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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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.
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.
Recommendations for Executive Action
|United States Customs and Border Protection||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)||
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 as well as expanding the model to deliver more ongoing analytical capability to respond to dynamic demand. In April 2020, CBP noted that it anticipated having the initial implementation of the model by the end of July 2020. In August 2020, CBP LSSD confirmed that the model was operational and would be used to inform staffing allocation decisions when labs have vacancies and if LSSD is appropriated additional funding. Further LSSD officials said that they would run the model on a quarterly basis to ensure that their staffing allocation to the labs ensures that CBP can strike the appropriate balance of volume and risk for its laboratories. We believe these efforts fulfill the intent of our recommendation, which we are closing as implemented.
|Office of National Drug Control Policy||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)||
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 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. In September 2022, ONDCP reported that they convened an Interagency Working Group on drug data issues and were working to find ways to leverage non-fatal overdose data and publish a Drug Data Plan to accompany the National Drug Control Strategy. In January 2023, ONDCP also reported that in December 2022, it launched the ONDCP Nonfatal Opioid Overdose Dashboard, which is informed by a derivation of clinical and patient characteristics within the National EMS Information System (NEMSIS) maintained by the National Highway Transportation Safety Administration. In February 2023, ONDCP reported the Drug Data Plan is at OMB for final approval and public release. We will review the Drug Data Plan, once released and continue to monitor ONDCP's efforts towards fully implementing this recommendation.
|Office of National Drug Control Policy||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)||
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. In November 2020, ONDCP provided documentation that the measures were implemented, which includes outcome-oriented performance measures such as the percentage of cases where HIDTA provided analytical support during the year. These measures are consistent with our recommendation. We are closing this recommendation as implemented.
|Executive Office for Organized Crime Drug Enforcement Task Forces||
Priority Rec.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)
We found that the Organized Crime Drug Enforcement Task Forces' (OCDETF) National Heroin Initiative had not established performance measures related to its goal of supporting local and regional initiatives to disrupt the flow of heroin into communities in every OCDETF region across the country. Therefore, OCDETF was unable to fully determine whether its resource investments were having the intended results. As a result, we recommended that OCDETF establish outcome-oriented performance measures for its National Heroin Initiative. In August 2020, OCDETF officials reported that the National Heroin Initiative was tracking measures, over time, and in each of its regions, that included the number of OCDETF cases initiated from National Heroin Initiative investigations. The officials explained that such tracking allows them to compare the performance of participating field components, better understand which efforts are working well, and adjust the efforts that may need additional attention. Further, these efforts allow OCDETF to see how efforts of the National Heroin Initiative are contributing to OCDETF's overall goal to disrupt and dismantle drug trafficking networks. Measures tracked in this manner are consistent with our recommendation.
|Department of Justice||
Priority Rec.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)
In March 2018, we reported on federal strategies to combat illicit opioids. We found that the Department of Justice had not established goals and outcome-oriented performance measures for its Strategy to Combat the Opioid Epidemic. Specifically, the Department set out its strategy with respect to opioids through a series of memos from Attorney General Lynch, Deputy Attorney General Yates, and Attorney General Sessions with focused efforts on three pillars-prevention, enforcement, and treatment. However, these memos comprising the Department's strategy did not outline goals related to the three pillars nor include outcome-oriented performance measures. Therefore, the Department was unable to set a course for its efforts and understand whether the efforts the department was undertaking as a part of the strategy were having the intended impact. As a result, we recommended that the Department, in consultation with relevant components such as the DEA and EOUSA, establish goals and outcome-oriented performance measures for its opioid strategy. In response, the Department developed a goal and outcome-oriented performance measures specific to opioids and incorporated them into the Department's broader fiscal year 2018-2022 Strategic Plan. According to Department officials, the process for developing this strategic goal and related performance measures was a collaborative process involving the Department as well as DEA, Organized Crime Drug Enforcement Task Forces, Federal Bureau of Investigations, U.S. Attorney's Offices, Criminal Division, and the Office of Legal Policy, and others. Specifically, the Department set a strategic goal to "disrupt and dismantle drug trafficking organizations to curb opioid and other illicit drug use in our nation" in its fiscal year 2018-2022 Strategic Plan The Strategic Plan also established 6 outcome-oriented performance measures to assess their progress towards that goal, such as reducing drug overdose deaths. According to Department officials, the series of memos are operational strategies to meet the broader goal in the Strategic Plan. The Department's establishment of the goal and outcome-oriented performance measures in its Strategic Plan is consistent with the intent of our recommendation. We are closing this recommendation as implemented.
|Drug Enforcement Administration||
Priority Rec.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)
We found that the Drug Enforcement Administration's (DEA) 360 Strategy had not established goals and outcome-oriented performance measures. Specifically, DEA's 360 Strategy sought to bring together three key DEA activities--enforcement, diversion control, and community engagement--under one strategy targeted towards opioids; however the strategy did not have goals or performance measures for its enforcement and diversion control activities nor did it have outcome-oriented performance measures for its community engagement activities. Therefore, DEA was unable to accurately and fully gauge these efforts and their overall effectiveness. As a result, we recommended that DEA establish goals and outcome-oriented performance measures for its enforcement and diversion control activities within the 360 Strategy and establish outcome-oriented performance measures to assess progress towards the goals for the 360 Strategy's community engagement activities. In August 2020, DEA officials informed us that the 360 Strategy was being retired and, in its place, DEA was to roll out a new program, Operation Engage, to target the top drug threats in each of its local DEA Divisions. In November 2020, DEA formally rolled out Operation Engage, which includes four outcome-oriented performance measures, such as increasing awareness and community collaboration on combating local drug threats, engaging educators and parents to use science-based prevention materials, and developing a community strategic plan of action. The establishment of these performance measures is consistent with our original recommendation for DEA's 360 Strategy. We are closing this recommendation as implemented.