The Opioid Crisis in America - Part II (The Drug Culture in the U.S.)

Turning the Improbable
Into the Exceptional!
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
Since its founding in 2003, The Advocacy Foundation has become recognized as an effective
provider of support to those who receive our services, having real impact within the communities
we serve. We are currently engaged in community and faith-based collaborative initiatives,
having the overall objective of eradicating all forms of youth violence and correcting injustices
everywhere. In carrying-out these initiatives, we have adopted the evidence-based strategic
framework developed and implemented by the Office of Juvenile Justice & Delinquency
Prevention (OJJDP).
The stated objectives are:
1. Community Mobilization;
2. Social Intervention;
3. Provision of Opportunities;
4. Organizational Change and Development;
5. Suppression [of illegal activities].
Moreover, it is our most fundamental belief that in order to be effective, prevention and
intervention strategies must be Community Specific, Culturally Relevant, Evidence-Based, and
Collaborative. The Violence Prevention and Intervention programming we employ in
implementing this community-enhancing framework include the programs further described
throughout our publications, programs and special projects both domestically and
internationally.
www.TheAdvocacyFoundation.org
ISBN: ......... ../2017
......... Printed in the USA
Advocacy Foundation Publishers
Philadlephia, PA
(878) 222-0450 | Voice | Data | SMS
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Dedication
______
Every publication in our many series’ is dedicated to everyone, absolutely everyone, who by
virtue of their calling and by Divine inspiration, direction and guidance, is on the battlefield dayafter-day
striving to follow God’s will and purpose for their lives. And this is with particular affinity
for those Spiritual warriors who are being transformed into excellence through daily academic,
professional, familial, and other challenges.
We pray that you will bear in mind:
Matthew 19:26 (NIV)
Jesus looked at them and said, "With man this is impossible,
but with God all things are possible." (Emphasis added)
To all of us who daily look past our circumstances, and naysayers, to what the Lord says we will
accomplish:
Blessings!!
- The Advocacy Foundation, Inc.
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The Transformative Justice Project
Eradicating Juvenile Delinquency Requires a Multi-Disciplinary Approach
The way we accomplish all this is a follows:
The Juvenile Justice system is incredibly overloaded, and
Solutions-Based programs are woefully underfunded. Our
precious children, therefore, particularly young people of
color, often get the “swift” version of justice whenever they
come into contact with the law.
Decisions to build prison facilities are often based on
elementary school test results, and our country incarcerates
more of its young than any other nation on earth. So we at
The Foundation labor to pull our young people out of the
“school to prison” pipeline, and we then coordinate the efforts
of the legal, psychological, governmental and educational
professionals needed to bring an end to delinquency.
We also educate families, police, local businesses, elected
officials, clergy, and schools and other stakeholders about
transforming whole communities, and we labor to change
their thinking about the causes of delinquency with the goal
of helping them embrace the idea of restoration for the young
people in our care who demonstrate repentance for their
mistakes.
1. We vigorously advocate for charges reductions, wherever possible, in the adjudicatory (court)
process, with the ultimate goal of expungement or pardon, in order to maximize the chances for
our clients to graduate high school and progress into college, military service or the workforce
without the stigma of a criminal record;
2. We then enroll each young person into an Evidence-Based, Data-Driven Restorative Justice
program designed to facilitate their rehabilitation and subsequent reintegration back into the
community;
3. While those projects are operating, we conduct a wide variety of ComeUnity-ReEngineering
seminars and workshops on topics ranging from Juvenile Justice to Parental Rights, to Domestic
issues to Police friendly contacts, to CBO and FBO accountability and compliance;
4. Throughout the process, we encourage and maintain frequent personal contact between all
parties;
5 Throughout the process we conduct a continuum of events and fundraisers designed to facilitate
collaboration among professionals and community stakeholders; and finally
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6. 1 We disseminate Quarterly publications, like our e-Advocate series Newsletter and our e-Advocate
Quarterly electronic Magazine to all regular donors in order to facilitate a lifelong learning process
on the ever-evolving developments in the Justice system.
And in addition to the help we provide for our young clients and their families, we also facilitate
Community Engagement through the Restorative Justice process, thereby balancing the interesrs
of local businesses, schools, clergy, elected officials, police, and all interested stakeholders. Through
these efforts, relationships are rebuilt & strengthened, local businesses and communities are enhanced &
protected from victimization, young careers are developed, and our precious young people are kept out
of the prison pipeline.
This is a massive undertaking, and we need all the help and financial support you can give! We plan to
help 75 young persons per quarter-year (aggregating to a total of 250 per year) in each jurisdiction we
serve) at an average cost of under $2,500 per client, per year.*
Thank you in advance for your support!
* FYI:
1. The national average cost to taxpayers for minimum-security youth incarceration, is around
$43,000.00 per child, per year.
2. The average annual cost to taxpayers for maximun-security youth incarceration is well over
$148,000.00 per child, per year.
- (US News and World Report, December 9, 2014);
3. In every jurisdiction in the nation, the Plea Bargain rate is above 99%.
The Judicial system engages in a tri-partite balancing task in every single one of these matters, seeking
to balance Rehabilitative Justice with Community Protection and Judicial Economy, and, although
the practitioners work very hard to achieve positive outcomes, the scales are nowhere near balanced
where people of color are involved.
We must reverse this trend, which is right now working very much against the best interests of our young.
Our young people do not belong behind bars.
- Jack Johnson
1
In addition to supporting our world-class programming and support services, all regular donors receive our Quarterly e-Newsletter
(The e-Advocate), as well as The e-Advocate Quarterly Magazine.
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
…a collection of works on
The Opioid Crisis in America
Evidence-Based Solutions at the Grassroots Level
Part II – The Drug Culture in the U.S.
“Turning the Improbable Into the Exceptional”
Atlanta
Philadelphia
______
John C Johnson III
Founder & CEO
(878) 222-0450
Voice | Data | SMS
www.TheAdvocacyFoundation.org
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Biblical Authority
______
1 Corinthians 10:13-14
13
No temptation has overtaken you except what is common to mankind. And
God is faithful; he will not let you be tempted beyond what you can
bear. But when you are tempted, he will also provide a way out so that you
can endure it.
James 4:7-10
7
Submit yourselves, then, to God. Resist the devil, and he will flee from
you. 8 Come near to God and he will come near to you. Wash your
hands, you sinners, and purify your hearts, you double-minded. 9 Grieve,
mourn and wail. Change your laughter to mourning and your joy to
gloom. 10 Humble yourselves before the Lord, and he will lift you up.
Psalm 50:15
15
and call on me in the day of trouble;
I will deliver you, and you will honor me.”
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Table of Contents
…a collection of works on
The Opioid Crisis in America
Evidence-Based Solutions at the Grassroots Level
Part II – The Drug Culture in the U.S.
______
Biblical Authority
I. Introduction – Drugs in the United States…………………………….. 17
II. History of U.S. Drug Prohibition……………………………………….. 31
III. The Illegal Drug Trade in the U.S……………………………………… 37
IV. Recreational Drug Use in the U.S…………………………………….. 43
V. The Ten States with the Biggest Drug Problems……………………. 57
VI. List of Schedule I Drugs in the U.S…………………………………… 59
VII. Drug Paraphernalia…………………………………………………….. 67
VIII. References……………………………………………………………… 69
Attachments
A. The High Price of the Opioid Crisis - Infographic
B. Prescription Nation – Addressing America’s Drug Epidemic
C. the Epidemic of Prescription Drug and Heroin Abuse in the U.S.
Copyright © 2018 The Advocacy Foundation, Inc. All Rights Reserved.
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I. Introduction
In the United States, the Federal Food, Drug, and Cosmetic Act definition of
a drug includes "articles intended for use in the diagnosis, cure, mitigation, treatment, or
prevention of disease in man or other animals" and "articles (other than food) intended
to affect the structure or any function of the body of man or other animals." Consistent
with that definition, the U.S. separately defines narcotic drugs and controlled
substances, which may include non-drugs, and explicitly
excludes tobacco, caffeine and alcoholic beverages.
Federal Drug Policy of the United States
Use of heroin peaked between 1969 and 1971, marijuana between 1978 and 1979,
and cocaine between 1987 and 1989. A major decline in the use of opium started after
the Harrison Act of 1914 was initiated.
An overarching effort to impose mandatory penalties for federal drug crimes took place
in the 1980s. This caused many drug crimes that were common at the time to carry
mandatory minimum sentences of 5 to 10 years in a federal prison.
In 1996, California voters passed Proposition 215, legalizing the growing and use
of marijuana for medical purposes. This created significant legal and enforcement
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conflict between federal and state government laws. Courts have since decided that a
state law in conflict with a federal law concerning cannabis is not valid. Cannabis is
restricted by federal law (see Gonzales v. Raich). In 2010 California Proposition 19
(also known as the Regulate, Control & Tax Cannabis Act) was defeated with 53.5%
'No' votes, and 46.5% 'Yes' votes. [3]
Pursuant to regulations (34 C.F.R. 86) required by the Drug-Free Schools and
Communities Act Amendments of 1989 (codified at 20 U.S.C. § 1011i), as a condition
of receiving funds or any other form of financial assistance under any Federal program,
an institution of higher education must certify that it has adopted and implemented a
drug prevention program which adheres to regulations in 34 C.F.R. 86.100. It has
recently gained renewed attention due to Colorado Amendment 64.
Drug Policy Beginning to Relax in New Millennium
A review of drug policies at the turn of the century has given way to more relaxed US
Drug Policies. The Reagan, and Nixon administration's "War on Drugs" policy has
proved to be ineffective. US prisons are populated with drug users via laws that were
implemented in the 1980s. The US has more incarcerated individuals than any other
nation. The number is about to reach 2.5 million inmates, of which half are incarcerated
on drug related offenses.
Many states looking for a solution to this issue are considering 'Rehabilitation' as
opposed to 'Incarceration' for drug users. As of January 2015, 23 states and the District
of Columbia have made the use of marijuana legal for medical use. Seven more states
are close to adopting the same policies, and Colorado has legalized marijuana
completely. Other drugs will come up against much stronger opposition to legalize;
however, many Americans believe that all drugs should be legalized, and also believe
that eventually it will happen. The money that is now being spent to incarcerate drug
users would be redirected to rehabilitation and drug education.
The Office of National Drug Control Policy (ONDCP) oppose legalization of marijuana
but support increased use of alternatives to incarceration for substance
abuse disorders. A declaration about that, proposed by the US, was in March 2015
approved at an international conference by United Nations Commission on Narcotic
Drugs (CND)
The War on Drugs
The War on Drugs is an American term usually applied to the United States
government's campaign of prohibition of drugs, military aid, and military intervention,
with the stated aim being to reduce the illegal drug trade. This initiative includes a set of
drug policies that are intended to discourage the production, distribution, and
consumption of psychoactive drugs that the participating governments and the UN have
made illegal. The term was popularized by the media shortly after a press conference
given on June 18, 1971, by United States President Richard Nixon—the day after
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publication of a special message from President Nixon to the Congress on Drug Abuse
Prevention and Control—during which he declared drug abuse "public enemy number
one". That message to the Congress included text about devoting more federal
resources to the "prevention of new addicts, and the rehabilitation of those who are
addicted", but that part did not receive the same public attention as the term "war on
drugs". However, two years prior to this, Nixon had formally declared a "war on drugs"
that would be directed toward eradication, interdiction, and incarceration. Today,
the Drug Policy Alliance, which advocates for an end to the War on Drugs, estimates
that the United States spends $51 billion annually on these initiatives.
On May 13, 2009, Gil Kerlikowske—the Director of the Office of National Drug
Control Policy (ONDCP)—signaled that the Obama administration did not plan to
significantly alter drug enforcement policy, but also that the administration would not use
the term "War on Drugs", because Kerlikowske considers the term to be "counterproductive".
ONDCP's view is that "drug addiction is a disease that can be successfully
prevented and treated... making drugs more available will make it harder to keep our
communities healthy and safe". One of the alternatives that Kerlikowske has showcased
is the drug policy of Sweden, which seeks to balance public health concerns with
opposition to drug legalization. The prevalence rates for cocaine use in Sweden are
barely one-fifth of those in Spain, the biggest consumer of the drug.
In June 2011, the Global Commission on Drug Policy released a critical report on the
War on Drugs, declaring: "The global war on drugs has failed, with devastating
consequences for individuals and societies around the world. Fifty years after the
initiation of the UN Single Convention on Narcotic Drugs, and years after President
Nixon launched the US government's war on drugs, fundamental reforms in national
and global drug control policies are urgently needed." The report was criticized by
organizations that oppose a general legalization of drugs.
Drug Courts
The first drug court in the United States took shape in Miami-Dade County, Florida, in
1989, as a response to the growing crack-cocaine problem plaguing the city. All
50 states now have working drug courts, with a total of more than 2,400 courts. About
120,000 people treated annually in drug courts, though an estimated 1.5 million eligible
people are currently before the courts.
Drug courts operate under a model that combines intensive judicial supervision,
mandatory drug testing, escalating sanctions and treatment to help substance abusing
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offenders break the cycle of addiction and the crime that accompanies it. In 1997
the National Association of Drug Court Professionals published Defining Drug Courts:
The Key Components designed to provide courts with a model which can be adapted to
fit the specific needs of the community.
Key components
Drug courts integrate alcohol and other drug treatment services with justice
system case processing
Using a non-adversarial approach, prosecution and defense counsel
promote public safety. Participants must waive their due process rights to
a speedy trial and sign a pre-emptive confession before being allowed to
participate
Eligible participants are identified early and promptly placed in the drug court
program
Drug courts provide access to a continuum of alcohol, drug, and other related
treatment and rehabilitation services
Abstinence is monitored by frequent alcohol and other drug testing
A coordinated strategy governs drug court responses to participants compliance
Ongoing judicial interaction with each drug court participant is essential
Monitoring and evaluation measure the achievement of program goals and
gauge effectiveness
Continuing interdisciplinary education promotes effective drug court planning,
implementation, and operations
Forging partnerships among drug courts, public agencies, and community-based
organizations generates local support and enhances their effectiveness
There is mixed evidence on whether drug courts save money, or cost more per
participant, than traditional dockets. Studies in the mid-2000s computed the average
cost savings per participant. Results revealed average cost savings ranging from nearly
$3,000 to over $12,000 per client. Depending upon the size of a given program, in some
counties the aggregate cost savings exceeded $7 to $9 million per year. There are
about 120,000 individuals treated annually in drug courts, which creates more than
$1 billion in annual savings. Overall, it is estimated that the current adult drug court
treatment program produces about $2.21 in benefit for every $1 in costs, for a net
benefit to society of about $624 million. Studies have shown that 1.5 million arrestees
who are probably guilty (the population most likely to participate in court monitored
substance abuse treatment) are at risk of abuse or dependence. Treating that 1.5
million at-risk arrestees through drug court would cost more than $13.7 billion and return
benefits of about $46 billion.
On the other hand, there are a number of studies by non-partisan research institutions
which show that drug courts are cost positive. In a meta-analysis of 86 drug courts,
which includes the full cost of rehabs and wrap around services and drug court
externalities, the Brookings Institution concluded in 2012 that the benefits of drug court
"probably [do] not" outweigh its costs, noting that "on average, drug court will cost
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$5,000 more per participant than is yielded in benefits, and there is only an 14% chance
that benefits will exceed costs". Similarly, the UK Ministry of Justice concludes that drug
courts are cost-positive by 4,633 British pounds per participant.
In recent years, drug courts and drug court research have become the subject of
significant criticism. Academic research questions both the constitutionality of drug
courts and the potential denial or limitation of defendant’s rights caused by the drug
court model. Others, such as former drug court Judge Morris Hoffman, have theorized
that drug courts cause net widening due to the increased willingness by police to arrest
offenders should they receive treatment versus jail time and an increased willingness by
offenders to try drugs when facing less serious legal consequences.
Similarly, while the majority of drug court research supports the concepts of reduced
recidivism rates and cost savings, the methodologies of these studies have come under
fire. The opportunity costs associated with wraparound services—rehabs, transitional
living facilities, etc.—which may promote reductions in recidivism rates are rarely
included in cost analyses of drug courts, nor are the externalities associated with crimes
committed by offenders who are free through drug court dockets, versus incarcerated
under the traditional model. A preliminary study conducted by the Brookings Institution
called "A Bayesian Meta-Analysis of Drug Court Cost-Effectiveness", which analyzed 86
existing drug court studies concluded that drug courts are probably cost positive, not
cost negative. Other works, including a 2007 white paper released by Yale Law
School Fellow and titled "Drug Court Fraud" concluded that selection bias invalidated
many of the studies suggesting drug courts reduce recidivism rates. The Justice Policy
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Institute and Drug Policy Alliance released papers in 2011 which were harshly critical of
the drug court model.
Several recent drug court scandals made national news, including that of 17-year-old
Lindsey Dills who was sentenced to 14 months in jail and 5.5 years of probation for two
forged checks of $20 and $40. In another shocking case, Judge Richard Baumgartner,
an ex-addict and Knox County, Tennessee's Drug Court Judge, pleaded guilty to
criminal misconduct for hearing cases while using drugs, purchasing drugs from
defendants in his courtroom, and having sex in his chambers with defendants. In St.
Clair County, Illinois, Drug Court Judge Joseph Christ died of a drug overdose. Christ
and another judge purchased their drugs from a drug court probation officer. Christ also
released a defendant in his court who was another of his alleged drug dealers.
Doping in Sports
Doping, or the use of restricted performance-enhancing drugs, has been a recurring
problem in the United States, most notably in the sports of baseball and football.
United States has had 8 Olympic medals stripped for doping violations. In the case
of Rick DeMont, the United States Olympic Committee (USOC) has recognized his gold
medal performance in the 1972 Summer Olympics in 2001, but only the IOC has the
power to restore his medal, and it has as of 2017 refused to do so.
Doping by the Sport
Professional sport
Major League Baseball (MLB)
National Football League (NFL)
National Hockey League (NHL)
National Basketball Association (NBA)
Commonly abused substances
Performance-enhancing drugs
Steroids
Stimulants
Drugs of abuse
Anabolic/androgenic steroids
Hormones
Anti-estrogenic agents
Selective androgen receptor modulators
Anabolic steroids
Cocaine
Performance-enhancing drugs
Steroids
Diuretics
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Substance
Any substance
banned by WADA
Anabolic steroids
Opiates
Smokeless tobacco
Alcohol Abuse
Athlete population
Elite athletes across
sports (positive drug
tests)
Professional football
players (self report)
Professional football
players (self report)
Professional basketball
players (self report)
Professional football
players (self report)
Percentage of athletes using
substance
2% over past year
9% used at some point in career
52% used at some point in career
(71% of those misused at some point
in career)
35%-40% over past year
20%-30% over past year
Alcohol abuse is a previous psychiatric diagnosis in which there is recurring harmful
use of alcohol despite its negative consequences. In 2013 it was reclassified as alcohol
use disorder (alcoholism) along with alcohol dependence.
There are two types of alcohol abuse, those who have anti-social and pleasure-seeking
tendencies, and those who are anxiety-ridden people who are able to go without
drinking for long periods of time but are unable to control themselves once they
start. Binge drinking is another form of alcohol abuse. According to surveys, the
heaviest drinkers are the United Kingdom's adolescents. In 2013, 139,000 deaths
globally were directly due to alcohol abuse and an additional 384,000 to cirrhosis from
excess alcohol consumption.
In the USA, binge drinking is defined as consuming more than five units in men and four
units in women. It increases chances for vandalism, fights, violent behaviours,
injuries, drunk driving, trouble with police, negative health, social, economic, or legal
consequences to occur. Binge drinking is also associated with neurocognitive deficits of
frontal lobe processing and impaired working memory as well as delayed auditory and
verbal memory deficits.
Binge drinking combined with the stress of returning to work is a contributing factor to
Monday deaths from heart attacks. The chances of becoming dependent are increased
greatly in men who have 15 or more drinks each week or women who have 12 or more
drinks each week. This is known as alcohol dependency.
It is believed that one way to prevent binge drinking is to raise the legal drinking age.
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Marijuana
The use, sale, and possession of all forms of cannabis in the United States is illegal
under federal law. As a Schedule I drug under the federal Controlled Substances Act of
1970, cannabis (legal term marijuana) is considered to have "no accepted medical use"
and have a high potential for abuse and physical and/or psychological
dependence. Cannabis use is illegal for any reason, with the exception of FDAapproved
research programs. However, individual states have enacted legislation
permitting exemptions for various uses, mainly for medical and industrial use.
Cannabis for industrial uses (hemp) was made illegal to grow without a permit under the
Controlled Substances Act because of its relation to cannabis as a drug, and any
imported products must adhere to a zero tolerancepolicy. The Agricultural Act of
2014 allows for universities and state-level departments of agriculture to cultivate
cannabis for research into its industrial potential.
As a psychoactive drug, cannabis continues to find extensive favor among recreational
and medical users in the United States. As of 2017, eight states –
Alaska, California, Colorado, Oregon, Massachusetts, Maine, Nevadaand Washington
– have legalized the sale and possession of cannabis for both medical and recreational
use; the District of Columbia has legalized personal use but not commercial
sale. Multiple efforts to reschedule cannabisunder the Controlled Substances Act have
failed, and the United States Supreme Court has ruled in United States v. Oakland
Cannabis Buyers' Cooperative (2001) and Gonzales v. Raich (2005) that the federal
government has a right to regulate and criminalize cannabis, whether medical or
recreational. As a result, cannabis dispensaries are licensed by each state; these
businesses sell cannabis products that have not been approved by the U.S. Food and
Drug Administration, nor are they legally registered with the federal government to sell
controlled substances. Although cannabis has not been approved, the FDA recognizes
the potential benefits and has approved two drugs that contain components of
marijuana.
The great majority of cannabis arrests are for possession. However, in 1997, the vast
majority of inmates in state prisons for marijuana-related convictions were convicted of
offenses other than simple possession.
According to the Federal Bureau of Investigation's annual Uniform Crime Report, there
have been over twelve million cannabis arrests in the United States since 1996,
including 749,825 persons for marijuana violations in 2012. Of those charged with
marijuana violations in 2012, 658,231 (88%) were charged with possession only. The
remaining 91,593 individuals were charged with "sale/manufacture", a category that
does not differentiate for cultivation offenses, even those where the marijuana was
being grown for personal or medical use. Marijuana arrests comprise almost one-half
(48.3 percent) of all drug arrests reported in the United States. According to
the American Civil Liberties Union, there were 8.2 million marijuana arrests from 2001 to
2010, and 88% of those arrests were just for having marijuana with them.
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Cocaine
Cocaine is the second most popular illegal recreational drug in the United
States behind marijuana, and the U.S. is the world's largest consumer of cocaine.
The 1999 Monitoring the Future (MTF) survey
found the proportion of American students
reporting use of powdered cocaine rose during
the 1990s. In 1991, 2.3% of eighth-graders
stated that they had used cocaine in their
lifetime. This figure rose to 4.7% in 1999. For
the older grades, increases began in 1992 and
continued through the beginning of 1999.
Between those years, lifetime use of cocaine
went from 3.3% to 7.7% for tenth-graders and
from 6.1% to 9.8% for high school seniors.
Lifetime use of crack cocaine, according to
MTF, also increased among eighth-, tenth-, and
twelfth-graders, from an average of 2% in 1991 to 3.9% in 1999.
Perceived risk and disapproval of cocaine and crack use both decreased during the
1990s at all three grade levels. The 1999 NHSDA found the highest rate of monthly
cocaine use was for those aged 18–25 at 1.7%, an increase from 1.2% in 1997. Rates
declined between 1996 and 1998 for ages 26–34, while rates slightly increased for the
12–17 and 35+ age groups. Studies also show people are using cocaine at younger
ages. NHSDA found a steady decline in the mean age of first use from 23.6 years in
1992 to 20.6 years in 1998.
Crack Cocaine
The American crack epidemic was a surge
of crack cocaine use in major cities across
the United States between the early 1980s and
the early 1990s. This resulted in a number of
social consequences, such as increasing crime
and violence in American inner
city neighborhoods, as well as a resulting
backlash in the form of tough on crime policies.
Using an index that combined indicators like
crack cocaine related deaths and medical
emergencies, arrests and seizures, and media
coverage, researchers Steven Levitt and Kevin
M. Murphy found that the drug's worst impact
was on the Northeastern and South Atlantic
States, headed by New York and Maryland.
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70% of the impact of crack was felt in large cities, and the rates per capita were 10
times higher in larger cities than in the rest of the nation. During the time period studied,
cities with the worst crack problems were Newark, Philadelphia, New York, Oakland,
Boston, San Francisco, and Seattle. Other cities that rank high include New Orleans,
Baltimore, Washington, D.C., and Los Angeles.
Between 1984 and 1989, the homicide rate for black males aged 14 to 17 more than
doubled, and the homicide rate for black males aged 18 to 24 increased nearly as
much. During this period, the black community also experienced a 20–100% increase in
fetal death rates, low birth-weight babies, weapons arrests, and the number of children
in foster care. In 1996, approximately 60% of inmates incarcerated in the US were
sentenced on drug charges. The United States remains the largest overall consumer of
narcotics in the world as of 2014.
The reasons for these increases in crime were mostly because distribution for the drug
to the end-user occurred mainly in low-income inner city neighborhoods. This gave
many inner-city residents the opportunity to move up the "economic ladder" in a drug
market that allowed dealers to charge a low minimum price. The basic reason for the
rise of crack was economic, though social, non-pecuniary contributing factors have
been suggested.
Crack cocaine use and distribution became popular in cities that were in a state of
social and economic chaos such as Los Angeles and Atlanta. "As a result of the lowskill
levels and minimal initial resource outlay required to sell crack, systemic violence
flourished as a growing army of young, enthusiastic inner-city crack sellers attempt to
defend their economic investment." Once the drug became embedded in the particular
communities, the economic environment that was best suited for its survival caused
further social disintegration within that city. An environment that was based on violence
and deceit was an avenue for the crack dealers to protect their economic interests.
In 1986, the U.S. Congress passed laws that created a 100 to 1 sentencing disparity for
the possession or trafficking of crack when compared to penalties
for trafficking of powder cocaine, which had been widely criticized as discriminatory
against minorities, mostly blacks, who were more likely to use crack than powder
cocaine. This 100:1 ratio had been required under federal law since 1986. Persons
convicted in federal court of possession of 5 grams of crack cocaine received
a minimum mandatory sentence of 5 years in federal prison. On the other hand,
possession of 500 grams of powder cocaine carries the same sentence. In 2010,
the Fair Sentencing Act cut the sentencing disparity to 18:1.
Methamphetamines
Methamphetamine in the United States is regulated under Schedule II of
the Controlled Substances Act. It is approved for extremely limited pharmacological use
in the treatment of attention deficit hyperactivity disorder and treatmentresistant
obesity, but it is primarily used as a recreational drug. In 2012, approximately
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1.2 million Americans reported using methamphetamine in the past year; 440,000
reported using the drug in the past month.
Much of the methamphetamine consumed in the US is manufactured domestically by
amateur chemists in meth labs from common household drugs and chemicals such
as lye, lithium, and ammonia. Since the passage of the Combat Methamphetamine
Epidemic Act of 2005, the Drug Enforcement Administration has reported a sharp
decline in domestic meth lab seizures, but drug cartels continue to meet demand by
manufacturing meth in Mexico and smuggling it across the border.
In 2012, the DEA seized a total of 3,898 kg of methamphetamine and 11,210 meth
labs. As of 2015, the Sinaloa Cartel is the most active drug cartel involved in smuggling
illicit drugs like methamphetamine into the United States and trafficking them throughout
the United States.
The Drug Enforcement Administration (DEA) is tasked with combating illegal meth
production, distribution and use. The seized quantities of meth can give an idea about
its changing popularity through the time.
The blue line represents the weight of meth seized (x100g);
The red line represents quantity of meth lab incidents.
Tobacco
Tobacco has a long history in the United States.
An estimated 36.5 million people, or 15.1% of all adults (aged 18 years or older), in
the United States smoked cigarettes in 2015. By state, in 2015, smoking prevalence
ranged from between 9.1% and 12.8% in Utah to between 23.7% and 27.4% in West
Virginia. By region, in 2015, smoking prevalence was highest in the Midwest (18.7%)
and South (15.3%) and lowest in the West (12.4%). Men tend to smoke more than
women. In 2015, 16.7% of men smoked compared to 13.6% of women. In 2009 46.6
million, or 20.6 percent of adults 18 and older were current smokers.
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Cigarette smoking is the leading cause of preventable death in the United States,
accounting for approximately 443,000 deaths, or 1 of every 5 deaths, in the United
States each year. Cigarette smoking alone has cost the United States $96 billion in
direct medical expenses and $97 billion in lost productivity per year or an average of
$4,260 per adult smoker.
On February 4, 2009, the Children's Health Insurance Program Reauthorization Act of
2009 was signed into law, which raised the federal tax rate for cigarettes on April 1,
2009 from $0.39 per pack to $1.01 per pack.
443,000 Americans die of smoking or exposure to secondhand smoke each year. For
every smoking-related death, another 20 people suffer with a smoking-related disease.
(2011)
California's adult smoking rate has dropped nearly 50% since the state began the
nation's longest-running tobacco control program in 1988. California saved $86 billion in
health care costs by spending $1.8 billion on tobacco control, a 50:1 return on
investment over its first 15 years of funding its tobacco control program.
A half million children work in the fields of America picking food in 2012. In
eastern North Carolina, children have been interviewed as young as fourteen who
worked harvesting tobacco, and recent news reports describe children as young as nine
and ten doing such work. Federal law provides no minimum age for work on small farms
with parental permission, and children ages twelve and up may work for hire on any size
farm for unlimited periods outside school hours. According to Human Rights Watch,
farm-work is the most hazardous occupation open to children.
Drug Use and Deaths per State
State Population (2010)
Drug
Users (2010)
Drug
Deaths
Total
2010)
Drug
Deaths (per
100,000)
Federal
Grants
Grant/Drug
User
Alabama 4,779,736 06.73% 554 12 $80,040,503 $248.82
Alaska 710,231 11.79% 75 11 $30,760,934 $367.36
Arizona 6,392,017 08.95% 981 15.5 $138,524,069 $242.36
Arkansas 2,915,918 07.96% 326 11.5 $47,138,163 $203.09
California 37,253,956 09.07% 4178 11.4 $832,107,905 $246.26
Colorado 5,029,196 11.72% 747 15.4 $111,188,470 $188.64
Connecticut 3,574,097 08.23% 444 12.7 $103,493,029 $351.84
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Delaware 897,934 09.14% 102 11.8 $24,161,839 $294.40
Florida 18,801,310 07.80% 2936 16.1 $338,129,029 $230.57
Georgia 9,687,653 07.32% 1043 10.6 $321,114,660 $452.83
Hawaii 1,360,301 09.92% 142 11.1 $37,176,146 $275.50
Idaho 1,567,582 08.00% 133 8.9 $21,076,027 $168.06
Illinois 12,830,632 07.17% 1239 9.6 $234,968,808 $255.41
Indiana 6,483,802 08.79% 827 13.0 $91,020,232 $159.71
Iowa 3,046,355 04.08% 211 7.1 $58,962,185 $474.39
Kansas 2,853,118 06.77% 294 10.6 $40,234,098 $208.30
Kentucky 4,339,367 08.41% 722 17 $100,547,625 $275.52
Louisiana 4,533,372 07.16% 862 20.1 $80,230,847 $247.18
Maine 1,328,361 09.09% 161 12.2 $36,320,286 $300.79
Maryland 5,773,552 07.29% 807 12.7 $192,136,722 $456.50
Massachusetts 6,547,629 08.87% 1003 15.6 $245,061,344 $421.96
Michigan 9,883,640 08.95% 1524 15.3 $243,556,706 $275.33
Minnesota 5,303,925 08.24% 359 6.9 $95,867,509 $219.35
Mississippi 2,967,297 06.39% 334 11.4 $50,554,343 $266.62
Missouri 5,988,927 07.38% 730 12.4 $123,020,244 $278.34
Montana 989,415 10.02% 132 13.8 $28,332,837 $285.79
Nebraska 1,826,341 06.43% 92 5.2 $34,675,170 $295.27
Nevada 2,700,551 09.35% 515 20.1 $46,367,799 $183.63
New
Hampshire
1,316,470 12.15% 172 13.0 $55,388,743 $346.29
New Jersey 8,791,894 06.42% 797 9.2 $113,795,702 $201.61
New Mexico 2,059,179 10.07% 447 12.8 $150,896,974 $727.71
New York 19,378,102 09.82% 1797 9.2 $1,875,136,099 $985.39
North
Carolina
9,535,483 08.88% 1223 13.0 $403,912,656 $477.01
North Dakota 672,591 05.3% 28 4.3 $36,344,108 $1,019.55
Ohio 11,536,504 07.61% 1691 14.7 $207,925,242 $236.84
Oklahoma 3,751,351 08.09% 687 19 $67,359,062 $221.95
Oregon 3,831,074 12.80% 564 15.1 $104,298,167 $212.69
Pennsylvania 12,702,379 06.57% 1812 14.6 $283,229,043 $339.38
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Rhode Island 1,052,567 13.34% 142 13.4 $43,604,718 $310.55
South
Carolina
4,625,364 06.70% 584 13.2 $77,790,340 $251.02
South Dakota 814,180 06.28% 34 4.3 $31,840,106 $622.72
Tennessee 6,346,105 08.22% 1035 16.8 $107,211,391 $205.52
Texas 25,145,561 06.26% 2343 9.8 $384,444,836 $244.23
Utah 2,763,885 06.24% 546 20.6 $47,059,651 $272.86
Vermont 625,741 13.73% 57 9.2 $58,913,913 $685.73
Virginia 8,001,024 07.33% 713 9.2 $173,221,243 $295.36
Washington 6,724,540 09.59% 1003 15.5 $130,527,165 $202.40
West Virginia 1,852,994 06.79% 405 22.4 $45,059,469 $358.13
Wisconsin 5,686,986 08.67% 639 11.4 $107,259,369 $217.54
Wyoming 563,626 06.82% 68 13 $12,483,581 $324.76
United States 308,143,815 08.11% 38260 12.4 $8,304,469,106 $332.19
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II. History of U.S. Drug Prohibition
This is a timeline of the history of drug prohibition in the United States.
Timeline
Around 1860: Efforts to regulate the sale of pharmaceuticals began, and laws were
introduced on a state-to-state basis that created penalties for mislabeling
drugs, adulterating them with undisclosed narcotics, and improper sale of those
considered "poisons". Poison laws generally either required labels on the packaging
indicating the harmful effects of the drugs or prohibited sale outside of licensed
pharmacies and without a doctor's prescription. Prominent pharmaceutical societies at
the time supported the listing of cannabis as a poison.
1880: The U.S. and Qing Dynasty China complete an agreement prohibiting the
shipment of opium between the two countries; Qing China itself was still reeling from the
effects of fighting the Opium War after a failed attempt to stem the British importing of
opium into China proper (see Lin Zexu).
1906: The Pure Food and Drug Act requires that certain specified drugs,
including alcohol, cocaine, heroin, morphine, and cannabis, be accurately labeled with
contents and dosage. Previously many drugs had been sold as patent medicines with
secret ingredients or misleading labels. Cocaine, heroin, cannabis, and other such
drugs continued to be legally available without prescription as long as they were
labeled. It is estimated that sale of patent medicines containing opiates decreased by
33% after labeling was mandated.
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1911: United States first Opium Commissioner, Hamilton Wright argues that of all the
nations of the world, the United States consumes most habit-forming drugs per capita.
1913: The American Medical Association created a propaganda department to outlaw
health fraud and quackery. In the same year, California outlawed cannabis.
1914: The first recorded instance of the United States enacting a ban on the domestic
distribution of drugs is the Harrison Narcotic Act of 1914. This act was presented and
passed as a method of regulating the production and distribution of opiate-containing
substances under the commerce clause of the U.S. Constitution, but a section of the
act was later interpreted by law enforcement officials for the purpose of prosecuting
doctors who prescribe opiates to addicts.
1919: Alcohol prohibition in the U.S. first appeared under numerous provincial bans and
was eventually codified under a federal constitutional amendment in 1919, having been
approved by 36 of the 48 U.S. states.
1925: United States supported regulation of cannabis as a drug in the International
Opium Convention. and by the mid-1930s all member states had some regulation of
cannabis.
1930: The Federal Bureau of Narcotics was created. For the next 32 years it was
headed by Harry J. Anslinger who came from the Bureau of Prohibition as did many of
its initial members.
1932: Democrat Franklin Roosevelt ran for President of the United States promising
repeal of federal laws of Prohibition of alcohol.
1933: Eighteenth Amendment to the United States Constitution is repealed. The
amendment remains the only major act of prohibition to be repealed, having been
repealed by the Twenty-first Amendment to the United States Constitution.
1935: President Roosevelt hails the International Opium Convention and application of it
in US. law and other anti-drug laws in a radio message to the nation.
1937: Congress passed the Marijuana Tax Act. Presented as a $1 nuisance tax on the
distribution of marijuana, this act required anyone distributing the drug to maintain and
submit a detailed account of his or her transactions, including inspections, affidavits,
and private information regarding the parties involved. This law, however, was
something of a "Catch-22", as obtaining a tax stamp required individuals to first present
their goods, which was an action tantamount to confession. This act was passed by
Congress on the basis of testimony and public perception that marijuana
caused insanity, criminality, and death.
1951: The 1951 Boggs Act increased penalties fourfold, including mandatory penalties.
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1956: The Daniel Act increased penalties by a factor of eight over those specified in the
Boggs Act. Although by this time there was adequate testimony to refute the claim that
marijuana caused insanity, criminality, or death, the rationalizations for these laws
shifted in focus to the proposition that marijuana use led to the use of heroin, creating
the gateway drug theory.
1965: In Laos, the CIA's airline, Air America, began flying Hmong (Meo) opium out of
the hills to Long Tieng and Vientiane. This opium was being refined into high grade no.
4 heroin, which is what was being used by U.S. soldiers. During the Laotian Civil War,
Long Tieng served as a town and airbase operated by the Central Intelligence
Agency of the United States.
1969: Psychiatrist Dr. Robert DuPont conducts urinalysis of everyone entering the D.C.
jail system in August 1969. He finds 44% test positive for heroin and starts the
first methadone treatment program in the Department of Corrections in September 1969
for heroinaddicts.
1970: The Controlled Substances Act (CSA) was enacted into law by Congress. The
CSA is the federal U.S. drug policy under which the manufacture, importation,
possession, use and distribution of certain substances is regulated.
1971: The Vietnam War is linked with concerns over drugs and the Nixon administration
coins the term War on Drugs.
Starting in 1965, the CIA's Airline, Air America had been flying opium for
the Hmong (Meo) hill tribe opium farmers until as late as 1971. "Southeast Asia's
Golden Triangle region has become a mass producer of high-grade no. 4 heroin
for the American market." The heroin refined in Laos was being shipped to
Vietnam and this high grade fluffy white no. 4 heroin is what was being used by
U.S. soldiers there.
May: Congressmen Robert Steele (R-CT) and Morgan Murphy (D-IL) release an
explosive report on the growing heroin epidemic among U.S. servicemen in
Vietnam.
June 17: Nixon declares war on drugs. [11][16][17] He characterized the abuse of
illicit substances as "public enemy number one in the United States". Under
Nixon, the U.S. Congress passed the Controlled Substances Act of 1970. This
legislation is the foundation on which the modern drug war exists. Responsibility
for enforcement of this new law was given to the Bureau of Narcotics and
Dangerous Drugs and then in 1973 to the newly formed Drug Enforcement
Administration. During the Nixon era, for the only time in the history of the war on
drugs, the majority of funding goes towards treatment, rather than law
enforcement.
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Later in the month the U.S. military announces they will begin urinalysis of all
returning servicemen. The program goes into effect in September and the results
are favorable: "only" 4.5% of the soldiers test positive for heroin.
1972, March 22: The National Commission on Marijuana and Drug Abuse recommends
legalizing possession and sales of small amounts of marijuana. Nixon and the Congress
ignore the suggestion.
1974: A Senate Internal Security Subcommittee, chaired by Sen. James O. Eastland on
The Marihuana-hashish epidemic and its impact on United States security invited 21
scientists of the first rank from seven different countries to testify, including Gabriel G.
Nahas and Nils Bejerot. The testimony of these experts showed that the evidence
accumulated by scientific researchers on marijuana had turned dramatically against this
drug.
1979: Illegal drug use in the U.S. peaks when 25 million of Americans used an illegal
drug within the 30 days prior to the annual survey.
1986: The Anti-Drug Abuse Act of 1986 was enacted into law by Congress. It changed
the system of federal supervised release from a rehabilitative system into a punitive
system. The bill enacted new mandatory minimum sentences for drugs, including
marijuana.
1988: Near the end of the Reagan administration, the Office of National Drug Control
Policy was created for central coordination of drug-related legislative, security,
diplomatic, research and health policy throughout the government. In recognition of his
central role, the director of ONDCP is commonly known as the Drug Czar. The position
was raised to cabinet-level status by Bill Clinton in 1993.
1992 Illegal drug use in the U.S. fell to 12 million people.
1993, December 7: Joycelyn Elders, the Surgeon General, said that the legalization of
drugs "should be studied", causing a stir among opponents.
1998: The government commissions the first-ever full study of drug policy, to be carried
out by the National Research Council (NRC); the Committee on Data and Research for
Policy on Illegal Drugs is headed by Econometrician Charles Manski.
2001: The National Research Council Committee on Data and Research for Policy on
Illegal Drugs is published. The study reveals that the government has not sufficiently
studied its own drug policy, which it calls "unconscionable". (see more under Efficacy of
the War on Drugs)
2001: 16 million in the U.S. were drug users.
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2008 Several reports state the benefits of drug courts compared with traditional courts.
Using retrospective data, researchers in several studies found that drug courts
reduced recidivism among program participants in contrast to comparable probationers
between 12% to 40%. Re-arrests were lower five years or more later. The total cost per
participant was also much lower. Office of National Drug Control Policy reports that the
Actual youth drug use, as measured as the percent reporting past month use has
declined from 19,4% to 14,8% among middle and high school students between 2001
and 2007.
2009 Gil Kerlikowske, the current Director of the Office of National Drug Control Policy,
signaled that the Obama Administration would not use the term "War on Drugs," as he
claims it is counter-productive and is contrary to the policy favoring treatment over
incarceration in trying to reduce drug use. "Being smart about drugs means working to
treat people who go to jail with a drug problem so when they get out and return to the
communities you protect, you will be less likely to re-arrest them".
2010 California Proposition 19 (also known as the Regulate, Control & Tax Cannabis
Act) was defeated, with 53.5% of California voters voting "No" and 46.5% voting "Yes."
2010 The Fiscal Year 2011 National Drug Control Budget proposed by the Obama
Administration devote significant new resources, $340 million, to the prevention and
treatment of drug abuse.
2012 Colorado and Washington (state) pass laws to legalize the consumption,
possession, and sale of marijuana.
2014 Alaska and Oregon pass laws to legalize the consumption, possession, and sale
of marijuana.
In 2016 recreational marijuana use is legalized in California, Massachusetts, Nevada
and Maine.
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III. The Illegal Drug Trade
In the U.S.
The U.S. Federal Government is an opponent of the illegal drug trade; however, state
laws vary greatly and in some cases contradict federal laws. Despite the US
government's official position against the drug trade, US government agents and assets
have been implicated in the drug trade and were caught and investigated during
the Iran-Contra scandal, implicated in the use of the drug trade as a secret source of
funding for the USA's support of the Contras. Page 41 of the December 1988 Kerry
report to the US Senate states that "indeed senior US policy makers were not immune
to the idea that drug money was a perfect solution to the Contra's funding problem."
The Organization of American States estimated that the revenue for cocaine sales in
the U.S. was $34 billion in 2013. The Office of National Drug Control Policy estimates
that $100 billion worth of illegal drugs were sold in the U.S. in 2013.
Acclaimed investigator and former DEA agent Michael Levine has alleged that the CIA
participated in orchestrating the 1980 Cocaine Coup in Bolivia to install an Operation
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Condor military government, in place of the pre-coup civilian government. The pre-coup
government had collaborated with the DEA in bringing leaders of the Roberto Suarez
cartel to justice, and Levine alleges that the CIA not only intervened judicially to release
the extradited cartel leaders and allow their flight to Bolivia, but also enabled them to
collaborate with right-wing military factions in overthrowing the civilian government that
had collaborated with the DEA. The drug links of the coup government were obvious to
the international community, which led to the coup becoming termed "the Cocaine
Coup" by historians. Levine alleges that one of the CIA agents who participated in the
coup was Klaus Barbie, the former SS Nazi known as the "Butcher of Lyon," who had
previously collaborated with the CIA in Bolivia during the capture and execution of Che
Guevara.
Contrary to its official goals, the US has suppressed research on drug usage, although
the CIA researched regardless during MKULTRA. For example, in 1995 the World
Health Organization (WHO) and the United Nations Interregional Crime and Justice
Research Institute (UNICRI) announced in a press release the publication of the results
of the largest global study on cocaine use ever undertaken. However, a decision in
the World Health Assembly banned the publication of the study. In the sixth meeting of
the B committee the US representative threatened that "If WHO activities relating to
drugs failed to reinforce proven drug control approaches, funds for the relevant
programmes should be curtailed". This led to the decision to discontinue publication. A
part of the study has been released. Several government-sponsored reports by
commissioned experts have pointed to public substance abuse treatment as opposed to
criminalization as the only effective way to battle the public health crisis caused by
drugs; these recommendations have been mostly ignored by US government officials,
and in some cases suppressed.
Minors
The U.S. government's most recent 2005 National Survey on Drug Use and Health
(NSDUH) reported that nationwide over 800,000 adolescents ages 12–17 sold illegal
drugs during the twelve months preceding the survey. The 2005 Youth Risk Behavior
Survey by the U.S. Centers for Disease Control and Prevention (CDC) reported that
nationwide 25.4% of students had been offered, sold, or given an illegal drug by
someone on school property. The prevalence of having been offered, sold, or given an
illegal drug on school property ranged from 15.5% to 38.8% across state CDC surveys
(median: 26.1%) and from 20.3% to 40.0% across local surveys (median: 29.4%).
Despite over US$7 billion spent annually towards arresting and prosecuting nearly
800,000 people across the country for marijuana offenses in 2005 (FBI Uniform Crime
Reports), the federally funded Monitoring the Future Survey reports about 85% of high
school seniors find marijuana “easy to obtain.” That figure has remained virtually
unchanged since 1975, never dropping below 82.7% in three decades of national
surveys.
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In 2009, the Justice Department identified more than 200 U.S. cities in which
Mexican drug cartels "maintain drug distribution networks or supply drugs to
distributors" - up from 100 three years earlier.
Women's Participation in The Drug Economy
In the United States women represent roughly a quarter of all arrests. Women and
men are both more likely to be arrested for less serious property crimes, but men are
more likely than women to be involved in violent crime. Since 1960, while arrests in total
have decreased, women have become a higher percentage of those arrests, partly due
to an increase in drug-related arrests. Steffensmeier and Schwartz (2008) claim that this
increase is not because more women are committing substance-abuse offenses, it is
because law enforcement officials have begun using broader, more expansive
definitions of crimes, arresting more people for minor crimes. Because women are more
likely to commit these minor crimes, females have been disproportionately added to the
number of arrests.
Women and The Informal Economy
The informal economy is a sector of the economy
that includes “all criminal activity that is income
generating”. In the United States, this means that
the selling and consumption of drugs is part of the
informal economy. Throughout the world, working
women are more likely to work in the informal
sector, partly because their traditional household
and childcare responsibilities may make it
preferable to work form home. Others believe that
women are “forced” into the informal sector
because the formal sector fails to accommodate
gender-specific needs for women, such as paid
maternity leave.
Since the 1980s, cheaper imports have been
competing for domestically manufactured goods
in the United States, leading to deindustrialization, particularly in urban areas. This has
caused unemployment in the formal sector. Furthermore, a decrease in welfare policies
has also encouraged unemployment. Both of these factors have led to a growth in the
informal sector of the U.S. economy, raising the number of women who work in this
sector. This has caused an influx of women into drug markets.
The Drug Economy as An Equalizer
The presence of women in drug markets has prompted sociologists, criminologists, and
anthropologists to discuss the role of women in these markets. Do they hold positions in
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the drug economy that are liberated from mainstream society’s gender inequality, or
does society’s sexism reproduce itself in the drug economy?
Anthropologist Phillippe Bourgois, in an ethnography of the crack market in Spanish
Harlem, states that the presence of women on the streets and in the crack market
illustrates their emancipation from household labor and childcare. They are free to
participate in street life. According to Natasha Du Rose, Wilson (1993) makes the
argument that women’s crime and drug use are rising to match men’s because of
women’s emancipation. Du Rose quotes Fagan as saying that women’s positions in the
drug economy are high-status enough that prostitution plays a “relatively insignificant”
part in generating income for these women.
The Drug Economy Perpetuating Inequalities
While Bourgois in 1989 states that women are free to take part in the drug trade now
that they have been liberated from being wives and mothers, he qualifies this by saying
that “traditional gender relations still govern income-generating strategies in the
underground economy”. His ethnographic research shows that the majority of women in
the Spanish Harlem crack market become sex workers to support their addictions.
While women participate more in the drug economy, they still are forced into traditional
street roles when they need to generate income.
Sociologists Lisa Maher and Kathleen Daly in 1996 performed an ethnographic study of
women in the Bushwick drug market in Brooklyn. They used a combination of
participant observation fieldwork and interviews with the women and found that, in a
highly hierarchical drug market, women occupy the lowest rungs of the market.
“Owners”, who all happen to be men, employ “managers” who control a number of
regular and casual “sellers”. These sellers in turn employ “runners”, “steerers”, and
“coppers”, who supply the sellers, advertise their brand of drugs, or buy drugs for other
customers. The runners, steerers, coppers, and casual sellers occupy the lowest-power
and lowest-income positions of this market, and have the most women participants. The
upper levels of the hierarchy have only men participants. In this study, Maher and Daly
refute the idea that the emergence of the crack economy has afforded emancipation
and opportunity for women; gender inequality has continued to be a presence even in
the informal economy. The only change Maher and Daly found brought by women’s
liberation appears to be a decrease in the number of women relying on male boyfriends
or husbands to sell drugs.
Lisa Maher continues her research on the Bushwick drug economy in her 1997
book Sexed Work. She reiterates her findings with Daly on the low-income, low-power
participation of women in the drug market, but she also focuses on the sex work women
more commonly perform to generate income. Since the influx of cheap crack into the
market, Maher finds out that more women have been induced to participate in streetlevel
prostitution, driving up competition and driving down prices, further disadvantaging
the women, especially low-income women of color who typically do not attract high-
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paying clients anyway. Furthermore, while the influx of crack lowered prices
significantly, Maher’s book does not support the idea that women frequently exchange
sex directly for drugs.
Women's Strategies for Coping with Inequalities
Although women can be disadvantaged in the drug economy, they find ways to cope
with these inequalities. In Sexed Work, Lisa Maher states that some women adopt a
“badass” or a “crazy” persona in order to survive amongst violent male
counterparts. Maher and Susan L. Hudson, in a literature review of the women in the
drug economy, explain that women are able to use their image as “feminine”,
“vulnerable”, or "innocent" to hide from police suspicions and sell drugs successfully.
They also may be able to use their “feminine” social and communication skills to defuse
potentially violent situations. Maher and Hudson also find that many women can cope
with limited opportunities for generating income in the drug economy by “diversifying”:
they make money through a flexible mix of sex work, welfare, formal sector jobs, and
drug selling.
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IV. Recreational Drug Use
In the U.S.
Recreational drug use is the use of a psychoactive drug to induce an altered state of
consciousness for pleasure, by modifying the perceptions, feelings, and emotions of the
user. When a psychoactive drug enters the user's body, it induces an intoxicating effect.
Generally, recreational drugs are in three categories: depressants (drugs that induce a
feeling of relaxation and calm); stimulants (drugs that induce a sense of energy and
alertness); and hallucinogens (drugs that induce perceptual distortions such as
hallucination). In popular practice, recreational drug use generally is a tolerated social
behaviour, rather than perceived as the serious medical condition of self-medication.
Recreational drugs include alcohol (as found in beer, wine, and distilled spirits);
cannabis and hashish; nicotine (tobacco); caffeine (coffee and black tea); and the
controlled substances listed as illegal drugs in the Single Convention on Narcotic Drugs
(1961) and the Convention on Psychotropic Substances (1971) of the United Nations.
What controlled substances are considered illegal drugs varies by country, but usually
includes methamphetamines, heroin, cocaine, and club drugs. In 2009, it was estimated
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that about 3% to 6% of people aged 15 to 65 had used illegal drugs at least once (149
to 270 million).
Risks
Severity and type of risks that come with recreational drug use vary widely with the drug
in question and the amount being used. There are many factors in the environment and
within the user that interact with each drug differently. Overall, some studies suggest
that alcohol is one of the most dangerous of all recreational drugs; only heroin, crack
cocaine, and methamphetamines are judged to be more harmful. However, studies
which focus on a moderate level of alcohol consumption have concluded that there can
be substantial health benefits from its use, such as decreased risk of cardiac disease,
stroke and cognitive decline. This claim has been disputed. Researcher David Nutt
stated that these studies showing benefits for "moderate" alcohol consumption lacked
control for the variable of what the subjects were drinking, beforehand. Experts in the
UK have suggested that some drugs that may be causing less harm, to fewer users
(although they are also used less frequently in the first place), include cannabis,
psilocybin mushrooms, LSD, and ecstasy. These drugs are not without their own
particular risks.
Responsible Use
The concept of "responsible drug use" is that a person can use drugs recreationally or
otherwise with reduced or eliminated risk of negatively affecting other aspects of one's
life or other people's lives. Advocates of this philosophy point to the many well-known
artists and intellectuals who have used drugs, experimentally or otherwise, with few
detrimental effects on their lives. Responsible drug use becomes problematic only when
the use of the substance significantly interferes with the user's daily life.
Responsible drug use advocates that users should not take drugs at the same time as
activities such as driving, swimming, operating machinery, or other activities that are
unsafe without a sober state. Responsible drug use is emphasized as a primary
prevention technique in harm-reduction drug policies. Harm-reduction policies were
popularized in the late 1980s, although they began in the 1970s counter-culture, when
cartoons explaining responsible drug use and the consequences of irresponsible drug
use were distributed to users.
Another issue is that the illegality of drugs in itself also causes social and economic
consequences for those using them—the drugs may be "cut" with adulterants and the
purity varies wildly, making overdoses more likely—and legalization of drug production
and distribution would reduce these and other dangers of illegal drug use. Harm
reduction seeks to minimize the harm that can occur through the use of various drugs,
whether legal (e.g., alcohol and nicotine), or illegal (e.g., heroin and cocaine). For
example, people who inject illicit drugs can minimize harm to both themselves and
members of the community through proper injecting technique, using new needles and
syringes each time, and proper disposal of all injecting equipment.
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Prevention
In efforts to curtail recreational drug use, governments worldwide introduced several
laws prohibiting the possession of almost all varieties of recreational drugs during the
20th century.
The West's "War on Drugs" however, is now facing increasing criticism. Evidence is
insufficient to tell if behavioral interventions help prevent recreational drug use in
children.
Society and Culture
Many movements and organizations are advocating for or against the liberalization of
the use of recreational drugs, notably cannabis legalization. Subcultures have emerged
among users of recreational drugs, as well as among those who abstain from them,
such as teetotalism and "straight edge".
The prevalence of recreational drugs in human societies is widely reflected in fiction,
entertainment, and the arts, subject to prevailing laws and social conventions.
In video games, for example, enemies are often drug dealers, a narrative device that
justifies the player killing them. Other games portray drugs as a kind of "power-up"; their
effect is often unrealistically conveyed by making the screen wobble and blur.
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Common Recreational Drugs
The following substances are used recreationally:
Alcohol: Most drinking alcohol is ethanol, CH 3CH
2OH. Drinking alcohol creates intoxication, relaxation and lowered inhibitions. It
is produced by the fermentation of sugars by yeasts to create wine, beer, and
distilled liquor (e.g., vodka, rum, gin, etc.). In most areas of the world, apart from
certain countries where Muslim sharia law is used, it is legal for those over a
certain age (typically 18–21). It is an IARC 'Group 1' carcinogen and a teratogen.
Alcohol withdrawal can be life-threatening.
Amphetamines: Used recreationally to provide alertness and a sense of energy,
whether for all-night studying or all-night dancing. Prescribed for ADHD,
narcolepsy, depression and weight loss. A potent central nervous system
stimulant, in the 1940s and 50s methamphetamine was used by Axis and Allied
troops in World War II, and, later on, other armies, and by Japanese factory
workers. It increases muscle strength and fatigue resistance and improves
reaction time. Methamphetamine use can be neurotoxic, which means it
damages dopamine neurons. As a result of this brain damage, chronic use can
lead to post acute withdrawal syndrome.
Cannabis: Its common forms include marijuana and hashish, which are smoked
or eaten. It contains at least 85 cannabinoids. The primary psychoactive
component is THC, which mimics the neurotransmitter anandamide, named after
the Hindu ananda, "joy, bliss, delight." The review article Campbell & Gowran
(2007) states that "manipulation of the cannabinoid system offers the potential to
upregulate neuroprotective mechanisms while dampening neuroinflammation.
Whether these properties will be beneficial in the treatment of Alzheimer's
disease in the future is an exciting topic that undoubtedly warrants further
investigation."
Caffeine: Often found in coffee, black tea, energy drinks, some soft drinks (e.g.,
Coca-Cola, Pepsi and Mountain Dew, among others), and chocolate.
Cocaine: It is available as a white powder, which is insufflated ("sniffed" into the
nostrils) or converted into a solution with water and injected. A popular derivative,
crack cocaine is typically smoked. When transformed into its freebase form,
crack, the cocaine vapour may be inhaled directly. This is thought to increase
bioavailability, but has also been found to be toxic, due to the production of
methylecgonidine during pyrolysis.
MDMA: Commonly known as ecstasy, it is a common club drug in the rave
scene.
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Ketamine: An anaesthetic used legal by paramedics and doctors in emergency
situations for its dissociative and analgesic qualities and illegally in the club drug
scene.
LSD: A popular ergoline derivative, that was first synthesized in 1938 by
Hofmann. However, he failed to notice its psychedelic potential until 1943. In the
1950s, it was used in psychological therapy, and, covertly, by the CIA in Project
MKULTRA, in which the drug was administered to unwitting US and Canadian
citizens. It played a central role in 1960s 'counter-culture', and was banned in
October 1968 by US President Lyndon B Johnson.
Nitrous Oxide: legally used by dentists as an anxiolytic and anaesthetic, it is
also used recreationally by users who obtain it from whipped cream canisters
(see inhalant), as it causes perceptual effects, a "high" and at higher doses,
hallucinations.
Opiates and Opioids: Available by prescription for pain relief. Commonly
abused opioids include oxycodone, hydrocodone, codeine, fentanyl, heroin, and
morphine. Opioids have a high potential for addiction and have the ability to
induce severe physical withdrawal symptoms upon cessation of frequent use.
Heroin can be smoked, insufflated or turned into a solution with water and
injected.
Psilocybin Mushrooms: This hallucinogenic drug was an important drug in the
psychedelic scene. Until 1963, when it was chemically analysed by Albert
Hofmann, it was completely unknown to modern science that Psilocybe
semilanceata ("Liberty Cap", common throughout Europe) contains psilocybin, a
hallucinogen previously identified only in species native to Mexico, Asia, and
North America.
Tobacco: Nicotiana tabacum. Nicotine is the key drug contained in tobacco
leaves, which are either smoked, chewed or snuffed. It contains nicotine, which
crosses the blood–brain barrier in 10–20 seconds. It mimics the action of the
neurotransmitter acetylcholine at nicotinic acetylcholine receptors in the brain
and the neuromuscular junction. The neuronal forms of the receptor are present
both post-synaptically (involved in classical neurotransmission) and presynaptically,
where they can influence the release of multiple neurotransmitters.
Tranquilizers: barbiturates, benzodiazepines (commonly prescribed for anxiety
disorders; known to cause dementia and post acute withdrawal syndrome)
"Bath Salts": this is the street name for
Mephedrone/Methylenedioxypyrovalerone (MDPV)
DMT – primary ingredient in ayahuasca, can also be smoked in a crack pipe;
briefly (c. 30 minutes) causes a "total loss of connection to external reality"
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Peyote: This hallucinogen contains mescaline, native to southwestern Texas and
Mexico
Salvia Divinorum: This hallucinogenic Mexican herb in the mint family; not
considered recreational, most likely due to the nature of the hallucinations (legal
in some jurisdictions)
Synthetic Cannabis: "Spice", "K2", JWH-018, AM-2201
Research Chemicals: 2C variants, etc.
Types
Depressants
Depressants are psychoactive drugs that temporarily diminish the function or activity of
a specific part of the body or mind. Colloquially, depressants are known as "downers",
and users generally take them to feel more relaxed and less tense. Examples of these
kinds of effects may include anxiolysis, sedation, and hypotension. Depressants are
widely used throughout the world as prescription medicines and as illicit substances.
When these are used, effects may include anxiolysis (reduction of anxiety), analgesia
(pain relief), sedation, somnolence, cognitive/memory impairment, dissociation, muscle
relaxation, lowered blood pressure/heart rate, respiratory depression, anesthesia, and
anticonvulsant effects. Depressants exert their effects through a number of different
pharmacological mechanisms, the most prominent of which include facilitation of GABA
or opioid activity, and inhibition of adrenergic, histamine or acetylcholine activity. Some
are also capable of inducing feelings of euphoria (a happy sensation).
Stimulants or "uppers", such as amphetamines or cocaine, which increase mental or
physical function, have an opposite effect to depressants.
Antihistamines
Antihistamines (or "histamine antagonists") inhibit the release or action of histamine.
"Antihistamine" can be used to describe any histamine antagonist, but the term is
usually reserved for the classical antihistamines that act upon the H1 histamine
receptor. Antihistamines are used as treatment for allergies. Allergies are caused by an
excessive response of the body to allergens, such as the pollen released by grasses
and trees. An allergic reaction causes release of histamine by the body. Other uses of
antihistamines are to help with normal symptoms of insect stings even if there is no
allergic reaction. Their recreational appeal exists mainly due to their anticholinergic
properties, that induce anxiolysis and, in some cases such as diphenhydramine,
chlorpheniramine, and orphenadrine, a characteristic euphoria at moderate doses. High
dosages taken to induce recreational drug effects may lead to overdoses.
Antihistamines are also consumed in combination with alcohol, particularly by youth
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who find it hard to obtain alcohol. The combination of the two drugs can cause
intoxication with lower alcohol doses.
Hallucinations and possibly delirium resembling the effects of Datura stramonium can
result if the drug is taken in much higher than therapeutical dosages. Antihistamines are
widely available over the counter at drug stores (without a prescription), in the form of
allergy medication and some cough medicines. They are sometimes used in
combination with other substances such as alcohol. The most common unsupervised
use of antihistamines in terms of volume and percentage of the total is perhaps in
parallel to the medicinal use of some antihistamines to stretch out and intensify the
effects of opioids and depressants. The most commonly used are hydroxyzine, mainly
to stretch out a supply of other drugs, as in medical use, and the above-mentioned
ethanolamine and alkylamine-class first-generation antihistamines, which are - once
again as in the 1950s - the subject of medical research into their anti-depressant
properties.
For all of the above reasons, the use of medicinal scopolamine for recreational uses is
also seen.
Analgesics
Analgesics (also
known as
"painkillers") are used
to relieve pain (achieve
analgesia). The word
analgesic derives from
Greek "αν-" (an-, "without")
and "άλγος" (álgos, "pain").
Analgesic drugs act in
various ways on the
peripheral and central
nervous systems; they
include paracetamol (para-acetylaminophenol, also known in the US as
acetaminophen), the nonsteroidal anti-inflammatory drugs (NSAIDs) such as the
salicylates, and opioid drugs such as hydrocodone, codeine, heroin and oxycodone.
Some further examples of the brand name prescription opiates and opioid analgesics
that may be used recreationally include Vicodin, Lortab, Norco (hydrocodone), Avinza,
Kapanol (morphine), Opana, Paramorphan (oxymorphone), Dilaudid, Palladone
(hydromorphone), and OxyContin (oxycodone).
Tranquilizers
Tranquilizers (GABAergics):
Barbiturates
Benzodiazepines
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Ethanol (drinking alcohol; ethyl alcohol)
Nonbenzodiazepines
Others
o carisoprodol (Soma)
o chloral hydrate
o diethyl ether
o ethchlorvynol (Placidyl; "jelly-bellies")
o gabapentin (Neurontin)
o gamma-butyrolactone (GBL, a prodrug to GHB)
o gamma-hydroxybutyrate (GHB; G; Xyrem; "Liquid Ecstasy", "Fantasy")
o glutethimide (Doriden)
o kava (from Piper methysticum; contains kavalactones)
o ketamine
o meprobamate (Miltown)
o methaqualone (Sopor, Mandrax; "Quaaludes")
o phenibut
o pregabalin (Lyrica)
o propofol (Diprivan)
o theanine (found in Camellia sinensis, the tea plant)
o valerian (from Valeriana officinalis)
Stimulants
Stimulants, also known as "psychostimulants", induce euphoria with improvements in
mental and physical function, such as enhanced alertness, wakefulness, and
locomotion. Due to their effects typically having an "up" quality to them, stimulants are
also occasionally referred to as "uppers". Depressants or "downers", which decrease
mental or physical function, are in stark contrast to stimulants and are considered to be
their functional opposites.
Stimulants enhance the activity of the central and peripheral nervous systems. Common
effects may include increased alertness, awareness, wakefulness, endurance,
productivity, and motivation, arousal, locomotion, heart rate, and blood pressure, and a
diminished desire for food and sleep.
Use of stimulants may cause the body to reduce significantly its production of natural
body chemicals that fulfill similar functions. Until the body reestablishes its normal state,
once the effect of the ingested stimulant has worn off the user may feel depressed,
lethargic, confused, and miserable. This is referred to as a "crash", and may provoke
reuse of the stimulant.
Examples include:
Sympathomimetics (catecholaminergics)—e.g. amphetamine,
methamphetamine, cocaine, methylphenidate, ephedrine, pseudoephedrine
Entactogens (serotonergics, primarily phenethylamines)—e.g. MDMA
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Eugeroics, e.g. modafinil
Others
o arecoline (found in Areca catechu)
o caffeine (found in Coffea spp.)
o nicotine (found in Nicotiana spp.)
o rauwolscine (found in Rauvolfia serpentina)
o yohimbine (Procomil; a tryptamine alkaloid found in Pausinystalia
yohimbe)
Euphoriants
Alcohol: "Euphoria, the feeling of well-being, has been reported during the early
(10–15 min) phase of alcohol consumption" (e.g., beer, wine or spirits)
Catnip Catnip contains a sedative known as nepetalactone that activates opioid
receptors. In cats it elicits sniffing, licking, chewing, head shaking, rolling, and
rubbing which are indicators of pleasure. In humans, however, catnip does not
act as a euphoriant.
Cannabis Tetrahydrocannabinol, the main psychoactive ingredient in this plant
can have sedative and euphoric properties.
Stimulants: "Psychomotor stimulants produce locomotor activity (the subject
becomes hyperactive), euphoria, (often expressed by excessive talking and
garrulous behaviour), and anorexia. The amphetamines are the best known
drugs in this category..."
MDMA: The "euphoriant drugs such as MDMA (‘ecstasy’) and MDEA (‘eve’)" are
popular amongst young adults. MDMA "users experience short-term feelings of
euphoria, rushes of energy and increased tactility."
Opium: This "drug derived from the unripe seed-pods of the opium
poppy…produces drowsiness and euphoria and reduces pain. Morphine and
codeine are opium derivatives."
Hallucinogens
Hallucinogens can be divided into three broad categories: psychedelics, dissociatives,
and deliriants. They can cause subjective changes in perception, thought, emotion and
consciousness. Unlike other psychoactive drugs such as stimulants and opioids,
hallucinogens do not merely amplify familiar states of mind but also induce experiences
that differ from those of ordinary consciousness, often compared to non-ordinary forms
of consciousness such as trance, meditation, conversion experiences, and dreams.
Psychedelics, dissociatives, and deliriants have a long worldwide history of use within
medicinal and religious traditions. They are used in shamanic forms of ritual healing and
divination, in initiation rites, and in the religious rituals of syncretistic movements such
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as União do Vegetal, Santo Daime, Temple of the True Inner Light, and the Native
American Church. When used in religious practice, psychedelic drugs, as well as other
substances like tobacco, are referred to as entheogens.
Starting in the mid-20th century, psychedelic drugs have been the object of extensive
attention in the Western world. They have been and are being explored as potential
therapeutic agents in treating depression, post-traumatic stress disorder, Obsessivecompulsive
disorder, alcoholism, and opioid addiction. Yet the most popular, and at the
same time most stigmatized, use of psychedelics in Western culture has been
associated with the search for direct religious experience, enhanced creativity, personal
development, and "mind expansion". The use of psychedelic drugs was a major
element of the 1960s counterculture, where it became associated with various social
movements and a general atmosphere of rebellion and strife between generations.
Deliriants
o atropine (alkaloid found in plants of the Solanaceae family, including
datura, deadly nightshade, henbane and mandrake)
o dimenhydrinate (Dramamine, an antihistamine)
o diphenhydramine (Benadryl, Unisom, Nytol)
o hyoscyamine (alkaloid also found in the Solanaceae)
o hyoscine hydrobromide (another Solanaceae alkaloid)
o myristicin (found in Myristica fragrans ("Nutmeg"))
Dissociatives
o
o
o
o
o
o
o
dextromethorphan (DXM; Robitussin, Delsym, etc.; "Dex", "Robo", "Cough
Syrup", "DXM")
• "Triple C's, Coricidin, Skittles" refer to a potentially fatal formulation
containing both dextromethorphan and chlorpheniramine.
ketamine (K; Ketalar, Ketaset, Ketanest; "Ket", "Kit Kat", "Special-K",
"Vitamin K", "Jet Fuel", "Horse Tranquilizer")
methoxetamine (Mex, Mket, Mexi)
phencyclidine (PCP; Sernyl; "Angel Dust", "Rocket Fuel", "Sherm", "Killer
Weed", "Super Grass")
nitrous oxide (N2O; "NOS", "Laughing Gas", "Whippets", "Balloons")
ibotenic acid (found in Amanita muscaria ("Fly Agaric"); prodrug to
muscimol)
muscimol (also found in Amanita muscaria, a GABAergic)
Psychedelics
o
Phenethylamines
• 2C-B ("Nexus", "Venus", "Eros", "Bees")
• 2C-E ("Eternity", "Hummingbird")
• 2C-I ("Infinity")
• 2C-T-2 ("Rosy")
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• 2C-T-7 ("Blue Mystic", "Lucky 7")
• DOB
• DOC
• DOI
• DOM ("Serenity, Tranquility, and Peace" ("STP"))
• MDMA ("Ecstasy", "E", "Molly", "Mandy", "MD", "Crystal Love")
• mescaline (found in peyote, Peruvian torch cactus and San Pedro
cactus)
o
Tryptamines (including ergolines and lysergamides)
• 5-MeO-DiPT ("Foxy", "Foxy Methoxy")
• 5-MeO-DMT (found in various plants like chacruna, jurema, vilca,
and yopo)
• alpha-methyltryptamine (αMT; Indopan; "Spirals")
• bufotenin (secreted by Bufo alvarius, also found in various Amanita
mushrooms)
• dimethyltryptamine (DMT; "Dimitri", "Disneyland", "Spice"; found in
most plants and animals as it is a common metabolite )
• lysergic acid amide (LSA; ergine; found in morning glory and
Hawaiian baby woodrose seeds)
• lysergic acid diethylamide (LSD; L; Delysid; "Acid", "Sid". "Cid",
"Lucy", "Sidney", "Blotters", "Droppers", "Sugar Cubes")
• psilocin (found in psilocybin mushrooms)
• psilocybin (also found in psilocybin mushrooms; prodrug to psilocin)
• ibogaine (found in Tabernanthe iboga ("Iboga"))
Atypicals
Inhalants
o
salvinorin A (found in Salvia divinorum, a trans-neoclerodane diterpenoid
("Diviner's Sage", "Lady Salvia", "Salvinorin"))
Inhalants are gases, aerosols, or solvents that are breathed in and absorbed through
the lungs. While some "inhalant" drugs are used for medical purposes, as in the case of
nitrous oxide, a dental anesthetic, inhalants are used as recreational drugs for their
intoxicating effect. Most inhalant drugs that are used non-medically are ingredients in
household or industrial chemical products that are not intended to be concentrated and
inhaled, including organic solvents (found in cleaning products, fast-drying glues, and
nail polish removers), fuels (gasoline (petrol) and kerosene), and propellant gases such
as Freon and compressed hydrofluorocarbons that are used in aerosol cans such as
hairspray, whipped cream, and non-stick cooking spray. A small number of recreational
inhalant drugs are pharmaceutical products that are used illicitly, such as anesthetics
(ether and nitrous oxide) and volatile anti-angina drugs (alkyl nitrites).
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The most serious inhalant abuse occurs among children and teens who "[...] live on the
streets completely without family ties." Inhalant users inhale vapor or aerosol propellant
gases using plastic bags held over the mouth or by breathing from a solvent-soaked rag
or an open container. The effects of inhalants range from an alcohol-like intoxication
and intense euphoria to vivid hallucinations, depending on the substance and the
dosage. Some inhalant users are injured due to the harmful effects of the solvents or
gases, or due to other chemicals used in the products that they are inhaling. As with any
recreational drug, users can be injured due to dangerous behavior while they are
intoxicated, such as driving under the influence. Computer cleaning dusters are
dangerous to inhale, because the gases expand and cool rapidly upon being sprayed.
In some cases, users have died from hypoxia (lack of oxygen), pneumonia, cardiac
failure or arrest, or aspiration of vomit.
Examples include:
chloroform
diethyl ether
laughing gas (nitrous oxide)
Poppers (alkyl nitrites)
solvents and propellants (including propane, butane, freon, gasoline, kerosene,
toluene) and the fumes of glues containing them
List of Drugs Which Can Be Smoked
Plants:
tobacco
cannabis
salvia divinorum
opium
datura and other Solanaceae (formerly smoked to treat asthma)
possibly other plants (see the section below)
Substances (also not necessarily psychoactive plants soaked with them):
methamphetamine
crack cocaine
black tar heroin
phencyclidine (PCP)
synthetic cannabinoids (see also: synthetic cannabis)
dimethyltryptamine (DMT)
5-MeO-DMT
many others, including some prescription drugs
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List of Psychoactive Plants, Fungi And Animals
Minimally psychoactive plants which contain mainly caffeine and theobromine:
coffee
tea (caffeine in tea is sometimes called theine) – also contains theanine
guarana (caffeine in guarana is sometimes called guaranine)
yerba mate (caffeine in yerba mate is sometimes called mateine)
cocoa
kola
Most known psychoactive plants:
cannabis: cannabinoids
tobacco: nicotine and beta-carboline alkaloids
coca: cocaine
opium poppy: morphine, codeine and other opiates
salvia divinorum: salvinorin A
khat: cathine and cathinone
kava: kavalactones
nutmeg: myristicin
Solanaceae plants—contain atropine, hyoscyamine and scopolamine:
datura
deadly nightshade atropa belladona
henbane
mandrake (Mandragora)
other Solanaceae
Cacti with mescaline:
peyote
Peruvian torch cactus
San Pedro cactus
Other plants:
kratom: mitragynine, mitraphylline, 7-hydroxymitragynine, raubasine and
corynantheidine
ephedra: ephedrine
damiana
Calea zacatechichi
Silene capensis
valerian: valerian (the chemical with the same name)
various plants like chacruna, jurema, vilca, and yopo – 5-MeO-DMT
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Morning glory and Hawaiian Baby Woodrose – lysergic acid amide (LSA, ergine)
Ayahuasca
Tabernanthe iboga ("Iboga")—ibogaine
Areca catechu (see: betel and paan)—arecoline
Rauvolfia serpentina: rauwolscine
yohimbe (Pausinystalia yohimbe): yohimbine, corynantheidine
probably many others
Fungi:
psilocybin mushrooms: psilocybin and psilocin
various Amanita mushrooms: muscimol
Amanita muscaria: ibotenic acid and muscimol
Claviceps purpurea and other Clavicipitaceae: ergotamine (not psychoactive
itself but used in synthesis of LSD)
Psychoactive Animals:
hallucinogenic fish
psychoactive toads: bufotenin, Bufo alvarius (Colorado River toad or Sonoran
Desert toad) also contains 5-MeO-DMT
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V. The Ten States
with the Biggest Drug Problems
Health Buzz: The 10 States with the Biggest Drug Problems
The state with the highest percentage of teenage drug users? Colorado.
By David Oliver, Associate Editor, Social Media
May 15, 2017
Drug problems abound in the U.S., and are most prominently concentrated in the
District of Columbia, according to a new WalletHub report.
The analysis comes amid the nation's opioid epidemic, an issue that President Donald
Trump's administration has seemingly approached paradoxically.
While the president has launched a commission for studying the opioid epidemic, his
administration has suggested slashing 95 percent of the Office of National Drug Control
Policy's budget and labeling addiction a preexisting condition, WalletHub notes. The
National Institute of Drug Abuse reports that people admitting to illicit drug use shot up
from 31.3 percent in 1979 to 48.8 percent in 2015.
Overall 'Biggest Problem' Rank State Drug Use and Addiction Rank
1 District of Columbia 1
2 Vermont 5
3 Colorado 2
4 Delaware 23
5 Rhode Island 3
6 Oregon 10
7 Connecticut 21
8 Arizona 12
9 Massachusetts 9
10 Michigan 6
WalletHub's analysis examined all 50 U.S. states and the District of Columbia across
three categories: drug use and addiction, law enforcement, and drug health issues and
rehab (i.e., a combination of the percentage of adults who needed but didn't receive
treatment for illicit drug use in the last year, as well as statistics on the number of
treatment facilities and admissions to those facilities).
The places with the highest percentage of teenage drug users were Colorado, the
District of Columbia, Vermont, Oregon and Rhode Island. Comparatively, states with the
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lowest percentage of drug users were Nebraska, Utah, North Dakota, South Dakota and
Iowa.
Most people who died from an overdose, per capita, died in West Virginia, followed by
New Hampshire, a Kentucky-Ohio tie and Rhode Island. The states with the fewest
overdose deaths were Iowa, Texas, North Dakota, South Dakota and Nebraska.
This chart ranks the states with the biggest drug problems, according to WalletHub. It
includes states' rankings for drug use and addiction, the study category examining the
percentage of teenagers using illegal drugs in the past month, among other statistics.
Page 58 of 98

VI. List of Schedule I Drugs
In the U.S.
This is the list of Schedule I drugs as defined by the United States Controlled
Substances Act. The following findings are required for drugs to be placed in this
schedule:
1. The drug or other substance has a high potential for abuse.
2. The drug or other substance has no currently accepted medical use in treatment
in the United States.
3. There is a lack of accepted safety for use of the drug or other substance under
medical supervision.
Except as specifically authorized, it is illegal for any person:
1. to manufacture, distribute, or dispense, or possess with intent to manufacture,
distribute, or dispense, a controlled substance; or
2. to create, distribute, or dispense, or possess with intent to distribute or dispense,
a counterfeit substance.
The complete list of Schedule I drugs follows. The Administrative Controlled Substances
Code Number for each drug is included.
Opioids
ACSCN
Drug
9815
Acetyl-alpha-methylfentanyl (N-[1-(1-methyl-2-phenethyl)-4-piperidinyl]-Nphenylacetamide)
9601 Acetylmethadol
9602 Allylprodine
9603
Alphacetylmethadol (except levo-alphacetylmethadol also known as levo-alphaacetylmethadol,
levomethadyl acetate, or LAAM)
9604 Alphameprodine
9605 Alphamethadol
9814
Alpha-methylfentanyl (N-[1-(alpha-methyl-beta-phenyl)ethyl-4-piperidyl]
propionanilide; 1-(1-methyl-2-phenylethyl)-4-(N-propanilido) piperidine)
9832
Alpha-methylthiofentanyl (N-[1-methyl-2-(2-thienyl)ethyl-4- piperidinyl]-Nphenylpropanamide)
9606 Benzethidine
9607 Betacetylmethadol
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ACSCN
Drug
9830
Beta-hydroxyfentanyl (N-[1-(2-hydroxy-2-phenethyl)-4- piperidinyl]-Nphenylpropanamide)
9831
Beta-hydroxy-3-methylfentanyl (other name: N-[1-(2-hydroxy-2- phenethyl)-3-
methyl-4-piperidinyl]-N-phenylpropanamide
9608 Betameprodine
9609 Betamethadol
9611 Betaprodine
9612 Clonitazene
9613 Dextromoramide
9615 Diampromide
9616 Diethylthiambutene
9168 Difenoxin
9617 Dimenoxadol
9618 Dimepheptanol
9619 Dimethylthiambutene
9621 Dioxaphetyl butyrate
9622 Dipipanone
9623 Ethylmethylthiambutene
9624 Etonitazene
9625 Etoxeridine
9626 Furethidine
9627 Hydroxypethidine
9628 Ketobemidone
9629 Levomoramide
9631 Levophenacylmorphan
9813
3-Methylfentanyl (N-[3-methyl-1-(2-phenylethyl)-4-piperidyl]-Nphenylpropanamide)
9833
3-methylthiofentanyl (N-[(3-methyl-1-(2-thienyl)ethyl-4-piperidinyl]-Nphenylpropanamide)
9632 Morpheridine
9661 MPPP (1-methyl-4-phenyl-4-propionoxypiperidine)
9633 Noracymethadol
9634 Norlevorphanol
9635 Normethadone
9636 Norpipanone
9812
Para-fluorofentanyl (N-(4-fluorophenyl)-N-[1-(2-phenethyl)-4-piperidinyl]
propanamide
Page 60 of 98

ACSCN
Drug
9663 PEPAP (1-(-2-phenethyl)-4-phenyl-4-acetoxypiperidine
9637 Phenadoxone
9638 Phenampromide
9647 Phenomorphan
9641 Phenoperidine
9642 Piritramide
9643 Proheptazine
9644 Properidine
9649 Propiram
9645 Racemoramide
9835 Thiofentanyl (N-phenyl-N-[1-(2-thienyl)ethyl-4-piperidinyl]-propanamide
9750 Tilidine
9646 Trimeperidine
Opium Derivatives
Heroin Powder
ACSCN
Drug
9051 Acetyldihydrocodeine
9052 Benzylmorphine
9053 Codeine-N-Oxide
9054 Cyprenorphine
9055 Desomorphine
9056 Etorphine (except hydrochloride salt)
9070 Codeine methylbromide
9145 Dihydromorphine
9200 Heroin (diacetylmorphine)
9301 Hydromorphinol
9302 Methyldesorphine
9304 Methyldihydromorphine
9305 Morphine methylbromide
9306 Morphine methylsulfonate
9307 Morphine-N-Oxide
9308 Myrophine
9309 Nicocodeine
9312 Nicomorphine
Page 61 of 98

ACSCN
9313 Normorphine
9314 Pholcodine
9315 Thebacon
9319 Acetorphine
9335 Drotebanol
Drug
Hallucinogenic or Psychedelic Substances
ACSCN
Drug
7249 Alpha-Ethyltryptamine (αET)
7391 4-bromo-2,5-dimethoxy-amphetamine (DOB)
7392 4-Bromo-2,5-dimethoxyphenethylamine (2C-B)
7396 2,5-dimethoxyamphetamine (DOA)
7399 2,5-Dimethoxy-4-ethylamphetamine (DOE)
7348
2,5-dimethoxy-4-(n)-propylthiophenethylamine (2C-T-7), its optical isomers,
salts and salts of isomers
7411 4-methoxyamphetamine (PMA)
7401 5-methoxy-3,4-methylenedioxyamphetamine (MMDA)
7395 4-methyl-2,5-dimethoxyamphetamine (DOM; STP)
7400 3,4-methylenedioxyamphetamine (MDA, Sassafrass)
7405 3,4-methylenedioxymethamphetamine (MDMA, Molly)
7404 3,4-methylenedioxy-N-ethylamphetamine (MDEA; MDE)
7402 N-hydroxy-3,4-methylenedioxyamphetamine (N-hydroxy MDA)
7390 3,4,5-trimethoxyamphetamine (TMA)
7431
5-methoxy-N,N-dimethyltryptamine (5-methoxy-3-[2-
(dimethylamino)ethyl]indole; 5-MeO-DMT)
7432 Alpha-methyltryptamine (αMT)
7433 Bufotenine
7434 Diethyltryptamine (DET)
7435 Dimethyltryptamine (DMT)
7439
5-methoxy-N,N-diisopropyltryptamine (5-MeO-DIPT), its isomers, salts and
salts of isomers
7260 Ibogaine
7315 Lysergic acid diethylamide (LSD)
7360 Marihuana or hemp, including cannabis resin
7350 Marihuana extracts; hemp extracts; cannabinoids [4]
7381 Mescaline
7374 Parahexyl
Page 62 of 98

ACSCN
Drug
7415 Peyote
7482 N-ethyl-3-piperidyl benzilate
7484 N-methyl-3-piperidyl benzilate
7437 Psilocybin
7438 Psilocin
7370 Tetrahydrocannabinol (THC)
7455 Ethylamine analog of phencyclidine (Eticyclidine; PCE)
7458 Pyrrolidine analog of phencyclidine (PCPy)
7470 Thiophene analog of phencyclidine (TCP)
7473 1-[1-(2-thienyl)cyclohexyl]pyrrolidine (TCPy)
1248 4-methylmethcathinone (Mephedrone)
7535 3,4-methylenedioxypyrovalerone (MDPV)
7509 2-(2,5-Dimethoxy-4-ethylphenyl)ethanamine (2C-E)
7508 2-(2,5-Dimethoxy-4-methylphenyl)ethanamine (2C-D)
7519 2-(4-Chloro-2,5-dimethoxyphenyl)ethanamine (2C-C)
7518 2-(4-Iodo-2,5-dimethoxyphenyl)ethanamine (2C-I)
7385 2-[4-(Ethylthio)-2,5-dimethoxyphenyl]ethanamine (2C-T-2)
7532 2-[4-(Isopropylthio)-2,5-dimethoxyphenyl]ethanamine (2C-T-4)
7517 2-(2,5-Dimethoxyphenyl)ethanamine (2C-H)
7521 2-(2,5-Dimethoxy-4-nitro-phenyl)ethanamine (2C-N)
7524 2-(2,5-Dimethoxy-4-(n)-propylphenyl)ethanamine (2C-P)
7540 3,4-Methylenedioxy-N-methylcathinone (Methylone)
Depressants
Gamma-Hydroxybutyrate Powder
ACSCN
Drug
2010
gamma-Hydroxybutyric acid (GHB; sodium oxybate; sodium oxybutyrate)
except formulations in an FDA-approved drug product are Schedule III
2572 Mecloqualone
2565 Methaqualone
Stimulants
Aminorex
Products containing BZP.
Page 63 of 98

ACSCN
Drug
1585
Aminorex (aminoxaphen; 2-amino-5-phenyl-2- oxazoline; or 4,5-dihydro-5-
phenly-2-oxazolamine)
7493
N-benzylpiperazine (some other names: BZP; 1-benzylpiperazine), its optical
isomers, salts and salts of isomers
1235 Cathinone
1503 Fenethylline
Methcathinone (Some other names: 2-(methylamino)-propiophenone; alpha-
(methylamino)propiophenone; 2-(methylamino)-1-phenylpropan-1-one; alpha-
1237 N-methylaminopropiophenone; monomethylpropion; ephedrone; N-
methylcathinone; methylcathinone; AL-464; AL-422; AL-463 and UR1432), its
salts, optical isomers and salts of optical isomers
1590 (+/-)cis-4-methylaminorex
1475 N-ethylamphetamine
1480
N,N-dimethylamphetamine (also known as N,N-alpha-trimethylbenzeneethanamine;
N,N-alpha-trimethylphenethylamine)
Cannabimimetic Agents
ACSCN
Drug
7297 5-(1,1-dimethylheptyl)-2-[(1R,3S)-3-hydroxycyclohexyl]-phenol (CP-47,497)
7298
5-(1,1-dimethyloctyl)-2-[(1R,3S)-3-hydroxycyclohexyl]-phenol
(cannabicyclohexanol or CP-47,497 C8-homolog)
7118 1-pentyl-3-(1-naphthoyl)indole (JWH-018 and AM678)
7173 1-butyl-3-(1-naphthoyl)indole (JWH-073)
7019 1-hexyl-3-(1-naphthoyl)indole (JWH-019)
7200 1-[2-(4-morpholinyl)ethyl]-3-(1-naphthoyl)indole (JWH-200)
6250 1-pentyl-3-(2-methoxyphenylacetyl)indole (JWH-250)
7081 1-pentyl-3-[1-(4-methoxynaphthoyl)]indole (JWH-081)
7122 1-pentyl-3-(4-methyl-1-naphthoyl)indole (JWH-122)
7398 1-pentyl-3-(4-chloro-1-naphthoyl)indole (JWH-398)
7201 1-(5-fluoropentyl)-3-(1-naphthoyl)indole (AM2201)
7694 1-(5-fluoropentyl)-3-(2-iodobenzoyl)indole (AM694)
7104 1-pentyl-3-[(4-methoxy)-benzoyl]indole (SR-19 and RCS-4)
7008 1-cyclohexylethyl-3-(2-methoxyphenylacetyl)indole 7008 (SR-18 and RCS-8)
7203 1-pentyl-3-(2-chlorophenylacetyl)indole (JWH-203)
Page 64 of 98

Temporary/ Emergency Listings
These items are listed by the Secretary of Health and Human Services pursuant to 21
CFR 1308.49.
ACSCN
Drug
(1-pentyl-1H-indol-3-yl)(2,2,3,3-tetramethylcyclopropyl)methanone, its optical,
7144 positional, and geometric isomers, salts and salts of isomers (UR-144, 1-pentyl-
3-(2,2,3,3-tetramethylcyclopropoyl)indole)
[1-(5-fluoro-pentyl)-1H-indol-3-yl](2,2,3,3-tetramethylcyclopropyl)methanone, its
7011
optical, positional, and geometric isomers, salts and salts of isomers (5-fluoro-
UR-144, 5-F-UR-144, XLR-11, 1-(5-fluoro-pentyl)-3-(2,2,3,3-
tetramethylcyclopropoyl)indole)
7048
N-(1-adamantyl)-1-pentyl-1H-indazole-3-carboxamide, its optical, positional,
and geometric isomers, salts and salts of isomers (APINACA, AKB-48)
7222 Quinolin-8-yl 1-pentyl-1H-indole-3-carboxylate (QUPIC, PB-22)
7225
Quinolin-8-yl 1-(5-fluoropentyl)-1H-indole-3-carboxylate (5-fluoro-PB-22; 5F-
PB-22)
7012
N-(1-amino-3-methyl-1-oxobutan-2-yl)-1-(4-fluorobenzyl)-1H-indazole-3-
carboxamide (AB-FUBINACA)
7035
N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-pentyl-1H-indazole-3-carboxamide
(ADB-PINACA)
7031
N-(1-amino-3-methyl-1-oxobutan-2-yl)-1-(cyclohexylmethyl)-1H-indazole-3-
carboxamide (AB-CHMINACA)
7023
N-(1-amino-3-methyl-1-oxobutan-2-yl)-1-pentyl-1H-indazole-3-carboxamide
(AB-PINACA)
7024 [1-(5-fluoropentyl)-1H-indazol-3-yl](naphthalen-1-yl)methanone (THJ-2201) [8]
7538
2-(4-iodo-2,5-dimethoxyphenyl)-N-(2-methoxybenzyl)ethanamine (25I-NBOMe;
2C-I-NBOMe; 25I; Cimbi-5)
7537
2-(4-chloro-2,5-dimethoxyphenyl)-N-(2-methoxybenzyl)ethanamine (25C-
NBOMe; 2C-C-NBOMe; 25C; Cimbi-82)
7536
2-(4-bromo-2,5-dimethoxyphenyl)-N-(2-methoxybenzyl)ethanamine (25B-
NBOMe; 2C-B-NBOMe; 25B; Cimbi-36)
9547 3,4-dichloro-N-[2-(dimethylamino)cyclohexyl]N-methylbenzamide) (U-47700)
9821 Acetylfentanyl (N-(1-phenethylpiperidin-4-yl)-N-phenylacetamide)
9834 N-(1-Phenethylpiperidin-4-yl)-N-phenylfuran-2-carboxamide (furanyl fentanyl)
7034
2-(1-(5-Fluoropentyl)-1H-indazole-3-carboxamido)-3,3-dimethylbutanoate (5F-
ADB, 5F-MDMB-PINACA)
7033
Methyl 2-(1-(5-fluoropentyl)-1H-indazole-3-carboxamido)-3-methylbutanoate
(5F-AMB)
7049
N-(Adamantan-1-yl)-1-(5-fluoropentyl)-1H-indazole-3-carboxamide (5F-
APINACA, 5F-AKB48)
Page 65 of 98

ACSCN
Drug
7010
N-(1-Amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(4-fluorobenzyl)-1H-indazole-3-
carboxamide (ADB-FUBINACA)
7042
Methyl 2-(1-(cyclohexylmethyl)-1H-indole-3-carboxamido)-3,3-
dimethylbutanoate (MDMB-CHMICA, MMB-CHMINACA)
7020
Methyl 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamido)-3,3-
dimethylbutanoate (MDMB-FUBINACA)
Page 66 of 98

VII. Drug Paraphernalia
"Drug paraphernalia" is a term,
to denote any equipment,
product, accessory, or material
that is modified for making, using,
or concealing drugs, typically for
recreational purposes. Drugs
such as cocaine, heroin,
marijuana,
and
methamphetamine are related to
a wide range of paraphernalia.
Paraphernalia generally falls into
two categories: user-specific
products and dealer-specific
products.
User-specific products include
glass hashish pipes, crack
cocaine pipes, smoking masks,
hashish bongs, cocaine freebase
kits, syringes, roach clips for
holding the burning end of a
marijuana joint. Some stores sell
items for growing hydroponic
marijuana, such as guidebooks,
fertilizer, and fluorescent growlights.
The term "paraphernalia"
also refers to items such as hollowed-out cosmetic cases or fake pagers when used to
conceal illegal drugs, or products purported to cleanse an individuals system of drug
residues to increase the individual's chance of passing a urine analysis for drug use.
Dealer-specific products are used by the drug sellers or traffickers for preparing drugs
for distribution. Items such as digital scales, vials, and small zipper storage bags that
can be used to sell crack, heroin, or marijuana fall into this category.
Legality
In the U.S., enterprising individuals would sell items openly in the street, until antiparaphernalia
laws in the 1980s eventually ended the practice. With the growth of the
Internet, drug paraphernalia sellers have greatly expanded their sales to a worldwide
market.
Page 67 of 98

According to the Federal Drug Paraphernalia Statute, 21 USC 863, which is part of the
Controlled Substances Act, in the U.S. it is illegal to sell, transport through the mail,
transport across state lines, import, or export drug paraphernalia as defined.
Possession is usually illegal under State law. The law gives specific guidance on
determining what constitutes drug paraphernalia. Many states have also enacted their
own laws prohibiting drug paraphernalia. In the 1982 case Hoffman Estates v. The
Flipside, Hoffman Estates, Inc., the U.S. Supreme Court found a municipal ordinance
requiring licensing for paraphernalia sales to have sufficiently distinguished marketing
for illegal use to be constitutional. Government crackdowns have resulted in the arrest
of sellers of recreational drug paraphernalia, such as actor Tommy Chong, who spent
time in prison in 2003 for having his name used on bongs for sale via the internet.
The American drug paraphernalia laws can also apply to many items that have more
legitimate uses than for illegal drugs. Small mirrors and other glass products (such as
Pyrex test tubes and "glass crack pipes"), lighters, rolled up currency, razor blades,
aluminum/tin foil, credit cards, and spoons have all been used to prosecute people
under paraphernalia laws, whether or not they contain residue of illegal drugs. While
United States federal statute defines paraphernalia with the concept of primary use, in
practice this can be interpreted to be what the individual was currently primarily using
the item for, allowing for common items to be treated as paraphernalia only in cases
where more clear evidence allows such determination of primary use.
Head shops are very much alive and well in the U.S., however. Generally, though, they
have signs near presumable paraphernalia saying "For tobacco use only" or "Not for
use with illicit drugs." Many also ban customers for referencing use of illegal drugs when
buying items. Similar policies are used in online head shops, where customers are often
made to verify detailed disclaimers of their non-use of illegal substances before buying
items.
Page 68 of 98

VIII. References
1. https://en.wikipedia.org/wiki/Drugs_in_the_United_States
2. https://en.wikipedia.org/wiki/History_of_United_States_drug_prohibition
3. https://en.wikipedia.org/wiki/Federal_drug_policy_of_the_United_States
4. https://health.usnews.com/wellness/health-buzz/articles/2017-05-15/the-10-states-withthe-biggest-drug-problems
5. https://en.wikipedia.org/wiki/Recreational_drug_use
6. https://en.wikipedia.org/wiki/War_on_drugs
7. https://en.wikipedia.org/wiki/Drug_courts_in_the_United_States
8. https://en.wikipedia.org/wiki/Doping_in_the_United_States
9. https://en.wikipedia.org/wiki/Alcohol_abuse
10. https://en.wikipedia.org/wiki/Cannabis_in_the_United_States
11. https://en.wikipedia.org/wiki/Cocaine_in_the_United_States
12. https://en.wikipedia.org/wiki/Crack_epidemic
13. https://en.wikipedia.org/wiki/Federal_drug_policy_of_the_United_States
14. https://en.wikipedia.org/wiki/Methamphetamine_in_the_United_States
15. https://en.wikipedia.org/wiki/Tobacco_in_the_United_States
16. https://en.wikipedia.org/wiki/Illegal_drug_trade_in_the_United_States
17. https://en.wikipedia.org/wiki/Women_in_the_drug_economy_in_the_United_States
18. http://www.nsc.org/RxDrugOverdoseDocuments/Prescription-Nation-2016-American-
Drug-Epidemic.pdf
19. http://www.pewtrusts.org/~/media/assets/2017/07/highpriceofopioidcrisis_infographic_fin
al.pdf?la=en
20. https://en.wikipedia.org/wiki/List_of_Schedule_I_drugs_(US)
21. https://en.wikipedia.org/wiki/Drug_paraphernalia
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Notes
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Page 71 of 98

Page 72 of 98

Attachment A
The High Price of the Opioid Crisis
Infographic
Page 73 of 98

An infographic from July 2017
The High Price of the Opioid Crisis
Increasing access to treatment can reduce costs
Untreated opioid use disorder (OUD), a chronic brain disease, has a serious cost to people, their families, and society via
increased health care spending, criminal justice issues, and lost productivity.
Each year, prescription opioid overdose, misuse,
and dependence account for:
$28.9 billion in health care costs 1
Patients with an OUD incur approximately $18,000 in
additional costs annually. 2
$7.6 billion in criminal justice costs 3
96% of costs fall to state and local governments. 4
$41.8 billion in lost productivity 5
7 in 10 employers experience issues associated with
prescription drug misuse, such as employee absenteeism,
decreased job performance, and injury. 6
Illicit opioids, including heroin and fentanyl, add even
more costs.
More than 33,000 Americans died of an opioid overdose in 2015. 7 Improving
access to evidence-based treatments for OUD can help save lives and reduce
costs to society.

Endnotes
1 Curtis S. Florence et al., “The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013”
Medical Care 54, no. 10 (2016): 901–6, http://journals.lww.com/lww-medicalcare/Abstract/2016/10000/The_Economic_Burden_of
Prescription_Opioid.2.aspx.
2 Alan G. White et al., “Economic Impact of Opioid Abuse, Dependence, and Misuse,” American Journal of Pharmacy Benefits 3, no. 4 (2011):
e59–70, https://ajmc.s3.amazonaws.com/_media/_pdf/AJPB_11julaug_White_e59_to_e70.pdf.
3 Florence et al., “The Economic Burden of Prescription Opioid Overdose.”
4 Ibid.
5 Ibid.
6 Deborah A.P. Hersman, “How the Prescription Drug Crisis Is Impacting American Employers,” National Safety Council (2017), http://
www.nsc.org/NewsDocuments/2017/Media-Briefing-National-Employer-Drug-Survey-Results.pdf.
7 Rose A. Rudd et al., “Increases in Drug and Opioid-Involved Overdose Deaths—United States, 2010–2015,” Morbidity and Mortality Weekly
Report 65, no. 50-51 (2016): 1445–52, http://dx.doi.org/10.15585/mmwr.mm655051e1.
For further information, please visit:
pewtrusts.org/substancemisuse
Contact: Megan Meline, manager, communications
Email: mmeline@pewtrusts.org
Project website: pewtrusts.org/substancemisuse
The Pew Charitable Trusts is driven by the power of knowledge to solve today’s most challenging problems. Pew applies a rigorous, analytical
approach to improve public policy, inform the public, and invigorate civic life.

Page 74 of 98

Attachment B
Prescription Nation
Addressing America’s Drug Epidemic
Page 75 of 98

ADDRESSING
AMERICA’S
DRUG
EPIDEMIC
PRESCRIPTION
NATION 2016

TABLE OF CONTENTS
Executive Summary 3
The Deadliest Drug Epidemic on Record
in Our Nation’s History 7
Americans are at Greater Risk for Addiction
than They Realize 8
The Transition to Heroin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Deadly Emergence of Fentanyl 11
State Progress 13
INDICATOR 1: Mandatory Prescriber Education . . . . . . . . . . . . . . . . . . . . .16
INDICATOR 2: Opioid Prescribing Guidelines 17
INDICATOR 3: Eliminating Pill Mills 19
INDICATOR 4: Prescription Drug Monitoring Programs (PDMPs) 21
INDICATOR 5: Increased Access to Naloxone 23
INDICATOR 6: Availability of Opioid Use Disorder
(OUD) Treatment 25
Recommendations 28
About the National Safety Council 29
2 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

EXECUTIVE SUMMARY
This is the most fatal drug crisis on record in United States history, and too many
families and communities are left to suffer in its path. These highly addictive
medicines have been incorrectly marketed as the most effective method for
treating pain and, subsequently, liberally prescribed. Prescription opioids also
serve as gateway drugs to heroin, which has a nearly identical chemical makeup
and is cheaper and sometimes easier to obtain.
The facts are clear:
ü More than 259 million opioid prescriptions were written in 2012
Prescription
opioid overdoses
kill 52 people
every day.
In 2014, the most
recent annual
statistics available,
18,893 people died as a
result of a prescription
opioid overdose.
ü 1.9 million Americans are addicted to opioid painkillers
ü The U.S. makes up 4.6 percent of the world’s populations but
consumes 81 percent of the world supply of oxycodone
ü 4.3 million adolescents and adults reported non-medical use
of prescription opioids in 2014
4 Key Actions:
ü 4 out of 5 heroin users started on prescription opioids
The National Safety Council is committed to ending unintentional injuries
and death in our lifetime and has been fighting this drug epidemic for years.
State governments also play a significant role in this fight, with state
legislators, Governors, and public health officials dictating the strategy.
This report identifies four key actions states can take that could have
immediate and sustained impact:
ü Require and expand prescriber education
ü Develop and implement prescriber guidelines
ü Increase access to naloxone, an overdose antidote
ü Expand access to treatment
Require and
expand prescriber
education
Develop and
implement prescriber
guidelines
Increase access
to naloxone, an
overdose antidote
Expand access
to treatment
3 | NATIONAL SAFETY COUNCIL

Some states have made significant progress. Others have much
more to do while each day people suffer from addiction and die
from this epidemic. States were given a rating of “Making Progress”,
“Lagging Behind” or “Failing” based on careful evaluation of efforts
in six key indicators:
6 KEY INDICATORS
1. Mandatory
Prescriber
Education
Mandatory prescriber education
helps providers make well-informed
decisions on medical treatment based
on best practice and the latest research,
carefully weighing the benefits and
risks of opioids and their alternatives.
The Centers for Disease Control and
Prevention (CDC) has shown that
the increase in opioid prescribing has
resulted in increased admissions for
treatment of opioid use disorder and
overdose deaths, despite a lack of a
corresponding decrease in reported
pain. Additionally, physicians report
receiving limited education on pain
treatment.
2. Opioid
Prescribing
Guidelines
Sound, evidence-based prescribing
guidelines encourage physicians to
incorporate alternative, non-opioid
treatments for pain and provide the
lowest effective doses and the fewest
number of pills when prescribing
dangerous opioid medications. The
recently released CDC guideline on
opioid treatment for chronic pain should
be adopted as the state prescribing
guideline, but states should also consider
the risks for acute pain patients. If
followed, NSC believes guidelines that
address acute and chronic pain could
reduce the number of opioid overdose
deaths in the United States.
3. Eliminating
Pill Mills
“Pill mills” are a doctor’s office, clinic
or health care facility that routinely
prescribes controlled substances
outside the scope of standard medical
practice and often in violation of state
laws and greatly increases the risk of
abuse and overdose. States should pass
legislation that regulates pain clinics and
pain management services, requiring
such actions as following prescribing
guidelines, defining ownership,
restricting dispensing of controlled
substances and requiring use of state
prescription drug monitoring programs.
4 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

6 KEY INDICATORS
4. Prescription
Drug Monitoring
Programs (PDMPs)
PDMPs play an important role in any
effective approach to the prescription
opioid epidemic. Doctor shopping,
or going to multiple providers for
prescriptions, and providers who
prescribe controlled substances outside
the scope of standard medical practice
will continue to fuel the opioid epidemic.
PDMPs directly address these issues.
Nearly every state has an operating
PDMP, and states should take steps to
simplify registration and utilization,
improve reporting response times
and upgrade technology to allow data
integration into clinical workflows.
5. Increased
Access to
Naloxone
Naloxone is an opioid antagonist that
saves lives by reversing an opioid
overdose, with no negative side effects.
Naloxone is not a controlled substance
and has no abuse potential. States should
ensure that naloxone is widely available
without a prescription under standing
orders and covered by insurance plans,
both public and private.
6. Availability of
Opioid Use
Disorder (OUD)
Treatment
Access to treatment is key to helping
those with a substance use disorder. In
order to increase this access, states must
expand capacity for treatment, including
medication-assisted treatments and
require both public and private health
insurers to cover medication-assisted
treatment and remove caps on duration
of treatment.
5 | NATIONAL SAFETY COUNCIL

States were evaluated on each of these indicators
which are critical to effectively and comprehensively
fighting this growing epidemic.
This report provides a roadmap for strengthening laws and regulations. NSC is prepared to assist states
with implementation of these evidence-based strategies which can save thousands of lives every year.
A ROADMAP FOR
STRENGTHENING LAWS & REGULATIONS
47
STATES
NEED TO
IMPROVE!
26
STATES
are “FAILING”
4
STATES
are “MAKING
PROGRESS”
FAILING
LAGGING
BEHIND
MAKING
PROGRESS
MEET ZERO
INDICATORS
MEETS 1
INDICATOR
MEETS 2
INDICATORS
MEETS 3
INDICATORS
MEETS 4
INDICATORS
MEETS 5
INDICATORS
MEETS 6
INDICATORS
THREE
HAVE
MET
ZERO
INDICATORS.
Michigan
Missouri
Nebraska
3
STATES
Alaska
District of
Columbia
Hawaii
Idaho
Kansas
Montana
Wyoming
Arizona
Connecticut
Florida
Georgia
Illinois
Iowa
Maryland
Mississippi
Nevada
New Jersey
New York
North Dakota
Oregon
South Carolina
South Dakota
Virginia
Arkansas
Colorado
Delaware
Louisiana
Maine
Massachusetts
Minnesota
Oklahoma
Pennsylvania
Texas
Utah
Washington
Alabama
California
Indiana
New Hampshire
North Carolina
Ohio
Rhode Island
West Virginia
Wisconsin
Kentucky
New Mexico
Tennessee
Vermont
ZERO
HAVE
MET
ALL 6
INDICATORS.
NO
STATES
6 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

DEADLIEST DRUG EPIDEMIC ON RECORD
IN OUR NATION’S HISTORY
The United States is confronting the
deadliest drug crisis on record. (CENTERS
FOR DISEASE CONTROL & PREVENTION, 2016)
Drug overdoses, mostly caused by
opioids, end far too many lives too
soon. More than 47,055 families lost
loved ones in 2014 to a drug overdose.
Opioid pain medications like Vicodin
(hydrocodone), OxyContin (oxycodone)
or Fentanyl accounted for 18,893 deaths.
(CDC NATIONAL CENTER FOR HEALTH
According to the CDC, the increase in
opioid-related fatalities and treatment
admissions parallels the increase in sales
of opioid pain relievers. (PAULOZZI, JONES,
MACK, & RUDD, 2011) Opioid prescribing
remains high, with more than 259
million prescriptions written in 2012.
(PAULOZZI, MACK, & HOCKENBERRY, VITAL SIGNS:
VARIATION AMONG STATES IN PRESCRIBING OF
OPIOID PAIN RELIEVERS AND BENZODIAZEPINES—
UNITED STATES, 2012, 2014)
Opioid pain medications, if taken too
long or at a high daily dose, can have
deadly and life-changing consequences
even when used under the care
of a medical professional.
The drug problems of past decades pale
when compared to the current opioid
epidemic which has killed 165,000
Americans from 2000 to 2014.
STATISTICS, 2015)
Poisoning Death Rates by Age
Poisoning From Death 1963 to 2014 Rates the age by Age adjusted death
rate increased from 2.0 to 13.0 or 550%.
This graphic shows the rate of poisoning deaths has changed in the past fifty years. In 1963,
poisoning deaths peaked in early childhood causing 5 deaths per every 100,000 people.
FACT
Deaths per 100,000 Population
DEATHS PER 100,000 POPULATION
30
25
20
15
10
5
0
0 10 20 30 40 50 60 70 80
Age
AGE
Today, there has been a 550 percent increase in the age-adjusted death rate of Americans killed by
poisoning. These deaths, primarily from an overdose of an opioid pain medication or heroin, peak
around age 50 with a secondary peak around age 30. Especially troubling is that these deaths span
from ages 20-70 as it shows an increase in the rate of poisoning death for nearly all working adults.
1963
1973
1983
1993
2003
2013
2014
From 1963
to 2014 the
age adjusted
death
rate for
poisoning
increased
550%
from 2.0
to 13.0.
7 | NATIONAL SAFETY COUNCIL

AMERICANS ARE AT GREATER RISK
FOR ADDICTION THAN THEY REALIZE
Opioid pain medications have a number
of side effects and the risk of addiction
may be the most serious. However, it
is clear most people do not understand
this risk. A 2015 National Safety Council
public opinion poll found nearly 90
percent of opioid users were not worried
about addiction, even though 60 percent
of respondents reported having an
addiction risk factor such as personal or
family history of alcoholism, depression,
use of psychiatric medications, or a
history of physical, mental or sexual
abuse. More education is needed about
who is at risk for addiction from opioid
pain medication use.
More than 1.9 million Americans
are addicted to opioid painkillers.
(SAMHSA, 2015) For some people, their
first prescription of an opioid pain
medication began an addiction that
was never intended or expected. More
than 4.3 million people have misused 1
an opioid painkiller in the past month.
(SAMHSA, 2015) Seventy percent of people
gain access to opioids from people they
know. (SAMHSA, 2015) Tragically, about
four percent of those who misuse opioid
painkillers will transition to heroin.
(JONES, 2013)
3,600
PEOPLE
in the U.S.
STARTED MISUSING
an opioid pain medication
for the first time
TODAY!
Risk
Factors
for Opioid
Addiction
Having depression,
anxiety or other
mental health illness
A personal and/or
family history
of alcohol or
substance abuse
A history of
physical, mental or
sexual abuse
Long term use
of opioid pain
medications
1
“Misuse” includes use without a prescription or taking the drug for the feeling or “high” it causes. Examples of misuse include using another person’s
prescription or using “saved” medications from a previous medical condition or surgery.
8 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

THE TRANSITION TO HEROIN
Opioid pain medications, like hydrocodone
and oxycodone, are chemically similar
to heroin and have a similar effect on
our minds and bodies.
As opioid pain medication use
dramatically increased, the United
States also experienced an increase
in heroin use and deaths. More than
900,000 people reported heroin use
in 2014, a 153 percent increase since
2007. (COMPTON, JONES, & BALDWIN, 2016)
Tragically, heroin deaths tripled in
the 5 year period from 2010 to 2014,
increasing from 3,300 to more than
10,000 deaths. (CENTERS FOR DISEASE
CONTROL & PREVENTION, 2016)
These facts clearly show heroin use
patterns have changed. In the 1960’s,
80 percent of heroin users reported
heroin was the first opioid they used.
Today, of the 600 people who begin
using heroin, (SAMHSA, 2015) four out
of five report that they started with
opioid pain relievers. (JONES, HEROIN USE
AND HEROIN USE RISK BEHAVIORS AMONG
NONMEDICAL USERS OF PRESCRIPTION OPIOID
PAIN RELIEVERS – UNITED STATES, 2002–2004
AND 2008–2010, 2013)
Opioid Pain Medications and Heroin
are Chemically Similar and just as Addictive
SIMILAR
EFFECT
SIMILAR
EFFECT
HYDROCODONE
HEROIN
OXYCODONE
O
H 3 C
O
O
O
H
O
O
H
N
O H
O H
N
H 3 C O
CH 3
H
O
O
OH
N
CHEMICALLY
SIMILIAR
CHEMICALLY
SIMILIAR
9 | NATIONAL SAFETY COUNCIL

In fact, nonmedical users of opioid pain medications were
19 times more likely to use heroin than people reporting no
States with the highest
heroin fatality rates.
misuse of opioids. (MUHURI, GFROERER, & DAVIES, 2013)
More research is needed to fully understand what prompts
a person misusing opioid pain medications to transition to
heroin. However, it is widely believed the transition
to heroin happens as users turn to dealers for their daily
supply of opioids, heroin is offered as a cost saving measure.
OVERALL
RANK
STATE
AGE-ADJUSTED
HEROIN DEATH
RATE PER 100,000
1 Ohio 11.1
2 West Virginia 9.8
3 Connecticut 8.9
4 New Hampshire 8.1
Nonmedical users of
opioid pain medications were
19 times more likely
to use heroin
5 Massachusetts 7.2
6 New Mexico 7.2
7 Rhode Island 6.8
8 Delaware 6.3
9 Vermont 5.8
10 Missouri 5.8
f i g u r e 1: Heroin Deaths by Year,
United States, 2009-2014
DEATHS
10500
10000
9500
9000
8500
8000
7500
7000
6500
6000
5500
5000
4500
4000
3500
3000
2500
2000
1500
500
0
2009 2010 2011 2012 2013 2014
YEAR
10 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

DEADLY EMERGENCE OF FENTANYL
Fentanyl, a synthetic opioid, is 50 times
more potent than heroin and 100 times
more potent than morphine. (CDC, 2016)
It is commonly prescribed to manage
pain for advanced stage cancer patients.
However, fentanyl, when added to
heroin, can create a lethal combination
and is often added by drug dealers
without the end user’s knowledge.
The Drug Enforcement Administration
(DEA) has documented the import of
illegally manufactured fentanyl into parts
of the U.S. (U.S. DEPARTMENT OF JUSTICE,
DRUG ENFORCEMENT ADMINISTRATION, 2015)
DEA National Forensic Laboratory
Information System (NFLIS) found
fentanyl reports increased 300 percent
from the second half of 2013 to the
first half of 2014. The DEA issued a
health advisory in March 2015 after
documenting a surge of fentanyl
drug seizures and deaths. (U.S. DRUG
ENFORCEMENT ADMINISTRATION, 2015)
The maps below show the extent to
which fentanyl reports have grown since
2009, when 35 states reported analyzing
fentanyl. That same year, no state had
more than 49 fentanyl reports. By 2014,
46 states reported fentanyl, with six
states having 100 or more reports.
(U.S. DEPARTMENT OF JUSTICE, DRUG
ENFORCEMENT ADMINISTRATION, 2015)
72
hours
In only a 72-hour
period in Chicago,
74 people died
from an overdose of
fentanyl laced heroin in
October 2015.
(GORNER, NICKEAS, & SOBOL, 2015)
f i g u r e 2:
2009 Fentanyl Reports
in NFLIS by State,
January - June 2009
f i g u r e 3:
2014 Fentanyl Reports
in NFLIS by State,
January - June 2014
REPORTS
PER STATE
100 or More
50 - 99
20 - 49
1 - 19
0
No Data
11 | NATIONAL SAFETY COUNCIL

25+
percent
A March 2015 DEA National Threat
Assessment Summary noted the true
number of fentanyl-related deaths
is most likely higher because “many
coroners’ offices and state crime
laboratories do not test for fentanyl
or its analogs unless given a specific
reason to do so.” (U. S. DRUG ENFORCEMENT
ADMINISTRATION, 2015) Better mortality
data is needed to accurately track the
involvement of fentanyl and other
drugs in opioid-related deaths. A
2013 study documented variation in
how states certify manner of death,
including toxicology, and found that
death certificates often do not specify
the drugs involved in overdose deaths.
For example, in 21 states, more than 25
percent of overdose death certificates
did not specify the drugs involved in the
death. (WARNER, PAULOZZI, NOLTE, DAVIS,
& NELSON, 2013)
In 21 states, more than
25 percent
of overdose death certificates
did not specify the drugs
involved in the death.
A CDC Health Advisory Network
(HAN) alert recommends that medical
examiners and coroners screen for
fentanyl in suspected opioid overdose
cases, especially in areas reporting
increases in fentanyl seizures or
unusually high spikes in heroin or
unspecified drug overdose fatalities.
(CENTERS FOR DISEASE CONTROL AND
PREVENTION, 2015) The HAN alert further
recommends that coroners and medical
examiners use Substance Abuse Mental
Health Safety Administration (SAMHSA)
consensus recommendations to report
opioid-related deaths. (GOLDBERGER,
MAXWELL, CAMPBELL, & WILDFORD, 2013)
The National Safety Council
urges states to adopt these
recommendations. Improved data
collection is vital to fully understand
the scope of the epidemic.
Critical
Collection
Improved
data
collection
is vital
to fully
understand
the scope
of the
epidemic.
12 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

STATE PROGRESS
REDUCE
OPIOID OVER-
PRESCRIBING
Multiple actions will be needed to end this drug epidemic and reduce the loss of life.
It is only with concentrated state focus and efforts to reduce opioid overprescribing
and to improve the ability to identify and offer help to those at risk. By ensuring that
effective and coordinated substance abuse treatment is readily available to those
with opioid use disorder, we can end the loss of life in the current drug crisis.
IDENTIFY
& OFFER
HELP
The National Safety Council examined
state progress on six key indicators:
1. Mandatory Prescriber Education
2. Opioid Prescribing Guidelines
PROVIDE
READILY
AVAILABLE
TREATMENT
3. Eliminating Pill Mills
4. Prescription Drug Monitoring Programs (PDMPs)
5. Increased Access to Naloxone
6. Availability of Opioid Use Disorder (OUD) Treatment
END
THE LOSS
OF LIFE
1. Requires Mandatory
Prescriber Education
2. Adopted Opioid
Prescribing Guidelines
17 states meet this indicator:
CA, CT, DE, IA, KY, MA, NV, NH, NM, NC, OR, RI, SC, TN, VT, WI, WV
22 states meet this indicator:
AL, AZ, AR, CA, CO, HI, IN, KY, MA, MN, NH, NM, NC, OH, OK,
PA, RI, TN, UT, VT, WA, WV
3. Eliminating Pill Mills 12 states meet this indicator:
AL, FL, GA, IN, KY, LA, MS, OH, TN, TX, WI, WV
4. Allows Physician and
Pharmacy delegates
to PDMPs
5. Allows Naloxone to
be prescribed with
a standing order
6. Availability of Opioid Use
Disorder (OUD)Treatment
42 states meet this indicator:
AL, AR, AZ, CA, CO, CT, DE, DC, ID, IL, IN, IA, KS, KY, LA,
MD, MA, ME, MN, MT, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA,
RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY
35 states meet this indicator:
AK, AL, AR, CA, CO, DE, FL, GA, IL, IN, KY, LA, MD, ME, MN, MS,
NC, ND, NV, NH, NJ, NM, NY, OH, OK, PA, RI, SD, TN,
TX, UT, VA, VT, WA, WI
3 states meet this indicator:
ME, NM, VT
13 | NATIONAL SAFETY COUNCIL

STATE PROGRESS
STATE
REQUIRES
MANDATORY
PRESCRIBER
EDUCATION
ADOPTS OPIOID
PRESCRIBING
GUIDELINES
ELIMINATES
PILL MILLS
ALLOWS PHYSICIAN
DELEGATES TO
ACCESS PDMPs
ALLOWS NALOXONE
STANDING ORDER
MEETS NEED FOR
OUD TREATMENT
Alabama ✔ ✔ ✔ ✔
Alaska
Arizona ✔ ✔
Arkansas ✔ ✔ ✔
California ✔ ✔ ✔ ✔
Colorado ✔ ✔ ✔
Connecticut ✔ ✔
Delaware ✔ ✔ ✔
District of Columbia
Florida ✔ ✔
Georgia ✔ ✔
Hawaii
Idaho
✔
✔
✔
Illinois ✔ ✔
Indiana ✔ ✔ ✔ ✔
Iowa ✔ ✔
Kansas
Kentucky ✔ ✔ ✔ ✔ ✔
Louisiana ✔ ✔ ✔
Maine ✔ ✔ ✔
Maryland ✔ ✔
Massachusetts ✔ ✔ ✔
Michigan
Minnesota ✔ ✔ ✔
Mississippi ✔ ✔
Missouri
✔
✔
State ranking were based on best available data at time of publication.
14 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

STATE PROGRESS
STATE
REQUIRES
MANDATORY
PRESCRIBER
EDUCATION
ADOPTS OPIOID
PRESCRIBING
GUIDELINES
ELIMINATES
PILL MILLS
ALLOWS PHYSICIAN
DELEGATES TO
ACCESS PDMPs
ALLOWS NALOXONE
STANDING ORDER
MEETS NEED FOR
OUD TREATMENT
Montana
✔
Nebraska
Nevada ✔ ✔
New Hampshire ✔ ✔ ✔ ✔
New Jersey ✔ ✔
New Mexico ✔ ✔ ✔ ✔ ✔
New York ✔ ✔
North Carolina ✔ ✔ ✔ ✔
North Dakota ✔ ✔
Ohio ✔ ✔ ✔ ✔
Oklahoma ✔ ✔ ✔
Oregon ✔ ✔
Pennsylvania ✔ ✔ ✔
Rhode Island ✔ ✔ ✔ ✔
South Carolina ✔ ✔
South Dakota ✔ ✔
Tennessee ✔ ✔ ✔ ✔ ✔
Texas ✔ ✔ ✔
Utah ✔ ✔ ✔
Vermont ✔ ✔ ✔ ✔ ✔
Virginia ✔ ✔
Washington ✔ ✔ ✔
West Virginia ✔ ✔ ✔ ✔
Wisconsin ✔ ✔ ✔ ✔
Wyoming
✔
State ranking were based on best available data at time of publication.
15 | NATIONAL SAFETY COUNCIL

INDICATOR 1
MANDATORY PRESCRIBER
EDUCATION
The medical community is an important and vital partner in addressing the opioid
epidemic. An Institute of Medicine report recommends that all healthcare providers
keep their knowledge of pain management current through continuing medical
education (CME). (NATIONAL RESEARCH COUNCIL, 2011) Licensure, certification and
recertification examinations should include assessments of providers’ pain education.
Unfortunately, research has shown that practicing physicians received fewer than
12 hours of pain management education in medical school. (MEZEI & MURINSON, 2011)
Another study found that 60 percent of physicians surveyed did not “receive
training on identifying prescription drug abuse and addiction” in medical school.
(THE NATIONAL CENTER ON ADDICTION AND SUBSTANCE ABUSE, 2005)
Addressing this knowledge gap is necessary to reduce dangerous prescribing
practices and improve treatment of pain. NSC recommends that states require
CMEs on pain management for prescribers of controlled substances. Seventeen
states currently require education for physicians and other professionals who
prescribe controlled substances to treat pain. (FEDERATION OF STATE MEDICAL BOARDS,
2015) For example, Kentucky doctors are required to take 4.5 hours of activity
related to KASPER (Kentucky All Schedule Prescription Electronic Reporting),
pain management or addiction disorders. In New Mexico, prescribers who are
registered with the DEA must complete a 5 hour CME class about pain and
addiction. Following implementation of New Mexico’s CME requirement, the
amount of opioids per prescription declined and prescribers issued fewer high-dose
prescriptions. (KATZMAN, ET AL., 2014)
NSC Calls for Federal Educational
Standards on Pain Management
Based on the successes seen by states like New Mexico in changing prescribing
patterns as a result of the requirement for CME classes, the National Safety Council
recommends that the DEA require CME for all prescribers who apply for a
new or renewed registration under the Controlled Substances Act of 1970. 2
The proposed CME should include the following topics:
✓ Relative efficacy and risks of medications used to treat acute and chronic pain
✓ Responsible prescribing, including the use of tools such as state Prescription
Drug Monitoring Programs
✓ Linkage to treatment for those with addiction
State requires
medical education
for prescribers on
pain management
17 states meet
this indicator:
California,
Connecticut,
Delaware,
Iowa,
Kentucky,
Massachusetts,
Nevada,
New Hampshire,
New Mexico,
North Carolina,
Oregon,
Rhode Island,
South Carolina,
Tennessee,
Vermont,
West Virginia
and Wisconsin
(FEDERATION OF STATE MEDICAL
BOARDS, 2015)
Not all prescribers are required to register with the DEA—only those who will
prescribe controlled substances such as opioid pain medications. Therefore,
DEA controlled substance registration and renewal provides a targeted
opportunity to address this knowledge gap.
2
The Controlled Substances Act of 1970 established that some medications require additional screening and oversight by the Drug Enforcement Agency
(DEA) when prescribed, including most opioid pain medications.
16 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

INDICATOR 2
OPIOID PRESCRIBING
GUIDELINES
Opioid prescribing guidelines helps medical providers make informed choices
about pain treatment. Guidelines consist of recommendations for pain treatment
based on the current knowledge of the risks and benefits of opioid use, as well as
the risks and benefits of alternative non-opioid treatments. A number of medical
professional organizations, state licensing agencies, state medical boards and,
most recently, the CDC have published opioid prescribing guidelines. When states
have developed guidelines, both regulatory and voluntary approaches have been
used to develop and implement a guideline. States have developed opioid prescribing
guidelines for a variety of clinical settings, including chronic pain, emergency
medicine and workers compensation.
Washington, Kentucky, Ohio, Vermont and Indiana are among the states that
have taken a regulatory approach by changing controlled substance regulations
and establishing interagency and prescriber workgroups to develop a
prescribing guideline.
Utah, in 2009, convened a steering committee and workgroups to develop their
guideline, Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain.
Arizona and North Carolina used a similar process, convening workgroups
comprised of prescribers and medical associations to develop a guideline for
hospital emergency departments regarding the prescribing of opioid pain
relievers for patients with non-cancer pain.
Types of Opioid Guidelines
Chronic Pain
Chronic pain guidelines comprise recommendations on the use of opioids in
treating pain lasting longer than three months or past the time of normal tissue
healing. Twenty-two states have developed prescribing guidelines for chronic pain.
In March 2016, CDC issued an Opioid Prescribing Guideline for Chronic Pain.
This guideline is intended to inform pain treatment decisions of primary care
providers treating chronic, non-cancer pain.
The CDC guideline includes:
✓ Lower dosage recommendations. Higher opioid doses are associated with
higher risk of overdose and death—even relatively low doses (20-50 morphine
milligram equivalents (MME) per day) increase risk
✓ Risk assessment criteria for all patients. Previous guidelines focused safety
precautions on “high risk patients,” however, opioids pose risk to all patients, and
currently available tools cannot rule out risk for abuse or other serious harm
✓ More specific recommendations compared to previous guidelines on
monitoring and discontinuing opioids when risks and harms outweigh benefits
State or state
medical board
has issued an
opioid prescribing
guideline
22 states meet
this indicator:
Alabama,
Arizona,
Arkansas,
California,
Colorado,
Hawaii,
Indiana,
Kentucky,
Massachusetts,
Minnesota,
New Hampshire,
New Mexico,
North Carolina,
Ohio,
Oklahoma,
Pennsylvania,
Rhode Island,
Tennessee,
Utah, Vermont,
Washington and
West Virginia
(NATIONAL SAFETY COUNCIL, 2016)
17 | NATIONAL SAFETY COUNCIL

INDICATOR 2
OPIOID PRESCRIBING
GUIDELINES ( CONTINUED)
Emergency Medicine
Nine states have adopted guidelines developed by the American College
of Emergency Physicians (ACEP) to inform the use of opioids in hospital
emergency departments. Key elements of the ACEP guideline include:
✓ Use of short-acting, instead of long-acting, opioids
✓ Prescriptions for no more than a seven-day supply. States like Ohio have
specified that no more than a three-day supply of opioid pain medications
should be prescribed for acute pain in emergency room settings
Workers’ Compensation
Three states have developed a guideline for the use of opioid pain medications
in the treatment of occupational injuries covered by state workers’ compensation
programs. Following the 2007 implementation of the opioid dosing guideline,
Washington workers’ compensation system examined detailed billing data
to learn about changes in opioid prescribing to workers receiving disability
compensation. The introduction in Washington of an opioid dosing guideline
appears to be associated with a decline in the mean dose for long-acting
opioids, percent of claimants receiving opioid doses ≥120 mg morphine
equivalent dose per day, and number of opioid-related deaths among injured
workers. (FRANKLIN, MAI, TURNER, SULLIVAN, WICKIZER, & FULTON-KEHOE, 2012)
Guideline development is critical as opioids, even when prescribed at low doses,
carry significant risks. States like Washington which have implemented a
prescribing guideline, reduced opioid prescribing and reduced opioid overdose
fatalities. As a result, the National Safety Council recommends that all
states adopt an opioid prescribing guideline. At a minimum, the guideline
should address:
✓ When initiation of opioid treatment is appropriate
✓ Guidance on maximum dose and duration of opioid treatment
✓ Information on how to monitor treatment to ensure patient safety
Washington
State Case Study
Washington has seen success
in reducing overdose deaths
and opioid prescribing rates
through the implementation
of a prescribing guideline.
In 2007, voluntary
guidelines were introduced
in Washington to guide
physicians on responsible
opioid prescribing for
non-cancer pain. Following
introduction of the guideline,
prescribers reported increases
in awareness of safer opioid
prescribing practices, and
the State realized subsequent
decreases in overdose
deaths. In 2010, Washington
required all licensing boards
to establish rules and
adopt one evidence-based
prescribing guideline. The
State developed a number
of tools and resources to
support responsible opioid
prescribing practices. In
addition, it increased training
and support for prescribers
to recognize substance
abuse and make referrals
to treatment. These efforts
have resulted in a 29 percent
reduction in drug overdose
death rate since 2008.
18 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

INDICATOR 3
ELIMINATING
PILL MILLS
“Pill mills” are a doctor’s office, clinic or health care facility that routinely
prescribes controlled substances outside the scope of standard medical practice
and often in violation of state laws. Frequently advertised as “pain management”
clinics, pill mills can operate within medical practices that treat a variety of
legitimate medical issues. Typical characteristics of pill mills include nonindividualized
care, lack of referrals to specialists or use of diagnostic tests and
repetitive combinations of medications that do not vary from patient to patient.
NSC recommends continued state policy development that stops the
establishment and/or operation of pill mills that function outside guidelines
for licensed, qualified physicians and whose primary treatment is prescribing
opioids. State policy should include requirements for acceptable standards
of medical care including:
✓ Following prescribing guidelines in accordance with standards established
by state licensing authorities and prevailing best practice standards
✓ Defining ownership requirements to ensure that clinic owners can be held
accountable by state licensing authorities
✓ Restricting the dispensing of controlled substances
✓ Requiring use of state prescription drug monitoring programs by pain clinics
✓ Requiring an appropriate medical evaluation including adequate patient
history and physical examination
✓ Conducting an appropriate risk assessment at each visit
Ten states have adopted pain clinic requirements to target activities consistent
with these practices. Two additional states–Alabama and Indiana–have enacted
regulations for prescribers related to specific prescribing activities rather than
regulations limited to pain clinics. This trend may allow for a greater variety
of enforcement options and address pill mills operating within other medical
specialties or practice settings. (NATIONAL ALLIANCE FOR MODEL STATE DRUG LAWS, 2014)
The State has a
law or laws that
regulate pain clinics
or pain management
services
12 states meet
this indicator:
Alabama,
Florida,
Georgia,
Indiana,
Kentucky,
Louisiana,
Mississippi,
Ohio,
Tennessee,
Texas,
West Virginia and
Wisconsin
(NATIONAL ALLIANCE FOR MODEL STATE
DRUG LAWS, 2014)
19 | NATIONAL SAFETY COUNCIL

INDICATOR 3
Florida State Case Study
By 2009, Florida was known as the epicenter of
the nation’s pill mill activity. DEA’s Automation of
Reports and Consolidated Orders System (ARCOS)
reported that 98 of the top 100 oxycodone
dispensing physicians in the nation were located
in Florida. (FLORIDA OFFICE OF THE ATTORNEY GENERAL)
Starting in 2010, in an effort to address this
growing public health threat, Florida began
requiring pain clinic registrations and inspections
and enacted a number of laws to curb high-volume
prescribing. These included:
Bans on physician dispensing
Establishment of a PDMP
Tougher penalties for illegal prescribing
As a result of these new requirements, opioid
prescribing rates decreased and overdose deaths
declined by 23 percent between 2010 and 2012.
(JOHNSON, PAULOZZI, PORUCZNIK, MACK, & HERTER, 2014) After
the 2010 law, Florida experienced a significant
decrease in the amount of opioids prescribed -
equal to 500,000 fewer 5-mg hydrocodone tablets.
(RUTKOW, CHANG, DAUBRESSE, WEBSTER, STUART, & ALEXANDER,
2015) Another study found the death rate from
prescription painkiller overdoses in Florida was
7 percent lower than expected. In 2011, the rate
was 20 percent lower and in 2012, 34.5 percent
lower. (KENNEDY-HENDRICKS, RICHEY, MCGINTY, STUART, BARRY,
& WEBSTER, 2016)
Today, none of the top 100 opioid dispensing
physicians reside in Florida.
20 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

INDICATOR 4
PRESCRIPTION DRUG
MONITORING PROGRAMS
Patients who obtain opioid painkillers from four or more doctors or pharmacies
are at an increased risk of overdose. Therefore, state Prescription Drug
Monitoring Programs (PDMPs) can be a valuable tool to help prescribers make
informed clinical decisions and avoid costly or fatal errors. PDMPs serve as
an early warning system, alerting prescribers and state officials about highrisk
patients seeking prescriptions from multiple doctors and risky prescribing
practices and allowing them to intervene when necessary to protect patients
and the community.
Unfortunately, PDMPs are underutilized by prescribers. A 2015 study of primary
care prescribers found that while a majority reported having obtained data from
their PDMP at some point in time, prescribers consulted PDMP data in fewer than
one-quarter of instances when they prescribed opioids to patients. (RUTKOW, TURNER,
LUCAS, HWANG, & ALEXANDER, 2015) In states with voluntary PDMP use, prescribers
verified patient history only 14 percent of the time before prescribing an opioid.
(SHATTERPROOF, 2016)
In a Johns Hopkins survey, family practice physicians reported they did not use the
PDMP because it was time-consuming process and data was not reported in an easy
to use format. Other issues identified include physician perception that data was
needed only for a few patients. (RUTKOW, TURNER, LUCAS, HWANG, & ALEXANDER, 2015)
State action remains necessary to ensure widespread adoption and utilization of
PDMPs by prescribers and pharmacists. Fourteen states require prescribers to
access the PDMP prior to prescribing a schedule II, III or IV controlled
substances. The number is based on how it is defined. (PDMP CENTER OF EXCELLENCE
BRANDEIS UNIVERSITY, 2016) In Kentucky, New York and Tennessee–three of the first
states to mandate prescriber use of the PDMP–increased PDMP utilization has
resulted in reductions in opioid prescriptions and in patients visiting multiple
providers–75 and 36 percent reductions respectively in doctor shopping in
New York and Tennessee.
However, the rapid implementation of these mandates has not been without
challenges. A Brandeis Center of Excellence report recommends that states establish
stakeholder groups to build consensus and offer feedback to better integration of
PDMP data in clinical decisions. (PDMP CENTER OF EXCELLENCE BRANDEIS UNIVERSITY,
2016) CDC has provided funding to states to develop universal registration and use,
making PDMPs easier to use and the data more timely. (CENTERS FOR DISEASE CONTROL
AND PREVENTION, 2016)
State PDMP
allows prescriber
and dispenser
delegates
42 states meet
this indicator:
Alabama,
Arizona, Arkansas,
California, Colorado,
Connecticut, Delaware,
District of Columbia,
Idaho, Illinois, Indiana,
Iowa, Kansas, Kentucky,
Louisiana, Maine,
Maryland,
Massachusetts,
Minnesota, Montana,
New Hampshire,
New Jersey,
New Mexico, New York,
North Carolina,
North Dakota, Ohio,
Oklahoma, Oregon,
Pennsylvania,
Rhode Island,
South Carolina,
South Dakota,
Tennessee, Texas,
Utah, Vermont,
Virginia, Washington,
West Virginia, Wisconsin
and Wyoming
(NATIONAL ALLIANCE FOR MODEL STATE
DRUG LAWS, 2014)
21 | NATIONAL SAFETY COUNCIL

INDICATOR 4
PRESCRIPTION DRUG
MONITORING PROGRAMS
(CONTINUED)
Forty-two states allow physicians and dispensers to appoint delegates or staff
from their practice to access PDMP data, making it easier to integrate into
clinical workflow. Institutional accounts are another PDMP innovation that makes
it easier for clinicians, hospitals or universities to manage and supervise a delegate’s
PDMP utilization. To increase the effective use of PDMPs, NSC recommends
that State PDMPs allow prescriber and physician delegates and the creation
of institutional accounts.
Another hurdle to PDMP utilization is complicated multi-step application
and verification processes. NSC recommends that states simplify the PDMP
registration process, integrating and automating when possible with other
licensing processes. Prescribers and pharmacists need easy-to-use reports with
real-time information. Oklahoma’s PDMP was the first to offer real-time data reports
to pharmacists and physicians to assist them in making timely clinical decisions
whether to issue a prescription or dispense medication to a patient. Since then,
27 state PDMPs now collect prescription information from pharmacies within
24 hours of dispensing controlled substances. The remaining state PDMPs collect
this data within 72 hours or weekly. NSC recommends that all states collect
prescription data within 24 hours.
NSC also recommends that States improve reporting response times and upgrade
PDMP technology to facilitate data transfer into clinical workflows. The Kentucky
PDMP processes the majority of PDMP queries within 15 seconds or less, and a
number of states are currently working on pilot programs to integrate PDMP date
into physician and hospital electronic health record systems.
Making
Changes
PRESCRIBERS
and
PHARMACISTS
NEED
EASY-TO-USE
REPORTS
with
REAL-TIME
INFORMATION
22 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

INDICATOR 5
INCREASED ACCESS TO
NALOXONE
Opioid overdoses are reversible with the timely administration of naloxone.
Naloxone, available by prescription, can be administered as an injection or nasal
spray. It is not a controlled substance and has no abuse potential.
Physicians can provide a prescription for naloxone to a person at risk of overdose,
similar to prescribing an EpiPen for people with severe allergies. However, unlike
some types of allergic reactions, an opioid overdose renders the victim unable to
self-administer this medication. Making naloxone available to family members and
friends of those suffering from addiction, as well as first responders, will save lives.
Some states have increased access to and use of naloxone by amending medical
practice laws and regulations to allow a licensed healthcare professional to
prescribe naloxone for use by a third-party such as a family member. For example,
Massachusetts allows community programs to provide naloxone to trained
individuals with a standing order from the health department.
Community overdose education and prevention programs distribute naloxone
overdose prevention kits and provide training. Education includes how to recognize
the signs of an overdose, when and how to administer naloxone and the importance
of rescue breathing until 9-1-1 first responders arrive.
Use of naloxone has increased greatly. From 1996 through June 2014, laypersons
reported using naloxone in 26,463 overdose reversals. In 2013 alone, nearly
40,000 laypersons with 93 organizations reported 8,032 overdose reversals—lives
that may not have been saved without laws allowing increased naloxone access.
(WHEELER, JONES, GILBERT, & DAVIDSON, 2015)
State allows
a standing order
for naloxone
35 states meet
this indicator:
Alabama, Alaska,
Arkansas, California,
Colorado, Delaware,
Florida, Georgia,
Illinois, Indiana,
Kentucky, Louisiana,
Maine, Maryland,
Minnesota,
Mississippi,
Nevada,
New Hampshire,
New Jersey,
New Mexico,
New York,
North Carolina,
North Dakota,
Ohio, Oklahoma,
Pennsylvania,
Rhode Island,
South Dakota,
Tennessee, Texas,
Utah, Vermont,
Virginia,
Washington and
Wisconsin
(NETWORK FOR PUBLIC HEALTH LAW, 2016)
23 | NATIONAL SAFETY COUNCIL

INDICATOR 5
INCREASED ACCESS TO
NALOXONE ( CONTINUED)
Thirty-five states permit naloxone to be prescribed with a standing order. 3
(NETWORK FOR PUBLIC HEALTH LAW, 2016) More recently, Connecticut, Idaho,
North Dakota and New Mexico started allowing naloxone to be dispensed by
pharmacists. About a dozen states permit pharmacists to establish collaborative
practice agreements with a physician to dispense naloxone. Other states allow
the pharmacy board to establish standards that permit naloxone to be dispensed.
However, while this progress is encouraging, more work is needed to ensure
that naloxone remains affordable. Therefore, NSC recommends that states,
insurers, and other relevant payers work to ensure that naloxone is covered
by all insurance plans, including public plans.
Good Samaritan Provisions
Opioid overdose often happen when the victim is with friends or family
members. Witnesses or bystanders to an overdose may be in the best position
to save a life by administering naloxone. However, some overdose bystanders
sometimes fail to summon medical assistance for fear of police involvement.
(TOBIN, DAVEY, & LATKIN, 2005)
“Good Samaritan” laws provide protection from negative consequences
associated with calling for help. Opioid overdose bystanders can become
“Good Samaritans” by calling emergency responders without fear of arrest
or other negative legal consequences.
Thirty-four states and the District of Columbia have enacted Good Samaritan
provisions. NSC recommends that all states enact Good Samaritan laws to
remove any barriers to seeking help for a drug overdose.
Sal’s Story
Patty DiRenzo, of Blackwood,
NJ lost her son Sal to a fatal
overdose. His death could have
been prevented if the people
with whom he was using drugs
had called 9-1-1 for help. They
didn’t, most likely afraid of legal
consequences. Instead of saving
a life by seeking help, Sal was
left alone to die, without the
medical help he needed. Patty
lost her son, and her grandson
lost his father, because someone
was afraid to call 9-1-1.
Patty believes with proper
treatment Sal could have
beaten his addiction, but this
opportunity was lost forever
with his passing. The majority
of overdose victims do not
die until one to three hours
after they have initially taken
a drug, and most of these
deaths occur in the presence of
others. This leaves a significant
amount of time for witnesses to
intervene and call for medical
help, but the fear of arrest and
prosecution prevents many
from making that call. Good
Samaritan laws remove these
legal barriers, so that calling
9-1-1 is never a crime.
Patty believes “Saving a life
is far more important than
punishing those who seek help.”
3
A standing order allows a drug to be dispensed by a pharmacy or other programs to any person who meets specific criteria
and without the prescriber or patient ever meeting.
24 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

INDICATOR 6
AVAILABILITY OF OPIOID USE
DISORDER TREATMENT
Opioid use disorder (OUD), occurs when the recurrent use of opioid pain
relievers or heroin cause significant clinical problems including health issues,
disability, and the failure to meet major responsibilities at work, school or home.
OUD is a brain disease and a serious chronic health condition like heart disease
or diabetes. And like these conditions, medication and support to make lifestyle
changes may be required to effectively treat an OUD. As a chronic disease, if left
untreated, OUD will worsen, often resulting in death. In 2014, more than 2.4
million people had an opioid use disorder related to use of opioid pain relievers
or heroin. (SAMHSA, 2015)
Medication assisted treatment (MAT) with buprenorphine or methadone is
the most effective treatment for OUD. (WORLD HEALTH ORGANIZATION, 2009) A third
medication, Naltrexone, can also be used to treat OUD. However, it is less
effective in sustaining long-term recovery. (COUSINS, RADFAR, CRÈVECOEUR-MACPHAIL,
ANG, DARFLER, & RAWSON, 2016)
Methadone is provided in a clinic setting at opioid treatment programs
(OTP). OTPs are federally regulated clinics that dispense methadone, usually
as a liquid, daily to patients. Barriers to methadone include waiting lists for
treatment, relatively few locations in most states, insurance coverage limits and
requirements for daily clinic visits. In 2012, nearly all state OTPs operated at
greater than 80 percent capacity, and OTPs in 12 states reported 100 percent
capacity. (JONES, CAMPOPIANO, BALDWIN, & MCCANCE-KATZ, 2015)
State has
sufficient
buprenorphine
treatment
capacity to treat
residents with
opioid dependence
3 states meet
this indicator:
Maine,
New Mexico
and Vermont
(JONES, CAMPOPIANO, BALDWIN &
MCCANCE-KATZ, 2015)
With most state OTPs operating at capacity, buprenorphine which can be
prescribed in office-based settings, offers the most viable way to expand access
for MAT. Buprenorphine is prescribed by SAMHSA certified physicians who
receive specialized training. Patient caseloads for buprenorphine prescribers
are capped at 30 individuals in the first year. (SAMHSA, 2016) After the first year,
physicians can expand their caseload to 100 patients, but many physicians do not
apply for this extension. If all physicians provide buprenorphine at the maximum
level, 1,093,150 people can receive treatment in the US, which is less than the
number needed. (JONES, CAMPOPIANO, BALDWIN, & MCCANCE-KATZ, 2015)
25 | NATIONAL SAFETY COUNCIL

INDICATOR 6
AVAILABILITY OF OPIOID USE
DISORDER TREATMENT
(CONTINUED)
Treatment capacity in the United States lags behind the need for opioid
treatment. An analysis of national and state treatment capacity found that rates
of opioid abuse or dependence (891.8 per 1,000,000 people) far exceeded the
maximum buprenorphine treatment capacity (420.3) and numbers of people
receiving methadone (119.9) at an OTP. Most states had opioid dependence rates
higher than their buprenorphine treatment capacity. Only three states—Maine,
New Mexico and Vermont had maximum buprenorphine treatment capacity
sufficient to meet the treatment need in their state. (JONES, CAMPOPIANO,
BALDWIN, & MCCANCE-KATZ, 2015)
States must close the treatment gap. NSC recommends that physician patient
caseload limits be raised for buprenorphine wavered physicians and that
advanced practice nurses are allowed to obtain DATA-2000 waivers to
prescribe buprenorphine. NSC also recommends that federal and statefunded
substance abuse services offer MAT, the most effective methods of
opioid dependence treatment. Care should be coordinated and MAT provided
in conjunction with counseling and recovery support services. Vermont and
Massachusetts have developed innovative care models to expand buprenorphine
treatment capacity in their states, and this treatment should also be affordable.
NSC recommends that States require public and private health insurers to
cover medication assisted treatment. All three options for medication-assisted
treatment should be available to all patients as unique patient characteristics
may mean one form of medication assisted treatment is more effective. Also
caps on the length and duration of MAT should be eliminated.
Reality
Check
RATES OF
OPIOID ABUSE/
DEPENDENCY
FAR EXCEED
the maximum
buprenorphine/
methadone
TREATMENT
CAPACITY
in nearly
all states
26 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

INDICATOR 6
Vermont: Effective and Coordinated Opioid Treatment
Through a unique partnership between the Vermont
Department of Health’s Division of Alcohol and
Drug Abuse Programs and the Department of
Vermont Health Access’s Blueprint for Health, the
Care Alliance was formed. The Care Alliance for
Opioid Addiction is a statewide partnership of
clinicians and treatment centers that provide
MAT to Vermonters addicted to opioids.
How it Works
The Care Alliance uses a Hub & Spoke model
to ensure that each person’s care is effective,
coordinated and supported. People can access
care by requesting services at a regional opioid
treatment center (Hub), or their primary care
provider (Spoke), or by dialing 2-1-1, a statewide,
free, confidential information and help service.
Five regional opioid treatment centers in
8 locations in Vermont serve as treatment hubs.
Regional opioid treatment centers treat patients
with complex needs with medication assisted
treatment, either methadone or buprenorphine.
In the Spokes, community physicians lead a team
of nurses and clinicians to treat patients with
medication assisted therapy, using buprenorphine.
Patient care is coordinated and supported and
supervised by a physician. Nurses and counselors
connect patients with community-based support
services. Support services may include mental
health and substance abuse treatment, pain
management, life skills and family support,
job development and recovery support.
Highlights of Vermont’s Opioid
Treatment System to Date:
In 2015, more than 4,800 people received MAT
in Vermont, up from 2,867 in January 2013
The 90-day retention rate among Vermont
Medicaid-eligible individuals served by the
Hub and Spoke system is 77 percent and
greater than the national average of 70 percent
and is increasing
Vermonters who stay in treatment in Hubs
longer than 90 days show improved overall
functioning at discharge than those who left
treatment earlier
27 | NATIONAL SAFETY COUNCIL

RECOMMENDATIONS
NSC believes that if the following recommendations
are implemented by state leaders, we can begin
to reverse this epidemic and save lives.
1. Establish state requirements for
medical education on effective
pain management
2. Require CME for prescribers
who apply for a new or renewed
registration under the Controlled
Substances Act of 1970. CME
should be pertinent to the classes
of controlled substances prescribed
by the provider. The proposed CME
should include the following topics:
✓ Relative efficacy and risks of
medications used to treat acute
and chronic pain
✓ Responsible prescribing, including
the use of tools such as state
Prescription Drug Monitoring
Programs (PDMPs)
✓ Linkage to treatment for those
with addiction
3. Adopt state opioid prescribing
guideline. At a minimum, the
guideline should address:
✓ When initiation of opioid
treatment is appropriate, provide
guidance on maximum dose and
duration of opioid treatment
✓ Monitor treatment to ensure
patient safety
4. Develop or strengthen state policy
that stops the establishment and/or
operation of pill mills that function
outside prescribing standards
for licensed, qualified physicians
and whose primary treatment is
prescribing opioids. State policy
should include requirements for
acceptable standards of medical
care including:
✓ Following prescribing guideline
in accordance with standards
established by state licensing
authorities and prevailing best
practice standards
✓ Defining ownership requirements
to ensure that clinic owners can
be held accountable by state
licensing authorities
✓ Restricting the distribution of
controlled substances
✓ Requiring use of state prescription
drug monitoring programs by
pain clinics
✓ Requiring an appropriate medical
evaluation including adequate
patient history and physical
examination
✓ Conducting an appropriate risk
assessment at each visit
5. Make PDMPs easy to use:
✓ Require the collection of
prescription data within 24 hours
✓ Simplify the PDMP registration
process, integrating and
automating when possible with
other medical professional
licensing processes
✓ Improve reporting response times
and facilitate data transfer into
clinical workflows
6. Improve reporting of drugs involved
in drug overdose fatalities:
✓ Encourage medical examiners and
coroners to screen for fentanyl for
suspected opioid overdose cases
✓ Require coroners and medical
examiners use SAMHSA
consensus recommendations to
report opioid-related deaths
7. Expand access to naloxone and remove
barriers to its purchase and use
✓ Enact laws allowing standing
orders for naloxone
✓ Require insurers, and other
relevant payers to ensure that
naloxone is covered by insurance
plans, including public plans
✓ Enact laws to enact “Good
Samaritan” laws to remove any
barriers to seeking help for a
drug overdose
8. Increase patient caseload caps for
buprenorphine waivered physicians
9. Allow advanced practice nurses
to obtain waiver to prescribe
buprenorphine. Expand use of
medication-assisted treatment,
ensure it is offered and available
at state-funded treatment providers
10. Require public and private health
insurers to cover medicationassisted
treatment
11. Remove caps on the duration of
medication-assisted treatment
28 | PRESCRIPTION NATION 2016: ADDRESSING AMERICA’S DRUG EPIDEMIC

ABOUT THE
NATIONAL SAFETY COUNCIL
Founded in 1913 and chartered by Congress, the National
Safety Council, nsc.org, is a nonprofit organization whose
mission is to save lives by preventing injuries and deaths
at work, in homes and communities, and on the roads
through leadership, research, education and advocacy.
NSC advances this mission by partnering with businesses,
government agencies, elected officials and the public in
areas where we can make the most impact—distracted
driving, teen driving, workplace safety, prescription drug
overdoses and Safe Communities.
Visit nsc.org to learn more.
29 | NATIONAL SAFETY COUNCIL

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Drug Monitoring Program and Pill Mill
Laws on Opioid Prescribing and Use. JAMA
Internal Medicine, 175(10):1642-1649.
doi:10.1001/jamainternmed.2015.3931.
Rutkow, L., Turner, L., Lucas, E., Hwang,
C., & Alexander, G. C. (2015). Many primary
care physicians are aware of prescription
drug monitoring programs, but many find
the data difficult to access. Health Affairs,
484-492.
SAMHSA. (2015). Results from the 2014
National Survey on Drug Use and Health:
Summary of National Findings. Rockville,
MD: Substance Abuse and Mental Health
Services Administration.
SAMHSA. (2016, April 12). Buprenorphine
Waiver Management. Retrieved April 20,
2016, from SAMHSA: http://www.samhsa.
gov/medication-assisted-treatment/
buprenorphine-waiver-management
Shatterproof. (2016, March). Prescription
Drug Monitoring Programs: Critical Elements
of Effective State Legislation. Retrieved April
5, 2016, from Shatterproof: https://secure.
shatterproof.org/page/-/Shatterproof_WP_
FINAL.pdf?_ga=1.228326110.217109100.14
61943552
Syed, Y., & Keating, G. (2013). Extendedrelease
intramuscular naltrexone
(VIVITROL): A review of its use in the
prevention of relapse to opioid dependence
in detoxified patients. CNS Drugs,
27(10):851-861 doi:10.1007/s40263-013-
0110-x.
The National Center on Addiction and
Substance Abuse. (2005). Under the Counter:
The Diversion and Abuse of Controlled
Prescription Drugs in the US. New York:
Columbia University.
Tobin, K. E., Davey, M. A., & Latkin, C. A.
(2005). Calling emergency medical services
during drug overdose: an examination of
individual, social and setting correlates.
Addiction, 100(3):397-404.
U. S. Drug Enforcement Administration.
(2015, April). National Heroin Threat
Assessment. Retrieved March 1, 2015, from
Drug Enforcement Administration: http://
www.dea.gov/divisions/hq/2015/hq052215_
National_Heroin_Threat_Assessment_
Summary.pdf
U.S. Department of Justice, Drug
Enforcement Administration. (2015).
Special Report: Opiates and Related Drugs
reported in NFLIS, 2009-2014. Springfield
VA: U.S. Drug Enforcement Administration.
U.S. Drug Enforcement Administration.
(2015, March 18). DEA Issues Nationwide
Alert on Fentanyl as Threat to Health and
Public Safety. Retrieved March 1, 2016, from
http://www.dea.gov/divisions/hq/2015/
hq031815.shtmlWarner, M., Paulozzi, L. J.,
Nolte, K. B., Davis, G. G., & Nelson, L. S.
(2013). State Variation in Certifying Manner
of Death and Drugs Involved in Drug
Intoxification Deaths. American Forensic
Pathology, 231-236.
Warner, M., Paulozzi, L. J., Nolte, K. B.,
Davis, G. G., & Nelson, L. S. (2013). State
Variation in Certifying Manner of Death
and Drugs Involved in Drug Intoxification
Deaths. American Forensic Pathology,
231-236.
Wheeler, E., Jones, T. S., Gilbert, M. K.,
& Davidson, P. J. (2015, June 19). Opioid
Overdose Prevention Programs Providing
Naloxone to Laypersons—United States,
2014. Retrieved March 1, 2016, from
Morbidity and Mortality Weekly Report
(MMWR): http://www.cdc.gov/mmwr/
preview/mmwrhtml/mm6423a2.htm?s_
cid=mm6423a2_e
World Health Organization. (2009).
Treatment of Opioid Dependence. Retrieved
April 15, 2014, from Guidelines for the
PsychosociallyAssisted Pharmacological
Treatment of Opioid Dependence: http://
www.who.int/substance_abuse/publications/
opioid_dependence_guidelines.pdf
31 | NATIONAL SAFETY COUNCIL

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Page 76 of 98

Attachment C
The Epidemic of Prescription Drug
and Heroin Abuse in the US
Page 77 of 98

EXECUTIVE OFFICE OF THE PRESIDENT
OFFICE OF NATIONAL DRUG CONTROL POLICY
Washington, D.C. 20503
The Epidemic of Prescription Drug and
Heroin Abuse in the United States
Committee on Oversight and Government Reform
United States House of Representatives
Tuesday, March 22, 2016
10:00 a.m.
Statement of
Michael P. Botticelli
Director of National Drug Control Policy

Chairman Chaffetz, Ranking Member Cummings, and members of the Committee, thank
you for this opportunity to address the issues surrounding opioid drugs, including heroin and
fentanyl, in the United States, and the Federal response. As you know, this is an important
concern for President Obama, who traveled to West Virginia in October to highlight this public
health and public safety challenge. During his State of the Union address in January, the
President specifically mentioned addressing prescription drug and heroin abuse as a priority –
and an opportunity to work with Congress in a bipartisan manner on this issue that transcends
political party, income level, gender, and race.
The Office of National Drug Control Policy (ONDCP) was established by Congress in
1988 with the principal purpose of reducing illicit drug use, manufacturing, and trafficking;
drug-related crime and violence; and drug-related health consequences. As a component of the
Executive Office of the President, ONDCP establishes policies, priorities, and objectives for the
Nation's drug control programs and ensures that adequate resources are provided to implement
them. We also develop, evaluate, coordinate, and oversee the international and domestic antidrug
efforts of Executive Branch agencies and ensure such efforts sustain and complement state
and local drug policy activities.
At ONDCP, we are charged with producing the National Drug Control Strategy
(Strategy), the Administration's primary blueprint for drug policy, along with a national drug
control budget. The Strategy is a 21 st century plan that outlines a series of evidence-based
reforms that treat our Nation’s drug problem as a public health challenge, not just a criminal
justice issue. It is guided by what science, experience, and compassion demonstrate about the
true nature of drug use in America. We recognize that any policies to limit the prescribing of
opioids need to take into account patients’ legitimate need for pain medications.
The considerable public health and safety consequences of nonmedical use, and
inappropriate prescribing, of prescription opioids and the use of heroin and illicit fentanyl,
underscore the need for action. Since the Administration’s inaugural 2010 Strategy, we have
deployed a comprehensive and evidence-based strategy to address opioid use disorders and
opioid induced overdose deaths. The Administration has increased access to treatment for
substance use disorders, expanded efforts to prevent overdose, and coordinated a Governmentwide
response to address the consequences of opioid misuse. We also have continued to pursue
actions against criminal organizations trafficking in opioid drugs.
This statement focuses largely on the Administration’s interventions to address opioid
drug misuse, as well as those of our Federal, state, and local partners that are involved with
opioid prescribing or the prevention and treatment of opioid misuse.
Opioid Use Trends and Consequences
Opioids – a category of drugs that includes heroin and prescription pain medicines like
oxycodone, oxymorphone, hydrocodone, and fentanyl – are having a considerable impact on
public health and safety in communities across the United States. Their misuse has evolved into
an epidemic that transcends locality, income level, gender, and race. According to the Centers for
Disease Control and Prevention (CDC), approximately 129 Americans on average died from a
1

drug overdose every day in 2014. 1 Of the 47,055 drug overdose deaths in 2014, heroin was
involved in 10,574 drug overdose deaths, while opioid analgesics were involved in 20,808 drug
overdose deaths. Among the opioid analgesic category, there were more than 5,544 drug
overdose deaths involving synthetic narcotics other than methadone, which includes fentanyl.
This number has more than doubled from two years earlier (2,628 in 2012). Deaths from opioids
in 2010 were 57 per day, and by 2014 they were 78 per day. Additionally, overdose deaths
involving opioids are likely undercounted. Of deaths where drug overdose is cited as the
underlying cause of death, approximately one-fifth of the death certificates do not list the drug
responsible for the fatal overdose. 2
The Administration continues to focus on vulnerable populations affected by opioids,
including pregnant women and their newborns. When used chronically by pregnant women, both
prescription opioids and heroin can cause withdrawal symptoms in newborns at birth; if these
opioids were withdrawn during pregnancy, fetal harm could result. From 2000 to 2009 the
number of infants displaying symptoms of drug withdrawal after birth, known as neonatal
abstinence syndrome (NAS), increased approximately threefold nationwide. 3 Newborns with
NAS have more complicated and longer initial hospitalizations than other newborns. 4 Newly
published data show the rate of NAS incidence per 1,000 births increased 40 percent, from 3.4 in
2009 to 5.8 in 2012. 5
Overdose rates in the United States are much too high; however, the Nation is making
some progress in addressing prescription opioid misuse. In 2014, more than 4.3 million
Americans ages 12 and older reported using prescription pain relievers non-medically within the
past month, down from 5.3 million in 2009. 6 The number of Americans 12 and older initiating
the nonmedical use of prescription pain relievers in the past year also has decreased from 2009 to
2014, from 2.2 million to 1.4 million. 7 Additionally, according to the latest Monitoring the
Future survey, the rate in 2015 of past-year use among high school seniors of narcotics other
than heroin, including OxyContin or Vicodin, is its lowest since 2002. 8
While progress has been made in reducing nonmedical use of prescription opioids, it has
been counteracted by a rise in availability and use of heroin, although nonmedical prescription
opioid use continues to far surpass heroin use. The number of past-year heroin users increased
1 Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death, 1999-2014 on CDC WONDER
Online Database, released 2015. Extracted by ONDCP from http://wonder.cdc.gov/mcd-icd10.html on December 9, 2015.
2
Rudd, RA, Aleshire, N, Zibbell, JE, and Gladden, RM. Increases in Drug and Opioid Overdose Deaths – 2000-2014. Centers for Disease
Control and Prevention: Mortality and Morbidity Weekly Report. Jan. 1, 2016. 64(50);1378-82. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w
3
Patrick, Stephen W., et al. Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, 2000-2009 (2012). Journal
of the American Medical Association. 2012 May 9;307(18):1934-40. doi:10.1001/jama.2012.3951. Epub 2012 Apr 30. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/22546608.
4
Patrick, SW, Schumacher, RE, Benneyworth, BD, Krans, EE, McAllister, JM, & Davis, MM. (2012). Neonatal abstinence syndrome and
associated health care expenditures: United States, 2000-2009. Journal of the American Medical Association, 307(18): 1934-40. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/22546608.
5
Patrick, SW, Davis, MM, Lehman, CU, and Cooper, WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome:
United States 2009-2012. Journal of Perinatology (2015): 1-6 online publication, April 30, 2015; doi:10.1038/jp.2015.36
6
Substance Abuse and Mental Health Services Administration. Results from the 2014 National Survey on Drug Use and Health: Detailed Tables.
Department of Health and Human Services. [September 2015] Table 7.3A – Types of Illicit Drug Use in the Past Month among Persons Aged 12
or Older: Numbers in Thousands, 2002-2014 Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs2014/NSDUH-
DetTabs2014.htm#tab7-3a
7
Substance Abuse and Mental Health Services Administration. Results from the 2014 National Survey on Drug Use and Health: Detailed Tables.
Department of Health and Human Services. [September 2015] Table 7.44A – Past Year Initiation of Substance Use among Persons Aged 12 or
Older: Numbers in Thousands, 2002-2014 Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs2014/NSDUH-
DetTabs2014.htm#tab7-44a
8
The Monitoring the Future study. Narcotics other than Heroin: Trends in Annual Use and Availability – Grades 8, 10, and 12. University of
Michigan. [December 2015]. Available: http://www.monitoringthefuture.org/data/15data/15drfig8.pdf
2

from 373,000 in 2007 to 914,000 in 2014, 9 and approximately 435,000 Americans reported pastmonth
use of heroin in 2014. 10 These figures likely undercount the number of users, as national
household surveys do not track all heroin-using populations, such as homeless users.
Heroin use and deaths involving heroin are rising significantly throughout the United
States among men and women, in most age groups, and regardless of income level. 11 Since
2007, there has been a 340 percent increase in heroin-involved overdose deaths, from 2,402 in
2007 to 10,574 in 2014. 12 Additionally, heroin purity has been rising since 2010, while prices
have remained low. 13 This increase in purity permits heroin use by snorting or smoking, which
broadens the drug’s appeal to a population that previously was disinclined to inject the drug
intravenously.
Similar trends concerning growth in heroin use are reflected in the country’s substance
use disorder treatment system. Data show a near tripling in the past 10 years of treatment
admissions for individuals primarily seeking treatment for non-heroin opiate use disorder, from
52,768 in 2003 to 154,778 in 2013. During the same period, the number of admissions for
primary heroin use increased by 15 percent (from 274,459 to 316,797). 14 Although all states have
not yet reported specialty treatment admission data for 2013 and 2014, the states that have
reported show an increase in the proportion of primary treatment admissions that are for heroin
use. 15
The heroin crisis is being compounded by the reemergence of illicit fentanyl, a powerful
Schedule II synthetic opioid analgesic more potent than morphine or heroin. 16 Fentanyl is
sometimes added to heroin to increase the product’s potency, or mixed with adulterants and sold
as “synthetic heroin” with or without the buyer’s knowledge. Since fentanyl is more potent than
heroin, its use increases risks for overdose death, even among individuals who are chronic opioid
users. 17
Some states are being hit especially hard by fentanyl-related overdoses. For example,
Ohio state medical authorities report there were 514 fentanyl-related overdose deaths in Ohio in
2014 alone – up from 92 in the previous year. 18 And in New Hampshire, the Office of the Chief
9
Substance Abuse and Mental Health Services Administration. Results from the 2014 National Survey on Drug Use and Health: Detailed Tables.
Department of Health and Human Services. [September 2015] Table 7.2A – Types of Illicit Drug Use in the Past Year among Persons Aged 12
or Older: Numbers in Thousands, 2002-2014. Available at: http://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs2014/NSDUH-
DetTabs2014.htm#tab7-2a.
10
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, National Survey on Drug
Use and Health, 2013 and 2014: Table 1.1A Types of Illicit Drug Use in Lifetime, Past Year, and Past Month among Persons Aged 12 or Older:
Numbers in Thousands, 2013 and 2014.
11
Jones et. al., Vital Signs: Demographic and Substance Use Trends Among Heroin Users – United States, 2002-2013, Morbidity and Mortality
Weekly Report (July 2015) 64(26); 719-725.
12
Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death, 1999-2014 on CDC WONDER
Online Database, released 2015. Extracted by ONDCP from http://wonder.cdc.gov/mcd-icd10.html on December 9, 2015.
13
Drug Enforcement Administration, El Paso Intelligence Center, National Seizure System, 2008-2014; and Drug Enforcement Administration.
Strategic Intelligence Section. 2015 National Heroin Threat Assessment. DEA-DCT-DIR-039-15.
14
Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS): 2003-2013. National Admissions to
Substance Abuse Treatment Services. [Table 1.1a. Admissions aged 12 and older, by primary substance of abuse: Number, 2003-2013]. U.S.
Department of Health and Human Services. [December 2015]. Available:
http://www.samhsa.gov/data/sites/default/files/2003_2013_TEDS_National/2003_2013_Treatment_Episode_Data_Set_National.pdf.
15
Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set (TEDS) Substance Abuse Treatment extracted
6/2/2015 http://wwwdasis.samhsa.gov/webt/newmapv1.htm
16
Zuurmond WW, Meert TF, and Noorduin H. (2002). Partial versus full agonists for opioid-mediated analgesia--focus on fentanyl and
buprenorphine. Acta Anaesthesiol Belg, 53(3):193-201.
17
U.S. Department of Justice, Drug Enforcement Administration, DEA Issues Nationwide Alert on Fentanyl as Threat to Health and Public
Safety, 2015. http://www.dea.gov/divisions/hq/2015/hq031815.shtml
18
2014 Ohio Drug Overdose Preliminary Data: General Findings, Ohio Department of Health, Office of Vital Statistics; Analysis Conducted by
Injury Prevention Program. Available at:
3

Medical Examiner reports that out of 385 drug deaths in 2015 (an additional 45 are pending
toxicology results), 351 involved opioids. Of those deaths involving opioids, 253 involved
fentanyl and 74 involved heroin. 19
It is important to note the complex relationship that exists between nonmedical
prescription opioid use and heroin use. A report from the Substance Abuse and Mental Health
Services Administration (SAMHSA) found that 80 percent of new heroin users reported
nonmedical prescription opioid use, but less than four percent of nonmedical prescription opioid
users transitioned to heroin use. 20 However, a review article in the New England Journal of
Medicine concluded that the transition from nonmedical prescription opioid use to heroin use
appears to be part of the progression of substance use disorder in a subgroup of nonmedical users
of prescription opioids, primarily among persons with frequent nonmedical use and those with
prescription opioid misuse or dependence. 21 This suggests that a certain segment of the
population is at higher risk of developing an opioid use disorder or likely to transition from
nonmedical prescription opioid use to heroin use. Moreover, research indicates that some
prescription opioid users will initiate heroin use if it is accessible, and especially if it is
inexpensive relative to prescription opioids, but they will also use prescription opioids and
prescription tranquilizers when heroin is hard to find or of poor quality. 22
This behavior also dramatically increases the risk of exposure to blood-borne infections
from injection drug use, including human immunodeficiency virus (HIV) and hepatitis C.
Intravenous use of the prescription opioid oxymorphone recently spurred an HIV outbreak in
southeast Indiana. Since the first patient in the outbreak was identified in January 2015, 190
people have tested positive for HIV. 23
Additionally, an evaluation of recent healthcare claims data found that a majority of nonfatal
opioid overdose victims were receiving an opioid from a prescriber at the time of their
overdose and that 91 percent of victims received an opioid prescription again from a prescriber
following their overdose. 24 This includes overdose due to a prescription opioid or heroin. This
study also found that the percentage of people who overdosed a second time was double among
those with an active prescription compared to those without one, and those on the highest doses
of opioids were at significantly greater risk of overdosing.
This interrelationship between prescription opioids and heroin indicates that we must
continue to push for mandatory education and training of opioid prescribers to alleviate the
circumstances that lead to prescription opioid misuse, heroin use and its consequences.
http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/injury%20prevention/2014%20Ohio%20Preliminary%20Overdose%20Report
.pdf. Accessed 11-24-15.
19
Personal Communication. January 14, 2016. New Hampshire Office of the Chief Medical Examiner.
20
Muhuri, P.K., Gfroerer, J.C., Davies, MC. SAMHSA CBHSQ Data Review. Associations of Nonmedical Pain Reliever Use and Initiation of
Heroin Use in the United States. August 2013. Available at: http://archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-relieveruse-2013.pdf.
21
Compton, W.M., Jones, C.M., and Baldwin, G.T.. Relationship Between Nonmedical Prescription Opioid Use and Heroin Use. N Engl J Med
2016; 374:154-163. January 14, 2016. DOI: 10.1056/NEJMra1508490. Available at: http://www.nejm.org/doi/full/10.1056/NEJMra1508490
22
Lankenau SE, Teti M, Silva K, Bloom JJ, Harocopos A, Treese M J Patterns of prescription drug misuse among young injection drug users.
Urban Health. 2012 Dec;89(6):1004-16. doi: 10.1007/s11524-012-9691-9. Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3531346/pdf/11524_2012_Article_9691.pdf. Downloaded 2-8-2016.
23
Morbidity and Mortality Weekly Report (MMWR), Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone —
Indiana, 2015, 64 (16); p 443-444, May 1, 2015. Data from State of Indiana https://secure.in.gov/isdh/26649.htm
24
Larochelle, Mark R., et al. Opioid Prescribing After Nonfatal Overdose and Association with Repeated Overdose. Annals of Internal Medicine.
doi: 10.7326/M15-0038. Published: December 29, 2015.
4

Mexico is a primary supplier of heroin to the United States, with Mexican drug
traffickers producing heroin in Mexico and smuggling the finished product into the United
States. 25 Opium poppy cultivation in Mexico has increased substantially in recent years, rising
from 11,000 hectares in 2013, with an estimated potential pure heroin production of 26 metric
tons, to 17,000 hectares in 2014 with potential production of 42 metric tons of pure heroin. 26
Fentanyl used for illicit purposes comes from several sources including pharmaceutical
fentanyl diverted from legal medical use, which accounts for a small percentage of the fentanyl
in the illicit market, and clandestine fentanyl that is manufactured in Mexico or China and
smuggled into the United States. 27 A portion of illicit fentanyl that is smuggled into the U.S.
market is ordered via the internet and shipped to the buyer using legal shipping companies. 28
The Administration’s Response
President Obama’s inaugural National Drug Control Strategy, released in May 2010,
labeled opioid overdose a “growing national crisis” and laid out specific actions and goals for
reducing nonmedical prescription opioid and heroin use. 29 In April 2011, the Administration
released a comprehensive Prescription Drug Abuse Prevention Plan (Plan) 30 , which created a
national framework for reducing prescription drug diversion and misuse. The Plan focuses on:
improving education for patients and healthcare providers; supporting the expansion of statebased
prescription drug monitoring programs; developing more convenient and environmentally
responsible disposal methods to remove unused and unneeded medications from the home; and
reducing the prevalence of pill mills and doctor shopping through targeted enforcement efforts.
Graduate medical education programs may not provide a comprehensive focus on the
identification or treatment of substance use disorders, and since the opioid drug epidemic is
connected to overprescribing of prescription opioid drugs in the United States, the first pillar of
the Plan focuses on ensuring that prescribers are better trained on the dangers of misuse and
abuse of prescription drugs. Much progress has been made in expanding available continuing
education for prescribers. At least fifteen states (Arkansas, 31 Connecticut, 32 Delaware, 33
Florida, 34 Iowa, 35 Kentucky, 36 Maryland, 37 Massachusetts, 38 Nevada, 39 New Hampshire, 40 New
25
Drug Enforcement Administration. Strategic Intelligence Section. 2015 National Heroin Threat Assessment. DEA-DCT-DIR-039-15.
26
US Department of State, Bureau of International Narcotics and Law Enforcement Affairs. International Narcotics Control Strategy Report -
2015 [INCSR] (March 2015) for data from 2013 - 2014 and unpublished U.S. Government Estimates.
27
Drug Enforcement Administration. Strategic Intelligence Section. 2015 National Heroin Threat Assessment. DEA-DCT-DIR-039-15.
28
DEA Background Briefing on Fentanyl. Presentation made at ONDCP on March 14, 2016.
29
Office of National Drug Control Policy. 2010 National Drug Control Strategy. Executive Office of the President. [2010]. Available:
http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/ndcs2010.pdf#page=49
30
Office of National Drug Control Policy. Epidemic: Responding to America’s Prescription Drug Abuse Crisis [2011] Available:
http://www.whitehouse.gov/sites/default/files/ondcp/issues-content/prescription-drugs/rx_abuse_plan.pdf
31
A.C.A. § 20-7-704 (2015), available at: http://www.lexisnexis.com/hottopics/arcode/Default.asp.
32
CONN. GEN. STAT. § 20-10b (2015), available at http://www.cga.ct.gov/2015/ACT/PA/2015PA-00198-R00HB-06856-PA.htm
33
24 DEL. CODE ANN. § 3.1.1, available at
http://regulations.delaware.gov/AdminCode/title24/Uniform%20Controlled%20Substances%20Act%20Regulations.pdf.
34
Florida Administrative Code, Rule 64B15-13.001, available at: https://www.flrules.org/gateway/ruleno.asp?id=64B15-13.001
35
IOWA ADMIN. CODE r. 253-11.4 (2011), available at https://www.legis.iowa.gov/docs/ACO/chapter/07-22-2015.653.11.pdf.
36
201 Ky. Admin. Reg. 9:250 (2013), available at http://www.lrc.ky.gov/kar/201/009/250.htm.
37
Maryland Department of Health and Mental Hygiene. Maryland Board of Physicians. CME Mandate (2015). available at:
http://www.mbp.state.md.us/pages/overdose.html
38
MASS. GEN. LAWS ch. 94C, § 18(e) (2011), available at https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXV/Chapter94c/Section18.
39
NV. SB 459 (2015), available at https://www.leg.state.nv.us/Session/78th2015/Reports/history.cfm?BillName=SB459
40
SB 576 (2016) [318-B:40], available at: http://gencourt.state.nh.us/bill_status/billText.aspx?id=949&txtFormat=html
5

Mexico, 41 North Carolina, 42 Tennessee, 43 Utah, 44 and West Virginia 45 ) now require education for
prescribers.
At the Federal level, in October 2015 President Obama announced a Presidential
Memorandum requiring all Federal agencies, to the extent permitted by law, to provide training
on the appropriate and effective prescribing of opioid medications to all employees and certain
contractors who are health care professionals and who prescribe controlled substances as part of
their Federal responsibilities and duties. 46 Also, CDC has issued a guideline for the prescribing
of opioid pain medication for patients 18 and older in primary care settings, focusing on the use
of opioids in treating chronic pain outside of active cancer treatment, palliative care, and end-oflife
care. 47 Additionally, the Administration has developed and made available free and low-cost
training options for prescribers and dispensers of opioid medications via several sources,
including SAMHSA and the National Institute on Drug Abuse at the National Institutes of
Health. Also, the Food and Drug Administration (FDA) now requires manufacturers of extendedrelease
and long-acting opioid pain relievers to make available free or low-cost continuing
education to prescribers under the Risk Evaluation and Mitigation Strategy for these drugs. And
over 40 prescriber groups organized by the American Medical Association agreed to boost the
number of prescribers trained to 500,000.
In order to help prescribers and pharmacists identify patients who may be at risk for
substance use disorders, overdose, or other significant health consequences of misusing
prescription opioids, the second area of the Administration’s Plan focuses on improving the
operation and functionality of state-administered prescription drug monitoring programs
(PDMP). PDMPs provide prescribers with information on the types and frequency of prescribed
controlled substances. State regulatory and law enforcement agencies may also use this
information to identify and prevent unsafe prescribing, doctor shopping, and other methods of
diverting controlled substances. Research also shows that PDMPs may have a role in reducing
the rates of prescribing for opioid analgesics. 48
In 2006, only 20 states had PDMPs. Today, the District of Columbia has a law
authorizing a PDMP, and 49 states have operational programs. 49 To drive PDMP utilization, 28
of the 49 states with PDMPs currently require prescribers to query the PDMP in certain
circumstances. 50 Given this growing national trend, the need for integration of PDMP data into
the health care setting has never been more critical. Integrating with provider health IT systems
(e.g., electronic health records or EHRs) will help drive the success of mandatory use
41
N.M. ADMIN. CODE § 16-10-14 (2012), available at http://164.64.110.239/nmac/parts/title16/16.010.0014.htm.
42
HB 97 (2015)[12F.16.(b)], available at: http://www.ncleg.net/PED/LegislativeTracking/H97Section12F16.pdf
43
TENN. CODE ANN. § 63-1-402 (2013), available at http://www.tn.gov/sos/acts/108/pub/pc0430.pdf.
44
UTAH ADMIN. CODE r. 58-37-6.5 (2012), available at http://le.utah.gov/xcode/Title58/Chapter37/58-37-S6.5.html?v=C58-37-
S6.5_1800010118000101.
45
W. VA. CODE § 30-1-7A (2011), available at http://www.legis.state.wv.us/wvcode/ChapterEntire.cfm?chap=30&art=1&section=7A.
46
Presidential Memorandum -- Addressing Prescription Drug Abuse and Heroin Use (October 21, 2015). Available at:
https://www.whitehouse.gov/the-press-office/2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-and-heroin.
47
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Available at:
http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm.
48
Brady, JE, Wunsch, H, Dimaggio, C, Lang, BH, Giglio, J, and Li, G. Prescription drug monitoring and dispensing of prescription opioids.
Public Health Reports 2014, 129 (2): 139-47. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904893/pdf/phr129000139.pdf
49
National Alliance of Model State Drug Laws. (2014). Status of State Prescription Drug Monitoring Programs (PDMPs). Retrieved from
http://www.namsdl.org/library/16666FCC-65BE-F4BB-A2BBAD44E1BC7031/.
50
See Prescription Drug Monitoring Training and Technical Assistance Center, List of State Criteria for Mandatory Enrollment or Query of
PDMP. Available at: http://www.pdmpassist.org/pdf/Mandatory_conditions.pdf.
6

equirements by reducing the burden placed on providers. 51 For example, in Tennessee, there
has been a 38 percent decrease in the number of high-utilizing patients of opioid pain relievers
since the mandatory requirement to check the PDMP went into effect on January 1, 2013. 52
The Department of Justice’s (DOJ) Bureau of Justice Assistance (BJA) is supporting
expanded interstate sharing of PDMP data. Currently, due to efforts of BJA, the Department of
Health and Human Services (HHS), ONDCP, and stakeholders such as the National Association
of Boards of Pharmacies, at least 34 states have some ability to request and share data across
state lines. 53 HHS has invested resources to make PDMP information readily available in health
IT systems like EHRs; this enables physicians and pharmacists to more quickly and easily check
a patient’s PDMP report before prescribing or dispensing a prescription pain medication. Since
the inception of BJA’s grant program in Fiscal Year (FY) 2002, grants have been awarded to 49
states and 1 U.S. territory. In recent years, the grant program has been expanded to include tribal
participation and to give support to states and localities to expand collaborative efforts between
public health and public safety professionals.
In addition, the Consolidated Appropriations Act, 2016 (Pub. L. 114-113) includes a total
of $70 million (an increase of $50 million) to scale up CDC's Prescription Drug Overdose
Prevention for States program. This program provides grants to states to help implement tailored,
state-based prevention strategies such as maximizing PDMPs, enhancing public insurer
mechanisms to prevent overdoses, and evaluating state policies and programs aimed at
addressing the opioid epidemic.
Data show that approximately 66 percent of past-year nonmedical users of prescription
pain relievers report getting them from a friend or relative the last time they used them, and
approximately 84 percent of the time, that friend or relative obtained the pain relievers from one
doctor. 54 Therefore, the third area of the Plan focuses on safely removing millions of pounds of
expired and unneeded prescription medications from circulation. Since September 2010, the
Drug Enforcement Administration (DEA) has partnered with hundreds of state and local law
enforcement agencies and community coalitions, as well as other Federal agencies, to hold 10
National Prescription Take-Back Days. Cumulatively, these events allowed DEA to collect and
safely dispose of more than 5.5 million pounds of unneeded or expired medications. 55 In
addition, DEA published a Final Rule for the Disposal of Controlled Substances, which took
effect October 9, 2014. 56 This regulation expands the options available to securely and safely
dispose of unneeded prescription medications. ONDCP and DEA have engaged with Federal,
state, and local agencies, and other stakeholders to educate the public about the new rule and
expand local drug disposal programs. State and local agencies throughout the country have
implemented disposal programs and prescription medication collection boxes. Additionally,
51
Haffajee, RL, Jena, AB, and Weiner, SG. Mandatory Use of Prescription Drug Monitoring Programs. JAMA. 2015;313(9):891-892. Available
at: http://jama.jamanetwork.com/article.aspx?articleid=2107540
52
Tennessee Department of Health Controlled Substance Monitoring Database Committee. Controlled Substance Monitoring Database 2015
Report to the 109th Tennessee General Assembly, February 1, 2015. Page 10. Available at
https://www.tn.gov/assets/entities/health/attachments/CSMD_AnnualReport_2015.pdf
53
Association of Boards of Pharmacy. Three Additional States Sign Agreement to Participate in NABP PMP Interconnect. (December 24,
2015). Available at: https://www.nabp.net/news/three-additional-states-sign-agreement-to-participate-in-nabp-pmp-interconnect
54
Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of
National Findings. Department of Health and Human Services. [September 2014]. Available:
http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#2.16
55
Drug Enforcement Administration. “DEA’s Prescription Drug Take-Back Effort - A Big Success.” Department of Justice. [October 1, 2015].
Available: http://www.dea.gov/divisions/hq/2015/hq100115.shtml
56
Disposal of Controlled Substances, 79 Fed. Reg. 53519 (Sep. 9, 2014). Available: https://www.federalregister.gov/articles/2014/09/09/2014-
20926/disposal-of-controlled-substances
7

Alameda County, California, and King County, Washington, have passed product stewardship
laws that require prescription drug manufacturers to develop and pay for county prescription
drug disposal programs.
The final part of the Plan focuses on improving law enforcement capabilities to reduce
the diversion of prescription opioids. Federal law enforcement, including our partners at DEA,
are working with state and local agencies to reduce pill mills, and prosecute and eradicate
unscrupulous registrants or anyone engaging in illegal prescribing practices.
Additionally, the Administration has focused on several key areas to reduce and prevent
opioid overdoses from prescription opioids and heroin, including educating the public about
overdose risk and interventions; increasing third-party and first responder access to the opioid
overdose reversal medication naloxone; working with states to promote Good Samaritan laws;
and connecting overdose victims and persons with an opioid use disorder to treatment.
The Administration continues to promote the use of naloxone by those likely to encounter
overdose victims, especially first responders and caregivers. Prior to 2012, just six states had any
laws that expanded access to naloxone or limited criminal liability for persons that took steps to
assist an overdose victim. Today, 46 states and the District of Columbia have enacted statutes
that expand access to naloxone or provide “Good Samaritan” protections for possession of a
controlled substance if emergency assistance is sought for a victim of an opioid overdose. 57 In
2014, FDA approved a naloxone auto-injector, Evzio, and in 2015, a nasal formulation of
naloxone, Narcan. These two delivery methods should facilitate administration of naloxone by
third parties who would be hesitant to administer the drug via injection when they encounter an
overdose. Additionally, the National Association of Counties, the National League of Cities,
and the United States Conference of Mayors, in conjunction with U.S. Communities Purchasing
Alliance and Premier, Inc., have secured discounts on naloxone and medications for treatment
through the purchasing program for state and local governments.
The expansion of treatment services for persons with opioid and other substance use
disorders has been a key focus of the Administration. The Affordable Care Act and Federal
parity laws are extending access to mental health benefits and substance use disorder services for
an estimated 62 million Americans. 58 This represents the largest expansion of treatment access in
a generation, and could help guide millions into successful recovery.
The FY 2016 appropriations act provides an increase of approximately $100 million over
the previous year to address the prescription opioid and heroin epidemic. As part of increased
investments in the HHS Opioid Initiative, it includes a $35 million increase for SAMHSA to
expand medication-assisted treatment for opioid use disorders in high-risk communities, increase
the use of the overdose-reversal drug naloxone, and improve prevention efforts. It also continues
to include $1 million for a Bureau of Prisons pilot program to provide appropriate substance use
disorder treatment for eligible inmates. In addition, the appropriation continues to provide $7
million in funding for the DOJ Community Oriented Policing Services’ Anti-Heroin Task Force
grants to help communities form innovative partnerships that address the opioid epidemic, and a
$38 million increase for SAMHSA’s Substance Abuse Block Grant, which distributes funding to
57
Only IA, KS, MT and WY do not have such laws.
58
Berino, K., Rosa, P., Skopec, L. & Glied, S. (2013). Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and
Parity Protections for 62 Million Americans. Research Brief. Assistant Secretary for Planning and Evaluation (ASPE). Washington, DC (Citation:
Abstract of the Brief found at http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm)
8

all 50 states to prevent and treat substance use disorders. The act also allows certain high-risk
communities to use Federal funds for services associated with syringe service programs and
increases funding for general drug prevention, anti-trafficking and treatment programs. Building
on this commitment, in his FY 2017 Budget President Obama proposed $1 billion in new
mandatory funding over two years to expand the availability of opioid use disorder services,
target areas of highest need, and allow states to implement evidence-based strategies that best
meet local needs, such as medication-assisted treatment and expansion of the availability of
substance abuse treatment providers (through enhanced loan repayment for healthcare providers
that offer medication-assisted treatment). Such efforts will help individuals seek treatment,
successfully complete treatment, and sustain recovery. These resources will support states in
expanding access to medication assisted treatment, include the placement of substance use
disorder providers in areas of the country that need them most, and invest in evaluation
Leadership and innovation is taking place at the local level as well. For example, in
Dayton, Ohio, Police Chief Richard Biehl implemented a community-based initiative,
“Conversation for Change,” where Dayton police officers collaborate with addiction and
recovery professionals, mediators, and family members to provide education, resources, and
assistance to people who are struggling with an opioid use disorder. In Gloucester,
Massachusetts, Police Chief Leonard Campanello launched an “Angel” initiative, where anyone
with a substance use disorder can enter a police station and ask for help. He or she will then be
assigned to a social services volunteer for placement into a treatment program. Police
departments across the country are now implementing similar programs.
To address the emerging rise in heroin and illicit fentanyl use and availability, the
National Drug Control Strategy focuses on identifying, disrupting and dismantling criminal
organizations trafficking in opioid drugs; working with the international community to reduce
cultivation of poppy; identifying labs creating dangerous synthetic opioids like fentanyl and its
analogues; and enhancing efforts along the Nation’s borders to decrease the flow of these drugs
into our country.
Expanding on these efforts, in October 2015, ONDCP created the National Heroin
Coordination Group, a multi-disciplinary team of subject matter experts to lead Federal efforts to
reduce the availability of heroin and fentanyl in the United States. This hub of interagency
partners is leveraging their home agency authorities and resources to disrupt the heroin and illicit
fentanyl supply chain coming into the United States and is establishing mechanisms for
interagency collaboration, and information-sharing focused on heroin and fentanyl.
This past December, the Administration released the report of the Congressionallymandated
interagency Heroin Task Force, which was co-chaired by ONDCP and DOJ. The
report includes recommendations of Federal agency experts in law enforcement, medicine,
public health and education, providing emerging evidence-based public health and public safety
models for Federal agency engagement in activities that promote solutions to reduce demand or
decrease spread of disease.
In addition, this past summer, ONDCP committed $2.5 million in High Intensity Drug
Trafficking Areas (HIDTA) Program funds to develop a strategy to respond to the Nation’s
heroin epidemic. This unprecedented project by ONDCP combines prevention, education,
intelligence, and enforcement resources to address the heroin threat across 15 states and the
9

District of Columbia. The effort will be carried out through a unique partnership of five regional
HIDTAs – Appalachia, New England, New York/New Jersey, Philadelphia/Camden, and
Washington/Baltimore. The HIDTA Program is a locally-based program that responds to the
drug trafficking issues facing specific areas of the country. Law enforcement agencies at all
levels of government share information and implement coordinated enforcement activities;
enhance intelligence sharing among Federal, state, local, and tribal law enforcement agencies;
provide reliable intelligence to law enforcement agencies to develop effective enforcement
strategies and operations; and support coordinated law enforcement strategies to maximize
available resources and reduce the supply of illegal drugs in designated areas. The HIDTA
Heroin Response Strategy will foster a collaborative network of public health-public safety
partnerships, sharing best practices, innovative pilots, and identifying new opportunities to
leverage resources.
Our Federal law enforcement agencies are aggressively addressing the heroin and
fentanyl issue here and abroad through a variety of means. The DEA and other U.S. Federal law
enforcement agencies have co-located Special Agents with international partners such as
Mexico, in South America, and in other parts of the world to assist in criminal investigations
targeting drug trafficking organizations, and to help develop their capacity to conduct the full
range of narcotics interdiction activities within their countries to target both heroin and fentanyl.
Our Federal law enforcement agencies, in conjunction with the Department of State, are working
with the countries that supply fentanyl and the precursor chemicals used in its manufacture to
stem the flow of these dangerous chemicals to the Western Hemisphere. And along our
southwest border, U.S. Customs and Border Protection continues to detect and interdict heroin
and illicit fentanyl entering the United States, and to apprehend those attempting to bring these
dangerous drugs into our communities. DEA, Federal Bureau of Investigation, Homeland
Security Investigations, and Department of Justice’s Organized Crime Drug Enforcement Task
Forces (OCDETF) target, disrupt, and dismantle international drug trafficking organizations that
manufacture, transport, and distribute heroin and fentanyl destined for and distributed across the
United States. In addition, OCDETF’s National Heroin Initiative, starting in December 2014,
vets and funds innovative regional approaches that improve information sharing and data
collection and support multi-agency, multi-jurisdictional enforcement actions.
This month, I traveled to Mexico City with Ambassador Brownfield, Assistant Secretary
of State for International Narcotics and Law Enforcement Affairs, and Chargé d’Affairs Duncan,
our acting Chief of Mission in Mexico. The primary purpose of the trip was to gain agreement
with the Government of Mexico on tangible, near-term actions to address the heroin and fentanyl
entering the United States from Mexico. We agreed to work closely together to address the issue.
Bilateral coordination is beneficial for both our countries, and we look forward to working
closely with our Mexican partners to reduce the flow of heroin and fentanyl into the United
States.
Conclusion
The Administration continues to work with our Federal, state, local, and tribal partners to
reduce and prevent the health and safety consequences of nonmedical prescription opioid, heroin,
and fentanyl use. Together with all of you, we are committed partners, working to reduce the
prevalence of substance use disorders and the number of overdose deaths through prevention,
increasing access to treatment, helping individuals recover from the disease of addiction, and
10

working with law enforcement to reduce diversion of prescription opioids and the supply of
heroin and fentanyl. Thank you for the opportunity to testify here today, and for your ongoing
commitment to these issues. I look forward to continuing to work with you on these pressing
public health matters.
11

Michael Botticelli
Director of National Drug Control Policy
Michael Botticelli was sworn in as Director of National Drug Control Policy on February 11, 2015.
Previously, he served both as Acting Director and Deputy Director of National Drug Control Policy. He
joined the Office of National Drug Control Policy (ONDCP) as Deputy Director in November 2012.
Mr. Botticelli has more than two decades of experience supporting Americans who have been affected by
substance use disorders. Prior to joining ONDCP, Mr. Botticelli served as Director of the Bureau of
Substance Abuse Services at the Massachusetts Department of Public Health, where he successfully
expanded innovative and nationally recognized prevention, intervention, treatment, and recovery services
for the Commonwealth of Massachusetts. He also forged strong partnerships with local, state, and
Federal law enforcement agencies; state and local health and human service agencies; and stakeholder
groups to guide and implement evidence-based programs. These programs include the establishment of
a treatment system for adolescents, early intervention and treatment programs in primary healthcare
settings, jail diversion programs, re-entry services for those leaving state and county correctional facilities,
and overdose prevention programs.
Mr. Botticelli has served in a variety of leadership roles for the National Association of State Alcohol and
Drug Abuse Directors. He was also a member of the Advisory Committee for the Substance Abuse and
Mental Health Services Administration’s Center for Substance Abuse Prevention and the National Action
Alliance for Suicide Prevention. He has also co-authored many peer-reviewed articles that have
significantly contributed to the substance abuse field .
In 2008, Mr. Botticelli was the first recipient of the annual Ramstad/Kennedy National Award for
Outstanding Leadership in Promoting Addiction Recovery. In 2012, he was awarded the Service Award
from the National Association of State Alcohol and Drug Abuse Directors.
Born in Upstate New York, Mr. Botticelli holds a Bachelor of Arts degree from Siena College and a Master
of Education degree from St. Lawrence University. He is also in long-term recovery from a substance use
disorder, celebrating more than 25 years of sobriety.

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Advocacy Foundation Publishers
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Advocacy Foundation Publishers
The e-Advocate Quarterly
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Issue Title Quarterly
Vol. I 2015 The Fundamentals
I
The ComeUnity ReEngineering
Project Initiative
Q-1 2015
II The Adolescent Law Group Q-2 2015
III
Landmark Cases in US
Juvenile Justice (PA)
Q-3 2015
IV The First Amendment Project Q-4 2015
Vol. II 2016 Strategic Development
V The Fourth Amendment Project Q-1 2016
VI
Landmark Cases in US
Juvenile Justice (NJ)
Q-2 2016
VII Youth Court Q-3 2016
VIII
The Economic Consequences of Legal
Decision-Making
Q-4 2016
Vol. III 2017 Sustainability
IX The Sixth Amendment Project Q-1 2017
X
The Theological Foundations of
US Law & Government
Q-2 2017
XI The Eighth Amendment Project Q-3 2017
XII
The EB-5 Investor
Immigration Project*
Q-4 2017
Vol. IV 2018 Collaboration
XIII Strategic Planning Q-1 2018
XIV
The Juvenile Justice
Legislative Reform Initiative
Q-2 2018
XV The Advocacy Foundation Coalition Q-3 2018
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XVI
for Drug-Free Communities
Landmark Cases in US
Juvenile Justice (GA)
Q-4 2018
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Issue Title Quarterly
Vol. V 2019 Organizational Development
XVII The Board of Directors Q-1 2019
XVIII The Inner Circle Q-2 2019
XIX Staff & Management Q-3 2019
XX Succession Planning Q-4 2019
XXI The Budget* Bonus #1
XXII Data-Driven Resource Allocation* Bonus #2
Vol. VI 2020 Missions
XXIII Critical Thinking Q-1 2020
XXIV
The Advocacy Foundation
Endowments Initiative Project
Q-2 2020
XXV International Labor Relations Q-3 2020
XXVI Immigration Q-4 2020
Vol. VII 2021 Community Engagement
XXVII
The 21 st Century Charter Schools
Initiative
Q-1 2021
XXVIII The All-Sports Ministry @ ... Q-2 2021
XXIX Lobbying for Nonprofits Q-3 2021
XXX
XXXI
Advocacy Foundation Missions -
Domestic
Advocacy Foundation Missions -
International
Q-4 2021
Bonus
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Vol. VIII
2022 ComeUnity ReEngineering
XXXII
The Creative & Fine Arts Ministry
@ The Foundation
Q-1 2022
XXXIII The Advisory Council & Committees Q-2 2022
XXXIV
The Theological Origins
of Contemporary Judicial Process
Q-3 2022
XXXV The Second Chance Ministry @ ... Q-4 2022
Vol. IX 2023 Legal Reformation
XXXVI The Fifth Amendment Project Q-1 2023
XXXVII The Judicial Re-Engineering Initiative Q-2 2023
XXXVIII
The Inner-Cities Strategic
Revitalization Initiative
Q-3 2023
XXXVIX Habeas Corpus Q-4 2023
Vol. X 2024 ComeUnity Development
XXXVX
The Inner-City Strategic
Revitalization Plan
Q-1 2024
XXXVXI The Mentoring Initiative Q-2 2024
XXXVXII The Violence Prevention Framework Q-3 2024
XXXVXIII The Fatherhood Initiative Q-4 2024
Vol. XI 2025 Public Interest
XXXVXIV Public Interest Law Q-1 2025
L (50) Spiritual Resource Development Q-2 2025
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LI
Nonprofit Confidentiality
In The Age of Big Data
Q-3 2025
LII Interpreting The Facts Q-4 2025
Vol. XII 2026 Poverty In America
LIII
American Poverty
In The New Millennium
Q-1 2026
LIV Outcome-Based Thinking Q-2 2026
LV Transformational Social Leadership Q-3 2026
LVI The Cycle of Poverty Q-4 2026
Vol. XIII 2027 Raising Awareness
LVII ReEngineering Juvenile Justice Q-1 2027
LVIII Corporations Q-2 2027
LVIX The Prison Industrial Complex Q-3 2027
LX Restoration of Rights Q-4 2027
Vol. XIV 2028 Culturally Relevant Programming
LXI Community Culture Q-1 2028
LXII Corporate Culture Q-2 2028
LXIII Strategic Cultural Planning Q-3 2028
LXIV
The Cross-Sector/ Coordinated
Service Approach to Delinquency
Prevention
Q-4 2028
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Vol. XV 2029 Inner-Cities Revitalization
LXIV
LXV
LXVI
Part I – Strategic Housing
Revitalization
(The Twenty Percent Profit Margin)
Part II – Jobs Training, Educational
Redevelopment
and Economic Empowerment
Part III - Financial Literacy
and Sustainability
Q-1 2029
Q-2 2029
Q-3 2029
LXVII Part IV – Solutions for Homelessness Q-4 2029
LXVIII
The Strategic Home Mortgage
Initiative
Bonus
Vol. XVI 2030 Sustainability
LXVIII Social Program Sustainability Q-1 2030
LXIX
The Advocacy Foundation
Endowments Initiative
Q-2 2030
LXX Capital Gains Q-3 2030
LXXI Sustainability Investments Q-4 2030
Vol. XVII 2031 The Justice Series
LXXII Distributive Justice Q-1 2031
LXXIII Retributive Justice Q-2 2031
LXXIV Procedural Justice Q-3 2031
LXXV (75) Restorative Justice Q-4 2031
LXXVI Unjust Legal Reasoning Bonus
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Vol. XVIII 2032 Public Policy
LXXVII Public Interest Law Q-1 2032
LXXVIII Reforming Public Policy Q-2 2032
LXXVIX ... Q-3 2032
LXXVX ... Q-4 2032
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The e-Advocate Journal
of Theological Jurisprudence
Vol. I - 2017
The Theological Origins of Contemporary Judicial Process
Scriptural Application to The Model Criminal Code
Scriptural Application for Tort Reform
Scriptural Application to Juvenile Justice Reformation
Vol. II - 2018
Scriptural Application for The Canons of Ethics
Scriptural Application to Contracts Reform
& The Uniform Commercial Code
Scriptural Application to The Law of Property
Scriptural Application to The Law of Evidence
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Legal Missions International
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Issue Title Quarterly
Vol. I 2015
I
II
God’s Will and The 21 st Century
Democratic Process
The Community
Engagement Strategy
Q-1 2015
Q-2 2015
III Foreign Policy Q-3 2015
IV
Public Interest Law
in The New Millennium
Q-4 2015
Vol. II 2016
V Ethiopia Q-1 2016
VI Zimbabwe Q-2 2016
VII Jamaica Q-3 2016
VIII Brazil Q-4 2016
Vol. III 2017
IX India Q-1 2017
X Suriname Q-2 2017
XI The Caribbean Q-3 2017
XII United States/ Estados Unidos Q-4 2017
Vol. IV 2018
XIII Cuba Q-1 2018
XIV Guinea Q-2 2018
XV Indonesia Q-3 2018
XVI Sri Lanka Q-4 2018
Vol. V 2019
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XVII Russia Q-1 2019
XVIII Australia Q-2 2019
XIV South Korea Q-3 2019
XV Puerto Rico Q-4 2019
Issue Title Quarterly
Vol. VI 2020
XVI Trinidad & Tobago Q-1 2020
XVII Egypt Q-2 2020
XVIII Sierra Leone Q-3 2020
XIX South Africa Q-4 2020
XX Israel Bonus
Vol. VII 2021
XXI Haiti Q-1 2021
XXII Peru Q-2 2021
XXIII Costa Rica Q-3 2021
XXIV China Q-4 2021
XXV Japan Bonus
Vol VIII 2022
XXVI Chile Q-1 2022
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The e-Advocate Juvenile Justice Report
______
Vol. I – Juvenile Delinquency in The US
Vol. II. – The Prison Industrial Complex
Vol. III – Restorative/ Transformative Justice
Vol. IV – The Sixth Amendment Right to The Effective Assistance of Counsel
Vol. V – The Theological Foundations of Juvenile Justice
Vol. VI – Collaborating to Eradicate Juvenile Delinquency
Page 92 of 98

The e-Advocate Newsletter
Genesis of The Problem
Family Structure
Societal Influences
Evidence-Based Programming
Strengthening Assets v. Eliminating Deficits
2012 - Juvenile Delinquency in The US
Introduction/Ideology/Key Values
Philosophy/Application & Practice
Expungement & Pardons
Pardons & Clemency
Examples/Best Practices
2013 - Restorative Justice in The US
2014 - The Prison Industrial Complex
25% of the World's Inmates Are In the US
The Economics of Prison Enterprise
The Federal Bureau of Prisons
The After-Effects of Incarceration/Individual/Societal
The Fourth Amendment Project
The Sixth Amendment Project
The Eighth Amendment Project
The Adolescent Law Group
2015 - US Constitutional Issues In The New Millennium
Page 93 of 98

2018 - The Theological Law Firm Academy
The Theological Foundations of US Law & Government
The Economic Consequences of Legal Decision-Making
The Juvenile Justice Legislative Reform Initiative
The EB-5 International Investors Initiative
2017 - Organizational Development
The Board of Directors
The Inner Circle
Staff & Management
Succession Planning
Bonus #1 The Budget
Bonus #2 Data-Driven Resource Allocation
2018 - Sustainability
The Data-Driven Resource Allocation Process
The Quality Assurance Initiative
The Advocacy Foundation Endowments Initiative
The Community Engagement Strategy
2019 - Collaboration
Critical Thinking for Transformative Justice
International Labor Relations
Immigration
God's Will & The 21st Century Democratic Process
The Community Engagement Strategy
The 21st Century Charter Schools Initiative
2020 - Community Engagement
Page 94 of 98

Extras
The Nonprofit Advisors Group Newsletters
The 501(c)(3) Acquisition Process
The Board of Directors
The Gladiator Mentality
Strategic Planning
Fundraising
501(c)(3) Reinstatements
The Collaborative US/ International Newsletters
How You Think Is Everything
The Reciprocal Nature of Business Relationships
Accelerate Your Professional Development
The Competitive Nature of Grant Writing
Assessing The Risks
Page 95 of 98

About The Author
John C (Jack) Johnson III
Founder & CEO
Jack was educated at Temple University, in Philadelphia, Pennsylvania and Rutgers
Law School, in Camden, New Jersey. In 1999, he moved to Atlanta, Georgia to pursue
greater opportunities to provide Advocacy and Preventive Programmatic services for atrisk/
at-promise young persons, their families, and Justice Professionals embedded in the
Juvenile Justice process in order to help facilitate its transcendence into the 21 st Century.
There, along with a small group of community and faith-based professionals, “The Advocacy Foundation, Inc." was conceived
and developed over roughly a thirteen year period, originally chartered as a Juvenile Delinquency Prevention and Educational
Support Services organization consisting of Mentoring, Tutoring, Counseling, Character Development, Community Change
Management, Practitioner Re-Education & Training, and a host of related components.
The Foundation’s Overarching Mission is “To help Individuals, Organizations, & Communities Achieve Their Full Potential”, by
implementing a wide array of evidence-based proactive multi-disciplinary "Restorative & Transformative Justice" programs &
projects currently throughout the northeast, southeast, and western international-waters regions, providing prevention and support
services to at-risk/ at-promise youth, to young adults, to their families, and to Social Service, Justice and Mental
Health professionals” everywhere. The Foundation has since relocated its headquarters to Philadelphia, Pennsylvania, and been
expanded to include a three-tier mission.
In addition to his work with the Foundation, Jack also served as an Adjunct Professor of Law & Business at National-Louis
University of Atlanta (where he taught Political Science, Business & Legal Ethics, Labor & Employment Relations, and Critical
Thinking courses to undergraduate and graduate level students). Jack has also served as Board President for a host of wellestablished
and up & coming nonprofit organizations throughout the region, including “Visions Unlimited Community
Development Systems, Inc.”, a multi-million dollar, award-winning, Violence Prevention and Gang Intervention Social Service
organization in Atlanta, as well as Vice-Chair of the Georgia/ Metropolitan Atlanta Violence Prevention Partnership, a state-wide
300 organizational member, violence prevention group led by the Morehouse School of Medicine, Emory University and The
Original, Atlanta-Based, Martin Luther King Center.
Attorney Johnson’s prior accomplishments include a wide-array of Professional Legal practice areas, including Private Firm,
Corporate and Government postings, just about all of which yielded significant professional awards & accolades, the history and
chronology of which are available for review online. Throughout his career, Jack has served a wide variety of for-profit
corporations, law firms, and nonprofit organizations as Board Chairman, Secretary, Associate, and General Counsel since 1990.
www.TheAdvocacyFoundation.org
Clayton County Youth Services Partnership, Inc. – Chair; Georgia Violence Prevention Partnership, Inc – Vice Chair; Fayette
County NAACP - Legal Redress Committee Chairman; Clayton County Fatherhood Initiative Partnership – Principal
Investigator; Morehouse School of Medicine School of Community Health Feasibility Study - Steering Committee; Atlanta
Violence Prevention Capacity Building Project – Project Partner; Clayton County Minister’s Conference, President 2006-2007;
Liberty In Life Ministries, Inc. – Board Secretary; Young Adults Talk, Inc. – Board of Directors; ROYAL, Inc - Board of
Directors; Temple University Alumni Association; Rutgers Law School Alumni Association; Sertoma International; Our
Common Welfare Board of Directors – President)2003-2005; River’s Edge Elementary School PTA (Co-President); Summerhill
Community Ministries; Outstanding Young Men of America; Employee of the Year; Academic All-American - Basketball;
Church Trustee.
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www.TheAdvocacyFoundation.org
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