The opioid epidemic remains one of the US’s worst public health crises — with 2018 ending up as the second-worst year for overdose deaths in US history, behind 2017. But you wouldn’t know that from listening to the Democratic presidential campaigns.
The omission is striking, especially given the importance of New Hampshire to the 2020 Democratic primaries. As recently as 2015, New Hampshire ranked second for overdose deaths in the US. It dropped to sixth by 2018, but mostly because overdoses in other states got much worse; New Hampshire’s overdose death rate in 2018, while 9 percent lower than it was at its peak in 2016, is actually higher than it was back in 2015. Nearly 500 people still die of overdoses in New Hampshire each year.
Yet in the lead-up to the New Hampshire primary election, the Democratic candidates haven’t focused much on the opioid crisis. Aside from October’s debate (when the moderators asked about it), it’s been mostly missing from the debates. On the campaign trail, candidates have mostly raised the issue when directly asked about it by voters (with some exceptions) or in the context of broader issues about health care, mental health, drug companies, and criminal justice reform.
Some of that may reflect reduced attention from the general public. In 2016, solving the opioid crisis was at the top of the priority list for New Hampshire voters of both parties, even topping the economy overall in one survey. Hillary Clinton said she made the opioid epidemic a priority after hearing about it from voters. President Donald Trump reportedly credited his Republican primary victory in New Hampshire to the state being, as he put it, “a drug-infested den.”
But in recent polls, Democratic voters in New Hampshire haven’t put much emphasis on the issue. It barely registered in a WBUR poll released in January, especially in comparison to the top three issues of health care, climate change, and the economy (although health care might include the opioid epidemic and addiction for some voters).
Still, that’s not a reason for neglecting the crisis. In the past decade, the opioid epidemic was one of the key reasons US life expectancy fell overall for three years straight. And even though there was a 4 percent decline in overdose deaths in 2018, the year was still the second worst in American history for such deaths, as states like New Hampshire continue to suffer disproportionately.
This is also an issue that Democrats would do well to take from Trump. Trump has a good narrative going into the 2020 election on the opioid epidemic, largely because the decline in overdose deaths in 2018 was the first such fall in the death toll in 28 years. It also might let Democrats make a play for areas that Trump flipped from blue to red in 2016: Historian Kathleen Frydl found that many of the Ohio and Pennsylvania counties that went from President Barack Obama to Trump that election year were hit particularly hard by the opioid crisis.
The good news is that if Democrats want to take this advantage away from Trump, they have a lot of room to do so. Despite his lavish campaign promises and occasional stunts, Trump has done very little of significance on the opioid crisis. Meanwhile, the top-polling Democratic candidates have plans — good plans! — that could help combat the epidemic.
If only they talked more about those proposals.
The candidates have plans. They should talk about them.
One of the most surprising things about Democratic candidates’ relative silence on the drug overdose crisis is that the candidates generally have very solid plans for tackling the issue, including Sen. Elizabeth Warren (D-MA) and Sen. Amy Klobuchar (D-MN).
The star here is Warren’s $100 billion plan to address the opioid crisis, particularly by investing in addiction treatment and harm reduction strategies. This was the first proposal that committed the tens of billions of dollars experts say is needed to combat the opioid epidemic.
As Stanford drug policy expert Keith Humphreys previously told me, the CARE Act, as it’s called, “is the only one that really grasps the nettle of how big the problem is. Whatever else people might say about it, this is the first thing that really recognizes that [the opioid crisis] is a massive public health problem, like AIDS, and is not going to be solved by a tweak here, a tweak there.”
Other candidates, including Sen. Bernie Sanders (I-VT), have backed the bill. Sanders even references it as part of his agenda to stop the opioid crisis. Klobuchar also signed on to it.
Since the CARE Act was introduced in Congress, some of the candidates have also put out similarly ambitious proposals. Klobuchar proposed a $100 billion plan to deal with mental health and addiction. Former South Bend, Indiana, Mayor Pete Buttigieg released another plan that would, among other changes, also spend $100 billion over 10 years on addiction and mental health services.
Separately, the candidates have put out all sorts of plans that directly or indirectly touch on other aspects of the opioid crisis. That includes criminal justice reform efforts to divert drug offenders from prison and jail to treatment. It includes more emphasis on and support for harm reduction strategies, like the opioid overdose antidote naloxone, needle exchanges, and supervised consumption sites. The candidates have also put out many proposals to hold pharmaceutical companies and their executives accountable for their role in the crisis.
Contrast that with Trump’s actual policies and proposals. Although Trump promised to “spend the money” to solve the crisis while on the 2016 campaign trail, he’s only authorized $3 billion extra a year — far from the tens of billions of dollars that experts say is needed and the Democratic candidates are committing to. His broader proposals to repeal Obamacare and cut Medicaid would likely make the opioid epidemic worse; researchers estimate that Obamacare expanded health care, including treatment, to hundreds of thousands of people with addictions, and a recent study linked Obamacare’s Medicaid expansion to a 6 percent reduction in opioid overdose deaths.
Meanwhile, what Trump has implemented or moved toward has been largely ineffective. He’s boasted about the ability of a wall at the US-Mexico border to stop the flow of drugs into the US, but experts have panned the idea in large part because most drugs come into the country through legal ports of entry that the wall does nothing about. Trump called for using the death penalty on high-level drug dealers, but that idea is discredited by research showing that tougher criminal penalties don’t slow the flow of drugs into the US. He declared a public health emergency over the opioid epidemic, but the US Government Accountability Office found the declaration led to almost nothing.
Trump’s failures are reflected in the overdose data. While overdose deaths declined overall in 2018, that was primarily the result of a fall in overdose deaths linked to opioid painkillers — and that’s likely attributable in part to a drop in opioid prescriptions that began in 2010, seven years before Trump took office. Meanwhile, overdose deaths due to synthetic opioids (such as illicit fentanyl), meth, and cocaine all went up — a testament to Trump’s inaction when it comes to treatment, harm reduction, and treating the underlying causes of drug use and addiction.
In short, this is a vulnerability for Trump — one that Democrats could take advantage of.
But you rarely hear about any of this. At the one debate in which the candidates talked at some length about the opioid crisis, they focused their attention on going after big drug companies and pharmaceutical executives for their role in the epidemic. That’s good, but it neglects the same parts of the problem that Trump has, particularly treatment and harm reduction.
This is one of the few areas in which something big could happen
There’s another reason the Democrats should focus on this problem: It could be one of the few areas in which a Democratic administration gets much done.
Democrats have all sorts of ambitious proposals, from health care to climate change to gun violence. The reality, though, is these are also extremely controversial and partisan issues — which are unlikely to go anywhere if Republicans maintain control of the US Senate or even if Democrats net a narrow majority there.
The opioid epidemic, however, is an issue ripe for more bipartisan attention. Several Republican senators, including Rob Portman (OH) and Shelley Moore Capito (WV), have shown a lot of interest in getting work done on the crisis. Among the few major bills that Trump has signed, an opioid epidemic bill was among them — even if it was criticized by experts for “simply tinkering around the edges.”
I’m skeptical if that means that, say, Warren’s $100 billion bill can pass. One of the things I have heard quite consistently from sources on the Hill is that Republicans in particular are very skeptical of spending too much money on addressing the drug overdose crisis. That dynamic will continue into a Democratic administration (maybe even more so as the GOP becomes resistant to giving a Democratic president a victory).
But starting from a place in which some Republicans and all Democrats are willing to work on an issue is certainly much better than a place in which no Republicans and not even all Democrats are willing to do something significant.
It’s also possible that the issue could become even more pressing in the next few years. If opioid painkiller overdose deaths plateau and deaths involving fentanyl, meth, and cocaine continue to increase, the next few years of overdose deaths could top records once again. That wouldn’t be unprecedented, as overdose deaths plateaued in 2012 before increasing to record highs in subsequent years. And experts have warned about the continuing spread of fentanyl and a potential stimulant epidemic.
So the next president, whoever it may be, should probably prepare for getting something done on the overdose crisis. Talking about the issue on the campaign trail is a good way to start.