcome. 

During Affordable Care Act (ACA) implementation, the survey became part of how CMS 

calculates the VBP Incentive, which gives hospitals maximal reimbursement when they reach 

certain targets. HHS previously included the pain question response information in calculations of 

incentive payments, but in 2017, CMS announced they would stop including the questions in the 

VBP program calculation. HHS’s stated reason for removing the pain questions from the VBP 

calculation was to ensure there would not be any financial incentive or pressure to prescribe.190

HHS has removed the former pain management questions and replaced them with pain 

management communication questions instead. Moving forward, they intend to continue to include 

them in HCAHPS. 

However, providers and provider associations have expressed they are being required to treat pain 

with opioids to maintain high ratings. Recent published research since has shown that those with 

new opioid prescriptions post-discharge are more likely to report their pain was always well 

managed suggesting that savvy providers have figured out that opioids are a way to manipulate 

satisfaction.191 This study also found a new opioid claim within seven days of discharge was likely 
57

to be associated with an opioid claim 90 days post-discharge in Medicare.192 Finally, other studies 

showed ratings of orthopedists performing knee and hip replacement were higher in patients 

reporting better pain control and orthopedist ratings and sometimes hospital ratings were also 

affected.193,194 The research suggests that the current approach to pain treatment in the hospital that 

meets the highest level of response is iatrogenic for ongoing (90-day post-hospital) opioid use.

18. The Commission recommends that CMS remove pain survey questions entirely on 

patient satisfaction surveys, so that providers are never incentivized for offering opioids 

to raise their survey score. ONDCP and HHS should establish a policy to prevent hospital 

administrators from using patient ratings from CMS surveys improperly.

Reimbursement for Non-Opioid Pain Treatments

A key contributor to the opioid epidemic has been the excess prescribing of opioids for common 

pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, 

acupuncture, chiropractic, surgery, as well as FDA-approved multimodal pain strategies have been 

proven to reduce the use of opioids, while providing effective pain management, current CMS 

reimbursement policies, as well as health insurance providers and other payers, create barriers to 

the adoption of these strategies. In the third Commission meeting, the Commission heard from 

several innovative pain management and pharmaceutical companies about the need for proper 

reimbursement of non-opioid pain medications to increase uptake among healthcare providers and 

limit the use of opioids. For example, the current CMS payment policy for “supplies” related to 

surgical procedures creates unintended incentives for those that prescribe opioid medications to 

patients for postsurgical pain instead of administering non-opioid pain medications. Under current 

policies, CMS provides one all-inclusive bundled payment to hospitals for all “surgical supplies,” 

which includes hospital administered drug products intended to manage patients’ postsurgical 

pain. This policy results in the hospitals receiving the same fixed fee from Medicare whether the 

surgeon administers a non-opioid medication or not. Any costs the hospital incurs for creating and 

administering a multimodal pain management strategy essentially get deducted from its fixed fee 

payment. Thus, purchasing and administering a non-opioid medication in the operating room 

increases the hospital’s expenses without a corresponding increase in reimbursement payment. 

Dispensing and writing a prescription for postsurgical opioids, on the other hand, costs the hospital 

very little, especially since most opioids are generic. Inadequate reimbursement significantly 

hampers providers’ ability to utilize non-opioid treatment for postsurgical pain.

A broader range of pain management and treatment services – including alternatives to opioids,

physical therapy, computerized pain management educational programming, PDMP checking, 

evidence-based behavioral health treatment, tapering off opioids, and drug testing to confirm 

adherence – should be adequately reimbursed by payers, including CMS.

19. The Commission recommends CMS review and modify rate-setting policies that 

discourage the use of non-opioid treatments for pain, such as certain bundled payments 

that make alternative treatment options cost prohibitive for hospitals and doctors, 

particularly those options for treating immediate post-surgical pain.
58

Reducing and Addressing the Availability of Illicit Opioids 

Along with reducing the supply of unnecessary prescription opioids, a major component of 

prevention is reducing the number of illicit opioids available on the streets, such as heroin, illicit 

fentanyl and fentanyl analogues, or diverted prescription opioids. In the Commission’s interim 

report, the Commission recommended prioritizing funding and manpower to federal law 

enforcement agencies to develop fentanyl detection sensors, to disseminate them to federal, state, 

local, and tribal law enforcement agencies, and to support federal legislation to stop synthetic 

opioids from coming into the country through the U.S. Postal Service (Appendix 3). The 

Commission believes the recommendations outlined below will further address the availability of 

and staunch the flow of existing and newly emerging dangerous opioids crossing the border into 

our country.

Improving Data Collection and Analytics

The opioid crisis is both a national security and homeland security threat that impacts the health 

of individuals and the safety of communities. To respond effectively to this multi-faceted 

challenge, stakeholders need to access timely and accurate information that provides a 

comprehensive view of the drug environment at the federal, state, local, and tribal levels. 

Unfortunately, data on drug use, treatment, and public safety outcomes are managed in different 

agencies and are often not integrated in a comprehensive way that facilitates the needs of public 

safety and public health. There is also variability in the way key indicators are defined, collected, 

and reported across states making it difficult to monitor and assess regional and national trends. It 

is imperative that all levels of government develop a set of core public health and public safety 

indicators that can be standardized, collected, analyzed, and shared to inform local, regional, and 

national prevention, education, outreach, treatment, and enforcement initiatives.

The Federal Government has made considerable investments in capabilities that facilitate 

collaboration among federal, state, and local agencies to enhance our Nation’s ability to address 

various threats affecting our communities. For example, the CDC has provided federal grant 

funding to select states to improve prevention and response efforts by supporting more timely 

public health data collection, disseminating public health surveillance findings to key stakeholders 

within states, and sharing data with the CDC to support improved multi-state public health 

surveillance. On the public safety side, the existing models of public health and public safety 

information sharing have largely been supported by federal grant programs and technical 

assistance administered through the DOJ’s Bureau of Justice Assistance (BJA), and the CDC.

Improved coordination among federal departments and agencies related to grant funding and 

technical assistance activities will expand models of public health, behavioral health, and public 

safety information sharing and collaboration at the state and local level.

Likewise, states have leveraged Department of Homeland Security (DHS) preparedness grant 

funding to effectively implement, in collaboration with federal partners, a decentralized and 

coordinated information sharing environment to identify, analyze, and share public safety

information across all levels of government and first responder disciplines. Significant strides have 

also been made to enhance the Nation’s capacity to collect, share, and analyze public safety

information, and disseminate actionable and strategic intelligence to key stakeholders from all 

levels of government. A critical component of the national response to the 9/11 terrorist attacks 

was the development of a national-level, decentralized, and coordinated information sharing 
59

environment that prioritizes information security and protects individual privacy, civil rights, and 

civil liberties. State and major urban area fusion centers, the High Intensity Drug Trafficking Areas 

(HIDTA) Program, and Regional Information Sharing Systems (RISS) Centers are some of the 

key field-based information sharing, analytic, and investigative entities that leverage this capability 

to enable interjurisdictional and multidisciplinary information sharing, and facilitate collaboration 

among federal, state, and local public safety partners to address both local and national threats. It 

is sensible to evaluate how investments in the national information sharing environment could be 

used to support public health and public safety information sharing and collaboration at all levels 

of government.

At the state and local levels, successful frameworks for public health and public safety 

collaboration are expanding. Several states have developed drug monitoring initiatives (DMIs) 

and overdose fatality review teams, while New York City has developed the RxStat initiative. 

These efforts integrate various public safety and public health data sets to include drug overdose 

deaths, non-fatal overdoses, naloxone administrations, prescriber data, drug arrests, drug seizures, 

and laboratory results. The analysis of these data enables public safety and public health 

stakeholders to develop and implement prevention, education, outreach, treatment, and 

enforcement initiatives that protect public safety and reduce drug use and its consequences. These 

data can be used to develop coordinated risk-reduction strategies tailored to local communities or 

specific regions. 

20. The Commission recommends a federal effort to strengthen data collection activities 

enabling real-time surveillance of the opioid crisis at the national, state, local, and tribal 

levels. 

In the United States, medicolegal death investigation (MDI) is conducted via a county-based 

system of medical examiners and coroners (ME/Cs). There are no national standards for 

conducting MDI in drug overdose cases; including when to investigate a death, any requisite 

accreditation of ME/C offices and the certification of their investigators, protocols for which drugs 

to test for and at what cut-off levels, the possibility of suicide, or how or to whom to report findings. 

The absence of shared standards and procedures prohibits the accurate and timely identification 

and prioritization of drug threats and the evaluation of the effectiveness of public health and safety 

policies implemented to abate them. The DOJ and the National Institute of Standards and 

Technology are currently leading an effort to standardize the process for forensic investigations. 

Consistency in the investigation and reporting procedures following fatal and nonfatal drug 

overdose events will permit improvements to the timeliness and completeness of mortality

reporting statistics and is necessary to make better and more efficient use of limited state and 

federal funds.

21. The Commission recommends the Federal Government work with the states to develop 

and implement standardized rigorous drug testing procedures, forensic methods, and use 

of appropriate toxicology instrumentation in the investigation of drug-related deaths. We 

do not have sufficiently accurate and systematic data from medical examiners around the 

country to determine overdose deaths, both in their cause and the actual number of 

deaths.

Estimates of the extent of the opioid epidemic in the United States may be underestimated due to 

inadequate systems reporting information on the number, location, and degree of opioid 
60

consequences. Surveys of chronic drug users and morbidity information could provide timely and 

in-depth insights into the opioid crises, but were defunded from the budgets of federal agencies. 

Current data systems do provide some level of measurement, but miss some important aspects of 

the opioid epidemic. Restoration of funding for these terminated programs is needed to obtain 

more detailed information on the opioid epidemic.

The unique aspects of opioid drugs exacerbate the issues of monitoring the misuse problem, unlike 

other illicit drugs such as marijuana, cocaine, or methamphetamine. Cocaine, for example, has 

been a drug of consequence for decades, is abused by millions of people in the United States, and 

has limited variations in composition. Data systems monitoring the extent of the cocaine problem 

have been standardized and institutionalized. Opioids, on the other hand, consist of many drug 

varieties, including prescription pain medications, heroin, and most recently, illicitlymanufactured fentanyl. Millions of people misuse prescription pain medications, but only a small 

fraction of that number abuse heroin. These fewer numbers present a challenge for estimating the 

prevalence of use by the standard federal survey. 

For example, the NSDUH, a federal statistical survey of about 70,000 Americans annually (cited 

often throughout this report), estimated that 600,000 people used heroin in 2010.

195 A study 

conducted by the RAND Corporation on illicit drug expenditures in America estimated the number 

of heroin users in 2010 to be closer to 1.5 million.196 This dramatic discrepancy has been discussed 

by the press.

197 Illicitly-produced fentanyl, another rapidly growing component of the opioid 

epidemic is not even routinely tracked by surveys such as NSDUH or drug seizure data systems.

Two discontinued data systems that would provide enhanced fidelity to measuring the extent of 

the opioid crisis are the Arrestee Drug Abuse Monitoring (ADAM) Program and the Drug Abuse 

Warning Network (DAWN). ADAM was a survey of current local high-risk arrestees in jails 

accompanied by a urinalysis test. Until its termination by the National Institute of Justice in 2003, 

over 30 jails in cities throughout the country were sampled and tested. These data would provide 

timely, geo-specific data on opioid use, supported with a confirmatory lab test. The lab analysis 

could also be adjusted to test for any new opioids appearing in the U.S. market. DAWN was a 

tabulation of drug mentions in hospital emergency rooms. SAMHSA funded the DAWN program 

until 2011. These morbidity data would provide a sentinel system, alerting decision makers of the 

consequences of opioid use before more serious overdoses would occur.

Existing data collection systems, including the major surveys, like the NSDUH and the Monitoring 

the Future study, need to be maintained and improved, and the data gaps need to be filled and 

revitalized using such novel approaches such as testing wastewater in highly circumscribed regions 

(e.g. a few blocks) for estimating drug metabolites. This innovative system has already collected 

biological specimens from high-risk populations for early indications of the changing drug 

landscape. Population-level data from toxicology screening can also provide a snapshot of drug 

use and misuse. Local information is essential to complement national data in informing public 

health and public safety responses to the opioid epidemic.

The possibility of a behavioral health surveillance system at sentinel sites across the country exists 

for 12+ sites currently under NIDA funding and additional resources have recently been awarded 

by CDC to 44 states and the District of Columbia to include better tracking of opioid-related 

overdoses. There is a need for an integrated system that, across the country, can track prevalence 

rates, treatment modalities, and comorbidities with other illnesses in real-time. Recognizing that 

there is variability across the United States, these surveillance or sentinel sites can be established 

for a multitude of local areas across the country.
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22. The Commission recommends reinstituting the Arrestee Drug Abuse Monitoring (ADAM) 

program and the Drug Abuse Warning Network (DAWN) to improve data collection and 

provide resources for other promising surveillance systems.

Disrupting the Illicit Fentanyl Supply 

The emergence of illicitly produced fentanyl and fentanyl analogues in the drug market has

drastically compounded the illicit opioid problem. Increasingly, fentanyl and fentanyl analogues 

are combined with inert substances and pressed into pill form to be sold as counterfeit prescription 

opioid pills. To help deter these features of the illicit drug market, changes to sentencing guidelines 

are underway in many states and in various stages of maturity. 

In Massachusetts, any person who traffics’ in fentanyl, “by knowingly or intentionally 

manufacturing, distributing, dispensing or possessing with intent to manufacture, distribute or 

dispense or by bringing into the commonwealth a net weight of more than 10 grams of fentanyl” 

faces punishment of up to 20 years in state prison. The term “fentanyl” includes any derivative of 

fentanyl and any mixture containing more than 10 grams of fentanyl or a derivative of fentanyl. 

M.G.L.A. 94C § 32E (c 1⁄2).

As of July 2017, West Virginia law specifically criminalizes the unlawful manufacture, delivery, 

transport into state, or possession of fentanyl. W. Va. Code, § 60A–4–415. A violation is a felony, 

with the following prison terms: (1) if the net weight of fentanyl involved in the offense is less 

than one gram, such person shall be imprisoned in a correctional facility not less than two nor more 

than ten years; (2) if the net weight of fentanyl involved in the offense is one gram or more but 

less than five grams, such person shall be imprisoned in a correctional facility not less than three 

nor more than fifteen years; and (3) if the net weight of fentanyl involved in the offense is five 

grams or more, such person shall be imprisoned in a correctional facility not less than four nor 

more than twenty years.

New Hampshire law defines the term “fentanyl class drug” with reference to a listing of specific 

substances. N.H. Rev. Stat. § 318-B:1(XI-a.). These drugs are assigned the same criminal penalties 

as are heroin or crack cocaine. N.H. Rev. Stat. § 318-B:26.

While states consider laws that aim to reduce the supply of fentanyl, including harsher penalties 

for smaller quantities, given the potency, it is also important to consider whether users, who buy 

fentanyl unknowingly, could be unnecessarily punished for distribution. For individuals with OUD 

who are arrested with fentanyl, other factors beyond quantity should be considered to determine 

possession for personal use versus distribution. 

23. The Commission recommends the enhancement of federal sentencing penalties for the 

trafficking of fentanyl and fentanyl analogues.

As mentioned above, illicit fentanyl and fentanyl analogues are increasingly being pressed into 

counterfeit prescription opioid pills, often mimicking the appearance of commonly prescribed 

opioid pain killers such as OxyContin, by Drug Trafficking Organizations (DTOs) and smuggled 

into the United States in large quantities. While fentanyl seizures are most typically in a powder, 

salt, or rock-like form, DEA’s El Paso Intelligence Center (EPIC) reports an increase in the number 

of pills seized. In 2016 an estimated 15,632 domestically seized tablets and capsules were 
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identified by DEA forensic laboratories as containing some amount of fentanyl or fentanyl 

analogues with or without other illicit drugs and non-narcotic substances. This represents 

approximately 16 times the number of fentanyl tablets and capsules analyzed by DEA’s 

laboratories in 2014.198

Fentanyl in pill form has enabled the development of a more diverse user population that is 

skewing younger and perhaps more opioid naïve. Moreover, the prototypical experienced 

intravenous drug user of previous illicit opioid crises has been joined by those who believe they 

are buying off-market prescription opioids, but are in fact buying fentanyl pressed into pill form.

Furthermore, the online marketplace and cryptocurrencies have empowered a “democratization of 

the drug trade,” where the hierarchical DTOs the United States has effectively confronted for the 

past several decades no longer have a monopoly on supplying drugs. Rather, individuals can 

simply go online to one of many internet drug marketplaces and purchase illicit drugs for their 

own personal use or for further sale on a limited scale, creating a constellation of “micro-networks” 

across the country that are difficult to locate and nearly impossible to dismantle. The ability to 

easily purchase drugs like fentanyl online, which are subsequently shipped in a manner and at 

volumes that make them hard to detect, demonstrates a new pathway for these potent drugs to enter 

the domestic supply chain. This change carries enormous implications for the law enforcement 

and justice communities, and requires a framework of relationships, laws and regulations, and 

procedures to deal with an environment of drug trafficking and use the nation is just beginning to 

see.

The growing internet drug market, particularly for fentanyl and fentanyl analogues, is a clearly 

identified critical vulnerability in interrupting the supply of these drugs into the United States. 

Since the 2013 closing of the first well-known cryptomarket, Silk-Road 1.0, both the clear and the 

dark web have further expanded the illicit drug market, allowing individuals to purchase dangerous 

drugs directly from their manufacturers instead of through established trafficking organizations. 

Internet sales of fentanyl and other synthetic substances has evolved into a direct to consumer 

market generating large revenues. A Carnegie Mellon University study estimated that revenues 

from online illicit drug sales increased from between $15-17 million in 2012 to $150-$180 million 

in 2015.199 The recent multi-agency and international effort, led by the DOJ, which resulted in the 

takedown of the Alphabay marketplace was a monumental step forward in this effort.

The dynamics of synthetic drugs and their availability online has the potential to permanently 

change the drug market. The Federal Government currently lacks a sustained, coordinated, and 

well-resourced effort to attack the illicit drug online purchase infrastructure to identify and target 

the network of actors involved, and limit the amount of fentanyl and fentanyl analogues entering 

the United States.

24. The Commission recommends that federal law enforcement agencies expressly target 

Drug Trafficking Organizations and other individuals who produce and sell counterfeit 

pills, including through the internet.

The importation of tableting machines (pill presses) is regulated by DEA. DEA has recently 

enhanced importation regulations by replacing paper reporting with an electronic process. 

However, the active use of pill presses remains unregulated. While DEA currently can inspect a 

registrant’s use of controlled substances in their usable form to verify they are well stored and used 
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for their stated registered purposes, the DEA currently cannot inspect pill presses to verify that 

equipment is not being used to produce counterfeit drugs.

25. The Commission recommends that the Administration work with Congress to amend the 

law to give the DEA the authority to regulate the use of pill presses/tableting machines 

with requirements for the maintenance of records, inspections for verifying location and 

stated use, and security provisions.

Interdiction and Detection Challenges

The detection of fentanyl and its analogues shipped directly into the United States via international 

mail and express consignment presents a unique challenge. U.S. Customs and Border Protection 

(CBP) is responsible for interdicting and screening inbound international mail before all letters, 

parcels, and packages are released to the U.S. Postal Service (USPS) for domestic delivery. 

The CBP operates within nine major USPS International Mail Facilities (IMF), inspecting 

international mail and parcels arriving from more than 180 countries. CBP partners with the U.S. 

Postal Inspection Service (USPIS) at each facility to target, detect, and seize international 

shipments of illicit narcotics, including fentanyl. International mail processing is primarily manual, 

requiring CBP officers to sort through large volumes of parcels to identify potential shipments of 

concern. CBP screens all international mail parcels for radiological threats, x-rays all international 

mail packages presented by USPS, and physically examines those deemed high-risk. 

The USPS processed over 275 million international inbound mailings in FY 2016. Of those items, 

there were over ten million international express mail items and over four million air and surface 

parcels. In FY 2016, the USPIS initiated 2,439 cases involving drug trafficking and made 1,850 

arrests which resulted in 1,571 convictions. Additionally, inspectors seized illegal assets valued 

at approximately $23.5 million, to include 89 pounds of heroin, 13,968 Oxycodone tablets, and 

fentanyl-family synthetic opioids on 36 occasions. In these cases, USPIS utilized intelligence 

derived from drug seizures, international partnerships, and strong relationships with federal, state, 

local and tribal law enforcement agencies.

Because of the increased threat of fentanyl, and the interagency focus on disrupting the fentanyl 

supply chain, CBP undertook a pilot program to train canines to detect fentanyl. Although training 

canines to detect synthetic drugs is a difficult undertaking, the CBP has already trained and fielded 

canines and placed them in critical locations in the United States to screen incoming parcels to 

indicate the presence of fentanyl and other synthetic opioids. Canine screening and detection, 

complemented by the deliberate targeting of shippers associated with fentanyl trafficking, has the 

potential to increase the likelihood that those containing illicit opioids are seized and removed 

from the supply chain.

The incredibly high volume of mail, fentanyl’s ability to be shipped in very small quantities, a low 

number of available automated detection systems, and the relatively small number of trained 

canines make intercepting fentanyl and fentanyl analogues at IMF’s monumentally difficult. 

26. The Commission recommends U.S. Customs and Border Protection (CBP) and the U.S. 

Postal Inspection Service (USPIS) use additional technologies and drug detection canines 
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to expand efforts to intercept fentanyl (and other synthetic opioids) in envelopes and 

packages at international mail processing distribution centers.

The sheer volume of international mail and IMF infrastructure make interdiction efforts focused 

on illicit opioids and other drugs a monumental task. One method to address this issue is the 

increased use of Advanced Electronic Data (AED). Federal regulation requires express package 

operators to transmit AED prior to package arrival in the United States. AED consists of electronic 

data about the particulars of each shipment such as sender/receipt names and addresses, contents 

and quantity. AED’s primary use is for advanced targeting for CBP inspections efforts. With AED, 

CBP can advance-target incoming shipments for additional examination based upon intelligence, 

prior violations, and other risk factors.

Over 90% of inbound international mail is sent from USPS’s top-volume trading partners. USPS 

now receives AED on inbound packages from 20 countries, including China. International mail 

services are not required by International law to transmit parcel information prior to arrival in the 

United States and many do not have the capability to do so even if required. However, international 

law requires nations establishing such requirements to ensure they can be met by all nations.

To this end, the Commission recommends support of the Synthetics Trafficking and Overdose 

Prevention (STOP) Act of 2016 or the STOP ACT of 2016, which amends the Tariff Act of 1930 

to make the Postmaster General the importer of record for non-letter class mail imported into the 

United States. The bill amends the Consolidated Omnibus Budget Reconciliation Act of 1985 to 

impose a duty of $1 on each item of non-letter class mail imported into the United States. The bill 

amends the Trade Act of 2002 to direct the Department of the Treasury to require the Postmaster 

General to provide for AED transmission to CBP of certain information on non-letter class mail 

imported into the United States.

27. The Commission recommends Congress and the Federal Government use advanced 

electronic data on international shipments from high-risk areas to identify international 

suppliers and their U.S.-based distributors.

28. The Commission recommends support of the Synthetics Trafficking and Overdose 

Prevention (STOP) Act and recommends the Federal Government work with the 

international community to implement the STOP Act in accordance with international 

laws and treaties.

DEA reports that diversion of licit fentanyl, either from theft or fraud, currently accounts for about 

2-3% of fentanyl-related overdose deaths. However, as government agencies and international 

partners achieve success disrupting the illicit fentanyl supply chain, there is high confidence that 

the licit fentanyl, as well as other prescription opioids, stock and supply chain will experience an 

increased risk of diversion. 

In 2011, Commission member Florida Attorney General Bondi fought for the passage of House 

Bill 7095 Florida Legislature, which aimed to regulate ‘pill mills’ by combating prescription drug 

diversion. Specific features of Florida’s legislation included adding new criminal penalties, 

requiring wholesale distributors to credential customers and report on distribution of controlled 

substances, as well as funding state Regional Drug Enforcement Strike Forces. Within 18 months 

of the legislation passage, Florida achieved the largest-by an order of several magnitude-year-onyear recorded drops in prescription drug overdose deaths in the nation.
65

At any point in the manufacturing, distribution, and prescription process, fentanyl, like other 

prescription opioids, can be diverted for illicit use. The nation should re-examine its current 

procedures to track the licit supply chain to prevent the diversion of precursor chemicals, partially 

processed product, and finished material in manufacturing facilities. Additionally, there are few 

mechanisms to track fentanyl and prescription opioid diversion once the drug is issued by a 

medical professional to a patient for consumption. One such method could be a requirement for 

the recipients and users of legally prescribed fentanyl to provide proof, such as empty transdermal 

patch envelopes or lollipop sticks to a pharmacist before receiving their refills. Another control 

initiative could be placing restrictions on dispensing fentanyl through the mail, or requiring that 

packages containing fentanyl or other opioids must be signed for by the recipient.

The DEA must be able to successfully disrupt the diversion of prescription opioid at any and all 

points in the supply chain.

29. The Commission recommends a coordinated federal/DEA effort to prevent, monitor and 

detect the diversion of prescription opioids, including licit fentanyl, for illicit distribution 

or use. 

Protecting First Responders from Harmful Effects Resulting from Exposure to 

Fentanyl and other Synthetic Opioids

The increased prevalence of fentanyl and other synthetic opioids in the illicit drug market requires 

law enforcement, fire, rescue, and emergency medical services (EMS) personnel to understand 

how to protect themselves from exposure to these substances. There have been reports nationwide 

of law enforcement professionals and EMS professionals experiencing opioid overdoses after

unknowingly coming into contact with fentanyl residue. Similarly, crime labs do not always have 

updated policies and procedures for dealing with potentially deadly substances such as fentanyl.

Currently, fear and misinformation regarding potential health concerns to first responders are 

hindering response efforts and increasing the risk to first responders. To make the environment 

more challenging, fentanyl can be present in a variety of forms (e.g., powder, tablets, capsules, 

solution, etc.).

At the state and federal level, there is no systematic method of tracking and examining reports of 

first responder opioid intoxication due to inadvertent exposure to fentanyl. Establishing uniform 

data collection and sharing protocols across states, including conducting confirmatory testing and 

collecting specific information about each incident of suspected first responder opioid intoxication, 

would assist the first responder community in validating and refining safety recommendations.

The White House convened and coordinated an interagency working group that included medical, 

public health, law enforcement, and EMS subject-matter experts to develop a set of scientific, 

evidence-based recommendations for first responders to protect themselves from the harmful 

effects associated with fentanyl exposure.

As noted in Appendix 4, the Fentanyl Safety Recommendations for First Responders are included 

in this report to maximize awareness.

The Commission commends the Federal Government for providing unified recommendations to 

frontline personnel. We also acknowledge the interagency working group for recognizing the value 
66

of incorporating feedback from stakeholder representatives from the medical, public health, 

occupational safety and health, law enforcement, and fire/EMS fields.

30. The Commission recommends the White House develop a national outreach plan for the 

Fentanyl Safety Recommendations for First Responders. Federal departments and 

agencies should partner with Governors and state fusion centers to develop and 

standardize data collection, analytics, and information-sharing related to first responder 

opioid-intoxication incidents.
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Opioid Addiction Treatment, Overdose Reversal, and 

Recovery

Drug Addiction Treatment Services

In the interim report, the Commission reported that the use of MAT has been associated with 

reduced overdose deaths, retention of persons in treatment, decreased heroin use, reduced relapse, 

and prevention of the spread of infectious disease. The Commission recommended several steps 

to increase the use of and access to all forms of SUD treatment, including MAT for SUDs, 

including removing the federal Institutes of Mental Diseases (IMD) exclusion within the Medicaid 

program, establishing a federal incentive to enhance access to MAT, and requiring regulators to 

take enforcement action against health plans that violate the Mental Health Parity and Addiction 

Equity Act (MHPAEA) (Appendix 3). The Commission also expressed support for the Overdose 

Prevention and Patient Safety Act/Protecting Jessica Grubb’s Legacy Act, and the need to update

patient privacy laws, such as 42 CFR Part 2, to ensure that information about SUDs are made 

available to medical professionals treating and prescribing medication to patients. Building off the 

previous recommendations, the Commission supports implementation of the steps outlined below 

to remove additional barriers and further improve access to and quality of drug addiction treatment 

services across the nation.

Increase Screenings and Referrals to Treatment through CMS Quality Measures

There is a great need to ensure that health care providers are screening for SUDs and know how 

to appropriately counsel, or refer, a patient that presents with an SUD.200 As Commission member 

Dr. Bertha Madras found in her analysis of a SAMHSA SBIRT program, training practitioners in 

hospitals and primary care settings in the SBIRT model can be effective in reducing rates of alcohol 

and illicit drug use. In this 2009 study, nearly 500,000 individuals were screened in six states 

across health care settings and those that demonstrated alcohol abuse and/or illicit drug use were 

given a brief intervention, brief treatment, or a referral to specialty treatment.201 A variety of 

screening tools were employed, and study sites had differences in population demographics and 

substance use rates; however, across all sites and demographics, self-reported substance use was 

less at six months after the initial screen and a brief or more intensive intervention. This research 

demonstrates the effectiveness of addiction screening in a health care setting, as well as the 

potential to better utilize primary care medical professionals in areas where there is a shortage of 

specialty treatment providers. 

There are opportunities to further the practice of substance use screenings and referrals through 

CMS quality measures. CMS has several quality measures throughout their programs (Medicaid, 

1115 demonstrations, Innovation Accelerator Program, Medicare, etc.) that could help further the 

practice of substance use screenings and referrals to treatment. The Federal Government, in 

coordination with the private sector, has a process through which measures are identified, specified 

and implemented to assure good patient health outcomes. All federal programs have different 

purposes and authorities and the selection of measures will vary to reflect those differences. At the 

same time, federal programs strive to adopt measures that will have strong reach without 

overwhelming providers with reporting requirements. There are currently several substance use 

measures being used in federal and private quality assurance programs, and many more under 
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consideration for adoption. However, measures are not deployed across all programs and, in some 

cases, do not address some of the gaps in care.

Quality measures for substance use screenings and referrals to treatment should address immediate 

treatment (24-48 hours) at all points of care for individuals in need of an assessment and treatment 

for OUD, including hospital induction of MAT, strengthening coordination of care and referral 

efficacy/improved treatment linkage, follow-up monitoring, and adoption of ‘hub-n-spoke’ models 

where specialty providers provide clinical support for primary care-based high need patients. High 

rates of co-morbidity with mental health disorders also warrant substance use screenings when a 

mental health diagnosis has been made.

31. The Commission recommends HHS, CMS, the Substance Abuse and Mental Health 

Services Administration (SAMHSA), the VA, and other federal agencies incorporate 

quality measures that address addiction screenings and treatment referrals. There is a 

great need to ensure that health care providers are screening for SUDs and know how to 

appropriately counsel, or refer a patient. HHS should review the scientific evidence on 

the latest OUD and SUD treatment options and collaborate with the U.S. Preventive 

Services Task Force (USPSTF) on provider recommendations.

Evidence-based Improvements to Treatment

Addiction is a chronic relapsing disease of the brain which affects multiple aspects of a person’s 

life. In addition to efforts to improve access to treatment, public policy should also seek to improve

the efficacy of treatment. Effective treatment must address the needs of the whole person to be 

successful. Research by NIDA outlines 13 principles upon which effective treatment programs and 

practices are built.202 Grounded in these principles, a growing body of evidence-based models 

guides the work of addiction treatment.203 Models demonstrating the greatest outcomes tend to 

incorporate behavioral, psychosocial, and pharmacological elements, if available,204 and are 

tailored to the individual client. The ability to adopt evidence-based models depends on provider 

ability to support skilled staff who are appropriately credentialed and/or licensed to implement 

necessary practices. Insurers and other payers can create pressure on treatment providers for a 

consistent, high-quality standard of care.

Treatment should include the following five elements:205

1. Complete evaluation for OUDs by a qualified medical professional including co-occurring 

other SUDs, psychiatric disorders, and medical disorders.

2. Access to MAT (e.g., methadone, buprenorphine/naloxone, naltrexone). Choice of medication 

should be made by a qualified professional in consultation with patient, and based on clinical 

assessment.

3. Simultaneous access to adjunctive psychosocial treatment that may include: group therapy, 

individual counseling, family therapy, relapse prevention, other psychosocial treatment. These 

services may be delivered in a variety of levels of care depending on what is clinically 

appropriate including inpatient, outpatient, intensive outpatient, residential, or partial 

hospitalization, depending on what is clinically appropriate for the client based on 

assessment.

206
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4. Treatment of co-occurring psychiatric disorders: The majority of patients with OUDs have cooccurring psychiatric disorders, especially trauma related disorders such as PTSD, depression, 

and anxiety disorders. Patients with OUDs who do not receive treatment for these mental health 

conditions generally have poor treatment outcomes.

5. Treatment of co-occurring medical conditions: Patients with OUDs may require treatment for 

the many medical conditions (e.g., cardiac, infectious, dermatologic, among others).

Connecting treatment to social supports, such as stable housing, employment/job training, 

education/vocational training, medical care, transportation, child care, etc. is also needed on an 

ongoing basis to help the individual be successful in their recovery and rebuild a lifestyle that is 

healthy and productive.207,208 Reports by the Agency for Healthcare Research and Quality (AHRQ)

at HHS endorsed process measures that emphasize treatment completion as key to achieving 

positive behavioral health outcomes. Similarly, the National Quality Forum, an organization that 

works to make improvements in healthcare, endorsed the adoption of process measures to count 

and increase the number of adults in MAT programs who receive at least 180 days of continuous 

treatment.209 Subsequently, services that facilitate client retention and engagement to at least 180 

continuous treatment days will improve client outcomes.

However, providers, practitioners, and funders often face challenges in translating such principles 

into practice to help individuals achieve positive long-term outcomes. Improving the quality of 

treatment programs will require increasing the number of skilled psychiatrists, medical 

practitioners, counselors, recovery coaches, and improving business practices of providers, which 

facilitates adoption of evidence-based practices such as MAT. Additionally, persons seeking care 

need user-friendly information on quality program and selection criteria to identify programs that 

match their needs. Use of evidence-based assessment tools and processes will help determine the 

appropriate level of care and configuration of services needed by the individual client. Adoption 

of ASAM’s patient placement criteria should guide referral to the appropriate setting, frequency, 

and duration of services.

32. The Commission recommends the adoption of process, outcome, and prognostic 

measures of treatment services as presented by the National Outcome Measurement210

and the American Society of Addiction Medicine (ASAM).

211 Addiction is a chronic 

relapsing disease of the brain which affects multiple aspects of a person's life. Providers, 

practitioners, and funders often face challenges in helping individuals achieve positive 

long-term outcomes without relapse.

Insurance and Reimbursement Barriers to Accessing MAT 

There are currently three FDA-approved medications for the treatment of OUD: methadone (an 

opioid agonist), buprenorphine (an opioid partial agonist) and naltrexone (an opioid antagonist). 

MAT for OUD is associated with decreases in opioid use, opioid-related overdose deaths, criminal 

activity, and infectious disease transmission, while improving social functioning and retention in 

treatment.212 Despite this, less than half of privately-funded SUD treatment programs offer MAT 

and only a third of patients with OUD at these programs receive it.213 Though rural areas have 

high rates of OUD, treatment options, including those that utilize MAT, are minimal.214

Furthermore, physicians that have the necessary training and DEA authorization to prescribe 

buprenorphine are limited in the number of patients they can treat.
70

There are commercial insurance barriers to MAT, such as dangerous fail-first protocols and 

onerous and frequent prior authorization requirements. Fail-first approaches require that a patient 

try counseling or other psychosocial approaches before being offered more intensive forms of 

treatment, or MAT. Families, consumers, and treatment providers have consistently identified 

these and other barriers to obtaining insurance coverage for opioid and other SUDs. These 

practices are not evidence-based and are not a tenable clinical protocol for individuals with OUDs, 

as they delay treatment and in doing so, open a window for renewed opioid use and potential death. 

Prior authorizations may also serve as a barrier, as they can take a significant amount of time and 

can disrupt the clinical ‘moment’ when a patient has finally agreed to try treatment. A 2017 survey 

of physicians indicated that prior authorization requirements by third party payers were the most 

commonly reported barrier to prescribing.215 In 2015, 48 Medicaid programs required prior 

authorization for buprenorphine.216 With addiction, the initial goal is to rapidly and immediately

engage a person in treatment. Rapid response is necessary to secure treatment before an individual 

goes into withdrawal and seeks drugs illegally in search of relief. 

In addition, CMS policies regarding MAT for Medicare recipients are complex and create barriers 

for Medicare patients seeking access to MAT. Methadone is covered under Medicare Part D when 

prescribed for pain, but not when given as part of an OUD treatment program. Some MAT 

reimbursements are part of a bundled payment for inpatient care, but it has come to the attention 

of the Commission that bundled payments can be a barrier to providers offering an array of services 

and medications. 

33. The Commission recommends HHS/CMS, the Indian Health Service (IHS), Tricare, the 

DEA, and the VA remove reimbursement and policy barriers to SUD treatment, 

including those, such as patient limits, that limit access to any forms of FDA-approved 

medication-assisted treatment (MAT), counseling, inpatient/residential treatment, and

other treatment modalities, particularly fail-first protocols and frequent prior 

authorizations. All primary care providers employed by the above-mentioned health 

systems should screen for alcohol and drug use and, directly or through referral, provide 

treatment within 24 to 48 hours.

Reimbursement rates for SUD treatment services are typically lower than those for other health 

conditions. Private and public insurers complain that they cannot find enough quality providers 

for their networks. The provision of SUD treatment, often in the form of counseling and 

psychosocial services, has a different business and service model than other health conditions. 

Lack of sufficient reimbursement impedes the ability of professionals and practices to implement 

high-quality and consistent care, including but not limited to the use of EHRs, the implementation 

of evidence-based practices, and the routine use of quality metrics. Moreover, the disincentives 

are so significant that many practitioners no longer take insurance, diminishing access to care even 

when there appears to be sufficient capacity. Such differential reimbursement strategies exist in 

the hospital setting as well. Hospital chemical dependency units, for instance, are paid lower rates 

than inpatient psychiatric facilities.

34. The Commission recommends HHS review and modify rate-setting (including policies 

that indirectly impact reimbursement) to better cover the true costs of providing SUD 

treatment, including inpatient psychiatric facility rates and outpatient provider rates. 
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Enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA)

Spearheaded by Commission member former Congressman Kennedy, MHPAEA aimed to build 

upon the patient protections enacted by the Mental Health Parity Act (MHPA) passed in 1996, 

which provided that large group health plans could not impose annual or lifetime dollar limits on 

mental health benefits that are less favorable than any such limits imposed on medical/surgical 

benefits. In other words, parity is a simple concept that requires health insurance plans to offer 

behavioral health coverage that is comparable, and equal to, the coverage for physical health. In 

reality, creating appropriate parity regulations, and enforcement of parity laws, is far from simple.

MHPAEA extended these parity requirements to SUDs, but legislation did not require large group 

health plans and health insurance carriers to cover mental health or SUD benefits. The Affordable 

Care Act changed this by requiring coverage of mental health and SUD services as an essential 

health benefit in individual and small group plans. 

However, while parity is a legal requirement, the existing means of monitoring and enforcing the 

parity act are insufficient. The sole means of enforcement under the parity act is equitable relief 

against the buyer of the insurance plan; and for the employer-based plans that are self-funding, 

DOL is presently permitted to enforce MHPAEA against only the employer, rather than the 

insurance company administering the benefits. The Commission heard from numerous 

organizations, such as the Parity Implementation Coalition, the Partnership for Drug-Free Kids, 

the National Council for Behavioral Health, Shatterproof, ASAM, and the American Academy of 

Addiction Psychiatry, about the need to systematically monitor and enforce MHPAEA to ensure 

parity in the coverage of mental health and addiction services.

MHPAEA has been the impetus for much progress towards parity for behavioral health coverage; 

plans and employers have, by and large, done away with policies that are clear violations; 

provisions such as dollar-limits, visit limits, and outright prohibitions on certain treatment 

modalities that exist only on behavioral health benefits. However, what remains are violations that 

are murkier and harder for regulators to discern, for example, non-quantitative treatment limits 

(NQTLs). These hurdles include medical necessity reviews that are more stringent on the 

behavioral health side than the medical/surgical side, limited provider networks, and onerous priorauthorization requirements. In reality, it is often difficult to discern when a behavioral health 

benefit is “on par” with a medical/surgical benefit as different care settings and diagnoses have 

different policies regarding benefits, providers, and authorizations. 

One goal of MHPAEA and other parity laws was to address cost-shifting from the commercial 

sector to the public sector for the financing of substance use and mental health treatment. 

Expanding the private sector share of expenditures could increase access to treatment for opioid 

and other drug use disorders. As of 2014, private cost-sharing did not increase in proportion to the 

private sector share of the insurance market. It financed only 18% of SUD treatment in 2014. 

Legislative changes providing DOL with the ability to impose a civil monetary penalty, such as 

those provided for violations of the Genetic Information Nondiscrimination Act (GINA), would 

encourage private insurance companies, and employers, to satisfy their legal obligations under 

MHPAEA and in turn, ensure they are adequately doing their part to address the country's opioid 

epidemic.

HHS has built an online portal to help individuals who have trouble accessing behavioral health 

services, including addiction treatment. This portal, available at https://www.hhs.gov/mentalhealth-and-addiction-insurance-help/index.html, directs individuals to different sites, including 
72

DOL, depending on the type of insurance coverage. The Commission applauds this project as well 

as the other activities of the Federal Mental Health and Substance Use Disorder Task Force in 

working towards public education and full parity compliance.

Building upon the recommendations provided in the interim report, the Commission believes the 

following actions will help to ensure parity violations do not impede access to substance use 

treatment.

35. Because the Department of Labor (DOL) regulates health care coverage by many large 

employers, the Commission recommends that Congress provide DOL increased 

authority to levy monetary penalties on insurers and funders, and permit DOL to launch 

investigations of health insurers independently for parity violations.

36. The Commission recommends that federal and state regulators should use a standardized 

tool that requires health plans to document and disclose their compliance strategies for 

non-quantitative treatment limitations (NQTL) parity. NQTLs include stringent prior 

authorization and medical necessity requirements. HHS, in consultation with DOL and 

Treasury, should review clinical guidelines and standards to support NQTL parity 

requirements. Private sector insurers, including employers, should review rate-setting 

strategies and revise rates when necessary to increase their network of addiction 

treatment professionals.

MAT in the Criminal Justice System

In the weeks following release from jail or prison, individuals with or in recovery from OUD are 

at elevated risk of overdose and associated fatality. MAT has been found to be correlated with 

reduced risk of mortality in the weeks following release and in supporting other positive outcomes. 

A large study of individuals with OUD released from prison found that individuals receiving MAT 

were 75% less likely to die of any cause and 85% less likely to die of drug poisoning in the first 

month after release.217 Compared to approaches that do not include FDA-approved medications, 

MAT for OUD is associated with better treatment retention,218 reductions in the spread of 

infectious diseases, such as HCV and HIV, and lower rates of criminal behavior.219,220,221,222,223,224

Despite the research evidence, a national survey of corrections staff in 14 states found very limited 

use of MAT. While 83% of prisons and jails offered some form of MAT, its use was limited mostly 

to detoxification or to maintenance treatment for pregnant women.225,226 One study found that 

nearly 60% of jail personnel surveyed strongly disagreed with the statement that their tax dollars 

should support methadone treatment. The same survey found that nearly 55% of jail security 

personnel agreed with the statement that “people who overdose on heroin get what they deserve.”

Twelve percent of jail health services staff shared this perspective. The authors noted that negative 

attitudes regarding MAT appeared to be related to negative judgments about drug users in general 

and heroin users in particular.227 While the National Institute on Corrections (NIC), the BJA, the 

National Association of Drug Court Professionals (NADCP), and other entities have made 

significant strides in educating correctional administrators and practitioners, much progress 

remains to be made.

Warranting special concern are pre-trial detainees involved in the criminal justice system. The 

population of pre-trial detainees is several times larger than the population of individuals sentenced 
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to jail. These individuals may be less likely to receive treatment and other services due to the fact 

that they may be released or transferred in a relatively short period of time. Increasing access to 

treatment, and especially MAT for OUD among these individuals is critically important. Doing so 

can save lives and reduce future public safety and public health costs associated with unchecked 

opioid addiction among these individuals.

37. The Commission recommends the National Institute on Corrections (NIC), the Bureau 

of Justice Assistance (BJA), the Substance Abuse and Mental Health Services 

Administration (SAMHSA), and other national, state, local, and tribal stakeholders use 

medication-assisted treatment (MAT) with pre-trial detainees and continuing treatment 

upon release.

Drug Courts and Diversion Programs 

There is evidence that a large majority of individuals who have an SUD do not receive treatment.228

Drug courts are a proven avenue to treatment for individuals who commit non-violent crimes 

because of their SUD. Drug courts have traditionally been a more effective response for nonviolent, low-level offenders with SUDs, rather than lengthy prison sentences. A systematic review 

of drug courts in 30 states published by the Campbell Collaboration in 2012 found that a 

combination of comprehensive services and individualized care is an effective way to treat 

offenders with serious addictions. However, 44% of U.S. counties in 2014 did not have a drug 

court for adults.229 The principal factors limiting drug court expansion are insufficient funding, 

treatment, and supervision resources, not a lack of judicial interest. The Commission heard from 

several organizations, including Advocates for Opioid Recovery, the Addiction Policy Forum, and 

Young People in Recovery, about the need to implement and oversee these problem-solving courts 

to create true ‘recovery ready communities.’

The U.S. Pretrial Diversion Program diverts certain individuals involved in the justice system for 

a first or second felony offence to a program of supervision and services administered by the U.S. 

Pretrial or Probation Services. The U.S. Attorney’s Office has the discretion to offer this alternative 

to eligible individuals. Under the program, diversion typically takes place before charging, 

although it is possible at any time before trial when a pretrial diversion agreement is executed. The 

period of supervision is up to 18 months. Drug, reentry, or veterans’ courts can be a central 

component of the pretrial diversion process. 

As of June 2015, the National Institute of Justice reported that there were 27 Federal District Courts 

that operated as drug courts as well as six federal veterans’ courts. Generally, Federal District 

Courts adopting the drug court model or similar approaches for diversion and/or reentry support 

are designated as Federal Reentry Courts. These courts can encompass pre- and post-adjudication 

diversion as well as post-incarceration reentry/recovery support. Federal reentry courts 

concurrently engage probation, parole, the Federal Public Defenders, and U.S. Attorneys' Offices. 

They utilize a blend of treatment and sanction alternatives to address behavior, rehabilitation and 

community re-integration for non-violent, offenders who are seeking recovery from SUD.

As a rule, Federal Reentry Courts make MAT available to individuals participating in pre- and 

post-adjudication diversion and post-incarceration reentry programs. Studies have shown that 

MAT recipients remain engaged in treatment at higher rates, have fewer positive tests for illicit 

drugs, and reoffend at lower rates than individuals with OUD not receiving MAT. For incarcerated 
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individuals, these courts typically incorporate an early-discharge program to replace the final year 

of incarceration with strictly-supervised release into the drug court regimen. Federal Reentry 

Courts adopting the drug court model incorporate the ‘Ten Key Components’ of a drug court 

program in a voluntary contractual program lasting a minimum of 12-18 months. Court program 

participants returning to the community from incarceration are transferred to traditional parole 

supervision following graduation. However, they may continue to receive case management 

services voluntarily through the reentry court.

Jurisdictions that run drug courts continue to innovate and adjust their programs and policies based 

on experience and in light of the current opioid epidemic. In Buffalo, NY, the court found that 

some arrestees were suffering fatal overdose between arrest and their formal entry into drug court. 

Therefore, they established the first Opiate Intervention Court in the country. This court 

temporarily suspends adjudication of charges in order to get those at high risk of overdose into 

treatment. The program is relatively new, but the initial results are promising and other 

jurisdictions should consider adopting a similar strategy.

38. The Commission recommends DOJ broadly establish federal drug courts within the 

federal district court system in all 93 federal judicial districts. States, local units of 

government, and Indian tribal governments should apply for drug court grants 

established by 34 U.S.C. § 10611. Individuals with an SUD who violate probation terms 

with substance use should be diverted into drug court, rather than prison.

Addiction Services Workforce and Training Needs

By the year 2025, workforce projections estimate that there will be a workforce shortage in the 

fields of substance abuse and mental health treatment of approximately 250,000 providers across 

all disciplines. Workforce needs include addiction psychiatrists, physicians specializing in 

addiction medicine, counselors, recovery coaches, and other behavioral health providers. There 

are simply too few physicians and other clinicians with the requisite training to meet the demands 

of the estimated 19.4 million Americans suffering from untreated SUDs. Expanding the workforce 

to meet treatment demand will require a comprehensive federal, state, local, public and private 

effort to develop the workforce pipeline. 

Opioid-related inpatient stays and ED visits have increased dramatically across the Nation.

230

 

Fourteen of the 18 states experiencing the highest rate of opioid overdose deaths have experienced 

an increase in opioid-related hospital admissions, ranging from 21.4% to 54.6%. Moreover, a 

recent analysis of private insurance data found that most privately insured patients do not receive 

recommended care following an opioid-related hospitalization.

231

Hospital programs are emerging across the country to address these surges in overdoses and 

improve post-discharge outcomes. One method has been the use of peer recovery coaches and 

other types of community health workers (CHWs), such as health educators, medical assistants, 

and community health outreach workers. The American Public Health Association defines a CHW

as a “frontline public health worker who is a trusted member of and/or has an unusually close 

understanding of the community served.” These workers are increasingly employed in physician 

offices and other health settings as care extenders. As such, they are uniquely positioned to be 

trained to provide substance use screening, brief intervention, referral management, and health and 
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community linkages in primary care and emergency room settings, and to provide outreach and 

care to substance using homeless populations. 

Peer recovery specialists/coaches are in recovery from an SUD. New programs are emerging 

across the country to use CHWs and recovery coaches in a range of settings, including hospitals, 

to provide immediate and ongoing support and treatment linkages to individuals who have 

overdosed from opioids, or support individuals newly in recovery. These programs can address 

alarming levels of readmissions due to overdose. In addition, recovery workers are supporting law 

enforcement, fire departments, and other community partners addressing the opioid overdose 

epidemic. The use of these types of care extenders can help address the workforce shortage, but 

more of them are needed.

Recovery coaches are often members of a recovery community organization (RCO), which can 

and do play unique rolls in helping individuals, families and communities respond to drug use, 

addiction, and their consequences; they are uniquely positioned to facilitate access to treatment, 

support retention and successful treatment completion, and provide ongoing services and support 

after treatment. Unfortunately, they exist in far too few communities. While states such as Vermont 

and Texas have developed and are expanding and enhancing statewide RCO networks, other states 

have no RCOs at all or only have RCOs in selected communities. RCOs play a critical role in 

engaging individuals addicted to opioids and other drugs, linking them to treatment and other 

needed services and supporting them as they pursue their recovery.

Integral in tackling this epidemic is the recognition that diverse communities experience different 

rates of mental disorders and/or SUDs, as well as challenges to treatment access. For example, in 

2016, the rate of illicit drug use in the last 30 days among American Indians and Alaska Natives 

ages 12 and up was 15.7%, the highest among all racial demography.

232 Research has shown that 

integrating culturally-based solutions into evidence-based treatment and recovery programs is a 

best practice and improves treatment outcomes. RCOs are best positioned to develop and 

implement culturally-specific ways to address the crisis in their communities.

RCOs are innovators and collaborators, working with hospitals, treatment providers, law 

enforcement, courts, corrections, child welfare systems, and broader communities to reduce drug 

use, and helping people achieve and sustain recovery. Their flexibility allows them to rapidly adapt 

to changing circumstances and to identify and fill gaps in systems and services. To maximize the 

benefit accrued from RCOs, federal efforts should help better integrate RCOs into local and 

statewide systems, services and sectors, such as Drug-Free Communities, HIDTA, correctional 

systems, law enforcement, hospitals, primary care, specialty treatment, and child welfare.

DOL has established an apprenticeship program for CHWs and recovery coaches with standard 

competencies, a curriculum, educational training, and on-the-job learning components, and 

routinely provides grants to augment the workforce. Through this program, employers provide a 

stipend for entry-level CHWs to receive on-the-job learning, on-site supervision, and educational 

training with the intent to secure employment as a credentialed CHW. Once an apprentice 

completes the CHW certification program, his or her name is registered into a DOL database, 

issued a certificate of completion, and is considered certified. The Presidential Executive Order 

Expanding Apprenticeships in America published on June 15, 2017 encourages federal agencies 

to fund and provide other supports to expand the use of CHWs to provide critically needed services 

across the country.233 Health entities such as hospitals and primary care offices can also sponsor 

training and employment.
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39. The Commission recommends the Federal Government partner with appropriate 

hospital and recovery organizations to expand the use of recovery coaches, especially in 

hard-hit areas. Insurance companies, federal health systems, and state payers should 

expand programs for hospital and primary case-based SUD treatment and referral 

services. Recovery coach programs have been extraordinarily effective in states that have 

them to help direct patients in crisis to appropriate treatment. Addiction and recovery 

specialists can also work with patients through technology and telemedicine, to expand 

their reach to underserved areas.

Estimates suggest there are currently about 4,400 actively practicing certified addiction specialist 

physicians (addiction medicine and addiction psychiatry) in the country, but data on the specialty 

workforce is limited. About 8 years ago, an estimate was made of the need for 6,000 addiction 

specialists, but that number is now insufficient given the growth of the opioid epidemic. 

Addiction medicine was only formally recognized as a medical subspecialty in 2016. Currently, 

46 of the Nation’s 160 accredited medical schools offer addiction medicine fellowships. The firstever addiction medicine board exam was held in September 2017. By 2021, fellowships will be 

the only pathway for physicians to take the addiction medicine certification exam. Without an 

adequate number of fellowships producing at least two new fellows per year, the field will quickly 

atrophy. Therefore, it is important to quickly ramp up the numbers of fellowships to address the 

opioid crisis. The goal is to grow the fellowships to 125 over the next five years. Significant 

funding is needed to start and sustain fellowship programs. 

The Health Resources and Services Administration (HRSA) provides unique vehicles for 

addressing the increasing trends in opioid use, overdose, and addictions across the United States. 

The agency funds health centers in urban, suburban, and rural areas, trains and strengthens the 

workforce, hosts the Federal Office of Rural Health Policy, and has grant programs for several 

high-need and underserved communities and populations. The 21

st Century Cures Act included 

funding for HRSA for addiction medicine fellowships starting in 2018. Starting this year, 

fellowships will be accredited by the Accreditation Council for Graduate Medical Education, 

which is a significant step toward getting funding from the VA and others.

Federal agencies should also be considering where telemedicine can play a role in ensuring access 

to care for those in geographically isolated regions and underserved areas.

40. The Commission recommends the Health Resources and Services Administration 

(HRSA) prioritize addiction treatment knowledge across all health disciplines. Adequate 

resources are needed to recruit and increase the number of addiction-trained 

psychiatrists and other physicians, nurses, psychologists, social workers, physician 

assistants, and community health workers and facilitate deployment in needed regions 

and facilities.

41. The Commission recommends that federal agencies revise regulations and 

reimbursement policies to allow for SUD treatment via telemedicine.

42. The Commission recommends further use of the National Health Service Corp to supply 

needed health care workers to states and localities with higher than average opioid use 

and abuse.
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Response to Overdose 

Expanded Access and Administration of Naloxone

Naloxone is an opioid antagonist medication that can rapidly reverse opioid overdose. It has been 

available for over forty years, has an excellent safety profile, and can be easily administered by 

either intravenous or subcutaneous injection or via nasal absorption. In the interim report, the 

Commission recognized the importance of ensuring naloxone is made as widely available as 

possible to save lives. Consequently, the Commission recommended that all law enforcement in 

the United States be equipped with naloxone, model legislation be provided to states to allow 

naloxone dispensing via standing orders, and ‘Good Samaritan’ laws be enacted to empower the 

public to seek help (Appendix 3). 

The Commission assessed the availability and accessibility of naloxone across the nation. Figure 

5 below shows the means at which the public can access naloxone in community pharmacies 

widely differs between the states. While there is not necessarily a naloxone supply shortage, price 

increases of the various forms of naloxone continue to create affordability issues, preventing state 

and local governments, as well as community organizations, from stocking naloxone at the levels 

necessary to rescue more people from overdose.

Figure 5. Naloxone Access (Source: National Alliance of State Pharmacy Associations)

To further ensure naloxone is made available when there is the greatest chance of an overdose, we 

must allow more first responders to be equipped with this life saving drug, including EMS

personnel. In 2007, the National Highway Traffic Safety Administration’s (NHTSA) issued its 
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National EMS Scope of Practice Model to provide guidance to states on the minimum skills and 

knowledge for licensure of each of four levels of EMS personnel; these four levels are:

• Emergency Medical Responder (EMR)

• Emergency Medical Technician (EMT)

• Advanced Emergency Medical Technician

• Paramedic

The Model suggests that the first two levels—EMR and EMT—not be approved for the 

administration of naloxone. Currently several states, following the NHTSA guidelines, prohibit 

EMRs and EMTs from administering naloxone in cases of opioid overdose. With the onset of the 

current opioid crisis, this prohibition has become problematic, especially in rural areas where the 

higher two levels—Advanced Emergency Medical Technician and Paramedic—are less common 

than in urban or suburban areas. Additionally, even in urban and suburban areas, EMS personnel 

in the two lower levels may be the first responders to incidents of opioid overdose. Given the 

critically narrow window that exists in which to administer naloxone to prevent overdose death, 

there may not be time to await arrival of higher level EMS personnel.

The Model has clearly become outdated with regard to its guidance on the ability to administer 

naloxone by EMS personnel in the two lower licensure levels, especially given the low risk of 

adverse effects of administering naloxone in either opioid overdose on non-opioid overdose 

conditions and the development of easily administered, pre-measured dose technologies. 

Furthermore, in New Jersey, Commission Chair Governor Christie recently directed his 

Administration to revise EMS guidelines to allow for higher doses of intranasal naloxone to be 

administered, as the initial guidelines allowed for 2 mg of naloxone, which proved insufficient for 

some of the stronger opioids like synthetic fentanyl. 

43. The Commission recommends the National Highway Traffic Safety Administration 

(NHTSA) review its National Emergency Medical Services (EMS) Scope of Practice 

Model with respect to naloxone, and disseminate best practices for states that may need 

statutory or regulatory changes to allow Emergency Medical Technicians (EMT) to 

administer naloxone, including higher doses to account for the rising number of fentanyl 

overdoses.

Combination opioid products, especially those co-formulated with naloxone (e.g., 

oxycodone/naloxone and or buprenorphine/naloxone) have been associated with lower rates of 

misuse and nonmedical use compared with their single-entity counterparts.234,235 In the interim 

report (Appendix 3), the Commission recommended a requirement that naloxone be prescribed in 

combination with any CDC-defined high-risk opioid being prescribed. Initial studies of the coprescribing of naloxone with high morphine equivalent narcotic analgesics suggest that coprescribing can reduce use and abuse of prescription opioids. The results from a 2016 study found 

a 47% reduction in opioid-related overdoses in the first six months after receipt of the 

prescription.236 Initial best practice guidance should be provided based on currently available data 

and, further, a federally-funded pilot project should be developed to confirm initial findings and 

clarify the most effective strategies related to co-prescribing.
79

44. The Commission recommends HHS implement naloxone co-prescribing pilot programs 

to confirm initial research and identify best practices. ONDCP should, in coordination 

with HHS, disseminate a summary of existing research on co-prescribing to stakeholders.

Overdose to Treatment and Recovery

Effectively linking individuals who have survived an opioid overdose and those at risk for 

overdose remains a challenge. However, several promising approaches are emerging. These 

include, but are not limited to:

• Buprenorphine induction in the ED or other hospital departments followed by linkage with 

primary care and psychosocial services;

• Methadone induction for hospitalized patients followed by direct linkage to an opioid 

treatment program (OTP); 

• An opioid urgent care unit adjacent to an ED that provides care coordination and linkage 

to office-based opioid treatment and psychosocial services; 

• Overdose prevention training and naloxone distribution in the ED and other hospital 

settings;

• Post-overdose ED-based engagement, service linkage, and ongoing support and service 

coordination by recovery coaches and other peer workers who are on-call 24 hours per day, 

365 days per year; 

• Co-location of recovery coaches and other peer recovery support services workers at opioid 

treatment programs and primary care practices providing buprenorphine for the treatment 

of OUD;

• Community outreach and engagement of opioid users, their friends, and family by recovery 

coaches and other peer workers; and,

• Specialty bedside care for hospitalized patients from an inpatient addiction consult team.

In hospital settings, immediate engagement and initiation of treatment with an FDA-approved 

medication and/or recovery support services while the patient is still in the ED or is still in an 

inpatient hospital setting is critically important to increasing the number of Americans with opioid 

addiction who access treatment, decreasing overdose rates and related fatalities, and gradually 

lessening the burden the opioid crisis is creating for first responders, hospitals, and communities 

as a whole. To increase treatment participation, retention, and improve long-term recovery 

outcomes, a combination of clinical and recovery support services is necessary.

EMTALA requires EDs to stabilize and treat emergency medical conditions regardless of the 

patient’s ability to pay. Medical stabilization language exists in other regulations as well. The 

general stabilization requirement is to resolve acute symptoms to avoid serious jeopardy to patient 

health. In the case of an individual with an OUD who has been revived after an overdose, initiation 

of MAT is often required to stabilize the patient prior to discharge. In addition, appropriate “health 

extenders,” such as CHWs and recovery coaches, are also required to provide treatment 

engagement and follow-up services. Many emergency rooms and hospitals do not have sufficiently 

trained staff to diagnose an OUD or to provide the range of MAT and psychosocial services that 
80

are needed to stabilize individuals. Thus, many overdose patients are being released without being 

appropriately stabilized and are at very high risk for subsequent overdose readmissions.

45. The Commission recommends HHS develop new guidance for Emergency Medical 

Treatment and Labor Act (EMTALA) compliance with regard to treating and stabilizing

SUD patients and provide resources to incentivize hospitals to hire appropriate staff for 

their emergency rooms.

Recovery Support Services

Over the past decade or more, recovery has re-emerged as a key area of policy, practice, and 

advocacy. Recovery has many definitions. SAMHSA defines recovery from mental and SUDs as 

a process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Recovery support services (RSS) are nonclinical services designed to help individuals navigate the early stages of recovery and achieve 

stable, long-term recovery. Several organizations and programs exist to provide a structured and 

supportive environment for people in long-term recovery and are an emerging infrastructure with 

approximately 100 national organizations. However, national standards delineating the essential 

components, as well as financing and operation of state and local RSS, do not exist. The RecoveryOriented Systems of Care framework identifies relevant values, principles, and strategies. It can 

be used as a starting point for development of standards.

While national peer RSS organizational accreditation standards have been developed and 

implemented by the Council on Accreditation of Peer Recovery Support Services, and national 

peer recovery support services specialist certifications have been developed by the two largest 

certification bodies in the addictions arena, states have not uniformly adopted these standards.

Similarly, while the National Alliance for Recovery Residences has developed recovery housing 

certification standards that recognize levels of recovery housing, ranging from homes leased and 

operated by the residents (e.g., Oxford Houses) to residences with linked to clinical services, 

substandard recovery housing/sober living homes remains a problem in many jurisdictions.

46. The Commission recommends that HHS implement guidelines and reimbursement 

policies for Recovery Support Services, including peer-to-peer programs, jobs and life 

skills training, supportive housing, and recovery housing.

Impact on Families and Children

Addiction impacts each member of a family, affecting each member differently, but the most 

vulnerable are children. Children whose parents have an OUD may be neglected or even require 

removal to foster care. The developing fetus is vulnerable to substance use by the pregnant mother, 

as drugs readily cross the placenta and enters fetal blood circulation. 

The opioid epidemic has impacted many states with increases in the number of children who have 

entered foster care due to parental drug use. Child welfare agencies have seen an increase in their 
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caseloads and are burdened with limited resources, e.g., funds to support drug treatment or 

parenting classes and community-based support for these children. 

Stakeholders in the child welfare arena must collaborate to identify best practices to support 

families and intervene sooner. Successful treatment for parents can take multiple attempts and 

requires varied support from many agencies and community-based groups (e.g., treatment 

providers, counseling, supportive housing, drug courts, parenting classes, and transportation). 

Once a child enters foster care, the time frame for reunification with their parents or the termination 

of their parental rights begins. While this varies state by state, due to the scope of the problem it 

is critical that social workers and child protection staff are equipped to identify substance use early. 

In New Jersey, Commission Chair Governor Christie announced in September 2017 that the state’s 

Department for Children and Families would be addressing these issues in a multi-prong approach; 

training Child Protection workers in SUDs, creating a program of peer-support for parents 

involved with the child welfare system, and increasing the investment in supportive house 

(“Keeping Families Together” program) for families involved in the child welfare system that 

experience parental SUD and housing instability. 

Children who are in foster care are at greater risk for mental health problems, poor physical health, 

experience more adverse family experiences and more likely to be suspended from school.237

The number of children experiencing NAS increased 383% during the period 2000-2012 (1.2 cases 

per 1000 hospital births in 2000 to 5.8 cases per hospital births in 2012).

238

 To address the number 

of children born with NAS, the passage of the Comprehensive Addiction and Recovery Act 

(CARA) of 2017 has modified state requirements related to how states must address SUDs, NAS 

and Fetal Alcohol Syndrome. Section 503 of CARA recommends that states implement a plan of 

safe care, yet the requirement does not identify a lead agency to oversee and ensure its 

implementation which continues to ensure a gap in leadership on this issue.

47. The Commission recommends that HHS, the Substance Abuse and Mental Health 

Services Administration (SAMHSA), and the Administration on Children, Youth and 

Families (ACYF) should disseminate best practices for states regarding interventions and 

strategies to keep families together, when it can be done safely (e.g., using a relative for 

kinship care). These practices should include utilizing comprehensive family centered 

approaches and should ensure families have access to drug screening, substance use 

treatment, and parental support. Further, federal agencies should research promising 

models for pregnant and post-partum women with SUDs and their newborns, including 

screenings, treatment interventions, supportive housing, non-pharmacologic 

interventions for children born with neonatal abstinence syndrome, medication-assisted 

treatment (MAT) and other recovery supports.

Supporting Collegiate Recovery and Changing the Culture on College Campuses

When American parents send their high school graduates to college, often at huge financial 

sacrifice, they hope to launch their children in pursuit of their American dream. Unfortunately, too 

many students get caught up in drug use and binge drinking, putting both their health, academic, 

extracurricular, and future prospects at risk. Many of these young people are unable to complete 

their studies. When they do achieve recovery, they are faced with the challenge of returning to the 

lion’s den—a college or university campus where alcohol misuse and drug use may be the norm 
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for large portions of the student body. It is not surprising that researches have characterized higher 

education campuses as “abstinence-hostile environments.” As more young people find recovery 

in their teens, they and their parents face the similar challenge of identifying a college or university 

that will not put their recovery at risk. 

In face of this a growing number of colleges and universities have established collegiate recovery 

programs (CRP). These programs offer support and assistance to students in recovery and to 

students seeking help for alcohol and other drug problems. To join, some CRP’s require treatment 

completion and/or a specified period of abstinence coupled with mutual aid participation while 

others are open to any student who believes they have an alcohol or other drug problem or who 

simply wishes to be part of a community for which alcohol or other drug consumption is not a part 

of social and recreational activities. Some CRPs provide a dedicated dorm or recovery residence 

for members and others do not.

Rutgers University, New Jersey’s flagship state university system has the longest-running CRP in 

the nation. The Rutgers CRP began in 1983, with dedicated housing added in 1988. For the student 

residents, the program provides recovery support, a substance-free living environment, and a 

variety of extracurricular and enrichment activities such as outings and intramural sports. Students 

are expected to attend two 12-step meetings each week, and meetings are offered on campus. 

Rutgers staff regularly provides assistance to colleges and universities around the country who are 

looking to create or improve programs on their campuses. 

To further these programs, New Jersey has passed legislation requiring all state colleges and 

universities with a significant portion of students living on-campus to have dedicated substancefree housing for students who wish to live in a substance-free environment. 

CRPs are relatively small and inexpensive, and provide significant benefits to schools by 

encouraging degree completion, reducing drop outs, and promoting the health and safety of 

students. Programs vary, but they commonly include the following components: a coordinator or 

executive director and small staff; student volunteers; a gathering place, such as a recovery lounge, 

for students to drop by and support each other and for events; academic advice for those seeking 

to return to or stay in school; scholarships for those in need who are in recovery and maintain good 

grades; sponsorship of drug and alcohol free events open to all students on campus; leadership, 

professional development, and other opportunities to speak out about effective solutions to drug 

and alcohol problems.

In addition to helping students in recovery flourish and succeed academically, CRPs offer an 

attractive campus community for students who are not in recovery, but wish to avoid alcohol and 

other drugs. Through their alcohol- and other drug-free events, including football game tailgates 

and parties, movies, restaurants, music, and theater outings, they offer safer and healthier 

alternatives not only for members, but for a range of other students. While the number of collegiate 

recovery programs has grown significantly over the past decade, it has been estimated that only 

3% of higher education institutions in the United States currently have a CRP.239

Although most of the costs associated with CRPs should be financed by the colleges themselves, 

government agencies can take some modest steps to accelerate adoption of these programs, as 

highlighted below. 

48. The Commission recommends ONDCP, the Substance Abuse and Mental Health Services 

Administration (SAMHSA), and the Department of Education (DOE) identify successful 
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college recovery programs, including "sober housing" on college campuses, and provide 

support and technical assistance to increase the number and capacity of high-quality 

programs to help students in recovery.

Employment Opportunities for Americans in Recovery

Americans who are in stable recovery from addiction deserve fair consideration for any job for 

which they are qualified. There are millions of Americans in recovery from all walks of life. Many 

of these individuals have past misdemeanor or felony drug-related criminal convictions that can 

impede or prevent them from securing employment for which they are qualified, even after having 

paid their debt to society and having achieved decades in recovery. When this occurs, it is not only 

those individuals who pay a price; their families and communities can be deprived of contributions 

these Americans might otherwise have been able to make. Laws and rules that impede or prevent 

employment for people in recovery can be counterproductive, making it more difficult to fully 

rejoin the community and sustain a life in recovery.

In addition to the barriers created by having a past criminal conviction, those in recovery can face 

long-lasting barriers to employment due to laws that prohibit the hiring of individuals with a past 

drug conviction in certain settings. For example, Section 1128 of the Social Security Act prohibits 

any entity receiving funding under federal health programs, such as Medicaid, Medicare, CHIP, 

TRICARE, or the VA, to employ individuals who have past felony convictions “relating to the 

unlawful manufacture, distribution, prescription, or dispensing of a controlled substance” (unless 

that conviction was related to an act that took place before the enactment of the Health Insurance 

Portability and Accountability Act of 1996) [42 U.S.C. 1320a–7 (4)]. This ban includes individuals 

with felony convictions related to the sale of illicit drugs outside of the context of a health care 

facility and covers not only health professionals, but all categories of staff, including custodians, 

drivers, administrative support staff, building engineers, mailroom personnel, etc.

Known as collateral consequences of conviction, laws of this kind apply restrictions to individuals 

that continue after they have completed their sentences. These laws can be found at the federal, 

state, and local levels. Collateral consequences of conviction can serve an important public safety 

function. However, to the extent that they impede successful recovery or reentry from incarceration 

without contributing significantly to public safety, they have the potential to actually undermine 

public safety, public health, and drug control policy goals. Under an award from DOJ, the 

American Bar Association created a publicly available comprehensive searchable online database 

cataloguing over 45,000 collateral consequences and civil disabilities and identifying remedies in 

instances where they are available.240,241

Ultimately, private sector employers are well positioned to play a central role in supporting the 

hiring and ongoing employment of those in recovery, identifying rules and laws that may impede 

hiring people in recovery, and increasing treatment access for employees with active addiction.

Employment for those with past drug use is a critical part of the solution to this drug crisis. The 

State of Florida has decoupled felony convictions and eligibility for certain business or 

occupational licenses with great success, expanding access to the wide arrays of jobs with licensing 

requirements.
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49. The Commission recommends that ONDCP, federal partners, including DOL, large 

employers, employee assistance programs, and recovery support organizations develop 

best practices on SUDs and the workplace. Employers need information for addressing 

employee alcohol and drug use, ensure that employees are able to seek help for SUDs 

through employee assistance programs or other means, supporting health and wellness, 

including SUD recovery, for employees, and hiring those in recovery.

50. The Commission recommends that ONDCP work with the DOJ, DOL, the National 

Alliance for Model State Drug Laws, the National Conference of State Legislatures, and 

other stakeholders to develop model state legislation/regulation for states to decouple 

felony convictions and eligibility for business/occupational licenses, where appropriate.

Support Recovery Housing

There is a critical shortage of recovery housing for Americans in or pursuing recovery. Recovery 

residences (also known as “sober homes” or “recovery homes”) are alcohol- and drug-free living 

environments for individuals seeking the skills and social support to remain free of alcohol or other 

drugs and live a life of recovery in the community. Generally, recovery residences do not offer 

treatment, although some are affiliated with, or are arms of treatment provider organizations that 

offer counseling or other services to residents, onsite or at a nearby location. Recovery residences 

strongly encourage attendance at 12-step groups or other mutual aid groups (e.g., SMART 

Recovery, Women for Sobriety, Celebrate Recovery, etc.) and are generally self-funded through 

resident fees, or in the case of Oxford Houses or other resident-run homes, shared rent, utility, and 

food payments. Benefits associated with staying in a recovery residence include decreases in 

alcohol and drug use, psychiatric symptoms, and arrests as well as increases in employment.242

Recovery residences can play a critical role for individuals in outpatient treatment, those exiting 

residential treatment, homeless individuals in early recovery, those involved in drug courts, those 

returning to the community from incarceration, and those who may not require residential 

treatment if they have a living environment that is supportive of recovery, outpatient treatment 

and/or mutual aid groups. Many who cannot return to a home where there is active drug use or a 

community where they used drugs find a safe haven in a recovery residence. Importantly, like peer 

RSS generally, recovery residences can help maximize the public and private investments in 

treatment by ensuring better long-term outcomes, by sometimes making a lower, less costly level 

of care possible and, in some instances, by making treatment unnecessary. 

Unfortunately, unethical operators have cast suspicion on recovery residences generally and have 

complicated the efforts of families, treatment centers, and court systems to identify safe, 

supportive, well run, and affordable recovery housing. Quality recovery residences operate in 

accordance with accepted national guidelines, such as the standards developed by the National 

Alliance for Recovery Residents (NARR) or the charter Oxford Houses must follow. Residences 

that do not meet these or state-established standards can place those they serve at risk. While some 

states have defined recovery residence licensing criteria and or required their treatment providers 

to only refer patients to certified recovery residences and Oxford Homes, many have no

mechanism for ensuring quality and accountability. 

51. The Commission recommends that ONDCP, federal agencies, the National Alliance for 

Recovery Residents (NARR), the National Association of State Alcohol and Drug Abuse 
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Directors (NASADAD), and housing stakeholders should work collaboratively to develop 

quality standards and best practices for recovery residences, including model state and 

local policies. These partners should identify barriers (such as zoning restrictions and 

discrimination against MAT patients) and develop strategies to address these issues.
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Research & Development

For too long addiction and pain research have been conducted and led by separate research 

communities and suffered from silos and in some cases excessive pressure from industry at the 

cost of patient health. The National Drug Control Strategy has never included a pain management 

emphasis despite the fact that prescription opioid misuse still is responsible for most opioid misuse 

in this country and providing better pain management is essential to preventing prescription opioid 

misuse and diversion that starts so many people down the path to heroin use. Several federal 

agencies are best suited for shepherding research initiatives and opportunities to combat the 

epidemic243 and enhance treatment options, including alternative pain management strategies, and 

treatment for vulnerable populations such as pregnant women, and substance-exposed infants. 

Addressing the gaps with basic, applied research, and development can conceivably expand the 

range of alternatives to imperfect medications currently used to mitigate pain or treat addiction. 

52. The Commission recommends federal agencies, including HHS (National Institutes of 

Health, CDC, CMS, FDA, and the Substance Abuse and Mental Health Services 

Administration), DOJ, the Department of Defense (DOD), the VA, and ONDCP, should 

engage in a comprehensive review of existing research programs and establish goals for 

pain management and addiction research (both prevention and treatment).

New Pain, Overdose, and MAT Medications

The bounties of scientific research are essential to mitigate the opioid crisis, drug addiction and 

associated morbidity and mortality. The most practical basic research goals for the current 

epidemic244 are to develop: (1) effective analgesics with limited or no abuse liability, i.e. 

alternatives to opioids; (2) drugs to reverse overdose capable of surmounting newly emerging 

fentanyl analogs or new psychoactive opioids; and (3) medications that do not engender abuse 

liability or physical dependence to assist in treating opioid addiction. Each of these areas requires 

short-, intermediate-, and long-term research strategies. The research goals have been charted and 

led by the NIDA Director, with support and coordination among the NIH institutes and the NIH 

Director. NIH has also recruited pharmaceutical companies to develop public-private partnerships

in pursuit of these goals. This initiative offers great promise to improve the range of choices for 

pain management, medications assistance, and overdose reversal. As an example, a NIDA 

partnership with a pharmaceutical company successfully developed a user-friendly intranasal 

naloxone formulation that results in blood naloxone levels equivalent to those reached with 

injection. The FDA approved it in 2015.

Alternatives to Opioid Pain Medications. μ-opioid signaling is among the most effective system 

to dampen or block pain. The same system also produces pleasurable sensations, even euphoria 

which drives addictive behaviors. For over a century, medicinal chemists have pursued safer 

opioids to disconnect pain relief from pleasurable sensations. Opioid over-prescribing in part 

reflects the limited number of effective medications to treat moderate to severe pain and the 

compelling need for alternatives. Among the candidate solutions are development of abusedeterrent formulations, new opioids that trigger “biased” μ-signaling pathways, or target other 

opioid receptors subtypes, or drugs that modify other receptors, and ion channels involved in 
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processing or modifying pain sensations, including transient receptor potential vanilloid (TRPV) 

channels, non-psychoactive cannabinoids, inflammatory pathways, or other modifiers of signaling 

pathways.

Novel therapeutics are also likely to emerge from a better understanding of pain biology, enabled

in part by transformative technologies such as the ability to solve the three-dimensional crystal 

structure of target proteins or assess pharmacology by computer simulations. Adoption of other 

transformative technologies, including induced stem cells and CRISPR, can result in more efficient 

validation of novel compounds through the development of models with better translational 

fidelity. Clinical studies can also be improved by patient selection and stratification.245 

Overdose Reversal Interventions. Over 140 Americans die daily from opioid overdoses. The 

primary reason is that overactivated μ-opioid receptors in brainstem neurons stop natural 

breathing. Naloxone targets the μ-opioid receptor, but unlike oxycodone, heroin, or fentanyl,

instead of activating it, it prevents it from functioning and reverses and overdose, if administered 

in sufficient time. It has saved thousands of lives, but is ineffective if the person overdosing is 

alone during a narrow window of time, or if requiring multiple doses to surmount a highly potent 

opioid.

246 This new challenge is reflected in the rapid rise in overdose fatalities driven by the highly 

potent drug fentanyl, or even more potent fentanyl analogs. Private partnerships are engaging with 

NIH to develop higher affinity longer-acting formulations of antagonists, including naloxone, to 

counteract the very-high-potency synthetic opioids that are now claiming thousands of lives.

Treatments for Opioid Addiction. Research and development are needed to improve the range of 

medications to assist in treating OUD. Currently, three medications are approved for treating 

OUD: methadone, buprenorphine, and ER naltrexone. Along with psychosocial support, they 

comprise the current standard of care for reducing illicit opioid use, relapse risk, and overdoses, 

while improving social function.247 Each of these medications has important strengths, but some 

shortcomings. Methadone is full agonist at the μ-opioid receptor, while buprenorphine is a partial 

agonist. Both methadone and buprenorphine can be reinforcing and thereby diverted, unlike 

naltrexone which, like naloxone, blocks the receptor. Compliance with treatment is higher with 

methadone than with buprenorphine or naltrexone,248 but overall success in abstinence is 

imperfect.249 There is a clear need to develop new treatment strategies for OUDs, including new 

pharmacologic approaches that focus on modulating activity of the reward circuit through other 

targets (e.g. neurokinin-1 receptor antagonists or κ-opioid receptors antagonists). Other target 

receptors and vaccines to prevent brain entry of opioids are under investigation.

Over a longer time-frame, prevention and treatment of opioid addiction will require more exquisite 

knowledge of the mechanisms underlying pain, reward, loss of control, and how biological and 

social factors shape the attractiveness of opioids. Treating chronic pain while avoiding misuse is 

problematic for patients with a prior history of SUD, and more research conceivably will reveal 

the degree of risk for OUD when people with serious pain are undertreated. Other research voids 

include brain research imaging of people who overdose one or more times. Recent reports have 

documented cases of amnesia after an overdose. The extent to which opioids cause significant and 

possibly irreversible brain damage warrants investigation. 

53. The Commission recommends Congress and the Federal Government provide additional 

resources to the National Institute on Drug Abuse (NIDA), the National Institute of 

Mental Health (NIMH), and National Institute on Alcohol Abuse and Alcoholism 

(NIAAA) to fund the research areas cited above. NIDA should continue research in 
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concert with the pharmaceutical industry to develop and test innovative medications for 

SUDs and OUDs, including long-acting injectables, more potent opioid antagonists to 

reverse overdose, drugs used for detoxification, and opioid vaccines.

Medical Technology Devices

Research and development in new technologies/devices to assist in the opioid crisis are emerging. 

Their development should be encouraged. A few examples are offered, with a caveat that few have 

received FDA approval, while others are in various stages of research and development and have 

yet to undergo FDA scrutiny or even be sufficiently developed for clinical trials.

• Detection of real-time substance use is a critical step for optimizing behavioral 

interventions and feedback to prevent drug abuse. Traditional methods based on selfreporting or rapid result urine screening are inefficient or intrusive for drug use detection, 

and inappropriate for timely interventions. Methods for real-time substance use detection 

are severely underdeveloped. A new real-time drug use event detection method is being 

developed that uses data obtained from wearable biosensor. Biosensors are designed to 

detect and establish thresholds of parameters in a real-time drug use event and to produce

wearable biosensor data streams.250

• Wearable devices that sense respiratory depression (rings, ear pieces) that can alert the 

user, a family member, or wirelessly report to a first responder to intervene, or 

automatically inject naloxone when blood oxygenation levels become dangerously low.

• Apps on electronic devices (phones, watches) that can function as behavioral coaches and 

reminders.

• Technology devices that transmit findings from smartphones directly into the medical 

record.

• In home monitoring of vital signs with transmission capability

• Transcranial magnetic stimulation (TMS) for treatment of pain.

• Monitoring appropriate consumption/compliance with medications that contain a 

transmitter to relay a signal as soon as a drug enters the digestive system. A similar 

transmitter can be adapted for naloxone use. 

• Behavioral monitoring feedback apps that can be as, or more effective than face-to-face 

behavioral training for addiction.

• Pain reduction devices such as subcutaneous field stimulators, dorsal column stimulators, 

dorsal root ganglion stimulators, multifidus muscle stimulators, implantable infusion 

pumps, and sensory cortex stimulators.

• Detection of drug consumption use (drugs/metabolites) in neighborhoods using a waste 

water collection system positioned in drains within small regions (two block radius) to 

identify hot zones of distribution and/or use. 

54. The Commission recommends further research of Technology-Assisted Monitoring and 

Treatment for high-risk patients and SUD patients. CMS, FDA, and the United States 

Preventative Services Task Force (USPSTF) should implement a fast-track review 
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process for any new evidence-based technology supporting SUD prevention and 

treatments.

55. The Commission recommends that commercial insurers and CMS fast-track creation of 

Healthcare Common Procedure Coding System (HCPCS) codes for FDA-approved 

technology-based treatments, digital interventions, and biomarker-based interventions. 

NIH should develop a means to evaluate behavior modification apps for effectiveness.

FDA Post-Market Research and Surveillance Programs

The FDA is a key federal agency designed to safeguard public health and safety, including opioids. 

Of all the drugs approved by the FDA, opioids are causing more illnesses and deaths than any 

other drug class currently on the market. FDA’s timeline of regulatory oversight of opioids from 

1911-onward shows a rapid expansion of approval of opioids starting in the mid-1990’s and 

continuing to this day. In 2001, as concerns of addiction and overdoses emerged, the FDA took 

steps to develop public education regarding prescription drug abuse, packet inserts for patient 

education, and stronger warnings. Other discrete steps taken to rein in their adverse consequences 

proved equally ineffective.251 

In 2016, the FDA once again initiated assessment and implementation of its policies to constrict

unfettered prescribing practices. These policies included expanded use of advisory committees, 

development of warnings and safety information for IR opioid labeling, strengthening postmarketing requirements, updating the Risk Evaluation and Mitigation Strategy (REMS) Program

that requires sponsors to fund continuing medical education to providers, at low or no cost, on 

appropriate use of opioids, expanding access to abuse-deterrent formulations to discourage abuse, 

and reassessing the risk-benefit approval framework for opioid use.252 In 2017, the FDA brought 

IR opioids under its REMS program authorities, along with ER long-acting opioids; however, 

prescriber education in this program is currently optional for prescribers. Currently, more than 20 

opioid analgesic formulations are approved by the FDA and an additional 52 applications for 

approval are being considered.253

The evidence base to guide the use of opioid medications, particularly in the setting of long-term 

use, is substantially lacking. Over decades, opioids were approved by the FDA with two significant 

gaps in vigilance: lack of concern of misuse, tampering, and diversion from a legitimate 

prescription and inadequate post-market surveillance of efficacy for long-term use, addiction, and 

other long-term consequences (e.g. depression or transition to heroin). The FDA is strengthening 

the requirements for drug companies to generate post-market data on the long-term impact of using 

ER/long-acting opioids and accumulate better evidence on the serious risks of misuse and abuse 

associated with long-term use of opioids, predictors of opioid addiction, and other important 

issues.

56. The Commission recommends that the FDA establish guidelines for post-market 

surveillance related to diversion, addiction, and other adverse consequences of controlled 

substances.
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Conclusion

The origins of the current opioid crisis can be traced to a sequence of at least twelve converging 

events and movements that catalyzed the most devastating drug epidemic in our nation’s history. 

A five-sentence letter to a biomedical journal in 1980, followed by other low-quality articles 

claiming that opioid narcotics are safe to use universally for chronic pain, bolstered advocacy by 

pain patients and professional societies to treat pain with opioids. It also instigated the opioid 

pharmaceutical industry to embrace and exploit the flawed claims with aggressive marketing and 

“educational outreach.” Government agencies and accreditation organizations then designated 

pain as a fifth vital sign. Without a counterbalancing force appearing in the medical community to 

question the evidence or conclusions, pain assessment became a preoccupation of healthcare 

practices and opioid prescribing became an accepted solution. 

Prescriptions for opioids surged, now fueled by financial and performance pressures on physicians 

to satisfy patients using opioids, insurers’ unrestrained reimbursements for opioids, an insufficient

response of federal regulators, and lack of public unawareness of the hazards of this class of drugs. 

Poor medical education on pain management, on opioid prescribing, and on screening for high risk 

patients undermined the ability of conscientious physicians to safely treat pain or addiction. 

A nation awash with prescription opioids became fertile ground for diversion by acquisition from 

medicine cabinets, through rogue pharmacies, rogue physicians, and for opportunistic sellers of 

illicit heroin, fentanyl, and other deadly opioids. The Commission has reflected on this history, for 

it is a compelling source for solutions to contain this national nightmare, solutions that are complex 

and multi-dimensional.

By the very nature of our federal-state-local governance, most solutions require responses at all

levels of government. Some need the cooperation and the support of private institutions, such as 

commercial insurers, companies engaged in data analytics, academic institutions, or individuals 

who have inadvertently contributed to this crisis. Unintentional contributors to the crisis are 

recognizing earlier missteps and devising strategies to ‘reverse engineer’ decisions with prudence.

The goals of the recommendations included in this report are to promote prevention of all drug use 

with effective education campaigns and restrictions in supply of illicit and misused drugs. To 

achieve supply reduction, we recommend shaping prescribing practices by improved medical 

education, by alternatives to pain management, as appropriate, by enhancing physician awareness 

of high risk patients though substance use, mental, and medical screenings and interrogation of 

PDMPs, insurance company oversight, and by interdiction of deadly opioids. Treatment and 

overdose rescue are both distinct and inextricably linked efforts. Overdose rescue procedures need 

to be opportunistic and include access to trained personnel, to medications, and to treatment 

services. Administering naloxone to a person who has overdosed and then abandoning them 

without offering medication and same-day entry to treatment is short-sighted and inadequate.

Treatment services need to be improved, foremost by developing thoughtful national evidencebased standards of care, record-keeping, and long-term support. In view of the need, expansion of 

services is imperative and so are surmounting barriers – to medications, limited healthcare 

workforce, to insurance reimbursement – and ensuring high-quality care and long-term recovery 

support services. 

The Commission strongly supports research and development of alternatives to opioids for pain 

management, treatment and rescue, and of modern medical devices essential to improving our 
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responses. The Commission also strongly recommends real-time data analytics to inform our 

mission and accomplishments. Above all, each recommendation should have accountability builtin and be subjected to measurable goals, quantitative solutions, and measurable outcomes. The 

Federal Government now must develop a level of accountability that has not been imposed 

rigorously in the past. 

Lessons learned. A catalog of lessons learned can guide our nation in devising current solutions

and alerting future generations on how to avoid inevitable emerging and potentially devastating 

drug-related crises. Important lessons can be extracted from earlier imprudence. The current focus 

on opioids is driven by the devastatingly high death rates. While death is the ultimate catastrophe, 

many psychoactive drugs with abuse potential do not precipitate an overdose crisis nor death as 

dramatically as do opioids. Nonetheless, other drugs can be markedly detrimental to the brain, 

body, and behavior.

• Low quality evidence that opioids are innocuous for chronic pain management was 

accepted without scrutiny, by the healthcare system, by physicians, medical schools, 

regulatory bodies, and insurers. High-quality assessment of the addictive potential of orally 

bioavailable opioids should have been imposed by the FDA. 

• Constant vigilance is necessary to recognize if marketing efforts are suppressing scientific 

evidence (e.g. addiction) and common sense. Early scientific scrutiny of dubious claims 

should be a key priority of regulatory agencies and physicians.

• Engage all stakeholders when creating standards and actionable outcomes. Do not restrict 

input to those who passionately favor a substance. Advocates may be less willing or able 

to see unintended consequences than others.

• The approval process of medications with abuse liability should not be restricted to drug

safety and efficacy in short term clinical trials. The drug approval process should expand 

its oversight and consider the number of doses and duration of a prescription for specific 

indications, the possibility of misuse, diversion, and tampering, and other consequences 

not traditionally a component of evidence required in the approval process. 

• Anticipate unintended consequences and devise effective data analytics, monitoring, and 

responses at the outset of a trend. A small, but significant portion of patients and other 

users or misusers of diverted prescription opioids transitioned to heroin. Screening for 

OUD when reducing opioid supply or creating a tamper-resistance formulation, and 

implementing procedures to assist treating OUD patients conceivably could have avoided 

the transition for some people. 

• Apply the lessons learned to current movements to medicalize and legalize other Schedule 

1 drugs. The catalyst of the opioid crisis was a denial of its addictive potential.

• Pharmaceutical sponsorship of medical society events needs rigorous oversight and review.

• Without adequate training in pain management and in addiction diagnosis and treatment, 

the medical establishment was caught off guard and unprepared for iatrogenic opioid 

addiction. Training in these disciplines should be mainstreamed into every level of medical 

education, to address the current crisis and to prepare for inevitable iterations.

• Healthcare insurers have a significant role in attenuating this public health crisis. They can

reduce opioid supply by declining reimbursement for unnecessary opioid prescriptions, and 
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facilitate recovery by seamless reimbursement for medications and treatment services. 

Federal oversight on insurance company practices was inadequate as the crisis expanded.
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Current Federal Programs and Funding Landscape

Overview

Congress has not enacted full year appropriations for fiscal year (FY) 2018, which began October 

1, 2017. The Federal Government is operating under a Continuing Resolution (CR) that will expire 

in December 2017. The funding levels presented in this report are consistent with the funding 

levels represented in the FY 2018 President’s Budget, including FY 2018 Request levels and FY 

2017 CR (annualized) estimates. 

The President’s FY 2018 Budget Request supports $27.8 billion for drug control efforts spanning 

prevention, treatment, interdiction, international operations, and law enforcement across 14 

Executive Branch departments, the Federal Judiciary, and the District of Columbia. This represents 

an increase of $279.7 million (1.0%) over the annualized CR level in FY 2017 of $27.5 billion. 

Within this total, the Budget supports $1.3 billion in investments authorized by the Comprehensive 

Addiction and Recovery Act (CARA), the 21st Century Cures Act, and other opioid-specific 

programs to help address the opioid epidemic.

FY 2018 Funding Specific to America’s Opioid Crisis

Reducing Overdoses. Reducing opioid overdoses, to include identifying those at risk of overdose, 

the signs of overdose, and expanding the use of naloxone, are key pieces of the Administration’s 

strategy to address the opioid overdose epidemic. 

The FY 2018 Budget request for SAMHSA includes $12.0 million for Grants to Prevent 

Prescription Drug/Opioid Overdose Related Deaths. This program will provide continuation 

grants to 10 states to significantly reduce the number of opioid overdose-related deaths by helping 

states purchase naloxone, equipping first responders in high-risk communities, supporting 

education on the use of naloxone and other overdose death prevention strategies (including 

covering expenses incurred from dissemination efforts), and providing the necessary materials to 

assemble overdose kits. This program was appropriated $12 million in FY 2016 and $12 million 

in the FY 2017 CR.

The FY 2018 Budget request for the CDC includes $70.0 million for the Prescription Drug 

Overdose Prevention for States program to cover overdoses from opioids and other drugs, the same 

level as the FY 2017 CR. This program, which advances and evaluates comprehensive state-level 

interventions for preventing prescription drug overuse, misuse, abuse, and overdose, is expanding 

to all 50 states and the District of Columbia in FY 2017. Funds in FY 2018 will support state 

efforts as well as rigorous monitoring, evaluation, and improvements in data quality at the national 

level. Funds will also be used to increase uptake among providers of the CDC's Guideline for 

Prescribing Opioids for Chronic Pain, as well as implementation of a coordinated care plan that 

addresses both opioid and heroin overdose prevention by improving care for high-risk opioid 

patients.

The FY 2018 Budget request also includes $5.6 million in funding for the CDC to address the 

rising rate of heroin-related overdose deaths by working to collect near real-time ED data and 
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higher quality and timely mortality data by rapidly integrating death certificate and toxicology 

information. This is a small increase above the FY 2016 appropriation and level with the FY 2017 

CR. Apart from these programs, the FY 2018 budget request continues to provide funding for 

expansion of electronic death reporting to provide faster, better quality data on deaths of public 

health importance, including prescription drug overdose deaths.

Enhancing Prescription Drug Monitoring Programs. PDMPs are an important state-based health 

care tool. They provide information to health care providers so they can better understand what is 

being prescribed and intervene before a prescription drug abuse disorder becomes chronic. 

Currently, PDMPs exist in 49 states. 

The FY 2018 request for DOJ’s PDMP activities includes $12.0 million for state grants to enhance 

the capacity of regulatory and law enforcement agencies to collect and analyze controlled 

substance prescription data. The FY 17 CR level for PDMP activities was $13.0 million, level with 

the FY 2016 final budget. The purpose of DOJ’s PDMP effort is to enhance the capacity of 

regulatory and law enforcement agencies to collect and analyze controlled substance prescription 

data. In coordination with HHS, the program aims to assist states that want to establish or enhance 

a PDMP. Objectives of the program include building a data collection and analysis system at the 

state level, enhancing existing programs' ability to analyze and use collected data, facilitating the 

exchange of collected prescription data between states, and assessing the efficiency and 

effectiveness of the programs funded under this initiative.

The FY 2018 Budget for SAMHSA includes $58.4 million for the Strategic Prevention 

Framework. Within this amount, SAMHSA will target $10 million to address prescription drug 

(including opioids) abuse and misuse, use PDMP data for prevention planning, and implement 

evidence-based practices and/or environmental strategies aimed at reducing prescription drug 

abuse and misuse. The final spending level for the Strategic Prevention Framework program was 

appropriated $119.5 million in FY 2016; in FY 2017, the CR level was $119.3 million.

Medication-Assisted Treatment Programs. MAT is an evidence-based treatment for individuals 

with OUDs. However, it is underutilized and often not available to those who could benefit from 

its administration. Expanding access to MAT, in combination with other behavioral health care, 

will help address this issue and help more individuals sustain their recovery from OUDs. 

The FY 2018 Budget includes $25.0 million for SAMHSA, to support the MAT for Prescription 

Drug and Opioid Addiction program for states, level with funding for FY 2016 and the FY 2017 

CR. In FY 2018, SAMHSA plans to expand and enhance its program to improve access to MAT 

services for treating OUDs. SAMHSA anticipates 22 new states that have demonstrated a dramatic 

increase in treatment admissions for OUDs will be funded under the FY 2018 request. 

Medication-Assisted Treatment in the Criminal Justice System. The Bureau of Prisons’ (BOP) 

budget contains $1.0 million in new resources to expand the MAT Pilot. The pilot provides an 

opportunity to evaluate whether MAT should be expanded in the corrections setting.

Residential Substance Abuse Treatment. The Office of Justice Program’s budget contains $12.0 

million for the Residential Substance Abuse Treatment (RSAT) program for state prisoners, level 

with funding for FY 2016 and the FY 2017 CR. The program was established to help state and 

local governments develop, implement, and improve residential substance abuse treatment 
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programs in correctional facilities, and establish and maintain community-based aftercare services 

for probationers and parolees. It is intended improve public safety and reduce criminal recidivism 

by helping offenders become drug-free and learn the skills needed to sustain themselves upon 

return to the community.

Enhanced Drug Enforcement Efforts. The Budget provides increasesto federal law enforcement

agencies aimed at reducing the flow of illicit drugs into the country and increasing investigations

of transnational criminal organizations, violent gangs, and drug traffickers. Specifically:

The FY 2018 Budget includes funding to maintain and expand capacity to fight against heroin and 

other illicit drugs at the DOJ. This includes a total of $2.6 billion for the DEA, including $21 

million in new discretionary resources are requested for DEA and $32 million in new mandatory 

resources for the DEA’s Diversion Control Program to reduce the diversion and abuse of 

pharmaceutical controlled substances and listed chemicals, including prescription opioids. The 

overall DEA request for FY 2018 is an increase of $158.1 million over the FY 2016 level and 

$150.3 million over the FY 2017 CR level. The FY 2018 Request for the DOJ also includes $526.0 

million for Organized Crime and Drug Enforcement Task Force (OCDETF) to support heroin 

enforcement efforts, address transnational organized crime, and to reduce violent crime in cities 

across the nation. The request is an increase of $14.0 million above the FY 2016 and $15.0 million 

more than the FY 2017 CR and will enhance heroin enforcement efforts, address transnational 

organized crime, and reduce violent crime in cities across the nation.

Drug Prevention. The Drug Free Communities (DFC) Support Program is built upon the idea 

that local problems require local solutions. DFC funding provides for the bolstering of community 

infrastructure to support environmental prevention strategies to be planned, implemented, and 

evaluated in communities across the United States, Territories and Protectorates. The DFC 

Program is guided by local communities who identify and develop evidence-based strategies to 

reduce drug use and its consequences. For FY 2018, $91.8 million will fund approximately 659

DFC grants and continue the DFC National Cross-Site Evaluation. This program received $95.0 

million in FY 16 and $94.8 million in FY 2017 through CR.

Addressing Domestic and Transnational Organized Crime. The Administration will employ 

tools to disrupt the flow of illicit drugs into our country, and reduce drug trafficking domestically.

In an effort to enhance security at the Southwest Border, in the FY 2018 President’s Budget, CBP 

requests $260.5 million to fund acquisition, delivery, and sustainment of prioritized border security 

capabilities. This is a new activity, reflecting the President’s commitment to border security.

The HIDTA program, created by Congress with the Anti-Drug Abuse Act of 1988, aids federal, 

state, local, and tribal law enforcement agencies operating in areas determined to be critical drugtrafficking regions of the United States. A total of $246.5 million is requested for the HIDTA 

program in FY 2018, a decrease from the FY 2016 funding level of $250.0 million and the FY 

2017 CR funding level of $249.5 million.
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The Comprehensive Addiction and Recovery Act (CARA)

The Comprehensive Addiction and Recovery Act (CARA) authorized new programs to help fight 

the scourge of opioid abuse plaguing our Nation, and authorized appropriations for existing 

programs to continue their work. Highlights of these programs are below:

In FY 2018, SAMHSA is requesting $12.0 million for the Preventing Prescription Drug/Opioid 

Overdose-Related Deaths (PDO II) program, authorized in CARA. FY 2018 is the first-time 

appropriations for this newly-authorized program will be requested. The purpose of this program 

is to reduce the number of prescription drug/opioid overdose-related deaths and adverse events 

among individuals at risk for OUD. Applicants will train first responders and members of other 

key community sectors at the state, local government, and tribal levels to implement secondary 

prevention strategies, such as the administration of naloxone through FDA-approved delivery 

devices to reverse the effects of opioid overdose. 

SAMHSA is also requesting $1.0 million to support a new cohort of grants through the Building 

Communities of Recovery program. This program mobilizes resources within and outside of the 

recovery community to increase the prevalence and quality of long-term recovery support for 

people with SUDs. These grants support the development, enhancement, expansion, and delivery 

of recovery support services, as well as promotion of and education about recovery.

At the DOJ, the Office of Justice Programs is requesting $20.0 million for grants under the 

Comprehensive Opioid Abuse Program. This new program aims to support cross-system 

collaboration; develop and implement strategies to reach survivors of non-fatal overdoses and their 

loved ones; provide treatment and recovery support services; expand diversion and alternative to 

incarceration programs; expand services in rural or tribal communities; implement and enhance 

PDMPs; and assess the impact of new strategies. 

At the VA, $50 million authorized under CARA is being requested for activities to increase opioid 

safety practices and improve care for Veterans within the Veterans Health Administration. VA 

began implementation of these activities with CR funds in FY 2017.

21st Century Cures Act

The 21st Century Cures Act provides a total of $970 million over two fiscal years (FY 2017 and 

FY 2018) to HHS to address the opioid crisis by increasing treatment, reducing unmet treatment 

need, and reducing opioid overdose related deaths through the provision of prevention, treatment, 

and recovery activities for OUD (including prescription opioids, as well as illicit drugs such as 

heroin). 

SAMHSA is administering the 21st Century Cures Act funding through the State Targeted 

Response to the Opioid Crisis Grants. The President’s Budget requests $500 million for state 

grants under this program. Grantees use epidemiological data to drive decision-making, rapidly 

address gaps in their systems of care, implement prevention strategies, deliver RSSs, and report 

progress on expanding treatment and reducing opioid overdose deaths.
97

Figure 6. Drug Resources by Function

FY 2018 Consolidated Federal Drug Control Budget

The consolidated National Drug Control Budget details agency resources by function. Functions 

categorize the activities of agencies into common drug control areas. Figure 6 details funding by 

function.

Prevention

Preventing drug use before it starts is a fundamental element of a comprehensive approach to drug 

control. Federal resources totaling $1.3 billion in support of education and outreach programs has 

been requested to educate young people about the consequences of drug use and prevent youth 

initiation. This represents a decrease of $167.5 million (11.1%) over the FY 2017 level; the major 

efforts are highlighted below:

Substance Abuse Prevention and Treatment Block Grant ($370.9 million)

Department of Health and Human Services – Substance Abuse and Mental Health Services 

Administration

Twenty percent of the $1.9 billion (i.e., $370.9 million) Substance Abuse Prevention and 

Treatment Block Grant is the minimum set aside to support prevention services. State Substance 

Abuse Administering Agencies use these funds to develop infrastructure and capacity specific to 

SUD prevention. Some State Substance Abuse Administering Agencies rely heavily on the 20% 

set-aside to fund prevention, target gaps in prevention services, and enhance existing program 

efforts.
98

Education’s Prevention Efforts ($48.9 million)

Department of Education

The $48.9 million request includes $46.3 million for School Climate Transformation Grants and 

related technical assistance. These funds help create positive school climates through multi-tiered 

decision-making frameworks that guide the selection, integration, and implementation of the best 

evidence-based behavioral practices. A key aspect of this multi-tiered approach is that it provides 

differing levels of support and interventions to students based on their needs. In schools where 

these frameworks are implemented well, there is evidence that youth risk factors are improved; 

improved risk factors are correlated with reduced drug use, among other improved behaviors. 

Prevention Research ($331.9 million)

Department of Health and Human Services – National Institutes of Health

NIH’s NIDA invests in genetics, neuroscience, pharmacotherapy, and behavioral and health 

services research, producing innovative strategies for preventing SUDs. In addition, NIDA is 

supporting research to better understand the impact of changes in state policies related to 

marijuana. Through NIAAA, the NIH helps to develop strategies to prevent the short- and longterm consequences of alcohol use among youth.

Drugged Driving ($2.72 million)

Department of Transportation, National Highway Traffic Safety Administration

NHTSA’s FY 2018 request supports the Drug-Impaired Driving Program, which provides public 

information, outreach efforts, and improved law enforcement training to help reduce drugged 

driving. Funding will also allow NHTSA to continue to conduct research designed to reduce the 

incidence of drug-impaired driving.

Anti-Doping Activities/World Anti-Doping Agency Dues ($11.8 million)

Office of National Drug Control Policy

Anti-doping activities focus on efforts to educate athletes on the dangers of drug use, eliminate 

doping in amateur athletic competitions, and rely on standards established and recognized by the 

United States Olympic Committee. Funding for both efforts promotes an increased awareness in 

the United States and internationally of the health and ethical dangers of illicit drug use and doping 

in sport. Funding and participation in the Anti-Doping Activities/World Anti-Doping Agency is 

necessary to compete in international events. These activities support state-of-the-art research 

within the scientific and public health communities, while striving to protect athletes’ fundamental 

rights to participate in drug-free sports, and thus promote the health and safety of athletes at all 

levels.

Treatment and Recovery

Treatment and recovery support services are essential elements of reducing drug use and its 

consequences. The FY 2018 Budget proposes $10.8 billion, an increase of $202.6 million (1.9%) 

over the FY 2017 annualized CR level in federal funds for early intervention, treatment, and 

recovery services. SUD treatment services need to be integrated better into primary care settings, 

made more widely accessible, and made eligible for insurance coverage on par with other medical 

conditions. The major efforts in this area include the following:
99

Medicare- & Medicaid-funded Substance Abuse Treatment Services ($5,840.0 million)

Department of Health and Human Services – Centers for Medicare & Medicaid Services

SUD treatment is usually financed through a variety of public and private sources (i.e., private 

health insurance, Medicaid, Medicare, state and local funds, and other federal support). The 

Federal Government makes its largest contribution to the payment for treatment through the 

Medicaid and Medicare programs. The Medicaid estimate is based on federal reimbursement to 

states for SUD treatment services. Medicare supports treatment for SUDs in both inpatient and 

outpatient settings. 

Substance Abuse Treatment for Veterans ($721.7 million)

Department of Veterans Affairs – Veterans Health Administration

The Department of Veterans Affairs (VA) operates a national network of SUD treatment programs 

located in the Department’s medical centers, residential rehabilitation facilities, and outpatient 

clinics. It provides effective, safe, efficient, recovery-oriented, and compassionate care for 

Veterans with SUDs and mental illness.

Substance Abuse Prevention and Treatment Block Grant ($1,483.8 million)

Department of Health and Human Services – Substance Abuse and Mental Health Services 

Administration

Up to 80% of the $1.9 billion Substance Abuse Prevention and Treatment Block Grant (i.e., 

$1,483.8 million) is estimated to support treatment services and related activities. This formula‐

based funding to states supports the provision of SUD treatment services, providing maximum 

flexibility to states to respond to their local and/or regional emergent issues impacting health, 

public health, and public safety through a consistent federal funding stream. The grant allows 

states to provide a range of clinical and recovery support services to clients during treatment and 

recovery, and supports planning, coordination, needs assessment, and quality assurance. 

Screening, Brief Intervention, and Referral to Treatment ($46.8 million)

Department of Health and Human Services – Substance Abuse and Mental Health Services 

Administration

The SBIRT program, funded via Public Health Service Evaluation funds, provides grants to health 

care providers to intervene early in the disease process before individuals achieve dependency, and 

to motivate the clients with SUDs to engage in SUD treatment. Grant funds will further integrate 

Screening, Brief Intervention, and Referral to Treatment within medical treatment settings to 

provide early identification and intervention to at-risk individuals within the context of their 

primary care provider.

Treatment Research ($575.8 million)

Department of Health and Human Services – National Institutes of Health

NIH’s NIDA invests in genetics, neuroscience, pharmacotherapy, and behavioral and health 

services research, producing innovative strategies for treating SUDs. For example, NIDA supports 

a large research network for conducting studies related to treatment of SUDs in the criminal justice 

system, including studies that pertain to the implementation of MAT and seek, test, treat, and retain 

for individuals with SUDs at risk for HIV. Through NIAAA, the NIH helps to develop strategies 

to treat the short- and long-term consequences of alcohol misuse among youth.
100

Substance Use Disorders Treatment for Military Service Members/Families ($76.7 million)

Department of Defense – Defense Health Program

DOD’s Defense Health Program provides medical and dental services, including treatment for 

SUDs, for all members of the armed forces to include all eligible beneficiaries, including military 

family members. In addition to treatment services, the Defense Health Program also conducts 

alcohol and SUD research. 

Homeless Assistance Grants - Continuum of Care ($494.2 million)

Department of Housing and Urban Development

The Strategy calls for federal support for reducing barriers to recovery from SUDs, including lack 

of housing. For persons in recovery, structured and supportive housing promotes healthy recovery 

outcomes. The Department’s Continuum of Care—Homeless Assistance Grants support efforts to 

eliminate homelessness by financing local solutions to locate, intervene, and house the homeless 

population. These programs provide housing and supportive services on a long-term basis. 

Drug Courts ($99.9 million)

Department of Health and Human Services - Substance Abuse and Mental Health Services 

Administration

Department of Justice - Office of Justice Programs

Drug courts help reduce recidivism, provide treatment to individuals with SUDs, and improve the 

likelihood of successful rehabilitation through early, continuous, and intense judicially supervised 

treatment, mandatory periodic drug testing, community supervision, appropriate sanctions, and 

other rehabilitation services. HHS ($59.9 million) and DOJ ($40.0 million), work together to 

enhance court services, coordination, and the SUD treatment capacity of juvenile, family and adult 

drug courts. 

Bureau of Prisons Drug Treatment Efforts ($119.1 million)

Department of Justice, Bureau of Prisons

BOP continues to develop evidence-based treatment practices to manage and treat incarcerated 

individuals with SUDs. BOP’s strategy includes early identification through psychological 

screening of individuals entering prison. According to the severity of the disease, BOP provides 

drug education, treatment for those within the general population, separate intensive residential 

SUD treatment and community transition treatment. The request includes $1.0 million to expand 

BOP’s MAT field trial program, which provides medication during the last two months of 

incarceration and for four to six weeks after release in community custody, a residential reentry 

center, or home confinement.

Judiciary Treatment Efforts ($172.8 million)

Federal Judiciary

The Federal Judiciary provides for court-ordered drug testing, drug treatment, and supervision of 

federal defendants, probationers, parolees, and those on supervised release after incarceration. 

Funding is used by the probation and pretrial services offices for drug testing and treatment of 

federal defendants and offenders. Probation and pretrial services officers have primary 

responsibility for enforcing conditions of release imposed by the courts and for monitoring the 

behavior of persons placed under their supervision. With Executive Office of the U.S. Attorneys

oversight, officers administer a program of drug testing and treatment for persons on pretrial 

release, probation, supervised release after incarceration, and parole. The goal is to eliminate 
101

substance use by persons under supervision and to remove violators from the community before 

relapse leads to recidivism.

Domestic Law Enforcement

Maximizing federal support for interagency law enforcement drug task forces is critical to 

leveraging limited resources. A total of $9.2 billion in federal resources are requested in FY 2018

to support domestic law enforcement efforts (including state and local assistance, as well as federal 

investigation, prosecution, and corrections), a decrease of $62.7 million (0.7%) below the FY 2017 

annualized CR level. The major efforts are highlighted below.

Methamphetamine Enforcement and Lab Cleanup Grants ($11.0 million)

Department of Justice

These grants aid state, local, and tribal law enforcement agencies in support of programs to address 

methamphetamine production and distribution. Working with the DEA, funding also supports 

assistance to state and local law enforcement in removing and disposing of hazardous materials 

generated by clandestine methamphetamine labs, and providing training, technical assistance, and 

equipment to assist law enforcement agencies in managing hazardous waste.

Federal Law Enforcement Training Center ($48.8 million)

Department of Homeland Security

The Federal Law Enforcement Training Center (FLETC) is a law enforcement training facility that 

provides training and technical assistance to federal, state, local, tribal, territorial, and international 

law enforcement entities. As part of its curriculum, FLETC provides training programs comprised 

of drug enforcement activities and drug-related investigations to enhance the qualifications of law 

enforcement personnel.

Federal Drug Investigations ($3,359.8 million)

Multiple agencies

Federal law enforcement personnel—including those from DOJ ($2,582.2 billion), DHS ($490.9

million), Treasury ($60.3 million), Interior ($14.9 million), and Agriculture ($14.6 million) -

prepare drug cases for the arrest and prosecution of leaders and traffickers of illegal drug 

organizations, seize drugs and assets, and enforce federal laws and regulations governing the 

legitimate handling, manufacturing, and distribution of controlled substances.

Federal Prosecution ($842.4 million)

Multiple agencies

Several agencies— (including DOJ’s Organized Crime Drug Enforcement Task Force Program 

($161.3 million), U.S. Marshals Service ($129.8 million), Executive Office of the U.S. Attorneys 

($78.1 million), Criminal Division ($37.7 million), and the Federal Judiciary ($435.5 million)—

conduct Federal criminal proceedings against drug trafficking and money laundering 

organizations. The related costs include salaries for attorneys and other court personnel, defender 

services, judicial and courthouse security, prisoner security, and other administrative costs. 
102

Corrections ($4,410.4 million)

Department of Justice/Federal Judiciary

The BOP ($3,284.7 million), the Federal Judiciary ($597.0 million), and the U.S. Marshals Service 

($528.6 million) conduct activities associated with the incarceration and/or monitoring of drug‐

related offenders. The request includes funding for the costs associated with inmate care, security 

and facility maintenance, contracted confinement, and general management and administration.

Interdiction

The United States continues to face a serious challenge from the large-scale smuggling of drugs 

from abroad that are distributed to every region of the Nation. In FY 2018, the Administration’s 

request includes $5.0 billion to support the efforts of federal law enforcement agencies, the 

military, the intelligence community, and our international allies to support collaboration to 

interdict or disrupt shipments of illegal drugs, their precursors, and their illicit proceeds. The FY 

2018 request represents an increase of $453.4 million, (9.9%) above the FY 2017 annualized CR 

level. The major efforts are highlighted below.

Customs and Border Protection ($3,118.7 million)

Department of Homeland Security

CBP implements border enforcement strategies to interdict and disrupt the flow of narcotics and 

other contraband across our Nation’s borders. The comprehensive interdiction strategy includes 

the border security personnel at and between ports of entry, detection and monitoring provided by 

aviation assets, and border security infrastructure and technology.

United States Coast Guard ($1,452.7 million)

Department of Homeland Security

One facet of the United States Coast Guard’s (USCG) mission is maritime interdiction. The USCG 

functions as the maritime counternarcotics presence in the source, transit, and arrival zones. Their 

maritime interdiction activities disrupt the flow of drugs into the United States.

Federal Aviation Administration Interdiction Support ($13.2 million)

Department of Transportation/Federal Aviation Administration

Air traffic controllers staffing Air Route Traffic Control Centers monitor the Air Defense 

Identification Zones to detect possible suspicious aircraft movement. When suspicious movement 

is identified, the Federal Aviation Administration (FAA) notifies the DEA and USCG of such 

activity. Upon confirmation of suspicious aircraft movement, FAA controllers support interdiction 

efforts by providing radar vectors to track the time of arrival, traffic advisory information, and last 

known positions to intercept aircrafts of interest.

Department of Defense Drug Interdiction ($413.2 million)

Department of Defense

DOD’s counterdrug programs detect, monitor, and support the disruption of drug trafficking 

organizations. Additionally, DOD coordinates interagency resources and force requirements of 

air and surface assets in the Western Hemisphere Transit Zone.
103

International Efforts

Illicit drug production and trafficking generate huge profits and are responsible for the 

establishment of criminal enterprise networks that are powerful and corrosive forces that destroy 

the lives of individuals, tear at the social fabric, and weaken the rule of law in affected countries. 

In FY 2018, $1.4 billion is requested for international drug control efforts, a decrease of 

$146.1 million (9.6%) below the FY 2017 annualized CR level. These funds are requested to 

support the efforts of the United States Government and our international partners around the globe 

to meet the challenges of illicit trafficking of all drugs, including synthetics and precursors, and 

illicit substance use. The major efforts in this area include the following. 

DEA’s International Efforts ($470.4 million)

Department of Justice

The focus of DEA’s international enforcement program is to disrupt or dismantle the most 

significant international drug and precursor chemical trafficking organizations around the world. 

Personnel in DEA’s foreign country offices focus their investigative efforts on the most significant 

international command and control organizations threatening the United States. DEA coordinates 

all programs involving drug law enforcement in foreign countries, and provides intelligence to 

assist the interagency community in determining future trends in drug trafficking and evaluating 

their long-term impact. DEA works closely with the United Nations, Interpol, and other 

organizations on matters relating to international drug and chemical control programs.

Bureau of International Narcotics and Law Enforcement Affairs ($290.3 million)

Department of State

In support of the Strategy, Bureau of International Narcotics and Law Enforcement Affairs (INL) 

works closely with partner nations and source countries to disrupt illicit drug production, 

strengthen criminal justice systems and law enforcement institutions, and combat transnational 

organized crime. INL is comprehensive in its approach to the counterdrug mission and provides 

training and technical assistance for prevention and treatment programs.

United States Agency for International Development ($83.6 million)

Department of State

The United States Agency for International Development (USAID) provides foreign assistance 

funds to develop holistic alternatives to illicit drug production by providing agricultural assistance, 

improving small scale infrastructure, increasing market accessibility, and incentivizing licit crop 

production. USAID’s alternative development programs foster economic growth, local 

governance and civil society strengthening, and enhanced security of impacted communities.

DOD International Counternarcotics Efforts ($491.1 million)

Department of Defense

The international support programs of DOD’s Combatant Commands detect, interdict, disrupt, or 

monitor activities related to drug trafficking organizations and transnational criminal 

organizations. In the Western Hemisphere Transit Zone, DOD functions as the command and 

control support for counterdrug activities for federal, state, local and international partners.
104

Table 3. Federal Drug Control Spending by Function, FY 2016 – FY 2018 (Budget Authority in

Millions)

FY 2016 FY 2017 FY 2018

Final CR Request Dollars Percent

Treatment $9,845.1 $10,580.8 $10,783.4 $202.6 1.9%

Percent 36.6% 38.5% 38.9%

Prevention 1,486.4 1,507.4 1,339.9 -167.5 -11.1%

Percent 5.5% 5.5% 4.8%

Domestic Law Enforcement 9,282.8 9,298.6 9,235.8 -62.8 -0.7%

Percent 34.5% 33.8% 33.3%

Interdiction 4,734.7 4,569.0 5,022.4 453.4 9.9%

Percent 17.6% 16.6% 18.1%

International 1,524.9 1,521.0 1,375.0 -146.1 -9.6%

Percent 5.7% 5.5% 5.0%

Total $26,874.0 $27,476.8 $27,756.5 $279.7 1.0%

Demand Reduction $11,331.5 $12,088.2 $12,123.3 $35.1 0.3%

Percent 42.2% 44.0% 43.7%

Supply Reduction 15,542.5 15,388.6 15,633.2 244.6 1.6%

Percent 57.8% 56.0% 56.3%

$26,874.0 $27,476.8 $27,756.5 $279.7 1.0%

FY17 - FY18 Change

Function

Supply/Demand

Total
105

Table 4. Federal Drug Control Spending by Agency (Budget Authority in Millions)

FY 2016

Final

FY 2017 CR FY 2018

Request

Department of Agriculture

U.S. Forest Service 12.3 12.9 15.6

Court Services and Offender Supervision Agency for the District of 

Columbia

55.4 55.3 56.1

Department of Defense

Drug Interdiction and Counterdrug Activities1(incl. OPTEMPO, 

 DSCA, and OCO)

1,302.8 1,299.4 1,127.8

Defense Health Program 76.7 75.8 76.7

Total DoD 1,379.5 1,375.1 1,204.6

Department of Education

Office of Elementary and Secondary Education 50.3 49.1 48.9

Federal Judiciary 1,147.8 1,166.7 1,210.9

Department of Health and Human Services

Administration for Children and Families 18.5 18.6 20.0

Centers for Disease Control and Prevention 75.6 75.4 75.4

Centers for Medicare & Medicaid Services2 5,390.0 5,550.0 5,840.0

Health Resources and Services Administration 119.0 121.0 171.0

Indian Health Service 104.7 104.9 105.1

National Institute on Alcohol Abuse and Alcoholism 55.2 55.2 42.7

National Institute on Drug Abuse 1,049.0 1,075.4 865.0

Substance Abuse and Mental Health Services Administration3 2,533.7 3,052.1 2,943.2

Total Health and Human Services 9,345.7 10,052.7 10,062.5

Department of Homeland Security

Customs and Border Protection 2,687.2 2,663.7 3,118.7

Federal Emergency Management Agency 8.3 8.3 6.2

Federal Law Enforcement Training Center 44.1 43.9 49.3

Immigration and Customs Enforcement 508.9 514.7 524.6

United States Coast Guard 1,597.1 1,456.0 1,452.7

Total Homeland Security 4,845.6 4,686.4 5,151.5

Department of Housing and Urban Development

Community Planning and Development 490.5 489.5 494.2

Department of the Interior

Bureau of Indian Affairs 9.7 9.7 9.3

Bureau of Land Management 5.1 5.1 5.1

National Park Service 3.5 3.3 3.3

Total Interior 18.3 18.1 17.7
106

FY 2016

Final

FY 2017 CR FY 2018

Request

Department of Justice

Assets Forfeiture Fund 258.4 230.1 227.5

Bureau of Prisons4 3,532.6 3,526.0 3,403.8

Criminal Division 39.0 38.0 37.7

Drug Enforcement Administration 2,425.5 2,433.4 2,583.6

Organized Crime Drug Enforcement Task Force Program 512.0 511.0 526.0

Office of Justice Programs 278.2 297.7 240.2

U.S. Attorneys 72.6 72.6 78.1

U.S. Marshals Service 771.3 792.8 812.8

Total Justice 7,889.7 7,901.7 7,909.7

Department of Labor

Employment and Training Administration 5.7 6.0 6.0

Office of National Drug Control Policy

High Intensity Drug Trafficking Areas 250.0 249.5 246.5

Other Federal Drug Control Programs 109.8 109.6 103.7

Salaries and Expenses 20.0 20.0 18.4

Total ONDCP 379.9 379.1 368.6

Department of State5

Bureau of International Narcotics and Law Enforcement Affairs 405.3 404.5 290.3

United States Agency for International Development 70.5 70.4 83.6

Total State 475.8 474.9 373.9

Department of Transportation

Federal Aviation Administration 30.4 31.6 31.7

National Highway Traffic Safety Administration 3.5 2.7 2.7

Total Transportation 33.8 34.3 34.4

Department of the Treasury

Internal Revenue Service 60.3 60.3 60.3

Department of Veterans Affairs

Veterans Health Administration 683.4 714.6 741.7

Total Federal Drug Budget $26,874.0 $27,476.8 $27,756.5

1. Due to statutory changes included in the FY 2017 National Defense Authorization Act that consolidated the 

DOD’s security sector assistance authorities, funding for building foreign partner counter-drug enforcement 

capacities is now included in DOD's Defense Security Cooperation Agency's budget request.

2. The estimates for the CMS reflect Medicaid and Medicare benefit outlays (excluding spending under Medicare 

Part D) for substance use disorder treatment; they do not reflect budget authority. The methodology for Medicaid 

estimates has been refined from prior years to more accurately reflect spending. The estimates were developed 

by the CMS Office of the Actuary.

3. Includes budget authority and funding through evaluation set-aside authorized by Section 241 of the Public 

Health Service (PHS) Act.

4. Funding for the FY 2018 column excludes a proposed rescission of unobligated balances.

5. Funding for 2017 column is a mechanical calculation that does not reflect decisions on funding priorities.

6. Detail may not add due to rounding
107

Charter, President’s Commission on Combating Drug 

Addiction and the Opioid Crisis
108
109
110

Appendices

Appendix 1. Acronyms

ACA: Affordable Care Act

ADAM: Arrestee Drug Abuse Monitoring Program

AED: Advanced Electronic Data

AUD: alcohol use disorder

AHRQ: Agency for Healthcare Research and Quality

ASAM: American Society of Addiction Medicine

BJA: Bureau of Justice Assistance

BOP: Bureau of Prisons

CARA: Comprehensive Addiction and Recovery Act

CBP: U.S. Customs and Border Protection

CDC: Centers for Disease Control and Prevention

CHW: community health worker

CME: continuing medical education

CMS: Centers for Medicare and Medicaid Services

CRP: collegiate recovery programs

DAWN: Drug Abuse Warning Network

DEA: Drug Enforcement Administration

DHS: Department of Homeland Security

DOD: Department of Defense

DOE: Department of Education

DOJ: Department of Justice

DOL: Department of Labor

DOT: Department of Transportation

DTO: Drug Trafficking Organization

ED: Emergency Department

EHR: electronic health records

EMR: emergency medical responder

EMS: emergency medical services

EMT: emergency medical technician

EMTALA: Emergency Medical Treatment and Labor Act

EPCS: electronic prescribing of controlled substances

ER: extended-release

FAA: Federal Aviation Administration
111

FDA: U.S. Food and Drug Administration

FLETC: Federal Law Enforcement Training Center

HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems

HCPCS: Healthcare Common Procedure Coding System

HCV: hepatitis C virus

HHS: U.S. Department of Health and Human Services

HIDTA: High Intensity Drug Trafficking Areas 

HIV: human immunodeficiency virus

HRSA: Health Resources and Services Administration

HUD: heroin use disorder

IMD: Institutes of Mental Disease

IMF: USPS International Mail Facilities

INL: Bureau of International Narcotics and Law Enforcement Affairs

IR: immediate-release

MAT: Medication-Assisted Treatment

MDI: medicolegal death investigation

ME/C: medical examiners and coroners

MHPAEA: Mental Health Parity and Addiction Equity Act

NARR: National Alliance for Recovery Residents

NASEM: National Academies of Sciences, Engineering, and Medicine

NAS: neonatal abstinence syndrome

NHTSA: National Highway Traffic Safety Administration

NIAAA: National Institute on Alcohol Abuse and Alcoholism

NIC: National Institute on Corrections

NIDA: National Institute on Drug Abuse

NIH: National Institutes of Health

NQTL: non-quantitative treatment limits

NSC: National Security Council

NSDUH: National Survey on Drug Use and Health

NPS: new psychoactive substances

ONDCP: Office of National Drug Control Policy

OTP: opioid treatment programs

OUD: opioid use disorder

PDMP: prescription drug monitoring program

RCO: recovery community organization

RSS: recovery support services
112

SAMHSA: Substance Abuse and Mental Health Services Administration

SBIRT: Screening, Brief Intervention, and Referral to Treatment

SUD: substance use disorder

USAID: United States Agency for International Development

USCG: United States Coast Guard

USPS: United States Postal Service

USPIS: United States Postal Inspection Service

USPSTF: United States Preventative Services Task Force

VA: Department of Veteran Affairs

VBP: Value-Based Purchasing
113

Appendix 2. History of Opiate Use and Abuse

The opium poppy was a medicinal plant used by ancient civilizations. It blunted pain; elevated 

mood; relaxed; dulled stress, melancholy, and anxiety; and induced sleep. With the dawning of 

modern chemistry in the early 1800’s, morphine, codeine, and thebaine were purified from the 

opium poppy Papaver somniferum, and their chemical structures identified. Scientific curiosity or 

optimization of medicinal properties drove chemists to synthesize variations of these naturally 

occurring opioids. The end products included heroin, oxycodone, oxymorphone, hydrocodone, 

hydromorphone, and others. 

To avoid reliance on the poppy plant for opioids, de novo compounds such as methadone, 

meperidine, fentanyl, tramadol, U47700, were subsequently created. These drugs were 

structurally distinct from morphine yet targeted the same pain-reducing/pleasure-inducing 

receptors/circuits as plant-derived morphine analogs to engender pain relief, suppression of cough 

and intestinal function and chemical coping of psychological distress. Susceptible individuals, 

whether medical or non-medical users discovered the euphoriant properties of potent opioids 

delivered rapidly into the brain, especially by smoking or injection.

Opioid mechanisms. Opioid analgesics target opioid signaling systems within circuits engaged in 

diverse homeostatic mechanisms, especially management of pain, anxiety, stress, intestinal 

motility, cough mechanisms and hedonic pleasure. Opioid signaling is comprised of endogenous 

chemical neurotransmitters (small and large mobile peptides such as endorphins that transmit 

signals) and their corresponding opioid receptors (large anchored proteins that interpret signals).

These signaling systems are widely distributed throughout the human brain and body. Three major 

opioid receptors (μ or mu, κ or kappa, and δ or delta), their subtypes and splice variants have been 

identified. Opioids activate one or more of these G-protein–coupled transmembrane molecules, to 

trigger diverse responses governed by splice variants, post-translational modifications, and 

receptor heterodimer or homodimer formation.254 All exogenous opioids that target the μ-opioid

receptor suppress pain perception, slow gastrointestinal motility, attenuate cough, and induce 

pleasurable sensations or intense euphoria. At sufficiently high doses, activation of μ-opioid

receptors in the brain stem can depress respiration, leading to reduced blood flow and oxygen in 

the brain and even death. Frequent exposure to opioids leads to tolerance, a diminution of specific 

signaling functions of the mu opioid receptor (e.g., euphoria and respiratory depression), which 

may drive the user to escalate drug doses to levels that can be fatal in the drug-naïve or in abstinent 

former users. If high dose opioids are reintroduced during abstinence (e.g. released prisoners or in 

long term recovery), the risk of a lethal overdose is grave as tolerance to opioids wanes during 

abstinence. 

Historical Origins of Iatrogenic Opioid Addiction. In the mid- to late-19th century, opioid use 

rose dramatically, fueled by physicians’ unrestrained opioid prescriptions (morphine, laudanum, 

paregoric, codeine, heroin) for pain or other ailments, by inclusion of opioids in aggressively 

promoted patent medicines, and by liberal use of opioid-based treatments for injuries and diseases 

gnawing at Civil War combatants and veterans. Opioids were undoubtedly more effective and 

reliable medications for a variety of ailments, compared with existing alternatives. During this first 

wave, physicians were largely responsible for iatrogenic addiction to opioids among patients. By 

1900, 1 in 200 people were addicted in the United States. In parallel with clinicians and 

pharmacists issuing unrestrained opioid supplies to treat medical ailments and addiction, profiteers 

organized clandestine, illicit opioid distribution networks. Powered by unregulated international 
114

production and shipments of opium, opium dens proliferated in the United States and created a 

non-medical, addicted population among denizens of these sites.

255,256,257 The steep rise in 

consumption of medical opioids or smoked opium led to an alarming surge of addictions, either 

medically-induced, or resulting from opium smoking. The two populations did not “cross-over,” 

nor merge regarding drug sources, types of opioids, or routes of administration. This nation-wide 

crisis extended across socio-economic strata, and reached urban and rural areas. Thereafter, 

smaller scale waves of heroin addiction surfaced periodically during the 20th century, but these 

were confined to large cities.

Response to the First Crisis. Medical professionals, federal, local, and international regulatory 

bodies awakened to the epidemic of iatrogenic and situationally-based opioid addiction. One 

physician James F.A. Adams wrote compellingly on the adverse side effects of these medicinal 

drugs - depression, constipation, and the “opium habit,” (addiction). Eventually, the first epidemic 

of opioid addiction was contained and then reversed by physicians, pharmacists, medical 

education, voluntary restraint, combined with federal regulations and law enforcement. In 1890, 

the U.S. government began taxing opium and by 1906, the Pure Food and Drug Act was passed, 

which required manufacturers to disclose the contents of their medicinal products to consumers. 

Three years later Congress passed the Opium Exclusion Act, banning its import for opium 

smoking. The International Opium Convention in the Hague and the Harrison Act of 1914 taxed 

and regulated the sale and distribution of opium and cocaine-based products, the first broadly based 

prohibition in American history. Opioids remained available for short-term medical use, but not 

for maintenance of addiction. Doctors and pharmacists who violated the Act, which discouraged 

morphine use to sustain addiction, were arrested. The United Nations Single Convention on 

Narcotic Drugs in 1961 and the Controlled Substances Act (CSA) of 1970 (Title II of the 

Comprehensive Drug Abuse Prevention and Control Act) established federal U.S. drug policy on 

regulating the manufacture, importation, possession, use and distribution of certain substances.

The CSA was the national legislation for implementing the Single Convention on Narcotic Drugs.

The DEA, the enforcement branch of the CSA, was charged with registration of physicians, 

stringent annual production quotas, chain-of-custody and other regulatory oversight.
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Appendix 3. Interim Report, President’s Commission on Combatting 

Drug Addiction and the Opioid Crisis

Dear Mr. President:

I am proud to present to you today the interim report prepared by your Commission on 

Combating Drug Addiction and the Opioid Crisis. This interim report is just a start; our work is 

ongoing and we will have more to share with you and the nation later in the Fall of 2017. We now 

recommend several actions for you to take as our nation’s Chief Executive and someone who 

spoke passionately on this issue in the 2016 campaign. 

Our nation is in a crisis. Your Executive Order recognized that fact. The work of your Commission 

so far acknowledges the severity of this national problem.

According to the Centers for Disease Control (CDC), the most recent data estimates that 142 

Americans die every day from a drug overdose. Our citizens are dying. We must act boldly to 

stop it. The opioid epidemic we are facing is unparalleled. The average American would likely be 

shocked to know that drug overdoses now kill more people than gun homicides and car crashes 

combined. In fact, between 1999 and 2015, more than 560,000 people in this country died due 

to drug overdoses – this is a death toll larger than the entire population of Atlanta. As we have 

all seen, opioids are a prime contributor to our addiction and overdose crisis. In 2015, nearly twothirds of drug overdoses were linked to opioids like Percocet, OxyContin, heroin, and fentanyl. 

This is an epidemic that all Americans face because here is the grim reality: Americans consume 

more opioids than any other country in the world. In fact, in 2015, the amount of opioids 

prescribed in the U.S. was enough for every American to be medicated around the clock for three 

weeks.

Since 1999, the number of opioid overdoses in America have quadrupled according to the CDC. 

Not coincidentally, in that same period, the amount of prescription opioids in America have 

quadrupled as well. This massive increase in prescribing has occurred despite the fact that there 

has not been an overall change in the amount of pain Americans have reported in that time 

period. We have an enormous problem that is often not beginning on street corners; it is starting 

in doctor’s offices and hospitals in every state in our nation.

But, the challenge of reducing opioid supplies has evolved. As access to prescription opioids 

tightens, consumers increasingly are turning to dangerous street opioids, heroin, fentanyl alone 

or combined, and mingled with cocaine or other drugs. In 2016, specific states witnessed an 

escalating number of overdose deaths due to heroin and/or fentanyl(s), in some states vastly 

exceeding deaths due to prescription opioids. 

In 2015, 27 million people reported current use of illegal drugs or abuse of prescription drugs. 

Despite this self-reporting, only 10 percent of the nearly 21 million citizens with a substance use 

disorder (SUD) receive any type of specialty treatment according to the most recent National 

Survey on Drug Use and Health. This is contributing greatly to the increase of deaths from 

overdose.
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Over forty percent of people with a substance use disorder also have a mental health problem, 

but less than half of these people receive treatment for either issue. The reasons for these 

treatment gaps are many, including lack of access to care, fear of shame and discrimination, and 

lack of motivation to seek treatment. 

This Commission has been hard at work to meet the goals set for us in the Executive Order on 

March 29th, 2017. As a Commission, we have already met with leading national organizations in 

the addiction space, and we have received information and recommendations from countless 

individuals and groups, all of whom share in our commitment to beating this epidemic. The 

Commission thanks all the individuals and organizations, including Governors and 

representatives from Governors Offices from around the country, that have reached out to offer 

their experiences, expertise, and input. 

In addition to conducting phone calls with Governors and their teams in all 50 states, we also 

held a listening session with bi-partisan members of Congress, and key cabinet members of your 

Administration. Individual Commission members have organized “listening sessions” and 

solicited recommendations from treatment providers, addiction psychiatrists and other 

physicians, data analysts, professional medical and treatment societies, medical educators, 

healthcare organizations, pharmacoepidemiologists, and insurance providers. Outreach also has 

been made to scientists with broad expertise in pain, addiction biology and treatment.

The first public meeting of the Commission was held on June 16th at the White House, and was a 

great success. The Commission members heard comprehensive public testimony by nine leading 

nonprofits, and have received more than 8,000 comments from the public, including comments 

from at least 50 organizations. 

This information was reviewed by the Commission members and helped inform this interim 

report. 

The first and most urgent recommendation of this Commission is direct and completely within 

your control. Declare a national emergency under either the Public Health Service Act or the 

Stafford Act. With approximately 142 Americans dying every day, America is enduring a death 

toll equal to September 11th every three weeks. After September 11th, our President and our 

nation banded together to use every tool at our disposal to prevent any further American deaths. 

Your declaration would empower your cabinet to take bold steps and would force Congress to 

focus on funding and empowering the Executive Branch even further to deal with this loss of life. 

It would also awaken every American to this simple fact: if this scourge has not found you or your 

family yet, without bold action by everyone, it soon will. You, Mr. President, are the only person 

who can bring this type of intensity to the emergency and we believe you have the will to do so 

and to do so immediately.

The Commission is additionally proposing the following recommendations for immediate action:
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• Rapidly increase treatment capacity. Grant waiver approvals for all 50 states to quickly 

eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases 

(IMD) exclusion within the Medicaid program. This will immediately open treatment to 

thousands of Americans in existing facilities in all 50 states. 

The Commission has been urged by every Governor, numerous treatment providers, parents, 

and non-profit advocacy organizations to eliminate the IMD exclusion within the Medicaid 

program. This component of the Social Security Act prohibits federal Medicaid funds from 

reimbursing services provided in an inpatient facility treating “mental diseases” (including 

SUDs) that have more than 16 beds. This exclusion makes states entirely responsible for 

Medicaid-eligible patients in inpatient treatment facilities, including patients undergoing 

withdrawal management in addiction treatment facilities rather than hospitals. The 

Commission members that serve as Governors, as well as individuals and organizations that 

treat Medicaid patients, are intimately aware of how the IMD exclusion impacts the ability to 

serve patients with severe SUDs that are best served in an inpatient setting. The Commission 

recognizes that legislation would be necessary to repeal the exclusion in its entirety. 

However, certainly after an emergency declaration by the President (and arguably even 

without it) the Department of Health and Human Services (HHS) Secretary would be 

empowered to immediately grant waivers to each state that requests one. This is the single 

fastest way to increase treatment availability across the nation. 

• Mandate prescriber education initiatives with the assistance of medical and dental schools 

across the country to enhance prevention efforts. Mandate medical education training in 

opioid prescribing and risks of developing an SUD by amending the Controlled Substance 

Act to require all Drug Enforcement Agency (DEA) registrants to take a course in proper 

treatment of pain. HHS should work with partners to ensure additional training 

opportunities, including continuing education courses for professionals. 

According to a Substance Abuse and Mental Health Services Administration (SAMHSA) Center 

for Behavioral Health and Statistics Quality (CBHSQ) report, four out of every five new heroin 

users begin with nonmedical use of prescription opioids.

In other words, Mr. President, this crisis began in our nation’s health care system. While we 

acknowledge that some of this inappropriate overprescribing is done illegally and for profit, 

we believe the overwhelming percentage is due to a lack of education on these issues in our 

nation’s medical and dental schools and a dearth of continuing medical education for 

practicing clinicians. This can and must be solved by using Presidential moral and legal 

authority to change this lack of education leading to addiction and death.

There are several initiatives around the country aimed at ensuring that providers are aware 

of the potential for misuse and abuse of prescription opioids.

Governor Baker’s administration in Massachusetts has worked with the medical and dental 

schools in that state and the Medical Society to develop core competencies related to opioids 

and SUDs that all graduating students are expected to learn and put into practice. Other 

states such as Arizona, Connecticut, Pennsylvania, New York, and Utah have expanded 
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continuing medical education requirements for opioid prescribers and dispensers. 

Alternatively, the American Society of Addiction Medicine (ASAM) has recommended 

implementing a requirement that clinicians who apply for a registration with the DEA to 

prescribe controlled substances demonstrate competency in safe prescribing, pain 

management, and substance use identification. In New Jersey, Governor Christie recently 

signed a law that requires providers themselves to take continuing education related to 

opioids, and requires prescribers to discuss the risks of opioid dependence with their patients 

prior to the first prescription. We urge national implementation of these initiatives.

In our first Commission meeting, we heard from several nonprofits about the need to 

promote expanded implementation of the CDC Guideline for Prescribing Opioids for Chronic 

Pain through increased prescriber education initiatives. The Office of National Drug Control 

Policy (ONDCP) estimates that, apart from federal prescribers who are required to be trained, 

fewer than 20% of the over one million prescribers licensed to prescribe controlled 

substances to patients have training on how to prescribe opioids safely. Similarly, it seems 

that many medical providers are not well-versed on how to screen for addiction, and what to 

do if a patient has become dependent on substances or presents with an SUD. We urge you 

to instruct the Department of Justice (DOJ) and the DEA to require continuing medical 

education for every physician requesting an initial DEA license or the renewal of such a 

license.

The CDC and the U.S. Food and Drug Administration (FDA) should finalize, review and 

recommend national training standards working with the Accreditation Council for 

Continuing Medical Education (ACCME) to ensure training courses are coordinated with other 

federal agencies, professional societies, medical schools, and residency programs to avoid 

discrepancies.

The FDA should also work with the ACCME to develop data analytics to determine whether 

courses change practices, increase patient referrals to treatment, and methods to improve 

compliance consistent with opioid prescribing education. 

Clinicians need more detailed and specific guidance on drug choice, dose, and quantity to be 

dispensed in treating specific pain conditions. We also recommend a detailed analysis of, and 

solutions to clinical problems encountered in applying recommended guidelines. 

• Immediately establish and fund a federal incentive to enhance access to MedicationAssisted Treatment (MAT). Require that all modes of MAT are offered at every licensed 

MAT facility and that those decisions are based on what is best for the patient. Partner 

with the National Institutes of Health (NIH) and the industry to facilitate testing and 

development of new MAT treatments.

MAT has proven to reduce overdose deaths, retain persons in treatment, decrease use of 

heroin, reduce relapse, and prevent spread of infectious disease. Expansion of MAT 

availability for qualified individuals and for short- or long-term treatment is an essential 
119

component of treatment services. Yet approximately 10 percent of conventional drug 

treatment facilities in the United States provide MAT for opioid use disorder.

Individuals seeking SUD treatment, and even those currently enrolled in a treatment system, 

often find barriers to using MAT as a component of their treatment. Particularly for 

populations with opioid use disorders (OUDs) involved in the criminal justice system, there is 

often inadequate access to FDA-approved medications that are proven to improve outcomes 

as part of a full continuum of care. Multiple studies have shown that individuals receiving 

MAT during and after incarceration have lower mortality risk, remain in treatment longer, 

have fewer positive drug screens, and have lower rates of recidivism than other individuals 

with OUDs that do not receive MAT. The DOJ, in consultation with HHS and ONDCP, should 

be directed to increase the use of MAT for OUDs in these correctional settings.

In addition, the Centers for Medicare & Medicaid Services (CMS) should require all federallyqualified health centers (FQHCs) to mandate that their staff physicians, physician assistants, 

and nurse practitioners possess waivers to prescribe buprenorphine. 

There are several barriers to the use of MAT, including a prevalent belief that use of MAT 

does not constitute true recovery or sobriety. The Federal Government, as a major purchaser 

of health care services, has a tremendous opportunity to increase the availability of MAT for 

individuals with OUDs. For example, across the Veterans Administration (VA) and Indian 

Health Services, there is a lack of providers able to prescribe/administer MAT. For Medicare 

patients, the Part B physician benefit does not cover methadone treatment and the Part D 

pharmaceutical benefit does not cover it either, as it is administered by a medical 

professional. CMS should send a state health official letter requesting that state Medicaid 

programs cover all FDA-approved MAT drugs for OUD.

Additionally, all FDA-approved MAT should be offered by authorized providers, not just one 

or two of these approved options. These decisions of which (if any) MAT to be used must be 

based upon what is best for the patient, not what is best for the provider. This can be 

mandated by the Executive Branch.

Finally, we urge you to instruct the NIH to begin to immediately work with the pharmaceutical 

industry in two areas; the development of additional MAT options and the development of 

new, non-opioid pain relievers based on research to clarify the biology of pain. The nation 

needs more options to treat those already addicted and can help to prevent addiction in the 

first place by avoiding the prescription of opioids. The NIH is best positioned, in our opinion, 

to lead this effort with industry partners.

• Provide model legislation for states to allow naloxone dispensing via standing orders, as 

well as requiring the prescribing of naloxone with high-risk opioid prescriptions; we must 

equip all law enforcement in the United States with naloxone to save lives.

Naloxone is a lifesaver that rapidly reverses opioid overdose. It is the first line of defense in 

many parts of our country; if we lose someone to overdose we obviously have no chance to 

treat them and return them to a productive life. We urge you to mandate, with federal 
120

assistance, that naloxone be in the hands of every law enforcement officer in the United 

States. By declaring a national emergency, you can empower the HHS Secretary to negotiate 

reduced pricing for all governmental units. Forty-seven states have expanded access to 

naloxone in some form. The Federal Government should ensure that naloxone is made 

available when there is the greatest chance for an overdose. Accordingly, model legislation 

should include a requirement that naloxone is prescribed in combination with any CDCdefined high-risk opioid being prescribed. 

An impediment to naloxone usage and people seeking help in the event of an overdose is the 

perceived threat of law enforcement involvement. Overly restrictive or punitive laws may 

prevent the uptake of naloxone or the seeking of aid in an emergency. In response, most state 

legislatures and some law enforcement agencies have created a variety of immunity and 

‘Good Samaritan’ laws to ensure bystanders and those experiencing an overdose are not 

deterred from seeking immediate help. States vary widely in the content of ‘Good Samaritan’ 

laws, but they generally offer protection to people assisting at the scene of an overdose, or 

seeking care for their own or another’s overdose, from civil or criminal prosecution. As of July 

2017, 40 states and the District of Columbia have enacted some form of a ‘Good Samaritan’ 

or 911 drug immunity law. In addition to enacting legislation, it is crucial that states ensure 

the public fully understands the protections provided by the ‘Good Samaritan’ law and how 

it empowers them to call 911 in the case of an overdose.

HHS and other federal agencies should be directed by you or your cabinet to make 

recommendations on ways to identify persons who have overdosed and been revived with 

naloxone and the feasibility of notification of their primary care and other physicians caring 

for them. These primary care providers may be prescribing medications that increase future 

risks of another overdose.

• Prioritize funding and manpower to the Department of Homeland Security’s (DHS) Customs 

and Border Protection, the DOJ Federal Bureau of Investigation (FBI), and the DEA to quickly 

develop fentanyl detection sensors and disseminate them to federal, state, local, and tribal 

law enforcement agencies. Support federal legislation to staunch the flow of deadly 

synthetic opioids through the U.S. Postal Service (USPS).

Illicit fentanyl and fentanyl analogs are the next grave challenge on the opioid front and the 

awful news is that it is much, much more deadly than hydrocodone, oxycodone or even 

heroin. Since 2012, the nation has seen an alarming increase in the number of drug overdose 

deaths that involve fentanyl, a synthetic opioid many times more powerful than heroin, as 

well as heroin and cocaine laced with non-pharmaceutical fentanyl. Fentanyl defies detection 

at our borders, as the small quantities involved for psychoactivity of fentanyl and fentanyl 

analogs challenge Customs and Border Protection, USPS, and express consignment carriers’ 

ability to detect and interdict. We are miserably losing this fight to prevent fentanyl from 

entering our country and killing our citizens. We are losing this fight predominately through 

China. This must become a top tier diplomatic issue with the Chinese; American lives are at 

stake and it threatens our national security. Our inability to reliably detect fentanyl at our 

land borders and at our international mail handling facilities creates untenable vulnerabilities. 
121

Key federal agencies, including the DEA, DHS, FBI, and DOJ, should coordinate pursuant to 

the Controlled Substances Act to intercept fentanyl (and other synthetic opioids) in envelopes 

and packages at mail processing distribution centers, and increase detection efforts using 

enhanced technology, more manpower, and expanded canine deployment. Only a 

presidential directive will give this issue the top level attention it deserves from DOJ, DHS, 

and USPS.

• Provide federal funding and technical support to states to enhance interstate data sharing 

among state-based prescription drug monitoring programs (PDMPs) to better track patientspecific prescription data and support regional law enforcement in cases of controlled 

substance diversion. Ensure federal health care systems, including Veteran’s Hospitals, 

participate in state-based data sharing.

PDMPs are state-run electronic databases used to track the prescribing and dispensing of 

controlled prescription drugs. They are designed to give providers access to critical 

information regarding a patient’s controlled substance prescription history, and can help 

health professionals identify patients who may be or are at risk of misusing prescription 

opioids or other prescription drugs. PDMPs are also used by professional licensing boards to 

identify clinicians with patterns of inappropriate prescribing and dispensing, and to assist law 

enforcement in cases of controlled substance diversion. Multiple published best practices for 

utilizing PDMPs, including guidelines from the Heller School for Social Policy and 

Management at Brandeis University, have identified interstate data sharing among PDMPs as 

a top priority to ensure that healthcare professionals and law enforcement have a complete 

picture of prescribing practices and controlled substances diversion. Numerous professional 

health organizations, including the American Medical Association (AMA) and the Association 

of State and Territorial Health Officials (ASTHO), agree that PDMPs are an effective and 

important clinical tool to combat the addiction crisis; however, they are being significantly 

underutilized in the vast majority of our states. Forty-nine states now have PDMPs but not 

nearly a majority of those are sharing their information. This is unacceptable. We urge you 

to direct the VA and HHS to lead an effort to have all state and federal PDMP systems to share 

information and to set a deadline of July 1, 2018 to achieve this data sharing.

In addition to sharing data between states and the Federal Government, the PDMP needs to 

be improved with regard to its ease of use, and inclusion of other data to assist prescribing 

doctors. Ideally, clinicians should check their state PDMP before making the decision to 

prescribe either an opioid or benzodiazepine (several states already have this requirement in 

place), determine whether their patient has had an overdose, and other relevant information 

that can be summarized into categories of high to low risk.

• Better align, through regulation, patient privacy laws specific to addiction with the Health 

Insurance Portability and Accountability Act (HIPAA) to ensure that information about SUDs 

be made available to medical professionals treating and prescribing medication to a 

patient. This could be done through the bipartisan Overdose Prevention and Patient Safety 

Act/Jessie’s Law. 
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Providers and other advocates have found that certain privacy regulations, while wellintentioned patient protections, act as a barrier to communication between providers, can 

make it difficult for family members to be involved in a loved one’s treatment, and limits the 

ability to use electronic health records to their full potential. 42 CFR Part 2, which requires 

addiction treatment professionals to acquire written patient consent before sharing any 

information with a patient’s other health care providers, including when the addiction 

treatment facility is part of a larger health care system, is a particular hindrance to 

comprehensive health care. Making it administratively difficult for providers to share 

information has ill-effects on patients in both physical and behavioral health settings, by 

restraining physicians’ ability to make informed healthcare decisions.

We urge you to direct that regulation be changed to permit the sharing of this type of 

information among health care providers and the loved ones of those suffering from 

SUDs. Otherwise, drugs with high abuse liability may be prescribed to people with OUD. That 

will lead to even more unnecessary and preventable deaths.

• Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) with a standardized 

parity compliance tool to ensure health plans cannot impose less favorable benefits for 

mental health and substance use diagnoses verses physical health diagnoses. 

As Congressman Kennedy spoke eloquently about at the first Commission meeting, there has 

long been a difference in how individuals with health insurance receive treatment and 

medication for physical health diagnoses versus mental health and SUD diagnoses. The 

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) prohibits health insurance 

plans that cover behavioral health from imposing benefit limitations on mental health or SUD 

treatment that are less favorable than limitations imposed on medical or surgical benefits. 

Benefit limitations can be quantitative, such as visit limits, or non-quantitative, such as preauthorization requirements. But not providing real parity is already illegal. The Commission 

urges you to direct the Secretary of Labor to enforce this law aggressively and to penalize the 

violators.

The Commission heard from numerous organizations, including ASAM and the American 

Academy of Addiction Psychiatry, about the need to systematically monitor and enforce 

MHPAEA with a standardized tool, and actual penalties for non-compliance, to ensure parity 

in the coverage of mental health and addiction treatment services. The Labor Secretary, with 

appropriate direction from you, is the person to do this.

At this point, the largest outstanding issue is treatment limits. Patients seeking addiction 

treatment, including MAT, are often subjected to dangerous fail-first protocols, a limited 

provider network, frequent prior authorization requirements, and claim denials without a 

transparent process. The Commission applauds SAMHSA’s work with multidisciplinary teams 

from states to improve parity enforcement and public education. However, we need robust 

enforcement of the parity law by the state and federal agencies responsible for implementing 

the law. Regulators should be required to levy penalties against health plans that violate 

MHPAEA, and information about parity violations should be made available to the public. 
123

It is not only critical that the Federal Government provide sufficient resources to prevent and 

combat this disease; it must also provide the easiest pathway for private providers and local and 

state governments to achieve success. 

That is why the Commission, as a primary focus of the final report, is undertaking a full-scale 

review of federal programs, regulations, laws, and funding mechanisms targeted toward 

addressing addiction. 

In addition to a full review of federal funding and programs and obstacles and opportunities for 

treatment, the final report will include, but not be limited to, a more thorough examination of 

the following issues: 

• Development of a national prevention strategy using “big data analytics” to devise 

targeted prevention messages that employ cutting-edge methods of marketing and 

communications.

• Evidence-based prevention programs for schools, and tools for teachers and parents to 

enhance youth knowledge of the dangers of drug use, as well as early intervention 

strategies for children with environmental and individual risk factors (trauma, foster care, 

adverse childhood experiences (ACEs), and developmental disorders).

• The need for satisfaction with pain level as a satisfaction criteria through which health 

care providers are evaluated by HHS.

• Workforce access and training needs within the treatment community nationally, with a 

particular focus on the regions of the country with the highest overdose deaths.

• Improvements in treatment programs, based on adherence to principles of evidencebased treatment, continuum of care, outcome measures, and patient education on 

quality treatment.

• Research initiatives and opportunities to combat the epidemic and enhance treatment 

options, including alternative pain management strategies, and treatment for vulnerable 

populations such as pregnant women, and substance-exposed infants through work by 

the NIH, HHS, CDC, FDA, SAMHSA, and pharmaceutical partners.

• Opportunities to further the practice of substance use screenings and referrals through 

CMS quality measures.

• Opportunities for patient protections providing better information about the risks and 

benefits of taking prescription opioids.

• Supply reduction of heroin, fentanyl analogs and counterfeit pills through coordinated 

federal and state law enforcement initiatives.

• Targeted data collection and analytics needed to identify most effective prevention and 

treatment strategies, quality treatment access programs, reimbursements, and aid to law 

enforcement activities. The possibility of a behavioral health surveillance system run 

through CDC that tracks prevalence rates, treatment modalities, and comorbidities with 

other illnesses in real-time. 

• Regulatory or statutory changes to reduce commercial insurance barriers to MAT, such as 

dangerous fail-first protocols and onerous and frequent prior authorization requirements. 
124

In our final report, we will provide an additional set of detailed recommendations that, if 

implemented, will ensure that the Federal Government operates as a strong partner in the fight 

against addiction and the opioid crisis. 

Finally, our country needs you, Mr. President. We know you care deeply about this issue. We 

also know that you will use the authority of your office to deal with our nation’s problems. The 

Commission looks forward to submitting its final report.

Sincerely, 

Commission members
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Appendix 4. Fentanyl Safety Recommendations for First Responders
126

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