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Clinton wants a public health response to the opioid crisis. Trump wants more of the old drug war.

Clinton has detailed specific policies to address America’s current drug epidemic. Trump has made a couple vague promises.

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Donald Trump has called the US’s opioid painkiller and heroin epidemic "a tremendous problem." But unlike many politicians, Trump has not used the crisis as an opportunity to rethink America’s old war on drugs. Instead, Trump has vowed to double down on the drug war — promising to stop the flow of drugs at the border and crack down even more harshly on drug dealers.

Hillary Clinton, meanwhile, has a broad public health–oriented plan for the opioid epidemic. In fact, she has a plan that attempts to address not just opioids but other drugs as well, from cocaine all the way to alcohol and marijuana. It adds up to a huge proposal, costing $10 billion and with specifics detailed on Clinton’s website.

These differences matter. So far, the opioid epidemic contributed to a record number of drug overdose deaths (more than 47,000) in 2014, killed tens of thousands in the years before, and it only seems to be getting worse. (And that doesn’t count the tens of thousands more deaths attributed to alcohol, or the hundreds of thousands attributed to tobacco.) There is a desperate need to find policy solutions for this massive death toll.

So it’s a serious problem that needs serious solutions. Yet Trump wants to essentially do more of the same policy that failed to prevent the opioid crisis, while Clinton is taking the approach advocated for by drug policy experts.

Hillary Clinton has a detailed plan for the opioid painkiller and heroin epidemic

Hillary Clinton speaks to the press in New York. Justin Sullivan/Getty Images

Clinton wants to spend about $10 billion over 10 years, on top of the $200 billion to $300 billion the federal government already spends each decade to combat drugs, in what she calls the "Initiative to Combat America's Deadly Epidemic of Drug and Alcohol Addiction."

About $7.5 billion of the federal funds would encourage states to set up their own plans to fight drug abuse and addiction, with the feds promising $4 for every $1 a state commits to a plan. The remaining $2.5 billion would go to drug abuse prevention and treatment programs directly funded by the federal government.

Clinton outlined specifics for how states could use the money:

  • Set up programs that can prevent teen drug abuse, such as school programs, after-school activities, peer and mentorship programs, and community service.
  • Identify and fill treatment gaps in communities — potentially through greater funding for hospitals and community health centers, stronger enforcement of insurance parity laws so health plans cover treatments for substance abuse, or streamlining licensing so different health care providers can more easily treat drug and alcohol addiction.
  • Give first responders access to naloxone, which reverses heroin, prescription painkiller, and other opioid overdoses that can be fatal.
  • Require better training and monitoring of drug prescribers to ensure opioid painkillers are being given out to patients who actually need them and aren’t at a serious risk for addiction.
  • Reform the criminal justice system to put drug users in treatment programs instead of in jails and prisons. For places that already have specialized courts and drug courts that focus on treatment instead of incarceration, encourage further reforms — such as allowing medication-based treatments like methadone and buprenorphine, which can stop opioid withdrawal.

Clinton also outlined several other initiatives that the federal government would lead, which are more about making regulatory changes than providing more funding:

  • Relaxed standards to let more medical professionals treat their patients for addiction
  • Greater federal enforcement to ensure health insurers pay for drug abuse treatments
  • Medicare and Medicaid reforms to remove obstacles to drug abuse treatments, and establish better guidelines for opioid prescribers through Medicare and the Veterans Administration
  • Directing the attorney general to prioritize treatment over incarceration for nonviolent and low-level drug offenders as part of a broader push encouraging federal and state governments to end mass incarceration

It’s an exhaustive, specific list — with some upsides and some downsides.

The biggest upside is the money. As Keith Humphreys, a drug policy expert at Stanford University, previously told me, committing $10 billion is really big. "Just the fact that it has the B-word — billion — says to me that Clinton grasps the depth of the problem," he said. "This is not a small problem, and it’s not going to go away."

All of that money would go after the root of the epidemic: insufficient access to drug abuse treatment. According to 2014 federal data, at least 89 percent of people who met the definition for a drug abuse disorder didn’t get treatment. Patients with drug abuse disorders also often complain of weeks- or months-long waiting periods for care. (Even Prince, a wealthy superstar musician, couldn’t access care quickly enough — and died as a result.)

The big worry with Clinton’s plan is its federalism: Most of the funding relies on states embracing the initiative’s funds, meaning they’ll get to decide whether they accept the plan at all — and politics, especially among Republican governors opposed to Clinton’s broader agenda, could make states less willing to act.

It’s not unprecedented for states to refuse federal funds out of political or ideological objections. One example: the Medicaid expansion. At least 90 percent of the expansion is funded by the federal government, and it could help fight the opioid epidemic. But states have turned down the Medicaid expansion largely due to ideological opposition to the other Obamacare policies it’s associated with.

If states follow the same stance against Clinton’s plan, it could prove a flop. Although it’s hard to see how that could happen, given that the opioid epidemic so far appears to be a bipartisan issue — with even Congress passing a bill to address the crisis earlier this year.

Donald Trump wants more of the old drug war to fight the opioid epidemic

Donald Trump speaks in North Carolina. Sara Davis/Getty Images

What about Trump? Here is all we know about his plan to fight the opioid epidemic, based on a speech he gave in mid-October and past remarks:

  • Trump would build a wall at the US-Mexico border, which he claims would stop the flow of heroin from America’s southern border. This is essentially what Trump has said for a while now: He began his campaign by, in part, saying we needed to build a wall to stop Mexican immigrants from "bringing drugs" into the US.
  • He proposed increasing mandatory minimum prison sentences on drug offenders.
  • He said the Food and Drug Administration should approve abuse-deterring drugs more quickly.
  • He suggested doctors should prescribe less opioids. "We have 5 percent of the world’s population but use 80 percent of the prescription opioids," Trump noted.
  • He would "spend the money" to get people into drug treatment.

Trump seems to at least admit that the opioid epidemic requires more money into treatment. But all the details necessary to evaluate his plan are lacking: how much he would spend, how exactly that money would be appropriated, what kind of treatment programs would receive funds, and whether he even wants to increase spending in the first place. We just have no idea what Trump means by "spend the money." (A Trump spokesperson didn’t respond to inquiries about his plan.)

The parts we have the most specifics for — the wall, harsher prison sentences on drug traffickers — don’t seem promising, either: They essentially continue the same drug war paradigm that failed to stop the opioid epidemic in the first place.

A key part of Trump’s proposal, for example, is to increase mandatory minimum sentences on drug offenders. But studies have found that harsher punishments do not actually stop the flow of drugs: A 2014 study from Peter Reuter at the University of Maryland and Harold Pollack at the University of Chicago found theres no good evidence that tougher punishments or harsher supply-elimination efforts do a better job of pushing down access to drugs and substance abuse than lighter penalties.

The big problem is that drug trafficking is so profitable and lucrative that when someone gets locked up for selling drugs, another person is very likely to take his or her place in the drug trade. This is such a well-known phenomenon that drug policy scholars have a name for it: "the balloon effect."

There’s also no evidence that the wall — or other border security measures — would stop drugs from passing through the border. A 2013 report by journalist Reed Karaim summarized the consensus, following the US’s border security buildup over the past few years:

Most border security analysts say there is little evidence the buildup has significantly reduced the availability of illegal narcotics in the United States. The U.S. Drug Enforcement Administration (DEA) has cited reduced use of some drugs, especially cocaine, as proof the buildup is working. But other drugs have grown in popularity, and smugglers have proved adept at shifting their methods and locations in response to interdiction efforts.

Peter Andreas, a political science professor at Brown University and author of Smuggler Nation: How Illicit Trade Made America, concurred with that analysis’s conclusion. By the way he described it, no realistic amount of border security — including a wall — could actually stop the flow of drugs into the US, because drugs are simply far too profitable and compact (and therefore easy to smuggle) for drug traffickers to give them up. Essentially, the balloon effect is real.

"It’s very simple business economics that you’re not going to stop a commodity like that by building a wall," he said. "The drugs can come under the wall, they can come over the wall, and they can come around the wall."

That’s where some of the exotic methods of drug smuggling come in: boats, tunnels, drones, and even homemade bazookas. Over the decades, drug traffickers have proven ingenious at finding alternative methods to sneak by border security — even as the US greatly increased the number of border patrol agents. There’s no reason to think a wall will be an indomitable barrier when the potential for drug profits is so high that the cost of new gadgets or technologies to surpass border security pales in comparison.

Andreas also noted that Trump would not lock down legal points of entry, where commercial vehicles go through every single day — at times carrying hidden drugs. "Much of the cocaine and heroin that comes into the US goes right on the road," he said, "through the substantial amount of cargo that comes into the United States from Mexico — one of our most important trading partners."

Even if the US managed to crack down on drugs from Mexico, traffickers would likely just shift their operations to the Caribbean, Canada, or someplace else, Andreas said.

This is another example of the balloon effect: When drug trafficking is stamped out in one area, it just pops up in other places — because drug profits are so lucrative that traffickers are incentivized to always find alternatives. This happened in the 1980s and ’90s as federal officials cracked down on trafficking from the Caribbean; trafficking simply moved to Mexico.

"I’m assuming he’s saying his wall is going to solve all sorts of problems simply because that sounds good politically," Andreas said. "It’s a simple, clear political sound bite. But a wall — the least effective thing it’s going to be for is stopping drug smuggling."

That’s why the most important issue in addressing the opioid epidemic comes down to addressing demand, not supply. If the supply of illicit drugs can’t be reasonably limited, perhaps the demand can be — by providing treatment programs that get opioid users to stop using drugs.

Public health policy, not law enforcement, is the likely answer to the opioid crisis

Ida Mae Astute/ABC via Getty

As Andrew Kolodny, who helps lead the national addiction treatment nonprofit Phoenix House, explained to the Daily Beast, "We need to prevent people from getting addicted and be more cautious prescribing [painkillers]. Heroin will just keep flooding in. If it’s not coming in through Mexico, you’ll have more fentanyl labs popping up in the US. It’s become more available because there’s a demand for it."

Consider how the current drug epidemic happened: In the 1990s, doctors were under enormous pressure to treat pain as a serious medical issue — with good reason, as roughly one-third of Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine. Now, the evidence for opioids treating long-term, chronic pain is fairly weak, despite their effectiveness for acute, short-term pain. But with encouragement from pharmaceutical companies through an aggressive marketing campaign, doctors prescribed excessive numbers of opioid painkillers — getting a lot of people hooked on the drugs and letting excess painkillers flood the black market.

So opioid painkiller overdoses steadily increased, reaching epidemic levels by the 2010s.

Over time, these opioid users developed a tolerance and sought a better high. They turned to heroin, which has long been cheaper, more potent, and — especially after the government crackdown on painkillers to fight addiction — more available than opioid painkillers. As a result, heroin deaths also rose. (A 2015 analysis from the Centers for Disease Control and Prevention found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.)

So the rise in heroin use only came after painkiller users got hooked on opioids. If heroin wasn’t available, the demand would still exist — and many drug users would likely turn to, as Kolodny suggested, fentanyl (an opioid that’s more powerful than heroin and can be produced in a lab) or just regular painkillers.

The root issue, then, is ensuring that people don’t want to use opioids to begin with. That’s where drug treatment can help. But Trump has no concrete plan for increasing funding or access to treatment — just a vague promise to "spend the money." The only concrete proposal we have from Trump are the wall and tougher sentences — which, again, don’t seem likely to work.

Trump does, like Clinton, want to slow opioid prescription rates. Drug policy experts generally argue that this could help — since it could stop future generations of potential users from getting addicted to the drugs by cutting them off at the source before it even becomes a source.

But as long as there aren’t enough treatment options, the people who are already addicted are going to languish. And that could lead to tens of thousands of more deaths.

The candidates need to take drug abuse seriously

For the candidates, the opioid epidemic — and drug abuse in general — should be a very serious issue. Although rarely mentioned on the campaign trail, drug abuse leads to at least tens of thousands of deaths each year.

In 2014, the latest year of data available, drug overdoses killed more than 47,000 people. Alcohol, another (albeit legal) drug, is linked to 88,000 deaths each year. Tobacco, yet another legal drug, is linked to 480,000 deaths each year.

For context: In 2014, car crashes killed nearly 34,000 people in the US, gun violence killed almost 34,000 that year, and terrorism killed 24. And at its peak in the US in 1995, HIV/AIDS killed more than 43,000 Americans.

All of these issues are, obviously, concerning and must be addressed. This isn’t about whether any of the issues listed above need to be ignored, but instead is to show how relatively serious the current drug epidemic and drug abuse in general are.

There are many other ideas for dealing with drug abuse

Beyond their current plans, there is a lot more either candidate could be proposing. Drug policy experts have many more ideas to supplant the war on drugs with approaches focused more on public health.

Here are several other ideas drug policy experts have proposed to me as I’ve reported on this issue over the years:

  • Eliminate collateral consequences: State and federal laws can stop drug offenders from accessing various government programs once they get out of prison, such as public housing, welfare benefits, and student loans. But putting already desperate people in even more desperate circumstances will only make them more likely to use drugs or reoffend. "[Eliminating collateral consequences] helps people who've been in contact with the criminal justice system get away from it," Humphreys said, "so they can get a job, go to school, and live somewhere."
  • 24/7 sobriety programs: These programs punish drug and alcohol abusers with a few days of jail time if they fail a regular drug or alcohol test in order to deter them from using or drinking. A 2013 study from the RAND Drug Policy Research Center attributed a 12 percent reduction in repeat DUI arrests and a 9 percent reduction in domestic violence arrests at the county level to South Dakota's 24/7 Sobriety Program. And a 2009 paper by Angela Hawken and Mark Kleiman found large reductions in positive drug tests and arrests among people in Hawaii's HOPE Probation program.
  • A higher alcohol tax: A 2015 review of the research from David Roodman, senior adviser for the Open Philanthropy Project, found that a higher alcohol tax saves lives: "A rough rule of thumb is that each 1% increase in alcohol price reduces drinking by 0.5%. Extrapolating from some of the most powerful studies, I estimate an even larger impact on the death rate from alcohol-caused diseases: 1-3% within months. By extension, a 10% price increase would cut the death rate 9-25%. For the US in 2010, this represents 2,000-6,000 averted deaths/year."
  • A state monopoly on alcohol sales: An April 2014 report from RAND suggested state governments could monopolize sales of alcohol through state-run shops, finding that states that did this kept prices higher, reduced access to youth, and reduced overall levels of use.
  • Radically rethink the war on drugs: America could turn to other policy ideas — even legalization — to reshape how it approaches drugs. One example: Instead of keeping drugs illegal, it could legalize drugs but tax and regulate them to make the less risky versions of drugs easier to access than their more dangerous counterparts. So, as an example, smoked opium could be easier to get than heroin, which could allow opioid users get a safer fix. (Much more on all of that in a previous piece I wrote for Vox.)
  • More stringent anti-tobacco policies: Anti-tobacco policies aren’t typically lumped in with other anti-drug policies. But it is a drug, and there are ways to further reduce its use: education campaigns, mandatory warning labels, public and workplace smoking bans, higher taxes on tobacco products, and a higher smoking age.

This list is by no means comprehensive. But it shows that there are a lot of options for the candidates to take on. So far, Clinton has put forward a sizable proposal — segments of which could indirectly adopt the ideas above if states choose to make them a part of their federally funded plans. Trump, meanwhile, has offered few specifics — and the details we have are more focused on trying the approach of old than any of the reforms that have been put forward as the drug war has failed to prevent multiple drug epidemics.

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