The Opioid Epidemic Demands Public Health Solutions, Not False Claims About Immigration
The drug overdose epidemic has long plagued the United States, killing more than 932,000 people in the country since 1999—and within that total, the number of opioid deaths has since increased eightfold, according to the Centers for Disease Control and Prevention (CDC). The country has faced three distinct waves of increasing opioid deaths—caused by prescription opioids, heroin, and synthetic opioids such as fentanyl—regardless of the political party in power. The most recent wave, driven by illicitly manufactured fentanyl, began in 2013 and has continued to rise since.
[L]ess than 1 out of 10 people in the United States who need addiction care get it.Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy
While the opioid epidemic is fundamentally a public health issue, right-wing voices have relentlessly scapegoated migrants for the fentanyl crisis—even though an overwhelming majority of fentanyl traffickers are U.S. citizens. Still, misleading claims about immigrants have gained traction with the American public, particularly around fentanyl. Despite a lack of evidence, a large number of Americans link the opioid epidemic to immigration. The dangerous and irresponsible tactic of treating drug overdose deaths as an immigration issue provides false hope that there is an immigration solution for a public health crisis.
Alarmingly, amid these rising overdose deaths, “[L]ess than 1 out of 10 people in the United States who need addiction care get it,” according to Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy (ONDCP). Policymakers must address the opioid epidemic as a public health crisis, not one linked to immigration, by expanding treatment for substance use disorder in addition to disrupting drug trafficking. The Biden administration has prioritized both these efforts, investing unprecedented resources in prevention, harm reduction, and treatment and recovery measures while also working to disrupt and reduce the supply of synthetic opioids into the United States. Furthermore, the continuing expansion of the Affordable Care Act (ACA) under the Biden administration has been pivotal in ensuring that public health resources critical for combating addiction are available and accessible to Americans who need them.
There is no link between immigration and the fentanyl crisis
During the Trump administration’s final year in office, there were more than 90,000 drug overdose deaths, a 31 percent increase compared with the previous year. In fact, drug overdose deaths were higher in each year of the Trump administration than in any year under the Obama administration. Yet some have blamed the rising number of drug overdose deaths in 2021 and 2022 on immigrants and the Biden administration’s border policies.
The majority of drug overdose deaths last year involved synthetic opioids such as fentanyl, which is primarily trafficked across the southern border in vehicles by U.S. citizens and legal residents, not by asylum-seekers. A Cato Institute analysis found that “fentanyl is overwhelmingly smuggled by U.S. citizens almost entirely for U.S. citizen consumers.”
The vast majority of the fentanyl seized at the southern border arrives in vehicles through legal ports of entry. According to the U.S. Drug Enforcement Administration (DEA), “Land transportation via the interstate system is the most predominant method of transporting illicit opioids.” An American Immigration Council analysis of government data found that 95 percent of all fentanyl seized by U.S. Customs and Border Protection (CBP) in fiscal year 2021 occurred at a port of entry or a Border Patrol vehicle checkpoint.
Increased fentanyl seizures are not due to an “open border” policy and are unrelated to displaced people seeking to apply for asylum under long-established immigration laws. Asylum-seekers often arrive at the border on foot with little more than the clothes on their back, and CBP agents require asylum-seekers to leave all their belongings behind, except what they can fit into a small plastic bag. In fact, displaced people seeking safety in the United States are often fleeing corruption and violence perpetrated by drug cartels in Mexico and Central America.
Trump’s approach threatened opioid treatment access for Americans
The Biden administration’s commitment to tackling the opioid epidemic as a public health crisis stands in stark contrast to the approach of the previous administration. The ACA’s coverage and treatment expansion provisions are key tools in battling the opioid epidemic, and Trump administration efforts to undermine the ACA harmed the national imperative to reduce overdose deaths.
How the ACA has helped to combat the opioid epidemic
Beginning in 2014, the ACA offered states the opportunity to expand Medicaid eligibility, allowing all adults under age 65 with family incomes up to 138 percent of the federal poverty level to qualify for Medicaid coverage. Research has indicated that Medicaid expansion had a tangible impact on reducing opioid fatalities. For example, researchers from New York University and the University of California, Davis, found that Medicaid expansion states had a 6 percent overall decrease in opioid deaths, an 11 percent lower rate of heroin-related deaths, and a 10 percent lower death rate for synthetic opioids such as fentanyl.
The ACA also improved access to opioid treatment options. Pre-ACA, coverage for treatment for substance use disorder either was not provided by private and public insurance plans or was severely restricted through high out-of-pocket costs, visit limits, or restrictions on treatment medications. The ACA mandated behavioral health coverage, adding mental health and substance use disorder to the list of required essential health benefits. It also ensured that insurance companies would provide benefits for substance use disorder treatment as they would other mental and surgical benefits.
The Trump administration’s health care cuts hurt rural and low-income Americans. President Donald Trump’s first budget reduced Medicaid funding, which provides coverage to an estimated 3 in 10 adults with opioid addiction, and cut funding for addiction treatment, research, and prevention. He released his budget in the wake of congressional Republican ACA repeal efforts that threatened to take away opioid treatment options from more than 500,000 low-income Americans, and shortly after the House passage of Republicans’ signature health care bill that would have dramatically reduced Medicaid coverage and caused “millions of Americans with drug use disorders … to suffer under the bill.”
The Trump administration also undermined the ONDCP by trying to eliminate funding for the office, froze out drug policy experts, and gave control of this national public health crisis to inexperienced political advisers. ONDCP officials noted that this turmoil hindered efforts to combat the worst opioid crisis in U.S. history.
In addition to trying to defund the ONDCP and gutting the ACA, the Trump administration diverted billions of dollars from military and counternarcotics funding for its border wall. This effort “took attention away from … drug smuggling and human trafficking.”
Medicaid expansion has helped to significantly lower opioid overdose deaths
Overall decrease in opioid deaths
Decrease in heroin-related deaths
Decrease in deaths caused by synthetic opioids such as fentanyl
Biden has taken robust actions to combat drug overdose deaths
The Biden administration has launched a comprehensive, governmentwide approach to reducing drug overdose deaths by continuing to expand access to high-quality health insurance, allocating historic levels of federal funding to create and expand treatment options, and working with neighboring countries to disrupt the production and trafficking of illicit drugs.
Expanding access to insurance coverage to fight the opioid crisis through treatment options
The Biden administration has made pivotal investments to strengthen the ACA to make health coverage more affordable and accessible. The American Rescue Plan Act (ARP), signed into law on March 11, 2021, increased the amount of and expanded the eligibility for premium tax credits for ACA coverage. The ARP helped drive ACA enrollment in early 2022 to a record high of 14.5 million and the U.S. uninsured rate to an all-time low of 8 percent. The Inflation Reduction Act, signed into law on August 16, 2022, extends the enhanced financial assistance made available by the ARP through 2025, further improving the affordability of health care for millions of Americans. In addition, the administration facilitated Medicaid expansion in Missouri and Oklahoma, expanding coverage to nearly half a million more low-income Americans.
By making health insurance accessible to low-income Americans who need it most through the ACA, millions of low-income Americans on Medicaid now have access to a wide range of treatments for substance use disorder, such as: screening and assessment, consultation, counseling, detoxification, inpatient care, intervention services, medication-assisted treatment, partial hospitalization, peer supports, physician services, and pharmacotherapy.
Investing historic levels of federal funding for prevention and harm reduction
As part of the administration’s inaugural National Drug Control Strategy, President Joe Biden’s ARP invested more than $5 billion in increasing access to mental health care and to prevent and treat opioid addiction, including more than $3 billion in grant programs for states and territories. This funding enabled the Substance Abuse and Mental Health Services Administration (SAMHSA) to increase its substance prevention funding threefold in 2021, amounting to the largest investment in primary prevention in the country’s history.
The Biden administration has invested in far-reaching opioid abuse prevention initiatives. For example, through ARP funding, the ONDCP made a historic investment in Drug-Free Communities program grants in 2021, awarding 745 local coalitions across the country more than $93 million to prevent and reduce youth substance abuse—with $81 million of this funding extending to 2022 for 645 communities. And, in 2021, the Health Resources and Services Administration (HRSA) allocated more than $104 million in grants and assistance to the Rural Communities Opioid Response Program.
Importantly, funding for the HRSA has allowed health centers to increase the number of patients receiving medication-assisted treatment. In 2021, more than 184,000 patients at these centers were being treated for substance use disorder with medication-assisted treatment, a 29 percent increase from 2019. And, combined with the U.S. Department of Health and Human Services’ work to reforming the guidelines for prescribing medications needed for treating opioid addiction, about 17,000 HRSA-funded health centers had the ability to prescribe medication-assisted treatment to treat opioid addiction in 2021—an almost 137 percent increase from 2019.
In addition to funding preventative and treatment measures, the administration has also invested in harm reduction public health measures in order to minimize the negative effects of opioid use. The ARP included nearly $30 million in grant funding for community-based overdose prevention programs and syringe services programs so that Americans battling substance use disorder can access the care they need. Additionally, SAMHSA’s Center for Substance Abuse Prevention has distributed more than 178,000 naloxone kits used to help more than 62,000 people experiencing overdoses.
The Biden administration has asked Congress to provide $42.5 billion for National Drug Control Program agencies in fiscal year 2023, a $3.2 billion increase over the fiscal year 2022 continuing resolution level. This funding would provide resources to expand evidence-based prevention, treatment, harm reduction, and recovery support services, and it would enhance efforts to reduce the supply of drugs such as fentanyl and to stop drug trafficking.
Working with regional governments to reduce the flow of illicit opioids into the United States
Key to the administration’s strategy to end the opioid epidemic is working with national, state, local, and regional partners to reduce the supply of illicit opioids that make their way across the border through transnational criminal organizations (TCOs). The administration has established the U.S. Council on Transnational Organized Crime to synchronize the national response to TCOs, and it announced the imposition of sanctions on individuals involved in the illicit international drug trade.
According to the DEA, while most of the fentanyl trafficked through international mail originates from China, Mexican TCOs are producing wholesale quantities of illicit fentanyl pills in homemade labs for distribution in the United States. These cartels, which have contributed to regional destabilization through their criminal activity and perpetration of violence, are reliant on an estimated 500,000 firearms that are illegally trafficked from the United States to Mexico every year, in large part due to lax gun laws in border states such as Texas.
In order to limit the amount of opioids entering the United States through the southern border, and to curb the crime and violence associated with the illicit transnational drug trade, the Biden administration is working with the Mexican government through the U.S.-Mexico Bicentennial Framework for Security, Public Health, and Safe Communities to promote public health, reduce transborder crime, and disrupt drug trafficking networks. Under the framework, the U.S. Department of State’s Bureau of International Narcotics and Law Enforcement Affairs (INL) has worked with Mexico to provide training to forensic chemists to better understand and identify fentanyl and its precursors for law enforcement purposes; training on dismantling high-hazard clandestine laboratories; and a legal workshop for Mexican prosecutors and chemists engaging in fentanyl-related trials. Additionally, since 2011, the INL has donated equipment and more than 400 U.S.-trained canines to Mexican entities working to disrupt fentanyl production and smuggling. These canines have helped detect and seize more than 172,000 fentanyl pills since 2019.
Similarly, since 2021, the ONDCP has also worked closely with the Colombian government to develop a holistic, bilateral counternarcotics strategy focused on disrupting and reducing the illicit drug supply, promoting rural security and development, and protecting the environment from the adverse effects of illicit drug production.
In 2021, the [DEA] seized more than 15,000 pounds of fentanyl powder, four times the amount seized in 2017 and enough to kill every member of the U.S. population.
At the domestic level, the DEA under the Biden administration has prioritized seizing drugs that have contributed to the opioid crisis. In February 2022, the DEA launched Operation Overdrive, aimed at decreasing drug-related crime and overdose deaths. Using a “data-driven, intelligence-led” approach, the DEA has surged resources to 57 locations across the United States where criminal drug trafficking networks are most active. In 2021, the agency seized more than 15,000 pounds of fentanyl powder, four times the amount seized in 2017 and enough to kill every member of the U.S. population. These actions have prevented these drugs from harming American communities.
The false narrative blaming immigrants for the opioid crisis ignores evidence-based solutions to an urgent public health crisis, harming those who are suffering from addiction, their families, and communities.
Without urgent interventions, 1.2 million people in North America are expected to die from opioid overdoses by 2029, according to a February 2022 report from the Stanford–Lancet Commission on the North American Opioid Crisis. As a commission member noted, rising death trends are linked to drivers such as the anxiety and isolation of the COVID-19 pandemic as well as continued lack of access to quality care, treatment, and prevention.
The Biden administration’s comprehensive approach to addressing the drug overdose crisis across federal agencies and in conjunction with state and local partners and foreign governments is a major step in ending the drug overdose crisis. Further efforts to stem the flow of illicit drugs into the United States and to ensure that those suffering from addiction have access to short- and long-term treatment options will require cooperation at all levels of government.
Congress must seize the opportunity to pass appropriations legislation for 2023 to significantly enhance Americans’ access to health care resources, including proven solutions to curb addiction. Furthermore, states can save thousands of lives in the years ahead by expanding Medicaid access, which was made possible by the ACA; 12 states have not yet done so. Such evidence-based measures to tackle the drug overdose epidemic are the meaningful, effective answers Americans need to tackle this growing crisis.
The authors would like to thank Natasha Murphy, Jill Rosenthal, Erin Simpson, Rachael Eisenberg, Nick Wilson, Nicole Prchal Svajlenka, Zefitret Abera Molla, and Nicole Lee Ndumele for their reviews and input.
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