Project LEAD: Laws to End Abuse and Diversion

Project LEAD is a three-state study examining the role that law and policy has on illicit opioid use and the transition to use of heroin and fentanyl, as well as the transition to injection drug use. Using data collected from in-depth interviews with active drug users and individuals working in substance use related fields, as well as survey data collected from active drug users, Project LEAD hopes to understand how law and policy directly impacts illicit opioid use. Understanding the unintended consequences of law and policy can help guide local interventions, overdose response, and help policy makers better understand the impact of laws they are passing.
Project LEAD_Intro

Specific Aims of the Project

1.) Identify state laws and policies designed to decrease opioid misuse and diversion in order to establish or refute their association with transition to opioid or heroin injection or using fentanyl.

2.) Identify how local implementation of state laws and policies may contribute to the transition from nonmedical prescription opioid use to injecting prescription opioids or injecting heroin or using fentanyl.

3.) Compare local factors in urban, suburban and rural areas that affect the riskiness of injection practices such as the availability of clean syringes, diffusion of norms, injection practices and perceptions of laws to reduce opioid misuse in drug using networks and accessibility of drug treatment programs.

Dangers of Opioids

of drug overdose deaths in 2020 involved an opioid
increase in overdose deaths involving opioids since 1999
people suffered from fatal drug overdoses in the United States in 2021
Non-medical use of prescription opioids is a public health epidemic that has been growing since the 1990s. There is considerable evidence that many new heroin and fentanyl users began as prescription opioid users. As law enforcement and policy makers have identified trends and implemented interventions to curb prescription opioid diversion and use (such as Prescription Drug Monitoring Programs), many individuals turn to street drugs to help with pain or mental health issues. With the advent of fentanyl, and how cheap it is to manufacture, nearly all street drugs now contain fentanyl, which has contributed significantly to the increase in drug overdose deaths. Prescription pills being sold on the street are often fake and other non-opioid drugs such as cocaine and methamphetamine contain variable amounts of fentanyl.

About the Project

It is essential to understand the conditions that facilitate transition from oral prescription opioid use to injection of prescription opioids, heroin, and fentanyl. In response to rising rates of opioid dependence and fatal poisonings, virtually every US state has incorporated laws to reduce the availability of medical opioids for diversion. However, little research has examined the effects of these laws on the transition to injecting opioids, or using heroin, or fentanyl.

Forty-nine states have implemented prescription drug monitoring programs (PDMPs) which are state-based data collection systems that record controlled medications. However, state PDMPs differ considerably, including the extent to which physicians are required to access PDMPs before prescribing opioids. The effects of different PDMP systems on the transition to injection drug use or heroin or fentanyl use is not clear. PDMPs may make prescription opioids more expensive or harder to obtain, leading to injecting these substances to produce the same effects, or turning to heroin or fentanyl. On the other hand, decreased opioid availability may decrease initiation of non-medical opioid use and consequently decrease transition to injection, or heroin or fentanyl use.

Learn more about Prescription Drug Monitoring Programs

Other laws states have introduced to help decrease the diversion of prescription opioids include regulation of pain clinics. Medicaid and private insurance companies, that also vary by state, have implemented practices to detect “doctor shopping” and excessive prescription of opioids and to reduce prescription opioid misuse that might affect transition to opioid injection or heroin or fentanyl use. State Medicaid policies also play a role in patients’ access to and use of Medication Assisted Therapy (MAT) such as buprenorphine or methadone. Such policies may increase or reduce the accessibility of MAT and increase the probability of injection.

Finally, features of the local context may increase the probability of transitioning to injecting prescription opioids or heroin or fentanyl, and may contribute to the riskiness of injection practices including the relative price and quality of heroin/fentanyl compared to prescription opioids and the relative density and size of social networks. In some urban areas, heroin markets may be well-established and heroin or fentanyl may be less expensive relative to prescription opioids. Rural and suburban areas may not have ready access to syringe exchange programs (SEPs), sterile syringes from pharmacies or other harm reduction or prevention services such as hepatitis vaccination.

Research Focus

This research will explore the influence of laws in three different states, Connecticut, Kentucky and Wisconsin, selected to represent differences in PDMPs, Medicaid restrictions on opioid prescription, and pain clinic regulation. We will also examine the effects of the local context (drug use networks, syringe availability, harm reduction services relative price and quality of heroin) on the transition to injecting non-prescription opioids and /or heroin injection or fentanyl use in three local areas, an urban area, a smaller metropolitan area or suburb, and a rural town and surrounding county, chosen to reflect areas with higher rates of opioid prescription.

Publications and Presentations

Dickson-Gomez J., Christenson E, Weeks M, et al. Effects of Implementation and Enforcement Differences in Prescription Drug Monitoring Programs in 3 States: Connecticut, Kentucky, and Wisconsin. Subst Abuse. 2021;15:1178221821992349. doi:10.1177/1178221821992349

Dickson-Gomez, J., Spector, A., Weeks, M., Galletly, C., McDonald, Green, D. Epub ahead of print. “You’re not supposed to be on it forever”: Medication Assisted Therapy (MAT) Related Stigma among drug treatment providers and other medical professionals. Substance Abuse: Research and Treatment

Dickson-Gomez, J., Spector, A., Krechel, S*, Li, J., Montaque, H. D. G., Ohlrich, J., Galletly, C., Weeks, M. In press. Barriers to drug treatment in police diversion programs and drug courts: A qualitative analysis. American Journal of Orthopsychiatry

Dickson-Gomez, J., Spector, A., Ohlrich, J., and Christiansen, E. A systems analysis of Milwaukee’s response to the opioid crisis. Oral presentation, Contemporary Drug Problems, Prato, Italy, 09/2019.

Dickson-Gomez, J., Krechel, S*, Spector, A., Weeks, M., Ohlrich, J., Montaque, H.D.G., Li, J. In press. The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: A qualitative analysis. Substance Abuse Treatment and Research

Dickson-Gomez, J., Weeks, M., Green, D., Boutouis, S., Galletly, C., Christenson, E. Epub ahead of print. Insurance barriers to substance use disorder treatment after passage of mental health and addiction parity laws and the Affordable Care Act: a qualitative analysis. Drug and Alcohol Abuse Reports

Dobbs, J., and Dickson-Gomez, J. Rural, suburban, and urban access to sterile injection equipment and syringe services programs. Poster presentation, MCW M3 Scholarship Forum, In Person, 6/2022

Montaque, H. D., Christenson, E., Spector, A., Wogen, J., McDonald, M., Weeks, M. R., Li., J., & Dickson-Gomez, J. (2022). Mechanisms for expanding harm reduction for opioid use in suburban and rural US settings. Journal of Drug Issues. DOI:10.1177/00220426221108694.

Ohlrich, J., Dickson-Gomez, J., Christiansen, E. “Keeping people out of jail in regards to drugs is a collaborative effort”: Public health and criminal justice collaboration in Milwaukee County Adult Drug Treatment Court. Oral presentation, Contemporary Drug Problems, Prato, Italy, 09/2019

Ohlrich, J., Dickson-Gomez, J., Christiansen, E. “Keeping people out of jail in regards to drugs is a collaborative effort”: Public health and criminal justice collaboration in Milwaukee County Adult Drug Treatment Court. Poster presentation, Virtual Research Week, Medical College of Wisconsin, Virtual, 02/2021.

Spector A, Christenson E, Dickson-Gomez J. “By the time my prescription got over...I was already hooked”: A preliminary examination of women’s experiences initiating opioid misuse. Poster presentation, InWomen’s Conference, Virtual, 06/2020

Spector, A and Dickson-Gomez, J. Changes in uptake following the expansion of naloxone access laws: Perspective of key informants in Wisconsin. Oral presentation, Contemporary Drug Problems, Prato, Italy, 09/2019

Spector, A and Dickson-Gomez, J. The role of syndemic and structural factors in substance use disorder treatment-seeking among women in the United States with a history of opioid misuse: A qualitative study. Oral Presentation, InWomen’s Conference, Virtual, 06/2021

Spector A, Dickson-Gomez J. “Well, my kids always come first”: A preliminary examination of the role of children in the lives of women who misuse opioids. Poster presentation, Annual Meeting of the American Psychological Association, Virtual, 08/2020

Spector, Antoinette L., Galletly, Carol L., Christenson, Erika, Montaque, H. Danielle G., & Dickson-Gomez, Julia. (In Press). A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin. BMC Public Health.

Spector AL, Quinn KG, deRoon-Cassini TA, Young SA, O'Brien M, & Dickson-Gomez J. (2021). Syndemics and the etiology of opioid misuse among women: A qualitative study. SSM-Qualitative Research in Health, 100028.

Spector AL, Quinn KG, Young SA, O'Brien M, deRoon-Cassini TA, & Dickson-Gomez J. (2021). A qualitative examination of substance use disorder treatment-seeking among women with opioid use disorders: The role of syndemics and structural violence. SSM-Qualitative Research in Health, 1, 100014.

National Institute on Drug Abuse (NIDA) honorable mention: “Mapping Patient Journeys in Drug Addiction Treatment Challenge

Project LEAD Team


Jared M. Dobbs, MPH

Medical Student


Juan Flores

Research Associate I


Carol Galletly, JD, PhD

Associate Professor; Director, Developmental Core


Sarah Krechel

PhD Student


Jessica Ohlrich, MPA

Research Coordinator

Non-MCW Team

Margaret Weeks, Jianghong Li, Danielle Montaque, Eduardo Robles, Lucy Rohena: Institute for Community Research in Hartford, CT
Jennifer Havens, Kristen Johnson, Jane Lynch: University of Kentucky
Antoinette Spector: UW-Milwaukee