The Opioid Crisis and Recent Federal Policy Responses

Summary

The opioid crisis emerged in the United States in the mid-1990s and has continued in a series of overlapping waves. In this report, the Congressional Budget Office describes the effects and evolution of the crisis, the factors that have contributed to it, the laws enacted to address it, and the effects of the coronavirus pandemic on the crisis.

What Are Opioids, and What Is Opioid Use Disorder?

Opioids are a class of drugs that includes prescription pain relievers. Although those prescription drugs are available legally and have valid clinical applications, they can be used nonmedically and distributed illegally. Other opioids, such as heroin, are produced illegally. Fentanyl can be produced legally and illegally. The misuse of opioids can lead to serious side effects and death.

People with certain harmful behaviors that result from opioid misuse—such as an increase in the amount and frequency of opioid use or failure to fulfill major responsibilities at work, home, or school—have opioid use disorder (OUD). Several treatments are available for people with OUD, including medications and psychosocial therapy, but research indicates that those treatments are underused.1 The drug naloxone can reverse opioid overdoses.

What Are the Effects of the Opioid Crisis?

The opioid crisis has had profound effects. In the United States, more than 500,000 people have died from opioid-involved overdoses since 2000. Deaths from opioid-involved overdoses were particularly numerous during the pandemic, placing them among the leading causes of death in 2020. Those deaths have contributed to the decline in life expectancy that the United States has experienced since 2014. The opioid crisis has also increased the incidence of related diseases. The injection of opioids has contributed to the wider spread of hepatitis C and HIV, and the number of newborns experiencing withdrawal as a result of their mothers’ opioid misuse has also increased.

The opioid crisis has affected spending and revenues in the federal budget. Federal spending on health care, the child welfare system, means-tested social programs, and efforts to reduce drug trafficking has increased. However, opioid-involved deaths have reduced federal spending on benefits, such as Medicare and Social Security, that people who died would have received in the future. Tax revenues have also decreased because of lost earnings from reduced longevity and from the decreased productivity of people who misuse opioids.2

How Has the Crisis Evolved?

The opioid crisis has occurred in overlapping waves (see Figure S-1). The first wave began in 1996 with the expanded use of prescription opioids to address chronic pain, nonmedical use of prescription opioids, and distribution of those drugs through illegal means, such as sharing or selling pills to people who do not have a prescription for them. Use of illegally manufactured opioids increased during the second and third waves of the crisis. The second wave began in 2010 with the increased use of heroin, and the third wave started in 2013 as fentanyl use increased. A fourth wave of the crisis seems to be emerging, one characterized by the use of illegally manufactured opioids in combination with psychostimulants such as cocaine and methamphetamine.

Figure S-1.

Overdose Deaths Involving Opioids, by Type of Opioid

Thousands of Deaths

Opioid-involved deaths have increased as the substances used have become more potent.

Notes

Data source: Congressional Budget Office, using information from the CDC WONDER database, Centers for Disease Control and Prevention, National Center for Health Statistics, “About Multiple Cause of Death 1999–2020” (accessed January 5, 2022), https://wonder.cdc.gov/mcd-icd10.html. See www.cbo.gov/publication/58221#data.

Psychostimulants include cocaine and psychostimulants with abuse potential, such as methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA), dextroamphetamine, levoamphetamine, methylphenidate (Ritalin), and caffeine. Because the subcategories of prescription opioids, heroin, and synthetic opioids (other than methadone) are not mutually exclusive, total deaths from any opioid can be fewer than the sum of the subcategories. Synthetic opioids include fentanyl and related substances. In addition, the category “any opioid” includes other subcategories of opioids—opium and other unspecified narcotics—not shown separately in the figure.

The first wave of the opioid crisis began in 1996, but the number of overdose deaths involving opioids is not available for the early years of the crisis. In addition, the former Assistant Secretary for Health at the Department of Health and Human Services noted the emergence of a fourth wave beginning in 2019. See Steven Ross Johnson, “Q&A: ‘We’re Entering the Fourth Wave, Which Is Methamphetamine,’” Modern Healthcare (August 3, 2019), https://tinyurl.com/muyjdfuu.

Although people from all income levels, regions of the country, and backgrounds use and misuse opioids, the opioid crisis has affected demographic groups in different ways. For example, non-Hispanic White people had the highest opioid-involved death rate during the first wave of the crisis. During the third wave, however, deaths per 100,000 people among non-Hispanic Black and Native American or Alaska Native people caught up to and then surpassed the death rate among non-Hispanic White people in 2020.

What Factors Have Contributed to the Crisis?

Several factors have contributed to the opioid crisis: an increase in the prescribing of opioids, changes in illegal opioid markets, and greater demand for opioids among people in some demographic groups that have experienced declines in real wages and social cohesion. Those factors have reinforced each other.

Opioid prescribing increased as a result of aggressive promotion efforts by pharmaceutical companies. Clinical norms also began to emphasize assessing patients’ pain and treating it with prescription opioids. In addition, oversight and reimbursement incentives in the health care system encouraged opioid prescribing.

Changes in illegal opioid markets have affected the crisis. At first, the excess supply of prescription opioids facilitated their nonmedical use and illegal distribution. More recently, demand for heroin and fentanyl has increased as their prices have fallen and as the availability of prescription opioids has declined. The price of fentanyl is relatively low because it is produced in a lab, and its high potency allows it to be transported in small quantities that are difficult to detect. Most illicitly produced fentanyl is made in Mexico from precursor chemicals manufactured in China.

Lastly, although the connection between socioeconomic factors and opioid use is not fully understood, evidence suggests that opioid demand increased among people who experienced declining real wages and social circumstances, including non-Hispanic White people without a college education.

What Federal Laws Have Been Enacted in Response to the Crisis?

Between 2016 and 2018, three laws were enacted in response to the opioid crisis:

• The Comprehensive Addiction and Recovery Act (CARA) of 2016 (Public Law 114-198, July 2016),
• The 21st Century Cures Act (P.L. 114-255, December 2016), and
• The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271, October 2018).

Provisions in the laws address the multifaceted aspect of the crisis with strategies aimed to reduce demand, supply, and harm.

To reduce the demand for opioids, the laws lower barriers to treatment, for example, by requiring state Medicaid programs to temporarily cover all medications approved by the Food and Drug Administration (FDA) for the treatment of OUD. Similarly, a temporary state plan option allows federal matching funds to be used for services provided to beneficiaries with substance use disorder (SUD) in institutions for mental diseases, which are facilities with more than 16 beds that primarily diagnose, treat, and care for people with mental diseases, including SUD. Two provisions add new Medicare coverage for opioid treatment programs and telehealth services for the treatment of SUD. In addition, certain provisions in the laws aim to limit the supply of opioids by increasing Medicare’s oversight of prescription drug utilization and authorizing partial refills to reduce the availability of unused prescription opioids. Finally, the laws authorized appropriations for grants to reduce harm by expanding the use of naloxone.

Provisions in the laws resulted in changes in mandatory outlays and authorizations of appropriations.3 Whereas provisions aimed at reducing the demand for opioids were estimated to increase mandatory outlays, provisions aimed at reducing the supply of opioids were estimated to increase spending in some cases and reduce spending in other cases. On net, CBO estimated that provisions in CARA would reduce mandatory outlays by $187 million over the 2017–2026 period and that provisions in the SUPPORT for Patients and Communities Act would increase mandatory outlays by $2.7 billion over the 2019–2028 period, mostly for Medicaid.4 Although most provisions affecting mandatory spending are permanent, a few are temporary and are set to expire in the next few years.5

Also, collectively, the three laws authorized additional appropriations of about $700 million to $1.6 billion per year between fiscal years 2017 and 2023; those funds would be available only if provided in subsequent discretionary appropriation acts.6 Quantifying the amount of authorized funding that was actually appropriated is challenging because appropriation acts do not always clearly identify the legislation authorizing the funding, and they may fund multiple programs at once, or not at all. According to one estimate, total federal appropriations to address the opioid crisis almost tripled—rising from $2.1 billion to $6.1 billion—between fiscal years 2017 and 2020.7

How Has the Crisis Evolved After Enactment of the Laws and During the Pandemic?

Prescription opioid use continued to fall after the three laws were enacted. Opioid-involved deaths increased in most subsequent years before the start of the pandemic, but the annual rate of increase in deaths slowed.

Deaths involving opioids increased dramatically during the pandemic, driven by a sharp increase in fatalities involving fentanyl. The rise in opioid-involved deaths may be due to greater demand, as well as to the availability of more potent opioids and an increase in the solitary use of opioids. Policy responses to the pandemic affected the opioid crisis in several ways. In March 2020, certain barriers to OUD treatment were reduced, and the American Rescue Plan Act of 2021 appropriated funds to address the opioid crisis.

Chapter 1The Opioid Crisis

The ongoing opioid crisis in the United States has evolved over more than two decades.1 The use and misuse of opioids can result in serious side effects, including death, and can have negative effects throughout society. Consequently, the crisis has affected the federal budget in various ways.

The opioid crisis has occurred in overlapping waves, which correspond to the different drugs prevalent at different times.2 Prescription opioid use rose during the first wave of the crisis and fell during subsequent waves, as people increasingly used illegally produced opioids. The number of overdose deaths has increased over most years of the crisis, but it has affected racial and ethnic groups in different ways. Opioid-involved mortality was initially highest among non-Hispanic White people, but it has surged among other racial and ethnic groups as the use of more potent, illegally manufactured opioids has increased. The crisis has also affected people with other sociodemographic and economic characteristics in different ways.

Opioids and Opioid Use Disorder

Opioids are a class of drugs used to treat pain. They include legally and illegally produced and distributed substances. Legally produced opioids include prescription pain relievers that can also be used nonmedically and distributed illegally. Fentanyl, which is many times more powerful than morphine, can be produced legally and is available in prescription form as a patch to treat severe pain. Fentanyl and its analogues are also produced and distributed illegally. Heroin is an illegal opioid with no accepted medical use in the United States.

Serious side effects can result from the use and misuse of opioids. A person who overdoses on opioids can stop breathing and die. Use of opioids can lead to dependence (when a person who stops taking a drug experiences withdrawal symptoms) and tolerance (when a person needs to take more of a drug to experience the same amount of pain relief or “high”).3 People who use opioids may experience euphoria, constipation, and increased sensitivity to pain. When people who use opioids experience clinically significant impairment or distress—such as increasing the amount and frequency of opioid use or failing to fulfill major responsibilities at work, home, or school as a result of opioid misuse—they can be diagnosed with opioid use disorder.4

Most people who take prescription opioids for pain do not develop OUD, but about 8 percent to 12 percent of patients who take prescription opioids for chronic pain (a longer course of treatment than that for acute pain) develop OUD.5 Risk factors for OUD include past or current misuse of substances, untreated psychiatric conditions, social or family connections that encourage misuse of substances, and post-9/11 combat deployment.6

Treatments for OUD have been shown to be effective at reducing the risks of overdosing, illegally using opioids, contracting hepatitis C and HIV, and engaging in criminal activity, as well as other outcomes.7 Several treatments are available. Medications for OUD that have been approved by the Food and Drug Administration include methadone, buprenorphine, and naltrexone. OUD can also be treated with psychosocial therapy in conjunction with medications. The Centers for Disease Control and Prevention (CDC) recommends that patients with OUD be offered treatment with medications in conjunction with psychosocial therapy.8

Treatment for OUD is underused, however: In 2019, less than one-third of the 1.7 million people with OUD reported receiving any treatment for substance use in the previous year.9 Barriers to receiving treatment include affordability, lack of access, and stigma associated with OUD.10

Another drug, naloxone, can reverse opioid overdoses. It can be administered by health care providers as well as people without medical training.11 Although naloxone prevents immediate adverse outcomes, it does not treat the underlying OUD.

Effects of the Opioid Crisis

The opioid crisis has had a significant effect on public health and on economic and social outcomes in the United States: More than 500,000 opioid-involved deaths have occurred since 2000.12 The United States has the world’s highest number of opioid-involved deaths per capita—more than five times the median for member countries of the Organisation for Economic Co-operation and Development.13 More U.S. residents have died from opioid overdoses than were killed during World War II.

In 2020, there were 68,630 deaths involving opioids.14 That number is smaller than those for the first three leading causes of death—heart disease (696,962), cancer (602,350), and COVID-19 (350,831)—but it is larger than those for some of the other top-10 causes of death, including influenza and pneumonia (53,544 deaths) and nephritis, nephrotic syndrome, and nephrosis (52,547 deaths).15

The number of opioid-involved overdose deaths in the United States has been particularly high among people ages 24 to 35, and many years of life have been lost as a result of those premature deaths.16 Research has shown that opioid overdose deaths have contributed to the decline in U.S. life expectancy that began after 2014.17 The opioid crisis has also had a profound negative effect on families. For example, parents with OUD may be unable to care for their children.18

Along with the deaths caused by opioid-involved overdoses, the use of opioids has led to a corresponding increase in certain medical conditions. The injection of opioids has increased the spread of hepatitis C and HIV through contaminated needles.19 Moreover, the use and misuse of opioids by people who are pregnant has resulted in a rise in neonatal abstinence syndrome.20 (Neonatal abstinence syndrome refers to a group of conditions that occur when a baby withdraws from certain drugs, including opioids, after being exposed to them before birth.)

Opioids have affected participation in the labor force. Although prescription opioids have made it possible for some people with pain to work, the side effects of prescription opioids and the misuse of opioids have also kept people from working. Research indicates that the net effect of opioids has been to lower labor force participation.21

The opioid crisis has affected the federal budget by affecting spending and revenues, although the exact size of the effect is unknown.22 Federal spending has increased because federally subsidized health insurance—including Medicare, Medicaid, and private health insurance obtained from employers or purchased through the marketplaces—has funded prescription opioids, treatment of patients with OUD, and overdose reversal drugs, for example.23 The opioid crisis also has increased federal spending on the child welfare system and means-tested social programs, including cash assistance and disability programs.24 In addition, the federal government has funded programs to combat the illegal trafficking of opioids and has prosecuted and incarcerated people engaged in opioid-related crimes.25

Moreover, federal tax revenues may have decreased because of the reduced productivity and lower wages of people with OUD, as well as the lost wages of people who die from opioid-involved overdoses.26 (Those effects are typically not incorporated in the Congressional Budget Office’s cost estimates for legislation related to the opioid crisis, which reflect the standard assumption that the overall output of the economy does not change.)

Some of the consequences of the opioid crisis reduce budget deficits: Deaths from opioids among older people have reduced federal spending on programs such as Medicare and Social Security, and such spending will be reduced in the future because of deaths among young people.

Waves of the Opioid Crisis

The opioid crisis began in the mid-1990s and has proceeded in several overlapping waves characterized by increases in overdose deaths associated with changes in the drugs used (see Figure S-1). In the years leading up to the first wave of the opioid crisis, prescription opioids were usually prescribed sparingly, and their use was generally restricted to relieving acute pain from injury, surgery, cancer, or terminal illness.27 At that time, physicians were cautious about prescribing opioids because of the associated risks, which had been observed in previous periods when opium, morphine, and heroin use had increased.28

The first wave of the opioid crisis began in 1996 with the expanded use of prescription opioids, particularly OxyContin.29 Opioids were increasingly prescribed for chronic conditions such as low back pain, despite an absence of evidence about the long-term effectiveness of opioids for chronic pain.30 During the first wave, prescription opioids were also increasingly used nonmedically and were distributed through illegal means. Nonmedical uses of prescription opioids include taking more of the product than is directed by a medical provider or crushing and injecting tablets that are meant to be swallowed. Illegal distribution of prescription opioids can occur through diversion of prescribed medications to others without a prescription. It also includes sales by drug dealers and “pill mills,” through which clinicians, clinics, or pharmacies distribute prescription drugs inappropriately.31

The second and third waves of the opioid crisis involved the use of several illicitly manufactured substances. The second wave of the opioid crisis began in 2010 with increased use of heroin, an illicitly produced semisynthetic opioid derived from opium poppies. The third wave, which began in 2013, was characterized by increased use of fentanyl and related substances. Fentanyl is a completely synthetic drug made from ingredients in a lab.

Some experts have identified an emerging fourth wave of the crisis, one characterized by the use of illegally manufactured opioids in combination with psychostimulants such as cocaine and methamphetamine.32 People may intentionally use illicitly manufactured opioids and psychostimulants at the same time to enhance the high from opioids or compensate for the undesirable effects of opioids.33 Users may also unknowingly take illicitly manufactured opioids and psychostimulants because they were combined by drug dealers and others supplying the substances.34 In September 2021, the Drug Enforcement Administration (DEA) issued a public safety alert about the increase in counterfeit prescription pills that contain fentanyl and methamphetamine.35

Trends in the Use of Prescription Opioids

The use of prescription opioids, commonly measured by morphine milligram equivalents (MMEs) dispensed, increased from 27 billion MMEs in 1992 to 246 billion MMEs in 2011 and has decreased since then. An estimated 100 billion MMEs were dispensed in 2020 (see Figure 1-1). The declines in opioid prescribing, measured in MMEs per capita, were largest in states that had previously had the highest rates of opioid prescribing. From 2018 to 2019, every state experienced a decline in MMEs per capita.36 (At the same time, however, the use of illicitly produced opioids increased substantially.)37

Figure 1-1.

Prescription Opioids Dispensed

Billions of Morphine Milligram Equivalents Dispensed

The amount of prescription opioids dispensed increased during the first wave of the opioid crisis and peaked in 2011. It decreased during subsequent waves as use of illicitly produced opioids increased.

Notes

Data source: IQVIA Institute for Human Data Science, Prescription Opioid Trends in the United States: Measuring and Understanding Progress in the Opioid Crisis (December 2020), https://tinyurl.com/5a9dk8en. See www.cbo.gov/publication/58221#data.

a. The value for 2020 is a projection.

Even with the decline in the volume of opioid prescriptions dispensed, the United States remains the world’s largest consumer of prescription opioids. The amount of prescription opioids dispensed per million people per day in the United States is approximately four times the median for member countries of the Organisation for Economic Co-operation and Development.38

Opioid-Involved Overdose Deaths During the Waves of the Crisis

The number of opioid-involved overdose deaths per year increased substantially between 2000 and 2020, but the types of opioids involved in those deaths have changed during the waves of the crisis. (Some deaths involved more than one type of opioid.) Increases in deaths involving prescription opioids drove the rise in opioid overdose mortality in the early 2000s. Since 2010, the annual number of deaths involving prescription opioids has remained relatively steady. The number of deaths involving heroin increased after 2010 and leveled off in 2016. Opioid overdose deaths involving synthetic opioids (other than methadone) increased dramatically after 2013. Synthetic opioids include a variety of substances, but many of the deaths involve illegally produced fentanyl and related substances.39 Deaths involving the combined use of opioids and psychostimulants have surged in recent years: More than five times as many people died from the combined use of those drugs in 2020 as in 2014.

Effects of the Crisis on Subpopulations

Although people of all backgrounds use and misuse opioids, opioid-involved deaths have affected demographic groups in different ways. More deaths per 100,000 people occurred among non-Hispanic White people during the first wave of the crisis than among people in other racial and ethnic groups (see Figure 1-2). Opioid-involved mortality was more connected to use of prescription opioids during the first wave of the crisis, and non-Hispanic White people may have had greater access to those drugs because they were more likely to be prescribed opioids.40

Figure 1-2.

Overdose Deaths Involving Opioids, by Race and Ethnicity

Deaths per 100,000 People

The number of opioid-involved deaths per capita for non-Hispanic White people grew during the first two waves of the crisis. As the use of more potent synthetic opioids increased, the number of deaths also rose among people from other racial and ethnic groups.

Notes

Data source: Congressional Budget Office, using information from the CDC WONDER database, Centers for Disease Control and Prevention, National Center for Health Statistics, “About Multiple Cause of Death 1999–2020” (accessed January 5, 2022), https://wonder.cdc.gov/mcd-icd10.html. See www.cbo.gov/publication/58221#data.

Opioid-involved deaths per 100,000 people among Native Americans or Alaska Natives and Asians or Pacific Islanders are unavailable for many years before 2013 because of the small amount of data available.

The first wave of the opioid crisis began in 1996, but the number of overdose deaths involving opioids is not available for the early years of the crisis. In addition, the former Assistant Secretary for Health at the Department of Health and Human Services noted the emergence of a fourth wave beginning in 2019. See Steven Ross Johnson, “Q&A: ‘We’re Entering the Fourth Wave, Which Is Methamphetamine,’” Modern Healthcare (August 3, 2019), https://tinyurl.com/muyjdfuu.

Opioid-involved deaths among racial and ethnic groups other than non-Hispanic White people and Asian or Pacific Islanders increased dramatically with the greater use of illegally produced opioids starting in the third wave of the opioid crisis. The number of deaths per 100,000 people among Native American or Alaska Native and non-Hispanic Black people caught up to the number of deaths among non-Hispanic White people in 2019 (the beginning of the emerging fourth wave of the crisis) and exceeded it in 2020. Opioid-involved overdose deaths have also increased over time among Hispanic people and Asian or Pacific Islanders, though much less than for other groups. Deaths among those two groups rose sharply in 2020, as they did for other racial and ethnic groups. The increase in deaths involving opioids and stimulants among racial and ethnic groups may be due to disparities in access to treatment and differences in the provision of treatment.41

The effects of the opioid crisis also differed by various other sociodemographic and economic characteristics. In an analysis of data from 2008 to 2015, researchers found that opioid-involved mortality was higher among individuals who were male, were ages 18 to 59, were disabled, had less education, had criminal justice involvement, or lived in the South Atlantic or Mountain states. More deaths involving opioids also occurred among people who were unemployed, who had low income, and who did not have health insurance.42

Chapter 2Factors Contributing to the Opioid Crisis

Researchers have identified a variety of factors that led to the opioid crisis, including increased prescribing of opioids, changes in illegal opioid markets, and societal changes that may have resulted in increased demand for opioids by people experiencing declines in real wages and social cohesion (see Figure 2-1). Those factors also reinforced each other. For example, increasing the supply of opioids had a greater effect on society because the demand for opioids also increased.1 But the relative importance of individual contributors to the crisis has not been established.2

Figure 2-1.

Factors Contributing to the Opioid Crisis

Notes

Data source: Congressional Budget Office.

a. Diversion of prescription opioids refers to the distribution or use of the drugs in ways not intended by the prescriber.

b. Economic deterioration includes declining real wages and worsening labor market opportunities. Social deterioration refers to declining marriage rates and deterioration in other aspects of social cohesion, including child-rearing and unionization.

Increased Prescribing of Opioids

The increased prescribing of opioids that contributed to the crisis resulted from three factors that reinforced each other: aggressive promotion efforts by pharmaceutical companies, greater emphasis on assessing patients’ pain and treating it medically, and changes in incentives in the health care system.

Aggressive Promotion of Prescription Opioids by Pharmaceutical Companies

Pharmaceutical companies encouraged the prescribing of opioids in several ways:

• They promoted the use of prescription opioids to prescribers and pharmacists and encouraged them to endorse the prescribing of opioids to their colleagues,
• They compiled profiles of individual physicians’ prescribing practices to target advertising toward physicians who were already heavy prescribers of opioids, and
• They distributed starter coupons that provided patients with free prescription opioids.3

Research has shown that some of the marketing materials used by pharmaceutical companies were misleading. For example, some advertisements promoted the use of certain prescription opioids for the treatment of chronic, non-cancer-related pain even though the clinical evidence was lacking. Some promotional materials also understated the addictive potential of prescription opioids.4 Research has demonstrated that areas that were subject to more intense opioid marketing experienced greater growth in opioid prescribing.5

Increased Emphasis on Assessment and Medical Treatment of Patients’ Pain

Clinical norms about managing patients’ pain and prescribing opioids for it began to change in the 1980s, in part because of two widely cited papers.6 Those studies, which were narrow in scope, were interpreted as evidence that patients who were prescribed opioids to treat pain had minimal risk of developing opioid use disorder.7

In addition, nonprofit organizations such as the American Academy of Pain Management and the American Pain Society—both funded by pharmaceutical companies—sought to raise awareness about pain management.8 In 1995, the American Pain Society began a campaign that characterized pain as the “fifth vital sign.”9 The following year, the two organizations released a consensus statement that advocated for the use of opioids to treat chronic, non-cancer-related pain.10 In 2000, the Joint Commission, an organization that accredits hospitals, introduced new standards for the regular and systematic monitoring and management of pain in hospitalized patients. The new standards regarded pain assessment and control as a “patients’ rights issue.”11 In addition, one of the pharmaceutical companies, Purdue Pharma, coined the term “opiophobia.”12 It was used to refer to providers’ “unreasonable fear of opioid use.”13 Many providers responded to the updated guidance from organizations by prescribing more opioids.14 Research has found that counties with higher prevalence of pain were shipped more prescription opioids and experienced more deaths from overdoses of prescription opioids.15

Changes in Incentives in the Health Care System

Changes in incentives in the health care system also encouraged the prescription of opioids. Some of those incentives affected the way providers were assessed and reimbursed. Other incentives affected the way opioids were prescribed.

Assessment of physicians and hospitals changed in ways that resulted in greater opioid prescribing. Standards for assessing physicians were affected by model guidelines issued by the Federation of State Medical Boards in 1998. The guidelines, which were used to regulate and discipline physicians, encouraged the use of opioids for chronic, non-cancer-related pain and discouraged the use of disciplinary action for physicians prescribing opioids.16 Hospitals’ assessment and payments were affected by the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which included questions about patient satisfaction with pain management. In 2010, survey scores were incorporated into the value-based incentive payments in the Hospital Value-Based Purchasing Program, which rewarded hospitals for providing high-quality care. According to studies, some providers felt pressure to overprescribe opioids to avoid receiving lower patient satisfaction scores.17

Changes in other incentives in the health care system resulted in the unintended consequence of increasing the use of opioids and their diversion to people who were not prescribed them. In response to demands to reduce the “hassle factors” of refilling prescriptions—one of the barriers to patient pain control—some insurance companies and retail pharmacists sought to lower the number of opioid refill requests by charging less for prescriptions with larger numbers of pills.18 As a result, the availability of opioids for legal and illegal consumption increased. In addition, some insurance companies placed restrictions, including utilization management and prior authorization rules, on the potentially more costly nonopioid alternatives to pain management such as physical therapy, which could have resulted in missed opportunities to direct patients toward potentially safer and more effective treatments for pain than prescription opioids.19

Greater Consumption of Opioids From Illegal Sources

Changes in illegal opioid markets also contributed to the opioid crisis. The increased supply of prescription opioids made them more available for nonmedical use and diversion in the earlier years of the crisis. More recently, demand for heroin and fentanyl and related substances increased because of lower prices for those drugs and reduced availability of prescription opioids.

Increased Nonmedical Use and Diversion of Prescription Opioids

Nonmedical use and diversion of prescription opioids changed along with the supply of the drugs.20 In data available from 2008 to 2019, nonmedical use of prescription opioids increased until 2011 and then decreased until 2019 (see Figure 2-2, top panel). Trends in the nonmedical use of prescription opioids coincide with trends in the amount of prescription opioids dispensed (see Figure 1-1). Common sources of prescription opioids for nonmedical use include diversion from friends or relatives, physicians, and drug dealers or strangers.21 Trends in diversion of prescription opioids followed a similar pattern: In data available from 2006 to 2019, diversion increased until 2011 and then decreased for most years until 2019 (see Figure 2-2, bottom panel).

Figure 2-2.

Nonmedical Use and Diversion of Prescription Opioids

Nonmedical use of prescription opioids increased until 2011 and then decreased as dispensing of prescription opioids fell and use of illicitly manufactured opioids increased.

Diversion of prescription opioids increased with the availability of the drugs until 2011 and then decreased for most years afterward as nonmedical use of prescription opioids declined and people used illegally manufactured opioids instead.

Notes

Data source: The Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System, RADARS System Drug Diversion Program and Poison Center Program: Abuse and Diversion of Prescription Opioids for the Congressional Budget Office (May 28, 2021), pp. 1–10. See www.cbo.gov/publication/58221#data.

Data on nonmedical use of prescription opioids are annualized quarterly rates from poison control center reports of people attempting to get high by improperly or incorrectly using the substances. Diversion of prescription opioids refers to the distribution or use of the drugs in ways not intended by the prescriber. Diversion data are annualized quarterly rates from documented cases of illegal acquisition or distribution of prescription opioids submitted by drug officials.

The figure includes data on the following prescription opioids: buprenorphine, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxymorphone, tapentadol, and tramadol.

Changes in the Market for Heroin and for Fentanyl and Similar Substances

The supply of heroin and fentanyl increased as a result of changes in the markets for those drugs and the decreased availability of diverted prescription opioids. Changes in international markets resulted in an influx of lower-priced heroin to the United States.22 The retail price of a gram of pure heroin fell from $1,237 in 1992 to $552 in 2002 and to $465 in 2012 (all in 2012 dollars).23 Heroin use also increased as federal and state policies limited the availability of prescription opioids for misuse in response to concerns about the rising number of overdose deaths involving prescription opioids.24 That shift is consistent with studies that found that about 80 percent of heroin users used prescription opioids nonmedically before initiating heroin use.

Other reasons people transition from nonmedical use of prescription opioids to heroin include the higher potency of heroin, the ease with which it can be manipulated for nonoral consumption, and its lower cost.25 The risks of overdose and the development of certain medical conditions (for example, HIV and hepatitis C) are higher with heroin use than with nonmedical use of prescription opioids.26

In addition, the supply of fentanyl and related substances increased because of changes in the market for those drugs. The ability to purchase such substances online (and the associated use of shipping services for distribution) has facilitated the purchase of fentanyl, related substances, and the precursor chemicals for making fentanyl, because they are relatively cheap to transport over long distances by mail and parcel delivery. Mexico is the primary source of illicitly manufactured fentanyl, which is made from precursor chemicals that are largely purchased from China.

Fentanyl can be produced more cheaply than heroin because it is made from ingredients in a lab. In addition, the chemicals required to make fentanyl are not always regulated and can be acquired relatively easily from countries that produce chemicals and pharmaceuticals—allowing fentanyl manufacturers to adjust if the supply from a particular source is reduced.27 Fentanyl is also 50 to 100 times more potent than heroin, which allows it to be transported in smaller quantities and to be smuggled and distributed more easily. At the same time, that potency makes it more dangerous than heroin, particularly for unsuspecting users, and more and larger doses of naloxone can be required to reverse an overdose from fentanyl than from other opioids.28

Increased Demand for Opioids for Self-Medication

Researchers have suggested that people experiencing despair as a result of economic and social deterioration have increased the demand for opioids and other substances used for self-medication.29 Although the relationship between socioeconomic variables and opioid use is subject to debate, changes in age-specific mortality rates indicate that non-Hispanic White people without a college education were particularly affected by economic and social deterioration and the opioid crisis in its earlier waves.30

Economic and social deterioration can help explain who has been most affected by the opioid crisis, but the timing of the crisis appears to involve a broader set of factors.31 Economic and social deterioration began in the 1970s, before the opioid crisis, when the labor market prospects for non-Hispanic White workers without a college education started to decline. That group’s real wages have fallen as a result of several factors, including globalization and automation. Worsening labor market opportunities contributed to the group’s declining marriage rates and deterioration in other aspects of social cohesion, including child-rearing and unionization. Mortality rates among middle-aged, non-Hispanic White people started rising in the late 1990s, primarily driven by an increase in deaths from drug overdose, suicide, and alcohol-related liver disease. Deaths that result from those causes are often referred to as “deaths of despair.”32 More than three-fourths of deaths of despair are due to drug overdoses.33

Although economic and social deterioration preceded the increase in opioid prescribing, research has shown that subsequent plant closures and increases in manufacturing unemployment (which can contribute to economic and personal despair) have resulted in increases in deaths from opioid overdoses. Research has also found an increase in overdose deaths among people affected by policies that liberalized international trade, particularly among White people.34 The effects of social and cultural factors, such as family stability, on opioid-involved deaths are challenging to identify with research studies.35

Chapter 3Recent Federal Legislation in Response to the Opioid Crisis

In 2016 and 2018, three major laws were enacted in response to the opioid crisis: the Comprehensive Addiction and Recovery Act of 2016, the 21st Century Cures Act, and the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. Because the opioid crisis is multifaceted, the laws seek to address it through provisions that aim to lower the demand for and supply of opioids and lessen the effects of opioid misuse. The laws direct funding to many federal programs, as well as to state and local governments, Native American and tribal organizations, and certain providers of health care services.

Those laws complement resources that the federal government regularly devotes to addressing substance use disorder, including resources for opioids. According to one estimate, total federal funding to address the opioid crisis nearly tripled from fiscal year 2017 to fiscal year 2020. The Department of Health and Human Services (HHS) received the bulk of those appropriations.1 The Substance Abuse and Mental Health Services Administration received most of the funds appropriated to HHS. Other agencies receiving funding included the Office of National Drug Control Policy and the Department of Justice.

Types of Responses

The laws aim to respond to the opioid crisis in three ways:

• Reducing the demand for opioids by preventing and treating opioid use disorder,
• Reducing the supply of opioids by limiting the inappropriate and nonmedical use of prescription opioids and the supply of illegally produced opioids, and
• Reducing the harm from OUD by supporting the health of people with OUD until they are ready to seek treatment.

Each type of response addresses the opioid crisis through a different mechanism.2 Responses aimed at reducing demand include expanding prevention efforts and eligibility for federally subsidized insurance, as well as the treatments those insurance plans cover.3 Responses to reduce the supply of opioids include increasing oversight of prescriptions among people at risk of misusing opioids and identifying medical professionals who prescribe opioids in significantly larger quantities or doses than their peers (“outlier” prescribers), as well as curbing the supply of illegally produced opioids. Lastly, strategies to reduce harm include enhancing access to overdose reversal drugs and improving the availability and quality of training for their administration.

Reducing the Demand for Opioids

The SUPPORT for Patients and Communities Act includes provisions aimed at reducing the demand for opioids by facilitating greater access to and use of treatment among people with OUD who are enrolled in Medicaid and Medicare (see Table 3-1).4 Medicaid provisions expand eligibility to certain young adults and increase federal requirements and support for Medicaid coverage of treatment of substance use disorder. For example, Medicaid provisions enable young adults involved in the criminal justice or foster care system to retain Medicaid coverage and access services (including treatments for OUD) and establish a demonstration project to increase the capacity of SUD providers.5 Another provision extends an enhanced federal medical assistance percentage (FMAP) for qualified activities for Medicaid health homes targeted at beneficiaries with SUD.6 In addition, the SUPPORT for Patients and Communities Act includes two temporary provisions that expand access to treatment for nonelderly Medicaid beneficiaries with SUD by allowing federal matching funds for services in institutions for mental diseases with a limit of 30 days per year (through September 30, 2023) and establish a requirement for state Medicaid programs to provide coverage for medications to treat OUD (through September 30, 2025).7

Medicare provisions expand access to telehealth for OUD and other SUDs for beneficiaries and add coverage for treatment at opioid treatment programs—resulting in coverage of methadone, which can only be provided in those programs (with few exceptions). Other provisions require annual screening for OUD and other SUDs for beneficiaries and provide funding to train clinicians to provide pharmacotherapy—medical treatment of disease with medication—to treat OUD at federally qualified health centers and rural health clinics until funding is expended.8

Other provisions in CARA and the SUPPORT for Patients and Communities Act that aim to lower demand for opioids ease restrictions related to the prescription of buprenorphine and create a program for families with parents or guardians with OUD. In particular, one provision permanently expands privileges for prescribing buprenorphine to licensed nurse practitioners and physician assistants and expands those privileges through October 1, 2023, for clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives. In addition, providers can now treat more patients with buprenorphine.9 Another provision appropriated funds for a grant program through 2026 to support recovery from OUD and to aid reunification for families affected by OUD. The laws also authorized appropriations for grants to support programs that aim to prevent and treat OUD, such as evidence-based treatments that use pharmacotherapy. Those authorizations target at-risk populations, including children, adolescents, young adults, and pregnant or postpartum women.

Reducing the Supply of Opioids

CARA and the SUPPORT for Patients and Communities Act include provisions intended to lessen the availability of legal and illegal opioids (see Table 3-2).10 Changes to Medicaid and Medicare aim to reduce the supply of prescription opioids. For example, a provision requires the use of safety edits for opioid refills that prompt prescribers and pharmacists to determine if Medicaid enrollees’ opioid use is appropriate and medically necessary and to identify fraud and abuse related to controlled substances. In Medicare, a provision establishes grants to educate and provide outreach to outlier prescribers about best practices for prescribing opioids and about nonopioid pain management therapies. In addition, opioids covered under Medicare Part D must be prescribed electronically, and prescription drug plans must use drug-management programs for at-risk Medicare beneficiaries by 2022.

Other changes to address the opioid crisis involve reducing the supply of opioids by changing the way in which prescriptions for opioids are filled and imposing new requirements on the Postal Service. One provision authorizes the partial filling of Schedule II controlled substances, including opioids.11 Another provision requires the Postal Service to transmit advance electronic data to Customs and Border Protection on merchandise arriving in the United States through international mail to improve monitoring and reduce the trafficking of illicitly produced fentanyl and other synthetic opioids.

Measures to improve the prescription of opioids and reduce their nonmedical use also included the authorization of appropriations for grants to states to establish, maintain, or upgrade prescription drug monitoring programs (PDMPs).12 The laws also authorized other grants to expand the return of unused prescription opioids and to help laboratories detect fentanyl and related substances.

Reducing the Harm From Opioid Use Disorder

All three laws authorized grants to minimize the harmful effects of OUD alone or in combination with strategies to reduce demand and supply (see Table 3-3). Some provisions authorized appropriations for grants to expand access and training related to medications or devices for reversing opioid overdoses. Most of those authorizations combined strategies to reduce harm with those that targeted lowering the demand for and supply of opioids. For instance, the 21st Century Cures Act authorized $500 million to be appropriated in 2017 and 2018 for state opioid response grants, for a total of $1 billion. The SUPPORT for Patients and Communities Act authorized additional funding for 2019 to 2021. State grants can be used for a variety of purposes, including expanding access to prevention and health care services to treat SUDs, funding recovery supports, improving PDMPs, and expanding access to opioid overdose reversal drugs.

Federal Funding

The laws devoted resources to address the opioid crisis through mandatory spending and also authorized appropriations for such purposes.13 For example, one provision that expands Medicaid coverage of treatments for OUD was estimated to increase mandatory spending, whereas authorizations of appropriation of funds, such as for grants to states to support programs to reduce opioid prescribing, will not affect federal spending unless funds are subsequently appropriated.14

The Congressional Budget Office estimated that provisions in CARA will reduce mandatory outlays, and provisions in the SUPPORT for Patients and Communities Act will increase mandatory outlays (see Table 3-4).15 The laws also authorized amounts to be appropriated, although CBO cannot quantify the amount of authorized appropriations that were later appropriated because appropriation acts do not always refer to specific authorizing laws, or they may refer to multiple authorizing laws.16

Estimated Changes in Mandatory Outlays

Individual provisions aimed at curbing the demand for and supply of opioids will increase mandatory outlays in some cases and decrease them in others. In particular, some of the provisions aimed at reducing supply will increase mandatory outlays, and others will reduce them. None of the provisions aimed at curbing demand will reduce mandatory outlays.

By CBO’s estimate, on net, opioid-related provisions in CARA will reduce mandatory outlays by $187 million over the 2017–2026 period, and provisions in the SUPPORT for Patients and Communities Act will increase mandatory outlays by $2.7 billion over the 2019–2028 period, mostly for Medicaid (see Figure 3-1). The estimated net reduction of $187 million in CARA reflects a $54 million increase in outlays from provisions related to reducing the demand for opioids, as well as a reduction of $241 million in outlays from provisions related to reducing the supply of prescription opioids subsidized by the federal government. By contrast, the estimated $2.7 billion net increase in mandatory outlays stemming from the SUPPORT for Patients and Communities Act results from an estimated $2.9 billion increase in spending from provisions related to reducing the demand for opioids and an estimated $205 million reduction in outlays from provisions aimed at reducing supply. A few of the provisions that will affect mandatory outlays are temporary and are set to expire in the next few years.

Figure 3-1.

Estimated Effects on Mandatory Outlays of Laws Enacted in Response to the Opioid Crisis

Millions of Dollars

Opioid provisions in the SUPPORT for Patient and Communities Act increased mandatory spending by more than those in CARA did, largely because of higher spending to lower the demand for opioids.

Notes

Data source: Congressional Budget Office. See www.cbo.gov/publication/58221#data.

CBO’s cost estimate for CARA spanned fiscal years 2017 to 2026. The cost estimate for the SUPPORT for Patients and Communities Act spanned fiscal years 2019 to 2028.

Estimated changes in mandatory outlays are based on CBO’s cost estimates. The cost estimate for CARA is available at www.cbo.gov/publication/51783, and the cost estimate for the SUPPORT for Patients and Communities Act is available at www.cbo.gov/publication/54515. In this report, CBO focuses on provisions that were estimated to increase or decrease mandatory spending by more than $500,000.

The figure includes provisions related to two of the three main strategies to address opioid use disorder: reducing demand and reducing supply. The two acts did not include provisions aimed at reducing harm that affect mandatory outlays. Effects of provisions not related to opioids or substance use are not included in the figure.

CARA = Comprehensive Addiction and Recovery Act; SUPPORT = Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment.

Spending Subject to Appropriation

Altogether, the three laws authorized the appropriation of $8.1 billion between 2017 and 2023; the SUPPORT for Patients and Communities Act accounted for most of those authorizations (see Figure 3-2). Specifically, CARA authorized appropriations totaling $835 million between 2017 and 2021, the 21st Century Cures Act authorized appropriations totaling $1.0 billion between 2017 and 2018, and the SUPPORT for Patients and Communities Act authorized appropriations totaling $6.3 billion between 2019 and 2023.17 Most provisions allowed for multiple strategies.

Figure 3-2.

Amounts Authorized to Be Appropriated by Laws Enacted in Response to the Opioid Crisis

Millions of Dollars

Amounts authorized under the SUPPORT for Patients and Communities Act were greater than those authorized by CARA and the 21st Century Cures Act. Although all three laws included amounts for multiple strategies, those amounts were considerably larger in the SUPPORT for Patients and Communities Act.

Notes

Data source: Congressional Budget Office. See www.cbo.gov/publication/58221#data.

CARA authorized appropriations between 2017 and 2021, the 21st Century Cures Act authorized appropriations between 2017 and 2018, and the SUPPORT Act authorized appropriations between 2019 and 2023.

Amounts authorized to be appropriated for the 21st Century Cures Act are based on CBO’s cost estimate available at www.cbo.gov/publication/52301. Because CBO’s cost estimates for CARA and the SUPPORT for Patients and Communities Act did not include changes in spending subject to appropriation, in this report the agency examined the text of the laws as enacted. For all three laws, CBO summed authorizations subject to appropriation related to opioids or substance use disorder with two exceptions. First, to focus on new activities to address the opioid crisis, the agency excluded authorizations of appropriations for programs in existence before the three laws were enacted. Second, CBO did not include authorizations of appropriations for programs aimed at addressing trauma in children in contact with adults with substance use disorder, because those programs address secondary effects, rather than direct effects, of the opioid crisis. Actual appropriations may have differed from the amounts authorized.

The figure includes provisions related to the three main strategies to address opioid use disorder: reducing demand, reducing supply, and reducing harm. Certain provisions in the laws used a combination of strategies.

CARA = Comprehensive Addiction and Recovery Act; SUPPORT = Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment.

Subject to future appropriation action, the laws authorized funding for different levels of government, including state and local governments. Other entities that could receive funding included tribal organizations, federally qualified health centers, community organizations, and accredited schools of allopathic medicine or osteopathic medicine and teaching hospitals.

The actual amounts appropriated may have differed from the amounts authorized. Quantifying how much of the funds that were authorized in the major opioid laws were later appropriated is challenging for two reasons. First, appropriation acts may not clearly identify the legislation that authorized the funding. For instance, the legislative text may be sufficiently broad to support a range of activities related to opioids, including ones authorized by the three major laws discussed in this report, but also those from other authorizations. Second, appropriation acts may identify specific authorizing legislation but provide one amount of funding for multiple programs, making it impossible to identify the appropriated amounts related to specific authorizing legislation.

According to one study, total federal appropriations to address the opioid crisis—including not only funds corresponding to the three major opioid laws but also annual funding for federal agencies with programs related to addressing OUD—increased from $2.1 billion in fiscal year 2017 to $6.1 billion in fiscal year 2020.18 Those funds were allocated to multiple federal agencies, including HHS, the Office of National Drug Control Policy, and the Department of Justice; most of the funds were appropriated to the Substance Abuse and Mental Health Services Administration.

Chapter 4The Crisis After Enactment of the Recent Laws and During the Pandemic

Deaths involving opioids increased in most years between the enactment of the laws and the start of the coronavirus pandemic but more slowly than in the immediately preceding years. In addition, the use of prescription opioids continued to fall after the laws were enacted, but those changes may not be attributable to the laws.

Deaths from opioid overdoses increased dramatically during the pandemic, with disproportionate increases among some racial and ethnic groups. A variety of factors may have contributed to increased opioid-involved mortality in 2020, including greater demand for opioids due to the stresses of the pandemic and disconnection from treatment and other recovery supports. Evidence also indicates that opioid use became more dangerous during the pandemic because some people switched to more potent substances and increased solitary drug use.

Policy changes enacted in March 2020 reduced certain barriers to treatment, and additional federal funds to address the crisis were made available through the American Rescue Plan Act of 2021.

The Opioid Crisis Between the Enactment of the Laws and the Pandemic

From 2016 to 2019, deaths involving opioids increased; however, the annual rate of increase slowed. During that time, the Food and Drug Administration approved opioid analgesics for the treatment of pain as well as treatments for opioid use disorder and drugs to reverse opioid overdoses. Although trends in opioid-involved mortality coincided with the timing of the federal legislation, it is difficult to determine whether the observed changes in deaths and the use of prescription opioids can be attributed to the laws.

Opioid-Involved Deaths

The annual number of deaths involving opioids doubled from 2010 to 2016, increasing from 21,089 to 42,249, the year that the Comprehensive Addiction and Recovery Act of 2016 and the 21st Century Cures Act were enacted (see Figure S-1). Fatalities involving opioids increased to 47,600 in 2017, fell to 46,802 in 2018, and then rose again to 49,860 in 2019, an increase of 7 percent from the previous year.1 The increase in opioid-involved fatalities continued to be driven by use of illicitly manufactured fentanyl and similar substances. In addition, the use of opioids in conjunction with psychostimulants continued its upward trend.2 Deaths resulting from the use of prescription opioids and heroin fell between 2016 and 2019.

The FDA’s Approval of New Products

In recent years, the FDA approved a number of new opioid analgesics. Several of the opioids were approved for the treatment of moderate to severe pain.3 One of the drugs approved was a potent opioid for use in medically supervised settings.4 The agency also approved the first generic opioid with an abuse-deterrent formulation.5

The FDA also approved several new products for the treatment of OUD and reversal of opioid overdoses. It approved the first nonopioid drug for the treatment of withdrawal symptoms associated with the abrupt cessation of opioid use and the first generic version of sublingual buprenorphine for the treatment of OUD. In addition, it approved the first generic naloxone nasal spray to reverse opioid overdose as well as a higher-dose naloxone nasal spray.6

Challenges in Evaluating the Effects of Federal Laws

The effects of recent federal laws on the opioid crisis are difficult to evaluate. Although total opioid-involved deaths increased between 2016 and 2019, the annual increase in deaths averaged 6 percent from 2017 to 2019, which was smaller than the 19 percent per year average increase from 2014 to 2016.

The slowdown could be due to increased use of naloxone to reverse opioid overdoses and of medication to treat OUD.7 Those activities were supported by the federal laws, but the slower growth in opioid-involved mortality cannot be directly attributed to the laws for two reasons. First, it is difficult to assess the extent to which the amounts authorized in the laws were subsequently appropriated and how funding was disbursed and eventually used for programs addressing the opioid crisis.8 Second, isolating the effect of the laws is challenging because the funding they provided complemented annual appropriations to agencies tasked with addressing the opioid crisis. Some of the issues involved in evaluating the effects of federal spending on drug misuse may be addressed by closing gaps in data collection.9

The Opioid Crisis During the Pandemic

Opioid-involved deaths increased sharply during the pandemic. Unlike the rise in mortality during the early stages of the crisis, opioid-involved death rates during the pandemic increased for several racial and ethnic groups in addition to non-Hispanic White people. Deaths involving fentanyl and the combined use of opioids and psychostimulants continued to increase during the pandemic, but deaths from prescription opioids also rose.

The increase in opioid overdose mortality may be attributed to increased demand for opioids and more dangerous use of opioids, such as when people switch to more potent opioids or increase their use of substances in isolation. That increase occurred even though policy changes during the pandemic expanded access to OUD treatment and increased federal funding to address the opioid crisis.

Opioid-Involved Deaths

Deaths involving opioids increased dramatically during the pandemic. In 2020, 68,630 opioid-involved fatalities occurred, a 38 percent increase from 2019 (see Figure S-1).10 The increase in deaths involving opioids during the first year of the pandemic continued to be driven by use of illicitly manufactured fentanyl and similar substances.11 Although those substances continued to account for most opioid-involved fatalities, deaths from prescription opioids also increased after a three-year period of no growth or declining growth.12 Deaths from using opioids in conjunction with psychostimulants continued to rise. Preliminary data for 2021 indicate that the trend of increases in the number of opioid-involved deaths has continued.13

Although the early waves of the opioid crisis had a disproportionate effect on non-Hispanic White people, greater increases in opioid overdoses occurred among other racial and ethnic groups during the pandemic. The number of opioid-involved deaths per 100,000 people among non-Hispanic Black and Native American or Alaska Native people surpassed the number for non-Hispanic White people in 2020 (see Figure 1-2). Dramatic increases in the number of deaths involving opioids per 100,000 people also occurred among Hispanic people and Asian or Pacific Islanders.14

The increases may have been driven by the greater health and economic effects of the pandemic on communities of color.15 Research has found that, during March 2020, the number of buprenorphine prescriptions filled declined for non-White patients but not for non-Hispanic White patients.16 (Buprenorphine is one of the medications used to treat OUD.) In addition, Black, Hispanic, and Native American or Alaska Native people had higher age-adjusted risk of hospitalization and death from COVID-19 than White people. Black and Hispanic people were also more likely than White people to have had difficulty paying household expenses and to have experienced food insecurity during the pandemic.17

Opioid Use

A number of factors may have contributed to increased use of opioids during the pandemic. Anxiety, depression, and social isolation increased because of measures intended to reduce the spread of the coronavirus, including school closures, as well as concerns about contracting the virus.18 Also potentially fueling the demand for opioids were pandemic-related job losses that contributed to economic insecurity, which was mitigated but not eliminated by government transfer payments.19 At the same time, disruptions in in-person treatment and social supports may have led to relapses among some people who were in recovery.20

The increased use of and deaths from fentanyl and related substances may have been due, in part, to a temporary disruption in the availability of less potent opioids, which became harder to get as a result of pandemic mitigation measures, such as lockdowns.21 Total prescription opioids received by patients during the early months of the pandemic fell, driven by a decline in opioid prescriptions given to patients who had not used prescription opioids in the past year. That decline was due to cancellations in nonemergency medical visits and surgeries stemming from pandemic mitigation measures in the spring of 2020.22

In addition, solitary use of opioids increased because of social distancing measures. Use of opioids in isolation can be more dangerous because of the lack of bystanders to administer naloxone in the event of an overdose.23

Policy Changes and Federal Funding During the Pandemic

The increase in opioid use occurred even though policy changes made in March 2020 in response to the pandemic may have resulted in lower barriers to treatment.24 The use of Medicaid emergency authorities resulted in expanded eligibility and access to services, which reduced financial barriers to accessing OUD treatment and naloxone.25 The federal government also eased restrictions on methadone dispensing by allowing take-home doses for a 14- to 28-day period instead of requiring observed daily doses at federally regulated opioid treatment programs.26 Lastly, the use of telemedicine to treat patients with OUD remotely was expanded.27

Additional federal funds were made available to address the opioid crisis during the pandemic. The American Rescue Plan Act of 2021 appropriated funds for the prevention and treatment of SUD and for harm-reduction activities.28 The law appropriated $1.5 billion for block grants to prevent and treat SUD, which are being distributed largely by the Substance Abuse and Mental Health Services Administration.29 The law also appropriated $30 million for community-based funding of harm-reduction services, including naloxone distribution and syringe services programs.30 In comparison, the three federal laws discussed in this report—CARA, the 21st Century Cures Act, and the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act—authorized appropriations of $3.4 billion between 2021 and 2023. In the future, nonfederal money from the settlement of lawsuits against companies involved in the manufacture and distribution of opioids may also be available to support OUD prevention, treatment, and harm-reduction activities.31

About This Document

This report by the Congressional Budget Office was prepared at the request of the Chairman of the House Committee on Energy and Commerce. In keeping with the Congressional Budget Office’s mandate to provide objective, impartial analysis, the report makes no recommendations.

Noelia Duchovny and Ryan Mutter wrote the report with guidance from Tamara Hayford. Ryan Greenfield and Kate Young contributed to the section on recent federal legislation. Elizabeth Bass, Chad Chirico, Carrie H. Colla, Ann E. Futrell, Etaf Khan, Paul Masi, David Newman, Lara Robillard, Sarah Sajewski, and Chapin White provided useful comments. Christian Henry and Robert Lindsay fact-checked the report.

Wilson Compton of the National Institute on Drug Abuse, Anand Parekh of the Bipartisan Policy Center, and Kosali Simon of Indiana University provided helpful comments. The assistance of external reviewers implies no responsibility for the final product; that responsibility rests solely with CBO.

Mark Doms, Mark Hadley, Jeffrey Kling, and Robert Sunshine reviewed the report. Rebecca Lanning edited it, and R. L. Rebach created the graphics, illustrated the cover, and prepared the text for publication. The report is available at www.cbo.gov/publication/58221.

CBO seeks feedback to make its work as useful as possible. Please send comments to communications@cbo.gov.

Phillip L. Swagel

Director

September 2022