More than 2 years before COVID-19, HHS declared a for . That this emergency unabated is reflected in the overdose deaths estimated to have occurred between April 2022 and April 2023, increases in , and the emerging threat of additional drugs in this crisis. The National Survey on Drug Use and Health () from the Substance Abuse and Mental Health Services Administration states that in 2022, 8.9 million Americans ages 12 and older "misused opioids (heroin or prescription pain relievers) in the past year."
The federal government and others have implemented many policies to address this ongoing , such as expanding the use of telehealth and broadening the workforce qualified to provide for opioid use disorder.
To these solutions I would suggest adding another: the Office of National Drug Control Policy (ONDCP), the Department of Justice, and other federal agencies should work with other federal and non-federal partners to reinstate and enhance the (ADAM).
Focused on assessing substance use among adult arrestees (within 2 days of their arrest/booking), ADAM data complemented other key epidemiological sources, such as the NSDUH cited above. ADAM was administered by the National Institute of Justice, part of the Department of Justice, before being in 2003. In 2007, it was taken over in a revised form by ONDCP, and then entirely for budget reasons in 2013. ADAM initially focused on results in 10 geographically diverse counties (35 sites) but was limited to five counties (10 sites) when administered by ONDCP.
As noted in the last (2013) for the ADAM project, ADAM offered an "important piece of information not available in other surveys -- a bioassay [voluntary urine specimen] that detects the recent use of each of ten different drugs -- providing the ability to validate self-reports of use." In this way, ADAM filled a relative to other major substance use-related that rely on substance use.
As the National Academies of Sciences, Engineering, and Medicine observed in a on the opioid crisis, "[t]he value of the ADAM data was evident in information on trends of illicit drugs other than marijuana, which generated strikingly different estimates from those extrapolated from the NSDUH [references omitted]. These data were useful for policy makers, law enforcement, and treatment resource planners. To date, this data source has not been replaced or reinvigorated."
Importantly, ADAM also captured data from arrestees who may have been homeless or transient, and therefore less likely to be included in NSDUH or other studies.
In a , the Brookings Institution endorsed reinstating the ADAM survey, observing that "[w]ithout the ADAM data, or something similar, it will be extremely difficult to credibly estimate the size of drug-using populations, and thus the total number of people with OUD [opioid use disorder], in the U.S." The Brookings report further notes that "the urine test results could also be very useful for monitoring the consumption of novel drugs, such as fentanyl, that individuals may not even know they are using."
Based on past expenses, re-developing ADAM or a similar survey would likely cost about $10 million per year. As the Brookings Institution report noted, the survey could be updated to include new questions, such as those about ability to obtain naloxone for overdoses. Also, rather than or in combination with urine specimens, hair or oral samples could be used as part of a revised ADAM survey's bioassay component. (Hair samples, for instance, may be viewed by some as "less invasive" and can detect use of some drugs over a period). A revised ADAM scope also could consider inclusion of additional sites or populations beyond those assessed in the past.
ONDCP's 2022 , while not calling for ADAM's revival, cited ADAM as one example of a survey that met two of the strategy's key goals: to "Establish systems to collect and analyze data on subpopulations at high risk of drug use for which data is inadequate" and to "Develop methods for identifying emerging drug use trends in real time or near real time."
The strategy notes that: "The rationale for the now-defunct ADAM was to study a high-risk population (male arrestees shortly after booking) with interviews (self-report) and a biological specimen (urine sample) to corroborate self-report. This was done at the local level because drug use patterns vary with geography, and the logistics of data collection were better organized at the local level. At present, there is no system in place to collect these data from high-risk populations, and we continue to have a blind spot in this area."
As the nation confronts the ongoing opioid crisis, working to restore ADAM or develop a similar survey is one important step to help the nation obtain additional information about substance misuse, filling a need not adequately met by other existing data sources. In light of the human toll and other of the , as well as widespread misuse of other substances, the expense of rebuilding ADAM in comparison to its potential benefits seems a relatively modest one.
Mitchell Berger, MPH, has worked on public health and behavioral health programs at the federal and local levels, including for HHS and SAMHSA. The opinions expressed are solely those of the author and should not be imputed to any public or private entities.