It’s no secret that opioid misuse has risen to the level of an epidemic. On November 1, 2017, the President’s Commission on Combating Drug Addiction and the Opioid Crisis, appointed by President Donald Trump last March, released its long-awaited recommendations on how best to tackle the nation’s opioid crisis.
The stakes have never been higher. Preliminary data indicate that in 2016, 64,000 people—more than the combined number of people killed by gun homicide and in car accidents in 2015—succumbed to drug overdoses. In most of these cases, opioids were involved. Natural and semisynthetic opioids were linked to more than 14,400 overdose deaths, while synthetic opioids other than methadone, which is often used in treatment, contributed to more than 20,100 fatalities. Heroin contributed to roughly 15,400.
Even so, President Trump drew sharp criticism last Thursday when he declared the opioid epidemic a nationwide public health emergency—a designation that does little more than shift grant money away from other public health needs, such as combating HIV/AIDS, and lift some red tape. Indeed, the declaration freed up just $57,000 from the Public Health Emergency Fund to go toward tackling opioid misuse, which is half the amount that the city of Middletown, Ohio, could spend on naloxone—a life-saving opioid antagonist that reverses overdoses—in a single year. Trump also highlighted a discredited tactic—essentially telling people to “just say no” to drugs—that has historically failed to mitigate drug use, betraying what is at best his own ignorance around the risk factors that lead to substance misuse.
The opioid commission’s 56 recommendations, by contrast, are largely productive, including proposals to remove barriers to treatment, improve primary prevention strategies, and increase access to the lifesaving opioid antagonist naloxone. It’s worth noting that there are also several more troubling proposals, including harsher sentences for fentanyl trafficking and recommendations that could shortchange the needs of people experiencing chronic pain. And the potential positive effects of the other recommendations are undermined by President Trump’s broader agenda, which seeks to rip away substance abuse treatment from those who need it, exposes people to increased economic insecurity—a key risk factor for opioid misuse—and doubles down on failed policies from the past war on drugs.
Opioid use disorder is nearly impossible to surmount without access to health care—which is under threat
The most critical component of recovery from opioid use disorder is substance abuse treatment—but President Trump and the congressional majority have sought to dismantle the very changes to the health care system that expanded access to such care for millions of people. Prior to the Affordable Care Act (ACA), individual market insurers were not required to provide coverage for addiction treatment programs. As a result, approximately one-third of people who bought insurance on the individual market lacked the care necessary for recovery from opioid use disorder. Today, such care is an essential health benefit—that is, insurers are legally required under the ACA to cover, and thus make affordable and accessible, behavioral and mental health treatment, as well as substance use treatment. Although efforts to repeal the Affordable Care Act have failed to date, three weeks ago, President Trump issued an executive order that permits insurers to create health care plans that exclude those essential health benefits. And in late October, the administration issued a proposed rule that, if finalized, would allow states to dramatically hollow out their plans’ essential health benefits.
Medicaid is also facing various attacks, including a possible rollback of the expansion. As the nation’s largest payer for substance misuse services, Medicaid—which offers health insurance to 68 million low-income individuals and people with disabilities—is of tremendous importance for those with opioid use disorder. Thanks to the Medicaid expansion, nearly 100,000 people with opioid use disorder have health insurance, and from 2013 to 2015, the states that expanded Medicaid saw the proportion of uninsured people hospitalized for substance abuse or mental health disorders decline sharply from 20 percent to 5 percent. What’s more, in expansion states, there was a 70.1 percent increase in buprenorphine prescriptions per enrollee. In West Virginia and Ohio—two of the states that have borne the brunt of the opioid epidemic, with 4,035 drug overdose deaths in 2015—Medicaid pays for 45 percent and 50 percent, respectively, of buprenorphine—a vital medication-assisted treatment used for opioid addiction for tens of millions of people.
In addition to ending the Medicaid expansion, President Trump and congressional Republicans have sought to enact billions of dollars’ worth of additional cuts to Medicaid over the next decades by capping federal support of the program, as well as imposing work requirements and putting forth other proposals that fundamentally undermine the program and translate into coverage losses. Simply put, Medicaid has delivered critical opioid use disorder treatment to those who need it, but President Trump and his colleagues in Congress aim to end the current program as we know it.
Trump’s economic agenda will worsen unemployment and economic hardship, key risk factors for opioid use disorder
While the opioid epidemic has struck nearly every corner of the country—from densely populated cities to suburban and rural areas—it has taken a disproportionate hold in areas where economic anxiety runs high. Research reveals several major risk factors associated with addiction, including childhood trauma, mental illness, and economic insecurity. Indeed, unemployment and material hardship are associated with opioid misuse; individuals who earn less than $20,000 per year are 3.4 times more likely to be addicted to heroin than are those with an income of $50,000.
Yet President Trump has taken steps that actively undermine people’s economic security and access to opportunity. Through an executive order earlier this year, Trump opened the door to low-quality, underpaid apprenticeship programs, though well-compensating programs that provide robust training have historically been a proven pathway to economic mobility. On top of that, he has sought enormous cuts to Workforce Innovation and Opportunity Act programs that may leave up to 571,000 people without access to critical employment services.
President Trump’s agenda will harm all parts of the country, including the nation’s rural regions, where the opioid epidemic has hit particularly hard. His budget proposal seeks to eliminate the Manufacturing Extension Partnership—a move that the Center for American Progress estimated will result in 41,000 fewer jobs —as well as the Community Development Block Grant, the Appalachian Regional Commission, and the Delta Regional Authority, all of which support economic development.
The commission’s recommendations are at odds with the administration’s backward tough-on-crime policies
The nation cannot arrest its way out of the opioid epidemic. As a recent Center for American Progress column makes clear, “Substance use disorder is a public health issue, not a criminal justice issue.” Nevertheless, the U.S. Department of Justice (DOJ) is renewing the war on drugs—an effort that even the conservative Cato Institute agrees is not only ineffective but also leads to higher rates of overdose deaths.
The draconian policies of the Reagan era imposed mandatory minimum sentences and a heavy reliance on incarceration to fight the prevalence of drugs. Earlier this year, Attorney General Jeff Sessions compounded the damage when he issued a memo directing DOJ prosecutors and staff to “charge and pursue the most serious, readily provable offense,” doubling down on arrests for drug offenses. Drug offenders already account for nearly 50 percent of federal prisoners. Sessions’ directive ignores the evidence from experts. As a recent Pew Charitable Trusts analysis indicated, there is no relationship between drug imprisonment and any significant decrease in drug misuse.
The DOJ’s current policies are antithetical to the goal of combating substance use disorder, a fact that Congress and the administration must recognize if they hope to make real progress. A smarter approach would not only include but also emphasize effective, data-driven strategies such as diversion programs and harm-reduction and overdose prevention programs. Policymakers can and should focus on providing comprehensive public health models to provide treatment. Although the recommendations from the president’s commission largely align with such approaches, DOJ policy directives will drown them out and reduce their efficacy.
The crisis of opioid misuse is complex, spanning the health care system, the economy, the criminal justice system, and beyond. Combating the opioid epidemic necessitates a comprehensive public health approach that goes beyond lip service and looks at substance abuse holistically. While the recommendations of the opioid commission are largely reasonable, the Trump administration’s wider agenda would undermine any positive steps to combat substance use disorders in U.S. communities.
Eliza Schultz is the research assistant for the Poverty to Prosperity Program at the Center for American Progress. Lea Hunter is a special assistant for Progress 2050 and the Criminal Justice and Executive teams at the Center.