Illicit Opioids:

While Greater Attention Given to Combating Synthetic Opioids, Agencies Need to Better Assess their Efforts

GAO-18-205: Published: Mar 29, 2018. Publicly Released: Apr 12, 2018.

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    INFOGRAPHIC: Stopping the Misuse of Fentanyl and Other Synthetic Opioids

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Diana C. Maurer
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maurerd@gao.gov

 

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What GAO Found

Federal agencies collaborate with foreign governments, such as China, Mexico, and Canada, as well as with international organizations, to limit the production of illicit synthetic opioids. They do this by enhancing investigations, sharing information on emerging trends, helping to expand the regulation of illicit substances, and building capacity to thwart the distribution of illicit drugs.
 
Federal agencies have ongoing efforts to limit the domestic availability of and enhance their response to illicit synthetic opioids. For example, federal efforts include treating overdose death scenes as crime scenes where officers collect evidence to investigate and identify the drug source.
 

Overdose Deaths Involving Synthetic Opioids and Size of a Lethal Dose of Fentanyl

 
Federal agencies have also documented specific strategies to combat illicit opioids. However, only one of the five strategies we reviewed included outcome, or results-oriented measures—largely due to agency perceptions that designing such measures posed challenges. The Government Performance and Results Act Modernization Act of 2010 directs agencies to develop goals, as well as performance indicators. Without specific outcome-oriented performance measures, federal agencies will not be able to truly assess whether their respective investments and efforts are helping them to limit the availability of and better respond to the synthetic opioid threat. We also found that while federal law enforcement agencies are increasingly coordinating with the public health sector to share overdose information, both sectors reported ongoing data sharing obstacles and related challenges with the timeliness, accuracy, and accessibility of overdose data. Standards for Internal Control in the Federal Government states that information for decision-making should be appropriate, current, complete, accurate, accessible, and provided on a timely basis. Embarking on a
concerted effort, led by the Office of National Drug Control Policy (ONDCP), to examine and address data related concerns will enhance agencies’ efforts continue to understand and respond to the opioid epidemic.
 
Federal agencies have adapted to the opioid epidemic by, among other things, expanding prevention programs and treatment options. For example, agencies have increased engagement with medical professionals about the implications of prescribing practices to help reduce opioid abuse, and provided additional resources to states and localities to expand the distribution and use of overdose reversal and treatment options.
 

Why GAO Did This Study 

Increased illicit use of synthetic (manmade) opioids has contributed to drugrelated overdose deaths. Synthetic opioids like fentanyl—a substance 100 times stronger than morphine— accounted for more than 19,000 of the nearly 64,000 overdose deaths in 2016, the most recent year for which
federal data are available. GAO was asked to review U.S. agency efforts to combat illicit synthetic opioids.
 
This report examines how U.S. agencies (1) work with international partners to limit production of illicit synthetic opioids; (2) work domestically to limit the availability of and enhance their response to these drugs and how agencies can improve their effectiveness; (3) measure performance in their documented opioid response strategies; and (4) have adapted their approaches to prevention and treatment.
 
GAO reviewed documents that described agencies’ international coordination efforts, domestic opioid reduction strategies and prevention and treatment approaches, and interviewed international and federal agency officials engaged in drug control policy. GAO also interviewed state and local law enforcement and public health officials in seven states, selected in part for their high rates of overdose deaths.
 

What GAO Recommends

GAO is making six recommendations, including that agencies develop performance metrics. DHS agreed, ONDCP did not state whether they agreed or disagreed, and DOJ did not agree with GAO’s recommendations. GAO continues to believe that these recommendations remain valid.
 
For more information, contact Diana Maurer at (202) 512-8777 or maurerd@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: In its written comments to our report, dated March 5, 2018, DHS stated that CBP planned to establish a working group to assess LSSD risk and resource allocations, analyze and assess its current program to support analysis and triage of suspected chemical parcels and determine whether the program could be expanded for 24/7 operations. Further, in May 2018, DHS stated that LSSD would assess risk per port of entry and establish policies and procedures to address resource allocations. To accomplish this, DHS stated that it had established a working group in March 2018 to assess LSSD risk and resource allocations. In addition, LSSD, with support from the Operations Support Integrated Planning Division, developed a risk matrix that is intended be used to inform leadership decisions about staff allocations. The risk matrix allows LSSD to identify field locations that represent areas of risk based on one or many threats. LSSD also developed a methodology paper that details how the risk matrix is "scored" to identify the field locations with the highest risk. According to CBP officials, it plans to continue to utilize the methodology and the risk matrix to periodically assess whether LSSD's resources are allocated appropriately. In addition, in December 2018, CBP officials stated that LSSD had completed its assessment and evaluation of its pilot program to assign front-line chemists to work alongside CBP officers at two ports of entry. In July 2019, CBP finalized its report of its findings and recommendations and concluded that the additional support from LSSD chemists at the ports of entry enhanced CBP's operations. Further, in July 2019, CBP reported that that it was working to identify high-level strategic options and build an initial prototype model for determining ports of entry with the greatest need for LSSD resources and risk-based staff and resource allocations. CBP also reported that it was working to expand the model to deliver more ongoing analytical capability to respond to dynamic demand. CBP noted that it anticipates having the initial implementation of the model beginning at the end of 2019. Once LSSD has completed the initial implementation of its model, GAO will review information on the model and work with CBP on the closure of this recommendation.

    Recommendation: The Commissioner of U.S. Customs and Border Protection (CBP) should, in consultation with the Executive Director of CBP's Laboratories and Scientific Services Directorate (LSSD) and the Laboratory Directors, assess volume and risk at each port of entry to determine those with the greatest need for resources, use this information as a basis for staff allocations, and document its risk-based, staff allocation process to ensure that CBP and LSSD priorities can be accomplished as effectively and efficiently as possible. (Recommendation 1)

    Agency Affected: Department of Homeland Security: United States Customs and Border Protection

  2. Status: Open

    Comments: In the 60-day letter, dated June 28, 2018, ONDCP officials noted a number of federal initiatives underway to evaluate the timeliness, accuracy, and accessibility of overdose data. For example, ONDCP discussed its participation in a new Interagency Working Group led by the National Security Council to consider the implementation of overdose tracking and analytic capability, such as the expansion of ODMAP, as well as evaluating the appropriate federal role to engage in this initiative. In March 2019, ONDCP reported that it had suspended its ODMAP working group in the summer of 2018, after determining that this effort would be more effective for the Department of Justice's Bureau of Justice Assistance (BJA) and the Centers for Disease Control and Prevention (CDC) to work together through the Comprehensive Opioid Abuse Program Initiative. Nevertheless, as of April 2019, ONDCP officials reported that they continue to provide grant funding and training and technical assistance towards the expansion and use of ODMAP by state and local jurisdictions. Further, ONDCP reported supporting other federal data initiatives, such as providing funding to develop software for the CDC's National Center for Health Statistics Mortality Data that could better read narrative fields in death certificates to improve the timeliness and accuracy of the data. While ONDCP's efforts are directed towards supporting and improving existing data sources, the recommendation asks ONDCP to lead a review which it has not done. Further, ONDCP's initiatives to date have not addressed issues raised in our report related to balancing law enforcement's access to restricted health data while protecting patient privacy. We will continue to monitor ONDCP's efforts towards implementing this recommendation.

    Recommendation: The Director of ONDCP, in collaboration with law enforcement and public health counterparts, should lead a review on ways to improve the timeliness, accuracy, and accessibility of fatal and non-fatal overdose data from law enforcement and public health sources that provide critical information to understand and respond to the opioid epidemic. Such a review should expand on and leverage the findings from previous federal studies. It should also assess the benefits and scalability of ongoing efforts to leverage data systems, such as the Washington-Baltimore High-Intensity Drug Trafficking Areas' (HIDTA) OD MAP program, and examine ways in which laws that restrict access to public health data to protect patient privacy have exemptions for law enforcement entities that could be more widely leveraged while protecting patient privacy. (Recommendation 2)

    Agency Affected: Executive Office of the President: Office of National Drug Control Policy

  3. Status: Open

    Comments: In the 60-day letter, dated June 28, 2018, ONDCP officials stated that they had engaged with leaders from HIDTA participating in the Heroin Response Strategy to develop performance measures. According to ONDCP, as of early May 2018, eleven performance measures had been established--nine mandatory measures and two optional measures--and four of these measures constitute outcome-oriented measures. The June letter also noted that the HIDTA Performance Management Process database was being updated to reflect the new measures and ONDCP expected the system to be fully operational by the end of September 2018. In March 2019, ONDCP reported that, throughout the summer of 2018, it had revisited the performance measures it had developed and settled on ten revised performance measures (eight mandatory measures and two optional measures) for the newly branded Opioid Response Strategy (formerly known as the Heroin Response Strategy). According to ONDCP, these measures were implemented in HIDTA's Performance Management Process as of February 1, 2019. We will continue to coordinate with ONDCP to obtain documentation of these new measures. Once we obtain them, we will review and work toward closing the recommendation, as appropriate.

    Recommendation: The Director of ONDCP should work with the HIDTAs participating in the Heroin Response Strategy to establish outcome-oriented performance measures for the four main goals set out in the strategy. (Recommendation 3)

    Agency Affected: Executive Office of the President: Office of National Drug Control Policy

  4. Status: Open

    Comments: In its 60 Day-letter, dated June 26, 2018, officials from the Organized Crime Drug Enforcement Task Force (OCDETF) noted the output metrics and statistics that OCDETF is tracking as part of its National Heroin Initiative. For example, the letter states that OCDETF will track statistics on opioid overdose deaths, however it is unclear how this tracking effort is being incorporated into the National Heroin Initiative. While our report noted that statistics on overdose deaths have been used as outcome-oriented measures by agencies like the Office of National Drug Control Policy to assess its efforts, it is unclear how OCDETF is using these statistics to assess its performance and inform its efforts under the National Heroin Initiative. In October 2018, OCDETFs National Heroin Initiative Coordinator told us that the OCDETF Regional Directors were in the process of establishing and tracking region-specific metrics, such as local data on drug overdoses. In October 2019, we reached out to OCEDTF officials for an update, and they did not have any further information to provide. We will continue to follow-up with OCDETF on their progress towards implementing the recommendation.

    Recommendation: The Executive Director of Organized Crime Drug Enforcement Task Forces should work with the National Heroin Initiative Coordinator to establish outcome-oriented performance measures for the goals set out for National Heroin Initiative. (Recommendation 4)

    Agency Affected: Department of Justice: Organized Crime Drug Enforcement Task Forces

  5. Status: Open

    Comments: In its 60 Day-letter, dated June 26, 2018, DOJ officials reported a number of output measures, such as conviction rates, that they will use to assess the effectiveness of the department's efforts to respond to the opioid epidemic. However, it is unclear how, if all, these measures have been incorporated into the department-wide strategy or if additional outcome-oriented metrics are being developed. In October 2018, DOJ officials reported that while they have not updated the strategy, then-Attorney General Sessions had issued a memo to the U.S. Attorneys that communicated some goals for their efforts, such as reductions in overdose deaths, and called for the U.S. Attorneys Office's Regional Opioid Coordinators to develop metrics specific to their regions. In October 2019, DOJ officials reported that the department is currently working on finalizing its Annual Priority Goals and related performance measures with respect to opioids, however they could not provide additional details nor a timeline for when these efforts are to be completed. We will continue to coordinate with DOJ to learn more about the these efforts and when officials expect them to be implemented.

    Recommendation: The Attorney General should, in consultation with its relevant components such as the Drug Enforcement Administration (DEA) and Executive Office for United States Attorneys (EOUSA), establish goals and outcome oriented performance measures for its Strategy to Combat the Opioid Epidemic. (Recommendation 5)

    Agency Affected: Department of Justice

  6. Status: Open

    Comments: In its 60-Day Letter, dated June 26, 2018, DEA officials noted the steps they had taken to develop performance metrics for its enforcement and diversion control activities under the 360 Strategy and reported that DEA had implemented outcome-oriented performance metrics for the 360 Strategy's community engagement activities for fiscal year 2019. Further, DEA officials noted applying DEA's Threat Enforcement Planning Process (TEPP) specifically to the 360 Strategy to develop outcome-oriented metrics. Further, according to DEA officials, the TEPP includes an impact report that assesses the outcomes of the activities undertaken under 360. In October 2018, DEA told us that TEPP was still in development and they did not give a date for projected completion. In October 2019, we reached out to DEA officials for an update, and they did not have any further information to provide. We will continue to follow up with DEA officials on their progress.

    Recommendation: The DEA Administrator should establish goals and outcome-oriented performance measures for the enforcement and diversion control activities within the 360 Strategy and establish outcome-oriented performance measures for the community engagement activities within the 360 Strategy. (Recommendation 6)

    Agency Affected: Department of Justice: Drug Enforcement Administration

 

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