The National Drug Control Policy The White House Office of National Drug Control Policy (ONDCP), a component of the Executive Office of the President of the United States, was e

2015

NAT IONA L DRUG CONTROL STR ATEGY

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Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1: Strengthen Efforts to Prevent Drug Use in Our Communities . . . . . . . . . . . 11

Chapter 2: Seek Early Intervention Opportunities in Health Care . . . . . . . . . . . . . . 23

Chapter 3: Increasing Access to Treatment and Supporting Long-Term Recovery . . . . . . . 29

Chapter 4: Criminal Justice Reform: Making the System More Effective and Fair . . . . . . . . 41

Chapter 5: Disrupt Domestic Drug Trafficking and Production . . . . . . . . . . . . . . 53

Chapter 6: Strengthen Law Enforcement and International Partnerships to Reduce the Availability of Foreign-Produced Drugs in the United States . . . . . . . . . . . . . . . 65

Chapter 7: Improve Information Systems for Analysis, Assessment, and Local Management . . . 79

Policy Focus: Preventing and Addressing Prescription Drug Misuse and Heroin Use . . . . . . 87

Policy Focus: Drugged Driving . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

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To the Congress of the United States: I am pleased to transmit the 2015 National Drug Control Strategy, my Administration’s 21st century approach to drug policy that works to reduce illicit drug use and its consequences in the United States. This evidence-based plan, which balances public health and public safety efforts to prevent, treat, and provide recovery from the disease of addiction, seeks to build a healthier, safer, and more prosperous country.

Since the release of my Administration’s inaugural National Drug Control Strategy in 2010, we have seen significant progress in addressing challenges we face along the entire spectrum of drug policy—including prevention, early intervention, treatment, recovery support, criminal justice reform, law enforcement, and international cooperation. However, we still face serious drug-related challenges. Illicit drug use is a public health issue that jeopardizes not only our well-being, but also the progress we have made in strengthening our economy—contribut- ing to addiction, disease, lower student academic performance, crime, unemployment, and lost productivity.

Therefore, we continue to pursue a drug policy that is effective, compassionate, and just. We are working to erase the stigma of addiction, ensuring treatment and a path to recovery for those with substance use disorders. We continue to research the health risks of drug use to encour- age healthy behaviors, particularly among young people. We are reforming our criminal justice system, providing alternatives to incarceration for non-violent, substance-involved offenders, improving re-entry programs, and addressing unfair sentencing disparities. We continue to devote significant law enforcement resources to reduce the supply of drugs via sea, air, and land interdiction, and law enforcement operations and investigations. We also continue to partner with our international allies, helping them address transnational organized crime, while ad- dressing substance use disorders and other public health issues.

I thank the Congress for its continued support of our efforts. I look forward to joining with them and all our local, State, tribal, national and international partners to advance this impor- tant undertaking.

President Barack Obama The White House

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Preface from Director Botticelli The 2015 National Drug Control Strategy continues our dynamic, reform-oriented approach to drug policy, and reflects our desire to continuously seek out individuals who will help improve and refine our efforts. As I traveled the country as a part of our consultation process, I went to Boston for a roundtable discussion with some of the most influential names in the substance use disorder field. While stopping for coffee, I happened to meet Melissa, who told me her story.

Melissa started misusing pain medication after being prescribed OxyContin for a back injury. For a while, she was able to take it as directed. But she eventually started misusing her medica- tion, developed a serious substance use disorder, and began using heroin. Eventually, Melissa lost her apartment and became homeless. She knew she needed help, so she turned to a local clinic that provides substance use disorder services, including medication-assisted treatment (MAT), for the homeless. Fortunately, Melissa lives in a state where she qualified for Med- icaid coverage and which supports all the Food and Drug Administration (FDA)-approved medications for opioid use disorders. She was also tested at the clinic for infectious diseases associated with injection drug use. We are thankful that Melissa does not have viral hepatitis or HIV. She still lives in a shelter for homeless women, but she is on the path to recovery. Not long ago, she landed a job at that same coffee shop. She is well on her way to getting back to life without drugs.

I met Michael at a recovery celebration at the White House. Michael was born in Compton, California. He was a bright teenager, and his mom did her best, but the circumstances he was born into prevailed and he got involved with a gang in high school. He dropped out. He de- veloped a substance use disorder involving crack cocaine, and found himself homeless, alone, and in despair. In 1996, he was arrested and convicted for possession of less than a gram of crack. Under California’s Three Strikes Law, he was sentenced to 25 years in prison. In prison, he began to study in the prison law library and spent his time appealing his sentence. In 2002, six years after his conviction, his appeal went to the U.S. District Court, where a judge, after re- viewing his case for two and a half years, overturned the sentence and freed Michael. Since his release, Michael has spent his time mentoring others in recovery and working to prevent teens in Compton from joining gangs or using drugs. He earned his GED, and now he is enrolled in college and working full-time.

Hearing from Melissa and Michael, and countless other Americans reaffirms my belief in the importance of our work and the role public policy can play in helping to improve lives. While we continue to pursue the goals set by the President’s inaugural National Drug Control Strategy, we remain mindful of the people the Strategy seeks to serve. I look forward to working with the Congress and the American people throughout the next year to implement the Strategy and reduce illicit drug use and its consequences.

Michael P. Botticelli Director of National Drug Control Policy

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Introduction Throughout much of the last century, our understanding of drug use was influenced by powerful myths and misconceptions about the nature of addiction . People who used illicit drugs and had substance use disorders were thought to be morally flawed or lacking in willpower . These views shaped our responses to drug policy, resulting in punitive rather than therapeutic approaches to reduce drug use . Today, the Nation’s response to addressing substance use disorders and our views about those who suffer from the disease of addiction have begun to change . Groundbreaking discoveries about the brain have revolutionized our understanding, therefore enabling us to develop evidence-based and humane interventions to reduce drug use and its consequences .

Substance use disrupts our families, schools, and communities and limits the hopes and dreams of young people across the country . Illicit drug use is associated with addiction, disease, and lower academic performance among our young people, and contributes to crime, injury, lost productivity and serious dangers on our Nation’s roadways . Successfully addressing these complex issues requires a range of approaches . The Obama Administration is committed to restoring balance to U .S . drug-control efforts by coordinating an unprecedented government-wide public health and public safety approach .

The Administration’s goal is to make sure services for substance use disorders remain a priority . We are focusing on improving access to services and treatment across the continuum of care, from prevention and intervention to treatment and recovery . We know how to effectively prevent youth substance use, we have treatment interventions that work, including MAT for alcohol and opioid use disorders, and we know how to sustain recovery . The Patient Protection and Affordable Care Act (ACA) enables mil- lions more people to have access to health care and treatment for their conditions . The ACA presents tremendous opportunities to reform drug policy . But to fulfill this promise, we must make sure that substance use disorder treatment is truly integrated into mainstream health care, and that the millions currently without access to necessary treatment for the disease of addiction get the care they need and are aided in their recovery .

Substance use disorders are medical conditions, and reducing stigma surrounding these medical condi- tions is a particularly important component of drug policy reform—one in which every American can play a part . As we have worked to help millions of people into recovery and support the millions more who are already in long-term recovery, we have learned that how we describe or refer to people with substance use disorders can have an important effect on outcomes . Research demonstrates that the use of stigmatizing words like “addict” can:

• Discourage individuals from seeking help .1

• Reinforce the idea that someone with a substance use disorder is exhibiting a willful choice rather than suffering from a recognized medical condition .2

• Evoke less sympathy than if the individual is described as having a disease .3

Avoiding these terms, thereby reducing the stigma, can play an important role in encouraging these individuals to seek help at an earlier stage in the disease .

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In terms of prevention, there is much more we can do to keep young people from ever initiating drug or alcohol use . There are many evidence-based prevention efforts but they are underutilized—they must exist in our schools, our communities and in our homes . Prevention is critical because the most cost effective way to deal with drug and alcohol use and substance use disorders is to prevent them from occurring in the first place . The Nation has seen remarkable success in preventing young people from smoking cigarettes . The prevalence of past 30 day cigarette use among 8th, 10th and 12th graders, as measured by the 2014 Monitoring the Future (MTF) study, are at their lowest levels ever recorded by the survey .4 MTF also demonstrates significant reductions over the past five years in the rates of alco- hol use in all grades and a significant drop in binge drinking among high school seniors, which is now under twenty percent . Still, nearly 1 in 5 high school seniors report binge drinking within the past two weeks . We can continue to reduce the rates of substance use through implementing evidence-based prevention programs that promote positive messages and advise young people of associated risks and consequences .

The Administration is also committed to criminal justice reform—reforming our sentencing policies so that scarce resources are applied in the most effective ways, supporting evidence-based alternatives to incarceration that mitigate risks to the general public and reduce recidivism, and ensuring access to evidence-based treatment models—including MAT for the treatment of opioid use disorders—and recovery support .

At the Federal level, legislative and policy changes have resulted in more just sentencing, ensuring that the most violent criminals serve sentences of appropriate length and allowing low-level, non-violent drug offenders to repay their debt to society in less costly methods that also allow them to access treatment and supportive services . At the state level, justice reinvestment principles have led state leadership to rely on data about their own costs and outcomes to pass legislation and expand alterna- tives to incarceration . In the future, by fully implementing these policies, non-violent drug offenders will be diverted away from jails and prisons and toward community-based solutions that allow them to be held accountable while also rejoining their families and communities .

One way the justice system can prepare people to succeed is by offering evidence-based treatment while individuals are incarcerated or under community supervision and helping them with treatment and recovery support for their return to the community . Facilitating connections with health insurance coverage, through either private insurance or Medicaid, is a critical step to maintaining continuity of care . A number of jurisdictions are working with criminal justice-involved people to enroll them in health care coverage, which is vital to connecting them with health care after they are no longer in custody .

The Administration wants to help people find stability and success once they leave the justice system, which means helping them attain safe, stable housing; educational opportunities; and employment . A criminal record can be a barrier to attaining these important supports; policymakers should consider record expungement policies and processes that are easily understood and followed, to prevent a criminal conviction from haunting someone for decades after a crime is committed and punishment completed .

The Administration’s balanced approach to international efforts are ultimately targeted at reducing drug production and trafficking, promoting alternative livelihoods, and strengthening the rule of law,

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democratic institutions, citizen security, and respect for human rights . Countries facing the threats of drug production and trafficking often experience increasing rates of drug use . International programs promote effective demand reduction interventions, to include building institutions to provide alterna- tives to incarceration, healthy alternatives for at-risk youth, improved drug treatment capacity, and programs that help build strong and resilient communities . International drug control partnerships protect public health and safety, while contributing to overall national security . The success of these international efforts is highly influenced by the commitment and cooperation of governments, interna- tional institutions, and civil society organizations that provide drug-related assistance around the globe . The Administration will continue to prioritize international programs with a focus on those regions most important to reducing drug availability, drug use, and their consequences in the United States .

Progress Toward Achieving the Goals of the Strategy

The Obama Administration’s inaugural National Drug Control Strategy, published in 2010, established the following two overarching Goals to reduce drug use and its consequences by 2015:

• Curtail illicit drug consumption in America; and

• Improve the public health and public safety of the American people by reducing the conse- quences of drug abuse .

The Strategy, including its two Goals, was developed through an extensive consultation process with Federal, state, local, and tribal partners, and addressed the Nation’s call for a balanced policy of preven- tion, treatment, recovery, enforcement, and international cooperation . The Strategy also reflected the close and strong collaboration between the Office of National Drug Control Policy (ONDCP) and its Federal drug control agency partners to undertake evidence-based programs, policies, and practices to achieve desired performance outcomes by 2015 .

Both Goals have been strongly supported by activities to reduce access to and the availability of drugs through domestic and international activities . Efforts to reduce the supply of illicit drugs and to enforce the laws of the United States are focused on decreasing crime, increasing the protection of U .S . borders, disrupting trafficking networks, and curtailing international and domestic production of drugs .

The 2010 Strategy called for reductions in the rate of youth drug use over 5 years and similar reductions in chronic drug use and drug-related consequences, such as drug deaths and illnesses and drugged driving . A suite of seven measures has been developed to assess progress (see Table 1-1) toward achiev- ing the two Goals . Described in detail in this chapter is each of the seven Strategy Goal measures along with their baselines, FY 2015 targets, data sources, and assessments of progress-to-date .

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Table 1-1: National Drug Control Strategy Goals & Measures, Baselines, Targets, and Progress-to-Date

National Drug Control Strategy Goal/Measure

Base-line Progress-to- date

2015 Target Assessment

Strategy Goal 1: Curtail illicit drug consumption in America

Strategy Measures

1a: Decrease the 30-day prevalence of drug use among 12–17 year olds by 15%5

10.1%

(2009)

8.8%

(2013) 8.6% Progress sufficient to enable meeting 2015

target

1b: Decrease the lifetime prevalence of 8th graders who have used drugs, alcohol, or tobacco by 15%6

– Illicit Drugs 19.9%

(2009)

20.3%

(2014) 16.9% No progress to date, accelerated progress

required to meet 2015 target

– Alcohol 36.6%

(2009)

26.8%

(2014) 31.1% Target met or exceeded, progress should be

maintained through 2015

– Tobacco 20.1%

(2009)

13.5%

(2014) 17.1% Target met or exceeded, progress should be

maintained through 2015

1c: Decrease the 30-day prevalence of drug use among young adults aged 18–25 by 10%7

21.4%

(2009)

21.5%

(2013) 19.3% No progress to date, accelerated progress

required to meet 2015 target

1d: Reduce the number of chronic drug users by 15%8

– Cocaine 2,700,000

(2009)

2,500,000

(2010) 2,295,000 Progress sufficient to enable meeting 2015

target

– Heroin 1,500,000

(2009)

1,500,000

(2010) 1,275,000 No progress to date, accelerated progress

required to meet 2015 target

– Methamphetamine 1,800,000

(2009)

1,600,000

(2010) 1,530,000 Progress sufficient to enable meeting 2015

target

– Marijuana 16,200,000

(2009)

17,600,000

(2010) 13,770,000 Significant progress required to meet 2015

target

Strategy Goal 2: Improve the public health and public safety of the American people by reducing the consequences of drug use

Strategy Measures

2a: Reduce drug-induced deaths by 15%9

39,147

(2009)

46,471

(2013) 33,275 Significant progress required to meet 2015

target

2b: Reduce drug-related morbidity by 15%

– Emergency room visits for drug misuse and abuse10

2,070,452

(2009)

2,462,948

(2011) 1,759,884 Significant progress required to meet 2015

target

– HIV infections attributable to drug use11

5,799

(2009)

4,366

(2013) 4,929 Target met or exceeded, progress should be

maintained through 2015

2c: Reduce the prevalence of drugged driving by 10%

– Data Source: National Roadside Survey12

16.3%

(2009)

20.0%

(2013/2014) 14.7% Significant progress required to meet 2015

target

– Data Source: National Survey on Drug Use and Health13

4.4%

(2009)

3.8%

(2011) 4.0% Target met or exceeded, progress should be

maintained through 2015

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Assessment of Progress

Measure 1a: Decrease the 30-day prevalence of drug use among 12-to-17-year-olds by 15 percent

Drug use typically begins in the adolescent years; consequently, the Strategy’s efforts focus on prevent- ing such initiation . The Nation has made substantial progress toward achieving this measure . According to the 2013 National Survey on Drug Use and Health,14 past 30-day use of any illicit drug among 12-to-17-year olds has declined 13 percent from 2009 (10 .1 percent) to 2013 (8 .8 percent), needing only a further decline of 0 .2 percent to achieve the 2015 target of 8 .6 percent . This decline includes a 10 percent drop in marijuana use from 2011 to 2013 and is even more apparent when drug use other than marijuana is considered . Such use has declined 35 percent from 2009 (4 .6 percent) to 2013 (3 .0 percent), well below the 2015 target of 3 .9 percent (assuming a similar 15 percent target reduction) .

Measure 1b: Decrease the lifetime prevalence of 8th graders who have used drugs, alco- hol, or tobacco by 15 percent

This goal targets the lower ages of the youth age group, 8th graders, when youth are most vulnerable to initiation of many substances . According to data from the 2014 Monitoring the Future (MTF) study,15 the Nation has already exceeded the targets for reducing alcohol and cigarette16 use among 8th graders: 27 percent for alcohol and 33 percent for cigarettes . Until this past year, the Nation was on target to achiev- ing the goal for illicit drugs; in 2013, the estimate rose again to the level of the 2009 baseline (20 .3%) .

Measure 1c: Decrease the 30-day prevalence of drug use among young adults aged 18–25 by 10 percent

Young adults typically have the highest rates of illicit drug use of any age group . The Nation has made no progress on achieving the goal of reducing drug use among 18-25 year olds according to the 2013 NSDUH .17 The primary reason for this lack of success is the continued and unchanging high prevalence of past month marijuana use among young adults—nearly 20 percent since 2009 . However, when marijuana is excluded from the estimation of illicit drug use, the Nation has actually already doubled the targeted reduction—a 20 percent decline from 2009 to 2013 . This decline has been driven by a 25 percent decline in past month nonmedical use of prescription drugs overall, which in turn was driven by a 31 percent decline in past month nonmedical use of pain relievers .

Measure 1d: Reduce the number of chronic drug users by 15 percent

Research suggests that about 20 percent of the user population for a specific drug accounts for about 75 percent of the amount consumed of that drug—these are chronic, heavy users .18 The Nation is exceed- ing the projected tracks for achieving the targets for reducing the number of chronic users of cocaine and methamphetamine, and based on available data (through 2010),19 is on the tracks for reducing the number of chronic users of heroin (other more current data sources suggest there may be a rise in heroin use during recent years) . However, the estimated number of chronic users of marijuana is going

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in the wrong direction—it has been rising since 2007 when it was about 14 million, through the baseline estimate of 16 million in 2009 to nearly 18 million in 2010 .

Measure 2a: Reduce drug-induced deaths by 15 percent

While the Nation has not made progress in achieving the target for the goal of reducing drug-induced deaths, there has been progress in arresting the alarming growth in deaths involving prescription drugs, the largest class of drugs contributing to overall drug deaths . According to Vital Statistics data20 from CDC, over the past decade drug-induced deaths have been driven by deaths involving prescription drugs (in 2013, they totaled 22,767—slightly less than half of all drug-induced deaths), especially prescription opioids (16,235) . The good news is that for the first time since 1999, these deaths may have stabilized or even declined slightly . Deaths involving prescription drugs peaked in 2011 at 22,810, then dropped in 2012 to 22,114 before rising slightly to 22,767 in 2013 . At the same time deaths involving prescrip- tion opioids peaked at 16,917 in 2010 and declined 4 percent to 16,235 in 2013 . Unfortunately, deaths involving heroin have risen sharply since 2010, from 3,039 to 8,260, or about half the number of deaths involving prescription opioids .

Measure 2b: Reduce drug-related morbidity by 15 percent

The data source for this measure was the Drug Abuse Warning Network (DAWN), which estimated the number and percentage of drug-related visits to hospital emergency departments . In 2011, DAWN was discontinued . The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Center for Health Statistics are currently collaborating to launch a new data system to col- lect this information . It is anticipated that it will begin reporting in late 2015 . Through 2011, data from DAWN indicated that the Nation was going in the wrong direction to achieve this target of reducing drug-related morbidity, rising from 2 .1 million visits in 2009 to slightly more than 2 .4 million in 2011 .21

The second source is the number of people diagnosed with Human Immunodeficiency Syndrome (HIV) who were infected through injection drug use (IDU) .22 This measure tracks progress at reducing the incidence of HIV infections attributable to injection drug use (including men who have sex with men and inject drugs) . The estimates are collected, analyzed and disseminated by the Centers for Disease Control and Prevention . The 2009 baseline estimate of the number of individuals diagnosed with HIV infection through IDU is 5,700; the 2015 target is to achieve a 15 percent reduction to 4,929 . As of 2013, the 2015 target has been exceeded with 4,366 individuals diagnosed with HIV infection through IDU; this progress will need to be maintained through 2015 to ensure the target is met .

Measure 2c: Reduce the prevalence of drugged driving by 10 percent

The National Highway Traffic Safety Administration (NHTSA) periodically conducts the National Roadside Survey to estimate the prevalence of impaired driving; in 2007, they included measures to estimate the prevalence of driving after consuming drugs, including medications that can impair driving skills . At ONDCP’s request, NHTSA conducted the survey again in 2013/2014 to assess the progress on achiev- ing this goal . Unfortunately, the Nation is moving in the wrong direction on this primary measure of drug-involved driving . Results from the 2013/2014 survey indicated that the prevalence of driving after consuming drugs on weekend nights was 20 percent, up from 16 .3 percent in 2009 .23 ONDCP also is

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tracking the prevalence of drugged driving with self-report data from the National Survey on Drug Use and Health (NSDUH) . According to data from the 2013 NSDUH,24 the Nation has achieved the target of reducing drugged driving by 10 percent; the 2015 target is 4 .0 percent, the level that was attained in 2013 .

Advocates for Action

Across America, individuals are doing extraordinary things to improve the health and safety of their communities . Whether it is developing groundbreaking programs to