President Donald Trump wants to do something about the opioid epidemic. It’s just not clear what, exactly, he’ll do.
Trump on Wednesday signed an executive order to deal with the opioid epidemic. It doesn’t take any specific actions against the epidemic. But it creates a commission, to be headed by New Jersey Gov. Chris Christie, that will decide what can be done.
The President’s Commission on Combating Drug Addiction and the Opioid Crisis will focus on putting together a report, due in the fall, on the opioid crisis and potential solutions to it. The commission will identify existing federal funding for the epidemic, locate places that have limited drug treatment options, review opioid addiction prevention strategies, and make recommendations to the president to improve the federal response to addiction and the opioid crisis.
Christie will work with other people designated by the president to the commission, although the final draft of the order does not specify who those people will be. The commission, which will be administrated by the White House Office of National Drug Control Policy, is expected to put out a preliminary report within three months and a final report by October.
Christie is a natural pick for the commission, due to his support for Trump since the 2016 campaign and strong advocacy in the opioid epidemic. Christie has long spoken about treating addiction as primarily a public health problem instead of a criminal justice issue. And he’s dedicated his past year as governor in large part to confronting the epidemic, recently signing a law that restricts opioid painkiller prescriptions. (One of Christie’s friends struggled with addiction, which seems to have pushed him to take on the epidemic in a compassionate, serious way.)
Whatever comes of the commission, it is long overdue. The opioid epidemic has led to the biggest drug overdose crisis in US history, with more than 560,000 people — more than the entire population of Atlanta — dying from drug overdoses between 1999 and 2015. The Obama administration and Congress previously took some steps to try to combat the crisis, but experts have long argued that there’s a desperate need for more.
Trump talked a lot about opioids on the campaign trail, but he’s yet to release a specific plan
Trump acknowledged the horrors of the opioid epidemic on the campaign trail, calling it a “tragedy” and laying out some policy ideas for stopping the drug crisis.
Most of Trump’s talk has focused on tougher border security measures, including his wall, to stop the flow of illegal narcotics into the US. But experts widely argue that such measures would fall far short of dealing with the epidemic, not least because most opioid overdose deaths are linked to painkillers that are legally prescribed and obtained — sometimes through a black market — within the US.
Trump has signaled other policies, including making drug treatment more accessible. But he’s offered few specifics on how he would accomplish that, typically promising to “spend the money” on drug treatment without many more details. (Although he did vow to raise the cap on how many patients doctors can prescribe to buprenorphine, an opioid used to let people with opioid use disorders manage their addiction more easily and in a much safer fashion.)
More spending on addiction treatment is desperately needed: 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.)
This is why the Obama administration took some steps to provide more treatment options, such as unlocking more than $100 million in funding for drug treatment in 2016. And it’s why Congress in late 2016 approved $1 billion over two years for drug treatment to combat the opioid epidemic.
Trump’s policy proposals to this point, however, have not done anything to fill this gap. His recent budget plan wouldn’t increase funding for drug treatment above what Congress already approved. In fact, Trump has proposed $100 million in cuts to the Substance Abuse and Mental Health Services Administration’s mental health block grants, which could ultimately impact some addiction services.
Trump also has not yet nominated a permanent director of the White House Office of National Drug Control Policy, who is commonly referred to as the nation’s “drug czar.” This office is meant to coordinate all of the nation’s anti-drug spending, bringing together the many federal agencies that tackle drugs through a variety of criminal justice, national defense, and public health programs. But without a permanent head of the office, the nation’s future drug strategy remains unclear.
There are similar vacancies in other agencies that deal with drug addiction, including the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration.
Keith Humphreys, a drug policy expert at Stanford, praised Christie’s appointment to the commission. But he argued that Trump should prioritize filling old positions over establishing a new commission. “We have multiple positions in government that can do all these things already,” he said. “Instead, a new layer of government is being created with no infrastructure or historical memory.”
To this end, Humphreys argued, much of what Trump is tasking the commission to do was already done by the surgeon general’s 2016 addiction report. “There is no need to reinvent the wheel with another planning and evaluation process,” Humphreys said, “just pick up [the surgeon general’s] report and act on it.”
There’s a reason for the sense of urgency: With tens of thousands of people dying from drug overdoses every year for the past few years, there’s a need to take action quickly. And it’s not really a mystery what needs to be done — with experts saying the problem comes down to lose access to opioid painkillers and too few drug treatment options. So to start yet another months-long investigative process seems like a slow reaction to an urgent crisis.
Still, the president’s commission presents an opportunity for Trump to reverse course on this issue and potentially direct policies and funds to dealing with the opioid epidemic in a more serious manner. Whether it will actually live up to that potential remains to be seen. But tens of thousands of lives may depend on it.
The opioid epidemic, explained
In 2015, more Americans died of drug overdoses than any other year on record — more than 52,000 deaths in just one year. That’s higher than the more than 38,000 who died in car crashes, the more than 36,000 who died from gun violence, and the more than 43,000 who died due to HIV/AIDS during that epidemic's peak in 1995.
This latest drug epidemic, however, is not solely about illegal drugs. It began, in fact, with a legal drug.
Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There's a good reason for that: About one in three Americans suffer from chronic pain, according to a 2011 report from the Institute of Medicine.
Pharmaceutical companies took advantage of this concern. Through a big marketing campaign, they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term, chronic pain is very weak (despite their effectiveness for short-term, acute pain), while the evidence that opioids cause harm in the long term is very strong.
So painkillers proliferated, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.
As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (typically prescribed to relieve anxiety). By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths.
Seeing the rise in opioid misuse and deaths, officials have cracked down on prescriptions painkillers. Law enforcement, for instance, threatened doctors with incarceration and the loss of their medical licenses if they prescribed the drugs unscrupulously.
Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being told to give more thought to their prescriptions.
Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids: heroin and fentanyl, a synthetic opioid that's often manufactured illegally for nonmedical uses.
Not all painkiller users went this way, and not all opioid users started with painkillers. But statistics suggest many did: A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by 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 other types of opioid overdoses, excluding painkillers, also rose.
That doesn't mean cracking down on painkillers was a mistake. It appeared to slow the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders.
But the likely solution is to get opioid users into treatment. So federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and Suboxone.
Some states, like Louisiana and Indiana, have taken a “tough on crime” approach that focuses on incarcerating drug traffickers. But the incarceration approach has been around for decades — and it hasn’t stopped massive drug epidemics like the current opioid crisis.
Trump’s new commission offers a chance to establish more funding, coordination, and guidance behind these mixed federal and state efforts. Now the country will have to wait over the next few months to see what, exactly, the commission produces.
For more on the opioid epidemic, read Vox’s in-depth explainer and visual explainer.