If President Donald Trump is serious about dealing with the opioid epidemic, we now have an official checklist by which to judge his administration’s actions.
On Wednesday, Trump’s opioid commission, led by New Jersey Gov. Chris Christie, put out its long-awaited recommendations to deal with the nation’s drug overdose crisis — just days after Trump declared a public health emergency over the epidemic, which contributed to the US’s record 64,000 drug overdose deaths in 2016.
The list includes more than 50 recommendations, touching on a variety of federal, state, and local agencies. They include streamlining federal money for drug addiction, knocking down barriers to treatment, expanding federal drug courts, and implementing new training requirements for doctors who prescribe opioid painkillers.
The commission does not say how much funding implementing its recommendations or tackling the opioid crisis will require — leaving a huge question open, even as it argues that “Congress must act” and “appropriate sufficient funds to implement the Commission’s recommendations.” It also does not call for a new, large investment into drug addiction treatment, as some advocates hoped for.
With its final report, the commission ends months of work in which it met with major stakeholders involved in the crisis, from people struggling with addiction to insurers to pharmaceutical companies.
The question now is whether Trump and Congress will listen to the recommendations.
What Trump’s commission recommends
Here are some of the biggest recommendations in the report:
- Streamline federal funding for drug addiction: According to the report, nearly every governor’s office complained about the “fragmented” state of federal funding for opioids and addiction. The report recommends streamlining the current process into a block grant, which should require “one application and one set of reporting requirements” for funding. The commission argues this would let states focus less on paperwork and more on actually implementing policies.
- Remove barriers to treatment: The report proposes a number of moves for federal agencies to remove barriers to addiction treatment, including better enforcement of parity laws that in theory require insurers to pay for such care. But it stops short of calling for a new, large federal investment into treatment. This is needed: According to a 2016 report by the surgeon general, only 10 percent of Americans with drug use disorders get specialty treatment — in large part because they often can’t afford such services and, even if they can, can face waiting periods of weeks or even months to get in.
- Open drug courts in all federal jurisdictions: Drug courts, which divert people from prison to addiction treatment, were up and running in less than 30 percent of federal districts in 2015, according to the report. The commission said this should be 100 percent. The argument for this is harm reduction: Drug courts can make sure that people who need treatment get that instead of prison time. But drug courts have been criticized for frequently ignoring evidence-based treatment options, including anti-addiction medications like methadone and buprenorphine, which are considered the gold standard for treating opioid addiction.
- More opioid prescriber training: The commission asks that the Department of Health and Human Services develop “a national curriculum and standard of care for opioid prescribers.” It also proposes that the Drug Enforcement Administration (DEA) require doctors renewing their opioid prescribing licenses to attend an education program for such prescriptions.
- Stop evaluating doctors based on pain scores: One of the reasons for the rise in the prescription of opioids is doctors were commonly evaluated in government-mandated surveys based on how well they treated a patient’s self-reported pain. This encouraged doctors to prescribe opioids that could lead to short-term improvements in pain but, in the long term, lead to addiction, overdose, and other problems. To end this perverse incentive, the commission asks that patient satisfaction surveys used to evaluate doctors no longer include any questions about pain.
- Allow more emergency responders to deploy naloxone: The National Highway Traffic Safety Administration currently puts out a best-practices guide that suggests certain emergency responders carry naloxone, an opioid overdose antidote. The commission wants that guide to include all emergency medical staff, which some states currently don’t allow. But the report’s recommendation doesn’t extend to opening access to naloxone beyond that — which some advocates would like to see.
- Tougher prison sentences for fentanyl: The commission calls for “the enhancement of federal sentencing penalties for the trafficking of fentanyl [a potent synthetic opioid] and fentanyl analogues.” The empirical evidence shows this will have little to no effect on drug use, but it’s a very popular idea within the law enforcement community.
- A media campaign: The report recommends a federally funded media campaign on addiction stigma and the dangers of opioids. This is one of Trump’s favorite ideas, which he has repeatedly invoked. The research, however, shows these campaigns often fail — or, worse, actually lead to more drug use by making drugs an attractive sign of rebellion or triggering curiosity about drugs that kids or teens previously didn’t know existed.
This is only a summary of some of the key recommendations, giving an idea of the many issues the commission tried to address. And they come on top of the commission’s previous recommendations. For all 56 proposals, read the full report.
So far, the reaction to the commission’s report by activists and experts is mixed. Baltimore City Health Commissioner Leana Wen, a major advocate on the opioid crisis, summed up much of the sentiment in a statement: “While the final report issued today by the President’s Commission on Combating Drug Addiction and the Opioid Crisis addresses critical aspects of the fight against the nation’s opioid epidemic, it does not go nearly far enough.”
It’s on Trump and Congress now
The question now is whether Trump and Congress will actually follow through on the recommendations. Trump, after all, took months to act on one of the proposals in the commission’s preliminary report issued in July — and he left many of the other early recommendations, at least so far, untouched.
Politically, this is a very important issue for Trump. A post-election analysis by historian Kathleen Frydl found, for example, that most of the Ohio and Pennsylvania counties that flipped from former President Barack Obama in 2012 to Trump in 2016 had very high drug overdose death rates.
The opioid epidemic goes back to the 1990s, with the release of OxyContin and mass marketing of prescription painkillers, as well as campaigns like “Pain as the Fifth Vital Sign” that pushed doctors to treat pain as a serious medical problem. This contributed to the spread of opioid painkiller misuse and addiction, which over time also led to greater use of illicitly produced opioids like heroin and fentanyl. Drug overdose deaths have climbed every year since the late ’90s as a result.
The issue has really turned into two simultaneous crises — which Keith Humphreys, a Stanford University drug policy expert, has described as the dual problems of “stock” and “flow.” On one hand, you have the current stock of opioid users who are addicted; the people in this population need treatment or they will simply find other, potentially deadlier opioids to use if they lose access to prescribed painkillers. On the other hand, you have to stop new generations of potential drug users from accessing and misusing opioids.
Addressing these crises will, experts say, require tens of billions of federal dollars. As I previously explained, we have a pretty good idea of what those resources should go to: They could be used to boost access to treatment, pull back lax access to opioid painkillers while keeping them accessible to patients who truly need them, and adopt harm reduction policies that mitigate the damage caused by opioids and other drugs.
Some states are attempting to confront this issue. Vermont, for example, has built a “hub and spoke” system that treats addiction as a public health issue and integrates treatment into the health care system. Potentially as a result, the state was the only one in New England to have a drug overdose death rate below the national average in 2015. (For more, check out our in-depth breakdown of Vermont’s system.)
But Vermont managed to build this new system in large part with federal dollars, particularly through Obamacare’s insurance expansion and a special Medicaid waiver that states can obtain through the health care law. It’s that kind of federal support that budget-strained states will need to deal with the opioid crisis — yet it’s unclear, even after this report, what Trump and Congress will do to make that federal support available to more states.