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We investigate behavioral responses to a staggered disruption in the supply of prescription opioids across U.S. states: the introduction of electronic Prescription Drug Monitoring Programs (PDMPs). Using administrative datasets, we find PDMPs curtail the proliferation of prescription opioids. Physicians respond to monitoring on the extensive margin, limiting the number of patients to whom they prescribe opioids without adjusting dosage or duration. This decreases supply to long-term opioid users, who evade the restrictions by acquiring prescriptions from out-of-state prescribers and by substituting to heroin. This causes a surge in heroin overdoses, which offsets reductions in hospitalizations and deaths from prescription opioids.

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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.

Opioid abuse --- Opioid abuse --- Drug abuse --- Medication abuse --- Opioid abuse --- Opioids --- Prevention. --- Social aspects --- Government policy --- United States