Summary

The opioid crisis has had devastating effects in the United States. To respond to the crisis and alleviate its effects on people, communities, and the economy, policymakers have enacted laws to limit the supply of opioids, lower the demand for opioids, and reduce the harm from opioid use. Despite those measures, drug overdoses and deaths have not only persisted but increased. During the COVID-19 pandemic, the number of opioid-involved deaths rose sharply because of increases in deaths involving the powerful synthetic opioid fentanyl and because of the concurrent use of multiple substances. More recently, from 2023 to 2024, drug overdose deaths declined by 27 percent to about 80,000, their level at the beginning of the pandemic.1

In this report, the Congressional Budget Office describes and assesses the effects of policy approaches that lawmakers could employ to address the ongoing opioid crisis. The agency chose approaches that have considerable Congressional interest, as reflected in legislative actions and proposals, and that are supported by substantial evidence about whether and how they would affect outcomes of interest, such as utilization of and retention in treatment, the number of overdoses, and rates of opioid-related mortality. Policy approaches that meet only one of the two criteria, or that do not meet either but have attracted significant attention from academics and policymakers, are briefly discussed at the end of each section.

Policy Approaches to Address the Opioid Crisis

To determine which policy approaches to evaluate, CBO reviewed the academic and policy literature and searched for related legislation. Among the policy approaches that CBO found, the agency chose six that had a lot of interest from Congress and substantial evidence about their effects on relevant outcomes. (An additional five approaches—each of which has received some interest from Congress, has less empirical evidence, or has attracted significant attention from academics and policymakers—are evaluated later in this report.) For more details about CBO’s process for selecting policy approaches, see “Details About the Policy Approaches That CBO Examined”.

The six main approaches that CBO examined seek to address three dimensions of the opioid crisis: supply, demand, and harm. The first approach would reduce the supply of illicit opioids, and the last approach would mitigate the harms associated with opioid use. The other four approaches would lower the demand for opioids by preventing and treating the compulsive use of opioids despite harmful consequences, known as opioid use disorder (OUD), which leads to physical dependence, tolerance, cravings, and difficulty controlling use.

To assess the effectiveness of the policy approaches, CBO examined recent studies that looked at a wide range of outcomes (see Table S-1). On the basis of that literature review, CBO found the following:

• Policies to limit the supply of opioids tended to reduce opioid misuse, hospital admissions, crime rates, and mortality rates (both opioid-related and overall), but such effects were temporary in some cases or offset by substitution of other opioids not targeted by the policy; and
• Policies aimed at reducing the demand for opioids increased treatment rates, and both demand- and harm-reduction approaches generally reduced opioid-involved mortality.2

CBO evaluated the policy approaches qualitatively; comparisons of the size of their effects are beyond the scope of this report.

Reducing Supply. CBO examined one policy approach that would reduce the supply of illegally produced opioids by intercepting and preventing the movement of illicit fentanyl (which is manufactured illegally and sold without a prescription) through additional information sharing and counterdrug efforts.

Supply reduction has a federal component and a state and local component. Federal supply interdiction policies—efforts by law enforcement to interrupt the supply chain of illegal drugs—could strengthen the monitoring of mail deliveries or expand the capacity of state and local law enforcement agencies to collect and share data. State and local activities could include alternative methods of surveillance, data collection, and drug identification. Such activities could improve the quality and timeliness of information used by law enforcement agencies.

Evidence suggests that such interdiction efforts by law enforcement agencies improve people’s health outcomes and reduce crime rates, although two studies found that the impact was temporary in the case of supply interdiction of methamphetamine in the United States. Given the widespread production and distribution of illicit fentanyl, policies that target the supply of opioids may be less effective now than in the past, when distributional channels were fewer.

Reducing Demand. CBO examined four policy approaches that would reduce the demand for opioids through treatment and prevention. Three of the policies would focus on treating people who have OUD, and the fourth would limit the inappropriate use of prescription opioids. In particular, the policies would reduce the demand for opioids by:

• Expanding the scope of Medicaid coverage for OUD treatment,
• Expanding access to telehealth services for OUD treatment,
• Increasing access to treatment for people with OUD in the criminal justice system, and
• Enhancing the effectiveness of prescription drug monitoring programs (PDMPs), which are state databases of prescriptions written for controlled substances.

Medicaid is the single largest payer for behavioral health services. In addition, compared with Medicare enrollees and individuals enrolled in private health insurance plans, a larger share of Medicaid enrollees have substance use disorder (SUD, which is the persistent use of drugs despite substantial harm and adverse consequences to self and others). In states that have expanded Medicaid coverage under the Affordable Care Act (ACA), most incarcerated adults are eligible for Medicaid upon release. Medicaid coverage of OUD treatments (including medication for OUD, or MOUD) tends to result in greater use of treatments and continued engagement in treatment. That coverage could be required or incentivized to expand its reach.

Another way to lower barriers to treatment would be by ensuring coverage for telehealth-based OUD services among payers, including Medicare and Medicaid, and improving telehealth technology. The expansion of telehealth services during the pandemic was associated with increases in treatment for OUD, longer retention in treatment, and lower odds of overdosing on opioids. (An association between two variables means that they tend to move together, whether in the same direction or in opposite directions. That association shows a relationship between the two variables but does not necessarily imply that one causes the other.)

Two tactics could be used to expand OUD treatment in criminal justice settings. Judges and police departments could offer treatment as an alternative to incarceration, and more prisons and jails could provide OUD treatment to their inmates. Both tactics are associated with lower recidivism and higher rates of treatment.

The inappropriate use of prescription opioids could be limited through PDMPs. Those types of programs are available in all states and the District of Columbia in 2025. The federal government could increase the programs’ effectiveness by strengthening state policies that mandate or facilitate the use of PDMPs. Those policies tend to reduce the use of prescription opioids, including the amount prescribed to new users, as well as opioid-related hospital visits and deaths. Although PDMPs also lower the amount prescribed to existing users, this report focuses on their role in preventing new cases of OUD because most overdose deaths now stem from nonprescription sources of opioids.

Reducing Harm. CBO examined one policy approach that would reduce the adverse health, social, and legal consequences of drug use by increasing access to opioid overdose reversal medications. The most widely used such medication is naloxone, an opioid antagonist that binds to opioid receptors in the brain and blocks the effects of opioids, such as heroin, fentanyl, oxycodone, and morphine. Medicaid and Medicare typically cover at least one form of naloxone.

That approach could be implemented in several ways. Opioid overdose reversal medications could be distributed more widely, pharmacists could be allowed to prescribe those medications to broader groups of people, or the medications could be coprescribed.3 Evidence suggests that increasing access to opioid overdose reversal medications reduces overdose deaths without increasing opioid use.

Budgetary Effects of the Policy Approaches

The policy approaches examined in this report would alter federal outlays and, in some cases, revenues. CBO assessed four key types of budgetary effects.

• Initial effects of the policies on spending for OUD treatment and overdose reversal medications. Such effects would depend mainly on the cost of those services and on changes in their use paid for by federally subsidized health insurance programs. Initial effects also would include funding provided for grant programs related to opioids.4
• Subsequent effects on health care spending as a result of the policies, which would typically result in averted health care spending because of, for example, fewer emergency department visits for opioid overdoses. In a few cases, policies could have negligible effects on spending or could increase spending through offsetting costs. A share of the changes in health care spending would accrue to the federal government.
• Population-change effects from reductions in opioid-involved mortality. Such effects would increase income and payroll tax revenues as more people remained in the workforce and would also raise outlays for federal programs, including Medicaid, the Supplemental Nutrition Assistance Program (SNAP), Medicare, and Social Security retirement and disability benefits, as more people received those benefits or collected them for longer.
• Dynamic effects, which include initial effects, subsequent effects on health care spending, population-change effects, and all other effects on spending and revenues stemming from changes in the size of the economy. Dynamic effects would encompass the broader economic impact of policies, including more labor force participation, increased wages, and greater investment.

Those effects are broader than what CBO usually includes in its cost estimates. Initial effects and subsequent effects on health care spending would typically be included in conventional cost estimates. Those estimates generally reflect the expectation that the size of the economy remains unchanged under a legislative proposal. When practicable, CBO derives budgetary estimates of population-change effects primarily from the effects on labor income and on eligibility for benefits. CBO would conduct dynamic analysis (which examines the effects on the total output of the economy) if the legislation was projected to have a major effect on gross domestic product (GDP) or if the analysis was requested and practicable. Cost estimates generally focus on a 10-year projection period, but CBO sometimes provides information on longer-term effects.

The Opioid Crisis in the United States

Opioids are a class of drugs that interact with opioid receptors in the brain and body to relieve pain, slow certain bodily functions (such as breathing), and, in some cases, produce a sense of euphoria. Synthetic opioids, such as fentanyl, are produced and used both legally (when prescribed to treat severe pain) and illegally. Heroin, a highly addictive opioid, is illicitly produced and has no accepted medical use in the United States. Opioid use and misuse (the use of a prescription drug without a prescription or in a different way than prescribed) can lead to dependence, addiction, overdose, and death.

From 2015 to 2024, annual drug overdose deaths involving any opioid increased by 65 percent (from 33,100 to 54,700) in the United States, contributing to an accumulated total of more than 850,000 opioid-involved deaths since 2000.5 Beginning in 2023, annual opioid-involved overdose deaths declined; from 2023 to 2024, they dropped by about 30 percent. Use of synthetic opioids with and without other types of drugs (including alcohol) has contributed to the current crisis, which has become particularly severe among Black people, Native Americans, and men ages 25 to 64. An estimated 7 million to 8 million people in the United States were living with opioid use disorder in 2019.6

The opioid crisis has profoundly affected health, economic factors, and social outcomes. The health consequences of chronic opioid use can be severe. That use is associated with cognitive impairments and, over time, injecting opioids can cause organ damage and infection with hepatitis B and C, HIV, and other blood-borne viruses.7 The economic and social effects of the crisis are widespread. Opioid-involved deaths have contributed to the decline in U.S. life expectancy that began in 2015.8 In addition, the opioid crisis has negatively affected family structure, children’s well-being, and labor force participation.9

To address the many facets of the crisis, lawmakers have enacted several laws spanning supply, demand, and harm reduction. Most provisions of laws enacted from 2016 to 2018 that authorized funding for opioid and drug-related interventions have expired or will expire in the next few years. More recently enacted opioid-related laws focus on enforcement to reduce the supply of illicit opioids. In addition to federal funding, a $26 billion settlement was finalized in 2022 between the attorneys general of nearly all states and pharmaceutical opioid distributors and one manufacturer to resolve legal claims against those companies for their roles in perpetuating the opioid crisis.10 State and local governments have started to receive funds from the settlement. Those funds are intended to support efforts to mitigate the adverse effects of the opioid crisis.11

Trends in Overdose Deaths Involving Opioids

Recent increases in overdose deaths have been driven by deaths involving synthetic opioids, largely fentanyl (see Figure 1). Over the past 10 years, overdose deaths involving synthetic opioids increased by 780 percent and, as of 2024, deaths involving synthetic opioids accounted for 89 percent of all opioid-related overdose deaths.12 In 2023, annual deaths involving synthetic opioids decreased for the first time since 2018, declining by 1.5 percent from 2022. The most recent provisional data about drug overdose deaths show that from 2023 to 2024, deaths involving synthetic opioids declined by 37 percent.13

Synthetic opioids have been driving the recent surge in overdose deaths mainly because of their potency, unintentional consumption, and increased availability. Fentanyl is commonly mixed with other illicit drugs, and many people may be unaware that their drugs contain fentanyl.14 The use of synthetic opioids has also increased as their prices have fallen and as prescription opioids have become harder to obtain legally. The prices of fentanyl and related substances are low because fentanyl can be produced in a laboratory at low cost and because sales are facilitated by the internet; at the same time, federal and state interventions have reduced the availability of prescription opioids.15 The pandemic further exacerbated the opioid crisis by disconnecting people with OUD from traditional treatments and by increasing the demand for opioids.

Moreover, the ongoing crisis is expanding beyond opioids, as seen in the recent trend of concurrent use of fentanyl and xylazine (a veterinary tranquilizer).16 Over the past few years, more drug overdoses and deaths have involved opioids in combination with either other opioids or nonopioid substances, including xylazine, benzodiazepines, and alcohol (all of which function as central nervous system depressants), as well as stimulants (a class of drugs that boosts alertness and energy, such as methamphetamine and cocaine).17 For example, in 2020, approximately 40 percent of deaths involving illegally made fentanyl also involved stimulants; in 2023, methamphetamine was detected in 60 percent of fentanyl-positive urine drug test results, and cocaine was detected in 20 percent of those results.18 Use of opioids with other substances has contributed to a higher risk of fatal overdoses and other adverse health outcomes recently because of the lack of effective treatment and because of lower rates of initiation of and shorter retention in OUD treatment among people who use multiple substances.19

Demographic Breakdown of Overdose Deaths Involving Opioids

From the early 2000s until 2015, the rate of opioid-involved deaths rose fastest among non-Hispanic White and Native American or Alaska Native people, and through 2017 those two groups also had the highest rates of any racial group. Over the past decade, though, increases in opioid-involved deaths have accelerated among non-Hispanic Black and Native American or Alaska Native people (see Figure 2, top panel), whereas growth among non-Hispanic White people has slowed. Since 2020, rates of opioid-involved deaths among non-Hispanic Black and Native American or Alaska Native people have exceeded deaths among non-Hispanic White people, and studies suggest that those trends are driven by higher rates of drug overdose deaths involving fentanyl.20 About 40 percent of the growth from 2010 to 2020 in opioid-involved deaths among non-Hispanic Black people, relative to non-Hispanic White people, can be attributed to the disproportionate spread of fentanyl in metropolitan areas in the eastern United States, where more than half of all non-Hispanic Black people lived in 2010.21 From 2021 to 2023, the rate of opioid-involved deaths declined among non-Hispanic White people but increased in all other racial and ethnic groups.

The breakdown of opioid-involved deaths by sex and age follows a different pattern. Over the past two decades, the rate of opioid-involved overdose deaths among men has been consistently higher than the rate among women. In addition, death rates among people ages 25 to 44 have been consistently higher than rates for people at older ages (among men, for the entire period in Figure 2, and among women, for about half of the period). During the pandemic, opioid-involved death rates surged across all age groups, particularly among men (see Figure 2, bottom panel). From 2019 to 2023, people ages 25 to 44 had the highest opioid-related death rates, and people ages 45 to 64 experienced the fastest growth in opioid-related death rates. Those figures suggest that the opioid crisis could have a large impact on the working-age population and, consequently, on labor market outcomes. (See Box 1 for a discussion about how the opioid crisis and related policies have affected labor market outcomes.)

Legislation Enacted to Address the Opioid Crisis

Lawmakers have enacted multiple pieces of legislation since 2016 to respond to the opioid crisis. Many authorizations of appropriations from those laws have expired or will expire over the next few years.22 The actual amounts appropriated could differ from the amounts authorized.

• The Comprehensive Addiction and Recovery Act (CARA) of 2016 (Public Law 114-198, enacted in July 2016) encompassed approaches to reduce the supply of opioids, demand for opioids, and harm from those drugs. That law authorized appropriations for grants to improve state PDMPs and to expand access to opioid overdose reversal medications. In 2017, the first year after the enactment of CARA, lawmakers appropriated $267 million pursuant to those authorizations. In 2021, authorizations of grants from CARA expired.
• The 21st Century Cures Act (P.L. 114-255, enacted in December 2016) authorized appropriations for grants to facilitate activities that reduce the demand for opioids and the harm caused by those drugs. The law established the State Targeted Response to the Opioid Crisis grant program. In 2017 and 2018, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded a total of $971 million to states and territories to fund that program. Those authorizations of grants expired after 2018.
• The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271, enacted in October 2018) included all three types of approaches but focused on reducing the demand for opioids by expanding access to treatment. Some authorizations in the SUPPORT Act were made permanent in 2024, including mandated Medicaid coverage for medications for OUD and a state plan option to cover services for Medicaid enrollees with SUD in eligible institutions for mental diseases (IMDs).23 Other authorizations in the SUPPORT Act expired by 2023. Lawmakers appropriated $1.2 billion for 2024 for activities related to substance use that have expired authorizations in the SUPPORT Act; the extent to which other authorizations in that law have been funded is unclear.24
• Several other laws were enacted between 2018 and 2020 to address the opioid crisis. The Synthetics Trafficking and Overdose Prevention (STOP) Act of 2018 (Title VIII of the SUPPORT Act), the International Narcotics Trafficking Emergency Response by Detecting Incoming Contraband with Technology (INTERDICT) Act (P.L. 115-112, enacted in January 2018), and the Fentanyl Sanctions Act, incorporated into the National Defense Authorization Act for Fiscal Year 2020 (P.L. 116-92, enacted in December 2019), focus on supply interdiction. Emergency appropriations of $350 million for SAMHSA in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136, enacted in March 2020) were intended to expand treatment for SUD.
• Since 2024, several laws have been enacted that aim to reduce the supply of illicit opioids and increase penalties for drug trafficking. The Eradicating Narcotic Drugs and Formulating Effective New Tools to Address National Yearly Losses (END FENTANYL) Act (P.L. 118-43, enacted in March 2024) directs Customs and Border Protection to update its inspection procedures for detecting fentanyl and related substances. Provisions of the Fentanyl Eradication and Narcotics Deterrence Off Fentanyl (FEND Off Fentanyl) Act, incorporated into the fiscal year 2024 emergency supplemental appropriations act (P.L. 118-50, enacted in March 2024), impose sanctions on individuals linked to cartels, authorize asset seizures, and target money laundering. The Halt All Lethal Trafficking of Fentanyl (HALT Fentanyl) Act (P.L. 119-26, enacted in July 2025) permanently classifies fentanyl analogs—synthetic opioids structurally related to fentanyl that can be even stronger and have unpredictable, dangerous effects—as Schedule I substances and increases criminal penalties for their possession and trafficking. Placement into Schedule I designates a drug as having no currently accepted medical use and a high potential for abuse under the Controlled Substances Act. Schedule I drugs are subject to the most restrictive controls on production and distribution, as well as more severe criminal penalties for trafficking.

Details About the Policy Approaches That CBO Examined

CBO examined a variety of policy approaches that could be used to reduce the supply of illicit opioids, the demand for opioids, and the harm that can ensue from opioid use.

Types of Policy Approaches

This report examines six main policy approaches and five additional approaches that seek to address the multiple dimensions of the opioid crisis. Of the six approaches examined in detail, one would reduce the supply of illicit opioids, four would lower the demand for opioids by preventing and treating OUD, and one would mitigate the harm associated with opioid use. For details about those approaches—including outcomes and CBO’s assessment of the empirical evidence about the approaches’ effectiveness—see Table 1.

How CBO Selected the Approaches

To examine the opioid crisis and policies that could be used to address its many facets, CBO reviewed the academic and policy literature and searched for related legislation. The six main approaches that CBO examined have a lot of interest from Congress and substantial evidence about how they would affect relevant outcomes. The additional five approaches have received some interest from policymakers or have less empirical evidence to support them. For the main policy approaches, CBO gauged Congressional interest through their inclusion in legislative actions and proposals. For the additional approaches that are discussed more briefly, the agency defined interest more broadly to also include actions and policies of executive branch agencies and general discussion by policymakers, stakeholders, and researchers.

For this analysis, CBO defined substantial evidence as at least six studies in total, consisting of three or more studies examining the effectiveness of a given policy—regardless of whether the results were positive, negative, or close to zero and thus null—that used randomized controlled trials or credible quasi-experimental designs and three or more correlational studies; both types of studies must have been published in peer-reviewed journals.25 Those criteria tended to filter out policies that were less amenable to treatment-control comparisons (such as more targeted international drug-control agreements) and policies that have only recently been introduced in the United States and have not yet been assessed (such as the establishment of sites that are meant to allow people to consume opioids and other drugs under supervision).

A Policy Approach to Reduce the Supply of Opioids

Strategies to reduce the supply of opioids aim to limit the supply of illegally produced opioids. Efforts by law enforcement to interrupt the supply chain of illegal drugs have been shown to reduce drug-related hospital inpatient admissions and overall mortality, although two studies found that the impact was temporary in the case of supply interdiction of methamphetamine (a powerful and highly addictive central nervous system stimulant) in the United States.26 Those findings are based on past interdiction efforts; they may not apply directly to the current opioid crisis (which is fueled by synthetic opioids) because of differences in production and distribution.

Reduce the Supply of Illicit Opioids Through Information Sharing and Counterdrug Efforts

Fentanyl and its analogs are the primary synthetic opioids associated with the rise in drug overdose deaths during the past decade. Fentanyl is often shipped to the United States by mail; Mexico and China are the main source countries for fentanyl and fentanyl-related substances trafficked directly into the United States.27 The supply and delivery methods used by illicit suppliers and traffickers are constantly evolving, and novel synthetic drugs continue to emerge.

Recent Legislation. Lawmakers have enacted several policies that intend to reduce the amount of fentanyl entering the United States. One policy leverages advance electronic data about parcels to identify illicit opioids from international shippers; that provision is part of the STOP Act of 2018. Another policy supports the capacity-building of foreign law enforcement agencies to reduce international drug trafficking; that provision is part of the Fighting Emerging Narcotics Through Additional Nations to Yield Lasting (FENTANYL) Results Act.28 The END FENTANYL Act and provisions of the FEND Off Fentanyl Act included in the fiscal year 2024 emergency supplemental appropriations act aim to reduce the supply of illicit opioids by strengthening border inspections and targeting cartels and their assets.

In addition, the HALT Fentanyl Act automatically and permanently classifies all fentanyl-related substances (compounds that are structurally related to fentanyl) as Schedule I drugs without any additional administrative action from the Drug Enforcement Administration (DEA) or the Food and Drug Administration (FDA).29 The recent permanent classification of fentanyl-related substances as Schedule I drugs is expected to strengthen supply interdiction efforts, but producers could respond by creating new synthetic opioids, dampening the intended effects on supply.

Examples of Potential Policy Approaches. Monitoring markets continuously, facilitating data collection, and additional interdiction efforts could reduce the supply of illicit opioids. Those approaches would include federal activities—for example, additional direct efforts by federal law enforcement agencies—and state and local activities.

Support for alternative methods of surveillance, data collection, and drug identification could improve the monitoring of markets for illicit opioids.30 To facilitate data collection, lawmakers could expand efforts to analyze and track the emergence of new illicit opioids, including quantitative analyses of drug seizures by the DEA and state crime laboratories. Expanded information and data sharing among jurisdictions could improve local drug surveillance.

Interdiction activities in the drug supply chain could include more investigation of online vendors by federal agencies to identify transnational criminal groups. For example, the FEND Off Fentanyl Act provides additional authority to the Department of the Treasury to address money laundering associated with the trafficking of illicit opioids. Another way to bolster counterdrug efforts—in addition to laws that increase monitoring of international mail shipments, such as the STOP Act of 2018, or that enhance border enforcement, such as the END FENTANYL Act—would be to incentivize state and local governments to share interdiction and investigation information with multiagency, multijurisdictional task forces that are focused on disrupting drug trafficking networks.31

Evidence of Effectiveness. Past interdiction efforts by law enforcement agencies have been shown to increase drug prices, reduce mortality and hospital admissions, and reduce crime rates, although two studies found that supply interdiction of methamphetamine in the United States had only a temporary impact. In the case of methamphetamine, regulation of wholesale and retail distribution of its ingredients in the United States in the 1990s led to an increase in prices and a reduction in adverse health outcomes, but those changes dissipated over time, possibly because producers found substitute ingredients.32 In contrast, the interdiction of large quantities of imported heroin in Australia in 2001 was associated with a persistent reduction in opioid-involved and overall mortality.33

Those results may not apply to the current fentanyl crisis in the United States because there are multiple points of production and greater distribution capacity for that drug. The inputs to manufacture fentanyl are more easily obtained than were inputs for other drugs during previous crises, and small quantities can be produced without specialized facilities or highly technical skills.34 Furthermore, the internet provides a broader distribution network for importers and distributors who traffic wholesale quantities of fentanyl and other synthetic opioids. As a result, traditional law enforcement and regulatory approaches that shut down production and disrupt drug trafficking networks may be less effective in combating the current crisis.

Policy Approaches to Reduce the Demand for Opioids

Strategies to lower the demand for opioids aim to treat and prevent opioid use disorder. The standard of care for treating OUD is ongoing maintenance medication in combination with psychosocial treatment, which refers to any nondrug, professionally delivered intervention (such as counseling or talk therapy) provided to individuals, families, or groups.35 Treatment for OUD is underused: In 2022 and 2023, only 34 percent of adults with OUD reported receiving any treatment for substance use in the previous year, and only 19 percent received medications for OUD.36 Barriers to receiving treatment include affordability, lack of access, and the stigma associated with the disorder.37

State Medicaid programs are generally required to cover all medications for OUD that have been approved by the FDA, but they are permitted to apply utilization management controls (such as prior authorization requirements) to that coverage.38 The three FDA-approved medications for OUD are methadone, buprenorphine, and naltrexone. Those medications reduce opioid cravings and help to disconnect opioid use from established situational or emotional triggers. A substantial body of research has shown that treatment with medication is effective for reducing opioid use and retaining patients in care.39 (See Box 2 for a discussion of the effectiveness of MOUD.)

Access to OUD treatment could be strengthened in several ways:

• By expanding the scope of Medicaid coverage,
• By expanding access to telehealth services, and
• By supporting treatment for people involved in the criminal justice system.

Those approaches have been shown to increase treatment utilization and to reduce rates of opioid use and overdose.

Some approaches to reduce the demand for opioids aim to prevent people from developing OUD. For example, prescription drug monitoring programs, which are available in all states and the District of Columbia in 2025, are state-run electronic databases that track the prescribing and dispensing of controlled substances. As of 2016, 18 states required prescribers to check the PDMP before prescribing controlled substances. Mandating or facilitating the use of PDMPs by providers tends to reduce the use of prescription opioids and the amount of opioids dispensed to new users, which can help prevent new cases of OUD and opioid overdose. Although PDMPs have also been used to curb overprescribing among existing opioid users, this report focuses on new users and the programs’ preventive role, given that most opioid-related overdose deaths now originate from synthetic opioids.

Another existing program is Screening, Brief Intervention, and Referral to Treatment (SBIRT), which aims to prevent inappropriate opioid use that can lead to OUD by identifying people at risk for substance misuse, providing brief counseling on the dangers of opioid use, and connecting those in need with appropriate treatment resources. SBIRT is unevenly implemented across states and health care settings. Federal activities could support increased access to SBIRT, including by promoting integration into electronic health records (EHRs) and potentially enhancing Medicaid coverage of SBIRT services.

The approaches examined here primarily focus on Medicaid rather than Medicare or private health insurance for several reasons. First, Medicaid is the single largest payer for behavioral health services (including mental health and substance use services), accounting for about one-fourth of all behavioral health spending.40 Second, the rate of SUD is higher among Medicaid enrollees, at 21 percent, than among people with private health insurance (16 percent) or elderly Medicare beneficiaries (2 percent).41 Those rates by payer are consistent with working-age adults’ having the highest and fastest-growing opioid-related death rates in recent years.

Expand the Scope of Medicaid Coverage for Treatment of OUD

Medicaid is the largest payer for OUD treatment services, and Medicaid enrollees with OUD make up roughly 22 percent of the entire population with OUD as of 2019.42 The scope of Medicaid coverage for OUD treatment and services varies across states, partly because coverage for many of those services is optional under Medicaid law.43 As of 2022, nearly all states covered all three FDA-approved medications for OUD and outpatient treatment services, but coverage of residential and inpatient services was more limited. For instance, 37 states covered medium- to high-intensity residential SUD treatment, which includes a highly structured environment with 24-hour oversight combined with at least 20 hours per week of counseling and other behavioral interventions.44 Coverage of other levels of care, such as intensive inpatient services and partial hospitalization, also varied across states in 2022.45

Recent Legislation. Several provisions in the SUPPORT Act of 2018 temporarily expanded Medicaid coverage of OUD treatment.46 Under the Consolidated Appropriations Act of 2024, some of those provisions were made permanent, including requiring Medicaid coverage of medications for OUD and allowing federal matching funds (through a new Medicaid state plan option) for services for Medicaid enrollees with SUD in eligible institutions for mental diseases.47 Most states (37 as of October 2024) provide SUD services in IMDs through section 1115 waivers rather than through the state plan option created by the SUPPORT Act; only two states have adopted the state plan option.48 Take-up of that option has been low, partly because section 1115 waivers offer more flexible length-of-stay limits.49

Examples of Potential Policy Approaches. Lawmakers could motivate or mandate state Medicaid programs to cover additional forms of OUD treatment. Those approaches might include expanding coverage of approved treatment settings in which medication for OUD is delivered, such as opioid treatment programs and federally qualified health centers, or offering additional types of treatment, such as intensive inpatient services and residential treatment.50 Lawmakers could also facilitate state innovations in services to treat OUD through section 1115 waivers and other demonstration programs by establishing frameworks for new demonstration opportunities and by providing guidance to states. For example, the SUPPORT Act authorized a demonstration project to help states increase the capacity of their Medicaid providers to treat SUD and through which participating states receive an enhanced federal medical assistance percentage (the federal government’s share of most spending for the Medicaid program) for SUD treatment services.51

Evidence of Effectiveness. Expanding Medicaid coverage of OUD treatment is associated with a higher likelihood that providers will offer those covered services (including MOUD) and greater use of treatment.52 Removing Medicaid coverage of treatment could have opposite effects: When Oregon removed SUD treatment coverage from its Medicaid plan in 2003, admissions to opioid treatment programs dropped by more than half among Medicaid enrollees with OUD who sought treatment, and patients who left treatment experienced declines in health.53

In some settings, expansions of Medicaid eligibility and covered benefits have reduced opioid-related hospital admissions and mortality rates, but those effects are not consistent across studies.54 Section 1115 SUD-IMD waivers increased acceptance of Medicaid at residential treatment facilities and may have moderately improved the use of medication treatment for Medicaid enrollees with OUD who had an inpatient or residential care stay.55

Expand Access to Telehealth Services for OUD Treatment

Broadening access to telehealth services could reduce people’s barriers to receiving OUD treatment by removing the need for time off from work, transportation, and childcare. Before the pandemic, telehealth was effectively used in other areas of medicine but was not used widely for mental health and SUD services.56 During the pandemic, broader access to telehealth services for OUD treatment—facilitated by changes to Medicare and Medicaid rules—was linked to increases in OUD treatment.

The drugs used to treat OUD were subject to certain restrictions before the pandemic. First, because those drugs are controlled substances, their prescribing and dispensing required an in-person medical evaluation. Second, Medicaid and Medicare restricted the coverage of telehealth for OUD treatment based on various factors, including the locations of the patient and the provider (referred to as originating and distant sites, respectively), the modality (for instance, audio-only telehealth visits versus video plus audio), and whether a patient had an established relationship with a provider.

Some of those restrictions were waived temporarily during the COVID-19 public health emergency (PHE), which was in effect from March 13, 2020, to May 11, 2023. (The PHE allowed the government to change specific policies to help provide services that were needed during the height of the pandemic, such as free COVID-19 testing and vaccination.) For example, buprenorphine prescribers were allowed to remotely initiate medication treatment for new patients in opioid treatment programs, stable patients were allowed to take methadone at home for up to a month, and Medicare covered telehealth services for behavioral or mental health care provided to beneficiaries in their home.57

Since then, some of the telehealth flexibilities implemented in Medicare during the PHE, including all of the examples mentioned above, have been made permanent.58 In addition, 32 states plan to or have implemented additional expansions to telehealth policies under Medicaid’s fee-for-service program. Those expansions include permanently adopting measures introduced during the PHE (such as allowing audio-only telehealth visits), expanding the range of services and providers accessible via telehealth services, and permitting patients to receive services from home.59

Examples of Potential Policy Approaches. Telehealth access for OUD treatment could be increased by expanding coverage in Medicare and Medicaid and by supporting the infrastructure that enables that technology. Lawmakers could broaden access to treatment for Medicare beneficiaries with OUD by making permanent certain telehealth flexibilities, most of which expired at the end of fiscal year 2025. (Some remaining provisions are set to expire by December 31, 2025.) Those flexibilities include allowing federally qualified health centers and rural health clinics to serve as distant-site providers of telehealth services and waiving the usual requirement for an in-person visit within six months of an initial behavioral or mental health telehealth visit and annually thereafter.60

For Medicaid, lawmakers could expand telehealth for OUD by encouraging or incentivizing state Medicaid programs to extend or make permanent PHE telehealth flexibilities for OUD treatment services. For example, continuing to cover the audio-only modality in Medicaid for OUD treatment services could help beneficiaries without access to high-speed broadband obtain treatment. That flexibility could especially benefit people who have lower income and who live in rural areas, because those people are less likely to have access to internet speeds that facilitate an audio-visual connection.61 If expansions were optional for states, existing state legislation or policies that limited MOUD prescribing via telemedicine could constrain take-up rates.62

The effectiveness of expanding Medicare or Medicaid coverage of telehealth services for OUD treatment would depend on the technological infrastructure and knowledge among providers and patients. Federal support could enable wider use of telehealth services by improving that technological infrastructure and training.

Evidence of Effectiveness. Expanding telehealth access for OUD treatment in Medicare and Medicaid would affect people with OUD who are enrolled in at least one of those programs. In 2019, those populations accounted for more than one-third of the total population with OUD.63

Research suggests that telehealth expansions could increase access to MOUD without compromising the effectiveness of treatment. Studies using prepandemic data suggest that telehealth for OUD treatment is about as effective as in-person treatment. Patients who were prescribed MOUD or received MOUD-related counseling via telehealth had treatment retention rates and subsequent reductions in opioid use that were comparable to those of patients who were treated in person.64 During the pandemic, expanded use of telehealth services to prescribe MOUD in Medicare was associated with an increase in MOUD use and a lower likelihood of opioid overdose (relative to overdose rates among patients not receiving MOUD).65

Increase Access to Treatment for People With OUD Who Are Involved in the Criminal Justice System

The rate of OUD among people who are incarcerated is estimated to be about 15 percent, compared with 2 percent among people ages 12 or older in the general population.66 People who are recently released from correctional facilities have a risk of death from opioid overdose that is 40 times higher than that of the general population.67

Although MOUD is the standard of care to treat opioid addiction, fewer than half (44 percent) of jails offered medication treatment of OUD in 2022, and only 10 percent of the federal prison population needing medication treatment received MOUD.68 One of the reasons cited by jail and prison administrators for not offering MOUD is a lack of funding, stemming in part from the prohibition against the use of federal Medicaid funds to pay for health care services for incarcerated people. In states that have expanded Medicaid coverage under the Affordable Care Act, most incarcerated adults may be eligible for Medicaid.69 Another commonly cited reason for not offering MOUD is a lack of licensed staff to dispense them.

Recent Legislation. Lawmakers enacted the First Step Act in 2018, which required the federal prison system to expand access to medications for inmates with OUD.70 The federal Bureau of Prisons (BOP) began implementing a medication treatment program in 2019 in response to that requirement and planned to expand the program nationwide, but the Government Accountability Office found that BOP lacked key planning elements to complete the expansion in a timely manner.71 Legislation introduced in recent years would allow Medicaid to cover behavioral health services, potentially including OUD treatment, for people who are incarcerated and nearing their release date, typically for a limited period.72 That coverage of OUD treatment prerelease is currently being implemented through Medicaid on a limited state-by-state basis using section 1115 waivers.73

Programs that divert people from the criminal justice system and toward support services have been used to increase access to OUD treatment as well. In those diversion programs, people who commit low-level drug offenses are offered a variety of support services, including SUD treatment, instead of arrest and prosecution for criminal charges. One example is the Law Enforcement Assisted Diversion (LEAD) program, which was developed in 2011 and now operates in 73 jurisdictions in 23 states; that program allows law enforcement officers to redirect low-level offenders engaged in drug or prostitution activity to community-based services instead of jail and prosecution.74

Another type of diversion program is drug courts, which are specialized court docket programs designed to reduce drug relapse and criminal recidivism through judicial interaction, graduated sanctions and incentives, and treatment and rehabilitation services.75 As of 2019, more than 1,600 adult drug courts were in operation, with a total of about 90,000 participants.76

Examples of Potential Policy Approaches. Lawmakers could increase access to OUD treatment in jails and prisons. One way to do that would be to expand OUD treatment services via telehealth in those settings. That approach could help incarcerated people with OUD more easily access substance use treatment practitioners and other providers who may be in short supply. Access to OUD treatment for incarcerated people could also be expanded through Medicaid coverage. Using proposed legislation that amends Medicaid’s exclusion of payments for inmates as a starting point, lawmakers could modify Medicaid coverage of OUD treatment services provided to inmates and thus reduce the administrative burden for reimbursement of OUD treatment in correctional facilities. Federal support could also be directed to existing or new diversion programs, drug courts, and other initiatives that offer treatment, including medications, as an alternative to incarceration for people with OUD who engage in low-level drug-related criminal activities.77

Evidence of Effectiveness. People with OUD who are involved in the criminal justice system—the population potentially affected by these policies—accounted for roughly 4 percent to 5 percent of the total population with OUD in 2019.78 Medication programs to treat OUD in correctional facilities tend to reduce injection drug use and opioid-involved overdose deaths.79 Those programs also led to increased treatment utilization after release and cost-effective reductions in recidivism.80

Diversion programs and drug courts are associated with lower rates of recidivism.81 Drug courts have also been found to reduce people’s probability of testing positive for illegal drugs.82 Among adults in Indiana who were sentenced for substance-related crimes and who applied to participate in a drug court treatment program, participants were less likely to die and less likely to use emergency medical services than people who were accepted into a program but chose not to participate.83

Enhance State Prescription Drug Monitoring Programs

Enhancing the effectiveness of PDMPs might reduce the use of prescription opioids and prevent new cases of OUD by changing the prescribing behavior of providers. PDMPs enable providers to check patients’ prescription history and limit access to controlled substances for patients who are misusing opioids or who are opioid naïve (in other words, have not had an opioid prescription in the recent past). Those programs can also be used to monitor the behavior of providers who prescribe opioids in significantly larger quantities or doses than their peers. Because the current crisis is driven by illegally manufactured opioids, this report emphasizes how PDMPs can prevent new cases of OUD and classifies them as a demand reduction approach. (In a 2022 report, CBO characterized PDMPs as a strategy to primarily reduce the supply of prescription opioids that could be misused.)

PDMPs that monitor more types of controlled substances and that update their data more frequently are associated with greater reductions in opioid-involved overdose deaths.84 In 2024, all but eight states monitored controlled substances under Schedules II, III, IV, and V, and all but two states updated their data daily.85 The SUPPORT Act of 2018 mandated several additional changes: It required all states to establish a PDMP that meets certain federal requirements, required providers who participate in Medicaid and are permitted to prescribe controlled substances to query PDMPs before prescribing those substances to Medicaid enrollees, and provided federal funds to match state Medicaid spending on the design, development, and implementation of PDMPs.86

Examples of Potential Policy Approaches. The federal government could support further improvements to PDMPs to increase their effectiveness and simplify their use. One such improvement would be to encourage states to require prescribers to access PDMPs before prescribing opioids and other controlled substances to any patient. Mandatory-access PDMPs could be made more effective through technological enhancements that make those systems functional without delay and accessible in locations where prescriptions are being written and dispensed.

If such mandates were in place and operational, one way to facilitate compliance would be by making PDMPs easier for providers to use by integrating them with electronic health records. Incompatibilities between PDMPs and EHRs—such as differences in user authentication requirements and standards for data access, use, and disclosure—are a barrier to the effective use of PDMP data in the clinical workflow.87 Federal lawmakers could support state activities to integrate PDMPs with EHRs across health care settings. For example, SAMHSA funded projects to integrate PDMPs into health information technology systems in nine states from 2012 to 2016.88 PDMP integration into EHR systems could reduce the time burden on providers and make it more likely that they would comply with requirements to check the PDMP.

The interoperability of PDMPs across states could be improved by supporting cross-state collaborations to exchange data and by providing federal guidance on data content and exchange standards. Furthermore, the federal government could consider ways to improve the coordination of state PDMPs with federal health programs’ own PDMPs, including those of the Department of Defense and the Department of Veterans Affairs, so that state residents who are receiving prescriptions through federal programs are also recorded in state PDMPs. Finally, more education and training for providers, payers, and patients on the use and benefits of PDMPs could enhance their effectiveness.

Evidence of Effectiveness. The available evidence suggests that requiring providers to query PDMPs and providing enhancements that facilitate greater use of PDMPs reduce the use of prescription opioids and the amount of opioids dispensed to new users, which can help prevent new cases of OUD and opioid overdose. Mandatory-access PDMPs reduce rates of opioid prescriptions, opioids dispensed to new users, opioid-related emergency department visits, and SUD treatment admissions.89 Among PDMP enhancements, integration with EHRs and health information technology systems is associated with reductions in the amount of opioids prescribed and opioid-related inpatient discharges.90 In contrast, evidence about the effectiveness of PDMP interoperability, which facilitates data sharing across states, is mixed.91

The benefits of improving PDMPs are offset by some amount of substitution from prescription opioids to illegal opioids (such as heroin and illicitly manufactured fentanyl). PDMPs may unintentionally cause some people who use prescription opioids nonmedically to switch to illegal opioids in response to reductions in the supply of prescription opioids and increases in the cost of obtaining prescription opioids. Evidence about the extent to which PDMPs increase heroin use and heroin-involved death rates is mixed.92 Illicitly manufactured opiates (such as heroin) are more harmful than legally prescribed opioids because of greater uncertainty about the types of drugs that are present and the potency of their doses.93

Three Additional Policy Approaches to Reduce the Demand for Opioids

Compared with the four main approaches to reduce demand, these three approaches have received less interest from lawmakers or have less empirical evidence of their effectiveness. In particular, evidence about the policies’ effects is either mixed or is obscured by other concurrent policies. Nonetheless, CBO has included them to present a broader range of options to lawmakers. These three approaches would expand prevention programs—such as Screening, Brief Intervention, and Referral to Treatment programs—in health care settings, reduce barriers to prescribing buprenorphine, and expand Medicaid coverage of services that support recovery.

Expand SBIRT Programs in Health Care Settings. In 2003, SAMHSA launched SBIRT, awarding grants to six states and one tribal council to encourage adoption of the program across various health care settings.94 The program’s goals include expanding treatment for all substance use disorders, integrating early intervention into health care, and offering brief treatment options along with referrals for more intensive care when needed.

Evidence shows that SBIRT programs effectively identify and reduce risky alcohol and drug use. Study participants assigned to SBIRT groups have reported fewer days of heavy drinking and stimulant use than people in control groups.95 SBIRT receipt was also associated with lower odds of substance-related diagnoses, hospitalizations, and drug use at follow-up.96 In another study, people receiving SBIRT services had higher abstinence rates for cocaine and heroin and showed more substantial reductions in levels of cocaine in their bodies than people in the control group.97 SBIRT is widely used, but evidence that it reduces opioid misuse or prevents progression to OUD is limited and mixed, especially compared with the evidence base for alcohol use.

States, health care organizations, and community programs could expand SBIRT services to prevent opioid use, potentially with federal support. In addition, states could be encouraged to increase Medicaid coverage of SBIRT services targeting opioid use in various health care settings, incentivizing providers to screen for opioid-related risks and intervene when necessary. Integration into EHRs could also expand SBIRT; that integration could include embedding validated screening tools, automated prompts, and referral tracking directly into routine clinical workflows.98

Reduce Barriers to Prescribing Buprenorphine. The Drug Addiction Treatment Act of 2000 instituted a federal requirement for health care providers to apply for a waiver to prescribe buprenorphine for the treatment of OUD and limited the number of patients that a waivered provider could treat.99 (Differences between buprenorphine and the other FDA-approved medications regarding the settings where they can be prescribed are explained in Box 2.) The Consolidated Appropriations Act of 2023 eliminated that requirement and the limits on the number of patients. To make that policy more effective, lawmakers could address the inconsistencies across states in the scope-of-practice laws that govern the prescribing of certain medications by licensed nurse practitioners or physician assistants.100 Increases in a county’s share of providers who are eligible to prescribe buprenorphine are associated with greater use of MOUD and reductions in the rate of drug-related emergency department visits.101

Other barriers to prescribing buprenorphine are a lack of training and resources for providers and health insurers’ prior authorization policies.102 Expansion of innovative service delivery models, such as the hub-and-spoke model for OUD treatment, potentially with federal support, could help address the lack of training and resources.103 In that model, hub sites provide more intensive treatment and management services for MOUD, particularly buprenorphine, and patients can be connected to spoke sites located within their communities for ongoing treatment and monitoring.104

Lawmakers could also encourage state Medicaid programs to limit the use of prior authorization requirements for buprenorphine, as has been done in Medicare.105 One study found that between November 2020 and March 2021, 32 state Medicaid programs required prior authorization for at least one formulation of buprenorphine.106 Evidence about whether removing Medicaid’s prior authorization requirement increases buprenorphine provision and improves opioid-related health outcomes is mixed.107

Expand Medicaid Coverage of Services That Support Recovery. Recovery support services include a broad range of nonclinical services that assist people in initiating and sustaining recovery from an SUD. Those services encompass comprehensive community support, peer support, skills training, supported employment, and supportive housing (transitional housing for people in recovery from an SUD). Although many states cover comprehensive community and peer support services, only four states covered some form of supportive housing as of 2018.108 Some researchers have proposed expanding Medicaid coverage of such support services to help people recover from an SUD.109

Assessing the effects of such an expansion is difficult for two reasons. First, there are few rigorous studies on the subject. Second, such changes in coverage often occur at the same time as other changes in Medicaid coverage, and separating the effects can be problematic. For example, a program that added Medicaid coverage of peer recovery supports in Virginia was associated with a 20 percent increase in the probability of MOUD treatment and an 11 percent reduction in the probability of an inpatient admission. However, the program also increased reimbursement rates for addiction treatment, so the effects cannot be attributed solely to coverage of recovery support services.110

Policy Approaches to Reduce the Harm From Opioid Use Disorder

Harm-reduction strategies aim to minimize the negative health, social, and legal impacts associated with drug use for people who use opioids (or other substances) and for their communities. Several federal laws have supported greater access to opioid overdose reversal medications as a harm-reduction approach. Expanding access to those medications has been shown to reduce opioid-involved overdose deaths.

Legislation has also supported syringe service programs, which are community-based initiatives that provide access to sterile syringes and safe disposal of needles. Those programs aim to reduce overdoses and transmission of diseases such as hepatitis C and HIV, but evidence about their effectiveness is mixed. Fentanyl test strips, one of several drug checking devices that allow people to analyze the chemical content of their drug samples, have also been supported by federal law.111 Evidence is emerging that fentanyl test strips are associated with behaviors that lower the risk of overdose and that other drug checking devices can be used to monitor the supply of illicit opioids. (An association between two variables means that they tend to move together, but it does not necessarily imply that one causes the other.)

Increase Access to Opioid Overdose Reversal Medications

Expanding access to naloxone and nalmefene, fast-acting opioid antagonists, could reduce the harm associated with OUD. Those drugs rapidly counteract the effects of opioid overdose by binding to the same central nervous system receptors that opioids bind to. Their primary function is to reverse the respiratory depression caused by an opioid overdose and thus prevent death.

Naloxone, available in either injectable or nasal spray form, can be administered by medical providers and laypeople. The survival rate for people who are administered naloxone by a layperson is as high as 96 percent, and higher doses of naloxone are considered effective for individuals overdosing on fentanyl.112 Nalmefene works similarly to naloxone and has stronger and more durable effects. The first nalmefene nasal spray was approved by the FDA in May 2023.113

Increased use of opioid overdose reversal medications faces several barriers, particularly among opioid users. One barrier is price. From 2016 to 2018, average out-of-pocket costs for Narcan, the dominant naloxone product, were $74 per claim among the uninsured, a population that makes up 14 percent of adults with SUD, compared with $14 per claim among the insured.114 Other barriers to increased use of those medications that have been identified in interviews with opioid users include a lack of availability in their region, misunderstandings about the drugs’ use and efficacy, the fear of legal consequences for seeking medical attention for a person who is overdosing, and the concern about being stigmatized by medical professionals.115

The FDA approved a nasal spray version of Narcan for over-the-counter (OTC) use in March 2023, a development that is expected to increase access to naloxone.116 The price of OTC naloxone is higher than the out-of-pocket cost for insurance-paid prescriptions but lower than the out-of-pocket cost for uninsured people before OTC availability.117

Examples of Potential Policy Approaches. Lawmakers could increase access to opioid overdose reversal medications by taking various actions. First, they could encourage states to pass certain forms of naloxone access laws (NALs), which directly allow pharmacists to prescribe naloxone or dispense it without a prescription, because NALs that enable that type of direct authority have been shown to be more effective at reducing opioid overdose deaths. Second, lawmakers could encourage or require coprescribing of opioid overdose reversal medications (when a doctor writes a prescription for such a medication for a patient at the same time as the opioid prescription). Third, they could support overdose education and naloxone distribution (OEND) programs.

• NALs make naloxone easier to obtain by expanding how the medication can be distributed to patients beyond traditional prescriptions. Those laws vary by state and can take several forms, including providing pharmacists with direct authority to prescribe naloxone to patients (also called prescriptive authority) or to dispense naloxone without a prescription; giving pharmacists indirect authority to provide naloxone to a large group of people meeting certain criteria, typically using a standing order or statewide protocol; or providing legal protection to those administering naloxone to people experiencing overdoses.118 By 2016, nine states had NALs that provided pharmacists with direct authority to prescribe or dispense naloxone.
• For patients who receive opioid prescriptions and are at risk of opioid overdose, coprescribing could broaden access to opioid overdose reversal medications and potentially save lives. In 2016, the Centers for Disease Control and Prevention (CDC) issued a “Guideline for Prescribing Opioids for Chronic Pain,” which recommended that patients who were at risk of opioid overdose, including those receiving opioid prescriptions of 50 morphine milligram equivalents or more per day or those receiving both opioid and benzodiazepine prescriptions, receive a prescription for naloxone along with their opioid prescription. Coprescribing could be encouraged through the distribution of educational materials for prescribers and the inclusion of coprescribing prompts in electronic health records. As of July 2022, 12 states required the coprescribing of naloxone in certain situations when patients are at risk of opioid overdose.119
• OEND programs train laypeople to respond during overdoses and provide access to naloxone. Participating organizations include homeless shelters, libraries, and syringe exchange programs.120 OEND programs do not require people to have a prescription to receive naloxone. Even though the FDA’s recent approval of OTC Narcan makes a prescription unnecessary, OEND programs may reduce other barriers to access, such as cost. Previously, states have used federal grants to purchase and distribute naloxone to first responders (such as emergency medical technicians, police officers, and firefighters) and to train them to administer the drug as part of OEND programs.121

Evidence of Effectiveness. Research suggests that broadening access to naloxone through NALs reduces opioid overdose deaths by 9 percent to 27 percent.122 Among those laws, ones that grant pharmacists direct authority to prescribe naloxone appear to be the most effective at reducing opioid overdose deaths.123 Additionally, states with direct authority NALs have had significantly higher naloxone dispensing rates and lower opioid-involved mortality rates following Narcan’s introduction, surpassing the effects of the laws alone.124 Other policies to increase access—naloxone coprescribing, OEND programs, and distribution to first responders—are associated with reductions in opioid-involved emergency department visits and overdose deaths, but more evidence is needed to assess the causal effects of those policies.125

Concerns have been raised that increasing access to naloxone could result in users engaging in more risky behavior because they believe that naloxone provides them with a “safety net,” a phenomenon known as moral hazard. However, empirical evidence does not support that hypothesis.126

Two Additional Policy Approaches to Reduce the Harm From OUD

Policies that support syringe service programs or expand the availability of drug checking devices and services could reduce opioid-related harm. The existing evidence base for these policies did not meet CBO’s criteria for substantial evidence, but the policies are included here because they have received some interest from lawmakers.

Syringe service programs, which provide a range of services to people who inject drugs, have been shown to increase treatment utilization but have had mixed effects on users’ health, possibly driven by increased use of heroin and fentanyl. Drug checking devices, which allow users or others to check the safety of drugs before consuming them, could be used by drug testing services and for monitoring the supply of illegal drugs. The use of some devices is associated with behaviors that lower the risk of opioid overdose.

Support Syringe Service Programs. Syringe service programs provide access to injection equipment and safe disposal of syringes. The programs are designed to reduce the spread of infectious conditions that can be transmitted through injection drug use, including hepatitis C, HIV, methicillin-resistant Staphylococcus aureus (MRSA), and endocarditis. Most syringe service programs also offer referrals to treatment. Among injection drug users, those who use syringe service programs are more than five times likelier to enter treatment than those who have never used them.127 However, a recent study that examined openings of syringe service programs found that even though they decreased HIV diagnosis rates, they were associated with three additional opioid-involved deaths per county per year, driven by new users of more potent opioids, such as heroin and fentanyl.128

Syringe service programs have been supported through federal grants in recent legislation. In the American Rescue Plan Act of 2021, for example, funding for those programs was included in the $30 million appropriated for community-based funding of harm-reduction services.

Expand the Availability of Drug Checking Devices and Services. Drug checking devices and drug checking services are harm-reduction strategies that promote product safety in the illicit drug market by allowing people to check drug samples themselves or submit those samples for chemical analysis. By providing crucial information to users before they consume drugs, the services enable users to make more informed decisions and thus reduce their risks. Although well established in several European countries, drug checking is still emerging in the United States.129

Drug checking devices include fentanyl test strips (FTS) and spectrometers (devices that use light to identify the presence of substances by analyzing their chemical signatures).130 FTS can be distributed to people who use drugs and can be used wherever drugs are being consumed. By contrast, spectrometers and other advanced testing devices usually require people to go to a specific site and submit their drugs for testing. Those devices detect fentanyl, its analogs, and other potential contaminants in the drug supply. The Massachusetts Drug Supply Data Stream (MADDS), the nation’s first statewide community drug checking program, detected fentanyl in 47 percent of samples tested in 2020.131 By early 2021, MADDS identified changes in cocaine purity, warned communities of a new toxic fentanyl analog and synthetic cannabinoid contaminant, and confirmed an increase in xylazine in Massachusetts.132

Although the distribution of fentanyl test strips has increased in the United States recently, their adoption has been hindered by the stigma associated with people who use drugs and by existing laws that may discourage states and organizations from applying for grants to acquire test strips or from establishing distribution programs.133 In April 2021, the CDC and SAMHSA began allowing federal funding to be used to purchase FTS for research, clinical, or public health purposes.134 As of July 2023, 31 states and territories and the District of Columbia had legalized the use of FTS.135

Despite those measures, access to drug checking services remains limited for vulnerable populations.136 Lawmakers could expand access to drug testing programs by supporting community organizations carrying out harm-reduction initiatives that include drug testing services.

Evidence shows that drug users who were given access to FTS and confirmed the presence of fentanyl reduced their overdose risk by using drugs more slowly, consuming less, discarding the batch, or using substances in the presence of another person.137 However, a lack of peer-reviewed evidence about the effectiveness of self-testing in preventing fentanyl overdoses has led some researchers to question those findings.138

Budgetary Effects of the Policy Approaches

If adopted, the six main policy approaches examined in this report would change federal outlays (and some of them would also change revenues), largely by altering spending in federally subsidized health insurance programs or by appropriating funds for federal grants.139

To assess the impact of the policies on the federal budget, CBO would track up to four types of effects: initial effects, subsequent effects on health care spending, effects stemming from changes in the total population, and dynamic effects. CBO would undertake dynamic analysis (which considers the effects on the total output of the economy) when practicable if opioid-related policies were part of a large set of policies that would have a major effect on GDP.

In general, CBO’s estimates cover a 10-year period. When assessing the potential impacts of a policy on outcomes and how those impacts might affect the federal budget, CBO considers whether adequate evidence exists to make those determinations and whether estimates of outlays and revenues are calculable for the 10-year period. To assess budgetary effects beyond the 10-year period, CBO could use present-value estimates (which summarize a series of projected values in the future as a single value in the present) in certain instances.

Initial Effects of the Policy Approaches

The policies that CBO examined in this report have initial effects that would occur regardless of whether the policies caused people’s health to change. Such initial effects are included in CBO’s conventional estimates, which reflect the long-standing convention (used in most of the agency’s cost estimates) that the size of the economy does not change. For example, the costs of OUD treatment are included in initial effects.

Most of the policy approaches that aimed to reduce the demand for opioids would affect either the scope of health coverage in Medicaid or Medicare or health care utilization by enrollees in those programs without coverage changes. Additionally, policy approaches that sought to reduce the supply of opioids or the harm from opioids would influence utilization in federally subsidized health insurance programs, including Medicaid, Medicare, employment-based health insurance, and nongroup coverage under the Affordable Care Act. If legislation authorized the appropriation of funds for opioid-related grants without directly providing the funding, the initial effects would be limited to the amounts authorized to be appropriated, and other subsequent effects would generally not be included in cost estimates.140

Policies Affecting the Scope of Coverage. Policies that affected the scope of coverage in Medicaid and Medicare would alter mandatory spending. Among the policies that would increase mandatory spending are ones that would expand Medicaid coverage of OUD treatment services (for example, by expanding coverage for approved treatment settings in which medication for OUD was delivered or by covering additional types of treatment, such as intensive inpatient services and residential treatment), policies that would allow federal Medicaid funding to cover treatment for OUD provided to incarcerated people, and policies that would make permanent certain telehealth flexibilities (which are set to expire at the end of 2025) for Medicare beneficiaries.

The size of those policies’ effects would depend on many factors, including the range of services, modalities, or settings included in any Medicaid or Medicare coverage expansion; the price of services; the size of affected populations; and the availability of providers. For Medicaid, the spending effects would also depend on the structure of any federal financial participation, whether the proposed coverage changes were required or optional, and, if optional, each state’s likelihood of choosing to take up the expansion.

CBO has previously estimated the budgetary impacts of policies that would increase mandatory spending on treatments for OUD.141 A policy requiring Medicaid to cover medications for OUD and behavioral health services was estimated to increase mandatory spending by $273 million over a 10-year period. A policy allowing Medicaid to pay for services provided to enrolled inmates during the last 30 days of their incarceration was estimated to increase mandatory spending by $3.7 billion over a 10-year period. Differences in the size of the effects on mandatory spending were driven in part by the extent of changes in coverage (and the share of Medicaid enrollees that would be affected by such changes) under the policy relative to coverage under current law.

Policies Affecting Health Care Utilization Without Coverage Changes. Federal outlays for Medicaid and Medicare could change if policies affected the health care utilization of enrollees in those programs without altering the scope of coverage. For example, making prescription drug monitoring programs more effective could decrease federal spending by reducing the number of opioid prescriptions paid for by Medicaid and Medicare. Outlays would rise, however, if policies were implemented that increased the use of opioid overdose reversal medications—for example, by allowing pharmacists to prescribe naloxone or encouraging doctors to coprescribe naloxone along with an opioid.

Changes in health care utilization among people enrolled in employment-based health insurance or nongroup coverage could affect federal subsidies for that insurance. Policies that increased the use of opioid overdose reversal medications could raise spending on those drugs for some individuals with employment-based or nongroup coverage, resulting in higher premiums. For enrollees with employment-based insurance, higher premiums would decrease the share of compensation that took the form of taxable wages and salaries and increase the share provided as nontaxable health benefits, in CBO’s estimation, which would lower federal revenues. Changes in premiums for enrollees with nongroup coverage would affect federal revenues and outlays for premium tax credits under the Affordable Care Act. The precise budgetary effects would depend on the size of those responses and the prices of the affected services and drugs.

Policies Funded Through Spending on Federal Grants. Many grant programs that address the opioid crisis have been funded in appropriation acts. Federal grants are used by federal agencies to carry out activities; the grants are also disbursed to state and local governments. Legislation authorizing those grants has authorized amounts ranging from $90 million to $1.1 billion in total over five years.142 The actual amounts appropriated may have differed from the amounts authorized.143 According to one estimate, from 2017 to 2020, total annual appropriations for the opioid crisis nearly tripled, rising from $2.1 billion to $6.1 billion.144

Subsequent Effects on Health Care Spending

In addition to their initial effects, policies aimed at addressing the opioid crisis could lead to subsequent changes in health care spending that arise because of changes in people’s health. When policy approaches improve people’s health, those changes can yield savings later through averted health care spending. Such averted spending includes fewer emergency department visits related to opioid overdoses or less need for treatment of conditions such as neonatal abstinence syndrome (NAS), which occurs in newborns as a result of prenatal exposure to certain substances, most often opioids. Other changes in people’s health could offset those savings, or health care costs could even increase. For instance, studies have found that when the supply of prescription opioids decreases, some people who had been misusing those drugs switch to heroin, resulting in no net change in opioid-involved mortality.145 Additionally, newborns of mothers who took medication treatment for OUD during their pregnancy may develop NAS, which would tend to increase costs.146

The magnitude of subsequent effects on health care spending related to OUD and opioid overdoses would depend on a policy’s effectiveness, as well as the health insurance status and coverage types of the people affected by the policy. Among adults with substance use disorder in 2020, 58 percent were privately insured, 21 percent were covered by Medicaid, 14 percent were uninsured, and the remaining 7 percent had other types of coverage.147 CBO has not estimated whether any particular policy would increase or decrease spending on net, because the budgetary effects would depend on the policy’s details. In its conventional cost estimates, CBO typically includes subsequent effects on health care spending when the agency can determine the magnitude of such effects on the federal budget.

Effects of Changes in the Total Population

Policies that reduced opioid-involved overdose deaths would extend people’s longevity and, in turn, increase outlays for various federal programs and boost revenues. Reducing opioid-involved mortality would expand the population of the United States and probably lead to an increase in the number of people who were working, because people in their prime working years (ages 25 to 44) have the highest rates of death from opioid overdose. If more people were working, the federal government would collect additional payroll and income taxes from an increase in labor income. Reducing opioid-involved mortality would also increase outlays for federal programs, including Medicaid, SNAP, Medicare, and Social Security, as more people collected those benefits or as people collected them for longer. Whether the changes resulted in budgetary savings or costs would depend on factors such as the amount of additional income earned by people who were affected by the policy and the amount of additional federal benefits they collected. Because overdose deaths are concentrated among younger people, greater spending on Medicare and Social Security retirement benefits from averted deaths would mostly occur beyond the typical 10-year period used for CBO’s budget analyses.

Dynamic Effects

Dynamic effects include the effects discussed above, as well as all other effects on spending and revenues stemming from changes in the size of the economy. The policy approaches examined in this report could affect the economy through improved health—resulting in more total hours worked, higher hourly wages, increased labor force growth, and greater business investment—which, in turn, could boost total income across the economy. The research literature has not consistently shown positive labor outcomes associated with reduced opioid use, beyond the impact of that use on mortality (see Box 2). Higher income would reduce the federal deficit in two primary ways: through more payment of income and payroll taxes and through less eligibility for federally supported programs that provide benefits to people with lower income. Higher income would boost interest rates as well, pushing up the government’s net interest costs and partially offsetting the increase in revenues.

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1. 1. Centers for Disease Control and Prevention, National Center for Health Statistics, “National Vital Statistics System: Provisional Drug Overdose Death Counts” (accessed on May 20, 2025), www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.

2. 2. By contrast, a recent randomized controlled trial evaluating evidence-based practices encompassing several policy approaches—such as overdose education and naloxone distribution, the use of medications for the treatment of opioid use disorder, and prescription opioid safety—found similar death rates in both the intervention and control groups over a 12-month multimodal intervention. That null effect may indicate that the benefits of those practices take longer to materialize or that the pandemic disrupted their effectiveness. For more information, see HEALing Communities Study Consortium, “Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths,” New England Journal of Medicine, vol. 391, no. 11 (September 19, 2024), pp. 989–1001, https://doi.org/10.1056/NEJMoa2401177.

3. 3. Coprescribe means to prescribe two or more medications together for the same person, usually at the same time. In March 2023, the Food and Drug Administration approved Narcan, a naloxone nasal spray, for over-the-counter use without a prescription, which is expected to enhance access to the drug. Several barriers may impede its widespread adoption, however, including pharmacy stocking decisions, cost, lack of awareness about how to obtain the drug in pharmacies, and confusing insurance reimbursement policies. See Heather Saunders and Robin Rudowitz, “Will Availability of Over-the-Counter Narcan Increase Access?” (KFF, September 19, 2023), https://tinyurl.com/ymk9x5te.

4. 4. For legislation that authorized the appropriation of funding for such grants but did not provide the funding directly, CBO would estimate the amounts authorized to be appropriated but would not attribute any subsequent effects from the grants to that legislation.

5. 5. Centers for Disease Control and Prevention, National Center for Health Statistics, “Mortality Data on CDC WONDER” (December 10, 2025), https://wonder.cdc.gov/mcd.html, and National Center for Health Statistics, “National Vital Statistics System: Provisional Drug Overdose Death Counts” (accessed on September 17, 2025), www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. The number for 2024 is the provisional count of opioid-involved drug overdose deaths for the 12-month period ending on December 31, 2024.

6. 6. Katherine M. Keyes and others, “What Is the Prevalence of and Trend in Opioid Use Disorder in the United States From 2010 to 2019? Using Multiplier Approaches to Estimate Prevalence for an Unknown Population Size,” Drug and Alcohol Dependence Reports, vol. 3 (June 2022), article 100052, https://doi.org/10.1016/j.dadr.2022.100052.

7. 7. Alexander Baldacchino and others, “Neuropsychological Consequences of Chronic Opioid Use: A Quantitative Review and Meta-Analysis,” Neuroscience & Biobehavioral Reviews, vol. 36, no. 9 (October 2012), pp. 2056–2068, https://doi.org/10.1016/j.neubiorev.2012.06.006; and National Institute on Drug Abuse, “What Are the Medical Complications of Chronic Heroin Use?” in Heroin Research Report (July 2011, accessed October 16, 2024), https://tinyurl.com/mtn2t32j.

8. 8. Steven H. Woolf and Heidi Schoomaker, “Life Expectancy and Mortality Rates in the United States, 1959–2017,” JAMA, vol. 322, no. 20 (November 2019), pp. 1996–2016, https://doi.org/10.1001/jama.2019.16932.

9. 9. Johanna Catherine Maclean and others, “Economic Studies on the Opioid Crisis: Costs, Causes, and Policy Responses,” Oxford Research Encyclopedia of Economics and Finance (June 2021), https://doi.org/10.1093/acrefore/9780190625979.013.283.

10. 10. Christine Minhee, “Frequently Asked Questions 2.0” (accessed October 23, 2024), www.opioidsettlementtracker.com/faq; and National Association of Attorneys General, “Opioids” (accessed October 23, 2024), www.naag.org/issues/opioids/.

11. 11. Sam Mermin, Rebeka Falkner, and Katie Greene, Understanding Opioid Settlement Spending Plans Across States: Key Components and Approaches (National Academy for State Health Policy, December 2022), https://tinyurl.com/NASHP2022.

12. 12. See endnote 5.

13. 13. See endnote 1.

14. 14. Centers for Disease Control and Prevention, “Fentanyl Facts” (April 2, 2024), https://tinyurl.com/542t6v7j.

15. 15. Congressional Budget Office, The Opioid Crisis and Recent Federal Policy Responses (September 2022), www.cbo.gov/publication/58221.

16. 16. A study from 10 U.S. cities revealed that xylazine’s involvement in drug overdose deaths increased from less than 1 percent in 2015 to nearly 7 percent in 2020. See Joseph Friedman and others, “Xylazine Spreads Across the U.S.: A Growing Component of the Increasingly Synthetic and Polysubstance Overdose Crisis,” Drug and Alcohol Dependence, vol. 233 (April 2022), article 109380, https://doi.org/10.1016/j.drugalcdep.2022.109380.

17. 17. Among people with OUD who entered treatment, the use of methamphetamine (a potent addictive central nervous system stimulant drug) increased by 85 percent from 2011 to 2018. Additionally, among synthetic opioid-related overdose deaths in 2016, 80 percent involved another drug or alcohol. See Christopher M. Jones, Emily B. Einstein, and Wilson M. Compton, “Changes in Synthetic Opioid Involvement in Drug Overdose Deaths in the United States, 2010–2016,” JAMA, vol. 319, no. 17 (May 1, 2018), pp. 1819–1821, https://doi.org/10.1001/jama.2018.2844; and Theodore J. Cicero, Matthew S. Ellis, and Zachary A. Kasper, “Polysubstance Use: A Broader Understanding of Substance Use During the Opioid Crisis,” American Journal of Public Health, vol. 110, no. 2 (February 2020), pp. 244–250, https://doi.org/10.2105/AJPH.2019.305412.

18. 18. Julie O’Donnell and others, “Trends in and Characteristics of Drug Overdose Deaths Involving Illicitly Manufactured Fentanyls—United States, 2019–2020,” Morbidity and Mortality Weekly Report, vol. 70, no. 50 (December 2021), pp. 1740–1746, https://doi.org/10.15585/mmwr.mm7050e3; and Millennium Health, “Millennium Health Signals Report” (accessed August 6, 2024), www.millenniumhealth.com/signalsreport/.

19. 19. Centers for Disease Control and Prevention, “Polysubstance Use Facts” (April 2, 2024), https://tinyurl.com/mrzjvvre; National Institute on Drug Abuse, “Methamphetamine” (November 2024), https://tinyurl.com/3wxsmw8u; and Jan Hoffman, “‘A Monster’: Super Meth and Other Drugs Push Crisis Beyond Opioids,” New York Times (November 13, 2023), https://tinyurl.com/ycyfswfh.

20. 20. Beth Han and others, “Racial and Ethnic Disparities in Drug Overdose Deaths in the U.S. During the COVID-19 Pandemic,” JAMA Network Open, vol. 5, no. 9 (September 2022), e2232314, https://doi.org/10.1001/jamanetworkopen.2022.32314; and Maria R. D’Orsogna, Lucas Böttcher, and Tom Chou, “Fentanyl-Driven Acceleration of Racial, Gender, and Geographical Disparities in Drug Overdose Deaths in the United States,” PLOS Global Public Health (March 2023), https://doi.org/10.1371/journal.pgph.0000769.

21. 21. David Powell and others, “Geography and Fentanyl: Explaining the Disproportionate Rise in Opioid Overdose Deaths Among Black Americans,” Health Affairs, vol. 44, no. 9 (September 2025), pp. 1050–1059, https://doi.org/10.1377/hlthaff.2025.00357.

22. 22. Some provisions of law authorize Congress to provide funds through a future appropriation act to administer a program or function. Such authorizations of appropriations differ from other authorizations (sometimes called enabling or organic statutes) that create a federal agency, establish a federal program, prescribe a federal function, or provide for a particular federal obligation or expenditure within a program. Appropriations provide funding to agencies to administer programs and functions. For more information, see Congressional Budget Office, Expired and Expiring Authorizations of Appropriations for Fiscal Year 2024 (July 2024), www.cbo.gov/publication/60390.

23. 23. SUPPORT provisions that have been made permanent can be found in Congressional Budget Office, cost estimate for Consolidated Appropriations Act, 2024 (March 5, 2024), Title I. Health and Human Services, Subtitle B. Medicaid, www.cbo.gov/publication/60058.

24. 24. Congressional Budget Office, Expired and Expiring Authorizations of Appropriations for Fiscal Year 2024 (July 2024), Supplemental Data, www.cbo.gov/publication/60390.

25. 25. Randomized controlled trials randomly assign participants to a treatment or control group to evaluate causal effects. Quasi-experimental designs use nonrandom methods to estimate causal effects, often leveraging natural experiments or statistical techniques to mimic randomization. Correlational studies examine associations between variables but cannot establish causality.

26. 26. Scott Cunningham and Keith Finlay, “Identifying Demand Responses to Illegal Drug Supply Interdictions,” Health Economics, vol. 25, no. 10 (October 2016), pp. 1268–1290, https://doi.org/10.1002/hec.3213; Carlos Dobkin and Nancy Nicosia, “The War on Drugs: Methamphetamine, Public Health, and Crime,” American Economic Review, vol. 99, no. 1 (March 2009), pp. 324–349, https://doi.org/10.1257/aer.99.1.324; and Timothy J. Moore and Kevin T. Schnepel, “Opioid Use, Mortality Risks, and Crime: Insights From a Rapid Reduction in Heroin Supply,” Review of Economics and Statistics (April 2024), https://doi.org/10.1162/rest_a_01453.

27. 27. Matthew K. Griswold and others, “Cryptomarket Drug Acquisition Leading to Furanyl Fentanyl Overdose,” Forensic Toxicology, vol. 36, no. 2 (July 2018), pp. 534–536, https://doi.org/10.1007/s11419-018-0406-0; and Drug Enforcement Administration, Fentanyl Flow to the United States, DEA-DCT-DIR-008-20 (January 2020), p. 2, https://tinyurl.com/mwcmmj6u.

28. 28. Testimony of Tammy Whitcomb, Acting Inspector General, Office of the Inspector General, U.S. Postal Service, before the Subcommittee on Government Operations of the House Committee on Oversight and Government Reform, Examining the Shipment of Illicit Drugs in International Mail (September 7, 2017), https://tinyurl.com/2u5k27m6; Title VIII, Subtitle A of the SUPPORT Act of 2018, P.L. 115-271, 132 Stat. 4073; and Congressional Budget Office, cost estimate for S. 1160, FENTANYL Results Act (June 24, 2022), www.cbo.gov/publication/58243.

29. 29. Congressional Budget Office, cost estimate for S. 331, HALT Fentanyl Act (March 10, 2025), www.cbo.gov/publication/61243.

30. 30. Rosalie Liccardo Pacula and David Powell, “A Supply-Side Perspective on the Opioid Crisis,” Journal of Policy Analysis and Management, vol. 37, no. 2 (Spring 2018), pp. 438–446, https://doi.org/10.1002/pam.22049.

31. 31. Office of National Drug Control Policy, National Interdiction Command and Control Plan (2022), p. 10, https://tinyurl.com/2cwr2pvr.

32. 32. Scott Cunningham and Keith Finlay, “Identifying Demand Responses to Illegal Drug Supply Interdictions,” Health Economics, vol. 25, no. 10 (October 2016), pp. 1268–1290, https://doi.org/10.1002/hec.3213; and Carlos Dobkin and Nancy Nicosia, “The War on Drugs: Methamphetamine, Public Health, and Crime,” American Economic Review, vol. 99, no. 1 (March 2009), pp. 324–349, https://doi.org/10.1257/aer.99.1.324.

33. 33. Timothy J. Moore and Kevin T. Schnepel, “Opioid Use, Mortality Risks, and Crime: Insights From a Rapid Reduction in Heroin Supply,” Review of Economics and Statistics (April 2024), https://doi.org/10.1162/rest_a_01453.

34. 34. Bryce Pardo and Peter Reuter, Enforcement Strategies for Fentanyl and Other Synthetic Opioids (Brookings Institution, June 2020), https://tinyurl.com/ycrsecb9.

35. 35. American Society of Addiction Medicine, The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update (ASAM, 2020), https://tinyurl.com/mv9cv4se.

36. 36. Manuel Cano and others, “Fewer Than 1 in 3 Adolescents With Past-Year Opioid Use Disorder Received Substance Use Treatment, 2022–23,” Health Affairs, vol. 44, no. 9  (September 2025), Exhibit A4, https://doi.org/10.1377/hlthaff.2025.00240.

37. 37. Nora D. Volkow and Carlos Blanco, “The Changing Opioid Crisis: Development, Challenges, and Opportunities,” Molecular Psychiatry, vol. 26 (2021), pp. 218–233, https://doi.org/10.1038/s41380-020-0661-4.

38. 38. Three states were granted an exception because of shortages of providers. See Department of Health and Human Services, Office of Inspector General, Many Medicaid Enrollees With Opioid Use Disorder Were Treated With Medication; However, Disparities Present Concerns, OEI-BL-22-00260 (September 2023), https://tinyurl.com/bde2tz3f.

39. 39. Alan I. Leshner and Michelle Mancher, eds., Medications for Opioid Use Disorder Save Lives (The National Academies Press, 2019), https://doi.org/10.17226/25310.

40. 40. Medicaid and CHIP Payment and Access Commission, “Behavioral Health in the Medicaid Program—People, Use, and Expenditures,” Chapter 4 in Report to Congress on Medicaid and CHIP (June 2015), https://tinyurl.com/bdfwhe8z.

41. 41. Heather Saunders and Robin Rudowitz, “Demographics and Health Insurance Coverage of Nonelderly Adults With Mental Illness and Substance Use Disorders in 2020” (KFF, June 6, 2022), https://tinyurl.com/ywdtcduz; and William J. Parish and others, “Substance Use Disorders Among Medicare Beneficiaries: Prevalence, Mental and Physical Comorbidities, and Treatment Barriers,” American Journal of Preventive Medicine, vol. 63, no. 2 (August 2022), pp. 225–232, https://doi.org/10.1016/j.amepre.2022.01.021.

42. 42. In 2019, 7.2 million nonelderly adults in the United States were estimated to have opioid use disorder, and about 22 percent were covered by Medicaid. See Katherine M. Keyes and others, “What Is the Prevalence of and Trend in Opioid Use Disorder in the United States From 2010 to 2019? Using Multiplier Approaches to Estimate Prevalence for an Unknown Population Size,” Drug and Alcohol Dependence Reports, vol. 3 (June 2022), article 100052, https://doi.org/10.1016/j.dadr.2022.100052; and Heather Saunders, “A Look at Substance Use Disorders (SUD) Among Medicaid Enrollees” (KFF, February 17, 2023), https://tinyurl.com/4jvvthwn.

43. 43. Colleen M. Grogan and others, “Survey Highlights Differences in Medicaid Coverage for Substance Use Treatment and Opioid Use Disorder Medications,” Health Affairs, vol. 35, no. 12 (December 2016), pp. 2289–2296, https://doi.org/10.1377/hlthaff.2016.0623; and Tami L. Mark and others, “Medicaid Coverage of Medications to Treat Alcohol and Opioid Dependence,” Journal of Substance Abuse Treatment, vol. 55 (August 2015), pp. 1–5, https://doi.org/10.1016/j.jsat.2015.04.009.

44. 44. KFF, “Medicaid Behavioral Health Services” (accessed October 22, 2024), https://tinyurl.com/4nb2ttd5; and American Society of Addiction Medicine, An Introduction to the ASAM Criteria for Patients and Families (ASAM, 2015), https://tinyurl.com/er7635mk.

45. 45. The exclusion of institutions for mental diseases contributes to the coverage gaps in residential SUD treatment. That exclusion prohibits states from using federal Medicaid dollars to pay for care provided in psychiatric hospitals or other residential treatment facilities that have more than 16 beds. See Madeline Guth and others, “Medicaid Coverage of Behavioral Health Services in 2022: Findings From a Survey of State Medicaid Programs” (KFF, March 17, 2023), https://tinyurl.com/2rdh22mz. Partial hospitalization is a structured treatment program that provides intensive therapy during the day, bridging the gap between outpatient care and inpatient hospitalization.

46. 46. Secs. 1006, 5051, and 5052 of the SUPPORT for Patients and Communities Act, 2018, P.L. 115-271, 132 Stat. 3913, 3971.

47. 47. Secs. 201 and 204 of the Consolidated Appropriations Act, 2024, P.L. 118-42, 138 Stat. 47, 48. See Congressional Budget Office, Budgetary Effects of Policies to Modify or Eliminate Medicaid’s Institutions for Mental Diseases Exclusion (April 2023), www.cbo.gov/publication/58962.

48. 48. KFF, “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State” (December 4, 2025), https://tinyurl.com/pzxbhvvd; and Megan B. Houston, Expiration of 1915(l) Medicaid State Plan Option, Report IN12212 (Congressional Research Service, August 3, 2023), https://tinyurl.com/ms4hzxzy. Section 1115 of the Social Security Act authorizes the Secretary of Health and Human Services to waive certain provisions of the Medicaid and Children’s Health Insurance Program (CHIP) statutes for states to carry out demonstration projects that promote the objectives of the program. Waiver approval is subject to budget neutrality requirements, and savings shown through section 1115 waivers can be used to finance other program spending.

49. 49. KFF, “A View From the States: Key Medicaid Policy Changes: Results From a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020” (KFF, October 18, 2019), https://tinyurl.com/3u4axjt4.

50. 50. Those approaches would require enacting legislation that provided financial incentives (such as a higher federal medical assistance percentage, or FMAP) or imposing requirements on the states as a condition for receiving federal Medicaid funding. An example of an enhanced federal medical assistance percentage is the 90 percent share that states currently receive for qualifying Medicaid Health Home services for the first two years of an enrollee’s participation. See Centers for Medicare & Medicaid Services, “Health Homes” (accessed April 1, 2023), https://tinyurl.com/ycy8c3uj.

51. 51. Centers for Medicare & Medicaid Services, “Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act: Section 1003” (accessed April 1, 2023), https://tinyurl.com/8m9phsmd.

52. 52. Brendan Saloner, Kenneth B. Stoller, and Colleen L. Barry, “Medicaid Coverage for Methadone Maintenance and Use of Opioid Agonist Therapy in Specialty Addiction Treatment,” Psychiatric Services, vol. 67, no. 6 (June 2016), https://doi.org/10.1176/appi.ps.201500228; Lori J. Ducharme and Amanda J. Abraham, “State Policy Influence on the Early Diffusion of Buprenorphine in Community Treatment Programs,” Substance Abuse Treatment, Prevention, and Policy, vol. 3 (2008), article 17, https://doi.org/10.1186/1747-597x-3-17; Ramin Mojtabai and others, “Medication Treatment for Opioid Use Disorders in Substance Use Treatment Facilities,” Health Affairs, vol. 38, no. 1 (January 2019), pp. 14–23, https://doi.org/10.1377/hlthaff.2018.05162; and Ellen Latsko, Alina Denham, and Michael L. Barnett, “Medicaid and Methadone for Opioid Use Disorder: Expanded Coverage Increased Distribution in 10 States, 2019–24,” Health Affairs, vol. 44, no. 9 (August 2025), pp. 1112–1121, https://doi.org/10.1377/hlthaff.2025.00319.

53. 53. Dennis D. Deck, Wyndy L. Wiitala, and Katherine E. Laws, “Medicaid Coverage and Access to Publicly Funded Opiate Treatment,” Journal of Behavioral Health Services & Research, vol. 33, no. 3 (July 2006), pp. 324–334, https://doi.org/10.1007/s11414-006-9018-2; and Bret E. Fuller and others, “Elimination of Methadone Benefits in the Oregon Health Plan and Its Effects on Patients,” Psychiatric Services, vol. 57, no. 5 (May 2006), pp. 686–691, https://doi.org/10.1176/ps.2006.57.5.686.

54. 54. Angélica Meinhofer and Allison E. Witman, “The Role of Health Insurance on Treatment for Opioid Use Disorders: Evidence From the Affordable Care Act Medicaid Expansion,” Journal of Health Economics, vol. 60 (July 2018), pp. 177–197, https://doi.org/10.1016/j.jhealeco.2018.06.004; Andrew J. Barnes and others, “Hospital Use Declines After Implementation of Virginia Medicaid’s Addiction and Recovery Treatment Services,” Health Affairs, vol. 39, no. 2 (February 2020), pp. 238–246, https://doi.org/10.1377/hlthaff.2019.00525; Sandra Decker and others, “The Impact of the Affordable Care Act Insurance Expansions on Opioid-Related Emergency Department Visits,” American Journal of Health Economics, vol. 9, no. 3 (Summer 2023), pp. 405–434, https://doi.org/10.1086/722928; Nicole Kravitz-Wirtz and others, “Association of Medicaid Expansion With Opioid Overdose Mortality in the United States,” JAMA Network Open, vol. 3, no. 1 (January 2020), e1919066, https://doi.org/10.1001/jamanetworkopen.2019.19066; Hefei Wen and others, “Association Between Medicaid Expansion and Rates of Opioid-Related Hospital Use,” JAMA Internal Medicine, vol. 180, no. 5 (May 2020), pp. 753–759, https://doi.org/10.1001/jamainternmed.2020.0473; Atheendar S. Venkataramani and Paula Chatterjee, “Early Medicaid Expansions and Drug Overdose Mortality in the USA: A Quasi-Experimental Analysis,” Journal of General Internal Medicine, vol. 34 (2019), pp. 23–25, https://doi.org/10.1007/s11606-018-4664-7; Susan L. Averett, Julie K. Smith, and Yang Wang, “Medicaid Expansion and Opioid Deaths,” Health Economics, vol. 28, no. 12 (December 2019), pp. 1491–1496, https://doi.org/10.1002/hec.3945; and Samantha G. Auty and Kevin N. Griffith, “Medicaid Expansion and Drug Overdose Mortality During the COVID-19 Pandemic in the United States,” Drug and Alcohol Dependence, vol. 232 (March 2022), article 109340, https://doi.org/10.1016/j.drugalcdep.2022.109340.

55. 55. Johanna Catherine Maclean and others, “Institutions for Mental Diseases Medicaid Waivers: Impact on Payments for Substance Use Treatment Facilities,” Health Affairs, vol. 40, no. 2 (February 2021), pp. 326–333, https://doi.org/10.1377/hlthaff.2020.00404; Stephan Lindner and others, “Effects of Medicaid Waivers on Use of Medications for Opioid Use Disorder and Nonfatal Overdoses in 17 States,” Health Affairs, vol. 43, no. 11 (November 2024), pp. 1597–1604, https://doi.org/10.1377/hlthaff.2024.00461; and Tamara Beetham and others, “Medicaid: Increased Patient Access to MOUD in Residential Treatment Associated With Facility Openings and Closures, 2012–22,” Health Affairs, vol. 44, no. 9 (September 2025), pp. 1122–1130, https://doi.org/10.1377/hlthaff.2025.00348.

56. 56. Seema Choksy Pessar and others, “Assessment of State and Federal Health Policies for Opioid Use Disorder Treatment During the COVID-19 Pandemic and Beyond,” JAMA Health Forum, vol. 2, no. 11 (November 2021), e213833, https://doi.org/10.1001/jamahealthforum.2021.3833; and Alisa B. Busch and others, “Telemedicine for Treating Mental Health and Substance Use Disorders: Reflections Since the Pandemic,” Neuropsychopharmacology, vol. 46, no. 6 (May 2021), pp. 1068–1070, https://doi.org/10.1038/s41386-021-00960-4.

57. 57. Substance Abuse and Mental Health Services Administration, “FAQs: Provision of Methadone and Buprenorphine for the Treatment of Opioid Use Disorder in the COVID-19 Emergency” (April 21, 2020), https://tinyurl.com/46z78xnr; Drug Enforcement Administration, letter to DEA Qualifying Practitioners (March 31, 2020), https://tinyurl.com/3r36ax92; and Centers for Medicare & Medicaid Services, “Medicare Telemedicine Health Care Provider Fact Sheet” (March 17, 2020), https://tinyurl.com/5fusyd32.

58. 58. For instance, Medicare permanently removed geographic restrictions on the originating site for behavioral health services, including restrictions for opioid use disorder. Offering telemedicine flexibilities that allow remote initiation of buprenorphine and methadone treatment for new patients in opioid treatment programs, as well as permitting stable patients to take doses of methadone at home, have also become permanent. See Health Resources and Services Administration, “Telehealth Policy Updates” (November 21, 2025), https://tinyurl.com/3zzwc7k3; and Medications for the Treatment of Opioid Use Disorder, 42 C.F.R. § 8 (2023).

59. 59. Elizabeth Hinton and others, “Telehealth,” in How the Pandemic Continues to Shape Medicaid Priorities: Results From an Annual Medicaid Budget Survey for State Fiscal Years 2022 and 2023 (KFF, October 2022), https://tinyurl.com/2fy6s7tj.

60. 60. Allison M. Cohen, Samuel Cottle, and Alex S. Lewis, “Medicare Telehealth Waivers Extended Until March 2025” (Baker Donelson, January 6, 2025), https://tinyurl.com/2u8vcs8v.

61. 61. Seventeen percent of Americans in rural areas lack access to broadband Internet, compared with only 1 percent of Americans in urban areas. See Federal Communications Commission, Fourteenth Broadband Deployment Report (January 2021), https://tinyurl.com/yc7ed65d. Fifty-six percent of families earning less than $40,000 annually have a broadband subscription, compared with 86 percent of families earning more than $70,000 per year. See George W. Zuo, “Wired and Hired: Employment Effects of Subsidized Broadband Internet for Low-Income Americans,” American Economic Journal: Economic Policy, vol. 13, no. 3 (August 2021), pp. 447–482, https://doi.org/10.1257/pol.20190648.

62. 62. Benjamin A. Barsky, Ateev Mehrotra, and Haiden A. Huskamp, “State Policies Could Impede New Efforts to Increase Access to Medications for Opioid Use Disorder,” JAMA Health Forum, vol. 4, no. 3 (March 2023), e230071, https://doi.org/10.1001/jamahealthforum.2023.0071.

63. 63. Katherine M. Keyes and others, “What Is the Prevalence of and Trend in Opioid Use Disorder in the United States From 2010 to 2019? Using Multiplier Approaches to Estimate Prevalence for an Unknown Population Size,” Drug and Alcohol Dependence Reports, vol. 3 (June 2022), article 100052, https://doi.org/10.1016/j.dadr.2022.100052; Heather Saunders, “A Look at Substance Use Disorders (SUD) Among Medicaid Enrollees” (KFF, February 17, 2023), https://tinyurl.com/4jvvthwn; Department of Health and Human Services, Office of Inspector General, Opioid Overdoses and the Limited Treatment of Opioid Use Disorder Continue to Be Concerns for Medicare Beneficiaries, OEI-02-22-00390 (September 2022), https://tinyurl.com/3k24ma7d; and Centers for Medicare & Medicaid Services, Medicare Fee-for-Service Beneficiaries With Opioid Use Disorder in 2018: Disparities in Prevalence by Beneficiary Characteristics, Data Highlight No. 21 (December 2020), https://tinyurl.com/2cphzxkm.

64. 64. Eric Weintraub and others, “Mobile Telemedicine for Buprenorphine Treatment in Rural Populations With Opioid Use Disorder,” JAMA Network Open, vol. 4, no. 8 (August 2021), e2118487, https://doi.org/10.1001/jamanetworkopen.2021.18487; Brian Chan and others, Retention Strategies for Medications for Addiction Treatment in Adults With Opioid Use Disorder: A Rapid Evidence Review, 20-EHC012 (prepared by Scientific Research Center for Agency for Healthcare Research and Quality, July 2020), https://tinyurl.com/yc6ts7pa; and Van L. King and others, “A Randomized Trial of Web-Based Videoconferencing for Substance Abuse Counseling,” Journal of Substance Abuse Treatment, vol. 46, no. 1 (January 2014), pp. 36–42, https://doi.org/10.1016/j.jsat.2013.08.009.

65. 65. Jessica Duncan Cance and Erin Doyle, “Changes in Outpatient Buprenorphine Dispensing During the COVID-19 Pandemic,” JAMA, vol. 324, no. 23 (December 15, 2020), pp. 2442–2444, https://doi.org/10.1001/jama.2020.22154; Phillip M. Hughes and others, “An Examination of Telehealth Policy Impacts on Initial Rural Opioid Use Disorder Treatment Patterns During the COVID‐19 Pandemic,” Journal of Rural Health, vol. 37, no. 3 (Summer 2021), pp. 467–472, https://doi.org/10.1111/jrh.12570; Christopher M. Jones and others, “Receipt of Telehealth Services, Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare Beneficiaries Before and During the COVID-19 Pandemic,” JAMA Psychiatry, vol. 79, no. 10 (October 2022), pp. 981–992, https://doi.org/10.1001/jamapsychiatry.2022.2284; and Christopher M. Jones and others, “Association of Receipt of Opioid Use Disorder–Related Telehealth Services and Medications for Opioid Use Disorder With Fatal Drug Overdoses Among Medicare Beneficiaries Before and During the COVID-19 Pandemic,” JAMA Psychiatry, vol. 80, no. 5 (May 2023), pp. 508–514, https://doi.org/10.1001/jamapsychiatry.2023.0310.

66. 66. Alan I. Leshner and Michelle Mancher, eds., Medications for Opioid Use Disorder Save Lives (National Academies Press, 2019), https://doi.org/10.17226/25310; and Katherine M. Keyes and others, “What Is the Prevalence of and Trend in Opioid Use Disorder in the United States From 2010 to 2019? Using Multiplier Approaches to Estimate Prevalence for an Unknown Population Size,” Drug and Alcohol Dependence Reports, vol. 3 (June 2022), article 100052, https://doi.org/10.1016/j.dadr.2022.100052.

67. 67. Shabbar I. Ranapurwala and others, “Opioid Overdose Mortality Among Former North Carolina Inmates: 2000–2015,” American Journal of Public Health, vol. 108, no. 9 (September 2018), pp. 1207–1213, https://doi.org/10.2105/AJPH.2018.304514.

68. 68. Sarah E. Wakeman and Josiah D. Rich, “Addiction Treatment Within U.S. Correctional Facilities: Bridging the Gap Between Current Practice and Evidence-Based Care,” Journal of Addictive Diseases, vol. 34, nos. 2–3 (2015), pp. 220–225, https://doi.org/10.1080/10550887.2015.1059217; Mardet Homans, Denise M. Allen, and Yesenia Mazariegos, A Review of Medication Assisted Treatment (MAT) in United States Jails and Prisons (UC Irvine Center for Evidence-Based Corrections, June 2023), https://tinyurl.com/yc48akym; and Elizabeth Flanagan Balawajder and others, “Factors Associated With the Availability of Medications for Opioid Use Disorder in U.S. Jails,” JAMA Network Open, vol. 7, no. 9 (September 2024), e2434704, https://doi.org/10.1001/jamanetworkopen.2024.34704.

69. 69. Medicaid and CHIP Payment and Access Commission, “Access to Medicaid Coverage and Care for Adults Leaving Incarceration,” Chapter 3 in Report to Congress on Medicaid and CHIP (June 2023), https://tinyurl.com/yf5azuhy.

70. 70. First Step Act of 2018, P.L. 115-391, 132 Stat. 5194.

71. 71. Government Accountability Office, Bureau of Prisons: Improved Planning Would Help BOP Evaluate and Manage Its Portfolio of Drug Education and Treatment Programs, GAO-20-423 (May 26, 2020), www.gao.gov/products/gao-20-423.

72. 72. Due Process Continuity of Care Act, S. 2697, 117th Cong. (2021); Medicaid Reentry Act of 2021, H.R. 955, 117th Cong.; and Humane Correctional Health Care Act, H.R. 3514, 117th Cong. (2021).

73. 73. In 2023, CMS approved California’s section 1115 demonstration project, which allows Medicaid to cover a limited set of health care services, including medication treatment and counseling for SUDs, for incarcerated individuals for 90 days prerelease. CMS has announced the new Medicaid Reentry Section 1115 Demonstration Opportunity, which will allow states to cover a package of services, including medication treatment for all types of SUD, for up to 90 days before release. By providing guidance to states and encouraging them to take up the waiver, this policy could increase the number of states that provide limited Medicaid coverage of some SUD treatment services in correctional facilities. As of August 19, 2024, CMS had approved section 1115 reentry waiver requests from 11 states, while 13 additional reentry waivers remain pending. For more information, see Elizabeth Hinton, Akash Pillai, and Amaya Diana, “Section 1115 Waiver Watch: Medicaid Pre-Release Services for People Who Are Incarcerated” (KFF, August 19, 2024), https://tinyurl.com/rxj6m89s; Lesley Baseman and Melinda Becker Roach, “Access to Medicaid Coverage and Care for Adults Leaving Incarceration: Review of Draft Chapter for June Report” (Medicaid and CHIP Payment and Access Commission, April 13, 2023), https://tinyurl.com/ywywct5e; and Daniel Tsai, Deputy Administrator and Director, Centers for Medicare & Medicaid Services, letter to State Medicaid Directors, “Opportunities to Test Transition-Related Strategies to Support Community Reentry and Improve Care Transitions for Individuals Who Are Incarcerated” (April 17, 2023), https://tinyurl.com/52urhk39.

74. 74. Law Enforcement Assisted Diversion National Support Bureau, “LEAD Sites” (accessed March 4, 2025), https://leadbureau.org/lead-sites/.

75. 75. National Institute of Justice, “Overview of Drug Courts” (July 22, 2020), https://nij.ojp.gov/topics/articles/overview-drug-courts.

76. 76. Kristen DeVall, Christina Lanier, and Lindsay J. Baker, Painting the Current Picture: A National Report on Treatment Courts in the United States (National Drug Court Resource Center, 2022), https://ndcrc.org/pcp/.

77. 77. U.S. Attorney’s Office, Western District of North Carolina, “U.S. Attorney’s Office Announces Over $6.8 Million in Federal Grants To Support Opioid Treatment Programs” (press release, November 25, 2024), https://tinyurl.com/3rxezdcr; and Maryland Governor’s Office of Crime Prevention and Policy, “Law Enforcement Assisted Diversion Initiatives” (accessed September 16, 2025), https://tinyurl.com/3p9uzwt6.

78. 78. The National Survey on Drug Use and Health (NSDUH) is known to substantially underestimate drug use. To determine the prevalence of OUD, Keyes and others (2022) adjusted estimates based on NSDUH data to arrive at lower and upper bounds of 6.7 million and 7.6 million. Using those bounds, CBO assumed the midpoint of 7.2 million people with OUD. The rate of OUD in jails and prisons is estimated to be 15 percent, and the combined jail and prison population in 2019 was 2.2 million. Using those data, CBO estimates that there were 324,000 incarcerated people with OUD, or 4.5 percent of the total population with OUD. See Katherine M. Keyes and others, “What Is the Prevalence of and Trend in Opioid Use Disorder in the United States From 2010 to 2019? Using Multiplier Approaches to Estimate Prevalence for an Unknown Population Size,” Drug and Alcohol Dependence Reports, vol. 3 (June 2022), article 100052, https://doi.org/10.1016/j.dadr.2022.100052; Alan I. Leshner and Michelle Mancher, eds., Medications for Opioid Use Disorder Save Lives (National Academies Press, 2019), https://doi.org/10.17226/25310; E. Ann Carson, Prisoners in 2019 (Bureau of Justice Statistics, October 2020), https://bjs.ojp.gov/content/pub/pdf/p19.pdf; and Zhen Zeng and Todd D. Minton, Jail Inmates in 2019, NCJ 255608 (Bureau of Justice Statistics, March 2021), https://bjs.ojp.gov/library/publications/jail-inmates-2019.

79. 79. Sarah Larney, “Does Opioid Substitution Treatment in Prisons Reduce Injecting-Related HIV Risk Behaviours? A Systematic Review,” Addiction, vol. 105, no. 2 (February 2010), pp. 216–223, https://doi.org/10.1111/j.1360-0443.2009.02826.x; and Monica Malta and others, “Opioid-Related Treatment, Interventions, and Outcomes Among Incarcerated Persons: A Systematic Review,” PLOS Medicine, vol. 16, no. 12 (2019), e1003002, https://doi.org/10.1371/journal.pmed.1003002.

80. 80. Timothy W. Kinlock and others, “A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Results at 12 Months Postrelease,” Journal of Substance Abuse Treatment, vol. 37, no. 3 (October 2009), pp. 277–285, https://doi.org/10.1016/j.jsat.2009.03.002; Dagmar Hedrich and others, “The Effectiveness of Opioid Maintenance Treatment in Prison Settings: A Systematic Review,” Addiction, vol. 107, no. 3 (March 2012), pp. 501–517, https://doi.org/10.1111/j.1360-0443.2011.03676.x; and Brady P. Horn and others, “Cost-Effectiveness Analysis of a Large Jail-Based Methadone Maintenance Treatment Continuation Program in New Mexico,” Journal of Substance Abuse Treatment, vol. 115 (August 2020), article 108042, https://doi.org/10.1016/j.jsat.2020.108042.

81. 81. Susan E. Collins, Heather S. Lonczak, and Seema L. Clifasefi, “Seattle’s Law Enforcement Assisted Diversion (LEAD): Program Effects on Recidivism Outcomes,” Evaluation and Program Planning, vol. 64 (October 2017), pp. 49–56, https://doi.org/10.1016/j.evalprogplan.2017.05.008; Seema L. Clifasefi, Heather S. Lonczak, and Susan E. Collins, “Seattle’s Law Enforcement Assisted Diversion (LEAD) Program: Within-Subjects Changes on Housing, Employment, and Income/Benefits Outcomes and Associations With Recidivism,” Crime & Delinquency, vol. 63, no. 4 (April 2017), pp. 429–445, https://doi.org/10.1177/0011128716687550; Etienne Blais and others, “Diverting People Who Use Drugs From the Criminal Justice System: A Systematic Review of Police-Based Diversion Measures,” International Journal of Drug Policy, vol. 105 (July 2022), article 103697, https://doi.org/10.1016/j.drugpo.2022.103697; Michael W. Finigan, Shannon M. Carey, and Anton Cox, The Impact of a Mature Drug Court Over 10 Years of Operation: Recidivism and Costs, Executive Summary (submitted by NPC Research to National Institute of Justice, Office of Research and Evaluation, April 2007), www.ojp.gov/pdffiles1/nij/grants/219224.pdf; and Denise C. Gottfredson, Stacy S. Najaka, and Brook Kearley, “Effectiveness of Drug Treatment Courts: Evidence From a Randomized Trial,” Criminology & Public Policy, vol. 2, no. 2 (March 2003), pp.171–196, https://doi.org/10.1111/j.1745-9133.2003.tb00117.x.

82. 82. Shelli B. Rossman and others, The Multi-Site Adult Drug Court Evaluation: The Impact of Drug Courts, vol. 4 of Final Report (prepared by Urban Institute for National Institute of Justice, Office of Justice Programs, November 2011), www.ojp.gov/pdffiles1/nij/grants/237112.pdf.

83. 83. Elizabeth Van Nostrand and others, “Indiana Adults Who Participated in Treatment Court Programs Had Better Health Outcomes Than Those Who Did Not,” Health Affairs, vol. 44, no. 9 (September 2025), pp. 1148–1156, https://doi.org/10.1377/hlthaff.2025.00346.

84. 84. Stephen W. Patrick and others, “Implementation of Prescription Drug Monitoring Programs Associated With Reductions in Opioid-Related Death Rates,” Health Affairs, vol. 35, no. 7 (July 2016), pp. 1324–1332, https://doi.org/10.1377/hlthaff.2015.1496.

85. 85. The Controlled Substances Act categorizes drugs and other substances into five schedules. For more information, see Drug Enforcement Administration, Diversion Control Division, “Lists of Scheduling Actions, Controlled Substances, Regulated Chemicals” (November 2025), https://tinyurl.com/3ah7y3um. Data about PDMP characteristics are from Prescription Drug Monitoring Program Training and Technical Assistance Center, “PDMP Policies and Capabilities” (accessed April 1, 2023), https://tinyurl.com/42nzzvjf.

86. 86. A qualified PDMP must allow providers to access their patients’ history of prescriptions for controlled substances and must integrate that information into providers’ workflows. See Centers for Medicare & Medicaid Services, “Frequently Asked Questions: SUPPORT for Patients and Communities Act, Section 5042–Medicaid PARTNERSHIP Act” (October 2018), https://tinyurl.com/3nr7t6u8; and Centers for Medicare & Medicaid Services, Report to Congress: State Challenges and Best Practices Implementing PDMP Requirements Under Section 5042 of the SUPPORT Act (June 2021), https://tinyurl.com/d223sku.

87. 87. Greg Slabodkin, “EHRs Need Better Integration With Prescription Drug Monitoring Programs” (February 28, 2018), https://tinyurl.com/44pvspnx.

88. 88. National Center for Injury Prevention and Control, Integrating & Expanding Prescription Drug Monitoring Program Data: Lessons From Nine States (February 2017), https://tinyurl.com/2rdpz343.

89. 89. Mir M. Ali and others, “Prescription Drug Monitoring Programs, Nonmedical Use of Prescription Drugs, and Heroin Use: Evidence From the National Survey of Drug Use and Health,” Addictive Behaviors, vol. 69 (June 2017), pp. 65–77, https://doi.org/10.1016/j.addbeh.2017.01.011; Thomas C. Buchmueller and Colleen Carey, “The Effect of Prescription Drug Monitoring Programs on Opioid Utilization in Medicare,” American Economic Journal: Economic Policy, vol. 10, no. 1 (February 2018), pp. 77–112, https://doi.org/10.1257/pol.20160094; Yuhua Bao and others, “Assessing the Impact of State Policies for Prescription Drug Monitoring Programs on High-Risk Opioid Prescriptions,” Health Affairs, vol. 37, no. 10 (October 2018), pp. 1596–1604, https://doi.org/10.1377/hlthaff.2018.0512; Anca M. Grecu, Dhaval M. Dave, and Henry Saffer, “Mandatory Access Prescription Drug Monitoring Programs and Prescription Drug Abuse,” Journal of Policy Analysis and Management, vol. 38, no. 1 (Winter 2019), pp. 181–209, https://doi.org/10.1002/pam.22098; and Hefei Wen and others, “Prescription Drug Monitoring Program Mandates: Impact on Opioid Prescribing and Related Hospital Use,” Health Affairs, vol. 38, no. 9 (September 2019), pp. 1550–1556, https://doi.org/10.1377/hlthaff.2019.00103.

90. 90. Scott G. Weiner and others, “Opioid Prescribing After Implementation of Single Click Access to a State Prescription Drug Monitoring Program Database in a Health System’s Electronic Health Record,” Pain Medicine, vol. 22, no. 10 (October 2021), pp. 2218–2223, https://doi.org/10.1093/pm/pnab051; and Lucy Xiaolu Wang, “The Complementarity of Drug Monitoring Programs and Health IT for Reducing Opioid-Related Mortality and Morbidity,” Health Economics, vol. 30, no. 9 (September 2021), pp. 2026–2046, https://doi.org/10.1002/hec.4360.

91. 91. Yuhua Bao and others, “Assessing the Impact of State Policies for Prescription Drug Monitoring Programs on High-Risk Opioid Prescriptions,” Health Affairs, vol. 37, no. 10 (October 2018), pp. 1596–1604, https://doi.org/10.1377/hlthaff.2018.0512; and Bradley D. Stein and others, “The Effect of State Policies on Rates of High-Risk Prescribing of an Initial Opioid Analgesic,” Drug and Alcohol Dependence, vol. 231 (February 2022), article 109232, https://doi.org/10.1016/j.drugalcdep.2021.109232.

92. 92. Justine Mallatt, “Policy-Induced Substitution to Illicit Drugs and Implications for Law Enforcement Activity,” American Journal of Health Economics, vol. 8, no. 1 (Winter 2022), pp. 30–64, https://doi.org/10.1086/716462; Bokyung Kim, “Must-Access Prescription Drug Monitoring Programs and the Opioid Overdose Epidemic: The Unintended Consequences,” Journal of Health Economics, vol. 75 (January 2021), article 102408, https://doi.org/10.1016/j.jhealeco.2020.102408; Magdalena Cerdá and others, “The Role of Prescription Opioid and Cannabis Supply Policies on Opioid Overdose Deaths,” American Journal of Epidemiology, vol. 194, no. 3 (March 2025), pp. 791-801, https://doi.org/10.1093/aje/kwae210; Silvia S. Martins and others, “Prescription Drug Monitoring Programs Operational Characteristics and Fatal Heroin Poisoning,” International Journal of Drug Policy, vol. 74 (December 2019), pp. 174–180, https://doi.org/10.1016/j.drugpo.2019.10.001; and Deborah Dowell and others, “Mandatory Provider Review and Pain Clinic Laws Reduce the Amounts of Opioids Prescribed and Overdose Death Rates,” Health Affairs, vol. 35, no. 10 (October 2016), pp. 1876–1883, https://doi.org/10.1377/hlthaff.2016.0448.

93. 93. Drug Enforcement Administration, “Facts About Fentanyl” (accessed May 20, 2024), https://tinyurl.com/2kadhp62.

94. 94. Catherine M. Lemieux and others, Curricular Resource on Screening, Brief Intervention, and Referral to Treatment (SBIRT): Mapping CSWE 2015 EPAS to SBIRT (Council on Social Work Education), https://tinyurl.com/2d8225an.

95. 95. Sharon Estee and others, Use of Alcohol and Other Drugs Declined Among Emergency Department Patients Who Received Brief Interventions for Substance Use Disorders Through WASBIRT (Washington State Department of Social and Health Services, May 2007), https://tinyurl.com/yc2wfkyc; and Mitchell P. Karno and others, “Effect of Screening, Brief Intervention, and Referral to Treatment for Unhealthy Alcohol and Other Drug Use in Mental Health Treatment Settings: A Randomized Controlled Trial,” Addiction, vol. 116, no. 1 (January 2021), pp. 159–169, https://doi.org/10.1111/add.15114.

96. 96. Stacy Sterling and others, “Young Adult Substance Use and Healthcare Use Associated With Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care,” Journal of Adolescent Health, vol. 71, no. 4 (October 2022), pp. S15–S23, https://doi.org/10.1016/j.jadohealth.2021.11.033.

97. 97. Judith Bernstein and others, “Brief Motivational Intervention at a Clinic Visit Reduces Cocaine and Heroin Use,” Drug and Alcohol Dependence, vol. 77, no. 1 (January 2005), pp. 49–59, https://doi.org/10.1016/j.drugalcdep.2004.07.006.

98. 98. Jean C. Hostage and others, “Integrating Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Use Into Prenatal Care,” Maternal and Child Health Journal, vol. 24, no. 4 (April 2020), pp. 412–418, https://doi.org/10.1007/s10995-020-02892-9.

99. 99. Drug Addiction Treatment Act of 2000, H.R. 2634, 106th Cong.

100. 100. Joanne Spetz and others, “Nurse Practitioner and Physician Assistant Waivers to Prescribe Buprenorphine and State Scope of Practice Restrictions,” JAMA, vol. 321, no. 14 (April 9, 2019), pp. 1407–1408, https://doi.org /10.1001/jama.2019.0834.

101. 101. Eric Barrette, Leemore Dafny, and Karen Shen, “Do Policies to Increase Access to Treatment for Opioid Use Disorder Work?” American Journal of Health Economics, vol. 9, no. 3 (Summer 2023), pp. 297–330, https://doi.org/10.1086/722980.

102. 102. Christopher M. Jones and Elinore F. McCance‐Katz, “Characteristics and Prescribing Practices of Clinicians Recently Waivered to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder,” Addiction, vol. 114, no. 3 (March 2019), pp. 471–482, https://doi.org/10.1111/add.14436; and Andrew S. Huhn and Kelly E. Dunn, “Why Aren’t Physicians Prescribing More Buprenorphine?” Journal of Substance Abuse Treatment, vol. 78 (July 2017), pp. 1–7, https://doi.org/10.1016/j.jsat.2017.04.005.

103. 103. California Grants Portal, “California Hub & Spoke System: State Opioid Response III” (June 14, 2023), https://tinyurl.com/y27bjydm.

104. 104. Rural Health Information Hub, “Hub and Spoke Model” (October 22, 2021), https://tinyurl.com/mtjnbccy; and Gloria M. Miele and others, “Implementation of the Hub and Spoke Model for Opioid Use Disorders in California: Rationale, Design, and Anticipated Impact,” Journal of Substance Abuse Treatment, vol. 108 (January 2020), pp. 20–25, https://doi.org/10.1016/j.jsat.2019.07.013.

105. 105. In 2018, CMS issued guidance to all Medicare Part D and Medicare Advantage plans to limit utilization management for buprenorphine. In response, nearly all Medicare plans that covered buprenorphine removed prior authorization requirements for buprenorphine-naloxone medications. For more information, see Tami L. Mark, William Parish, and Gary A. Zarkin, “Association Between Medicare and FDA Policies and Prior Authorization Requirements for Buprenorphine Products in Medicare Part D Plans,” JAMA, vol. 322, no. 2 (July 9, 2019), pp. 166–167, https://doi.org/10.1001/jama.2019.6581.

106. 106. Max Jordan Nguemeni Tiako and others, “Thematic Analysis of State Medicaid Buprenorphine Prior Authorization Requirements,” JAMA Network Open, vol. 6, no. 6 (June 2023), e2318487, https://doi.org/10.1001/jamanetworkopen.2023.18487.

107. 107. Christina M. Andrews and others, “Impact of Medicaid Restrictions on Availability of Buprenorphine in Addiction Treatment Programs,” American Journal of Public Health, vol. 109, no. 3 (March 2019), pp. 434–436, https://doi.org/10.2105/AJPH.2018.304856; Paul J. Christine and others, “Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder,” JAMA Health Forum, vol. 4, no. 10 (October 2023), e233549, https://doi.org/10.1001/jamahealthforum.2023.3549; and Peter Treitler and others, “Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access,” JAMA Network Open, vol. 6, no. 5 (May 2023), e2312030, https://doi.org/10.1001/jamanetworkopen.2023.12030.

108. 108. Medicaid and CHIP Payment and Access Commission, Recovery Support Services for Medicaid Beneficiaries With a Substance Use Disorder (July 2019), https://tinyurl.com/4nbvfpk6

109. 109. Anna Bailey and others, Medicaid Is Key to Building a System of Comprehensive Substance Use Care for Low-Income People (Center on Budget and Policy Priorities, March 18, 2021), https://tinyurl.com/4tf3er39.

110. 110. Andrew J. Barnes and others, “Hospital Use Declines After Implementation of Virginia Medicaid’s Addiction and Recovery Treatment Services,” Health Affairs, vol. 39, no. 2 (February 2020), pp. 238–246, https://doi.org/10.1377/hlthaff.2019.00525.

111. 111. Congressional Budget Office, The Opioid Crisis and Recent Federal Policy Responses (September 2022), www.cbo.gov/publication/58221.

112. 112. Christopher Keane, James E. Egan, and Mary Hawk, “Effects of Naloxone Distribution to Likely Bystanders: Results of an Agent-Based Model,” International Journal of Drug Policy, vol. 55 (May 2018), pp. 61–69, https://doi.org/10.1016/j.drugpo.2018.02.008; and Teijo I. Saari, John Strang, and Ola Dale, “Clinical Pharmacokinetics and Pharmacodynamics of Naloxone,” Clinical Pharmacokinetics, vol. 63 (April 2024), pp. 397–422, https://doi.org/10.1007/s40262-024-01355-6.

113. 113. Food and Drug Administration, “FDA Approves Prescription Nasal Spray to Reverse Opioid Overdose” (news release, May 22, 2023), https://tinyurl.com/mryjfh4k.

114. 114. Mean out-of-pocket costs in nominal dollars are defined as total out-of-pocket costs per year divided by the total number of naloxone claims. See Evan D. Peet, David Powell, and Rosalie Liccardo Pacula, “Trends in Out-of-Pocket Costs for Naloxone by Drug Brand and Payer in the U.S., 2010–2018,” JAMA Health Forum, vol. 3, no. 8 (August 2022), e222663, https://doi.org/10.1001/jamahealthforum.2022.2663.

115. 115. Sarah Bessen and others, “Barriers to Naloxone Use and Acceptance Among Opioid Users, First Responders, and Emergency Department Providers in New Hampshire, USA,” International Journal of Drug Policy, vol. 74 (December 2019), pp. 144–151, https://doi.org/10.1016/j.drugpo.2019.09.008.

116. 116. Food and Drug Administration, “FDA Approves First Over-the-Counter Naloxone Nasal Spray” (news release, March 29, 2023), https://tinyurl.com/3xka94aj.

117. 117. Xinyi Jiang and others, “Trends in Out-of-Pocket Costs for and Characteristics of Pharmacy-Dispensed Naloxone by Payer Type,” JAMA, vol. 331, no. 8 (January 29, 2024), pp. 700–702, https://doi.org/10.1001/jama.2023.26969; and Emergent BioSolutions, “Emergent BioSolutions’ NARCAN Nasal Spray Launches Over the Counter Making It Possible for Everyone to Help Save a Life From an Opioid Overdose Emergency” (press release, August 30, 2023), https://tinyurl.com/mryky38w.

118. 118. Rosanna Smart and others, “Investigating the Complexity of Naloxone Distribution: Which Policies Matter for Pharmacies and Potential Recipients,” Journal of Health Economics, vol. 97 (September 2024), article 102917, https://doi.org/10.1016/j.jhealeco.2024.102917.

119. 119. Legislative Analysis and Public Policy Association, Naloxone: Summary of State Laws (LAPPA, July 2022), https://tinyurl.com/ytbab2bp.

120. 120. Janet Weiner, Sean M. Murphy, and Czarina Behrends, Expanding Access to Naloxone: A Review of Distribution Strategies (Leonard Davis Institute of Health Economics, May 2019), https://tinyurl.com/4mskprfw.

121. 121. Robert M. Bohler and others, “The Policy Landscape for Naloxone Distribution in Four States Highly Impacted by Fatal Opioid Overdoses,” Drug and Alcohol Dependence Reports, vol. 6 (March 2023), article 100126, https://doi.org/10.1016/j.dadr.2022.100126.

122. 122. Chandler McClellan and others, “Opioid-Overdose Laws Association With Opioid Use and Overdose Mortality,” Addictive Behaviors, vol. 86 (November 2018), pp. 90–95, https://doi.org/10.1016/j.addbeh.2018.03.014; Daniel I. Rees and others, “With a Little Help From My Friends: The Effects of Good Samaritan and Naloxone Access Laws on Opioid-Related Deaths,” Journal of Law and Economics, vol. 62, no. 1 (February 2019), pp. 1-27, https://doi.org/10.1086/700703; and Rahi Abouk, Rosalie Liccardo Pacula, and David Powell, “Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose,” JAMA Internal Medicine, vol. 179, no. 6 (June 2019), pp. 805–811, https://doi.org/10.1001/jamainternmed.2019.0272.

123. 123. Rahi Abouk, Rosalie Liccardo Pacula, and David Powell, “Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose,” JAMA Internal Medicine, vol. 179, no. 6 (June 2019), pp. 805–811, https://doi.org/10.1001/jamainternmed.2019.0272.

124. 124. Evan D. Peet, David Powell, and Rosalie Liccardo Pacula, Using Policy and Innovation to Improve Life-Saving Access to Naloxone, Working Paper 33105 (National Bureau of Economic Research, November 2024), www.nber.org/papers/w33105.

125. 125. Amir Razaghizad and others, “The Effect of Overdose Education and Naloxone Distribution: An Umbrella Review of Systematic Reviews,” American Journal of Public Health, vol. 111, no. 8 (August 2021), pp. e1–e12, https://doi.org/10.2105/ajph.2021.306306; Tarlise Townsend and others, “Cost-Effectiveness Analysis of Alternative Naloxone Distribution Strategies: First Responder and Lay Distribution in the United States,” International Journal of Drug Policy, vol. 75 (January 2020), article 102536, https://doi.org/10.1016/j.drugpo.2019.07.031; Phillip O. Coffin and others, “Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain,” Annals of Internal Medicine, vol. 165, no. 4 (August 2016), pp. 245–252, https://doi.org/10.7326/m15-2771; and Ryan C. Costantino and others, “Naloxone Prescribing Associated With Reduced Emergency Department Visits in the Military Health System,” Medical Care, vol. 60, no. 12 (December 2022), pp. 901–909, https://doi.org/10.1097/MLR.0000000000001782.

126. 126. Wai Chung Tse and others, “Does Naloxone Provision Lead to Increased Substance Use? A Systematic Review to Assess If There Is Evidence of a ‘Moral Hazard’ Associated With Naloxone Supply,” International Journal of Drug Policy, vol. 100 (February 2022), article 103513, https://doi.org/10.1016/j.drugpo.2021.103513; and Chandler McClellan and others, “Opioid-Overdose Laws Association With Opioid Use and Overdose Mortality,” Addictive Behaviors, vol. 86 (November 2018), pp. 90–95, https://doi.org/10.1016/j.addbeh.2018.03.014.

127. 127. Centers for Disease Control and Prevention, “Safety and Effectiveness of Syringe Services Programs” (February 8, 2024), https://tinyurl.com/3hrtm74w.

128. 128. Analisa Packham, “Syringe Exchange Programs and Harm Reduction: New Evidence in the Wake of the Opioid Epidemic,” Journal of Public Economics, vol. 215 (November 2022), article 104733, https://doi.org/10.1016/j.jpubeco.2022.104733.

129. 129. Matthew K. Laing, Kenneth W. Tupper, and Nadia Fairbairn, “Drug Checking as a Potential Strategic Overdose Response in the Fentanyl Era,” International Journal of Drug Policy, vol. 62 (December 2018), pp. 59–66, https://doi.org/10.1016/j.drugpo.2018.10.001.

130. 130. One study evaluated three devices for public health–led drug checking: fentanyl test strips, a handheld Raman spectrometer, and a desktop Fourier-transform infrared spectrometer. Fentanyl test strips are small pieces of paper capable of identifying the presence of fentanyl in various types of drugs. A handheld Raman spectrometer is a portable device that uses Raman spectroscopy to identify and analyze the molecular composition of materials by measuring the scattering of laser light, and a desktop Fourier-transform infrared spectrometer uses infrared light to scan test samples and observe chemical properties. Fentanyl test strips demonstrated high sensitivity and specificity, detecting additional analogs in various forms, but they do not provide information on quantity or purity, limiting their utility in fentanyl-saturated markets. See Traci C. Green and others, “An Assessment of the Limits of Detection, Sensitivity, and Specificity of Three Devices for Public Health–Based Drug Checking of Fentanyl in Street-Acquired Samples,” International Journal of Drug Policy, vol. 77 (March 2020), article 102661, https://doi.org/10.1016/j.drugpo.2020.102661.

131. 131. Traci C. Green and others, “Implementation and Uptake of the Massachusetts Drug Supply Data Stream: A Statewide Public Health–Public Safety Partnership Drug Checking Program,” Journal of Public Health Management & Practice, vol. 28, supplement 6 (November/December 2022), p. S347–S354, https://doi.org/10.1097/PHH.0000000000001581.

132. 132. Synthetic cannabinoids are a group of lab-made substances that are chemically similar to compounds found in cannabis, though they often produce very different effects on users. Many synthetic cannabinoids are illicitly manufactured and sold.

133. 133. Andy Miller, “As Overdoses Soar, More States Decriminalize Fentanyl Testing Strips,” KFF Health News (May 5, 2022), https://tinyurl.com/3n8fjur9.

134. 134. Substance Abuse and Mental Health Services Administration, “Federal Grantees May Now Use Funds to Purchase Fentanyl Test Strips” (press release, April 7, 2021), https://tinyurl.com/mu52ebc4.

135. 135. Victoria Pless and others, Overdose Prevention Policy Considerations: A Policy Playbook for State and Territorial Health Officials and Agencies (Association of State and Territorial Health Officials, 2024), https://tinyurl.com/525utc2a.

136. 136. Geoff Bardwell and others, “‘We Don’t Got That Kind of Time, Man. We’re Trying to Get High!’: Exploring Potential Use of Drug Checking Technologies Among Structurally Vulnerable People Who Use Drugs,” International Journal of Drug Policy, vol. 71 (September 2019), pp. 125–132, https://doi.org/10.1016/j.drugpo.2019.06.018.

137. 137. Maxwell S. Krieger and others, “Use of Rapid Fentanyl Test Strips Among Young Adults Who Use Drugs,” International Journal of Drug Policy, vol. 61 (November 2018), pp. 52–58, https://doi.org/10.1016/j.drugpo.2018.09.009; and Nicholas C. Peiper and others, “Fentanyl Test Strips as an Opioid Overdose Prevention Strategy: Findings From a Syringe Services Program in the Southeastern United States,” International Journal of Drug Policy, vol. 63 (January 2019), pp. 122–128, https://doi.org/10.1016/j.drugpo.2018.08.007.

138. 138. Catherine R. McGowan and others, “Fentanyl Self-Testing Outside Supervised Injection Settings to Prevent Opioid Overdose: Do We Know Enough to Promote It?” International Journal of Drug Policy, vol. 58 (August 2018), pp. 31–36, https://doi.org/10.1016/j.drugpo.2018.04.017.

139. 139. Discretionary spending stems from authority provided in appropriation acts; direct (or mandatory) spending and revenues (tax receipts and other collections that arise from the federal government’s use of its sovereign power) are generally controlled by laws other than appropriation acts.

140. 140. Programs that are funded in appropriation acts can affect mandatory spending (because of changes in health care utilization) and spending paid for by federally subsidized health insurance. Effects on mandatory spending and revenues stemming from changes in a discretionary federal grant would not be included in cost estimates prepared for budget enforcement purposes because of scorekeeping guidelines. When providing budgetary information to Congress, CBO follows a set of principles that include 16 scorekeeping guidelines. In estimating the cost of appropriation bills prepared for budget enforcement purposes, CBO is directed by guideline 3 to exclude anticipated changes to mandatory spending or revenues that may result if the bill only increases or decreases discretionary funding for related activities (rather than making substantive changes to the way a program operates). For more information, see Congressional Budget Office, CBO Explains Budgetary Scorekeeping Guidelines (January 2021), www.cbo.gov/publication/56507.

141. 141. Examples are illustrative and do not imply that future cost estimates will fall within that range. Permanently extending a provision in the SUPPORT Act, which requires Medicaid coverage of medications for OUD and behavioral health services, would increase spending by $273 million over 10 years; see Congressional Budget Office, cost estimate for Consolidated Appropriations Act, 2024 (March 5, 2024), www.cbo.gov/publication/60058. Creating a five-year exception to the Medicaid inmate exclusion, which would allow Medicaid to pay for services to enrolled inmates during the last 30 days of their incarceration, would increase mandatory spending by $3.7 billion over 10 years; see Congressional Budget Office, cost estimate for Reconciliation Recommendations of the House Committee on Energy and Commerce (February 12, 2021), www.cbo.gov/publication/57002. Nearly all state Medicaid programs already cover buprenorphine and naltrexone, and three-quarters cover methadone, contributing to the lower cost of permanently extending a requirement for Medicaid to cover medications for OUD. For more information, see Medicaid and CHIP Payment and Access Commission, “Access to Substance Use Disorder Treatment in Medicaid,” Chapter 4 in Report to Congress on Medicaid and CHIP (June 2018), https://tinyurl.com/2bx9rc6h. In contrast, federal Medicaid reimbursement for services provided to incarcerated people is generally prohibited in nearly all states, contributing to the higher cost if lawmakers enacted an exception to this prohibition. As of August 2024, eleven states have approved section 1115 waivers to provide prerelease services to certain incarcerated, Medicaid-eligible people. See Elizabeth Hinton, Akash Pillai, and Amaya Diana, “Section 1115 Waiver Watch: Medicaid Pre-Release Services for People Who Are Incarcerated” (KFF, August 19, 2024), https://tinyurl.com/rxj6m89s.

142. 142. CARA authorized the appropriation of $90 million for grants for expanding access to opioid overdose reversal medications, devices, and education. See Congressional Budget Office, The Opioid Crisis and Recent Federal Policy Responses (September 2022), www.cbo.gov/publication/58221. In the middle of the range, S. 2789, the Substance Abuse Prevention Act of 2018, would authorize the appropriation of $300 million over four years for the Office of National Drug Control Policy’s Drug Court Program. See Congressional Budget Office, cost estimate for S. 2789, Substance Abuse Prevention Act of 2018 (August 14, 2018), www.cbo.gov/publication/54380. On the higher end of the range, the same bill would authorize $1.1 billion over four years to coordinate drug control efforts among local, state, and federal law enforcement agencies.

143. 143. Quantifying how much of the funds that were authorized in opioid-related 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 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.

144. 144. Michele Gazda, G. William Hoagland, and Arnand Parekh, Combating the Opioid Crisis: Smarter Spending to Enhance the Federal Response (Bipartisan Policy Center, April 2022), Figure 10, https://tinyurl.com/93dcwb7w.

145. 145. William N. Evans, Ethan M. J. Lieber, and Patrick Power, “How the Reformulation of OxyContin Ignited the Heroin Epidemic,” Review of Economics and Statistics, vol. 101, no. 1 (March 2019), pp. 1-15, https://doi.org/10.1162/rest_a_00755; and Abby Alpert, David Powell, and Rosalie Liccardo Pacula, “Supply-Side Drug Policy in the Presence of Substitutes: Evidence From the Introduction of Abuse-Deterrent Opioids,” American Economic Journal: Economic Policy, vol. 10, no. 4 (November 2018), pp. 1–35, https://doi.org/10.1257/pol.20170082.

146. 146. Karen McQueen and Jodie Murphy-Oikonen, “Neonatal Abstinence Syndrome,” New England Journal of Medicine, vol. 375, no. 25 (June 21, 2016), https://doi.org/10.1056/NEJMra1600879.

147. 147. Heather Saunders and Robin Rudowitz, “Demographics and Health Insurance Coverage of Nonelderly Adults With Mental Illness and Substance Use Disorders in 2020” (KFF, June 6, 2022), https://tinyurl.com/2vvyhz9z.

About This Document

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

Claire Hou and Grace Hwang wrote the report with guidance from Aditi Sen and Tamara Hayford. Carrie H. Colla (a consultant to CBO) and Ryan Mutter (formerly of CBO) contributed to the report. Molly Dahl, Elizabeth Cove Delisle, Noelia Duchovny, Sean Dunbar, Ryan Greenfield, Justin Humphrey, Sarah Masi, John McClelland, Aaron Pervin, Lara Robillard, Emily Stern, Robert Sunshine (a consultant to CBO), and Chapin White provided useful comments. Julianna Mack (formerly of CBO), Kaylee Nielson, and Joyce Shin fact-checked the report.

Rosalie Pacula of the University of Southern California and Keith Humphreys of Stanford University commented on an earlier draft. The assistance of external reviewers implies no responsibility for the final product; that responsibility rests solely with CBO.

Mark Doms (formerly of CBO) and Jeffrey Kling reviewed the report. Christine Bogusz edited it, and Casey Labrack created the graphics and prepared the text for publication. The report is available at www.cbo.gov/publication/60889.

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

Phillip L. Swagel

Director

January 2026