Tens of thousands of people will likely die of drug overdoses under President Donald Trump’s watch, as America’s horrific opioid epidemic continues. Yet with his first big policy document — the 2018 budget proposal — Trump is proving that he’ll do little to nothing about the crisis.
If anything, Trump’s proposal could make the opioid epidemic worse. Where the budget does anything of significance regarding the epidemic, it comes through cuts to the office in charge of coordinating drug policy, Medicaid, public health programs, and more. And there is nothing in the budget to balance out the cuts — leaving a crater in the government’s response to a crisis that led to more than 33,000 opioid overdose deaths and more than 52,000 total drug overdose deaths in 2015.
Drug policy advocates have said for years that the federal government, including the Obama administration, has reacted slowly to the opioid epidemic — given that it took until 2016 for Congress and President Barack Obama to pass any major legislation responding directly to the epidemic, finally adding $1 billion to drug treatment over two years through the 21st Century Cures Act. But advocates argue that the drug overdose crisis will require much more money than that, since it’s now killing more people than guns, cars, and even HIV/AIDS did at its peak.
“It would have been easy for Trump to come in and do better than Obama,” said Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. “But he’s off to an awful start.”
It’s not just the budget plan. The spending proposal also fits the pattern we’ve seen with Trump on the opioid epidemic so far: Despite all his talk and promises on the campaign trail, this is an issue in which Trump is doing little to nothing as president — and the little his administration is doing will very likely prove counterproductive.
What Trump’s budget does on drugs
According to the Office of National Drug Control Policy (ONDCP), Trump’s budget does propose what amounts to a nearly 2 percent increase in drug treatment spending — with an increase of around $200 million to the $10.6 billion the federal government already spent on drug treatment.
But there’s a huge catch to this increase: It includes the $500 million added by the 21st Century Cures Act, which was approved by Congress and signed into law by Obama. In other words, without the Cures Act spending that Congress put into place, Trump’s budget would actually cut drug treatment spending this year. In fact, this is what’s very likely to happen the year after Trump’s 2018 budget, since the Cures Act money is allocated only for fiscal years 2017 and 2018.
What’s more, the money that is added simply falls far short of what advocates want. Kolodny, for one, estimated that the US will need to spend potentially tens of billions of dollars more a year on the epidemic — far more than Trump or anyone else has put forward. (To this end, he is also highly critical of the Obama administration; he argues it took too long to do anything on the epidemic, and what it did was far too small.)
Trump, at the very least, doesn’t propose cutting overall drug treatment spending this year, based on ONDCP’s figures. But he suggests other cuts to public health and anti-drug programs that completely outweigh the tiny gains that ONDCP claims.
For one, the budget proposal slashes drug prevention programs across all federal agencies by about 11 percent — from about $1.5 billion to more than $1.3 billion.
The budget didn’t, as originally rumored, suggest a 95 percent cut to ONDCP, which is the top office in charge of coordinating anti-drug programs spread through multiple federal agencies. But it does propose cutting some of the office’s programs by a few percentage points.
Some drug policy advocates see ONDCP as somewhat problematic, given its history of supporting ineffective “tough on drug” policies. But they argue the office should be reformed and propped up to lead the response to the opioid epidemic, not cut back.
Kolodny agreed. He said, “There are things that ONDCP can do. Certainly, in the midst of this epidemic … cutting funding to an office that can play a role in coordinating a response is foolish. [Trump] should be looking in different ways to be finding more money for the opioid crisis, not cutting ONDCP.”
Trump also proposes a 47 percent cut to Medicaid over the next 10 years. This would rob millions of people of the one affordable source of health insurance that they have — to pay for, in part, drug treatment. According to a 2014 study by Truven Health Analytics researchers, Medicaid paid for a quarter, or $7.9 billion of $31.3 billion, of projected public and private spending for drug treatment in 2014. As a patient using Medicaid to pay for drug addiction care at a New Jersey facility told me earlier this year, “If it wasn’t for insurance, I wouldn’t be here.”
The budget further asks for nearly $400 million in cuts to the Substance Abuse and Mental Health Services Administration, hundreds of millions in cuts to mental health block grants, and billions in cuts altogether to the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and Food and Drug Administration (FDA). This funding didn’t all go specifically to drug treatment, but these agencies and programs in part help address the opioid epidemic and drug addiction in general.
Advocates are already sounding the alarm over these cuts. The Baltimore City Health Department, for example, said in a statement, “At a time of a public health emergency around opioids, with unprecedented numbers of Marylanders dying from overdose, this proposal could deprive millions of the care that they need.”
Finally, the budget significantly increases overall spending on federal law enforcement. It’s unclear exactly how much of this will go toward fighting drugs. But generally, drug policy experts and researchers agree that what’s needed is not more policing but more spending on drug treatment. After all, the US has spent hundreds of billions on anti-drug law enforcement for decades — and it didn’t prevent the opioid epidemic.
The budget proposal is likely dead on arrival. It needs Congress’s approval to become law, and Congress will likely put forward its own spending measures instead of using Trump’s.
But the budget plan is still the most comprehensive policy agenda that we can expect from the Trump administration at this point — and it shows a total lack of interest in seriously addressing the opioid epidemic.
Everything else Trump has done or proposed on opioids ranges from ineffective to bad
The rest of Trump’s opioid policy isn’t much better. Generally, it can be described as the opposite of what Trump said on the campaign trail — instead of allocating more funding to deal with the epidemic as a public health issue, he’s often undercutting such efforts.
Beyond his budget proposal, here’s a broad rundown of what the Trump administration has said and done on opioids since Trump took office:
- Trump wants to build a wall at the US-Mexico border and beef up border security, in part to stop the flow of heroin into America. There’s wide consensus among border security experts, however, that a wall and tougher border security measures would have little to no effect on drug trafficking. The simple reason: Most drugs come through the legal ports of entry, meaning a wall and similar efforts will do nothing to hinder drugs where they’re actually coming through.
- Trump supports the American Health Care Act, which would cost millions of people their health insurance and severely weaken protections for drug treatment coverage. According to a previous analysis, this could leave as many as 2.8 million Americans with drug use disorders — including 222,000 with opioid use disorders — without adequate access to care.
- Trump set up a commission to study the opioid crisis and recommend a coordinated response. This is a positive step. But the commission will take months to produce its recommendations, and the administration isn’t required to follow through on any of them.
- The FDA this week announced another committee to study the agency’s own response to the opioid epidemic. Again, it’s a positive step. But it’s unclear what, if anything, will come out of it.
- Health and Human Services Secretary Tom Price recently acknowledged that opioids are an issue of public health, not criminal justice, but he also argued that medication-assisted treatment — which essentially uses drugs to medicate opioid addiction — is “just substituting one opioid for another.” This is a common myth that has been used to denigrate and restrict medication-assisted treatment, even though it’s considered the gold standard for opioid addiction treatment and has decades of research behind it. (A spokesperson later said, though, that Price supports all kinds of drug treatment.)
- Attorney General Jeff Sessions earlier this month rescinded an Obama-era memo that told federal prosecutors to avoid some of the harshest charges on low-level drug offenders. He instead told prosecutors to “charge and pursue the most serious, readily provable offense,” calling this concept “a core principle” of the Justice Department.
The only concrete action on this list is Sessions’s memo, which doubled down on the old war on drugs. But the research suggests that this “tough on crime” approach — focused on increasing criminal penalties for drugs to, hopefully, deter drug use — just won’t work.
For example, a 2014 study from Peter Reuter at the University of Maryland and Harold Pollack at the University of Chicago found there’s no good evidence that tougher punishments or harsher supply-elimination efforts do a better job of driving down access to drugs and substance misuse than lighter penalties. So increasing the severity of the punishment doesn’t seem to do much, if anything, to slow the flow of drugs.
Similarly, a 2015 review of the research by the Brennan Center for Justice estimated that more incarceration explained only about 0 to 7 percent of the crime drop since the 1990s, while other researchers estimate it drove 10 to 25 percent of the crime drop since the ’90s. That’s why criminal justice experts now emphasize that there are better ways, from new policing tactics to more stringent alcohol policies, to bring down crime without resorting to longer prison sentences.
The punitive criminalization of drugs is also sometimes a reason that drug users don’t seek care. Reporter Maia Szalavitz, who’s covered addiction for decades, has long argued that criminalization just leads to stigma, which pushes drug users underground. And a 2009 report by the libertarian Cato Institute found that after Portugal decriminalized all drugs, more drug users sought treatment because the policy change removed the fear of arrest and the stigma attached to it.
At the same time, Trump has, if anything, vowed to reduce funding on opioid addiction care through his budget cuts — contradicting his campaign promise to “spend the money” on drug treatment.
Trump’s budget cuts could make the core opioid problem worse
The fundamental problem in the opioid crisis is that America needs to put a lot more resources toward drug addiction prevention and treatment.
In 2016, the surgeon general released the most comprehensive analysis of the state of addiction in America. Its core finding was that the US massively underfunds addiction care. It found, for example, that just 10 percent of Americans with a drug use disorder get specialty treatment, in large part due to a shortage in treatment options.
The Obama administration took some steps to alleviate this. It dedicated $2.5 million in 2015 to fight heroin use. Its Department of Health and Human Services also unlocked more than $100 million for drug treatment in 2016. And Congress in 2016, with Obama’s approval, allocated $1 billion over two years to combat the opioid epidemic.
But experts widely agree that this all was far, far from enough. They have hoped that Trump would do more, given that some of his biggest areas of support are places that have been hit hardest by the opioid epidemic.
“We need a massive increase in funding for addiction treatment,” Kolodny argued. “We’re not going to get anywhere in terms of reducing overdose deaths until you have very low threshold access to buprenorphine treatment or methadone in some cases” — referring to two medications used for treating opioid addiction.
Beyond drug treatment, the federal government could do more to stop doctors from prescribing so many opioid painkillers, whose overprescription launched the epidemic. The FDA, for example, could limit how drug companies promote opioids, forcing them to follow CDC recommendations to not use the drugs for chronic non-cancer pain. (There is no good scientific evidence for the use of opioids for chronic pain, while there’s plenty of evidence that prolonged use can result in very bad complications, including a higher risk of addiction, overdose, and death.)
Instead of doing any of this, Trump has proposed cutting public health programs and Medicaid, and he’s pushed to repeal Obamacare without a replacement that would cover Americans’ health insurance needs.
More broadly, Trump has done nothing to address the structural issues behind drug addiction — the poverty, joblessness, deteriorating communities, and other common contributors to despair that lead to drug addiction. “If you look at overall public health trends, there are a lot of things like alcohol use and suicide that have increased in concert with opioid use,” said Leo Beletsky, a professor of law and health sciences at Northeastern University. “That speaks to underlying, larger problems.”
It’s not unusual for Trump to make a promise and do the opposite. But in this case, people’s lives are quite literally at stake — and his administration is at best dawdling and at worst taking steps that will make a very deadly crisis even deadlier.