SAFE Takes reflects our analysis and assessment of the progress made in each of the recommendations made by the President’s Commission (Commission) on Combatting Drug Addiction and the Opioid Crisis (November 2017) and the National Governors Association’s (NGA) Recommendations for Federal Action to End the Nation’s Opioid Crisis (January 2018). The following SAFE Takes focuses on government action pertaining to law enforcement and medical response.
Legend
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: The Administration should issue guidance to facilitate more open data sharing. Congress should provide the Department of Justice (DOJ) with increased federal funding for trainings and technical assistance that support state law enforcement, public health data and information sharing initiatives.
 New Funding Available |
New federal funding through the 21st Century Cures Act and DOJ Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP) is available to states. These programs can and should be used to help states better integrate public health and public safety data sharing initiatives. response. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: Congress should increase Justice Assistance Grant Program (JAG) funding for state and local narcotic interdiction efforts and officer safety programs, increase funding and emphasize the role of preparing for and connecting individuals to community-based treatment programs, and increase funding (for the National Institute of Corrections, SAMHSA, and the Office of Justice Programs) to develop and provide MAT for justice-involved populations.
 |
This is one of the most important recommendations in the NGA report. There are some great state and county models for providing Medical- Assisted Treatment (MAT) to justice-involved populations, but they need to be scaled and universally adopted. Additionally the transition from incarceration back into society is the most deadly time for any substance users. Incarcerated individuals with substance use disorder are 130 times more likely to die of an overdose than the general population within the first two weeks following release.
In December 2019, the DOJ’s Office of Justice Programs awarded “more than $376 million in grant funding to enhance state, local and tribal law enforcement operations and reinforce public safety efforts in jurisdictions across the US.” More than $252 million is being awarded to 929 states, tribes, and local governments” to support various programs, including: “law enforcement; prosecution and courts; crime prevention and education; corrections; drug treatment and enforcement; technology improvement; victim and witness initiatives; mental health programs and others.” While these efforts show momentum towards making improvements in this area, there is a lack of reference to assisting those needing MAT. More needs to be done to continue on this effort to assist a broader population. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: The federal government should offer more assistance to accelerate state crime lab testing and share real-time drug data. Increase federal coordination and funding for state medical examiner offices to increase understanding and provide a more targeted public safety and public health response by states.
Needs Standardization
|
States need federal assistance to respond to rapid increases in overdose cases and toxicology reports. Medical examiners must continue to work to identify ways of unify the language and coding used to identify and report cause of death and associated substances found in post mortem drug screens. States should also participate in mapping projects such as the Overdose Detection Mapping Application Program (ODMAP) and the Opioid Mapping Initiative to track overdose deaths and overdose reversals. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: Increase federal efforts to strengthen electronic customs relation and to develop better chemical screen devices.
Essential But Difficult
|
The STOP ACT addresses these concerns, but it never moved beyond proposal in the 115th Congress. The effectiveness of these efforts, however, depends on cooperation by international partners, namely China. The majority of fentanyl and opioid analogues are being manufactured in China and shipped through the international mail system. Fentanyl is the primary driver in the dramatic spike in opioid deaths over the last 4 years. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: The Office of National Drug Control Policy (ONDCP) should continue to engage and convene additional federal and non-federal agencies to better understand the priorities of both public health and public safety entities at all levels of government.
 |
Ever since early rumors that the Trump Administration planned to eliminate ONDCP the agency has been largely absent from the policy debate. The two primary offices run by ONCDP, High Intensity Drug Trafficking Areas and Drug Free Communities, are critical and independent voices that lead and augment the work of the Department of Justice and Department of Health and Human Services. ONDCP must re-exert leadership as the chief convening power that focused on aligning the public safety and public health drug policy priorities for the country. Too often we’re addressing public health issues with public safety solutions. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: ONDCP should continue and/or increase federal support for regional High Intensity Drug Trafficking Areas (HIDTAs) and state law enforcement efforts, and scale up and replicate innovative partnerships at state and local level – nationwide; increase federal grant dollars for state fusion centers and other state law enforcement entities requiring more personnel and analysts; increase flexibility in grant funding to meet dynamic challenges, such as direct investments in state and local narcotic interdiction initiatives; and expand the role of HIDTAs to allow more robust assistance to state and local law enforcement led prevention efforts.
More Funding Needed
|
HIDTAs play a critical role in augmenting state and local drug interdiction efforts. HIDTA funding should have been drastically increased as the crisis unfolded. This did not occur and additional federal funding is required. However, H.R. 6, Support for Patients and Communities Act includes a reauthorization for ONDCP, the Drug Free Communities program and the HIDTA program with multiple provisions to improve coordination, strategy, and progress. In September, ONDCP named 10 new areas as HIDTAs and this month President Trump announced $34 million in additional funding for the HIDTA program.
In 2018, President Trump, through ONDCP, established the first new HIDTA program in 17 years to combat emerging threats in Alaska, bringing to completion the Administration’s effort to ensure that all 50 States receive funding through the program In April 2019, ONDCP released the largest-ever annual baseline funding for its HIDTA Program. More than $264 million will be disbursed to 29 regional HIDTA Programs in 50 States, Washington, DC, Puerto Rico, and the U.S. Virgin Islands. Then, in October 2019, ONDCP announced plans to distribute over $1.6 million across the 13 counties in 12 states that were recently designated as HIDTAs. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: The federal government should ensure concerns and key issues from state law enforcement are incorporated into larger federal supply reduction efforts. Future Drug Enforcement Agency (DEA) and the Organized Crime Drug Enforcement Task Forces (OCDETF) Program priorities and strategies should incorporate state law enforcement concerns about illicit opioid distribution, targeting transnational criminal organizations and violent gangs, emerging and existing markets, and reinforce DEA’s ability to regulate distributors suspected of misconduct.
 Unknown
|
While it is absolutely true that DEA and OCDETF should be incorporating the recommendations of states and local jurisdictions, it’s hard to know whether or not they are. More specific information about the recommendations state and local agencies are making to federal agencies is needed. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: The federal government should support research, development, and court admissibility of a simple, accurate and cost-effective roadside testing method for drugged driving (including marijuana) to reduce risk to the motoring public.
Unknown
|
It does not appear that there are currently initiatives to make progress on this recommendation. The President’s Budget request from the Office of National Drug Policy (ONDCP) for fiscal year 2018 (Oct 1 2017-Sep 30 2018) asked for $2.72 million in the Department of Transportation, National Highway Transportation Safety Administration to do this kind of research. However, between FY2018 and FY 2019, there was a 95% decrease in the total amount the Trump administration proposed to dedicate to the office, claiming instead that they hoped to move efforts under the DOJ and HHS. His FY 2020 budget attempted to make the same cuts. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| NGA: The federal government should increase support for National Guard Counterdrug Program to allow greater program capacity, providing states with funds to partner with local agencies and community groups and augment state use of this program to cut illicit drug supply.
Partnerships Growing |
This is an achievable goal – strong federal/state cooperative opportunity. Congress and the President approved $217,178,000 for the National Guard counter-drug program; and $25,276,000 for the National Guard counter-drug schools program in the fiscal year 2019 appropriations bill.
However, in FY 2020, the National Guard counter-drug program was appropriated almost $45 million less than 2019 and the counter-drugs school program only received $5.3 million |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #20: The Federal Government should strengthen data collection activities enabling real-time surveillance of the opioid crisis at the national, state, local, and tribal levels.
Some Momentum, Needs Improvement
|
This needs increased funding for federal and state data sharing of law enforcement and health data to address the crisis in real time. A lot of innovation is happening in this area, but it is largely funded by philanthropy and state governments. The Centers for Medicare & Medicaid Services (CMS) has a map that shows Medicare prescription rates for opioids, but the newest data is from 2017.
The HHS five-point Opioid Strategy, announced in April 2017, includes the following goal: “Strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response as the epidemic evolves;” The CDC has also been working to improve the quality and timeliness of mortality data through a project called Modernizing the Infrastructure for Capturing Drug Death Data and Enhancing Research on Opioid Poisoning using Death Certificates’ Literal Text Field. The webpage for this project has monthly updates beginning in May 2018 and going until April 2020. In January 2020, HHS announced an agreement with Millennium Health to “provide near real-time drug testing data that will enhance efforts and targeted approaches in fighting the overdose crisis in the U.S” Overall, more still needs to be done to further this initiative but more progress is needed |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #21: The Federal Government should work with the states to develop and implement standardized rigorous drug testing procedures, forensic methods, and use of appropriate toxicology instrumentation in the investigation of drug-related deaths.
Slow Movement
|
The Department of Justice and the Department of Health and Human Services have established the Medicolegal Death Investigation (MDI) Federal Interagency working group (MDI-WG) which started work in March 2018. The MDI-WG is developing short and long term goals for activities including: Developing technologies/systems to facilitate information/data sharing between ME/C offices; toxicology laboratories; and Federal, State, and local entities, with specific focus on combating the opioid crisis. States like West Virginia have already begun using data on drug- related deaths to help in prevention efforts. Delayed coordination with states is a missed opportunity to reverse the trajectory of injuries and deaths in the shorter term. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #22: Re-instituting the Arrestee Drug Abuse Monitoring (ADAM) program and the Drug Abuse Warning Network (DAWN) to improve data collection and provide resources for other promising surveillance systems.
Slow Progress
|
Substance Abuse and Mental Health Services Administration (SAMHSA) is reinstating the Drug Abuse Warning Network in mid-2019. According to SAMHSA, “Important improvements to new DAWN include improved timeliness of data, data available at more frequent intervals, and data for a wider range of geographic area types, including urban, suburban, and rural areas. Having data available more quickly means that DAWN can serve as a true “early warning” system and inform public health response efforts in local areas.” It does not appear there are any plans to reinstate ADAM. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #23: Enhance federal sentencing penalties for the trafficking of fentanyl and fentanyl analogues.
In Motion |
The United States Sentencing Commission voted to approve an amendment in April 2018 to alter guidelines on synthetic drugs. It included a multipart change to address synthetic cathinones (bath salts), synthetic cannabinoids, fentanyl, and fentanyl analogues. The amendment creates a new guideline definition for “fentanyl analogue” and raises penalties with a four-level sentencing enhancement.According to the USSC, “In setting the new drug ratios, the Commission considered among other factors, the severity of the medical harms to the user, the current ratios applied in similar cases, known trafficking behaviors, and concerns for public safety. In recognition that potencies vary, the Commission also adopted departure language for drugs in a class that are more or less potent.” |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #24: Federal law enforcement should target Drug Trafficking Organizations and other individuals who produce and sell counterfeit pills, including including those sold via the internet.
DEA targeting Pill Presses and Dark Web |
SAMHSA estimates that less than 1% of the misused pain relievers are sourced from the internet (surface and Dark Web). In the last few years the Drug Enforcement Agency (DEA) has increased its efforts to track key components of pill presses that have been ordered separately and assembled illegally. More information is needed on the source of counterfeit and diverted medications. The Federal Government has looked to technology giants like Google and Facebook to assist in their crackdown. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #25: Congress should amend the law to give the DEA the authority to regulate the use of pill presses/ tableting machines with requirements for the maintenance of records, inspections for verifying location and stated use, and security provisions.
Needs Funding and Authority |
The DEA is already responsible for the purchase of pill presses, but they are often illegally assembled from ordering unregulated replacement parts. The DEA does need the ability to regulate key parts and ongoing operations. Pill presses and key components should be tracked by serial number and tracked for regular inspection. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #26: The U.S. Customs and Border Protection and the U.S. Postal Service should use additional technologies and drug detection canines to expand efforts to intercept fentanyl (and other synthetic opioids) in envelopes and packages at international mail processing distribution centers.
Logistical Challenge |
The STOP Act of 2018 (H.R. 5788) includes critical tools to reduce international tracking through the mail. It passed the House in the early summer and was included in the Senate version of H.R. 6, SUPPORT for Patients and Communities Act. It should be noted that the rise of fentanyl coming through the international mail system coincided with the explosion of e-commerce. U.S. Customs and Border Protection is already dealing with a 300% increase in international packages. Efficiently finding a needle in a cardboard stack is exceedingly difficult.
There have been efforts to make additional progress on this recommendation: In May 2018, the New York Time reported that Officials at Customs and Border Protection and Homeland Security Investigations “are increasingly relying on hand-held sensors that can peek inside packages and detect potent, but tiny, shipments of opioids.” The Support Act requires improvement of detection for international packages by the Inspection Service through advancements in the collection and receipt of customs advance electronic data (AED). In July 2019, the Chief Postal Inspector confirmed there were efforts being taken to actively meet these objectives. Despite these efforts, Logistical Challenge still persist |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #27: Congress and the Federal Government should use advanced electronic data on international shipments from high-risk areas to identify international suppliers and their U.S.-based distributors.
Doesn’t Ensure Compliance |
Provisions supporting this recommendation from the STOP Act of 2018 (H.R. 5788) were also included in H.R. 6, SUPPORT for Patients and Communities Act (Section 8003). While encouraging international governments to utilize Advanced Electronic Data (AED) on all packages is important, ensuring compliance is more critical. It will cost China billions of dollars to modernize their postal system and there is very little discussion about how to incentivize them to do so. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #28: Congress should support the Synthetics Trafficking and Overdose Prevention (STOP) Act and the Federal Government should work with the international community to implement the STOP Act in accordance with international laws and treaties.
Good First Step |
The STOP Act of 2018 (H.R. 5788) was passed by the House in mid-2018 and included in the final version of H.R. 6, SUPPORT for Patients and Communities Act signed into law by President Trump. The President has also requested and secured global support from 130 member nations of the United Nations (U.N.) in what he called a “Global Call to Action on the World Drug Problem.” However, a piece published in July 2019 suggests that the laws, while in place, have not been enforced. For example, the article highlights missed deadlines and lacking reports. While the initial step is good, it seems those steps have not been capitalized on and opportunities have been missed. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #29: Coordinate federal government and the Drug Enforcement Agency’s (DEA) effort to prevent, monitor, and detect the diversion of prescription opioids for illicit distribution or usage.
Significant Progress |
This coordination is happening. Both the DEA and States believe they have made significant progress in the last 2-3 years. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #30: The White House should develop a national outreach plan for the Fentanyl Safety Recommendations for First Responders. The Federal Government should partner with Governors and state fusion centers to develop and standardize data collection, analytics, and information-sharing related to first responder opioid-intoxication incidents.
Solutions On Hand |
Fentanyl and other powerful opioid analogues present a real danger to law enforcement, but too much emphasis on the danger and too little on the mitigation techniques is counter productive. For example, many local law enforcement agencies have stopped all field testing of substances for fear of fentanyl exposure. Fentanyl exposure is a real danger, but one that is also easily mitigated. The U.S. Customs and Border Protection has a Youtube video to ensure law enforcement agencies are protecting their The key to success will be in coordination, which has already proven challenging. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #38: The Department of Justice (DOJ) should broadly establish federal drug courts within the federal district court system in all 93 federal judicial districts. States, local units of government, and Indian tribal governments should apply for drug court grants established by 34 U.S.C. § 10611. Individuals with a substance use disorder (SUD) who violate probation terms with substance use should be diverted into drug court, rather than prison.
Needs More Growth |
Every criminal court in the United States should have diversion programs in place. Every judge should have the opportunity and procedure to afford the appropriate plaintiffs the opportunity to complete a treatment program. Additional funds are required for federal grants for the state and local drug courts.
In December 2019, $83.5 million was granted to the Drug Court Program “to provide financial and technical assistance to states and federally recognized tribes to develop and implement drug courts to help adults, youth and veterans suffering from substance abuse issues.” On February 14, 2019, The U.S. Department of Justice (DOJ), Office of Justice Programs (OJP), Bureau of Justice Assistance (BJA) released a grant application seeking to “establish or enhance drug court services, to include coordination, management of drug court participants, and recovery support services. This program furthers the Department’s mission by providing resources to state, local, and tribal governments to enhance drug court programs and systems for nonviolent offenders with addictions, including opioid abuse and overdose.” These applications were due on April 16, 2019. They was also a note highlighting that the funds from this grant could not be used to support any activities that were in violation of the the Controlled Substances Act. This highlights that there are clear updates and initiatives attempting to create tangible results for this recommendation, however, more still needs to be done to fully realize the main goal. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #43: The National Highway Traffic Safety Administration (NHTSA) should review its National Emergency Medical Services (EMS) Scope of Practice Model with respect to naloxone, and disseminate best practices for states that may need statutory or regulatory changes to allow Emergency Medical Technicians (EMT) to administer naloxone, including higher doses to account for the rising number of fentanyl overdoses.
States Have Answered |
First responders’ inability to provide naloxone, from a regulatory standpoint, has not been as big of a problem as access and cost for communities to stock naloxone, in large part because states have provided temporary authorities in the midst of the crisis. However, no first responder should be threatened with the loss of their license or certification as a result of administering naloxone. |
| RECOMMENDATIONS | S.A.F.E. TAKE |
| Commission #45: The Department of Health and Human Services (HHS) should develop new guidance for Emergency Medical Treatment and Labor Act (EMTALA) compliance with regard to treating and stabilizing SUD patients and provide resources to incentivize hospitals to hire appropriate staff for their emergency rooms.
|
Treating and stabilizing acute patients is what emergency rooms do. It is what happens after the initial assessment and triage has taken place that is so important. A warm handoff to medical treatment and therapy is key. A shortage of treatment centers is at the crux of this problem. Funding will be required to bridge the gap for hospitals that have a shortage of staff, high demand for assistance, and few options for nearby treatment. The practice of discharging patients SUD patients from emergency departments is complex and a matter of capacity that requires funding and professionals. |