Drug Policy: Preliminary Observations on the 2019 National Drug Control Strategy
Released: 2019-03-07T00:00:00

Letter

Background

More than a dozen federal agencies—known as National Drug Control Program agencies—have responsibilities for drug prevention, treatment, and law enforcement activities. For example, the Department of Health and Human Services (HHS) has led efforts to expand access to drug treatment, and the Departments of Justice (DOJ) and Homeland Security (DHS) have taken lead roles in limiting the availability of illicit drugs through criminal investigations and prosecutions. The Anti-Drug Abuse Act of 1988 established ONDCP to enhance national drug control planning and coordination. In this role, the office is responsible for (1) leading the national drug control effort, (2) coordinating and overseeing the implementation of national drug control policy, (3) assessing and certifying the adequacy of National Drug Control Programs and the budget for those programs, and (4) evaluating the effectiveness of national drug control policy efforts.

Until its 2018 reauthorization, ONDCP had been operating under the provisions of the ONDCP Reauthorization Act of 2006 pursuant to annual appropriations acts. In October 2018, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act) was enacted and reauthorized ONDCP and a number of its programs. The SUPPORT Act aims to address overprescribing and opioid misuse in the United States and includes provisions involving law enforcement, public health, and healthcare financing and coverage. Under both the ONDCP Reauthorization Act of 2006 and the SUPPORT Act, the Director of ONDCP is required to promulgate the National Drug Control Strategy and work with National Drug Control Program agencies to develop an annual National Drug Control Program Budget. Prior to the SUPPORT Act, the Director was required to promulgate a National Drug Control Strategy on an annual basis, while under the SUPPORT Act, generally, the National Drug Control Strategy is required to be developed every two years. ONDCP did not issue a National Drug Control Strategy for 2017 or 2018 despite the statutory requirement. Under both the ONDCP Reauthorization Act of 2006 and the SUPPORT Act, the National Drug Control Strategy is to set forth a comprehensive plan to reduce illicit drug use and the consequences of such illicit drug use in the United States by limiting the availability of and reducing the demand for illegal drugs.

Preliminary Observations on the 2019 National Drug Control Strategy

As part of our ongoing work, we are reviewing the 2019 National Drug Control Strategy that ONDCP issued on January 31, 2019. Agency officials told us that they began preparing the National Drug Control Strategy in early 2018—prior to the enactment of the SUPPORT Act in October 2018. Officials stated that the National Drug Control Strategy was intended to respond to the requirements of the ONDCP Reauthorization Act of 2006, which was the applicable law at that time. In light of ONDCP’s stated approach, we based our preliminary analysis of the National Drug Control Strategy on the ONDCP Reauthorization Act of 2006. However, the SUPPORT Act retained certain similar requirements for the National Drug Control Strategy contained in the prior law.

According to ONDCP, the 2019 National Drug Control Strategy provides a high-level vision of federal drug control efforts by focusing on prevention, treatment and recovery, and reducing the availability of illicit drugs. The 2019 National Drug Control Strategy designates one overarching strategic objective—to reduce the number of lives lost to drug addiction— and provides some general descriptions of federal agencies’ activities. However, our preliminary observations related to the 2019 National Drug Control Strategy indicate that it does not include several pieces of required information, including the following:

Quantifiable and measurable objectives. The National Drug Control Strategy was required to include “annual quantifiable and measurable objectives and specific targets to accomplish long-term quantifiable goals that the Director determines may be achieved during each year beginning on the date on which the National Drug Control Strategy is submitted.” However, our work showed that the 2019 National Drug Control Strategy does not include this information. While it lists seven items that it designates as measures of performance or effectiveness, it does not indicate how they would be quantified or measured, or targets to be achieved each year. For example, one of the measures of performance relates to educating the public, especially adolescents, about drug use. However, it lacks information on how ONDCP would measure its efforts to educate adolescents, as well as targets ONDCP hopes to achieve, such as the number of adolescents educated or specific knowledge gains. Further, none of the seven measures has a baseline of current performance or annual targets, and four of the seven measures do not have associated timelines—which are important ways that results could be quantified. For example, one of the Strategy’s measures of effectiveness is that evidence-based addiction treatment, particularly medication-assisted treatment for opioid addiction, is more accessible nationwide for those who need it. However, there is no information on the current level of treatment access, any targets for expanding access, or any associated timeline by which ONDCP hopes to achieve desired results.

Program and budget priorities. The National Drug Control Strategy was required to include “a 5-year projection for program and budget priorities.” While the 2019 National Drug Control Strategy outlines several high-level priorities, including a top priority to address the current opioid crisis and its associated deaths, it does not include such a 5-year projection.

Specific assessments. The National Drug Control Strategy was required to include specific assessments related to illicit drug use. For example, the National Drug Control Strategy was required to include “an assessment of the reduction of illicit drug availability.” This assessment was to be measured by, among other things, the quantities of cocaine, heroin, marijuana, methamphetamine, ecstasy, and other drugs available for consumption in the United States; the amount of marijuana, cocaine, heroin, methamphetamine, ecstasy, and precursor chemicals and other drugs entering the United States; and the number of illicit manufacturing laboratories seized and destroyed as well as the number of hectares of marijuana, poppy, and coca cultivated and destroyed domestically and in other countries. The 2019 National Drug Control Strategy does not include this information. In addition, the National Drug Control Strategy was required to include “an assessment of the reduction of the consequences of illicit drug use and availability.” This assessment was to include the burden illicit drug users placed on hospital emergency departments; the annual national health care cost of illicit drug use; and the extent of illicit drug-related crime and criminal activity. Similarly, the 2019 National Drug Control Strategy does not include this information.

Performance measurement system. The ONDCP Director was required to submit “as part of the National Drug Control Strategy a description of a national drug control performance measurement system.” Among other things, this system was to describe the sources of information and data that would be used for each performance measure incorporated into the performance measurement system. This system was also to coordinate the development and implementation of national drug control data collection and reporting systems to support policy formulation and performance measurement. Further, the system was to monitor consistency across the drug-related goals and objectives of the National Drug Control Program agencies and ensure that each agency’s goals and budgets support are fully consistent with the National Drug Control Strategy. The 2019 National Drug Control Strategy does not contain a description of such a national drug control performance measurement system.

As part of our ongoing work, we also asked ONDCP for information regarding how ONDCP officials determined the adequacy of National Drug Control Program agencies’ budget submissions without a National Drug Control Strategy in effect for 2017 and 2018. The National Drug Control Program Budget is to provide information on federal drug control funding requested by the executive branch to implement the National Drug Control Strategy. National Drug Control Program agencies are required to submit to ONDCP the portion of their annual budget requests dedicated to drug control activity undertaken by the department, agency, or program. Agencies are to prepare these as part of their overall budget submission to the Office of Management and Budget for inclusion in the President’s annual budget request. ONDCP is required to review and certify whether these budgets are sufficient to support the relevant goals and objectives outlined in the National Drug Control Strategy and then include these budgets in the consolidated National Drug Control Program Budget, which the President issues alongside his budget each year. As of March 4, 2019, ONDCP had not provided information on how it accomplished the required determination. In addition, as of March 4, 2019, the President’s FY 2020 budget, and the accompanying National Drug Control Program Budget, had not been released. We will continue to consider ONDCP’s activities in this area as part of our ongoing work.

As part of our ongoing work, we will also discuss the 2019 National Drug Control Strategy with ONDCP and plan to examine how ONDCP intends to address additional requirements in the SUPPORT Act. The lack of information in the 2019 National Drug Control Strategy on assessing progress toward its objective to reduce lives lost reflects findings in our previous reports. Our prior work in general, and our work on federal drug control efforts in particular, has consistently emphasized the importance of setting clear priorities through measurable and quantifiable goals, and assessing progress toward those goals over time, in order to achieve results. For example: In March 2018, we reported on federal agencies’ efforts—including those of ONDCP—to limit the availability of and enhance their response to illicit opioids, such as heroin and fentanyl. We reviewed five strategies related to combating illicit opioids and determined that only one included outcome-oriented performance measures that aim to assess the effectiveness of its efforts—ONDCP’s Heroin Availability Reduction Plan (HARP). In contrast, we found that ONDCP’s High Intensity Drug Trafficking Areas (HIDTA) programs’ Heroin Response Strategy did not include any outcome-oriented performance measures. Outcome measures address the results of programs and services, such as reductions in overdose deaths, and they can help in assessing the status of program operations, identifying areas that need improvement, and ensuring accountability for results. Among other things, we recommended in March 2018 that ONDCP coordinate with the HIDTAs to establish outcome-oriented performance measures to assess progress towards the goals set out in the Heroin Response Strategy. While ONDCP neither agreed nor disagreed with our recommendation, ONDCP told us in June 2018 that they had engaged with leaders from the HIDTAs participating in the Heroin Response Strategy to develop performance measures, including some outcome performance measures. As of March 4, 2019, this recommendation has not yet been addressed and ONDCP has not provided additional information on these efforts. We continue to believe that establishing these measures would enhance the HIDTAs’ ability to assess whether these efforts are producing intended results.

In October 2017, we reported on HHS’s efforts to reduce the prevalence of opioid misuse and the fatalities associated with it by expanding access to medication-assisted treatment (MAT) for opioid use disorder. These efforts included four grant programs that focus on expanding access to MAT in various settings (including rural primary care practices and health centers) and implementing regulatory and statutory changes that expanded treatment capacity by increasing patient limits for a MAT medication—buprenorphine—and by expanding the types of practitioners who can prescribe it in an office-based setting. We found that HHS had not established performance measures with targets that would specify the results that HHS hoped to achieve through its efforts, and by when. We concluded that without this information, HHS would not have an effective means to determine whether its efforts are helping to expand access to MAT or whether new approaches are needed. Among other things, we recommended that HHS establish performance measures with targets related to expanding access to MAT for opioid use disorders. HHS concurred with the recommendation and in February 2019, provided information that the agency had established performance measures with targets to increase the number of prescriptions for certain MAT medications, one of the potential ways to measure access to MAT. However, the recommendation has not yet been fully addressed, in part because HHS did not provide information on measures related to the treatment capacity of providers who prescribe or administer MAT medications, which HHS had identified as another way to measure access. We continue to believe that fully implementing this recommendation will help ensure that invested resources in the program are yielding intended results.

As our prior work shows, using data—such as information collected by performance measures and findings from program evaluations and research studies—to drive decision-making can help federal agencies improve program implementation, identify and correct problems, and make other management decisions. Although agencies may struggle to effectively use this approach, regular performance reviews and evidence- based policy tools can help them incorporate performance information into federal decision-making. Without effective long-term plans, such as a national strategy, that clearly articulate goals and objectives and without specific measures to track performance, federal agencies cannot fully assess whether taxpayer dollars are invested in ways that will achieve desired outcomes. ONDCP’s responsibility to develop the National Drug Control Strategy and coordinate among federal agencies offers the agency an important opportunity to guide federal activities to address the unprecedented number of drug overdose deaths. We are continuing with ongoing and planned work to monitor and assess federal drug control efforts.

Chairman Cummings, Ranking Member Jordan, and Members of the Committee, this concludes our prepared statement. We would be happy to respond to any questions you may have at this time.

GAO Contact and Staff Acknowledgments

If you or your staff has any questions concerning this testimony, please contact Triana McNeil at (202) 512-8777 (McNeilT@gao.gov) or Mary Denigan-Macauley at (202) 512-7114 (DeniganMacauleyM@gao.gov). Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. In addition to the contacts named above, Joy Booth (Assistant Director), Will Simerl (Assistant Director), Michelle Loutoo Wilson (Analyst in Charge), Billy Commons, Helen Desaulniers, Wendy Dye, Jane Eyre, Kaitlin Farquharson, and Jan Montgomery made key contributions to the testimony. Other staff who made key contributions to the reports cited in the testimony are identified in the source products.

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