President Donald Trump declared opioid addiction and overdoses a public health emergency on Thursday. Is this announcement a victory for public health?
Trump is directing federal health officials to remove a few regulations that create barriers to addiction treatment. However, experts on the front lines of the opioid crisis say his "emergency" plan does not go nearly far enough to expand access to crucial medicines and health care services, especially for poor and criminalized people.
"There is nothing desirable about drugs; they are bad," Trump said on Thursday.
In an address announcing the plan, Trump repeated decades-old themes of the war on drugs, pledging to crack down on immigration and illegal drug use and sales in order to build a "drug-free society." This effort will include a "massive" advertising campaign targeted at young people, even though similar anti-drug campaigns have proven largely ineffective in the past. As Truthout has reported, social stigma, racist policing and mass incarceration resulting from the war on drugs have exacerbated opioid problems across the country.
"There is nothing desirable about drugs; they are bad," Trump said on Thursday.
The president also hailed drug courts, which coerce people suffering from opioid disorders into treatment after they are arrested and facing jail time. Critics say drug courts embolden judges with no medical experience to make crucial medical decisions that should be made by patients with the support of their doctors. Advocates also emphasize that people should not be criminalized for drug use or addiction in the first place.
In the past, Trump made statements indicating he would declare the opioid overdose crisis a national emergency, which could have unlocked large sums of the same federal emergency management funds use for natural disaster relief. Instead, he declared a public health emergency, allowing the Department of Health and Human Services to tap into an emergency fund with only $57,000 left in it.
"Studies show that only 1 in 10 people with addiction can receive the treatment that they need -- a statistic we would not find acceptable for any other disease," said Leana Wen, the public health commissioner of Baltimore, a city hard-hit by opioids and overdose deaths, in a statement. "The president needs to announce a specific dollar amount for new funding, not repurposed dollars that take away from other key health priorities."
Wen spearheaded a groundbreaking initiative in Baltimore, expanding access to the overdose reversal drug naloxone. The program is saving lives, but her department is running out of money to purchase naloxone, forcing public health workers to ration doses of a key medication in the fight to prevent overdose deaths. She called on the White House to use its full federal authority to negotiate prices with the drug's manufacturers, which have increased the price of naloxone in order to maximize profits.
The White House, however, has punted the funding question to Congress, promising to work with lawmakers to carve out funds for expanding addiction treatment and prevention programs in the already highly contentious budget package by the end of the year. Advocates on the front lines are also turning to Congress, because Trump's initiatives do not support the expansion of certain public health strategies that are proven to reduce the harms of drug use and prevent overdose deaths.
"The actions announced by the White House today make one thing clear: Real solutions will need to come from Congress," said Daniel Raymond, policy director at the Harm Reduction Coalition, in an email to Truthout.
However, the Republican majority in Congress has an agenda that could undermine efforts to expand addiction treatment. House Republicans on Thursday passed a Senate-approved budget resolution that outlines $1.3 trillion in cuts to Medicaid and healthcare subsidies for lower-income people over the next decade in order to pay for massive tax cuts for the wealthy. Medicaid has made addiction treatment more affordable for millions of people, but Trump and other Republicans have spent months trying to roll back expansions to the program as part of their effort to repeal the Affordable Care Act.
Democrats in Congress were quick to point out the hypocrisy, both in the GOP's plan for Medicaid and the president's budget. In a statement, Sen. Pat Leahy (D-Vermont), vice chair of the Senate Appropriations Committee, said there is no new funding behind Trump's "empty words" on the opioid crisis, and the White House is attempting to take credit for $1 billion in opioid funding approved by Congress last year.
"In fact, the President's fiscal year 2018 budget would reduce funding for the opioid epidemic by $97 million," Leahy said, adding that the appropriations committee has not taken up the proposed cuts.
"We have a critical gap in lifesaving medication-assisted treatment that can support recovery and reduce overdose risk."
As part of his opioid response plan, Trump is allowing the Department of Labor to issue dislocated worker grants to help workers "displaced from the workforce because of the opioid crisis," but Leahy said the president's budget would cut funding for the emergency dislocated worker program by $500 million, or 40 percent, in 2018.
Trump's emergency plan does take some limited steps to expand access to opioid addiction medication and treatment, reflecting some of the draft recommendations drawn up by a presidential commission headed by New Jersey Gov. Chris Christie.
A presidential memorandum directs federal health officials to grant waivers allowing states to circumvent a decades-old rule prohibiting federal Medicaid dollars from paying for inpatient services at rehabs and mental health facilities with more than 16 beds. It will also shift resources in federal HIV/AIDS programs to provide eligible participants with addiction treatment.
The order also loosens regulations around telemedicine services, allowing people in rural areas to receive prescriptions for certain addiction medications remotely. Currently, federal law requires doctors to receive training and a special federal waiver to prescribe the opioid addiction medication buprenorphine, forcing people in some parts of the country to travel hundreds of miles to find a doctor who can prescribe the drug.
Trump's order does nothing to loosen or waive these rules, which also cap the number of patients to whom doctors can prescribe buprenorphine. Buprenorphine acts like an opioid in the brain to reduce cravings and withdrawal symptoms and has some potential for misuse, but critics point out that there are no such restrictions on prescribing the painkiller opioids fueling high rates of addiction. Methadone, another "medication-assisted treatment" used to treat addiction, is also subject to regulations that limit its availability in hard-hit areas.
"We have a critical gap in lifesaving medication-assisted treatment that can support recovery and reduce overdose risk," Raymond said. "Congress needs to take action to remove regulatory and statutory barriers to broader prescribing and mandate adequate access through health clinics and treatment programs receiving federal funds."
Kevin Fiscella, a professor of public health at the University of Rochester and a member of the American Society of Addiction Medicine, said the Trump administration should push to lift restrictions on prescribing these medication-assisted treatments, or at least provide incentives and mandates to ensure that as many doctors as possible are able and willing to prescribe them.
Trump did not mention "harm reduction" even once in his speech. One initiative he did mention: his proposed wall.
"This is critical if the original law is not changed or waived," Fiscella told Truthout. "Without these steps, the shortage of prescribers will persist."
Fiscella said that access to buprenorphine and other drugs used to treat addiction must also be expanded in jails and prisons. Incarceration interrupts treatment regimens and causes people with opioid disorders to lose their drug tolerance, which is a major reason why the risk of fatal overdose skyrockets for patients recently released from jail or prison. The federal prison system could lead by example and provide such medications, but a recent Truthout investigation found that an Obama-era effort to do just that fizzled by the time Trump took office.
In fact, in late July, Trump's opioid commission called for expanding access to medication-assisted treatment in jails and prisons, but like a number of draft recommendations the commission released earlier this year, the White House has yet to propose anything specific on that front. The commission will be submitting its final report next week, and Trump indicated that the White House may take further action on those recommendations but did get into specifics.
Raymond said advocates and public health workers on the front lines "desperately" need more support from leaders in Washington for harm-reduction programs, including syringe exchange and supervised injection facilities. Despite an ever-growing body of evidence that these services stem the spread of disease and prevent fatal overdoses, Trump did not mention "harm reduction" even once in his speech.
One initiative Trump did mention: his proposed wall on the Mexican border, which he said would stem the flow of heroin into the country. However, experts say drug traffickers have plenty of tricks for getting around a wall, and the Drug Enforcement Administration reports that heroin is most commonly smuggled in vehicles through border crossings. Trump's opioid commission made no mention of a border wall in its recommendations.