The opioid crisis in America: Domestic and international dimensions

Cataldo Ambulance medics Rick Yunker (L), Derek Travers (C) and Timothy Stahl revive a 38-year-old man who was found unresponsive after an opioid overdose in the parking lot of a Walgreens drug store in the Boston suburb of Malden, Massachusetts, U.S., October 19, 2017. The man was revived with 4mg of naloxone. REUTERS/Brian Snyder  SEARCH "SNYDER OPIOIDS" FOR THIS STORY. SEARCH "WIDER IMAGE" FOR ALL STORIES.

As the United States—and the world—reel from the COVID-19 pandemic, the epidemic of opioid addiction continues to ravage the country. It has cost the lives of hundreds of thousands of Americans, devastated families and communities, and exposed critical weaknesses in U.S. drug policy as well as in health and welfare systems for our low-income population.

To provide new insights and best practices for addressing the multiple dimensions of this epidemic—both for policy stakeholders and for members of the public on the front lines—Brookings has brought together some of the United States’ leading experts on drug policy. In this series of papers, we:

  • Analyze policy options to reduce demand, provide treatment, design regulatory frameworks, and implement domestic law enforcement and international supply control measures.
  • Explore local impacts on communities as well as state and federal level responses and international actions.
  • Pay special attention to vulnerable communities, such as politically and economically disenfranchised Americans, women and children, and military veterans.

Nine of these papers, as well as an overview of the history of the opioid epidemic and the main findings of the project, are published below. Another paper is forthcoming.


Chapter 1


The opioid crisis in America
Prescription medication laid out on a counting tray prior to distribution

The opioid epidemic is a story of the dangers of commercialized sales and unfettered promotion of highly addictive drugs, causing an intense substance dependence fueling and supplied by the illegal market. What started as the blight of a poorly regulated legal market mutated to fuel the illegal drug market. The authors provide a brief review of how the opioid epidemic has unfolded in the United States and around the world.

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Chapter 2

Preventing opioid misuse and addiction

New thinking and the latest evidence
A seized counterfeit hydrocodone tablets in the investigation of a rash of fentanyl overdoses in northern California is shown in this Drug Enforcement Administration (DEA) photo released on April 4, 2016. At least 42 drug overdoses in the past two weeks have been reported in northern California, 10 of them fatal, in what authorities on Monday called the biggest cluster of poisonings linked to the powerful synthetic narcotic fentanyl ever to hit the U.S. West Coast.    REUTERS/Drug Enforcement Administration/Handout via Reuters    FOR EDITORIAL USE ONLY. NOT FOR SALE FOR MARKETING OR ADVERTISING CAMPAIGNS. THIS IMAGE HAS BEEN SUPPLIED BY A THIRD PARTY. IT IS DISTRIBUTED, EXACTLY AS RECEIVED BY REUTERS, AS A SERVICE TO CLIENTS

Authors: Jonathan P. Caulkins, Keith Humphreys

Prevention of opioid misuse and addiction encompasses reductions in both demand and availability, argue Jonathan P. Caulkins and Keith Humphreys. Prevention in the era of prescription opioids, heroin, and synthetic opioids faces great challenges, but the fact that traditional prevention tactics did not work particularly well in the 20th century does not mean that prevention as a strategy is doomed.

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Chapter 3

The role of despair in the opioid crisis

Lessons from the science of well-being
A 41-year-old man found unconscious after overdosing on opioids in the driver's seat of a car, with the engine running and the transmission in drive, puts his hands over his head in the back of a Cataldo Ambulance at a gas station in the Boston suburb of Malden, Massachusetts, December 2, 2017. A used syringe was found in the car with the victim, who was revived with 10mg of naloxone. REUTERS/Brian Snyder  SEARCH "SNYDER OPIOIDS" FOR THIS STORY. SEARCH "WIDER IMAGE" FOR ALL STORIES. - RC13F461C890

Authors: Carol Graham

Deaths of despair—suicides, drug overdose, and alcohol-related deaths—claimed the lives of over 1 million Americans between 2006-2015. Carol Graham examines the deep roots of despair and drug demand and differences in resilience across population groups.

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Chapter 4

Reducing barriers and getting creative

10 federal options to increase treatment access for opioid use disorder and reduce fatal overdoses
April 24, 2017; New City, NY, USA; Michael Murphy, chief of operations for the Rockland Paramedic Services, demonstrates how to administer narcan, an opioid antagonist, April 24, 2017 in New City. Mandatory Credit: Tania Savayan/The Journal News via USA TODAY NETWORK

Authors: Beau Kilmer

Effective treatment for those with opioid use disorder is a life-saving measure that, like better prevention, can significantly reduce the broad costs of the opioid crisis. But many obstacles exist to providing effective treatment, as Beau Kilmer explains. Simply increasing funding will not achieve the desired outcome. There are laws, policies, and other barriers that need to be overcome.

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Chapter 5

State approaches to tackling the opioid crisis through the health care system

Gail Dufault, the Transitional Healthcare Coordinator at the Barnstable County House of Corrections, prepares a dose of Vivitrol at the prison in Buzzards Bay, Massachusetts September 2, 2014.  Barnstable is believed to be the first jail in the country to launch an intensive voluntary recovery program for opiate-addicted inmates with the use of Vivitrol, an injectable non-narcotic drug that blocks receptors in the brain and bars addicts from getting high off heroin and other opioids for about 25 days, at a cost of about $1,000 a shot. Picture taken  September 2, 2014.  To match Feature USA-HEROIN/PRISONS/    REUTERS/Brian Snyder (UNITED STATES - Tags: SOCIETY CRIME LAW DRUGS HEALTH)

Authors: Rosalie Liccardo Pacula, Bradley D. Stein

States have implemented multiple strategies to enhance the capacity and quality of treatment services for opioid use disorder. Rosalie Liccardo Pacula and Bradley D. Stein highlight three intervention categories: 1) increasing insurance coverage and payment for opioid and other substance-use disorder treatment services; (2) increasing the capacity of treatment services; and (3) improving the quality of treatment.

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Chapter 6

Enforcement strategies for fentanyl and other synthetic opioids

Packages already inspected by U.S. Customs and Border Protection officers sit in orange bins at the International Mail Facility at O'Hare International Airport in Chicago, Illinois, U.S. November 29, 2017. Picture taken November 29, 2017. REUTERS/Joshua Lott

Authors: Bryce Pardo, Peter Reuter

The arrival of fentanyl and other potent synthetic opioids in some parts of the United States amplifies the opioid crisis and challenges law enforcement. Bryce Pardo and Peter Reuter illustrate the need for innovation to address this unique threat.

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Chapter 7

All in the family

A comprehensive approach to maternal and child health in the opioid crisis
Lisa Collinsworth (R) holds her baby son Luke during a visit with him at Lily's Place, a treatment center for opioid-dependent newborns in Huntington, West Virginia, October 19, 2015.  Picture taken October 19, 2015. To match Special Report BABY-OPIOIDS/   REUTERS/Jonathan Ernst

Authors: N. Jia Ahmad, Joshua M. Sharfstein, Paul H. Wise

The nationwide increase in opioid use has resulted in greater opioid use during pregnancy and higher rates of a pediatric withdrawal called neonatal abstinence syndrome (NAS). N. Jia Ahmad, Joshua M. Sharfstein, and Paul H. Wise outline an alternative to current policy responses that are too narrowly focused on NAS, not always grounded in evidence, and too often have a deleterious long-term effect on mothers and children.

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Chapter 8

Assessing and improving the government’s response to the veterans’ opioid crisis

Soldiers salute

Authors: John Hudak

Veterans represent a uniquely vulnerable community in the opioid crisis, given their higher likelihood to experience chronic pain. John Hudak examines how Congress and the U.S. Department of Veterans Affairs have sought to help veterans and practitioners deal with the opioid crisis, how successful their efforts have been, and what further policy changes are necessary.

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Chapter 9

Fentanyl and geopolitics

Controlling opioid supply from China
Packets of fentanyl mostly in powder form and methamphetamine, which U.S. Customs and Border Protection say they seized from a truck crossing into Arizona from Mexico, is on display during a news conference at the Port of Nogales, Arizona, U.S., January 31, 2019.   Courtesy U.S. Customs and Border Protection/Handout via REUTERS   ATTENTION EDITORS - THIS IMAGE HAS BEEN SUPPLIED BY A THIRD PARTY.

Authors: Vanda Felbab-Brown

Since 2013, China has been the principal source of illicit fentanyl and fentanyl precursor agents for the United States. In April 2019, China prohibited the production, sales, and export of all fentanyl-class drugs without government authorization, but how effectively will China enforce the regulation? Vanda Felbab-Brown attempts to answer this question by drawing on lessons from other regulatory domains.

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Chapter 10

Fending off fentanyl and hunting down heroin

Controlling opioid supply from Mexico
Poppy field

Authors: Vanda Felbab-Brown

Mexican drug trafficking organizations are key players in the distribution of fentanyl in the United States. Vanda Felbab-Brown assesses options for suppressing the flow of heroin and fentanyl from Mexico.

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