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Tackling the Opioid Crisis Requires a Whole-of-Government, Society-Wide Approach
Report

Tackling the Opioid Crisis Requires a Whole-of-Government, Society-Wide Approach

The opioid epidemic is a complex public health crisis that can be ameliorated by addressing root causes of drug use; expanding access to treatment and harm reduction strategies; and reducing the supply of illicit opioids entering the United States.

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In this article
U.S. Customs and Border Protection agents sift through packages in search of fentanyl.
In a windowless hangar at New York’s JFK International Airport, dozens of U.S. Customs and Border Protection agents sift through packages, looking for fentanyl. The U.S. Postal Service facility has become one of multiple fronts in the United States’ war on opioid addiction, which kills tens of thousands of people every year and ravages communities, June 2019.
Key takeaways

  • The opioid crisis is primarily a public health issue, but it presents additional complex challenges for foreign policy, border security, and criminal justice and racial equity. An enhanced whole-of-government and society-wide approach involving coordination at the federal, state, and local levels is necessary to prevent additional overdose deaths.

  • Congress and policymakers at all levels of government should expand access to evidence-based community harm reduction, treatment, and recovery options. Policies must address the social determinants of health and ensure equitable access to treatment options in the most heavily affected communities.

  • The majority of fentanyl traffickers are U.S. citizens, and the majority of fentanyl entering the United States is seized from vehicles coming through legal ports of entry. Congress should provide resources for the U.S. Department of Homeland Security (DHS) to invest in scanning technologies at all ports of entry to reduce the supply of illicit opioids entering the United States. DHS should also continue working strategically with other federal, state, and local partners to interdict trafficked fentanyl.

  • Internationally, an array of actors, both in the licit and illicit economies, in two main countries—China and Mexico—play an outsize role in the production and trafficking of fentanyl. The U.S. Department of Justice (DOJ) should target the brokers of precursor chemicals in Mexico and China with individualized sanctions and prosecution, working with private sector players in the chemical and pharmaceutical industries to devise financial safeguards akin to “know your customer” regulations in the banking sector.

  • Actionable criminal legal reform measures, centered around public health and safety, are needed to address fentanyl misuse and the opioid crisis but should reject the aggressive enforcement strategies that proliferated during the war on drugs, which failed to reduce overdose deaths and led to overcriminalization for communities of color. The role of local law enforcement in combating the opioid crisis should be to drive down drug-related violence, and communities should implement diversion and support programs to facilitate access to drug addiction treatment for individuals impacted by the criminal legal system.

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Introduction and summary

The United States has the world’s highest rate of opioid-involved deaths.1 Since 1999, more than 1 million people have died from drug overdoses in the United States, with an increasing share of those deaths occurring from opioids.2 In 2022 alone, more than 100,000 people died from drug overdoses3—the leading cause of injury mortality in the United States,4 surpassing motor vehicle accidents and gun violence.5 Of these deaths, more than 83,000 involved opioids.6 Fentanyl, a synthetic opioid, was the leading cause of rising death rates for Americans ages 18 to 49 in 2021, according to a Washington Post analysis.7 Opioid use during pregnancy has also risen significantly, with implications for maternal and infant outcomes.8 The overdose epidemic grew rapidly during times of economic insecurity9 and the COVID-19 pandemic,10 which led to social isolation and barriers for accessing in-person addiction treatment. In addition to causing devastating losses of life in families11 and communities,12 the overdose crisis is responsible for an estimated $1 trillion in annual costs to the U.S. health care and criminal justice systems, and lost productivity from premature deaths.13

Though many politicians have dangerously and irresponsibly perpetuated anti-immigrant rhetoric,14 most fentanyl traffickers are U.S. citizens and legal residents, and the majority of fentanyl entering the United States is seized from vehicles coming through legal ports of entry.15 While border security solutions are necessary to any whole-of-government approach to address the opioid overdose crisis, border policies alone are not sufficient for addressing a complex public health crisis. The narrative by some Republicans implicating immigration as a cause of this crisis—and threatening the use of military force in Mexico to counter drug cartels—is irresponsible, dangerous, and detrimental to building the partnerships necessary between the United States and Mexico to work together effectively to tackle illicit drug production and distribution.16 The opioid epidemic is a complex public health issue that cannot be credibly linked to immigration or asylum-seekers.17

Since 1999, more than 1 million people have died from drug overdoses in the United States, with an increasing share of those deaths occurring from opioids.

The current opioid epidemic presents a complex and multifaceted challenge that cannot be tackled by a single approach. According to the Commission on Combating Synthetic Opioid Trafficking, the overdose epidemic presents one of the most pressing national security, law enforcement, and public health challenges in the United States today.18 As the administration and policymakers consider options to meet these challenges, it is imperative that the ineffective war on drugs—which treated addiction as a criminal justice rather than public health issue and led to overcriminalization for communities of color—not be repeated.19 In addition to centering public health solutions that focus on expanding access to prevention, treatment, and recovery support services, the administration and policymakers must also focus on fostering international cooperation to detect and disrupt illicit opioid production and trafficking from China20 to Mexico.21

Government officials and policymakers should implement these actionable and evidence-based recommendations to address the complex challenges of the opioid overdose epidemic:

Public health solutions

  • Expand access to evidence-based treatment and recovery services, such as naloxone, an opioid overdose reversal agent, and fentanyl test strips; medication-assisted treatment (MAT), which includes medications and therapy to treat opioid use disorder; and syringe services programs.
  • Address the needs of heavily affected communities by implementing policies and programs that support equitable access to treatment and recovery services, eliminate discriminatory policies, and invest in communities by addressing health disparities.
  • Tackle the underlying causes of drug use in communities by implementing policies and programs that address the social determinants of health and support people in meeting their basic needs, such as child care, universal paid sick time, and workforce development investments to reduce poverty, address socioeconomic inequities, and improve economic security.

Border security solutions

  • Invest in scanning technologies at all ports of entry to screen passenger vehicles and freight cargo entering the United States to help ensure that illicit opioids are not being trafficked across land borders.
  • Deploy personnel and resources in strategic and targeted fentanyl anti-trafficking operations to interdict illicit fentanyl at land ports of entry, airports, and rail and maritime freight shipping hubs.
  • Continue partnering with the U.S. Postal Service to leverage technology to intercept illicit opioids, ensuring it has the capacity and resources to detect lethal narcotics entering the United States through the international mail system.
  • Conduct evidence-based research and oversight of drug interdiction efforts to ensure that enforcement measures are effective and implemented in a timely manner and that law enforcement officials involved are adhering to the highest professional standards.

Foreign policy solutions

  • Target key actors in fentanyl trade through individualized sanctions and prosecutions to disrupt key choke points in the global fentanyl production and supply chain and to prevent these actors from accessing the U.S. and international financial systems.
  • Create accountability mechanisms for the chemical and pharmaceutical sectors, with help from international partners and major private sector players in these industries, to devise and implement safeguards, akin to “know your customer” regulations in the banking sector, that can disrupt global fentanyl production and trafficking.

Criminal justice and racial equity solutions

  • Build trust between police and the communities they serve to ensure quality drug enforcement standards that strengthen police-community relations, drive down drug-related violence, and hold law enforcement accountable to maintaining equitable and just standards in their enforcement practices.
  • Implement pre-booking diversion programs to divert individuals with often-untreated substance use disorders away from the criminal legal system and into appropriate treatment and support services, helping to reduce overdoses in the long run.
  • Rethink the automatic scheduling of all fentanyl-related substances to ensure that the response to the opioid overdose crisis complements public health efforts that increase the availability of prevention and treatment, specifically by allowing scientists to continue developing treatments for fentanyl-related overdoses, without fueling mass incarceration.
  • Invest in reentry programs for criminal legal system-impacted individuals with substance use disorders to expand access to treatment and recovery services upon release, decreasing overdose risks and recidivism as well as costs to the criminal justice and health care systems.
The opioid crisis can only be addressed by cooperation at all levels of government and society and will be worsened by fearmongering about immigration and political inaction on credible solutions.

More than a million additional people in North America are expected to die from opioid overdose by the end of the decade.22 This crisis can only be addressed by cooperation at all levels of government and society and will be worsened by fearmongering about immigration and political inaction on credible solutions. A whole-of-society and whole-of-government approach is needed at the national, state, and local levels to address the opioid epidemic by addressing the root causes of drug use, expanding access to addiction treatment and harm reduction strategies, and reducing the supply of illicit opioids entering the United States.

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The Biden administration’s actions to address the opioid epidemic should be strengthened with support from Congress

The Biden administration has taken a multipronged, government-wide approach to combat the opioid epidemic.23 Through the American Rescue Plan, the administration has invested more than $5 billion in increasing access to mental health care and in preventing and treating opioid addiction, with funding for community-based prevention and treatment efforts, expanding health care infrastructure, and harm reduction services.24

Harm reduction is critical for overdose prevention

Harm reduction25 is an evidence-based public health approach that engages and supports people who use drugs and provides them with the services and resources they need to improve their physical, mental, and social well-being.26 Addressing broad health and social issues in a compassionate manner builds trust and empowers drug users to reduce the harms of drug use, including injury, infectious disease, and overdose. Harm reduction is part of a comprehensive prevention, treatment, and recovery strategy that can improve access to health care services and resources, including substance use and mental health disorder treatment, fentanyl test strips to help prevent overdose, naloxone to reverse an overdose, and other needed services. Harm reduction is a critical component of the U.S. Department of Health and Human Services’ Overdose Prevention Strategy.27

Additionally, in an effort to address the flow of illicit opioids into the United States, the Biden administration has adopted several supply reduction measures, including enforcing targeted sanctions against foreign entities;28 partnering with Mexico, Colombia, and the United Nations to disrupt the global flow of illicit drugs;29 coordinating domestic enforcement efforts through the Drug Enforcement Administration (DEA); and calling for Congress to pass legislation30 to designate fentanyl-related substances as Schedule I substances with no medical use and high potential for abuse.31 For fiscal year 2024, the Biden administration has asked Congress for a historic $46.1 billion for National Drug Control Policy agencies to continue expanding prevention, treatment, and recovery support services32 and for $40 million to combat fentanyl trafficking and disrupt transnational criminal organizations.33

Through the American Rescue Plan, the administration has invested more than $5 billion in increasing access to mental health care and in preventing and treating opioid addiction.

A recent analysis found that federal prosecutions and convictions for drug-related crimes, particularly those involving methamphetamines and fentanyl, are on the rise under the Biden administration34 after record lows under the prior administration.35 This is because federal prosecutors have shifted their focus from offenses involving marijuana to offenses involving controlled substances such as methamphetamines and fentanyl. In 2018, fentanyl-related convictions were rare, with only 63 being reported.36 Yet during the first half of 2023, they reached more than 1,200.37 Overdoses have also continued to rise to record highs,38 demonstrating that the increased focus on law enforcement solutions alone is not enough to address a worsening public health crisis.

Public health solutions

Opioid overdose deaths have increased steadily since the 1990s39 and will remain high unless policymakers at all levels of government rapidly deploy and expand evidence-based public health measures.40 Research shows that only about 28 percent of people get the opioid addiction care they need,41 with major disparities in access to care for “younger age groups, pregnant women, residents of rural counties, adults involved in the criminal legal system, and racial and ethnic minority individuals.”42

The waves of the opioid epidemic

According to the Centers for Disease Control and Prevention (CDC), there have been three distinct but interconnected waves of the opioid overdose epidemic.43 The first began in the 1990s with the increased prescribing of opioids to treat pain, followed by a second wave beginning in 2010 characterized by heroin overdose deaths.44 The third wave of the opioid epidemic began in 201345 and has been driven by synthetic opioids;46 fentanyl emerged as the most prevalent opioid involved in overdoses during this third wave of the opioid epidemic. And recent data suggest that there is a nascent fourth wave:47 Illicitly manufactured fentanyl, not to be confused with pharmaceutical fentanyl commonly used in anesthesia, has been rapidly introduced into the illicit drug supply48 by drug dealers mixing it with other drugs.49 Due to its potency, just a small amount of fentanyl can be lethal.50

Policymakers at all levels of government must continue to address the opioid epidemic as a public health crisis by expanding treatment for substance use disorder, in addition to domestic and international enforcement measures to tackle drug trafficking. These measures, paired with additional policy solutions below, can ensure an effective and comprehensive response to the opioid epidemic.

Expand access to evidence-based treatment and recovery services

Expanding access to evidence-based community harm reduction, treatment, and recovery options is critical to reduce opioid overdoses. These strategies include access to naloxone, a medication that can reverse an opioid overdose, as well as fentanyl test strips; medication-assisted treatment (MAT), which includes medications along with counseling and behavioral therapy to treat opioid use disorder; training and support for health care practitioners to provide MAT and safe opioid prescribing practices; syringe services programs;51 and “good Samaritan” laws that provide limited immunity from drug-related criminal charges for victims and/or bystanders who call first responders for an overdose.52 Despite overdoses being preventable, the CDC found that from 2019 to 2020, most people who died by overdose had no evidence of substance use treatment before their deaths.53

Expanding access to Narcan can prevent overdoses

The U.S. Food and Drug Administration (FDA) approval of the first-ever Narcan naloxone over-the-counter nasal spray in March 2023 was a critical step toward expanding access.54 Research shows that when Narcan is made widely available and community members are trained on how to use it, overdose deaths decrease.55 Reductions in cost to make the drug more accessible and affordable,56 placement of Narcan in accessible areas within pharmacies, and widespread training for community members on how to use Narcan are therefore important to reduce stigma and further expand access and use.57

In 2021, 46 states agreed to a $26 billion national settlement with pharmaceutical distributors and manufacturers to resolve opioid lawsuits for fueling the opioid epidemic.58 An additional settlement of $13.8 billion with pharmacy chains followed.59 Most of the funds, which vary by state, are intended to be used for opioid remediation efforts.60

Despite overdoses being preventable, the CDC found that from 2019 to 2020, most people who died by overdose had no evidence of substance use treatment before their deaths

As states develop plans and processes for allocating opioid settlement funds, they should prioritize evidence-based approaches and ensure that they align their strategies with preexisting state plans and federal resources such as State Opioid Response Grants and Substance Abuse Prevention and Treatment Block Grants.61 In addition to various substance use disorder treatment and recovery initiatives already underway, the White House announced in May 2023 that the Substance Abuse and Mental Health Services Administration (SAMSHA) would be awarding $5.4 million in grants to “increase access to and quality of long-term recovery support for people with substance use disorders and co-occurring substance use and mental health disorders.”62

Address the needs of heavily affected communities and ensure equitable access to treatment and recovery services

Even though communities of color have similar rates of substance use disorder as other racial groups,63 Black and Indigenous communities have experienced a more rapid increase in the rate of opioid overdose deaths in recent years compared with the white population,64 calling for a need to examine how structural racism and inequity influence root causes of drug use, treatment, and response.

An estimated 8.3 million Black and Latino residents live in “pharmacy deserts,” disproportionately limiting their access to lifesaving treatment.

Communities of color face more access barriers to high quality treatment and recovery services. A November 2022 study found that racial and ethnic minority patients receive buprenorphine treatment—used to treat opioid use disorder—for shorter periods of time than white patients.65 Moreover, a May 2023 analysis of Medicare claims data for patients with disability from 2016 to 2019 found that Black and Hispanic patients were less likely than white patients to receive opioid use disorder medications despite frequent interactions with the health care system.66 An estimated 8.3 million Black and Latino residents live in “pharmacy deserts,” disproportionately limiting their access to lifesaving treatment.67

Given these inequities, policies and programs geared toward addressing substance use must support equitable access to treatment and recovery services, eliminate discriminatory policies, and invest in communities by addressing health disparities. For example, strategically targeting outreach and locating support services in communities of color could improve access to treatment and mitigate barriers that impede access, such as lack of transportation. Expanding access to treatment services must also include hiring a diverse workforce from within the communities being served and integrating culturally competent and language-appropriate strategies.68

Tackle the underlying causes of drug use in communities

The increase in deaths attributable to drug overdose, alcohol, and suicide between 1999 and 2013 has been referred to as “deaths of despair,”69 a term coined by economists Anne Case and Angus Deaton.70 Factors that have fueled drug use include eroding economic opportunity,71 along with changes in medical treatment of pain and limited addiction treatment. Indeed, factors such as low income and education levels, high job insecurity, unemployment, housing insecurity or significant changes in housing wealth, and living in rural areas have been associated with deaths of despair.72 The disparities seen in overdose deaths are often driven by these socioeconomic inequities, notably income inequality. Addressing social determinants of health and unequal access to substance use treatment services is therefore critical.

The COVID-19 pandemic also led to social isolation, which has been cited as a factor regarding opioid overdoses.73 Policies and programs to support people in meeting their basic needs—such as child care,74 universal paid sick time,75 and workforce development investments,76 along with jobs and community investment77—can reduce poverty and improve economic security, addressing some of the social determinants that drive drug use.

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Border security solutions

It is impossible to interdict every single illicit narcotic brought across all land, air, and sea entry points to the United States, and attempting to address the opioid overdose crisis solely through the lens of drug seizures at the southern border misses the mark. For one thing, in previous waves of the epidemic, domestic production of opioids and overprescription were the primary cause of opioid-related deaths—not illicit drugs imported into the country.78 More than 234,000 people died in the United States due to opioid overdoses between 1999 and 2012 during the first and second waves of the crisis.79 Illicit opioid use only accounted for 46 percent of these deaths, while overdose deaths involving prescription opioids increased by more than four times.80

Today, fentanyl is being trafficked into the United States through land and maritime borders,81 airports,82 and international mail processing centers.83 Federal officials estimate that they are only interdicting 5 to 10 percent of the fentanyl being smuggled across the border from Mexico and acknowledge it could be less.84 Thus, interdiction efforts must be strategically enhanced and targeted to encompass the various methods drug traffickers use. Though interdicting illicit drugs is only one part of addressing the opioid epidemic, the United States must robustly expand supply reduction efforts to include targeting smuggling pathways beyond land borders.

More than 234,000 people died in the United States due to opioid overdoses between 1999 and 2012. Illicit opioid use only accounted for 46 percent of these deaths, while overdose deaths involving prescription opioids increased by more than four times.

Increased interdictions of fentanyl at land borders, airports, maritime ports, and in the mail are just some of the actionable solutions the Biden administration has undertaken, and additional support can be provided to increase interdictions. In fact, the volume of drug seizures of fentanyl by U.S. Customs and Border Protection (CBP) has continued to rise in 2023 compared to past years,85 indicating its increased prevalence in narcotics trafficking as well as growing improvements in detecting it, including the deployment of more sophisticated scanning technologies at land ports of entry.86

While recognizing the limitations of drug interdictions alone as part of the overall effort needed to deal with opioid overdose crisis, there are steps the Biden administration can take, working with Congress, to provide sufficient technology and staffing resources to vastly increase capability to interdict lethal narcotics, bulk cash, and smuggled firearms at U.S. land, sea, and air ports of entry.

Invest in scanning technologies at all ports of entry

The vast majority of the fentanyl seized at the southern border is trafficked by U.S. citizens or legal residents87 and arrives in vehicles through legal ports of entry.88 Pursuant to the 2021 Securing America’s Ports Act,89 DHS was mandated to come up with a plan to scan 100 percent of all passenger and freight traffic entering the United States within six years. Additional “nonintrusive inspection” (NII) technology, such as scanners for examining passenger vehicles and commercial cargo transiting through the southern border, is needed at ports of entry to ensure that illicit opioids are not being trafficked into the United States.90 If deployed on southbound lanes, these scanning technologies could also disrupt the illegal trafficking of hundreds of thousands of guns from the United States to Mexico on an annual basis.91

Deploy personnel and resources in strategic and targeted fentanyl anti-trafficking operations with federal, state, and local partners

DHS should continue surging personnel and resources such as CBP officers, Homeland Security Investigations (HSI) agents, canine units, and advanced technology to interdict illicit fentanyl. In 2023, DHS launched operations Blue Lotus and Four Horsemen, targeting fentanyl smuggling at the southern border.92 In two months, the combined operations led to the seizures of nearly 10,000 pounds of fentanyl and more than 10,000 pounds of other drugs, such as cocaine and methamphetamines. Through Operation Artemis,93 DHS has also undertaken additional interdiction efforts targeting the fentanyl production supply chain,94 including at the international mail facility at JFK International Airport, which processes more than half of all incoming mail entering the United States.95 More than 5,000 pounds of fentanyl precursor chemicals have been detected and seized in just the first few weeks of the operation. In addition to targeting land ports of entry, targeted efforts could also be coordinated at additional airports and rail and maritime freight shipping hubs—and sustained over time.

Continue partnering with the U.S. Postal Service to leverage technology to intercept illicit opioids

DHS should continue working with the U.S. Postal Service (USPS) to ensure it has the capacity and resources to detect lethal narcotics entering the United States through the international mail system.96 Pursuant to the Synthetics Trafficking and Overdose Prevention Act of 2018, USPS began collecting advanced electronic data from packages shipped from abroad and sending this information to CBP;97 and it has made great progress.98 In 2019, this information was collected for 85 percent of packages from China, compared with 32 percent in 2017, and for 60 percent of all inbound packages, compared with 26 percent in 2017.99 However, additional funding is needed to ensure the program can continue to be scaled up.100

Conduct evidence-based research and oversight of drug interdiction efforts

Federal agencies, inspectors general, and Congress should conduct robust oversight and evaluation to ensure that enforcement measures related to drug interdiction are effective and that the law enforcement officials involved are adhering to the highest professional standards. U.S. enforcement efforts to address the opioid overdose epidemic will be undermined by unlawful conduct of federal law enforcement officers, some of whom have been charged101 and convicted102 for involvement in cross-border drug trafficking. Additionally, due to issues awarding contracts and delays resulting from the General Services Administration (GSA) consultation process regarding physical infrastructure at ports of entry, the plan to install NII scanners at more ports of entry remains three years behind schedule.103

See also

Foreign policy solutions

The international fentanyl trade is a networked phenomenon that has significant and complicating overlap with important sectors of the licit economy. As with any networked threat, effective responses must be dynamic and multifaceted. Despite the eagerness of some Republicans to oversimplify the challenge, including by threatening U.S. military responses,104 the fentanyl trade is not—contrary to popular perceptions105—dominated by a small number of concentrated actors or “cartels” who can be effectively targeted to cut off the flow of fentanyl into the United States. Internationally, an array of actors, both in the licit and illicit economies, in two main countries—China and Mexico—play an outsize role in the production and trafficking of fentanyl.106

Internationally, an array of actors, both in the licit and illicit economies, in two main countries—China and Mexico—play an outsize role in the production and trafficking of fentanyl.

In recent years, U.S. law enforcement cooperation with China and Mexico has been severely strained. Through a combination of carrots and sticks, the United States must take steps to both restore effective law enforcement cooperation and broaden the number and nature of positive actors involved in targeting those who facilitate the production and movement of fentanyl as well as precursor and pre-precursor chemicals essential to the production of fentanyl.

Target key actors in fentanyl trade through individualized sanctions and prosecutions

Enforcement efforts need to be more focused on the relatively small number of brokers of precursor and pre-precursor chemicals in Mexico, as well as key suppliers in China, that largely fly under the radar but represent the closest thing to a choke point that exists in the fentanyl production and supply.107 For example, more needs to be done by DOJ to deny those engaged in producing and trafficking fentanyl access to the United States and international financial systems. Resources must be dedicated to identifying and seizing illicit finance flows that are the lifeblood of the transnational criminal organizations at the heart of the fentanyl trade.108 Key market actors, especially in China and Mexico, should be subject to individualized sanctions and prosecution.

Create accountability mechanisms for the chemical and pharmaceutical sectors

The United States and its partners in the international community must also work with major private sector players in the chemical and pharmaceutical industries to devise and implement safeguards—perhaps initially as voluntary measures—regarding with whom they do business,109 akin to “know your customer” regulations in the banking sector.110 Given the overlap between licit trade by multinational chemical and pharmaceutical companies and the fentanyl trade, reducing the flow of fentanyl into the United States will be impossible without the active participation of key private sector actors. Meanwhile, companies that continue doing business that facilitates the production of fentanyl—be it in China or in Mexico—should be denied the ability to do business in the United States and prosecuted.111

See also

Criminal justice and racial equity solutions

Actionable criminal legal reform measures are needed to address fentanyl misuse and the opioid crisis, but they should reject the aggressive enforcement strategies that proliferated during the disastrous war on drugs,112 which increased police violence against civilians113 while falling short of reducing street-level drug activity, overdose deaths, and substance abuse disorders.114 Since 1971, America has spent more than $1 trillion on the war on drugs, with robust investments in law enforcement and incarceration.115 This spurred a threefold increase in drug possession arrests between 1982 and 2007116 and a 1,216 percent increase in the state prison population for drug offenses between 1980 and 2008.117 Today, an alleged drug offense is the most common reason a person is arrested in the United States, with more than 1 million drug arrests occurring each year.118 Currently, 1 in 5 incarcerated people is being held due to a drug offense.119

The most egregious harms from the war on drugs have been concentrated among communities of color. Despite similar rates of drug use across races,120 research has shown that racial and ethnic minorities are more likely than white people to be incarcerated for drug offenses.121 Specifically, African Americans are imprisoned at nearly six times the rate of white individuals for drug charges.122

The war on drugs: By the numbers

$1T

Amount spent on the war on drugs since 1971

1,216%

Increase in state prison population for drug offenses (1980–2008)

1 in 5

Share of incarcerated population currently being held for drug offense

6x

Higher rate of imprisonment for African Americans, compared with white individuals, for drug charges

America’s approach to the current fentanyl crisis risks perpetuating failed war-on-drug policies if it prioritizes criminalizing addiction123 and mass incarceration,124 rather than harm reduction, and fails to ensure equal treatment under the law for communities of color for fentanyl-related offenses.

The role of law enforcement should focus on driving down drug-related violence while improving police-community relations. Communities should also invest in prevention strategies that address the underlying socioeconomic factors that contribute to drug misuse, as mentioned previously, and expand treatment access to criminal legal system-impacted individuals with substance use disorder.

Build trust between police and the communities they serve

In combination with increased police violence against civilians,125 discriminatory drug enforcement strategies have significantly deteriorated police-community relations,126 leading to low trust in law enforcement among Black Americans in particular.127 Communities that consider police illegitimate, untrustworthy, or unresponsive128 are less likely to turn to law enforcement for help or to report crime,129 which leads to cycles of violence and retaliation.130 They are also less likely to cooperate or offer information in investigations.131 Without community cooperation, law enforcement investigations into drug-related violence or serious high-level traffickers will be far more difficult.

Communities that consider police illegitimate, untrustworthy, or unresponsive are less likely to turn to law enforcement for help or to report crime, which leads to cycles of violence and retaliation.

To reverse this trend, law enforcement policies should focus on improving community trust and emphasizing harm reduction. Policies to increase transparency around enforcement practices, such as using body-worn cameras and making police department data publicly available, help restore public confidence. Limiting the use of force and no-knock warrants can, likewise, help limit police violence against citizens, which substantially reduces community engagement with law enforcement.132 Additional policies should include those similarly adopted by DOJ in 2022, such as training on de-escalation, an affirmative duty to intervene in instances of excessive force, and an affirmative duty to render medical aid when necessary.133

Building community trust through community responder programs

Local jurisdictions can also work to build trust between law enforcement and their communities by adopting community responder programs where specialized response teams are dispatched to substance abuse crisis calls.134 Police are often relied on to respond to crisis situations outside of their area of expertise, which can delay or even deny individuals from receiving proper care and treatment and might ultimately lead to worse outcomes, such as an arrest or fatality at the hands of police. For instance, studies have found that rates of arrest are higher for individuals in the midst of a mental health or substance use crisis.135 Community responders help to reduce the chance of a crisis situation escalating while connecting individuals to proper care and treatment in real time.

Learn more about community responders

Implement pre-booking diversion programs

Pre-booking diversion programs can play a crucial role in reducing drug use by diverting individuals with substance use disorders away from the criminal legal system and into appropriate treatment and support services. These programs aim to identify individuals who are experiencing addiction, mental health conditions, behavioral health conditions, or other social challenges—which are often the driver of their interaction with law enforcement. By establishing pre-booking diversion programs such as Law Enforcement Assisted Diversion (LEAD) programs, jurisdictions can offer an alternative to arresting individuals for low-level drug offenses related to opioid use.136 Instead, officers can exercise their discretion to divert eligible individuals away from the legal system by connecting them with a case manager who can assist the individual in obtaining community-based services, including substance use treatment programs, to help address their substance use and other needs.

Since the launch of the first LEAD program in 2011, several studies have demonstrated positive outcomes. In Seattle’s LEAD program, for example, researchers found that program participants were 58 percent less likely than people in their control group to be arrested after involvement in the program.137 Other studies have also shown that LEAD programs contribute to better housing and employment outcomes and decreased substance use among program participants.138

Reconsider the automatic and permanent scheduling of all fentanyl-related substances

In 2018, President Donald Trump temporarily classified all fentanyl-related substances (FRSs)139 as Schedule I controlled substances—a classification reserved for drugs with both high potential for abuse and no therapeutic or medical value.140 Because automatic scheduling is determined by chemical structure alone, many FRSs have gone untested for harm. Under class-wide control, any offense that involves FRSs is subject to criminal prosecution and harsh penalties, including mandatory minimums and lengthy prison sentences, regardless of the potency or purity of the FRS. Although temporary class-wide scheduling of FRSs has been in effect for more than five years, overdoses and overdose deaths have continued to steadily increase.141 Increasing the severity of criminal penalties for possession or distribution of FRSs and relying on punitive approaches has not proven to be effective in stopping overdoses or reducing the prevalence of fentanyl.142 Experts express concern that a punitive approach is beginning to result in parallel waves of racial bias and prejudice through media and law enforcement, first seen during the war on drugs.143

A permanent class-wide scheduling of FRSs may result in the criminalization of potentially therapeutic and lifesaving medications, including overdose reversal drugs. Furthermore, the classification prevents scientists from conducting additional research or developing treatments for fentanyl-related overdoses because of certain research restrictions imposed by class-wide scheduling. Any efforts to permanently or automatically schedule FRSs should allow for proper testing of the substances and include a pathway for an FRS to be removed or rescheduled if it is shown there is no potential for abuse.

Invest in reentry programs for criminal legal system-impacted individuals with substance use disorder

According to the National Institute on Drug Abuse, 85 percent of the nearly 2 million individuals incarcerated in the United States144 have active substance use disorders or were incarcerated for a charge related to drugs or drug use.145 Yet most corrections systems do not offer any treatment for incarcerated individuals with opioid use disorder, nor do they provide referral to treatment services upon release.146 For the millions of individuals in the United States released from prison and jail each year,147 reentry programs for criminal legal system-impacted individuals with substance use disorders have been proven to both decrease recidivism148 and decrease fatal overdose occurrences upon release,149 all while reducing costs to the criminal justice and health care systems overtime.150 Funding evidence-based substance use reentry programs is essential to decreasing recidivism and saving lives.

Funding evidence-based substance use reentry programs is essential to decreasing recidivism and saving lives.

For individuals already receiving treatment for substance use disorder, jail and prison time can disrupt their health management and leave them without access to quality care while incarcerated.151 Many incarcerated individuals with untreated opioid addictions experience a reduced tolerance to opioids due to abruptly terminating drug use when entering the carceral system.152 When opioid addictions go untreated during their entire time incarcerated, they are at elevated risk of fatal overdose upon release.153 Insufficient counseling and treatment availability behind bars and once released contribute to high overdose death risk and recidivism.154

The Federal Bureau of Prisons (BOP) developed a drug abuse treatment trial program in 2010 and found that people who participated in the program while incarcerated were 27 percent less likely to recidivate.155 Despite robust evidence of effectiveness,156 substance use treatment in reentry programs has been underfunded and underutilized.157

Additional reading

Conclusion

Without a whole-of-society and whole-of-government approach to addressing the opioid overdose crisis, more than a million additional people in North America will likely die from opioid overdose by the end of this decade.158 The Biden administration and Congress must continue to invest in evidence-based prevention, treatment, harm reduction, and recovery support services; strengthen security and scanning infrastructure in mail-sorting facilities and at ports of entry; and work with global partners to strategically target international actors involved in the illicit drug trade in order to address the complex opioid crisis. Given the alarming rate of increase in opioid-related overdose deaths in the United States in the past decade,159 it is critical that a multipronged set of solutions across disciplines, from public health to national security, cuts through this issue to outpace the opioid crisis.

The seriousness of the current opioid crisis demands that elected officials set aside their ideological differences and join forces to get behind an evidence- and solutions-based approach.

Policymakers at the national, state, and local levels of government should strengthen this response to address the crisis on both the supply and demand sides. In addition to reducing the supply of illicit opioids entering the United States, more steps should be taken to tackle the underlying causes of drug use, improve health care infrastructure and addiction treatment access for heavily affected communities, and implement harm reduction strategies. Throughout these efforts, it is crucial that necessary guardrails are in place to ensure that the mistakes of the ineffective war on drugs, which criminalized addiction rather than treating it and led to disproportionately punitive impacts for communities of color, are not repeated.

The seriousness of the current opioid crisis demands that elected officials set aside their ideological differences and join forces to get behind an evidence- and solutions-based approach. Failing to recognize the public health roots of this crisis and instead weaponizing the crisis will needlessly cost lives.

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Acknowledgements

The authors would like to thank Emily Gee, Will Roberts, Rachael Eisenberg, Lindsey McLendon, Joel Martinez, Sarnata Reynolds, Kate Donald, Nick Wilson, Tom Jawetz, and Silva Mathema for their input and feedback.

Endnotes

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Authors

Trinh Q. Truong

Policy Analyst, Immigration

Debu Gandhi

Senior Director, Immigration Policy

Jill Rosenthal

Director, Public Health

Marquisha Johns

Associate Director, Public Health

Mariam Rashid

Associate Director

Dan Restrepo

Senior Fellow

Akua Amaning

Director, Criminal Justice Reform

Cleo Bluthenthal

Intern

Team

Immigration Policy

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