What We Found
Federal agencies must effectively coordinate and implement a strategic national response to drug misuse and make progress toward reducing rates of drug misuse and the resulting harmful effects to society.
As we reported in March 2020, our body of work on drug misuse, and specifically our work since fiscal year 2015, has highlighted challenges the federal government faces to address drug misuse.
In March 2020, we also reported that the severe public health and economic effects of the Coronavirus Disease 2019 (COVID-19) pandemic could further fuel some of the contributing factors of drug misuse, thereby highlighting the need to sustain and build upon ongoing efforts.
We noted that maintaining sustained attention on drug misuse would be challenging, as many of the federal agencies responsible for addressing drug misuse would be focused on addressing the pandemic. In consideration of the challenges from the onset of the COVID-19 pandemic, we reported that the high-risk designation would be effective in 2021. As a result, we will not rate federal agencies’ progress until our next High-Risk Report in 2023.
Leadership commitment. Our work has identified the need for the Office of National Drug Control Policy (ONDCP) to improve its leadership and coordination of the national effort to address drug misuse. Further, we have identified the need for leaders of National Drug Control Program agencies who help implement the National Drug Control Strategy (Strategy)—such as the Departments of Health and Human Services (HHS), Justice, Homeland Security, and Education—to engage in more effective coordination across the government and with stakeholders.
ONDCP’s responsibility to develop the National Drug Control Strategy offers the office an important opportunity to help prioritize, coordinate, and measure key efforts to address the drug crisis. Our work has shown that ONDCP can improve its efforts to develop a National Drug Control Strategy that meets statutory requirements and effectively coordinates national efforts to address drug misuse. In 2017 and 2018, as rates of drug misuse and overdose deaths continued to worsen, ONDCP lacked a statutorily required National Drug Control Strategy. ONDCP produced the National Drug Control Strategy in 2019 and 2020, but neither iteration fully addressed all statutory requirements. The federal government invests billions of dollars each year in programs spanning over a dozen agencies. Therefore, the development and implementation of a comprehensive Strategy is critical to guiding and ensuring the effectiveness of federal activities to address drug misuse.
Our work has also addressed the importance of coordination across federal agencies as well as between federal agencies, other levels of government, and private stakeholders. In addition to its role in developing and issuing the Strategy, ONDCP is uniquely situated to promote coordination across National Drug Control Program agencies.
The 2020 Strategy included some information about existing or new coordinating mechanisms needed to achieve the Strategy’s long-range quantifiable goals and ONDCP’s role in facilitating achievement of such goals. Through these mechanisms, ONDCP has the potential to strengthen coordination and provide sustained leadership.
As we reported in March 2020 when we identified drug misuse as a high-risk issue, it is important for the federal government to coordinate among different levels of government and across issue areas. This includes coordinating with state, local, and tribal agencies, as well as with community groups and organizations in the private sector working to address the drug crisis.
For example, we reported in October 2020 that the federal government has supported the use of prescription drug monitoring programs (PDMP) to help ensure appropriate prescribing of drugs. Physicians we interviewed found PDMPs useful while reporting challenges when PDMPs are not integrated with electronic health record systems.
Capacity. Our past work found that the treatment availability for substance use disorders has not kept pace with needs, and the federal government has faced barriers to increasing treatment capacity.
For example, we reported in December 2020 that, according to Substance Abuse and Mental Health Services Administration (SAMHSA) data, as of May 2020, nearly one-third of counties (31 percent) had no facilities offering any level of substance use disorder treatment. According to stakeholders, shortages in the treatment workforce, insurance reimbursement and payment models, federal and state requirements, and stigma are barriers to expanding substance use disorder treatment.
The 2020 Strategy included a plan to expand treatment of substance use disorders, which is required to identify unmet treatment needs, and a strategy for closing the gap between available and needed treatment, among other things. Additionally, the Fiscal Year 2021 Budget and Performance Summary, which ONDCP issued in June 2020 as a companion document to the Strategy, took further steps to address statutory requirements for identifying resources needed to expand treatment of substance use disorders.
However, the 2020 Strategy did not include the required 5-year projection for the National Drug Control Program and budget priorities. We also found that the 2020 Strategy did not include estimates of federal funding or other resources needed to achieve each of the Strategy’s long-range quantifiable goals. Addressing our December 2019 recommendation that ONDCP develop and document key planning elements for future Strategy iterations would help ensure it has identified funding and other resources needed to address the crisis. ONDCP agreed with this recommendation.
Addressing the drug misuse crisis also requires the capacity to address the effects of drug misuse on individuals and society. For example, providing clearer direction on the role of states and use of grant funding in the nation’s workforce system to address the employment and training needs of those affected by substance use disorders could help ensure the economic well-being of communities affected by drug misuse.
We reported in May 2020 about programs funded through the Workforce Innovation and Opportunity Act that are addressing the employment and training needs of those affected by substance use disorders. We found that the Department of Labor (DOL) did not plan to share information that grantees submit to the agency, such as lessons learned and successes, with all states.
However, doing so could help states better position workforce agencies to address the needs of job seekers affected by substance use disorders and help employers understand and address the perceived risks of hiring job seekers in recovery.
In May 2020, we recommended that DOL share information from targeted grantees with all state workforce agencies, tribal governments, and outlying areas regarding lessons learned and promising practices. DOL agreed with our recommendation and is creating resources that are available to all states. DOL plans to host at least one webinar that could be useful to local workforce boards around the country.
Action plan. Our work has identified limitations in the Strategy, which could serve as an action plan for addressing this high-risk area. The Strategy is required to set forth a comprehensive plan to reduce illicit drug use and related consequences in the United States by limiting the availability of and reducing the demand for illegal drugs, among other things. However, our past work has highlighted ways in which the Strategy does not meet statutory requirements. As noted above, in December 2019, we recommended that ONDCP develop and document key planning elements to help ONDCP structure its ongoing efforts and to better position the agency to meet these statutory requirements for future iterations of the Strategy.
The 2020 Strategy made progress in addressing several statutory requirements. For example, the Fiscal Year 2021 Budget and Performance Summary included information describing how each long-range quantifiable goal in the Strategy will be achieved. The Budget and Performance Summary included for each goal a list of relevant National Drug Control Program agencies; their programs, activities, and assets; and the role of each of those in achieving the Strategy’s goals.
However, as part of our efforts to review key programs that support the Strategy’s prevention goals, we found that the 2020 National Drug Control Assessment, a companion document to the Strategy, did not include complete information on performance measures for a number of programs related to the prevention goal. For example, ONDCP did not report on any performance measures or document how its $100 million Drug-Free Communities Support program contributes to achieving specific goals in the Strategy, and some programs at HHS’s SAMHSA did not include adequate metrics to link the programs’ activities to the prevention goal. We also found that the approximately $10 million grants to states component of Education’s School Climate Transformation Grant program could more fully provide performance information related to the Strategy’s prevention education goal. Without including performance information for these programs, the Strategy and other companion documents are not comprehensive.
To fully ensure that Congress and the public understand how investment in the program contributes to the Strategy, we recommended in November 2020 that these three agencies clarify how the programs help to achieve specific goals of the Strategy. ONDCP and HHS agreed with our recommendations and plan to clarify how their performance metrics link the programs to the Strategy, and Education partially agreed and plans to explore collecting and reporting related performance data. We will continue to monitor the agencies’ efforts and report on progress over time.
Monitoring. Our past work has identified gaps in the availability and reliability of data for measuring the federal government’s progress to address drug misuse.
For example, ONDCP and other federal, state, and local government officials have identified challenges with the timeliness, accuracy, and accessibility of data from law enforcement and public health sources related to both fatal and non-fatal overdose cases. In March 2018, we recommended that ONDCP lead a review on ways to improve overdose data. ONDCP did not indicate whether it agreed with our recommendation.
While ONDCP has made efforts to support and improve existing data sources, ONDCP has not led a review to identify ways to improve the timeliness, accuracy, and accessibility of fatal and non-fatal overdose data.
ONDCP is responsible for evaluating the effectiveness of national drug control policy efforts across the government. But, in March 2020 we reported that ONDCP has not fully developed performance evaluation plans to measure progress against each of the Strategy’s long-range goals, as required by law.
These performance evaluation plans must include, for each long-range goal, for each National Drug Control Program agency, (1) specific performance measures, (2) annual and—to the extent practicable—quarterly objectives and targets for each measure, and (3) an estimate of federal funding and other resources necessary to achieve each performance objective and target.
Without effective long-term plans that clearly articulate goals and objectives and specific measures to track performance, federal agencies cannot fully assess whether taxpayer dollars are invested in ways that will achieve desired outcomes such as reducing access to illicit drugs and expanding treatment for substance use disorders.
We have also made recommendations since fiscal year 2015 to federal agencies to establish outcome-oriented performance measures for drug control programs. Implementing outcome measures can help agencies in assessing the status of program operations, identifying areas that need improvement, and ensuring accountability for end results.
Some agencies have taken action to address our recommendations. For example, as of March 2020, HHS had implemented our recommendation to establish performance measures with targets to expand access to medication-assisted treatment (MAT) for opioid use disorders. HHS has established such performance measures with targets to increase prescriptions for MAT medications and treatment capacity, as measured by the number of providers authorized to treat patients using MAT. Monitoring progress against these targets will help HHS determine whether its efforts to expand treatment are successful or whether new approaches are needed.
Demonstrated progress. Data through 2019 highlight the need to sustain drug misuse prevention, response, and recovery efforts. Rates of drug misuse increased from 2002 through 2019, and the rates of drug overdose deaths have also generally increased nationally from the early 2000s through 2019. Although the rate of drug overdose deaths in 2018 decreased compared to 2017, this improvement was reversed in 2019—specifically, the overdose death rate increased from 2018 to 2019 (from 20.7 to 21.6 deaths per 100,000 population), with the rate in 2019 being similar to the peak in 2017 (21.7 deaths per 100,000 population).
Many agencies responsible for addressing drug misuse are currently engaged in COVID-19 response and relief efforts and the attendant public health and economic effects that could fuel contributing factors of drug misuse, such as unemployment. In December 2020, the Centers for Disease Control and Prevention (CDC) reported—based on its analysis of National Center for Health Statistics provisional data—the largest recorded increase of drug overdose deaths during the 12-month period ending in May 2020. In particular, CDC reported a concerning acceleration of the increase in drug overdose deaths from March 2020 to May 2020, coinciding with the implementation of widespread mitigation measures for the COVID-19 pandemic.
Drug misuse—the use of illicit drugs and the misuse of prescription drugs—has been a persistent and long-standing public health issue in the United States. Ongoing efforts seek to address drug misuse through education and prevention, substance use disorder treatment, and law enforcement and drug interdiction, as well as programs that serve populations affected by drug misuse. These efforts involve federal, state, local, and tribal governments as well as community groups and the private sector.
National rates of drug misuse have increased over the past 2 decades and represent a serious risk to public health. This has resulted in significant loss of life and harmful effects to society and the economy, including billions of dollars in costs. In recent years, the federal government has spent billions of dollars and has enlisted more than a dozen agencies to address drug misuse and its effects.
We determined in March 2020 that this issue is high risk. At that time, in consideration of the challenges from the onset of the COVID-19 pandemic, we reported we would be making the high-risk designation effective in 2021.
Maintaining sustained attention on preventing, responding to, and recovering from drug misuse will be challenging in the coming months as many of the federal agencies responsible for addressing drug misuse are currently focused on addressing the COVID-19 pandemic. This makes developing and implementing a coordinated, strategic approach even more important as agencies’ resources are also being diverted, in part, to pandemic priorities.
Furthermore, implementing the more than 65 of our recommendations since fiscal year 2015 related to preventing, responding to, and recovering from drug misuse could serve to help agencies continue to address these challenges. See the complete list of our recommendations as a workbook file (XLSX, 37KB) or comma-separated values file (CSV, 77KB). Our findings and recommendations identify opportunities to strengthen the federal government’s efforts to address this persistent and increasing problem. For example:
- ONDCP should ensure future iterations of the National Drug Control Strategy include all statutorily required elements. Examples of statutorily required elements include a 5-year projection for the National Drug Control Program and budget priorities; a description of how each of the Strategy’s long-range goals will be achieved, including estimates of needed federal resources; and performance evaluation plans for these goals, among other requirements;
- ONDCP should ensure effective, sustained implementation of the 2020 Strategy and future Strategy iterations; and
- HHS, Education, and ONDCP should clarify how grants that can include drug prevention education programs support related goals of the National Drug Control Strategy.