research study of drugs

The goal of all NIDA studies is to find out how substance use affects the brain and body.

Drug Use Studies at NIDA

If you currently use drugs like marijuana, heroin, or cocaine or if you are seeking treatment for a substance use disorder or are currently in treatment for a substance use disorder, you might be able to join one of our research studies. It’s free to join, and you will be paid for your time and local travel. All study participants receive ongoing medical care while they are in the study to monitor their health and safety.

• Outcome inference in the sensory preconditioning task in opioid-use disorder : 019
• Assessing Theta Burst Stimulation as an Effective Treatment to Reduce Cocaine Use: 002
• Developing field tools for real-time assessment of exposure to psychosocial stress and drug use in an outpatient treatment population: 020
• Opioid Use Disorder (OUD): 17-AA-0114

Outcome inference in the sensory preconditioning task in opioid-use disorder

Study id: 019, currently screening participants for enrollment..

People with addictions often find it hard to choose the long-term benefits of abstinence over the short-term effects of using drugs. Based on studies in lab animals and humans, we think this is partly due to parts of the brain involved in certain types of learning and decision-making. We can test these basic functions using a simple task with pictures and odors.

The purpose of this study is to see whether performance in a learning task differs between people who have opioid-use disorder and people who don’t.

You may be eligible for this study if you meet all these criteria:

• age between 21 and 60 years;
• willing to fast for at least 6 hours before the study session and smell food odors;
• if you have an opioid-use disorder, you must either
• be abstinent for at least 3 weeks or
• be in methadone or buprenorphine treatment

Design: This study takes place at the National Institute on Drug Abuse Intramural Research Program (NIDA IRP) in Baltimore. It requires 1 visit for a lab session. The visit will take up to 5 hours.

Lab session. Before you come for the lab session, we’ll ask you not to eat or drink anything except water for at least 6 hours. When you get here:

• We’ll check you for signs of intoxication. If you’re intoxicated, we’ll have to reschedule the session.
• We’ll take a urine and breath sample to test for drugs and recent drinking. When you give the urine sample, you may be watched by a staff member of the same sex as you. If you’re female, we’ll test your urine to see if you’re pregnant. If you’re pregnant, you can’t stay in the study.
• We’ll give you tests of learning and behavior. The tests involve looking at shapes on a computer screen; those shapes will be paired with different food odors. After you’ve seen enough pairings, we’ll show you the shapes and ask you which odor you expect.
• To expose you to the odors, we’ll place a sterile tube under your nose. We’ll also monitor your breathing pattern with a belt around your upper abdomen. None of this should interfere with your natural breathing.
• About 30 days and 60 days later, participants will be called and asked about their drug use over the past 30 days.

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All Drug Use Studies

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Assessing Theta Burst Stimulation as an Effective Treatment to Reduce Cocaine Use

Study id: 002.

The purpose of this study is to assess how iTBS (a type of non-invasive brain stimulation) affects brain function, thinking, decision-making and cocaine use. This study is accepting men and women who are 18 to 60 years of age, have a cocaine use disorder and are in generally good health.

Participation will include multiple study visits over the course of 35 weeks. Some visits will last up to 8 hours, but most will be between 1-3 hours in length.

For research purposes, participants will:

• Complete questionnaires about mood, substance use, general health
• Receive a physical exam
• Participate in 10 iTBS sessions
• Complete 8 MRI scans
• Provide blood, urine samples

This study takes place at the NIDA Intramural Research Program located on the Johns Hopkins Bayview campus in east Baltimore. There is no cost for participation and participants are paid for their time and travel.

All Nicotine Studies

Developing field tools for real-time assessment of exposure to psychosocial stress and drug use in an outpatient treatment population

Study id: 020.

Research shows that the environment is important in shaping who we are. Not much is known about how to measure the effects of stress from the environment. In this study we are developing methods to study how the environment may influence stress and drug use. We will also study the effects of genes on stress and drug use.

The main purpose of this study is to develop ways to measure how drug use and stress are affected by people’s neighborhood surroundings. To help us do this, we also need to measure differences in how people respond to stress in a lab setting.

Who Can Be In This Study: People between 18 and 75 who use heroin or other opioids, live or spend most of their time in or around Baltimore, are seeking treatment for opioid dependence, and can come to the Archway clinic three days a week.

Design: In total, the study will last 30 weeks (about 7 months). You’ll be maintained on buprenorphine/naloxone (referred to as “buprenorphine” in this consent form) at Archway Clinic. You will come to the Archway Clinic two or three days a week and take-home medications for the other days. You will have to bring in a lockbox to show us that you can safely store the take-homes.

Weeks 1, 2 and 3 of Baseline Phase.

• You'll come to Archway (NIDA’s outpatient clinic) three days a week to get buprenorphine, including your take-home doses.
• The following things will start on week 1:
• During weeks 1-22, you will give urine and breath samples at each visit while being watched. Your breath will be tested for alcohol; your urine will be tested for other drugs. We’ll also ask you about your recent drug use.
• During your first week you will have a meeting with the counselor. After that, once a week, you can opt to attend individual drug counseling. Each session will last about an hour. This visit does not have to be on the same day as your medication visits.
• End of Week 2: You’ll be issued a smartphone to use as an Electronic Diary.
• Weeks 3-18: You can earn money for responding to prompts and for correct reporting on the smartphone.
• Week 2 to Week 30:
• Every two weeks you’ll fill out a few questionnaires about your employment, housing, use of health care stress and mood. This should take about 25 minutes each time.
• Week 19: You will return your smartphone.
• Weeks 19-22: Maintenance phase
• During this phase, you might be able to participate in a secondary study if you want to. If you do that, you won’t return your smartphone at week 19. Instead, you’ll keep it for a few more weeks, and earnings for returning the phone will be delayed until you complete the secondary study.
• If you’re not in a secondary study, you’ll just keep coming to the clinic two days a week to get your buprenorphine and give urine.
• Weeks 23-30: Optional medication taper.
• As week 22 approaches, you’ll have the following choices: (a) to remain in the study for an 8-week medication taper, (b) to try to transfer to another program, or (c) to request a 21-day taper.
• During these 8 weeks, your buprenorphine dose will be slowly reduced to zero. But if you prefer, we’ll try to help you transfer to another methadone or buprenorphine program instead.

Opioid Use Disorder (OUD)

Study id: 17-aa-0114, screening and enrollment are currently closed..

This research study seeks volunteers who are dependent on opioids like heroin, hydrocodone, fentanyl, methadone, or oxycodone and are receiving or not receiving treatment for their addiction. The purpose of this research study is to learn how opiate use disorder affects dopamine signaling in the brain.

Participants must be 18 - 65 years of age who are receiving or not receiving treatment for OUD. Participation includes one day for screening and up to three days for tests and procedures. Participants will have positron emission tomography (PET) and magnetic resonance imaging (MRI) scans. Participants will do tasks on a computer screen while inside the scanner and will have tests of memory, attention, and thinking. Participants will wear an activity monitor for one week. You may not be eligible if you are pregnant of breastfeeding, have a psychiatric illness or condition, such as major depression, addiction, PTSD or schizophrenia that required medication or hospitalization.

There is no cost for study-related tests and procedures.

For more details, call NIH Clinical Center Office of Patient Recruitment at 1-800-411-1222 1-800-411-1222 .

NIDA also partners with the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Bethesda, Maryland, to conduct research studies to help better understand substance use and improve treatment.

• UNC Chapel Hill

Understanding Pharmaceutical Research Studies

Medical researchers are constantly looking for new or better ways to treat illness or disease. If they discover something that may be helpful, it cannot be put into general use until years of careful testing has been done. Research studies are what link medical research to a drug becoming available to physicians and patients. Research studies may also be called clinical trials, drug trials or drug studies.

What are Research Studies?

• Research studies are designed to test the effect of a medication or treatment in a group of volunteers, measure a drug’s ability to treat the medical condition, monitor the drug’s safety, and possible side effects.
• Pharmaceutical companies or other health organizations may sponsor research studies by providing funding and designing the protocol, which is a set of detailed guidelines. A study that is conducted at several different locations is called a multi-center study.
• Trained doctors, nurses and researchers conduct research studies. The study coordinator is in charge of the day-to-day running of the study. The principal investigator (usually a physician) has overall responsibility for carrying out the protocol.

How Are Study Subjects’ Rights and Safety Protected?

• The Food and Drug Administration (FDA) is the government agency that is responsible for research studies. It regulates the conduct of research studies, enforces the laws on the use of drugs, and must approve all new drugs before they are available to the general public.
• In every university or medical center, the Institutional Review Board (IRB) reviews any study that may be done in that location. The IRB is composed of physicians and lay people. They review the study protocol to make sure patients’ rights are protected and that there are no unnecessary risks in the study. Any physician awarded a research study must get approval from the IRB before beginning the study.
• Participants are required to sign an “informed consent” form, which is also signed by the investigator (the doctor conducting the study). It details the nature of the study, the risks involved and what will happen throughout the study. It informs study subjects that they have a right to leave the study at any time and who to call if they have questions. Finally, since the patient is under a doctor’s supervision, the same laws and ethics that normally regulate the medical profession protect the study subject.

What Are the Different Types of Pharmaceutical Research Studies?

There are three phases, or steps, in doing research studies. All three of these steps must be successfully completed and all results known before a new drug can be approved for public use.

• Phase I studies are done on healthy volunteers who agree to take the study drug to help the doctors determine how safe the drug is and if there are any side effects. Studies are also done to determine how the drug is absorbed, metabolized and excreted. Usually a small number of subjects (20-100) participate in Phase I studies. Approximately 70% of new drugs will pass this phase.
• Phase II studies measure the effect of the new drug in patients with the disease or disorder to be treated. The main purpose is to determine safety and effectiveness of the new drug. Usually several hundred patients participate. These studies are usually “Double-blinded, randomized and controlled”. In controlled studies, the effect of the active drug is compared to the effect of a placebo (inactive or “sugar” pill). In double blinded studies neither the investigator nor the study subject knows who is getting active drug and who is receiving placebo medication. One third of studied drugs complete both Phase I and II.
• Phase III studies also use patients with the disorder to be treated by the new drug. These studies are done to gain a more thorough understanding of the effectiveness, benefits and side effects of the study drug. These studies use a large numbers of subjects, several hundred to several thousand. Of the new drugs that enter Phase III studies, 70 to 90% of drugs successfully complete this phase. If the results show a good effect and safety profile, the company will submit the data and request FDA approval for marketing the drug.

Who Is Eligible to Be in a Research Study?

Almost anyone can be in some type of research study. Each study has certain requirements about health, medications or age depending on what specific questions are being asked. You must meet the requirements of a particular study to be an eligible volunteer

What Is Involved in Participating in a Research Study?

• Participating in a research study is much like a regular visit to a clinic or doctor’s office, but with even greater personal attention. The study subject may be referred by their doctor or may have heard about the study elsewhere.
• Preliminary screening for the study is usually done over the phone. Basic criteria of age, symptoms, and medical history are reviewed and the details of the study are discussed. If the caller seems to qualify for the study and is interested, they are asked to come in for the initial, or screening, visit.
• The screening visit is done in the a clinic, office or hospital. After reviewing the information gathered over the phone, the informed consent form is signed by the subject and the supervising physician. A copy is given to the subject. A physical exam, blood, and other tests may be done. Following this, in most studies, there is a period, usually a few weeks, where baseline information is collected, for example severity and frequency of symptoms.
• At the end of the screening period the patient returns to the clinic for the randomization visit. If the patient’s baseline information shows that they qualify for the study, they are then randomized (usually by computer) to receive placebo or active drug.
• During the treatment period the subjects are taking the study medication on a regular basis, and recording their symptoms. There are regular visits with the study coordinator during the treatment period. At the end of the treatment period, medication use and symptoms are reviewed. Possible side effects from the study medication are recorded. After completion of the treatment period, many studies have a follow up period to assess how symptoms and possible side effects have changed. There may be one additional visit or a telephone call to assess how the subject has been doing since stopping the study drug.

What Are the Risks of Participating in a Study?

Risks vary from study to study. Researchers expect certain results but since the treatment is new and is still being studied it is impossible to say exactly what the risks may be. If a side effect or adverse event does occur, it is generally temporary and will go away as soon as the treatment is stopped.

Why Think About Participating in a Research Study

• To help yourself, as you might have a beneficial effect from the study drug.
• You will receive a great deal of personal medical attention generally at no cost to you.
• To help others, as a great deal of information is gathered during studies, making new treatments available.

Deciding to Participate in a Research Study

• Think it over carefully, weigh possible benefits against risks.
• Make sure all your questions are answered by the study personnel.
• Discuss the study with your own doctor to see what their feelings may be about it.
• If you decide to enter a study, do not do so just out of curiosity. It is important to make a commitment to try to finish the study, unless you develop serious problems.
• Remember participation in a research study is always voluntary.
• You may refuse to participate, or withdraw your consent at any time, and for any reason, without jeopardizing your future care at this institution or your relationship with your doctor.
• If you are a patient with an illness, you do not have to participate in research in order to receive treatment.

Resources for Studies

• Current On-going Studies at the UNC Center for Functional GI & Motility Disorders
• International Foundation for Functional GI Disorders: www.iffgd.org
• IBS Self Help Group: www.ibsgroup.org

United Nations

Office on drugs and crime.

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Research on drugs

test UNODC research on drugs generates the sound knowledge needed to support evidence-based policies and programmes. Analysis of persistent and emerging challenges across the drug supply chain, from drug cultivation to trafficking and use, aims at strengthening responses to the drug problem at global, regional and national levels.

UNODC research activities on drugs dates back to the 1990s, when the 1997 World Drug Report, first of a long series, was published. The Report has become the flagship publication of the UNODC and its preparation, including the research activities it entails, embodies the large spectrum of issues that UNODC research on drugs covers.

World drug report

For the first time since its conception, this year the World Drug Report consists of two products, a web-based element and a set of booklets. The latest global, regional and subregional estimates of and trends in drug demand and supply are presented in a user-friendly, interactive  online segment . While  Special points of interest  include key takeaways and policy implications,  booklet 1  takes the form of an executive summary based on analysis of the key findings of the online segment and the thematic  booklet 2  and the conclusions that can be drawn from them. In addition to providing an in-depth analysis of key developments and emerging trends in selected drug markets, including in countries currently experiencing conflict, booklet 2 focuses on a number of other contemporary issues related to drugs. 

RESEARCH ON DRUG CULTIVATION AND PRODUCTION

UNODC provides evidence on the general situation and trends in the production of opiates, cocaine, amphetamine-type stimulants and cannabis at the global, regional and national levels.

To enhance knowledge and support countries in the collection of and reporting on data, UNODC works with Member States to monitor drug cultivation, production and manufacture, while collaboration with regional partners, intergovernmental organizations and academic institutions enhances monitoring capacities at national, regional and international levels.

RESEARCH ON DRUG TRAFFICKING

UNODC monitors global and regional developments in drug trafficking based on regular reporting from Member States, the monitoring of open sources and first-hand information from structured interviews or similar exercises.

Research on drug trafficking provides an overall picture of the illicit markets, covering aspects such as trafficking routes and flows, latest trends and emerging patterns in trafficking and distribution, criminal actors involved and modi operandi employed.

RESEARCH ON DRUG USE

UNODC monitors global and regional developments in the demand for drugs, including the non-medical use of pharmaceutical drugs, through various channels and activities, including regular reporting from Member States, household surveys and targeted studies of vulnerable population groups. 

Information from these sources is used to produce datasets but also analysed holistically to provide an overall picture of the many challenges the world faces in terms of drug use and health consequences, covering aspects such as trends in extent and patterns of drug use, risk behaviours, drug related morbidity and mortality and coverage of drug treatment for those suffering from drug use disorders.

UNODC regularly updates global statistical series on drugs, including on drug trafficking (drug seizures, drug prices, drug purity, drug-related arrests). These data are available at dataUNODC

Following an extensive review of the current data collection instrument on drugs, the Annual Report Questionnaire, the UNODC, in consultation with experts from the Member States and international organisations, is preparing a revised Annual Report Questionnaire, which will be implemented from 2021.

28-30 August 2019 ,  Second Expert Working Group on improving drug statistics and strengthening the Annual Report Questionnaire (ARQ)

29-31 January 2018 ,  Expert Working Group on Improving Drug Statistics and Strengthening the Annual Report Questionnaire (ARQ)

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Step 3: Clinical Research

While preclinical research answers basic questions about a drug’s safety, it is not a substitute for studies of ways the drug will interact with the human body. “Clinical research” refers to studies, or trials, that are done in people. As the developers design the clinical study, they will consider what they want to accomplish for each of the different Clinical Research Phases and begin the Investigational New Drug Process (IND), a process they must go through before clinical research begins.

On this page you will find information on:

Designing Clinical Trials

Clinical Research Phase Studies

The Investigational New Drug Process

Asking for FDA Assistance

FDA IND Review Team

Researchers design clinical trials to answer specific research questions related to a medical product. These trials follow a specific study plan, called a protocol , that is developed by the researcher or manufacturer. Before a clinical trial begins, researchers review prior information about the drug to develop research questions and objectives. Then, they decide:

Who qualifies to participate (selection criteria)

How many people will be part of the study

How long the study will last

Whether there will be a control group and other ways to limit research bias

How the drug will be given to patients and at what dosage

What assessments will be conducted, when, and what data will be collected

How the data will be reviewed and analyzed

Clinical trials follow a typical series from early, small-scale, Phase 1 studies to late-stage, large scale, Phase 3 studies.

What are the Clinical Trial Phases?

Watch this video to learn about the three phases of clinical trials.

Study Participants: 20 to 100 healthy volunteers or people with the disease/condition.

Length of Study: Several months

Purpose: Safety and dosage

During Phase 1 studies, researchers test a new drug in normal volunteers (healthy people). In most cases, 20 to 80 healthy volunteers or people with the disease/condition participate in Phase 1. However, if a new drug is intended for use in cancer patients, researchers conduct Phase 1 studies in patients with that type of cancer.

Phase 1 studies are closely monitored and gather information about how a drug interacts with the human body. Researchers adjust dosing schemes based on animal data to find out how much of a drug the body can tolerate and what its acute side effects are.

As a Phase 1 trial continues, researchers answer research questions related to how it works in the body, the side effects associated with increased dosage, and early information about how effective it is to determine how best to administer the drug to limit risks and maximize possible benefits. This is important to the design of Phase 2 studies.

Approximately 70% of drugs move to the next phase

Study Participants: Up to several hundred people with the disease/condition.

Length of Study: Several months to 2 years

Purpose: Efficacy and side effects

In Phase 2 studies, researchers administer the drug to a group of patients with the disease or condition for which the drug is being developed. Typically involving a few hundred patients, these studies aren't large enough to show whether the drug will be beneficial.

Instead, Phase 2 studies provide researchers with additional safety data. Researchers use these data to refine research questions, develop research methods, and design new Phase 3 research protocols.

Approximately 33% of drugs move to the next phase

Study Participants: 300 to 3,000 volunteers who have the disease or condition

Length of Study: 1 to 4 years

Purpose: Efficacy and monitoring of adverse reactions

Researchers design Phase 3 studies to demonstrate whether or not a product offers a treatment benefit to a specific population. Sometimes known as pivotal studies, these studies involve 300 to 3,000 participants.

Phase 3 studies provide most of the safety data. In previous studies, it is possible that less common side effects might have gone undetected. Because these studies are larger and longer in duration, the results are more likely to show long-term or rare side effects

Approximately 25-30% of drugs move to the next phase

Study Participants: Several thousand volunteers who have the disease/condition

Purpose: Safety and efficacy

Phase 4 trials are carried out once the drug or device has been approved by FDA during the Post-Market Safety Monitoring

Learn more about Clinical Trials .

Drug developers, or sponsors , must submit an Investigational New Drug (IND) application to FDA before beginning clinical research.

In the IND application, developers must include:

Animal study data and toxicity (side effects that cause great harm) data

Manufacturing information

Clinical protocols (study plans) for studies to be conducted

Data from any prior human research

Information about the investigator

Drug developers are free to ask for help from FDA at any point in the drug development process, including:

Pre-IND application, to review FDA guidance documents and get answers to questions that may help enhance their research

After Phase 2, to obtain guidance on the design of large Phase 3 studies

Any time during the process, to obtain an assessment of the IND application

Even though FDA offers extensive technical assistance, drug developers are not required to take FDA’s suggestions. As long as clinical trials are thoughtfully designed, reflect what developers know about a product, safeguard participants, and otherwise meet Federal standards, FDA allows wide latitude in clinical trial design.

The review team consists of a group of specialists in different scientific fields. Each member has different responsibilities.

Project Manager: Coordinates the team’s activities throughout the review process, and is the primary contact for the sponsor.

Medical Officer: Reviews all clinical study information and data before, during, and after the trial is complete.

Statistician: Interprets clinical trial designs and data, and works closely with the medical officer to evaluate protocols and safety and efficacy data.

Pharmacologist: Reviews preclinical studies.

Pharmakineticist: Focuses on the drug’s absorption, distribution, metabolism, and excretion processes.Interprets blood-level data at different time intervals from clinical trials, as a way to assess drug dosages and administration schedules.

Chemist: Evaluates a drug’s chemical compounds. Analyzes how a drug was made and its stability, quality control, continuity, the presence of impurities, etc.

Microbiologist: Reviews the data submitted, if the product is an antimicrobial product, to assess response across different classes of microbes.

The FDA review team has 30 days to review the original IND submission. The process protects volunteers who participate in clinical trials from unreasonable and significant risk in clinical trials. FDA responds to IND applications in one of two ways:

Approval to begin clinical trials.

Clinical hold to delay or stop the investigation. FDA can place a clinical hold for specific reasons, including:

Participants are exposed to unreasonable or significant risk.

Investigators are not qualified.

Materials for the volunteer participants are misleading.

The IND application does not include enough information about the trial’s risks.

A clinical hold is rare; instead, FDA often provides comments intended to improve the quality of a clinical trial. In most cases, if FDA is satisfied that the trial meets Federal standards, the applicant is allowed to proceed with the proposed study.

The developer is responsible for informing the review team about new protocols, as well as serious side effects seen during the trial. This information ensures that the team can monitor the trials carefully for signs of any problems. After the trial ends, researchers must submit study reports.

This process continues until the developer decides to end clinical trials or files a marketing application. Before filing a marketing application, a developer must have adequate data from two large, controlled clinical trials.

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Regions & Countries

As obesity rates rise in the u.s. and worldwide, new weight-loss drugs surge in popularity.

Obesity affects roughly 42% of U.S. adults , according to the Centers for Disease Control and Prevention (CDC). And about two-thirds of Americans (65%) say willpower alone usually isn’t enough for most people who are trying to lose weight and keep it off, according to a new Pew Research Center survey.

Put those two facts together, and it should come as no surprise that a new class of drugs to help people lose weight – including Ozempic, Wegovy and similar medications – has soared in popularity . In the Center survey, about three-quarters of Americans say they have heard or read at least a little about these drugs.

This post analyzes obesity rates and uptake of weight-loss drugs in the United States and worldwide. It uses data from Pew Research Center’s recent report “How Americans View Weight-Loss Drugs and their Potential Impact on Obesity in the U.S.” and other sources.

Data on the prevalence of U.S. adults classified as obese and overweight was obtained from the National Health and Nutrition Examination Survey (NHANES), a project of the Centers for Disease Control and Prevention. The NHANES is normally conducted every two years. Some of our findings come from this most recent dataset, and others are from the 2017-18 NHANES. Data from the 2021-23 survey is not yet available.

Global obesity rates for adults were obtained from the World Health Organization (WHO). The most recent estimates are from 2016. To estimate the number of people worldwide with obesity, we also used 2016 population data for adult men and women from each country from the World Bank. We applied WHO’s gender-specific obesity rates to those population estimates, then totaled them to arrive at a global obesity estimate.

Data on the number of prescriptions for and patients using weight-loss drugs came from ClinCalc.com , an online resource for physicians and other health care practitioners. ClinCalc aggregates data from the Prescribed Medicines File (PMED) of the Medical Expenditure Panel Survey , a project of the U.S. Agency for Healthcare Research and Quality.

We also analyzed recent financial statements from Novo Nordisk, producer of Ozempic and other semaglutide drugs, and Eli Lilly, maker of Mounjaro and Zepbound. We obtained the companies’ financials via the Securities and Exchange Commission’s EDGAR database of corporate filings .

In the case of Novo Nordisk, which as a Danish company reports its financials in Danish kroner rather than U.S. dollars, we converted its reported revenues to dollars at the rate of 1 krone = $0.145, the prevailing exchange rate when we did the analysis.

Obesity patterns in the U.S. and abroad

Over the past three decades, the share of Americans categorized as obese (based on body mass index, or BMI, data from the CDC) has risen considerably.

In 2017-18 – the timespan with the most recent data available – about three-quarters of U.S. adults ages 20 and older were considered either overweight (31%) or obese (42%). Just over 9% of adults were considered severely obese. (Note that the CDC survey period spans two years.) About three decades earlier, by comparison, 56% of Americans ages 20 and older were considered overweight or obese, including 3% who were considered severely obese.

The COVID-19 pandemic disrupted the CDC’s data collection, which is why the most recent figures are from 2017-18. However, there’s some evidence from other federal agencies that adult obesity rates rose even higher during the pandemic.

The CDC classifies someone as “overweight” if they have a BMI of 25.0 to 29.9, and “obese” if they have a BMI of 30.0 or greater. People whose BMI is 40.0 or greater are sometimes categorized as “severely obese.” The CDC has more information about BMI , its uses and how to calculate it.

While clinicians and researchers use BMI as a population-level metric and as an individual screening tool to identify potential weight problems, many now advise that BMI alone is an incomplete measure of health . In 2023, for instance, the American Medical Association (AMA) urged doctors to consider additional factors when assessing obesity and health risks, such as body composition, waist circumference and genetic factors. The AMA also noted that health risks differ both between and within demographic groups, and that BMI cutoffs were “based primarily on data collected from previous generations of non-Hispanic White populations and [do] not consider a person’s gender or ethnicity.”

The United States had one of the highest adult obesity rates in the world as of 2016, the most recent year for which the World Health Organization (WHO) has comprehensive data. That year, the U.S. ranked 12th among 191 countries. (Note that the WHO defines adults as those 18 and older, so its figures aren’t directly comparable with the CDC data.)

Worldwide, obesity affected about 663 million adults, or 13% of the global adult population, in 2016. Global obesity rates were 15% for women and 11% for men, based on Center estimates of WHO and World Bank data.

Demand for weight-loss drugs

Americans have only modest expectations that the new weight-loss drugs – formally known as glucagon-like peptide-1 (GLP-1) receptor agonists – will reduce obesity in the U.S. , according to the Center’s new survey. Still, these drugs have taken off in popularity in America, as well as around the world.

Since its 2017 approval as a diabetes treatment, semaglutide (the generic name for Ozempic and its offshoots, Rybelsus and Wegovy) has become one of the most popular prescription drugs in the U.S. It ranked 90th in 2021, the most recent year for which federal data on hundreds of the most commonly prescribed drugs is available. That year, an estimated 8.2 million prescriptions for it were written in the U.S., more than quadruple the number just two years earlier.

Almost 2 million people in the U.S. were taking semaglutide medications in 2021 – more than three times as many as in 2019. (The number of prescriptions exceeds the number of patients because prescription refills and renewals are counted separately.)

Another indication of weight-loss drugs’ rapid uptake globally comes from the financial statements of their manufacturers. Last year, Ozempic, Rybelsus and Wegovy had combined sales of about $21.1 billion for Novo Nordisk, the Danish company that produces them. That made up nearly two-thirds of Novo Nordisk’s entire revenue that year. The drugs’ combined sales were 89% higher than in 2022. Last year, 71% of semaglutide revenues came from the U.S.

Mounjaro, a similar diabetes drug produced by Eli Lilly with the active ingredient tirzepatide, launched in mid-2022. By the end of 2022, Mounjaro had sales of $482.5 million. In 2023, its first full year on the market, Mounjaro brought in nearly $5.2 billion. In November 2023, the Food and Drug Administration approved a version for weight loss under the name Zepbound.

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Weight loss caused by common diabetes drug tied to “anti-hunger” molecule in study

A Stanford Medicine study found that metformin, a commonly prescribed diabetes drug associated with moderate weight loss, stimulates production of lac-phe, a molecule abundant after exercise.

March 18, 2024 - By Krista Conger

Jonathan Long co-discovered lac-phe, known as the "anti-hunger" molecule. Courtesy Jonathan Long

An “anti-hunger” molecule produced after vigorous exercise is responsible for the moderate weight loss caused by the diabetes medication metformin, according to a new study in mice and humans. The molecule, lac-phe, was discovered by Stanford Medicine researchers in 2022.

The finding, made jointly by researchers at Stanford Medicine and at Harvard Medical School, further cements the critical role the molecule, called lac-phe, plays in metabolism, exercise and appetite. It may pave the way to a new class of weight loss drugs.

“Until now, the way metformin, which is prescribed to control blood sugar levels, also brings about weight loss has been unclear,” said Jonathan Long , PhD, an assistant professor of pathology. “Now we know that it is acting through the same pathway as vigorous exercise to reduce hunger. Understanding how these pathways are controlled may lead to viable strategies to lower body mass and improve health in millions of people.”

Long, who is supported by the Knight Initiative for Brain Resilience, and Mark Benson, MD, PhD, an assistant professor of medicine at Harvard Medical School, are co-senior authors of the study , which was published on March 18 in Nature Metabolism . Postdoctoral scholar Shuke Xiao , PhD, is the lead author of the study.

Many people with diabetes who are prescribed metformin lose around 2% to 3% of their body weight within the first year of starting the drug. Although this amount of weight loss is modest when compared with the 15% or more often seen by people taking semaglutide drugs such as Ozempic and Wegovy, the discoveries that led to those drugs also grew from observations of relatively minor, but reproducible, weight loss in people taking first-generation versions of the medications.

Post-workout appetite loss

When Long and colleagues at Baylor University discovered lac-phe in 2022, they were on the hunt for small molecules responsible for curtailing hunger after vigorous exercise. What they found was a Frankenbaby of lactate — a byproduct of muscle fatigue — and an amino acid called phenylalanine. They dubbed the hybrid molecule lac-phe and went on to show that it’s not only more abundant after exercise but it also causes people (as well as mice and even racehorses) to feel less hungry immediately after a hard workout.

“There is an intimate connection between lac-phe production and lactate generation,” Long said. “Once we understood this relationship, we started to think about other aspects of lactate metabolism.”

Metformin was an obvious candidate because as it stimulates the breakdown of glucose (thus reducing blood sugar levels) it can trigger the generation of lactate.

The researchers found that obese laboratory mice given metformin had increased levels of lac-phe in their blood. They ate less than their peers and lost about 2 grams of body weight during the nine-day experiment.

The fact that metformin and sprint exercise affect your body weight through the same pathway is both weird and interesting.

Long and his colleagues also analyzed stored blood plasma samples from people with Type 2 diabetes before and 12 weeks after they had begun taking metformin to control their blood sugar. They saw significant increases in the levels of lac-phe in people after metformin compared with their levels before treatment. Finally, 79 participants in a large, multi-ethnic study of atherosclerosis who were also taking metformin had significantly higher levels of lac-phe circulating in their blood than those who were not taking the drug.

“It was nice to confirm our hunch experimentally,” Long said. “The magnitude of effect of metformin on lac-phe production in mice was as great as or greater than what we previously observed with exercise. If you give a mouse metformin at levels comparable to what we prescribe for humans, their lac-phe levels go through the roof and stay high for many hours.”

Further research revealed that lac-phe is made by intestinal epithelial cells in the animals; blocking the ability of mice to make lac-phe erased the appetite suppression and weight loss previously observed.

Finally, a statistical analysis of the people in the atherosclerosis study who lost weight during the several-year study and follow-up period found a meaningful association between metformin use, lac-phe production and weight loss.

“The fact that metformin and sprint exercise affect your body weight through the same pathway is both weird and interesting,” Long said. “And the involvement of the intestinal epithelial cells suggests a layer of gut-to-brain communication that deserves further exploration. Are there other signals involved?”

Long noted that, while semaglutide drugs are injected into the bloodstream, metformin is an oral drug that is already prescribed to millions of people. “These findings suggest there may be a way to optimize oral medications to affect these hunger and energy balance pathways to control body weight, cholesterol and blood pressure. I think what we’re seeing now is just the beginning of new types of weight loss drugs.”

Researchers from Beth Israel Deaconess Medical Center, Harbor-UCLA Medical Center, Cedars-Sinai Medical Center, Baylor College of Medicine, the University of Colorado, the University of Virginia and the Broad Institute contributed to the work.

The study was funded by the National Institutes of Health (grants GM113854, K08HL145095, DK124265, DK136526, HHSN2682015000031, HSN26800004, UM1DK078616 and 1R01HL151855), a Stanford School of Medicine’s Dean’s Fellowship, the American Heart Association, Wu Tsai Human Performance Alliance, Knight Initiative for Brain Resilience and Stanford Diabetes Research Center. 

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

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What is preventive chemotherapy and how effective is it? The Princess of Wales’ treatment explained

As Princess of Wales begins treatment after cancer diagnosis, we answer some key questions

The Princess of Wales has begun preventive chemotherapy after her doctors discovered she had cancer following major abdominal surgery in January. What is preventive chemotherapy and how effective can it be?

What is preventive chemotherapy?

The treatment, known formally as adjuvant chemotherapy, is a course of anti-cancer drugs that is given to mop up any cancer cells that might remain in the body after primary cancer treatment, which is usually surgical removal of a tumour.

What does it do?

The therapy aims to reduce the risk of the original cancer coming back and spreading. This can happen when cancer cells, which are too small to detect with hospital scans and tests, are left behind after surgery. The risk of cancer returning tends to be smaller if the cancer is caught at a very early stage, before it has had a chance to spread, but greater if the disease is found at a later stage, or has spread to nearby lymph nodes.

How does the therapy work?

Most cancer chemotherapy drugs target rapidly dividing cells. A typical course of preventive chemotherapy lasts three to six months depending on the type and stage of the cancer, which is determined by examining the cancer removed during surgery. Occasionally, courses of adjuvant chemotherapy are given over several years.

How many courses of therapy do people have?

It depends on the nature of the original tumour that was picked up after surgery. When cancer is discovered during operations for other conditions, the tumour is often at an early stage, when subsequent chemotherapy is more effective. “This is likely to mean that a single course of chemotherapy will be sufficient to ensure that if any cancer cells are present, they will be destroyed,” says Prof Lawrence Young, the director of the Warwick Cancer Research Centre at the University of Warwick.

How effective is the therapy?

It is particularly effective for breast, bowel and lung cancer, but can be recommended for other forms of the disease, too. For example, adjuvant chemotherapy is often used after surgery for epithelial ovarian cancer, the most common form of ovarian cancer, because of the risk of the disease returning. Doctors decide whether adjuvant therapy is likely to have a benefit based on the type of cancer, how advanced the disease is, and other properties of the tumour.

Are there side-effects?

No chemotherapy is completely harmless. The side-effects depend on the specific drugs given, but patients can experience tiredness, nausea, vomiting, diarrhoea, an increased risk of picking up infections, and a loss of appetite. The side-effects arise because the drugs affect not only cancer cells but all rapidly dividing cells, including hair, bone marrow, skin and the lining of the digestive system. The damage to healthy tissues tends to be temporary, however, and side-effects usually disappear once the treatment is over.

Younger people often tolerate chemotherapy better than older patients and experience fewer side-effects because of their “greater functional reserves” and the “ability of young tissues to heal more rapidly,” says Dr Mangesh Thorat, an honorary reader at Queen Mary University of London and consultant breast surgeon at Homerton university hospital. Because of this, younger people may be given higher doses of the drugs, which are more likely to wipe out any cancer cells that remain in their bodies.

How long does it take to recover?

It depends on the patient and the particular drugs given, but it can take several months for a person to be back to full strength. Since younger people tend to be healthier and fitter than older people, their recovery times are usually shorter.

• Catherine, Princess of Wales

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• v.54(1); 2022

How the war on drugs impacts social determinants of health beyond the criminal legal system

Aliza cohen.

a Department of Research and Academic Engagement, Drug Policy Alliance, New York, NY, USA

Sheila P. Vakharia

Julie netherland, kassandra frederique.

b Drug Policy Alliance, New York, NY, USA

Associated Data

Data sharing is not applicable to this article as no new data were created or analysed in this study.

There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the “war on drugs” in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that “drug war logic” has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts.

KEY MESSAGES

• A drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.
• The U.S. drug war’s frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.
• Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.

Introduction

Social determinants of health (SDOH) are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” [ 1 ] There is a growing recognition in the fields of public health and medicine that SDOH play a key role in driving health inequities and disparities, such that a focus on individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. For instance, differences in access to nutritious foods, safe neighbourhoods, stable housing, well-paying job opportunities, enriching school environments, insurance, and healthcare can lead to differential health outcomes for individuals, their families, and their communities. And as these mid- and downstream SDOH have gained more attention, we must also focus on more macro SDOH in order to understand “how upstream factors, such as governance and legislation, create structural challenges and impose downstream barriers that impact the ability and opportunity to lead a healthy lifestyle.” [ 2 ]

One underexplored upstream SDOH is the “war on drugs” in the United States and how it exacerbates many of the factors that negatively impact health and wellbeing, disproportionately affecting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism [ 3 ]. President Richard Nixon launched the contemporary drug war in the U.S. in 1971 when he signed the Controlled Substances Act and declared drug abuse as “public enemy number one.” [ 4 ] Since the declaration of the U.S. drug war, billions of dollars each year have been spent on drug enforcement and punishment because it was made a local, state, and federal priority [ 5 ]. For the past half century, the war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating access to adequate resources and supports to live healthy lives.

Drug offences remain the leading cause of arrest in the nation; over 1.1 million drug-related arrests were made in 2020, and the majority were for personal possession alone [ 6 ]. Black people – who are 13% of the U.S. population – made up 24% of all drug arrests in 2020, despite the fact that people of all races use and sell drugs at similar rates [ 6–8 ]. While incarceration rates for drug-related offences skyrocketed in the 1980s and 1990s, they have decreased in recent years motivated both by cost savings and criminal legal reform efforts to promote a public health approach to drug use. However, estimates still suggest that roughly 20% of people who are incarcerated are there for a drug charge, and racial disparities in incarceration persist [ 9 , 10 ].

Meanwhile, the illicit drug supply has become increasingly unpredictable and contaminated due to drug supply disruptions, contributing to an exponential increase in drug overdose deaths [ 11 , 12 ]. Estimates suggest that one million people died of a drug-involved overdose between 1999 and 2020, with over 100,000 deaths occurring in a calendar year for the first time in 2021 [ 13 , 14 ]. Since 2015, overdose deaths have disproportionately impacted racial and ethnic minorities; Black people have had the biggest increase in overdose fatality rates, and today, Black and Native people have the highest overdose death rates across the U.S [ 15 ]. The most recent “fourth wave” of the overdose crisis can be attributed to a fentanyl-contaminated drug supply caused by drug prohibition; criminalisation that leads to stigma and fear of punishment that deters people from getting support they might need; and a lack of robust, scaled-up investment in harm reduction and evidence-based treatment services [ 16 , 17 ]. Although harm reduction interventions, including supervised consumption spaces (also called supervised injection facilities, drug consumption rooms, or overdose prevention centres) and heroin-assisted treatment have been widely studied and found effective outside of the U.S., these strategies have not been widely adopted in this country [ 18–21 ].

The drug war has also become deeply embedded within many of the systems and structures of U.S. life well beyond the criminal legal apparatus [ 3 ]. Since the health impacts of incarceration have been studied elsewhere, this paper will specifically discuss the impacts of criminalisation in other facets of life [ 22 ].

We argue that an underlying drug war logic has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the U.S. We define drug war logic as a logic that prioritises and justifies drug prohibition, criminalisation, and punishment to purportedly address the real and perceived health harms of drug use over a public health approach to address these issues. In coining this term, we hope to make more visible the implicit assumptions about drug use that are often unnamed but common in the policies and practices across different institutions. We acknowledge that many actors in these settings where drug war logic is embedded, including physicians and other healthcare providers, are often well-intentioned yet unaware of how they may be perpetuating this logic through their own actions. We argue that drug war logic defies and contradicts widely accepted understandings of addiction as a health issue and has, in many cases, made a public health approach more challenging to implement [ 23 ]. Notably, the American Society of Addiction Medicine defines addiction as “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” [ 24 ] As this paper will outline, drug war logic undermines rather than supports the health of people who use drugs, their families, and their communities by treating drug use as a criminal issue.

Drug war logic is made concrete, not just within criminal legal systems, but also through mandated drug reporting and monitoring systems in treatment and healthcare settings, compulsory drug testing in employment and for the receipt of social services, the proliferation of zero-tolerance workplaces and school zones, mandated treatment in order to receive resources or avoid loss of benefits, background checks for work and housing, and numerous other measures which will be discussed in detail below. As a result, the drug war’s frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others who are required to engage in these forms of surveillance and punishment.

This commentary will use a SDOH lens to explore a number of systems where the drug war and its logic have taken root, impacting individual and community health and subjecting many people in the U.S. to surveillance due to suspected or confirmed drug use. Healthcare providers must have a robust understanding of the impact of drug war logic in employment, housing, education, public benefits, the family regulation system (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system because these deeply impact the health of their patients, particularly their patients who use drugs (For the purposes of this paper, we are using the term “Family Regulation System,” coined by Emma Williams and used by other scholars, instead of the more commonly used term “Child Welfare System” to reflect the fact that, particularly for low-income families and families of color, state intervention often occurs in order to regulate their families rather than to prioritize the welfare of the entire family unit, of which the child is a part).

Employment, with its link to income and health insurance, is an important determinant of health. However, drug testing, criminal background checks, and exclusions of those with criminal histories from certain professions create significant barriers to obtaining and maintaining employment. Beginning in the 1980s, employment-based drug testing became widespread. In a 1994 report, the National Research Council noted that “[i]n a period of about 20 years, urine testing has moved from identifying a few individuals with major criminal or health problems to generalized programs that touch the lives of millions of citizens.” [ 25 ] Between 2017 and 2020, the National Survey on Drug Use and Health found that approximately 21% of respondents were tested as part of the hiring process, and 15% were subject to random employee drug testing [ 26 ].

Despite the widespread use of testing, less than 5.5% of results are positive for any drug, according to data from Quest Diagnostics, one of the largest testing companies in the country [ 27 ]. There is little evidence that these policies are effective in reducing drug use, improving workplace safety, or increasing productivity [ 28–30 ]. Notably, drug tests cannot specify how much of a drug was consumed, whether the person is currently intoxicated or impaired, or if they have a SUD. Drug tests cannot indicate if drug use will impact a person’s ability to perform their work or if they present a safety risk. Rather, drug tests simply show whether or not someone has a particular metabolite in their system [ 31–35 ].

Beyond workplace drug testing, hundreds of thousands are excluded from stable, well-paid work because of drug-related convictions. Over 70 million people – more than 20% of the U.S. population – have some type of criminal record [ 36 ]. A drug arrest or charge, even without a conviction, can be a barrier to getting a job because it can appear in many web searches and background checks [ 37 ]. Criminal background checks have become cheaper and easier to access, even though these records are notoriously inaccurate [ 38 , 39 ]. In addition, more than a quarter of jobs in the U.S. require some kind of licence, and a drug conviction history can automatically prevent people from getting a professional licence for their trade, like trucking or barbering [ 40 ].

These employment barriers disproportionately affect Black men, who already face additional impediments to employment and who are most harmed by the drug war and criminalisation [ 41 ]. The federal Equal Employment Opportunity Commission issued guidance stating that denying employment based on criminal records could be a form of racial discrimination because people of colour are more likely to be targeted by law enforcement and thus more likely to have an arrest or conviction record [ 42 , 43 ]. As a recent report by the Brennan Centre points out: “the staggering racial disparities in our criminal justice system flow directly into economic inequality” [ 36 ]. This same report found that those with a history of imprisonment earned 52% less than those with no history of incarceration.

Employment is a health issue that should be of concern to healthcare providers because it provides income, access to health insurance and medical treatment, and social connection [ 44 ]. Precarious employment and low income are linked to poor health, and some research has shown that people who use drugs and who are precariously employed face increased vulnerability to violence and HIV infection [ 45–47 ]. Being unemployed can lead to poverty and negative health effects and is associated with increased rates of drug use and SUDs [ 48 ].

Rather than supporting people who use drugs in accessing employment and the health benefits attached to it, drug war logic in employment settings can erect barriers. Eliminating or greatly restricting workplace drug testing as well as banning criminal background checks and professional licencing restrictions are important steps towards restoring access to employment and the many health benefits it confers.

Housing is another key SDOH that is significantly impacted by drug war policies and practices. Drug war surveillance in housing began with the passage of the Anti-Drug Abuse Act of 1988, which prohibited public housing authorities (PHAs) from allowing tenants to engage in drug-related activity on or near public housing premises and deemed such activity grounds for immediate eviction [ 49 ].

The Cranston-Gonzalez National Affordable Housing Act of 1990 expanded on this so that if a tenant’s family member or guest - regardless of whether they live on-site - engages in drug-related activity, the tenant and their household can be evicted [ 50 ]. Additionally, the Act states that evicted households must be banned from public housing for a minimum of three years unless the tenant completes an agency-approved drug treatment program or has otherwise been “rehabilitated successfully.” [ 50 ]

Six years later in 1996, Congress passed the Housing Opportunity Program Extension Act, which established “One Strike” laws and expanded on previous acts to give PHAs the authority to evict tenants if they or a guest was suspected of using or selling drugs, even outside of the premises [ 51 ]. This series of public housing policies requires neither a drug arrest nor proof that a tenant or their guest is involved in drug use, sales, or activity [ 52 ].

Private housing markets can also enforce zero-tolerance drug policies. In over 2,000 cities across the U.S., landlords can certify their property as “crime-free” by taking a class, implementing “crime prevention” architecture, and including clauses in their leases that allow for immediate eviction should a tenant, family member, or guest engage in “criminal activity,” particularly drug-related activity, on or off the premises [ 53 , 54 ]. Landlords, in close partnership with law enforcement, can invoke these laws by claiming to enforce crime-free ordinances, regardless of whether the alleged drug-related activity is illegal. In states across the U.S., private landlords have evicted tenants following an overdose [ 55–59 ]. In practice, these programs and ordinances increase the surveillance and displacement of low-income Black and Latinx tenants while not decreasing crime and potentially deterring someone from calling 911 for medical assistance in case of an overdose [ 55 ].

Evictions can lead to unstable housing or homelessness, which is associated with a host of chronic health problems, infectious diseases, emotional and developmental problems, food insecurity, and premature death [ 60–63 ]. Lacking a permanent address and reliable transportation makes it more difficult to receive and store medications and travel to a hospital or clinic; this is compounded with the stigma and discrimination that unhoused people often face from healthcare providers [ 64 ]. Being unhoused or housing unstable is also associated with difficulty obtaining long-term employment and education [ 65–67 ]. Longitudinal studies have found that family eviction has both short- and long-term impacts among newborns and children, including adverse birth outcomes, poorer health, risk of lead exposure, worse cognitive function, and lower educational outcomes [ 68 ]. These negative health outcomes are compounded for people with SUDs [ 69 ]. Unhoused people who use drugs are often forced into more unsafe, more unsanitary, and riskier injection and drug-using practices to avoid detection [ 70 ]. Evictions and homelessness are also associated with increased risk of drug-related harms, including non-fatal and fatal overdose, infectious diseases, and syringe sharing [ 71–73 ]. In addition, evictions can disrupt relationships between users and trusted sellers, making an already unregulated drug supply even more unpredictable [ 70 ].

While housing is understood as a key component of health and safety for all people, including people who use drugs, drug war logic can encourage and facilitate displacement, making it hard for housed people to remain so and creating barriers for those who are unhoused to find safe, affordable housing options. Solutions for improving housing access include ending evictions and removing housing bans based solely on drug-related activity or suspected activity, restricting landlords from using criminal background checks to exclude prospective tenants, and ending collaborations between housing complexes and law enforcement. Housing interventions that can improve the health of people who use drugs, in particular, include investing in Housing First programs and permanent supportive housing, providing eviction protection to people who call for help during an overdose emergency (i.e. expanding 911 Good Samaritan laws), and establishing overdose prevention centres.

Education is also understood as a strong predictor of health [ 74–76 ], but drug war logic in educational settings can subject young people who use drugs to punishment rather than needed support. Adolescent substance use is associated with sexual risk behaviour, experience of violence, adverse childhood experiences, and mental health and suicide risks, which should justify greater mental health and support services in schools [ 77 ]. Despite this, punitive responses to suspected or confirmed drug use, ranging from surveillance and policing to drug testing and expulsion, are commonplace in the field of education.

In 2018, 94% of high schools used security cameras, 65% did random sweeps for contraband, and 13% used metal detectors [ 78 ]. Twenty-four states and the District of Columbia have almost as many police and security officers in schools as they do school counsellors [ 79 , 80 ]. Drug use is one of the most common sources of referrals of students to police [ 80 ]. And recent estimates show that over a third of all U.S. school districts with middle or high schools had student drug testing policies [ 81–83 ].

Drug war policies also impact higher education, which is integral to economic mobility [ 84 ]. Prior to December 2020, federal law prohibited educational grants and financial aid to people in prison, one-fifth of whom were there for a drug offence, and drug convictions could lead to temporary or indefinite suspension of federal financial aid for students [ 85 ]. Still today, fourteen states have some temporary or permanent denial of financial aid for college or university education for people with criminal records [ 86 ].

These education policies – surveillance, policing, drug testing, zero tolerance, and barriers to financial aid – restrict access to education and ultimately impede economic wellbeing and positive health outcomes. For example, dropout risk increases every time a student receives harsh school discipline or comes into contact with the criminal legal system, including through school police officers [ 87 ]. Dropping out, in turn, is associated with higher unemployment and chronic health conditions [ 88 ]. In addition, discipline, such as expulsion for a drug violation, can contribute to more arrests for drug offences or the development of SUDs [ 89–91 ]. In contrast, school completion can help reduce higher risk substance use patterns [ 92 ], and education is a strong predictor of long-term health and quality of life [ 93 ].

Rather than supporting young people in completing their education and getting the support they may need, drug war logic prioritises punishing them in schools while often restricting access to financial aid and educational services for those seeking higher education. If we want to improve the health of young people, we need to reverse these policies. For example, the American Academy of Paediatrics opposes the random drug testing of young people based on an exhaustive review of the literature finding it did more harm than good [ 94 ]. Removing police from schools, ending zero-tolerance policies, and offering young people who use drugs counselling and support, instead of expulsion, could also help improve completion rates, ultimately leading to better health outcomes.

Public benefits

Though economic and food insecurity are linked with poor health outcomes, decades of drug policies have restricted access to public assistance programs. In 1996, Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) [ 95 ], and one of the stated goals was to facilitate the transition from reliance on public assistance to full-time employment [ 96 ]. This law restricted benefits for people who use drugs, people with prior drug convictions, and their families in several ways.

The PRWORA introduced a lifetime ban on Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) cash assistance benefits for people with felony drug convictions, unless the state modified or opted out of the ban. Today, one state - South Carolina - fully bars people with felony drug convictions from receiving SNAP, and twenty-one states have instituted a modified SNAP ban [ 97 ]. Seven states fully bar people with felony drug convictions from receiving TANF, and seventeen states and the District of Columbia have instituted modified TANF bans [ 97 ]. Common features of modified bans can include mandatory drug treatment, drug testing, and parole compliance [ 98 , 99 ]. These zero-tolerance bans have discriminatory and disproportionate impacts among Black and Latinx people and women, who are disproportionately incarcerated for federal and state drug offences [ 100 ].

Drug testing of public benefits applicants is less discussed in the peer-reviewed literature [ 101 ]. Although the PRWORA authorised, but did not require, drug screenings of public benefits applicants, today 13 states drug test TANF applicants [ 102 , 103 ]. States that drug test as a condition of receiving TANF can only test if drug use is suspected. For example, some states automatically require people with felony drug convictions to take a drug test [ 104 ], while other states require all applicants to undergo a drug screening questionnaire and then require a test if there is suspicion of drug use [ 105 ]. Many TANF applicants, who are already low income, are expected to pay for their drug tests. The impact of drug testing on people with felony drug convictions is compounded since they are already disproportionately poor, unemployed, and food insecure compared to people who have never been incarcerated [ 106–108 ].

In most states that test, a positive drug test can temporarily or permanently disqualify a person from receiving TANF benefits [ 105 ]. Even if cash assistance is allocated to other household members (e.g. children) through a different parent or guardian, overall benefits for the family can be reduced. In some cases, a person who tests positive for drugs may still receive benefits but only if they complete mandated, abstinence-based treatment [ 105 ]. Such policies and practices can deter many eligible candidates and those in need of support from ultimately seeking these public benefits altogether [ 109 ].

There are numerous negative health consequences associated with food and economic insecurity [ 110–112 ]. In particular, studies have found that loss or reduction of SNAP is associated with increased odds of household and child food insecurity and increased odds of forgoing health or dental care [ 113 ]. Loss or reduction of TANF is associated with increased risk of hunger, homelessness or eviction, utility shutoff, inadequate medical care, and poor health [ 114 ].

When people are seeking financial and nutritional support to better care for themselves and their families, especially in crisis, drug war logic justifies more barriers to SNAP and TANF and the discontinuation of assistance precisely when people need it the most. To better support financial and economic security of low-income people, advocates can support removing TANF and SNAP bans for people who have felony drug convictions, ending drug testing requirements for public assistance, eliminating mandatory drug treatment requirements for public benefits applicants and recipients, and adequately investing in public benefit programs to ensure they provide enough assistance for families.

Family regulation

The family regulation system (FRS) often treats any drug use as a predictor of child abuse or neglect, even though research shows that poverty is one of the largest predictors of adverse infant and child health outcomes [ 115 ]. Drug war logic within the FRS justifies the separation and punishment of families for drug use even absent evidence of abuse or neglect. Half of all states and the District of Columbia require healthcare professionals to report any suspected drug use during pregnancy to FRS authorities, and eight states require them to drug test patients suspected of drug use [ 116 ]. Statutes in nineteen states and the District of Columbia define any drug use during pregnancy as a form of child maltreatment [ 117 ]. These policies exist even though most people who use drugs use them infrequently and do not meet criteria for SUDs [ 118 ]. Additionally, evidence proving causal links between prenatal drug use and child harm and maltreatment is limited. Research finds that in utero exposure to drugs may not have long-term negative developmental impacts on the child and that confounding variables, like poverty and food insecurity, have significant and often stronger impacts on child development than drug use [ 117 ].

Drug testing, mandatory reporting, and the prospect of punishments result in poorer health outcomes for pregnant people who use drugs, especially if they struggle with their use. A fear of punishment and family separation leads some pregnant people who use drugs to avoid honest, open conversations about healthcare needs or how to reduce drug use harms so that many delay, avoid, or forgo prenatal care altogether [ 119 , 120 ].

Like healthcare professionals, most school teachers, counsellors, social workers, and mental healthcare providers are required by law to report any suspicion of child maltreatment or neglect, which then initiates an FRS investigation [ 121 ]. A child can be removed from their home if the caregiver tests positive for drugs, even absent any other evidence of mistreatment or abuse. In addition, a positive drug test can lead to a parent being mandated to complete abstinence-based treatment even if the parent does not meet criteria for a diagnosable SUD [ 122 ]. Intervention by the FRS, such as placing children in foster care, can lead to adverse education, employment, and mental and behavioural health outcomes among children; increased parental mental illness diagnoses; and increased parental drug use to cope with the trauma of family separation [ 123–125 ].

These policies have disproportionate impacts on Black people. Black pregnant women are more likely to be tested for drug use, and Black women are reported to the FRS at higher rates than white women [ 126–128 ]. Over half of Black children will experience an FRS investigation at some point during their lifetime [ 129 ]. One study that analysed cumulative foster system removals between 2000 and 2011 found that 1 in 17 U.S. children, 1 in 9 Black children, and 1 in 7 Indigenous children will experience foster placement before they turn 18, and data show that many FRS cases involve allegations of parental drug use at some point [ 130 ]. These disparities in FRS involvement are not because Black parents are using drugs or mistreating their children at higher rates; rather, it’s because Black families, especially poor Black families, more often encounter state systems – like public hospitals and public benefits offices – and mandated reporters within these systems that monitor behaviour and drug use [ 131 ].

Drug war logic prioritises separation, coercion, and punishment in families where drug use occurs or is suspected. For pregnant people and parents who do use problematically, their use should be treated as a public health issue, according to international bodies like the United Nations General Assembly Special Session on drugs [ 132 ]. Advocates can support legislative policy changes to prohibit removals based on drug tests alone, eliminate mandatory reporting for drug use alone, and repeal laws that define drug use during pregnancy as de facto child abuse or maltreatment. Healthcare professionals can also advocate to only allow drug testing when medically necessary and when the parent provides informed consent; support practices that keep parents and infants together, like breastfeeding and skin-to-skin contact, that can mitigate the effects of neonatal abstinence syndrome [ 133 , 134 ]; and create programs providing both perinatal healthcare and SUD treatment to improve access and continuity of care as well as initiation and maintenance of medications for addiction treatment.

Substance use treatment system

Substance use treatment can be an essential lifeline for people with SUD working towards recovery. Yet surveillance and punishment are embedded into SUD treatment through the numerous constraints placed upon clients because of the role of institutional referral sources in treatment, such as the criminal legal system, the FRS, social services, and others. Studies suggest that roughly 25% of clients in publicly funded treatment were referred from the criminal legal system as a condition of their probation, parole, or drug court program [ 135 ]. This has led to therapeutic jurisprudence: the belief that the criminal legal system can support and facilitate efforts towards rehabilitation using the threat of incarceration [ 136 ]. Another 25% of clients are referred to treatment by other sources, including the FRS, social services, schools, and employers [ 133 ]. Criminal legal controls such as those from the courts, or formal social controls such as those from the other aforementioned institutions, coerce clients to either comply with treatment or face other harsh consequences, like incarceration, the termination of parental rights, or losing public benefits [ 137 ].

Treatment providers monitor client compliance and abstinence by conducting and observing routine urine drug tests, and providers are often in regular contact with referral sources about client progress in treatment. Any drug use or negative progress reports can be used as grounds to sanction those on probation, parole, or in drug court which can lead to incarceration and, in cases of drug courts, longer sentences than if participants had accepted a jail sentence [ 136 ]. Clients referred by other sources can also face ramifications for positive drug tests or treatment non-compliance, impacting child custody hearings as well as their ability to secure certain social services and resources, stay enrolled in school, or remain employed.

Referral sources influence the type of care that clients receive in facilities, including evidence-based treatments. Research suggests that only 5% of clients with opioid use disorder (OUD), who were referred to treatment from the criminal legal system, received either methadone or buprenorphine, compared to nearly 40% those who were not referred by the system [ 138 ]. This represents an extension of a broader problem within the criminal legal system wherein access to these gold standard medications for OUD is almost nonexistent in most jails and prisons across the U.S [ 139 ].

Drug war logic is also deeply rooted in the restrictions for prescribing and dispensing methadone and buprenorphine since they are controlled substances under the oversight of the Drug Enforcement Agency, a federal law enforcement entity. When taken in effective doses, these life-saving medications can cut the risk of overdose and all-cause mortality dramatically among people with OUD [ 140 ]. However, due to tight federal restrictions and guidelines for these controlled medications, patients can be subjected to routine drug testing, counselling requirements, daily clinic visits, and observed or highly monitored medication dispensing. Patients deemed non adherent to medications or who test positive for other drugs can then be subjected to dose reductions, required to attend treatment more frequently, or even terminated from care altogether [ 141 ]. The tight restrictions on both methadone and buprenorphine, combined with the oversight of the DEA, create obstacles for prescribers and stigmatise these medications by conveying that they cannot be used like other medications in routine healthcare [ 142 ]. These policies have also contributed to striking racial disparities in who receives buprenorphine versus methadone due to costly co-pays and insurance coverage issues [ 143 ]. Studies also suggest that the DEA’s involvement in monitoring buprenorphine has made pharmacies reluctant to stock the medication or to dispense it to patients for fear of triggering an investigation [ 144 , 145 ]. Ultimately, it is estimated that only 10% of all people with OUD receive these medications [ 146 ].

Providers can take steps to extract the drug war from our substance use treatment system, through their conscious and judicious documentation of treatment progress since those records could be used by criminal legal and other referral sources in decisions about clients and their families. In addition, eligible buprenorphine prescribers should begin prescribing to patients and join advocacy efforts to change policies to expand access to buprenorphine and methadone through looser restrictions.

Healthcare system

People with SUDs often have high rates of co-occurring medical needs requiring treatment, including psychiatric disorders, infectious diseases, and other chronic health conditions. However, research suggests that people with SUDs are often deterred from seeking healthcare to address their medical needs due to prior negative and stigmatising experiences with providers, and that having experienced discrimination in healthcare is associated with greater risk behaviours, psychological distress, and negative health outcomes among people who use drugs [ 147–149 ]. Some of these challenges are due to a lack of training on how to work with patients with SUDs, in addition to pre-existing personal biases and stigmatising views held by healthcare professionals, which impacts the type of care they provide [ 142 ].

The widespread use of drug testing in healthcare settings also creates ethical challenges and conflicts for providers and patients since results are often entered into the electronic health record (EHR). While EHRs are typically thought of as beneficial and intended for greater transparency and access, they also pose challenges surrounding patient privacy, confidentiality, and autonomy; they can, therefore, make patients reluctant to disclose drug use or consent to drug testing [ 150 ]. For instance, medical records that include drug test results, can be accessed by a wide variety of actors in the medical system, subpoenaed for court, and used in future medical decision making without the patient’s knowledge or consent. Providers might not receive adequate training to weigh the need for these tests as part of treatment adherence monitoring with the potential social or legal ramifications of these tests for the patient. Patients might also not be adequately informed of these potential consequences prior to testing.

Universal drug screening and testing in obstetric and gynecological care is an example wherein testing intersects with the role of most healthcare providers as mandated reporters. Mandated reporting for suspected child abuse or neglect due to parental drug use is purported to protect the foetus or children in the parents’ custody, yet this can often be a deterrent for patients to seek medical treatment altogether if they believe that they may lose their children or be subject to other mandates. The racial and class disparities in how such testing is used, as well as the punitive measures used against families, have been noted earlier in the text but is a compelling reason for healthcare providers to consider making recommendations for counselling or supportive case management in order to address family challenges.

Healthcare providers need more training and resources to work with patients with SUDs to ensure that they are engaging them in evidence-based treatments and treating their complex medical needs while avoiding some of the lifelong and harmful ramifications that can occur when drug testing, health records, and mandated reporting deter patients from seeking and receiving care.

Because of the social, economic, and health effects of drug policies, the work of ending the drug war cannot be situated within criminal legal reform efforts alone. The drug war and a punitive drug war logic impact most systems of everyday life in the U.S., subjecting people to surveillance, suspicion, and punishment and undermining key SDOH, including education, employment, housing, and access to benefits. Combined, these have resulted in poorer health outcomes for individuals, families, and communities, particularly for people who use drugs. These policies and practices, while race-neutral as written, are not [ 151 ]. The targeted effects on people of colour further entrench health and economic disparities. As the public and policymakers call for a health approach to drug use, it is vital to recognise how systems meant to care and support are often unable to serve their intended purposes; rather than help people who use drugs or are suspected of using drugs, they frequently punish them.

In their day-to-day practice, healthcare professionals must understand the deep roots of the drug war as well as their role in both perpetuating and undermining drug war logic and practices. Healthcare providers can treat people who use drugs with dignity, respect, and trust and ensure that healthcare and treatment decisions are made in partnership with individuals. Medical professionals can also work to situate drug use within a larger social and economic context [ 152 ], understanding that drug-related harms often stem from lack of resources – like housing and food precarity, economic insecurity, and insufficient healthcare – rather than from drugs themselves. Treatment need not be the only antidote for people who experience drug-related harms but should be one option among an array of health services, resources, and support.

At the mezzo- and institutional levels, healthcare providers can advocate to shift hospital and programmatic policies around drug testing, mandatory reporting, and collaborations with law enforcement. As outlined in this paper, drug testing is not an effective monitoring strategy for care and support, but rather, it is more often a punitive tool of surveillance. If drug testing cannot be eliminated, at the very least, patients should have the right to understand the implications of drug testing and provide explicit consent for the test. To the extent possible, providers should not share private patient information with police or state agencies. Healthcare professionals should understand the implications of reporting positive drug tests and suspicion of use and should work to change these policies where possible and inform their patients of them. Providers can ensure that their patients who use drugs have access to evidence-based, non-coercive harm reduction and treatment options in addition to robust and supportive primary healthcare. Healthcare professionals involved with medical education and licensure can work to ensure that all students graduate with a deep understanding of SDOH and the impact of the drug war on individual and community health.

Finally, healthcare providers can get involved with policy-level changes to end drug testing, mandatory reporting, zero-tolerance policies, coerced treatment, and denial of services and resources based on arrest or conviction records at the municipal, state, and federal levels. Providers can follow the leadership and expertise of people who use drugs, some of whom have organised themselves into user unions [ 153 ]. Policy advocacy can include drafting and joining sign-on letters, delivering expert testimony, speaking to media, writing op-eds, and lobbying medical professional organisations to release policy statements. Providers, who see firsthand the consequences of the war on drugs, are well positioned to be effective advocates in undoing these harmful policies that have for too long undermined key SDOH [ 154 ]. In order to improve individual and collective health, healthcare providers should resist drug war logic and work to transform these systems so they can truly promote health and safety.

For the purposes of this paper, we are using the term “Family Regulation System,” coined by Emma Williams and used by other scholars, instead of the more commonly used term “Child Welfare System” to reflect the fact that, particularly for low-income families and families of color, state intervention often occurs in order to regulate their families rather than to prioritize the welfare of the entire family unit, of which the child is a part.

Authors contribution

All authors (AC, SV, JN, KF) were involved in the conception and drafting of the paper, revising it critically for intellectual content; and the final approval of the version to be published. All authors agree to be accountable for all aspects of the work.

Disclosure statement

All authors are employed by the Drug Policy Alliance, a non-profit policy advocacy organisation. No other interests to disclose.

Data availability statement

The views expressed in the submitted article are those of the authors.