Our findings have several policy and public health implications. Notably, our results indicate that the illegal behaviors in which persons with POUD have become increasingly likely to engage are consistent with the motivation to maintain their use disorder. Our finding that persons with POUD have become increasingly likely to sell illicit drugs, coupled with the finding that they have become more likely to buy opioids from friends and family, are relevant to recent policy debates regarding increased severity of legal punishment for illicit drug selling (24). Our results suggest that for persons with POUD, illicit sales are becoming increasingly likely to occur among friends and family, and that persons with POUD are increasingly likely to sell illicit drugs. The latter result raises the larger issue of whether some persons with POUD would be better served by effective addiction treatment instead of increased legal punishments. Indeed, the United States spent 7.7 billion dollars on justice system costs related to POUD in 2013; less than half of this amount was spent on POUD treatment (35).
