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Research Questions

  1. Who uses opioids in the United States, what are their characteristics, and how can the lives of those with OUD be improved?
  2. How are families of those with OUD affected, and how can their lives be improved?
  3. What are the most important components of the opioid ecosystem?
  4. How do these components interact with each other?
  5. How can one component have a major impact on opioid-related outcomes in other components?
  6. What policy opportunities exist that require interacting with or reducing barriers among multiple components of the ecosystem?

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids (such as fentanyl) are involved in a majority of U.S. drug overdoses, but the problems are broader and deeper than drug fatalities. Depending on the drugs involved, there can be myriad physical and mental health consequences associated with having a substance use disorder. And it is not just those using drugs who suffer. Substance use and related behaviors can significantly affect individuals' families, friends, employers, and wider communities.

Efforts to address problems related to opioids are insufficient and sometimes contradictory. In this 600-page report, researchers provide a nuanced assessment of America's opioid ecosystem, highlighting how leveraging system interactions can reduce addiction, overdose, suffering, and other harms. At the core of the opioid ecosystem are the individuals who use opioids and their families. Researchers also include chapters on ten major components of the opioid ecosystem: substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education.

The primary audience for this book is policymakers, but it should also be useful for foundations looking for opportunities to create change that have often been overlooked. This report can help researchers better consider the full consequences of policy changes and help members of the media identify the dynamics of interactions that deserve more attention.

The Opioid Ecosystem

Visualization representing the opioids ecosystem—A person who uses opioids and their family are at the center and there are ten components in a circle around them including medical care, criminal legal system, illegal supply and supply control, harm reduction, first responders, child welfare, income support and homeless services, employment, education, and substance use disorder treatment.

Key Findings

U.S. issues surrounding opioids are most appropriately viewed in the context of an ecosystem

  • Like a biological ecosystem, the opioid ecosystem is dynamic, and its components often interact.
  • Ecosystem components often focus on individuals, but families are also at the heart of the system. Each ecosystem component has its own mission, priorities, and funding; policies furthering those priorities may hamper the efforts of other system components.

Current responses to U.S. opioid problems are insufficient—innovation is needed

  • Increasing access to and use of high-quality treatment for substance use disorder remains the top priority, but it will not be enough to stem the tide of overdose deaths and addiction.
  • The federal government should make it easier for states or localities to pilot and evaluate interventions intended to reduce harms associated with opioids and other drugs.

It is not always clear who is responsible for coordinating among ecosystem components or managing the transition from one component to another

  • By making clear who is responsible at these junctures and providing the resources necessary to meet the commitment, some of the disconnects that hamper the provision of treatment and support could be decreased.

The United States is often flying blind, which makes it difficult to evaluate existing interventions, develop new ones, or improve understanding of ecosystem interactions

  • Unlike many prior public health challenges, the onset of the overdose crisis has not motivated substantial new surveillance efforts.
  • The data infrastructure for understanding people who use drugs, drug consumption, and markets urgently needs improving.


Researchers offer nine portfolios of action that could help decisionmakers prioritize and organize their efforts to address problems associated with opioid use.

  • Support individuals as they move across ecosystem components.
  • Coordinate across components and address different priorities.
  • Address legal consequences and stigma associated with drug use or possession.
  • Prevent nonprescribed opioid use and escalation to opioid use disorder.
  • Identify individuals who need treatment, increase access to effective treatment, and enhance support to make treatment more effective.
  • Reduce the probability that an overdose is fatal.
  • Address nontreatment needs of individuals using opioids for nonprescribed purposes.
  • Mitigate the burdens that opioids impose on family members.
  • Improve the data infrastructure for understanding people who use drugs, drug consumption, and drug markets.

Funding for this venture was provided by gifts from RAND supporters and income from operations.

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