Abstract

Drug overdose prevention has been a key discussion in healthcare policy in the United States. As a result, this brief conducts an in-depth analysis of the conversations within US healthcare policy, and legislative suggestions for drug overdose prevention, which have the potential to help US citizens. Access  is a large question in the context of overdose prevention, with overdoses at historical levels. As a result, one of the most important healthcare considerations in recent years is associated with drug overdose prevention policies. Thus, some policies are analyzed with their unique ability to help the United States and its citizens.

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Executive Summary

This brief will cover the discussions surrounding drug overdose prevention in the United States and current policy considerations, developments, and future possibilities. Some key pieces of our analysis include analyzing the historical context of drug overdose prevention efforts and an in-depth overview of current actions the federal government is taking, problems with such legislation, and future considerations.

Overview

A. Historical Context

Decades into America’s opioid epidemic, with the drugs and their effects ever present in today’s society — from being condemned in classrooms to being observed in every corner of every city — understanding the root causes for the growing opioid crisis is critical. Despite the potency, addictiveness, and supply of the drugs dramatically changing over time, their underlying mind-numbing effects continue to take thousands of lives.

The term “opioid” encompasses a wide family of synthetic (laboratory-produced) and non-synthetic (natural) drugs, all of which target specific nerve cells in the brain. Such cells, called opioid receptors, have the unique role of blocking the feeling of pain. As a result, opioids act as painkillers, allowing users to not only experience pain relief but frequently an intense euphoria as well. Yet, opium’s purest form — the opium poppy — was around far before its true medical effects could be studied. Opium was cultivated before 3000 BC, but only when German pharmacist Friedrich Sertürner isolated morphine itself in 1806 could opium begin its infamous surge into notoriety as a prescribed painkiller. 

In the 1990s, the first of three major waves of the American opioid epidemic began, a direct result of Sertürner’s research. At that time, undertreated pain was a widespread issue in the pharmaceutical and medical industries. With a growing patient-centric culture and policies encouraging the limitation of pain, providers began to prescribe opioid pain relief to patients. As opioids became more frequent in hospitals and pharmacies, the rate of overdose grew as well. 

B. Relevance

The second and third stages of the opioid epidemic were both caused by innovations in synthetic drugs. First, in 2010, heroin’s usage skyrocketed. It was first introduced as a supposed cough suppressant by the same researchers who developed aspirin, hence the “hero” in the drug's name. Heroin’s ability to be injected, sniffed, snorted, smoked, or mixed with other drugs certainly contributed to its rapid rise in usage. In 2021 alone, it claimed over 9,000 reported lives. Just three years later in 2013, however, the third and final stage of the opioid epidemic began. 

Fentanyl, an opioid over 50x more potent than Heroin and 100x more potent than morphine, took Heroin’s lethal grasp on the public health system to the extreme. As just two milligrams — 10-15 grains of table salt — of fentanyl is lethal, many of its victims only consumed fentanyl unknowingly. Importantly, fentanyl is smuggled into the US from the southern border in immense quantities, with over 26,000 pounds seized in FY 2023 alone. The vast majority of this is due to the Sinaloa and Jalisco cartels — two rival organized crime groups in Mexico that are able to produce illicit drugs both rapidly and extensively. In the past few years, the amount of laced fentanyl on fake prescription pills has jumped to 60%, meaning that 6 in 10 trafficked pills may be deadly. 

Altogether, “opioid-involved death rates” increased by a factor of 15% from 2020-2021, and ¾ of the 100,000+ overdose deaths in 2021 “involved an opioid.” Ultimately, the opioid epidemic continues to threaten both at-risk and unsuspecting Americans and requires more purposeful action to prevent. 

Policy Considerations

A. Tried Policy

Since President Nixon’s commitment to the War on Crime in the mid-1960s, the United States government and its legislative bodies have taken a contentious stance against drug usage. With the rise of counterculture and a substantial increase in juvenile drug usage and countless cases of unreported health hazards, the Controlled Substances Act (CSA) of 1970 was passed to supplement the governmental sentiment for restoring American gentility by beginning federal regulation of a wide range of chemical concoctions that constitute the definition of drugs, including but not limited to narcotics, stimulants, depressants, hallucinogens, and anabolic steroids. Following the passage of the CSA was the 1973 establishment of the United States Drug Enforcement Administration (DEA), serving since then to enforce the regulatory guidelines set in 1970. Past four decades, a second major drug regulation act was passed in 2018 during the 115th Congress, titled the Substance Use–Disorder Prevention that Promoted Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. Each of these two legislations have been focal factors in drug regulation in the United States.

As an early form of drug regulation, the CSA operates on the basis of classifying drugs under five scheduled categorizations of their viability for medical purposes and abuse potential. With Schedule I drugs being known as high-abuse potential substances including heroin and marijuana—although the latter is legalized for recreational use in some states—the DEA has carried out prosecutive orders on those who manufacture, handle, store, distribute, or purchase such harmful drugs without properly registering to administrative records on their inventory and security. Following an order of potential concerns for dependency and abuse, the CSA scheduling system also controls comparatively unthreatening substances like codeine, used minimally for cough preparations. With the initial establishment of controlled substances, the CSA addresses concerns of newly emerging chemical threats by outlining that any unknown or unsourced drugs will be addressed as Schedule I.

B. Recent Developments

Entering the 21st century, it became apparent through the opioid epidemic that new legislation to address a rapidly growing death toll of lethal synthetic opioid substances like fentanyl, in which death from fentanyl overdose has increased by 50% just over the one-year period of 2019 and 2020. Despite many forms of fentanyl being included in the controlled substances list of the CSA as Schedule I drugs, the low lethal dosage of the substance compounded by its under-the-table accessibility for juveniles has accounted for the passage of the SUPPORT for Patients and Communities Act in late 2018. Passed under former President Donald Trump’s administration and deemed as “the single largest bill to combat the drug crisis in the history of [The United States],” the act comprises multiple dozens of laws that respond to natural and synthetic opioid abuse. It has necessitated medical protocols in hospitals such as the provision of toolkits and emergency procedures to prevent and address opioid overdoses while expanding education on opioids and strengthening the prosecution of Schedule II, III, IV, and V substances via a mandated electronic system of substance prescriptions that are widely trackable. While the effectiveness of the SUPPORT for Patients and Communities Act is inconclusive in resolving the opioid epidemic, it serves as a modern measure that reaches beyond policing efforts to reduce the impacts of opioid abuse, making assistance and pre-intervention care more accessible throughout the nation.

Policy Problem

According to the testimony surrounding the impeachment of United States Deputy of Security Alejandro Mayorkas and border concerns, there have been 10 million illegal border crossings that have partially fueled the fentanyl crisis. Fentanyl continues to be the leading contributor to drug overdose deaths, having been found in over 96% of opioid-related deaths in 2022.  Fentanyl is incredibly lethal; the drug requires the user to ingest far less than ketamine or cocaine to provide a lethal dose. 

There is a consistent cry for help along the border. There is a vast majority of people who feel that the border is the only way to prevent a continuous flow of fentanyl into the United States, as there has been an 800% increase in the amount of fentanyl seized at the border, with estimates of only 10% of the drug being seized.  That means that despite 27 tons of fentanyl being seized at the border, that is likely only 10% of what made it into the United States. Sadly, this is not the only concern among citizens. 

In Colorado, recent legislation was passed to stiffen the penalties that dealers can face, but it is not working as anticipated. The new legislation requires coroners to confirm that fentanyl was the cause of death for the dealer to be convicted. As stated earlier, it requires an incredibly small amount of fentanyl to overdose, making it especially difficult to confirm fentanyl as the primary source of someone’s death. Based on the understanding of the lethal dose of fentanyl, people would like to see medical examiners who find combinations of ethanol and opioids conclude that the presence of fentanyl was adequate and would have killed the victim with or without alcohol. However, changes in the approach medical examiners can legally take will not occur without a complete rehaul of current drug overdose legislation. 

Policy Options

Enhanced communication from the federal government will play a crucial role in increasing public awareness of individuals' rights to appropriate care and services for substance use disorders. In the Legislative Proposals of FY 2024, a notable inclusion is the Mandatory Recall Authority for All Drugs. This proposal seeks to broaden the FDA's mandatory recall authority, initially granted under the SUPPORT Act of 2018 for controlled substances, to encompass all human and animal drugs. The FDA believes that expanding this authority will expedite the removal of harmful drugs from the market, ultimately minimizing harm to consumers.

Official communication efforts are essential to alleviate confusion among patients, providers, and insurers. Furthermore, efforts should be directed toward extending the reach of treatment, reducing the prevalence and severity of substance use disorders, and minimizing associated costs. Healthcare organizations can contribute by actively screening for substance misuse and disorders, coupled with clear communication about available treatment programs to encourage untreated individuals to seek care. Treatment approaches should encompass brief interventions for mild cases and a comprehensive range of evidence-based therapies and medications for severe disorders, delivered by well-trained healthcare professionals.

Future research should build upon existing knowledge to develop prevention and treatment strategies targeting the underlying brain circuit abnormalities of substance use disorders. It is crucial to identify personalized medicine interventions that are most effective for specific patients, understand how the brain and body recover after chronic drug exposure and develop evidence-based strategies for supporting recovery. Long-term prospective studies focusing on at-risk youth are particularly needed, concurrently exploring personal and environmental risks, substance use patterns, and changes in brain structure and function.

Conclusion

Overall, a detailed description of the issues regarding current efforts to combat drug overdoses has been provided. The analysis details how historical legislative efforts remain relevant in the status quo. However, there is still vast progress to be made to ensure the safety of America and its people.

Acknowledgement

The Institute for Youth in Policy wishes to acknowledge, Michelle Liou, Joy Park, Nolan Ezzet, and other contributors for developing and maintaining the Policy Department within the Institute.

References

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