President Donald Trump promised as a candidate to “spend the money” to address the opioid epidemic, which is now the deadliest drug overdose crisis in US history. In his first State of the Union speech in 2018, Trump said his administration “is committed to fighting the drug epidemic and helping get treatment for those in need.”
But two years into Trump’s time in office, heading into his second State of the Union speech on Tuesday, he hasn’t kept those promises.
When Trump took office in January 2017, 2016 had just hit a record with drug overdose deaths at nearly 64,000. By Trump’s first State of the Union speech in 2018, the US had hit another record: In 2017, there were more than 70,000 drug overdose deaths. Based on preliminary data as of June 2018, that year was on track to hit 70,000 overdose deaths as well. About two-thirds of those overdose deaths involve opioids.
Drug overdose deaths now kill far more people each year than car crashes, gun violence, or HIV/AIDS ever did. The Centers for Disease Control and Prevention (CDC) said that overdose deaths were in part to blame for the drops in annual life expectancy in the past three years.
The US has been notoriously slow to respond to a health crisis before. With HIV/AIDS, the slow response to the crisis led to tens of thousands of unnecessary deaths. But Congress did eventually enact the Ryan White CARE Act, which effectively guaranteed treatment to those with HIV/AIDS, and other programs — dedicating tens of billions of dollars over years to a huge public health problem.
The opioid crisis is now killing far more people each year in the US than HIV/AIDS ever did. Yet Trump has mostly acted on the margins.
Experts have described the legislation he has signed to tackle the epidemic as “simply tinkering around the edges” and insufficient in terms of funds. After Trump declared an emergency over the opioid crisis, a government watchdog agency found the declaration didn’t lead to much actual policy change.
Instead, Trump has spent much of his time focusing on building a wall at the US-Mexico border, in part to stop the flow of illegal drugs like heroin and fentanyl. But experts have long said that a wall wouldn’t do much, if anything, to stop drugs from pouring into the US.
The opioid epidemic, despite Trump’s talk, has not been a priority for him. On the White House’s website, there are five categories to navigate through: the economy, national security, budget, immigration, and opioid crisis. In a telling symbol of the issue’s place on Trump’s agenda, only the opioid crisis section hasn’t received an update in almost a year.
The White House did not respond to a request for comment.
What Trump did about the opioid crisis in 2018
Prior to 2018’s State of the Union speech, experts and advocates told me that Trump’s first year in office had amounted to “a lot of talk, little action” when it came to the opioid crisis. Since then, Trump and Congress have taken some minor steps to address the epidemic — but not much more.
The most notable step was allocating $3 billion more a year toward the crisis. This money is mainly for addiction treatment, which remains in short supply in the US. According to the 2016 surgeon general’s addiction report, only about 10 percent of people with a substance use disorder get specialty treatment — in large part due to a lack of access to care. Experts argue that the US needs to invest tens of billions of dollars into addressing this gap.
Trump and Congress also passed the Support for Patients and Communities Act, which takes some positive steps to increase access to addiction treatment, scale back the overprescription of opioid painkillers, and encourage more people to carry the opioid overdose antidote naloxone. But the law doesn’t allocate significant new money to address the crisis.
As Keith Humphreys, a Stanford drug policy expert who worked on the legislation, told me, “This reflects a fundamental disagreement between the parties over whether the government should appropriate the large sums a massive response would require. Lacking that, Congress did the next best thing — which is to find agreement on as many second-tier issues as they could.”
Shortly after getting into office, Trump also appointed a commission to study the opioid crisis and make recommendations. One proposal that the commission came up with was to declare an emergency over the epidemic. Trump did this with a lot of fanfare in October 2017, holding a press conference in which he claimed that “the number of drug users and the addicted will start to tumble downward over a period of years.”
But a report by the Government Accountability Office found that about a year later, Trump’s administration had only used the declaration to clear some paperwork requirements for a survey, expedite two states’ opioid crisis programs, and speed up some research.
The Trump administration has said that it did what it could with the emergency declaration, which ended up fairly limited in scope. But one of the things that experts told me when the emergency was first declared is that it could allow for a big public awareness effort — one that shined a light on the opioid crisis, and rallied everyone, from lawmakers to health care institutions to the public, into action.
The Trump administration hasn’t really taken advantage of that. The last time Trump talked much about the opioid epidemic, outside the context of his proposed wall at the US-Mexico border, was in March 2018, when he made a bizarre speech that focused almost entirely on using the death penalty on drug traffickers and dealers (which is unlikely to happen or do much to stop the crisis).
Similarly, Trump has at times invoked the opioid crisis to make the case for his wall. But this, too, would be ineffective, in large part because most illicit drugs come through legal ports of entry, not via the illegal border crossings that a wall would attempt to stop.
Trump has also continued calling for the repeal of Obamacare. This would hurt access to addiction treatment: A previous analysis, from researchers at Harvard Medical School and New York University, found that without Obamacare an additional 220,000 people with opioid use disorders would lose insurance coverage to pay for treatment. Nothing that the administration has done or called for, not in its National Drug Control Strategy or elsewhere, would make up for such a massive increase in the treatment gap.
Trump needs to go bigger
The big problem is Trump and his administration simply aren’t thinking big enough.
The opioid epidemic is a truly massive crisis. Since the 1990s, more than 700,000 people in the US have died of drug overdoses, mostly driven by the rise in opioid-related deaths. That’s comparable to the number of people who currently live in big cities like Denver and Washington, DC. Some estimates predict that hundreds of thousands more could die in the next decade of opioid overdoses alone.
When experts talk about the current epidemic, they compare it to previous public health crises like HIV/AIDS, which also killed tens of thousands of Americans each year.
“To actually stem the tide of overdose deaths, we need funding and innovation that is on par with our response to HIV/AIDS,” Sarah Wakeman, an addiction medicine doctor and medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, previously told me. That, she explained, will require “a massive infusion of funding and a fundamental restructuring of how we treat addiction in this country.”
The New York Times last year asked 30 experts how they would spend $100 billion over five years to address the opioid epidemic — a number comparable to how much the US spends domestically on HIV/AIDS. That may sound like a lot, but some experts cautioned that even that amount of cash may not be enough.
That’s in large part because a lot of America’s addiction treatment infrastructure is in a very bad spot.
Federal data suggests that only one in 10 people with any substance use disorder and one in five people with an opioid use disorder seek specialty treatment. Even when an addiction treatment clinic is available, fewer than half of facilities offer any of the opioid addiction medications, such as methadone or buprenorphine, as an option, even though the medications are widely considered the gold standard for opioid addiction treatment. In other words, treatment is inaccessible enough that most people who need it don’t get it, and even when treatment is available, it doesn’t meet the best standards of care.
To change this, Congress will need to invest much more, and for the long term. In response to the HIV/AIDS crisis, for example, Congress set up the Ryan White program to provide long-term, sustained resources to deal with HIV/AIDS, particularly in the worst-hit communities. Unlike the limited-time grant money that lawmakers have allocated for the opioid crisis so far, the Ryan White funding is something that people on the ground know they can rely on for years to come.
Some lawmakers have called for similar actions in response to the opioid crisis, like the CARE Act proposed by Rep. Elijah Cummings (D-MD) and Sen. Elizabeth Warren (D-MA). But these proposals have not moved forward in Congress, largely due to Republican concerns about the extra spending.
Even beyond money, experts argue that a truly effective bill will have to systemically reform how America approaches addiction.
Leana Wen, formerly Baltimore’s health commissioner and now president of Planned Parenthood, previously drew a comparison to past disease scares, such as Ebola and Zika. These crises led hospitals and doctors, with government support, to retrain and restructure so they were properly built to handle any patients that came in with potential problems related to these diseases.
“We are now dealing with an epidemic of opioid overdose and addiction,” Wen said. “Why shouldn’t we require all doctors and all hospital systems to treat the disease of addiction?”
Some states have provided a model for this systemic reform. Vermont, for one, set up a hub and spoke system that not only expanded addiction treatment but also integrated it into health care settings, from traditional doctors’ offices to hospitals. Perhaps as a result, the state has seen its drug overdose death rates stabilize and fall in recent years.
As experts have long told me, there is no silver bullet that will solve the opioid epidemic overnight, but there’s a mix of policies that would help: more treatment (particularly medications like methadone and buprenorphine), more harm reduction (such as better access to naloxone), fewer painkiller prescriptions (while ensuring the drugs are available to those who really need them), and policies that can help address the root cause of addiction (like mental health issues and socioeconomic despair).
A recent study by Stanford researchers found that a mix of these options could save at least tens of thousands of lives in the next decade.
But Trump hasn’t embraced the full approach. He hasn’t called for putting tens of billions of dollars toward treatment infrastructure. He hasn’t taken advantage of all the tools at his disposal, like his own emergency declaration. When he has spoken about the crisis, he has done so to advocate for ineffective policies such as the wall and expanded use of the death penalty.
So whatever promises Trump makes about the opioid epidemic in this year’s State of the Union address, they seem likely to end up as empty words.