by cdc director thomas frieden stating that "america is awash in opioids; urgent action is critical." soon after, many state governors declared a "state of emergency" to combat the opioid epidemic in their own states, and undertook major efforts to stop it. in july 2017, opioid addiction was cited as the "food and drug administration's biggest crisis", followed by president donald trump declaring the opioid crisis a "national emergency." in september 2019, he ordered u.s. mail carriers to block shipments of fentanyl coming from other countries. in 2016, the us surgeon general listed statistics which describe the extent of the problem. the house and senate passed the ensuring patient access and effective drug enforcement act which was signed into law by president obama on april 19, 2016, and may have decreased the dea's ability to intervene in the opioid crisis. in december 2016, the 21st century cures act, which includes $1 billion in state grants to fight the opioid epidemic, was passed by congress by a wide bipartisan majority (94-5 in the senate, 392–26 in the house of representatives), and was signed into law by president obama. as of march 2017, president donald trump appointed a commission on the epidemic, chaired by governor chris christie of new jersey. on august 10, 2017, president trump agreed with his commission's report released a few weeks earlier and declared the country's opioid crisis a "national emergency". trump nominated representative tom marino to be director of the office of national drug control policy, or "drug czar". one interview in 2015 with the then director of the white house office of national drug control policy under the obama administration, michael botticelli, where he states that because opioid users are predominantly 'white and middle class', they "know how to call a legislator, fight with their insurance company." however, on october 17, 2017, marino withdrew his nomination after it was reported that his relationship with the drug industry might be a conflict of interest. in july 2017, fda commissioner scott gottlieb stated that for the first time, pharmacists, nurses, and physicians would have training made available on appropriate prescribing of opioid medicines, because opioid addiction had become the "fda's biggest crisis". trump nominated his then deputy chief-of-staff, james carroll as the acting director of the office of national drug control policy in 2018. carroll was subsequently approved by the senate in january 2019. in april 2017, the department of health and human services announced their "opioid strategy" consisting of five aims: improve access to prevention, treatment, and recovery support services to prevent the health, social, and economic consequences associated with opioid addiction and to enable individuals to achieve long-term recovery; target the availability and distribution of overdose-reversing drugs to ensure the broad provision of these drugs to people likely to experience or respond to an overdose, with a particular focus on targeting high-risk populations; strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response as the epidemic evolves; support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments, and identifies effective public health interventions to reduce opioid-related health harms; and advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, and society while also reducing the inappropriate use of opioids and opioid-related harms. the us food and drug administration (fda) has taken another approach to this epidemic: requiring manufacturers of long-acting opioids to sponsor educational programs for prescribers. the fda hoped that these educational programs would help deter off-label and overprescribing; however, it is still unclear if these programs truly have a positive effect on reducing opioid prescriptions. in march 2019, two fda specialists publicly demanded that the fda suspend new opioid approvals, alleging that the fda's oversight of opioid approvals had been dangerously deficient. in july 2017, a 400-page report by the national academy of sciences presented plans to reduce the addiction crisis, which it said was killing 91 people each day. the substance abuse and mental health services administration administers the opioid state targeted response grants, a two-year program authorized by the 21st century cures act which provided $485 million to states and us territories in the fiscal year 2017 for the purpose of preventing and combatting opioid misuse and addiction. dr. thomas frieden, former director of the centers for disease control and prevention, said that "america is awash in opioids; urgent action is critical." the crisis has changed moral, social, and cultural resistance to street drug alternatives such as heroin. many state governors have declared a "state of emergency" to combat the opioid epidemic or undertaken other major efforts against it. in july 2017, opioid addiction was cited as the "fda's biggest crisis". in october 2017, president donald trump concurred with his commission's report and declared the country's opioid crisis a "public health emergency". federal and state interventions are working on employing health information technology in order to expand the impact of existing drug monitoring programs. recent research shows promising results in mortality and morbidity reductions when a state integrates drug monitoring programs with health information technologies and shares data through a centralized platform. the substance use-disorder prevention that promotes opioid recovery and treatment for patients and communities act or the support for patients and communities act was introduced by the us house of representatives on june 22, 2018, and was advanced on june 22, 2018. the bill includes medicare and medicaid reform in order to improve treatment, recovery, and prevention efforts while also strengthening the fight against synthetic drugs like fentanyl. on september 17, 2018, the us senate approved the support for patients and communities act (h.r. 6). the committee reached a final agreement on terms of the bill on september 25, 2018. the final agreement included provisions from multiple other acts, such as the opioid crisis response act of 2018, the helping to end addiction and lessen (heal) substance use disorders act of 2018, and the synthetics trafficking and overdose prevention (stop) act of 2018. the house and the senate passed the final draft on september 28 and october 3, respectively. president donald trump signed the package into law on october 28, 2018. in july 2019, english multinational consumer goods corporation reckitt benckiser, parent of us pharmaceutical company indivior, agreed to pay $1.4 billion to the u.s. department of justice and the federal trade commission to resolve false marketing claims about the effectiveness of its opioid addiction drug, suboxone, and to resolve charges over their scheme to direct patients towards doctors who were likely to prescribe suboxone. in september 2019, president trump issued an executive order to block shipments of fentanyl and counterfeit goods from other countries, where illegal distributors were using regular mail for deliveries. while china was a focus for the action, the order included any nation where it was either manufactured or shipped from. trump claimed that the chinese government had not done enough to stop the smuggling of fentanyl manufactured there: i am ordering all carriers, including fedex, amazon, ups and the post office, to search for and refuse all deliveries of fentanyl from china (or anywhere else!). fentanyl kills 100,000 americans a year. president xi said this would stop – it didn’t. a march 25, 2020, report by propublica revealed that walmart used its political influence with the trump administration to avoid criminal prosecution for over-dispensing opioids in texas. in july 2020, indivior solutions, indivior inc., and indivior plc agreed to pay $600 million to resolve liability related to false marketing of suboxone to masshealth for use by patients with children under the age of six years old. additionally, indivior solutions pled guilty to one-count of felony information. state and local governments in response to the surging opioid prescription rates by health care providers that contributed to the opioid epidemic, us states began passing legislation to stifle high-risk prescribing practices (such as prescribing high doses of opioids or prescribing opioids long-term). these new laws fell primarily into one of the following four categories: prescription drug monitoring program (pdmp) enrollment laws: prescribers must enroll in their state's pdmp, an electronic database containing a record of all patients' controlled substance prescriptions pdmp query laws: prescribers must check the pdmp before prescribing an opioid opioid prescribing cap laws: opioid prescriptions cannot exceed designated doses or durations pill mill laws: pain clinics are closely regulated and monitored to minimize the prescription of opioids non-medically multi-state compact in july 2016, governors from 45 us states and 3 territories entered into an interstate compact titled a "compact to fight opioid addiction" organized by massachusetts governor charlie baker where they agreed to adopt the strategies for addressing the opioid epidemic modeled after the policies implemented in massachusetts. they agreed that collective action would be needed to end the opioid crisis, and they would coordinate their responses across all levels of government and the private sector, including opioid manufacturers and doctors. alabama in 2017 alabama had the highest overall opioid prescribing rate in the us. the university of alabama – birmingham has made a commitment to battle the opioid epidemic. uab's “addiction scholars program” trains health care professionals - doctors, nurses, therapists, and social workers with insights into addiction in a 15-month course. the uab school of nursing offers “nursing competency suites” with training on treating infants born to opioid-addicted mothers. the university also began an “opioid stewardship committee” to “…consistently and frequently address opioid stewardship.” opioid data for alabama indicated that, from 2006 to 2014 2.3 billion pain pills were prescribed in the state. mckesson corporation distributed 728 million of these pain pills; par pharmaceutical manufactured 713 million. the highest number of the pills went to senior care pharmacy in northport al. arizona arizona's governor doug ducey signed the arizona opioid epidemic act on january 26, 2018, to confront the state's opioid crisis. in maricopa county which includes phoenix, 3,114 overdoses were reported from june 15, 2017, through january 11, 2018. the law provides $10 million for treatment and limits an initial opioid prescription to five days with some exemptions. arizona also implemented a new strategy of prescription drug monitoring programs in 2017. since then, the number of opioid prescriptions filled has dropped nearly forty percent, while the number of opioid prescriptions written has dropped forty-three percent (king, 2018). the reductions in these numbers both show arizona going in the right direction, although, even with the decrease, the number of deaths and overdoses continue to rise. arkansas in october 2016, the state began the arkansas naloxone project, a partnership of the state drug director's office, dhs, and the criminal justice institute (cji) to allocate kits containing the nasal spray naloxone to first responders, schools, libraries, as well as drug treatment and recovery agencies to reverse the effects of opioid overdose. the project, funded by federal grants and the arkansas blue & you foundation, distributed 7,000 kits and provided training to 8,000 individuals. additionally, the drug director's office and the cji developed an app, narcansas, a free opioid overdose training vehicle that shows how to administer the life-saving antidote and provide other information about opioids and overdoses, in both english or spanish versions. the project has saved lives in almost half of arkansas’ 75 counties, with the most success in pulaski county, the state's most populated. california in california, sb 482 took effect on october 2, 2018, requiring doctors and other healthcare professionals to check the controlled substance utilization review and evaluation system, also known as cures, before issuing any opioid prescriptions. sb 1109 was signed by governor jerry brown in september 2018 (to take effect on january 1, 2019), requiring certain healthcare professionals undergo mandatory continuing education courses on the risk of addiction with opioids. in addition, this law would require outpatient pharmacies to apply warning labeling on all opioid prescription bottles cautioning patients of the risk of overdose and addiction associated with the drug. sb 1109 also targets vulnerable populations like students, requiring schools to provide students participating in youth sports or athletic programs with the cdc's opioid factsheet for patients, that again address the risks of opioid use. in 2019, the city of san francisco began a program called the drug overdose prevention & education (dope)