national drug control strategy · the trump administration’s national drug control strategy is...

NatioNal Drug CoNtrol

Strategy

A Report by theOffice of National Drug Control Policy

JANUARY 2019

NATIONAL DRUG CONTROL STRATEGY

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TABLE OF CONTENTS

Preface

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Strategic Objective and Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Strategy Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Treatment and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Reducing the Availability of Illicit Drugs in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Metrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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Thenegativeconsequencesofthetraffickinganduseofillicitdrugs,along withthetollthatdrugmisuseandabuseistakingacrossAmerica,haveendangeredtoomanycommunities,ruinedtoomanyfamilies,andtakenthelivesoftoomanyofourfellow Americans .

The Trump Administration’s National Drug Control Strategy is focused on reversingthesedevelopments,savingAmericanlives,andsettingourNationonapathtobeingstronger,healthier,anddrug-free.ThisStrategy is intended to guide and focus Federalgovernmenteffortsalongthreecomplementarylinesofeffort.First,wemustreducethesizeofthedrug-usingpopulationbypreventinginitiatestoillicitdrugusethrougheducationandevidence-basedpreventionprograms.Second,wemustreducebarrierstotreatmentservicessothataccesstolong-termrecoveryisavailableforthosesufferingfromsubstanceusedisorder.Andfinally,wemustdrasticallyreducetheavail-ability of these drugs in the United States through law enforcement and cooperation with internationalpartnerstolessenthenegativeeffectsofdrugtraffickingthatimpactthesafetyofourcommunitiesandthewell-beingofourcitizens.

While this StrategyreflectsthePresident’stopprioritytoaddressthecurrentopioidcrisisandreducethenumberofAmericansdyingfromthesedangerousdrugs, italsosetsusonthepathtodevelopfurtherthecapability,knowledge,andinfrastructureto respond to the evolving nature of the drug threat as we move deeper into the twenty-firstcentury.

This is a Strategyofaction.ItreflectsourunderstandingofthecomplexinterplaybetweentheavailabilityofdrugsintheU.S.marketandtheiruse,anticipateschangesinthedrugenvironmentinboththepublichealthandlawenforcementdomains,andallowsustoadaptouractionsandmakelastingprogressagainstthishistoricnationalsecurity,lawenforcement,andpublichealthchallenge.Mostimportantly,itdemandsourfulleffortandarelentlessfocusondeliveringresults.TheAmericanPeopleshouldexpectnothing less .

James W . CarrollDirectorofNationalDrugControlPolicy


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“We will work to strengthen vulnerable families and communities, and we will help to build and

grow a stronger, healthier, and drug-free society.”

—PRESIDENTDONALDJ.TRUMP

INTRODUCTIONThe drug crisis our country faces today is unprecedented . It has evolved over the past several decades andhassteadilyworsenedwithtime.Everystateandcounty,andeverysocioeconomicgroupinourcountry,isdirectlyaffectedbythenegativeconsequencesofillicitdruguse.However,todaywecanseeAmericaningenuityacrosstheNation,sparkedbythecommitmenttosavelives,atworktoestablishlastingsolutionstothismonumentalproblem.Lawenforcementandpublichealthinnovatorsworkingside-by-sideatthelocallevel,assistedandinspiredbyfamilieswhohavelostlovedonestothescourgeofdruguse, resourcedbygovernmentagencies at every levelworkingwithprivate sectorpartners,arealreadymakingadifference.ThisNational Drug Control Strategy,theTrumpAdministration’sfirst,establishesthePresident’sprioritiesforaddressingthechallengeofdrugtraffickinganduse,nowandin coming years . It also provides the strategic direction necessary for the Federal government to prevent initiatestodrugusethrougheducationandevidence-basedprevention,providetreatmentforthosesufferingfromthediseaseofaddictionsotheycanreachlong-termrecovery,andreducetheavailabilityof these dangerous drugs in every American community .

ThePresident’stoppriorityistoaddress,headon,thecurrentopioidcrisisandreducethenumberofAmericans dying from these dangerous drugs . This crisis alone has resulted in more American deaths in justtwoyearsthaninthecourseoftheentireVietnamWar.In2017,thereweremorethan70,200drugoverdose deaths in the United States according to the Centers for Disease Control and Prevention (CDC) . Morethan47,500ofthesedeaths involvedanopioid,andmorethanhalfofthesedeaths involvedasyntheticopioidsuchasillicitfentanyloroneofitsanalogues.From2014to2017,thenumberofdeathsattributedtosyntheticopioids like fentanyland itsanalogues increased413percent,andthesesyn-theticopioidsarenowinvolvedinmoredeathsthananyotherdrugsuchasprescriptionopioids,heroin,orcocaine.Alongwiththecurrentopioidcrisis,overdosedeathsinvolvingheroin,cocaine,metham-phetamine,andprescribedopioidpainkillershaveallincreasedsince2014aswell,andmanyofthesedeaths involved more than one drug .

The Trump Administration is matching the magnitude of today’s historic crisis with a historic level of focus and resources . In addition to providing an array of Federal grants across the spectrum of drug issuesthePresidentincreasedresourcesinhisFiscalYear(FY)2019Budgetdedicatedtotheopioidcrisis,held twoopioidsummitsat theWhiteHouse,establishedThe President’s Commission on Combating Drug Addiction and the Opioid Crisis(hereinreferredtoastheCommission)viaExecutiveOrderinMarch2017,andannouncedhisInitiative to Stop Opioid Abuse and Reduce Drug Supply and Demand in March 2018 .


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Whileconfrontingtoday’sdrugcrisistoarrest itsgrowthandreduceitseffects,wemustalsofurtherdevelop thecapability,knowledge,and infrastructure to respond to theevolvingnatureof thedrugthreataswemovedeeperintothetwenty-firstcentury.Drugtraffickerswillcontinuetoattempttosecureever-greaterprofitsbyexpandingtheircustomerbase,reducingoverhead,andmitigatingriskstotheirsupplychains.TheexponentialgrowthintheavailabilityanduseofsyntheticdrugsintheUnitedStates,especiallysyntheticopioidslikefentanylanditsanalogues,providesawindowintothelikelyfutureofdruguseandtrafficking.Drugtraffickingorganizationscanavoidthecostlyprocessofharvestingillicitcropsandproducingplant-baseddrugsbythemuchcheaperandfasterprocessofchemicalsynthesis.Potent synthetic drugs can be smuggled across our borders in small quantities that can be more easily concealedthanbulkierplant-baseddrugs.Theycanalsobepurchasedcheaplyonthedarkwebusingcryptocurrencies that provide anonymity, and shipped into theUnited States through internationalmailorasexpressconsignmentshipments.Thecombinationoflowproductioncost,theanonymityofthedarkwebandcryptocurrencies,anddrugswithhigherpotencythanplant-baseddrugs,createsafavorablerisk-rewardstructurethatdrugtraffickerswillembracetoanevengreaterdegreeintheyearsto come .

Alongwiththeemergenceofthegreateravailabilityandtraffickingofsyntheticdrugs,wemustalsoconfront an emerging crisis of cocaine availability and use in the United States . The increased cultiva-tionofcocaandproductionofcocaineinColombia,thesourceofmorethan90percentofthecocaineintheU.S.market,hasonceagainreachedrecordlevels.Moreover,thesuspensionofaerialeradicationprogramsinColombiaduringitspeaceprocess,from2015untiltoday,hasledtoevengreateryieldfromcocaplants,resultinginincreasedproductionandpuritylevels.CocaineuseintheUnitedStatesstartedrisingagainaftermanyyearsofdecline.From2016to2017,overdosedeathsinwhichcocainewastheprimarycontributingdrugincreased34percentaccordingtotheCDC,andtheNationalSurveyofDrugUseandHealth(NSDUH)showsthatin2017past-monthusersofcocaineaged12andaboveincreasedfrom1.9millionAmericansto2.1millionandnewinitiatestococaineuseincreasedto1million,averag-ingapproximately2,800perday.

GiventhecurrentdrugcrisisfacingAmerica,andthePresident’spriorities,thisStrategy adopts a strong bias toward action.ItfocusesonleveragingourunderstandingofthecomplexinterplaybetweentheavailabilityofdrugsintheU.S.marketandtheiruse,anticipatingchangesinthedrugenvironmentinboththepublichealthandlawenforcementdomains,andadaptingouractionstoseizetheinitiativetomakelastingprogressagainstthishistoricchallenge.Theglobaldrugtraffickingenterpriseisvast,dynamic,andadaptable,butitisnotwithoutvulnerabilities.ItisonlythroughaunifiedeffortinwhichtheFederalgovernmentworkswith,andinsupportof,creativeandresourcefulindividualsandorgani-zationsacrossthecountry,thatcanweaddressthiscomplexnationalsecurity,lawenforcement,andpublic health problem .

STRATEGIC OBJECTIVE AND ASSUMPTIONSThis Strategy is focused on achieving one overarching strategic objective:

Building a stronger, healthier, drug free society today and in the years to come by drastically reducing the number of Americans losing their lives to drug addic-tion in today’s crisis, and preparing now to dominate the drug environment of the


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future. This will be done by preventing initiates to drug use, providing treatment services leading to long-term recovery for those suffering from addiction, and aggressively reducing the availability of illicit drugs in America’s communities.

This Strategy consists of three interrelated elements designed to achieve the President’s goal of build-ingandfosteringastronger,healthier,anddrugfreesociety:prevention,treatmentandrecovery,andreducing the availability of drugs in America . The single and most important criterion of success is saving Americanlives,andachievingthatobjectiverequirestheFederalgovernmenttoworkwithpartnersatthestate,local,andtriballevels;thehealthcaresector;industry;foreignpartners;andeveryconcernedAmericancitizentoadvanceourNation’seffortstopromoteandmaintainhealthylifestyles,andhelpbuild and grow safe communities free from the scourge of drug use and addiction .

This Strategymakesseveralkeyassumptions:

• Deliberate,sustained,andwell-coordinatededucationandpreventioneffortswill,overtime,reduce the number of Americans who initiate illicit drug use .

• Betterprescribingpracticesandtheexpansionofalternativestoprescriptiondrugsthatholdahighpotentialforaddictionandabusewillhaveapositiveeffectonreducingthenumberofinitiates to illicit drug use .

• Increasing the availability of treatment services for substance use disorder will lead to a greater numberofAmericansachievingsustainedrecoveryandreducethesizeoftheillicitdrugmarketand demand in the United States .

• ReducingtheavailabilityofillicitdrugsintheUnitedStateswillenablepublichealtheffortstotakehold,increasingthepotentialforsuccessfulpreventionandtreatmentefforts.

• Aggressiveandversatiledrugtraffickingorganizationswillrespondtosustainedpressureplaceduponthembydisruption,dismantlement,interdictioneffortsandjudicial/prosecutorialefforts,andwilladapttheirproductionandtraffickingmethodstominimizeriskandmaximizeprofit.

STRATEGY IMPLEMENTATION The three fundamental elements that form the heart of this Strategy—prevention,treatmentandrecov-ery,andreducingavailability—arecomplementaryandmutuallysupporting.Reducingthesizeoftheillicit drug using population involves preventing initiates to illicit drug use through education and evi-dence-basedpreventionprograms.Providing treatment services leading to long-term recovery for thosesufferingfromsubstanceusedisorder,oftenusingmedication-assistedtreatment(MAT)combinedwiththerapy,movespeopleoutoftheactiveuserpopulationandonthepathtorecovery.Byreducingthenumberof individualswhouse illicitdrugs throughpreventionand treatment,wecandiminishthemarket forcespulling illicitdrugsacrossourbordersand intoourcommunities.Simultaneously,we must drastically reduce the availability of these drugs in the United States . Increased availability increases theopportunity for individuals to initiatedruguse,and thepath fromfirstuse tochronicusecanbebrutallyshort,particularlyforpotentandhighlyaddictivedrugslikeopioids.Byreducingavailabilitywenotonlylessenthenegativeancillaryeffectsofdrugtraffickingthatimpactthesafetyof


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ourcommunitiesandthewell-beingofourcitizens,wealsorelievethepressureonthepublichealthdomaininitspreventionandtreatmentefforts.Reducingthesizeoftheillicitdrug-usingpopulationthroughpreventionandtreatment,togetherwithreducingtheavailabilityofdrugsintheUnitedStatesthroughlawenforcementandcooperationwithinternationalpartners,arecomplementaryeffortsthatinformandsupportoneother,andwillsettheNationonthepathtobeingstrong,healthy,anddrug-free.

This StrategyisnotintendedtoenumerateeveryactivitytheFederalgovernmentandkeystakeholdersmustexecuteinordertoachievethePresident’sstrategicobjective.Rather,itarticulatesthePresident’sdrugcontrolprioritiesandsetsthestrategicdirectionfortheAdministrationtotakemeasurestopreventAmericans,especiallyourfuturegenerations,fromfallingintothecycleofdruguseandaddiction;toprovideAmericanswhosufferfromsubstanceusedisorderswithworldclasstreatmentandrecoveryservices;andtoprotectAmerica’scitizensfromthenegativeeffectsofdrugtraffickinganduse.Italsoprovides Federal drug control departments and agencies the strategic guidance they need for devel-opingtheirowndrugcontrolplansandstrategies,anditensuresprogrammingandresourcedecisionsabout Federal drug control budget dollars are allocated in a manner consistent with the Administration’s priorities .

PREVENTION Preventing drug use before it starts is a fundamental tenet of a comprehensive approach to drug control . Thescienceofpreventionhasevolvedandsignificantlyimproved,anddecadesofresearchshowthatpreventionworkswhenimplementedthroughevidence-basedprogramsfocusedonspecificaudiences.Early intervention through informational media campaigns and community support mechanisms can alter the trajectory of young people in a positive direction and increase protective factors while reduc-ing risk factors.Studiesshowthataddiction isadisease thatcanbepreventedandtreatedthroughsoundpublichealthinterventions.Evidence-basedpreventionismosteffectivewhenitiscarriedoutoverthelong-termwithrepeatedinterventionstoreinforceoriginalpreventiongoals.

Combining two ormore evidence-based elements in a comprehensive prevention program ismoreeffectivethanasingleactivityalone.Moreover,theseearlyinvestmentspaylargedividendsinsubstan-tiallyreducedtreatmentandcriminaljusticecosts,savingtaxpayerdollarswhilereducingthenumberofyoungpeoplewhoselivesaretragicallyaffectedbyearlysubstanceabuse.

AstheCommissionnoted,“substanceabusepreventionisaprocesswhichrequiresashiftinthebehav-ior,culture,andcommunitynorms.”TheCommissionemphasizedthethreecategoriesofpreventionintervention that target risk factors and increase protective measures: universal interventions thatattempt to reducespecifichealthproblemsacrossallpeople inaparticularpopulationby reducingavarietyofrisk factorsandpromotingabroadrangeofprotectivemeasures;selective interventionsdeliveredtoparticularcommunities,families,andchildrenwho,duetotheirexposuretocertainenvi-ronmental considerations, are at increased risk of substancemisuse; and appropriate interventionsdirectedtothosealready involved inariskybehaviorsuchassubstancemisuse,orarebeginningtodemonstrate problems but have not yet developed a substance use disorder .


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Implementing a Nationwide Media Campaign

Massmedia campaignsaremost effectivewhendevelopedwith coherent, credible, evidence-basedmessages grounded in behavioral science research . The Administration is already addressing the unmetneedofacompellinganduniversalinformationcampaigntoeducateourNationonthedrug-re-latedvulnerabilitiesofouryouthandotherat-riskpopulations.TheAdministrationimplementedtheRxAwarenesscampaignasafirststeptoaddressthisproblem,andaugmentedthatinitiativebylaunch-inganationalsubstanceabusepreventionmediacampaign,The Truth About Opioids.Thismajoreffortwill reach audiences not targeted by RxAwareness by addressing topics Thismajor effortwill reachaudiences not targeted by RxAwareness by addressing topics related to the speed at which chronic sub-stanceusecandevelop,thedrasticmeasuresthosesufferingfromsubstanceusedisorderwilltaketofeedtheiraddiction,andtheneedtoreducethestigmaassociatedwithaddictionandtreatmentforsubstance abuse .

Themediacampaignisprincipallyfocusedonopioidsthatarekillingsomanyofourcitizens.Preventionmessages targeting youth are being disseminated through social media and other popular platforms utilized by young people. As the campaignmoves forward, itsmessagingwill use data analytics todetermineappropriatemessagingbasedon targetpopulationandsubstance,andwillemploycom-municationandmarketingmethodssuchasmarket segmentation,demographicdataonusers,andmultiple formats and languages for individuals with disabilities and individuals with limited English proficiency. The campaignwill be augmentedby science-basedprimaryprevention acrossmultiplesectorsusingapproachesthateffectivelyengagestudents,parents,schools,healthcaresystems,faithcommunities,socialserviceorganizations,andothersectors,inthedevelopmentandimplementationofcommunityandschool-basedpreventioninitiatives.

Addressing Safe Prescribing Practices

There is a compelling need for additional research on, and the implementation of, evidence-basedguidelines for thedosagesanddurationofprescriptionopioid treatment for injuriesandpost-surgi-cal pain management . This is particularly important for patients with a history of substance abuse oratelevatedriskfordrugmisuse.Additionally,informationonviablealternativesforparticularsur-geriesandpain-relatedconditions,alongwithanexaminationofhealthcarecoverageforalternativetreatment,willadvanceeffortstoreduceoverallopioidprescribingintheUnitedStates.Governmentexperts,thehealthcaresector,theresearchcommunity,andstakeholderorganizationsallplaykeyrolesinaddressingtheseneedstobuildevidenceoneffectivetreatmentandperiodicallyupdatingprescriberguidelines.Moreover,clinicalguidelinesandbestpracticesshouldbestandardizedinprovidertrainingprograms and continuing medical education programs for those who prescribe and administer opioids suchassurgeons,emergencymedicineproviders,andemergencymedicaltechnicians.

In2016,CDCpublishedtheCDC Guideline for Prescribing Opioids for Chronic Pain for using opioids to treat chronic pain intended to improve communication between the primary care provider and the patient regardingtheriskandbenefitsof these treatmentsandto improvetheeffectivenessofpainmanagement treatment in general . The Guideline focus on three areas: determining when to initiate orcontinueopioids forchronicpain;opioidselection,dosage,duration, follow-up,anddiscontinua-


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tion;andassessingtheriskandharmsofopioiduse.TheAdministrationwillbuildontheCDCGuideline andsafeprescribingpracticesby:workingwithkeystakeholders todevelopmodel statutes, regula-tions,andpoliciesthatensureinformedpatientconsentpriortoanopioidprescriptionforchronicpain;coordinating the development of a national curriculum and standard of care for opioid prescribers that supplements the CDC’s Guideline and focuses on primary care physicians; and developing amodeltraining program to be disseminated to all levels of medical education on the screening for substance useandhealthstatustoidentifyat-riskpatients.Mentalillnessoftenoccurstogetherwithsubstanceusedisorders . Underpinning these initiatives is the awareness that patients with chronic pain must receive thebestmedicalcareavailabletoamelioratetheirsufferingandenablethemtoenjoythebestpossiblequalityoflife,whilesimultaneouslyreducingthelikelihoodthatpatientswillbecomeaddictedtothesetreatment regimens .

Expanding the Use of Prescription Drug Monitoring Programs

A Prescription Drug Monitoring Program (PDMP) is a proven means to increase accountability in opioid prescribing practices and prevent patients from receiving opioids and other controlled medications that mayhaveadverseinteractionswithopioidsfrommultipleproviders.InsomestateswherePDMPcheck-ingisoptional,providersreportdifficultyusingtheirPDMPduetolackof integrationwithelectronichealthrecords(EHR)whichinterruptsworkflowandcanresultindecreaseduse.Providersalsocitelackofinterstatedata-sharingandconcernsaboutpatientconfidentialityasreasonsnottousethePDMP.Inthosecaseswherestates’integrationservicesaremadeavailable,theservicecanbecostly.Currently,atleasttwoPDMPdatasharinghubsexistandmanystatessharedata.However,twodistinctbutrelatedissuesmakedatasharingchallenging.First,apatchworkofdifferentstatelawsgoverningdatasharinghasthusfarpreventedthedevelopmentandexecutionofanationwidePDMPcapability.Theproblemofbeing unable to share data includes Federal healthcare providers attempting to access PDMP data who encountersimilardifficultiesdealingwithvariousstatelaws.Second,eveninthosecaseswheretherearenotlegalimpedimentstosharingdata,interoperabilitychallengestosharingthesedataexistresult-ingfromthetwodifferentdatasharingplatforms. Improving interoperabilitywithintheclinicaldataworkflow,andmakingPDMPdatafromneighboringstatesmoreaccessible,canimprovethelikelihoodthatproviderswillconsultthePDMPs.Inthecomingyears,wewillbuildonexistingresearchregardingbarrierstonation-widePDMPimplementation,andemployvariousstrategiestosupportPDMPintegra-tionanddatasharing,includingeffortsthataddressthelegalandinteroperabilitychallenges,aswellasmeasurestoincentivizestatestomakecheckingofPDMPsmandatoryforallproviders.

Strengthening the Capacity of State, Local, and Tribal Communities to Identify and Prevent Substance Abuse

Family,friends,andlocalcommunitiesarethefirstlineofdefenseinpreventingsubstanceabuse,andpositiveadult involvement inchildren’s lives reduces the likelihoodofdruguse.As theCommissionconcludes,“Withtoolsforteachersandparentstoenhanceyouthknowledgeofthedangersofdruguse,earlyinterventionstrategiescanbeimplementedforchildrenwithenvironmentalandindividualriskfactors.”Parentsandprimarycaregiversmustunderstandthattheycanmakethemostsignificantdif-ference in the child’s attitudes and values regarding the use of drugs . Religious organizations are also an


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integralpartofthecommunityresponsetosubstanceabuse,andclergyandfaith-basedorganizationshavebeensuccessfulatkeepingyouthawayfromdrugs,aswellasprovidingsuccessfulsupportwhentheyhaveturnedtodruguse.Thisstrategywillsupportandreinforcethepositiveresourcesthatfamily,friends,andthecommunitycanbringtobearonthiscrisisatboththepreventionaswellasthetreat-mentandrecoverylevels.Parentsarehistoricallyunder-representedinpreventionprogramsdespitethefactthatparent-basedprogramsplayavitalroleindelayingtheonsetanduseofalcoholandotherdrugs . This is true for school outreach programs as well .

Enhancing Research and the Development of Evidence-Based Prevention Programs

TheNationalAcademiesofSciences,Engineering,andMedicineoutlinethreecategoriesofpreventionintervention:universal,selective,andindicated.Theseinterventionshavebeenstudiedbasedontar-getedpopulationsandriskfactors,and,astheCommissionobserves,“Whenevidence-basedprogramsareselectedforspecificpopulationsandimplementedwithfidelity,theycanbeeffective.Preventionprogramsneedtobetestedforscalability,fidelity,andsustainabilityafterresearchchampionsarenolongerpresenttodrivetheprograms.”

Advancingourcapabilitytopreventdrugusebeforeitstartswillrequire,amongotherthings,themorewidespreadadoptionanduseofevidence-basedmethodstoidentifyatriskindividualsusingstrategiesthatallowforscreening,briefintervention,andreferraltotreatment.Thisisespeciallyimportantforadolescentsandyoungadultsfrommiddleschoolthroughcollege.Inaddition,wemustincreaseoppor-tunities to educate and inform child welfare professionals and healthcare providers about the early signsofsubstanceabuseandidentifyresourcestosupportpregnantandparentingwomen,childrenofparentswithsubstanceabusedisordersoraddiction,andchildrenbornwithneonatalabstinencesyn-drome(NAS).Whereevidenceaboutpreventioninterventionsforapopulationorsubstanceislacking,wemustworktobuildevidenceoneffectiveapproaches.

Continuing to Strengthen ONDCP’s Drug Free Communities (DFC) Program

ONDCP’sDrug-FreeCommunities(DFC)SupportProgram,createdbytheDrug-FreeCommunitiesActof1997,undergirdstheAdministration’sfocusonpreventingandreducingyouthsubstanceuseatthecommunity level . The DFC Program provides grants to community coalitions to strengthen the infra-structure among local partners to create and sustain a reduction in local youth substance use . Since theDFCProgram’s inception, findings fromevaluations of theDFCprogram found thatDFC-fundedcommunitycoalitionshavereducedyouthsubstanceuse.AccordingtotheDFC’s2018NationalCross-SiteEvaluationReport,onaverageDFC-fundedcommunityparticipantscutalcoholuseby19percentand prescription drug abuse by 18 percent among high school students in their communities . The DFC Programwillconductsemiannualtrainingtoensurecoalitionshavetheresourcesandskillsettheyneedto strengthen the prevention infrastructure within their communities and among their local partners toeffectivelypreventandreduceyouthalcohol,tobacco,marijuanaand(illicit)prescriptiondruguse.ThistrainingwillprovideDFC-fundedcommunitycoalitionswiththeresourcesandtoolstheyneedtodevelop local and sustainable prevention initiatives .


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Expanding Drug Take-Back Across the Country

TheDrugEnforcementAdministration’s(DEA’s)twice-yearlyTake-BackDayservesasanopportunityforcitizens to dispose of unused and unneeded prescription drugs and a chance to support community drug preventionefforts.Althoughyear-roundtake-backprogramsareexpanding, includingsomebyretaildrugstores,theDEAprogramremainsanimportantelementofpublicawarenessaimedatreducingtheamountofunusedmedicationsavailableforpotentialdiversionandmisuse.Expandingthenumberofregisteredcollectors,includinghospitalsandlawenforcementcenters,wouldallowstatesandmunici-palitiestoreducetheirrelianceontheFederalgovernmentforcollection,disposal,andtransportation.TheDEAandotherFederalpartnersshouldworktoengagestate,local,andtribalgovernmentstoraiseawarenessoftheimportanceofdisposingunusedmedications,expandthenumberofpermanentdis-posalsitesacrossthecountry,andincreasetheopportunityfortheircitizenstodososafelyandeasily.

Conclusion

Decadesofresearchanddatademonstrateaddictionisapreventabledisease.Today,wefaceacom-pellingneedtoinvestinacomprehensiveapproachtopreventingdrugabuse,onewhichemphasizesconcreteandlastingpolicychangeattheFederal,state,tribal,andcommunitylevels.TheAdministrationwillfocusitseffortsandworkacrossthegovernmenttoempowercommunities,youth,parents,care-givers,andfamiliestocometogethertocreatesustainableprograms,policies,andpracticestocombatdrugabuse.Weknowthateverydollarweinvestinresearch-basedsubstanceabusepreventionpro-grams has the potential to save much more in treatment and criminal justice system costs and enhance the overall quality of life for communities and their citizens .

TREATMENT AND RECOVERYAddictionisachronicmedicalconditionthataffectsthebrainbycausingdistinctcognitive,behavioral,and physiological changes . There is a need to improve the availability of treatment while concurrently enhancing the quality of that treatment. Research shows that treatment is most effective when itaddresses addiction as a chronic condition requiring continuing services and support structures over an extendedperiodoftime.Thiscanbeaccomplishedwithongoingoutpatientservicesprovidedthroughopioidtreatment,ormoreintensiveinitialservicessuchasdetoxificationandresidentialtreatment,fol-lowed by continued care and recovery support in the community . Every individual needs an assessment and individualized treatment plan to address their needs as they relate to opioid and other substances use disorders .

Unfortunately,mostpeoplewhoneedtreatmentdonotseekit.AccordingtotheNSDUH, in2017anestimated20.7millionAmericansaged12orolderneededtreatmentforasubstanceusedisorder,butonly4millionreceivedanykindoftreatmentandonly2.5millionreceivedthattreatmentataspecialtyfacility—adisparityknownasthe“treatmentgap.”Insomecasestreatmentcapacityissimplynotavail-able,andinotherspeopledonotfullyacknowledgetheirneedfortreatment.Therefore,inadditiontoexpandingtreatmentcapacity,thereisaneedtoengagewiththosepeoplewhoneedtreatmentbut,forwhateverreason,arenotseekingit.AsaNation,wemustencouragepeoplewhoneedtreatmenttoseekit,creategreateraccesstotreatment,andensurethereisadequatecapacitytoaccommodatetheneed.


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The Administration prioritizes several distinct initiatives to achieve these goals. First, a proactiveresponse to overdoses to ensure that the patient can enter into a treatment program designed to meet hisorherindividualneeds.Second,consistentlyusingevidence-basedapproachestotreatmentandmakingMedication-Assisted Treatment (MAT) a standard of care for opioid addiction. This includesincreasingthenumberofphysiciansprovidinghigh-quality,evidence-basedtreatmentforopioidusedisorderswithMAT,andincreasingtheavailabilityofMATforincarceratedindividuals.Expandingtreat-ment infrastructure will enable us to increase the initial treatment for the vast majority of people who requiretreatmentbutareunableorunwillingtoobtainit.Third,examiningwaystoexpandandencour-agingtheexpansionoftreatmentinsurancewhilereducingreimbursementbarrierstoencouragethoseon themarginsofaccepting treatment tomake thepositivedecision tobegina treatment regimen.Finally, theexpandeduseofDrugCourtsanddiversionprogramswill fosterentrance intotreatmentprogramsandawayfromthecycleofdestructiveandself-defeatingbehaviorsthatisthehallmarkofthediseaseofaddiction.Addressingtheseandotherchallengeswillrequireacomprehensivemulti-yearstrategytoeducate thepublicandpolicymakers, reducestigmaandmisunderstandingofaddiction,better integrate substance abuse screening and treatment into mainstream health care, build andstabilize theaddiction treatmentworkforce, increaseaccess to treatment, and fostermoreeffectiveapproaches to care for substance use disorders .

Improving the Response to Overdose

Naloxoneisanopioidantagonistmedicationthatcanrapidlyreverseanopioidoverdose.However,therearevaryinglevelsofaccesstonaloxonethroughoutthecountry.Moststateshaveprotocolstoexpandaccesstonaloxone,suchasbyallowingdispensingofnaloxoneunderastandingphysician’sorder.TheFoodandDrugAdministration isworkingto facilitatethedevelopmentofnonprescriptionnaloxone,bycreationandtestingofappropriateconsumer-friendlyDrugFactslabeling.TheCommissionrecom-mendedthatall lawenforcementpersonnel intheUnitedStatesbeequippedwithnaloxone,modellegislationbeprovidedtostatestoallownaloxonedispensingviastandingorders,andGoodSamaritanlawsbeenactedtoempowerthepublictoprovidehelp.However,evensimplerescuebreathingcankeepapersonaliveuntilhelparrives,anddeviceslikepocketmaskscanprotectarescuerwhilesavingsomeone’s lifeusingrescuebreathinguntilnaloxonecanbeadministered.Wewillbeginto increasepublic awareness of the importance of rescue breathing in the event of an opioid overdose in those caseswhennaloxoneisnotavailableasacriticallive-savingmeasure.Moreover,wemustdomoretoensure that the reversal of a potentially fatal overdose is not just another event in a long and protracted strugglewithanaddictiontodangerousdrugs,butratherthefirstimportantsteptowardeffectivetreat-ment and the path to sustained recovery .

Enhancing Evidence-Based Addiction Treatment

Wemustensurethathealthcareprovidersscreenforsubstanceusedisordersandknowhowtoappropri-ately counsel or refer patients they encounter with such a disorder . Treatment models that demonstrate thebestoutcomesincorporatebehavioral,psychosocial,andpharmacologicalelements,andaretai-loredtothespecificcircumstanceoftheindividual.Theabilitytoprovideapathwaytoevidence-basedtreatmentforthosewhoneeditdependsonskilledandwell-trainedproviderswhoareappropriately


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credentialed and licensed . This must include a complete evaluation for opioid use disorder and other substanceusedisordersbyaqualifiedmedicalprofessional;accesstoMATasadeliberatechoicemadebyaqualifiedprofessionalinconsultationwiththepatient;simultaneousaccesstorelevantpsychoso-cialtreatmentssuchastherapyandrelapseprevention;thetreatmentofco-occurringmentaldisordersthatmany patientswith substance use disorder suffer from such as Post-Traumatic Stress Disorder(PTSD),depression,andanxietydisorders;andthetreatmentofco-occurringmedicalconditionssuchascardiac,infectious,anddermatologicissuesoftenassociatedwithprolongeddruguse.Additionally,identifying and treating pediatric patients with early substance use disorder can prevent their transition tolongerandmoreseveredruguse,potentiallysavingtheirlives.Therefore,wemustscaleupadoles-cent addiction screening and treatment in pediatrician and family medicine settings .

Eliminating Barriers to Treatment Availability

Individuals with substance use disorders, including opioid addiction, should have access to evi-dence-based treatment. Fewer than half of the privately funded substance use disorder treatmentfacilitiesofferMAT,andonlyathirdofpatientswithopioidusedisordershaveaccesstothosetreat-ments . This is especially true in rural areas where the compelling need for access to treatment far exceedsitsavailability.TheAdministrationwillworkacrosstheFederalgovernmenttoremovebarrierstosubstanceusedisordertreatments,includingthosethatlimitaccesstoanyformsofFDA-approvedMAT,counseling,certaininpatient/residentialtreatment,andothertreatmentmodalities.Allprimarycare providers employed or funded by the Federal government should screen for alcohol and drug use disordersand,ifthepatientrequestsit,providesubstanceusetreatmentorareferralforsuchtreatmentwithin24-48hours.

Increasing the Size of the Addiction Service Workforce, and Treatment and Recovery Infrastructure

Critical shortages in trained and professional addiction service providers is one of the many factors contributingtothetreatmentgap.Theaddictionserviceworkforcecurrentlyemploysvaryingstylesofservicedelivery.Promotingtraining,professionalincentivesforenteringtheworkforce,andestablishingagreaterlevelofstandardizationforcarewillequiptheaddictionserviceworkforcetoprovidesupportservicesacrossallsettings,frompreventionthroughtreatmentandrecovery.Opioidandotheraddic-tionsrequireintensiveinterventionsthroughateam-basedapproachthatincludesrecoverycoachesandmedicalprofessionalsinhospitalsandprimarycareoffices,andincludesthefullrangeofhealthprofessionalssuchasdrugcounselors,behavioralhealthtechnicians,healtheducators,physicianassis-tants,andcommunityhealthworkers.Growingouraddictionserviceworkforcerequiresapprenticeshipopportunities for a range of addiction treatment professions . This will enable the more rapid increase ofavailablecareprofessionalsthanrelianceonstandardtrainingregimensalone,andenablethemtoprovideaddictiontreatmentservicesforscreening,intervention,andrecoverysupportacrossthecon-tinuumofcare,toenhanceteamtreatmentforindividualswithsubstanceusedisorders.Furthermore,increasedstandardizationofcareanditsassociatedtrainingwillhelpprofessionalizethefieldthroughcredentialing,andprovidementoringopportunitiesforthosepatientswhosuccessfullycompletetheirtreatment and want to assist in the recovery of others .


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Leveraging Drug Courts and Diversion Programs

Providing individualsarrestedfornon-violentdrug-relatedoffensestheopportunitytoparticipate ina Drug Court program or outpatient treatment while under supervision is increasingly becoming the practice throughout the country . From 2009 to 2014 the number of Drug Courts in the United States increasedby24percent,reaching3,057,andbyJune2015thenumberofDrugCourtsreached3,142pertheDepartmentofJustice.Recently,somepioneeringpolicedepartmentsbegandivertingindivid-ualsaddictedtodrugsdirectlytotreatmentinlieuofarrest.Manycommunitiesareadoptingpre-arrestdiversionprogramsandotherlawenforcementdiversionanddeflectionmodels,inwhichthosestrug-glingwithaddictioncanwalkintoaparticipatingpolicestation24hoursadayforpolice-assistedrapidtreatment entry . The Administration supports these innovative programs and will scale up support for State,Tribal,and localdrugcourts inorder toprovideoffenders strugglingwithaddictionaccess toevidence-basedtreatmentasanalternativetoorinconjunctionwithincarceration,orasaconditionofsupervised release .

Increasing Employment Opportunities for Those in Recovery

Americans in stable recovery from addiction deserve fair consideration for any job for which they are qualified.Today,millionsofAmericans fromallwalksof lifeare inrecovery.Manyof these individu-als have pastmisdemeanor or felony drug-related criminal convictions that can impede or preventthemfromsecuringemploymentforwhichtheyarefullyqualified,evenafterhavingpaidtheirdebttosociety and having emerged from the shadow of addiction . In addition to the obstacles created by a past criminalconviction,those inrecoverycanface long-lastingbarrierstoemploymentdueto lawsthatprohibit the hiring of individuals with a past drug conviction in certain settings . These legal restrictions cancreateadditionaldifficulties forthoseseekingto fullyrejointhecommunityandsustaina life inrecovery.TheAdministrationwillworkacrosstheFederalgovernmentandtheprivatesectortoincreasehiring opportunities for those in recovery . This will include providing the best information to employers ontheoverallbenefitsofbringingtheseindividualsbackintoourworkforce,developingbestpracticesto increasetheiremploymentprospects,and increasingtheavailabilityofsafehousingthatenablesthoseinrecoverytoholdafull-timejobandtaketheirplaceintheAmericanworkforce.

Expanding Access to Peer Recovery Support Services

Peer recovery support services provide the bridge between formal systems and services and communi-ty-basedsupportnetworks.WhenprovidedthroughaRecoveryCommunityOrganization(RCO),theseservicescanbeofferedpriorto,during,after,andsometimesinlieuoftreatment.TheseRCOsandpeerrecoverysupportworkersprovideurgentlyneededservices.Thecountryneedstoquicklyincreasethenumberofpeerrecoverysupportworkers,includingthosewhoareinMATandrecoveryprograms.Thisworkforceservesadual function; ithelpsdevelopthenationalpeerrecoverysupportservices infra-structure,anditprovidesemploymentopportunitiesforpeopleinrecoverywhoarewell-suitedtomakethiskindofcontribution.Furthermore,whilethenumberofCollegiateRecoveryPrograms(CRPs)onthecampusesof largepublicuniversities,privatehighereducation institutions,andcommunitycollegeshasincreasedrapidlyoverthepastdecade,theyarestilltheexceptionratherthantherule.Everyhigher


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educationcampus inAmericacouldpotentiallybenefit fromsometypeofCRP.Adolescent recoverysupportservicesareespeciallyscarceandoftremendousvaluetoyouth,giventheimportanceofpeernetworkstotheirsocialdevelopment.Recoveryhighschoolsandalternativepeergroupmodelsholdgreatpromiseformeetingtheneedsofyouth,eitherinactiverecoveryorinencouragingyouthtoseekit,andwemustencouragetheirincreaseduseacrosstheNation.

Expanding the Scientific Understanding of Peer Recovery Support Services

Whilemuchisknownabouttheprocessofaddictionandaboutinterventionstohelpaddressit,lessis known about the recovery process and its various trajectories, components, and stages. A betterunderstanding of this process will help in the design and targeting of both clinical and recovery support service interventions that are stage-and trajectory-specific. More research is needed to design andtargetclinicalandrecoverysupportinterventionsandstrategiesforlong-termrecovery.However,whilethepositiveanecdotalevidenceofthenear-termeffectivenessofrecoverysupportservicemodels isstrong, rigorous, empirical research is required on their long-term effectiveness, the characteristicsofthosewhobenefitmostfromthem,andpeerrecoverysupportservices’rolewithinandimpactonbroader systems and communities .

Reducing Stigma and Making Recovery Possible

AmericansinrecoveryareavitalpartofeverycommunityintheUnitedStates,andtheyseekthesamethingsotherAmericanswantandneed—agoodjob,asafeplacetolive,thefellowshipofafaithcommu-nity,andthecompanionshipofneighborsandfriends.ThemillionsofAmericansinlong-termrecoveryfromaddictiondemonstratethatrecoveryispossible,andtheysharethemessagethatwhileaddictionisachronicdisease,treatingitispossible.Indoingso,theyhelpliftthestigma,misunderstanding,andshamethatpreventtoomanyAmericans fromseekinghelp forsubstanceusedisorders.Bypromot-ing,supporting,andcelebratingrecovery,wecanreducestigmaandofferhopeandencouragementtothosestrugglingwiththisincrediblydifficultdisease.Manypeopleinrecoveryhavealsodedicatedtheirlivestohelpingothersaffectedbysubstanceabuseasrecoverycoachesandcounselors,acriticallyimportantandgrowingcomponentoftheaddictionserviceworkforce.TheAdministrationwillcontinueinitseffortstobettereducatethepublic,healthcareprofessionals,andpolicymakersonthescienceofaddictionandthepromiseofrecovery,andhowstigmaandmisunderstandingcanundermineeffortstoreduce drug use and its consequences .

Conclusion

Untreatedsubstanceabusecanresultinviolence,crime,andriskybehaviorthatjeopardizesthehealthandsafetyofindividuals,families,andcommunities.Themomentapersonisreadyandwillingtoentertreatmentcanbefleetingandinfrequent.Inadditiontomatchingtheindividualwiththemostappro-priatecaremodel,effortstoexpandtreatmentmustincludethecapabilitytoactquicklyonthedemandfor treatmentwheneverandwherever theopportunity ispresented.Anytimesomeoneseekinghelpforaddictioncallsatreatmentcenter,doctor’soffice,hospital,healthclinic,orothermedicalfacility,


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that person should immediately be referred to some level of assistance . Even if a treatment slot is not immediatelyavailable,recoverycoaches,peercounselinggroups,andfamilieswhohavelearnedaboutaddiction can provide help until the right treatment opportunity becomes available . It is in everyone’s best interest—affected individuals, their families, and the Nation—for high-quality, evidence-baseddrug treatment to become more easily accessible . The current opioid crisis highlights the urgent need to encouragethosewhoneedtreatmenttoseekit,rapidlyincreasetreatmentadmissionsforopioidaddic-tion, improve treatment retention,and increase thenumberof individualswhosuccessfullyachievesustainedrecovery.Itisalsoessentialtoeliminatethestigma,misunderstanding,andlegalandregu-latory barriers that delay or prevent treatment access and impede recovery . In addition to saving lives andhelpingpeopleinrecoveryachievetheirfullpotential,thesechangeswillhelpensurethatthesig-nificantpublicinvestmentintreatmentpaysoffintermsoflong-termrecovery.

REDUCING THE AVAILABILITY OF ILLICIT DRUGS IN THE UNITED STATES

Almost all of the illicit drugs causing American deaths are produced outside the United States and traffickedacrosstheNation’sbordersand,increasingly,throughtheinternationalmailandexpresscon-signmentcarriers.LargeandestablishedDrugTraffickingOrganizations(DTOs)andforeignproducersshippingdrugsintotheUnitedStatesthreatenthehealthandsafetyofourcommunitiesbyexposingourcitizenstosubstancessuchasfentanyl,heroin,cocaine,andmethamphetamine,whichkilltensofthousands of Americans each year . The increased use of illicit drugs burdens the U .S . health care system andleadstolostproductivityandcivilengagement.Moreover,drugtraffickingsustainsavastdomesticand international criminalenterprise thatenablescorruption,underminesgovernance,hasadesta-bilizingeffectonourpartnernations,andfundsarangeofillicitactivities.Lawenforcementagenciesatall levels—Federal,state, local,andtribal—haveachievedconsiderablesuccess incombatingdrugtraffickinganduse,yettraffickerscontinuetorefinetheirmethodsandadoptnewtechniquesfordeliv-eringpotentillicitdrugstoourcommunities.Respondingtotheaggressivetraffickinganddistributiontechniques of DTOs is an urgent national security and law enforcement priority .

The non-medical use of prescription drugs presents another dimension of the availability problem.Manyactivedrugusersreportobtainingprescriptiondrugsfromfriends,familymembers,andinsomecases, healthcareproviders. Theoverprescribingofprescriptiondrugs, thediversionofprescriptiondrugsfornon-medicaluse,andthelackofaccountabilityoroversightinprescribingpracticesincreasetheavailabilityofprescriptiondrugsinAmerica’shomesandworkplaces,makingitfartooeasyforthemtofallintothewronghands.Moreover,drugdealersexploitthedemandforprescriptionmedicinesandtrafficincounterfeitpillscontainingheroin,fentanyl,oroneofitsanalogues.Thesedrugsaredifficulttodistinguishfromlegitimateprescriptionmedicines,andbecausetheyaremostoftenmilledandpressedinvariableformulationsinclandestinelocations,increasethechanceforaccidentaloverdose.


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Disrupting, Dismantling, and Defeating Drug Traffickers and Their Supply Chains

WhileDTOsoftenareinvolvedinpoly-drugtraffickingandothercriminalactivity,theunprecedentedriseindeathsfromtheopioidcrisisdemandsthatweprioritizeU.S.governmenteffortsontheindivid-uals and groups involved in the smuggling and sale of the most deadly drugs such as synthetic opioids and heroin . As these organizations continue to modify their techniques and operations in an attempt to reduceriskandmaximizeprofit,wemustanticipateandthenrespondtoemergingchangesinthedrugtraffickingenvironment,identifyandexploitvulnerabilitiesintheillicitdrugsupplychain,andseizetheinitiativefromdrugtraffickersinordertodisrupttheiractivitiesanddismantletheinfrastructuretheyusetosustaintheirillicitenterprise.Alongwithaggressiveactionstopreventthefurtherexpansionofthesecriminalenterprisesinourcountry,wemustalsoworkwithforeignpartnerstoattackcriminalnetworks,principallythoseintheWesternHemisphere,whosedrugtraffickingandassociatedcriminal-itydirectlyimpactmigrationandbordersecurityissuesaffectingtheUnitedStates.

Working with International Partners

TheU.S.Governmentwillfocusitsdiplomaticeffortstoencouragepartnernationstoproduceresultsthat match the growing threat from illicit drugs . Consistent with the National Security Strategy,wewillprioritizeassistancewithpartnerswhoarealignedwithU.S.interests,areshowingresults,andbuildingthe capacity to address these threats independent of U .S . assistance programs . This will require part-ners’ renewed commitment to disrupt the illicit supply chain through the interdiction and seizure of the illicitdrugsupply,illicitfunds,andweapons;eradicatepoppyandcocaplants;findanddismantlethelabsusedforallillicitdrugprocessing;developandsustainrobustlawenforcementandjusticesystems;maintaintheruleoflawandferretoutcorruption;andarrestandprosecutedrugtraffickersoperatingwithintheirownlandborders,territorialwaters,andairspace.Theseeffortsarenotonlyimportantintheirownrightbutwillcomplement,andbe informedby,astrongdomesticpublichealthresponsetothecrisisaimedatreducingtheuseofthesedrugs intheUnitedStates.WewillcontinuetoworkbilaterallywiththeprimarydrugproducingandtraffickingcountriesmostaffectingtheUnitedStates,emphasizing our shared responsibility for today’s drug problems and the strong desire for tangible prog-ress in the years to come . Regional relationships will be an important part of our international approach goingforward,allowingustoshareinformationandharmonizeourdrugpoliciesinthefaceofacon-stantlychangingthreat.Moreover,wewilltakefulladvantageofthestrongmultilateralframeworkthatexiststoaddresstheglobaldrugproblem,particularlyintermsofsupportingthethreeinternationaldrugcontrolconventionsandprovidingleadershipintheprocessesforinternationallyscheduling,con-trolling,andmonitoringillicitdrugsandtheirprecursorchemicals.

Combating Illicit Internet Drug Sales

Overthepasttwoyears,illicitdrugsalesonboththeclearandthedarkwebhavefurtherexpandedtheillicitdrugmarket,allowingindividualstopurchasedangerousdrugsdirectlyfromtheirmanufacturersinsteadofthroughestablishedtraffickingorganizations,andhavethemshippeddirectlytotheirhomes.Wemustdisrupttheabilityofdrugtraffickerstoexploittheanonymity,distance,andfinancialtrans-


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action reliability provided through internet sales by degrading the implicit trust between buyer and sellerrequiredforilliciton-linetransactions.Wemustuseexistingauthoritiestotheirmaximumeffecttosuccessfullytargetdrugtraffickersandtheirenablersbyemployingbothpassiveandactivemeasurestodisruptandexploitillicitdrugrelatedactivitiesoperatingonbothclearanddarkwebs.Contestingdrugmarketplacesinthecyberdomainanddisruptingtheuseofcryptocurrenciesforillicitdrugsaleswillrequireacoordinatedandwell-resourcedframeworkofrelationships, lawsandregulations,pro-cedures,andcapabilities.Thiswillallowustoidentifyandtargetthenetworkofactorsinvolved,andprosecutethosewhousetheopenordarkwebstomarket,sell,andpurchaseillicitdrugs.Developingadrugcyberdefensecapability,andexercisingittoachievesustainedeffortagainsttheinternetdrugmarket,willerodethisimplicittrustanddisruptillicitoperationsontheclearanddarkwebsovertime.

Focusing Federal Government Effort Against Illicit Drug Delivery Through the Mail and Express Consignment Networks

Wemust complement our efforts against internet drug sales with a sustained effort to disrupt theflowof illicitdrugs shipped through the internationalmail andexpress consignmentenvironments.Thisrequiresdevelopingthepolicyandregulations,internationalrelationships,facilityinfrastructureupgrades, and technology required to aggressively target, detect, and intercept illicit drugs trans-portedthroughtheinternationalmailandexpressconsignmentenvironmentsbothinternationallyanddomestically.Wemustworkwithour internationalpartners todevelop theability to shareAdvanceElectronicDataforallinternationalshipments,inaccordancewiththePresident’s Opioid Initiative,andcontinuouslyrefinetargetingalgorithmstoidentifyandinterdictinternationalshipmentsbeforetheydepart the source country and at U .S . Ports of Entry . We must help critical partner countries develop theabilitytodetectandinterceptillicitdrugsintheirdomesticmailandexpressconsignmentsystemsbefore those drugs depart for the United States and enter the U .S . mail or commercial carrier system . Finally,wemustdevelopnextgenerationtechnologyandscreeningcapabilitiestoincreaseourabilitytodetectillicitdrugsoncetheyenterthemailandexpressconsignmentsystemswithinthecountry,andimprove testing capability to determine the precise type and source of illicit drugs seized . This invest-mentinscience,technology,resources,andinternationalrelationshipsisnecessarytodeterminethetype, source region,production location,and route traveled forall illicitdrugs seizedby theUnitedStates and its international partners .

Interdicting the Flow of Drugs Across the Physical Borders and into the United States

Alongwiththenewchallengeofdrugtraffickingviainternetsalesandmailandexpressconsignmentdelivery, drugs continue to flow across our land borders and through themaritime and air routes.Stoppingtheseflowsmustremainpartofourcomprehensiveinterdictionefforts.Thehistoricallyhighlevels of cocaine production in Colombia, along with heroin andmethamphetamine production inMexico,combinedwiththevastnumberofroutesandconveyancesintotheUnitedStates,makethechallengeofcombatingdrugtraffickingacrossourphysicalbordersnolessdauntingthanithasbeenforthepastseveraldecades.FederalagenciesshouldexpandeffortsinthedetectionandmonitoringoftheairandmaritimeapproachestotheUnitedStates;thedetectionofillicitdrugsandprecursorchem-


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icalsbeingshipped incommercial containers;and interdictionofplant-baseddrugs suchasheroin,cocaine,andmarijuana,aswellassyntheticdrugsandtheirprecursorchemicals,alongtheNation’slandborders.Moreover,thisincreasedeffortmustbecomplementedbyincreasedeffortandcooper-ationfromforeignpartnerswhocancontributevitalinformationontraffickingpatternsandassetstoseize drugs bound for the United States .

Disrupting and Dismantling the Illicit Drug Production Infrastructure

TheUnitedStatesandMexicohaveexpandedcooperationtoaddressthecommonthreatofillicitopioids,andbothgovernmentsagreethatreducingthesupplyofheroin,methamphetamine,andfentanylisasharedresponsibility.Mexicoisincreasingitseffortstoeradicatepoppyfieldsmoreeffectively,destroyclandestinelaboratories,andinterdictheroinandotherdrugsbeforetheyreachtheU.S.border.TheU.S.GovernmentprovidestrainingtoMexicanlawenforcementofficers,analysts,chemists,andmilitarypersonneltoidentifyandsafelydismantleclandestinedruglaboratoriesthatproduceheroin,metham-phetamine,andfentanyl,andhowtoaddressthedangerssyntheticdrugspresenttolawenforcement.

ExpandingcocacultivationandcocaineproductioninColombiaandthebroaderAndeanregionmustcontinue to be addressed in a comprehensive manner . Key elements of cooperation with proven part-nerssuchasColombiaandPeruincludeincreasingallformsoferadication,alternativedevelopmentandeconomicopportunities,interdiction,investigationandprosecution,judicialsupport,andpublichealthcooperation,allofwhichmustbelong-termandsustainable.Sincecocafieldsdifferintheirlevelofproductivity,thisapproachwillbemostsuccessfulifcollectivelyfocusedinareasofhigh-yieldcocacultivation.Unfortunately,theseareasgenerallyhavelimitedgovernmentservicesandlingeringsecu-rityconcerns,andwillrequireconcertedeffortoverseveralyearstokeeppartnernationsfocusedontheissue and turn the rising tide of cocaine production .

WithintheUnitedStatesmarijuanacultivationonpubliclands,andwithinNationalForestSystemlandsinparticular,isasignificantissue.Cultivationactivitiesnotonlysustaintheillicitmarijuanatradebutalsoproduce largevolumesofhazardousmaterials thatposeasignificantrisktothepublicandtheenvironment.Wildlife,soil,andvegetationareoftencontaminatedbythevarioushazardoussubstancesinvolvedinthecultivationprocess.Personnelconductingenforcement,cleanup,andregulatoryactivi-ties,aswellasthepublic,areatconsiderablehealthriskfromexposuretothesechemicals.ContinuedfirmactionisrequiredagainsttheexploitationoftheNation’spubliclandsthroughincreaseddetection,disruption,reclamation,andprosecutions.

Themajority of illicit synthetic drugs available in theUnited States aremanufactured abroad.Newillicit synthetic drugs and the precursor chemicals used to make them originate predominantly inChina, although most of the methamphetamine available in the United States is manufactured inMexico.IncreasedcollaborationwithMexico,China,andotherpartnersonshareddrugprioritiescanhelpdisruptdrugtraffickingnetworks,alongwiththecorruptorcompromisedsystemsthatsupportthem,andreducetheavailabilityofdangeroussyntheticdrugsintheUnitedStates.TheUnitedStateswillcontinuebilateralexchangeswithChina,Mexico,Colombia,andothersourceandtransitcountriestoreduceproductionandtraffickingofsyntheticdrugsdestinedformarketsintheUnitedStatesandsupport collaboration with international partners impacted by drugs from the very same sources .


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Leveraging the Full Capabilities of Multi-Jurisdictional Task Force Programs

TheHighIntensityDrugTraffickingAreas(HIDTA)Programprovidesassistancetolawenforcementagen-ciesoperatinginareasdeterminedtobecriticaldrug-traffickingregionsoftheUnitedStates.HIDTAsprovideanumbrellatocoordinateFederal,state,local,andtribaldruglawenforcementagencies’inves-tigations,andactasneutralcenterstomanage,de-conflict,analyze,provideintelligence,andexecutedrugenforcementactivitiesintheirrespectiveregions.WiththerecentinclusionofAlaska,thefirstnewHIDTAin17years,the29regionalHIDTAsnowincludedesignatedareasinall50states,PuertoRico,theU.S.VirginIslands,andtheDistrictofColumbia.TheregionalHIDTAsbringtogethermorethan21,000Federal, state, local, and tribal personnel from500 agencies through 800 enforcement, intelligence,andtraininginitiatives,alldesignedtodisruptillicitdrugtraffickinganddismantlecriminalanddrugtraffickingorganizations.TheAdministrationwillensurestrongsupportforcounterdrugenforcement,includingbysupportingFederalparticipationinmulti-jurisdictionaltaskforcesandenhancingsupportforinformationsharingatalllevels.Thiswillensurethatnationaldatasystemsreceiveinputfromstate,local,andtribalagencies,andthattheseagencies, in turn,haveaccesstodatacompiledbyFederalagencies that can prove vital to their own investigations .

Interrupting the Financial Activities of Drug Traffickers

IllicitdrugsentertheUnitedStatesfromglobalsuppliersastheresultofalongandcomplexprocessinvolvingmanufacture,concealment,movement,purchase,anddelivery.Theillicitdrugsmaychangehands several timesduring theprocess,and thisoftennecessitates the transferofmoney,eitheraspaymentforservicesorfordeliveryofthefinalproduct.Traditionally,street-levelsalesofillegaldrugsare conductedwithcash, creating immediately liquidassets thatarealmost impossible to track.Astechnologyandmoney launderingmethodshaveadaptedover the years to circumventAnti-MoneyLaunderingregulations,drugtraffickershaveinitiatedmanynewtechniquestoenablethetraditionalmethod of hard currency transactions . Although some of these methods create additional investiga-tiveevidence,emergingtechnologiescontinuetooutpacebankingregulationsandconsistentlyprovidedrugtraffickersthemeanstolaunderlargeamountsoftheirillicitproceeds.

Most of the revenue generated from illegal drug sales in the United States is maintained at the retail level ofdrugdistribution.However, illicitproceeds thatflowback to internationalsourcesofdrugsupplyaremostoftenusedtofinanceother illegalactivitiesorthenextcycleof illegaldrugstobedirectedintoourcommunities,posingacontinualthreattothecountry.Thesefundsalsocorruptandweakenthegovernment infrastructureofsourceandtransitcountries, limitingthosegovernments’abilitytocombatTransnationalCriminalOrganizations(TCOs),escalatingviolence,andthreateningthestabilityof the governments we partner with to counter illicit activity . We will combat this threat and target the drugproceedsthatmotivatecriminalactivitybyattackingTCOs’financialcapital;preventingthecircu-lation,transfer,andconcealmentoftheir illicitproceeds;andultimatelydecreasingtheirwealthandtheir incentive to function .


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Enhancing Law Enforcement Capacity

Success in reducing the availability of illicit drugs in our country requires building the capacity and toolstofullyunderstand,andrelentlesslyrespondto,theincreaseddrugthreatweface.AsstatedinourNational Security Strategy,thiscapacitybuildingincludesnational-levelstrategicintelligenceandplan-ningcapabilitiestoimprovetheabilityofdepartmentsandagenciestoworktogethertocombatTCOs,particularlythosewhotrafficdrugsathomeandabroad.WemustimproveourcapabilitytodismantleTCOsasawholethroughgreatercoordinationandfocus,directlybenefitingourcounterdrugefforts.Improved strategic planning must be informed by better strategic intelligence on transnational organized crimeandglobalcriminalnetworks,fusinglawenforcementandIntelligenceCommunityinformationandintelligencetocreatethemostcompletepictureavailableofcriminalnetworks.Wemustusethatinformationto identifyandexploitvulnerabilities indrugtraffickingnetworksusingthefull rangeoflawenforcementcapabilitiesincludingcriminalprosecutions,financialdisruptiontoolssuchasassetforfeitureproceedings,andsecurityoperationstoremovetheprofitsfromcrime.Moreover,wemustmaintain pressure on these organizations over time and prevent them from regenerating their capa-bilities.Wemustalsoemphasizebothactionsthatleadtoprosecutions—toreducenetworks’abilitytooperate,throughtheinvestigation,arrest,andprosecutionofcriticalpersonnel—andthosethatleadtothelong-termdisruptionofnetworkoperationssuchastheseizuresofillicitdrugs,precursorchemicals,illicitfunds,andweapons.

Ourconventionalfocusontargetinghigh-levelindividualswithinthehierarchyofwell-organizedandsophisticated DTOs must evolve toward identifying and targeting vulnerable critical components of morefluidanddynamicorganizationssuchasfinancialfacilitators,corruptofficials,andkeytransport-ers,toaffectasignificantdisruptionofDTOactivities,targetingkeynodestoattacktheentirenetworkthrough its enablers. Degrading and defeating criminal networks that have becomemore resilientbecause they are decentralized, redundant in capabilities and capacities, and compartmentalized,requires identifying the key nodes enabling DTO operations and simultaneously targeting them formaximumeffectivenessovertime.Agileinteragencyandinternationalcoordinationwillallowforbetterdetectionofchangesinthetraffickingsupplychain,whichwillsupportintelligence-drivenoperationsagainstidentifiedvulnerabilities,fromdrugproductiontodeliverytotheenduser.

Conclusion

TheincreasedavailabilityanduseofillicitdrugsistakingfartoomanyAmericanlives.ItburdenstheU.S.healthcaresystemandleadstolostproductivityandcivilengagementhereathome,andglobaldrugtraffickingsustainsavastdomesticandinternationalcriminalenterprisethatenablescorruptionanddestabilizespartnernationsabroad.America’sdrugcrisishascreatedacomplexnationalsecurity,lawenforcement,andpublichealthchallengefortheNation,andthischallengewillremainwithusforthe foreseeable future . We must leverage the full capabilities of the U .S . intelligence and law enforce-ment communities, our military, domestic law enforcement and criminal justice capabilities, andsustainedengagementswiththegovernmentsofkeypartnernationsandinternationalorganizationstostoptheflowofthesedrugsacrossourbordersandintoourcommunities,andusethatcapabilitytopostureourselvesforanever-evolvingdrugtraffickingenvironment.Ouractionswillincludedisruptingtheevolvingillicitsupplychain,decreasingthevolumeofdrugsbeingsoldovertheinternet;decreasing


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thecultivationofillicitcropslikepoppyandcocaaswellasthevolumeofillicitdrugsbeingproducedforexporttotheUnitedStates;increasingtheamountofillicitdrugsseizedbeforeenteringtheUnitedStates;increasingtheamountofforfeitedassets;increasingthenumberofconvictionsfordrug-relatedcrimes;andincreasingthepaceofemergingdangeroussubstancesbeingreviewedandscheduledfordomestic and international controls .

Achieving the President’s objective of reducing the number of Americans losing their lives to drug addictionintoday’scrisis,andpreparingnowtodominatethedrugenvironmentofthefuture,requiresdeliberate actions focused on clear priorities and tangible outcomes to reduce the availability of drugs inourNation.However,lastingsuccessrequiresthoseactionstocomplement,andbeinformedby,astrong domestic public health response to reduce the use of these drugs in the United States which makespossibleenormousprofitsfordrugtraffickersandfuelstheillicitdrugmarket.Boldanddeci-sivenationalsecurity,lawenforcement,andpublichealtheffortsareneededtolifttheNationfromtheshadowofdruguseandmovetowardthePresident’sgoalofastronger,healthier,anddrugfreesocietytoday and in the years to come .

METRICSBecause this Strategy focusesonoutliningahigh-levelapproach rather thanenumeratingallof thekeytasksandactivitiesthatorganizationsattheFederal,State,localandTriballevelsmustundertakeinordertostemthetideofthiscrisis,itisimportanttoemploysomebroadmeasuresofperformanceandeffectivenesstoguidetheStrategy’simplementation.Thisnotonlyensuresthenecessarypolicies,priorities, and objectives of drug control agencies and interagency partners are adequately alignedandresourcedtoadvancethePresident’sdrugcontrolpriorities,butalsoservestoidentifythoseareaswherearefinementoftheStrategymaybenecessarytocloseanidentifiedgap,orareaswhereashiftinspecificagencyresourcescanattaingreatereffectsinachievingthePresident’soverarchingstrategicobjective .

This requires that we focus on effects and not simply performance. While a performancemeasurerepresents the specific characteristic or aspect of the program or policy used to gauge successfulperformanceofaspecifictask,effectivenessrepresentstheaggregateprogress,ofmultipleagenciescontributingtoachievingtangibleimprovementthroughtheirprograms,initiatives,andpolicies.DoingsorequireslinkingactionstakenonthefrontendoftheglobalsupplychaintoreducetheavailabilityofillicitdrugsintheUnitedStateswithmeasurableeffectsonthehealthandsafetyofourcommunities.

Measures of Performance

• Educatethepublic,especiallyadolescents,aboutdruguse,specificallyopioidsincrease,man-datory prescriber education and continuing training on best practices and current clinical guidelines;andincreasePDMPinteroperabilityandusageacrossthecountry

• Encourage expanded access to evidence-based addiction treatment in every state, particu-larlyMedication-AssistedTreatmentforopioidaddiction;supportlegislativechangestoallow


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Medicaidtoreimbursecertainresidentialtreatmentatfacilitieswithmorethan16beds;andencourage states to apply for state Medicaid demonstration projects that address barriers to inpatienttreatmentasapartofacomprehensiveopioid/substanceusedisorderstrategy

• SignificantlyreducetheavailabilityofillicitdrugsintheUnitedStatesbypreventingtheirpro-ductionoutsidetheUnitedStates,disrupttheirsaleontheinternet,andstoptheirflowintothecountrythroughthemailandexpresscourierenvironments,andacrossourborders

Measures of Effectiveness

• ThenumberofAmericansdyingfromadrugoverdoseissignificantlyreducedwithinfiveyears

• Nationwideopioidprescriptionfillsarereducedbyone-thirdwithinthreeyears,andwithinfiveyears all healthcare providers have adopted best practices for opioid prescribing

• Evidence-based addiction treatment, particularly Medication-Assisted Treatment for opioidaddiction,ismoreaccessibleNationwideforthosewhoneedit

• Theproductionofplant-basedandsyntheticdrugsoutsidetheUnitedStateshasbeensignifi-cantlyreduced,illicitdrugsarelessavailableintheUnitedStatesasreflectedinincreasedpriceanddecreasedpurity,anddrugseizuresatallU.S.portsofentryincreaseeachyearoverfiveyears

national drug control strategy · the trump administration’s national drug control strategy is...

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