Opioids: Treating an Illness, Ending a War

Executive Summary

More people died from opioid-related deaths in 2015 than in any previous year. This record number quadrupled the level of such deaths in 1999. Unlike the heroin and crack crises of the past, the current opioid emergency has disproportionately affected white Americans—poor and rural, but also middle class or affluent and suburban. This association has boosted support for preventative and treatment-based policy solutions. But the pace of the response has been slow, critical components of the solution—such as health insurance coverage expansion and improved access to medication-assisted treatment—face resistance, and there are growing efforts to revamp the failed and costly War on Drugs.

This report examines the sources of the opioid crisis, surveys health and justice policy responses at the federal and state levels, and draws on lessons from past drug crises to provide guidance on how to proceed.

The War on Drugs did not play a major role in ebbing past cycles of drug use, as revealed by extensive research and the reflections of police chiefs. In 2014, the National Research Council concluded:¹

The best empirical evidence suggests that the successive iterations of the war on drugs—through a substantial public policy effort—are unlikely to have markedly or clearly reduced drug crime over the past three decades.

Growing public awareness of the limited impact and devastating toll of the War on Drugs has encouraged many policymakers and criminal justice practitioners to begin its winding down. The number of people imprisoned nationwide for a drug offense skyrocketed from 24,000 in 1980 to a peak of 369,000 in 2007.² It has since declined by nearly one-quarter, reaching approximately 287,000 people in the most recent count.³

The lessons from past drug crises and the evidence base supporting a public health approach can guide policymakers as they seek an end to the current opioid crisis. Recommended strategies include:

End Overprescribing of Opioids

A key step in tackling the opioid crisis is to reverse the historically unprecedented and internationally anomalous rate at which U.S. physicians are prescribing opioids. To address overprescribing:

• Align physicians’ prescribing practices with the Centers for Disease Control and Prevention’s (CDC) guidelines to ensure adequate consideration of risks and proper dosage.
• Revise health insurance policies to increase access to medications that carry a lower risk of addiction or dependence, and non-drug treatments.
• Improve the use of drug monitoring programs at the state level to identify problematic prescribing practices among physicians and support patients who need treatment for an opioid use disorder.
• Address illegal opioid sales by wholesale companies.

Expand Access to Treatment for Drug Use Disorders

Policymakers should close the treatment gap for both the general and incarcerated populations, and ensure investment in effective forms of treatment.

• Continue to expand health insurance coverage so that people can access healthcare and mental health services that assist in preventing and treating opioid use disorder. Lack of health insurance and the expense of treatment were the top-ranked reasons why people who wanted treatment for a substance use disorder did not receive it in 2015.⁴
• Improve enforcement of the Mental Health Parity and Addiction Equity Act to increase health insurance coverage of treatment for substance use disorder. Lowering barriers to receiving medication-assisted treatment, as recommended by the American Medical Association, would enable more people to access what the CDC, National Institute on Drug Abuse, and the World Health Organization consider the most effective form of treatment for opioid use disorder.⁵
• Prioritize drug treatment in communities and not in the criminal justice system, while ensuring that those who are brought into the system receive effective treatment. The federal Bureau of Prisons, state prisons, and local jails should follow the recommendation of the President’s Commission on Combating Drug Addiction and the Opioid Crisis to increase access to medication-assisted treatment, particularly using methadone or buprenorphine.⁶

Reduce Overdose Deaths

While use-reduction policies are important to mitigating the opioid crisis, it is also critical to reduce the harms caused by opioid use disorder.

• Broadly expand access to and training for administering naloxone to prevent overdose deaths.
• Implement supervised consumption sites and syringe service programs to reduce the spread of infectious diseases and overdose deaths among opioid users.
• Educate individuals who are using opioids on the risks of mixing substances.

End the Drug War

Policy makers and criminal justice professionals should continue to significantly reduce the use of incarceration for all drug types and eliminate the collateral consequences imposed on people with drug convictions.

• Given the evidence that incarceration of drug users and sellers is not an effective remedy for substance use disorder, significantly reduce the number of people incarcerated for possessing or selling drugs of all types.
• To address the harms caused by the more punitive response to past drug crises and by ongoing enforcement, ensure that people with felony drug convictions are not barred from federal benefits such as the Supplemental Nutrition Assistance Program and federal student aid.

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