The year of 2016 has been one of great strides for the addiction community. We saw the passage of the Comprehensive Addiction Recovery Act, record federal funding dedicated to opioid abuse and other substance use disorder (SUD) issues, and, for the first time, politicians running for election and re-election addressing drug abuse as a public policy priority.
We’ve made good strides within the criminal justice system as well. From drug courts, veterans courts and the expansion of medication assisted treatment (MAT) in the criminal justice system to sentencing reform for simple possession crimes and reforms of mandatory minimum laws, there has definitely been a shift at the federal level away from enforcement and towards treatment.
Despite all of this progress, however, the number of U.S. deaths from opioid overdose is still consistently rising, having roughly quadrupled since 1999. In 2014, the Centers for Disease Control and Prevention (CDC) reported an astonishing record of more than 28,000 overdoses. Curiously enough, the problem is especially flagrant in rural corners of the Rust Belt where Trump support proved the strongest on Election Day. Now, with his January 20 inauguration fast approaching, the severity of the issue lies on his shoulders and administration.
Though it’s impossible to know for sure what Trump will do once he gets into office, one thing that we have seen is he’s come a long way from his initial understanding of addiction. In the beginning, during his campaign trail in October, he referred to addiction as a “habit” rather than a disease and focused primarily on trafficking and enforcement as an antidote. It was quite a simple plan by his words: “I’m going to get the government of Mexico and other governments to stop. We get the drugs, they get the money. Big vans coming across, drugs coming in, money going out. Those days are over, folks."
However, if you give two cents to what the DEA says, you will know that there will always be a market for trafficking. Our current enforcement manpower and criminal justice system only feasibly allows us to seize 20 percent of the supply coming across the border. This is not a top national secret either. The cartels know fully well our limitations and actually factor in this 20 percent loss into their business model. It’s evident that nothing—not even a wall—can stop this type of workflow. (Take this, for instance.)
Fortunately enough, things did take an encouraging turn towards the end of Trump’s campaign at a roundtable in New Hampshire made possible by the Addiction Policy Forum when he spoke about the topic in a much more comprehensive manner. Trump praised the passage of CARA and promised to expand incentives for states to use drug courts and mandated treatment for those with substance use disorders. He also proposed dramatically expanding access to drug treatment and altering Medicaid policies that obstruct inpatient treatment, such as the Institutions for Mental Diseases (IMD) exclusion, while also improving the availability of Narcan, an opiate antidote used to reverse overdoses, to first responders. Trump also plans to restore the accountability of the Veteran's Administration by granting accessible support and resources to U.S. veterans with substance use disorders. All of this, no doubt, sounds good and, if all goes according to plan, is a step in the right direction.
Of course, in the world of politics, we always need to take a look at the bigger picture. The reality is that under Trump and a GOP Congress, federal spending will be, in a word commonly quipped by the man himself, a “total disaster.” Due to the federal sequester that was established in 2011, the spending caps in the 2018 fiscal year will be harsh and impact all domestic programs if Congress does not take action. David Reich of the Center on Budget & Policy Priorities reports that the budget will cut those programs by $47 billion (or $58 billion in inflation-adjusted terms) for 2018 and then freeze funding at that level for the next eight years. This will then additionally leave inflation to steadily erode the value of that spending level.
In fact, by 2021, the same report says that House budget’s level for non-defense appropriations will be $83 billion (15 percent) lower than what would occur if the caps and the additional cuts from sequestration were left fully in place. Since public spending accounts for 70 to 80 percent of SUD services, it’s important to note that when federal spending suffers, SUD treatment inevitably suffers as well.
Another important thing to note is that opioids and SUD programs in general are part of a greater public health continuum, and do not exist in a vacuum. That is, many people who require opioid treatment require other health services as well, and are reliant on other federal programs to help them in their recovery. These programs are vital in cutting back on recidivism and ensuring that people stay healthy upon completing treatment. In order to keep these programs running, the most productive thing we can do as a concerned society is advocate for an increase in government non-defense spending in the 2018 fiscal year.
The Power Players
Based on how Trump has been managing his powers so far in the past month, it is highly possible that he will be a hands-off President and giving his Cabinet members much more free reign in overseeing their areas of expertise. That’s why in order for us to have a better idea of what addiction treatment is going to look like, we need to take a closer look at who he has elected, starting from Vice-President Elect Mike Pence.
Mike Pence has been the Governor of Indiana since 2013 and, according to the CDC, the state has had one of the fastest growing overdose death rates in the country. On November 26, 2016, the Lafayette Journal & Courier explained this troubling trajectory in due part because “Indiana tries to treat drug addiction as a criminal problem instead of a medical problem.” It was also widely known that Pence opposed needle exchange programs, even in the instance of a major HIV outbreak that prompted a public health emergency for Scott County. Only then did he finally allow for a needle exchange in which Carrie Ann Lawrence, of Indiana University’s Rural Center for AIDS/STD Prevention said, “The [CDC] pretty much said you need to do this.”
Another person that Trump has elected to his cabinet is Attorney General appointee Jeff Sessions. As far as he’s shown in his past voting record and actions, Sessions has maintained the mindset of drug use as a moral behavior. He has been quoted as saying that “good people don’t smoke marijuana,” a typical “drug addicts are bad people” mindset that has taken our nation decades to get out of. Now that we are finally on the cusp of true reform, Sessions can be a serious threat to our priorities at the Department of Justice. On top of that, Senator Sessions is also a supporter of mandatory minimum sentences for drug possession and opposes sentencing reform, claiming that “it is seldom effective.”
More recently, Trump also elected Rep. Tom Price to head the Department of Health and Human Services. Price has always been an outspoken opponent of the Affordable Care Act, which categorizes substance use and mental health disorders as an “essential health benefit.” He voted Yes on CARA (along with 399 members of the House) but is characterized as quite the budget hawk, which does not bode well for programs like the Substance Abuse Prevention and Treatment Block Grant (SABG). He is the author of the Empowering Patients First Act, which is one of the most thorough and detailed proposals to repeal and replace Obamacare. And as for his stance on opioids, only time will tell.
Over the course of the month, as things further settle and fall into place, we as a nation will have an even better idea of where the Trump administration is taking us. Addiction is a disease and will always be around. While it’s true that the issue of addiction will not be close to solved under the hands of any one party, the next four years can bring our nation towards the direction of recovery or an even lower bottom. And if we’ve learned anything at all in 2016, it’s that anything can happen.
Information for this article was provided by Andrew D. Kessler, Founder and Principal of Slingshot Solutions LLC, a consulting firm that specializes in behavioral health policy. He collaborates frequently with congressional offices, the White House Office of National Drug Control Policy, the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and other federal actors. He recently held a live webinar sponsored by Rx Summit titled “The 2016 Election: What the Results Mean for Addiction Treatment Programs and the Opioid Epidemic.”