President Donald Trump declared America’s opioid crisis a public health emergency on Thursday, after sending mixed signals on the issue for the past three months. But there’s one big thing missing: money.
Trump won’t direct any new federal money to the opioid crisis, per administration officials. The declaration will free up the federal Public Health Emergency Fund to be used to fight the drug epidemic, but Congress hasn’t replenished the fund in years. There’s just $57,000 left in it — and public health experts say a serious response to the addiction crisis would cost $183 billion over the next decade.
For public health officials, doctors, and treatment advocates on the ground in states hardest hit by the epidemic, the federal government — under both the Obama and Trump administrations — has been slow to respond to America’s deadliest drug crisis, which killed a record 64,000 Americans last year.
Trump’s Thursday declaration, though encouraging, wasn’t the decisive action that many were looking for.
“I think it was a step forward but it wasn’t the big step, because it does not bring new money,” said Tym Rourke, chair of the New Hampshire Governors Commission on Alcohol and Drug Abuse Prevention, Treatment, and Recovery and a longtime treatment advocate in the state. New Hampshire has the second-highest rate of fatal drug overdoses in the nation, behind West Virginia.
“There are unmet needs right now that this declaration, while welcome, does not address,” Rourke said. “If we don’t get additional resources on the ground, there is only so much positive impact we can have.”
In West Virginia, where the death toll from heroin, fentanyl, and prescription opioids is the worst in the United States, public health officials say they want help from the federal government matching the scale of the devastation they see every day.
“People are dying out here,” said Michael Brumage, executive director of the Kanawha-Charleston Health Department in Charleston, West Virginia, in a recent interview. “We are having a Vietnam in America every single year from overdoses. If this is a war, why would we not apply the resources as we could?”
Brumage said he believes there’s a disconnect between government officials in Washington, DC, and people who are seeing the toll of the drug crisis play out every day in America’s communities.
“When you’re sitting in a position of power and you’re removed from the day-to-day misery of this epidemic, I believe it’s easy to dismiss,” he said. “I think at an intellectual level they see the numbers of deaths from overdoses, but they’re abstractions because they’re figures on a piece of paper.”
“The public health hurricane of our generation”
Hard-hit states like New Hampshire and West Virginia have already had mixed experiences with the government’s response to the opioid crisis: They’ve gotten much less help than states with lower death rates.
The 21st Century Cures Act, passed last year, included $1 billion to be dispersed among states for drug treatment. The bill’s intent was for more federal money to go to states with the highest per capita drug death rates.
But after the bill was signed into law by President Obama, the Substance Abuse and Mental Health Services Administration changed the funding formula to take into account states with the biggest overall numbers of overdose deaths.
That meant more populous states like California, Florida, and Texas got the most money, even though their per capita death rates were much lower. New Hampshire, with the second-highest death rate in the nation, received about $6.2 million over two years. Texas, with the fourth-lowest per capita rate for drug fatalities in the US, received $27.4 million.
Michael Fraser, the executive director of the Association of State and Territorial Health Officials, called the 21st Century Cures Act money “the first down payment in what’s going to be a long term investment” fighting the crisis.
Trump’s declaration Thursday will do several things, including letting states shift federal funds dedicated for HIV to also deal with opioid addiction, allow the US Department of Health and Human Services dedicate more staff to the addiction crisis, and let patients use telemedicine to get medication-assisted treatment like methadone or buprenorphine.
Fraser says he’s optimistic the declaration will help federal agencies streamline their response to the crisis and work more efficiently with states. But it’s now up to Congress to appropriate more money to help combat the opioid epidemic.
Administration officials said Thursday that they expect Congress’s December spending bill to contain money for treatment, but gave no specific dollar amount. But any congressional response is likely to fall far short of what some experts believe is needed to solve the crisis: close to $183 billion.
“If you’re going to actually do something, you’re going to have to put down some serious capacity building money,” said Richard G. Frank, a health economics professor at Harvard Medical School who has written extensively on the cost of treating addiction.
Every bit of money from the state and federal governments is helpful, said Dr. Rahul Gupta, West Virginia’s state health commissioner. Obamacare’s Medicaid expansion helped 50,000 people in the state get drug treatment, and the state received $5.8 million from the federal government this year as part of the 21st Century Cures Act.
“This is the public health hurricane of our generation,” Rourke said. “We are running against the clock.”
The epidemic goes beyond deaths
Why is the epidemic so expensive? Because while drug overdose deaths are often what gets the most attention, treatment advocates, doctors, and public health officials say they are just the tip of the iceberg. The opioid crisis has turned into what Tufts University assistant professor Thomas Stopka called a “syndemic,” “multiple diseases feeding off each other.”
IV drug use, for example, led to rates of hepatitis C infections tripling nationwide from 2010 to 2015. If untreated, the virus can liver cancer or cirrhosis years later; there is a cure, but it costs tens of thousands of dollars, and many state Medicaid programs won’t cover it unless the patient’s liver is starting to fail.
In Kentucky, Dr. Jennifer Havens, a researcher at the University of Kentucky’s College of Medicine, says many of the drug users she sees who test positive for hepatitis C are young. And she describes the reaction she’s seen from many young drug users who test positive for hepatitis C as “complete and utter apathy,” because drug use and disease has become a part of daily life.
“We’ve had very few people that have been upset by the news,” Havens said. “It’s kind of inevitable, and now it’s kind of endemic.”
Beyond hepatitis C, many drug users develop abscesses and soft tissue infections from drug use. Some of these can be cleared up with antibiotics, but if infections become more serious and travel to the heart, a patient may need their heart valve replaced, a procedure that can cost between $100,000 to $200,000.
Then there’s the toll on children of addicted parents, including babies born dependent to drugs in the womb if their mothers are still using, and the thousands of children who have to go into foster care because their parents are dead from an overdose or can’t take care of them due to active drug use.
“This is an epidemic like no other because it touches every fabric of society,” said Gupta.
A 2016 report found that prescription opioid abuse alone was costing America $78.5 billion, including $20 billion in lost productivity, $28 billion in health care costs, $21.5 billion in overdose deaths, and another $7.7 billion in criminal justice costs.
“The cost is tremendous,” Gupta said. “It’s the Boeing 737 crashing every single day.”