Like his predecessor, President Trump has promised to take bold action to address the nation's opioid crisis and overdose epidemic, but critics say his efforts to undo President Obama's signature health care law could prevent large numbers of people with opioid use disorders from receiving treatment.
Others fear that instead of expanding community access to opioid disorder treatments, the Trump administration will push poor and marginalized people into "treatment" within the brutal confines of the prison system.
With his "law and order" approach to governing, Trump is poised to reverse federal momentum on opioids, shifting the focus from public health back to law enforcement and incarceration. What could that look like, besides more drug arrests? For starters, the man rumored to be Trump's pick for drug czar, Rep. Tom Marino of Pennsylvania, has called for placing parents facing minor drug charges in a "hospital-slash-prison."
The government reports that 435,000 people in the United States used heroin in 2014 and 1.9 million had opioid use disorders stemming from prescription painkillers, but researchers say 80 percent did not receive treatment. When treatment for opioid dependence is not available, some people turn to street drugs like heroin and fentanyl, causing rates of deadly overdoses to skyrocket. Opioid-related overdoses killed 33,000 people in 2015 alone.
The Affordable Care Act (ACA) has made a dent in this problem by requiring insurance companies to cover treatments for opioid use disorder and expanding Medicaid benefits for lower-income people. However, Republicans are reportedly considering a revised health care overhaul that would gut these key ACA protections and cut Medicaid spending by $839 billion over the next decade.
The White House and House Speaker Rep. Paul Ryan failed to rally enough GOP votes behind a bill to "repeal and replace" the ACA last month, but Republicans are reportedly back in negotiations over a revised package that makes concessions to House conservatives, including provisions allowing states to opt out of key ACA requirements that protect people with pre-existing conditions such as opioid use disorders. On Tuesday, The Hill reported that Republicans were coming "close" to a deal on repealing the ACA.
A 2015 study on low-income adults in 14 states found that Medicaid expansion reduced the unmet need for substance abuse treatment by 18 percent, indicating that more people were accessing treatment or understood that they could. The number of people with substance use or mental health disorders that were hospitalized without insurance dropped by 20 percent since the ACA's implementation, according to government data.
In the states that expanded Medicaid, the number of Medicaid-covered prescriptions for the addiction-treatment medication Suboxone increased by 70 percent in 2014, according to a recent study. Suboxone is a proven treatment option for severe opioid disorders, but for years many low-income people have been forced to obtain the drug illegally due to financial barriers and severe restrictions on the number of prescriptions that doctors can hand out. The Obama administration relaxed some of these restrictions last year.
The ACA's impact is obvious in states hit hard by the overdose epidemic. After electing to expand Medicaid in 2014, Kentucky saw a 700 percent increase in beneficiaries accessing substance abuse treatment at a time when the state suffered from one of the highest rates of overdose deaths in the nation.
Under the Medicaid cuts included in the American Health Care Act -- the original Republican proposal to "repeal and replace" the ACA -- Kentucky would lose $20 billion in public health funding, and other hard-hit states could lose billions more, according to the Center for Budget and Policy Priorities. West Virginia, which had the highest drug-related death rate in 2015, would lose nearly 10 percent of its current health funding under the Republican plan.
In a letter to Congress last month, the American Association of Addiction Medicine urged lawmakers to consider how the proposed health care overhaul would affect "the millions of Americans suffering from addiction who may lose their healthcare coverage entirely."
Trump's "Law and Order" Agenda on Opioids
Despite its efforts to undermine the ACA, the Trump administration has pledged to "combat" the opioid crisis, echoing some of the language used by Obama, who moderately shifted the federal government's approach to drug-related problems.
Under President Obama and his drug czar, Michael Botticelli, the government began to frame the opioid crisis as a public health issue rather than simply a criminal one, a transition that human rights advocates say was long overdue.
Non-prescription use of opioids is still criminalized, and people continued to be imprisoned for opioid-related convictions under the Obama administration; in fact, some states enhanced penalties for selling the drugs. Obama himself supported law enforcement efforts, particularly to limit the supply of fentanyl entering the US. However, he also took key steps to increase access to substance abuse treatments, in addition to pushing the ACA through Congress.
Trump's approach to drugs has already been markedly more punitive than Obama's. Since taking office, the new president has blamed the opioid crisis on "cartels" and initiated a law enforcement crackdown on immigration and drug trafficking with a focus on the Mexican border. Now advocates fear his vague "law and order" agenda could roll back much of the progress made under Obama.
"He sees this as a crime issue that needs to be cracked down on first, and secondarily as a health issue," said Daniel Raymond, a spokesman for the Harm Reduction Coalition, a group that advocates for human rights and a public health approach to drug-related problems.
Two weeks ago, the White House launched a commission on drug addiction led by New Jersey Gov. Chris Christie, a Trump ally from a state that has long faced a high number of opioid-related challenges. The launch featured a roundtable with advocates, including Vanessa Vitolo, a young woman from New Jersey who became addicted to heroin after receiving a painkiller prescription. Vitolo was homeless and living on the streets of Atlantic City during the height of her addiction.
Trump was apparently shocked to learn that Vitolo had been a cheerleader at a private high school and a sorority member in college before developing an opioid use disorder.
"Because I'm looking at you, you're like all-American -- perfect," Trump told Vitolo. "You're a perfect person. And I'm saying it's hard to believe that you're living on the streets."
Vitolo is the face of Christie's anti-opioid campaign, appearing in online videos and commercials for his administration.
For decades, lower-income communities have struggled with opioid problems without adequate access to health care and treatment, but recently, narratives about white, middle-class lives falling apart have inspired politicians -- including conservatives -- to take some action.
Vitolo was arrested while living with an opioid use disorder. Under a new law championed by Christie, she was placed in a rehab facility under court orders instead of being sentenced to prison, a step that she credits with her recovery.
Republicans like Christie have ideas about "treatment" that are much different than the community-based, patient-centered type of care that health workers, activists and drug users themselves have long advocated. On Monday, Christie reopened a prison in New Jersey that will be the state's first "licensed substance abuse disorder treatment prison," according to a news release. Christie's position on Trump's opioid commission suggests that the prison could serve as model for the rest of the country.
Advocates have long pushed for expanding drug abuse treatment in prisons, but it's unclear if Christie's program will provide a full spectrum of treatments, including Medication Assisted Treatments such as Suboxone, which are banned in many jails and prisons. Christie's office did not respond to an inquiry from Truthout on the matter.
"A Prison Dressed Up to Look Like a Hospital"
Advocates have applauded Christie for approaching opioid disorders as a medical problem and expanding insurance coverage for treatment. But his emphasis on treating the disease with court orders and prison bars is raising concerns about what direction the self-proclaimed "law and order" president will take on opioids, particularly as the GOP looks to eliminate health coverage for large numbers of people living with substance use disorders.
Reports indicate that Rep. Tom Marino, a Republican from Pennsylvania and a Trump loyalist in the House, is set to become Trump's drug czar and replace Botticelli at the National Office of Drug Control Policy. While testifying before a House subcommittee last year, Marino suggested that parents living with substance use disorders who are separated from their children after being charged with a drug offense should be placed in a "hospital-slash-prison."
"One treatment option I have advocated for years would be placing non-dealer, nonviolent drug abusers in a secured hospital-type setting under the constant care of health professionals," Marino said. "Once the person agrees to plead guilty to possession, he or she will be placed in an intensive treatment program until experts determine that they should be released under intense supervision."
Raymond said Marino's proposal is "basically coerced treatment in a prison dressed up to look like a hospital," and it's quite similar to Christie's program in New Jersey. As Truthout has explained, uprooting people from their homes and families and confining them in a "prison-slash-hospital" is not a just or effective strategy for dealing with addiction, and such programs quickly fill up with low-income people and people of color who have few other options.
Additionally, advocates emphasize that people charged with any crime should be considered innocent until proven guilty, not coerced into pleading guilty to win their freedom and rejoin their families. Government data shows that only a fraction of people using illegal drugs are actually dependent on them, but many could end up in mandatory rehab anyway, especially if they are poor, Black or Brown, and therefore more likely to be targeted for arrest.
As for people who do have substance use disorders, advocates like Raymond would rather they receive treatment from a doctor before landing in prison, something that the ACA has helped thousands of people do by expanding access in a country where treatment for drug problems has long been underfunded and stigmatized.
"We are somehow jumping to coercion as if treatment was plentiful, high quality and easy to access," Raymond said. "[It's as if] the only failure was that people were not being forced into it, not that we don't have the capacity."
Trump's appointees on drug policy have sent some alarming signals, but the White House has yet to finalize a plan for tackling the opioid crisis. Trump's budget outline does call for $1 billion in spending to help individual states roll out public health initiatives to combat opioid problems over the next two years, but that funding was originally President Obama's idea, and Congress approved it last year before Trump took office.
Raymond said the rest of Trump's budget reveals his real priorities, which revolve around gutting funding from domestic programs to bolster military budgets and building an expensive wall on the southern border.
"As a broad signal of where this administration's priorities are in terms of spending, it is not encouraging," Raymond said.
Luckily for those receiving drug treatment thanks to the ACA, Trump's effort to "repeal and replace" still faces an uphill battle. The first attempt was a wash, and Congress is readying itself to deal with other tough issues like the federal budget. Polls show that a majority of likely voters did not approve of the Republican health care package, and three-fourths say Trump should work with Republicans to make the ACA work better instead of replacing it.
Republican are learning that it's not easy to eliminate health care benefits during a major public health crisis, a fact Democratic strategists are keenly aware of. However, the GOP still controls both Congress and White House, and its response to the opioid crisis will shape public policy for years to come. The lives of millions hang in the balance.