State of the Union: Trump shouldn’t brag about his opioid epidemic response

President Donald Trump used Tuesday’s State of the Union address to take credit for a recent drop in drug overdose deaths and a reversal in the opioid epidemic.

“With unyielding commitment, we are curbing the opioid epidemic,” Trump said. “Drug overdose deaths declined for the first time in nearly 30 years. Among the states hardest hit, Ohio is down 22 percent, Pennsylvania is down 18 percent, Wisconsin is down 10 percent — and we will not quit until we have beaten the opioid epidemic once and for all.

It’s true that the number of drug overdose deaths in the US fell in 2018 — the first time that happened in 28 years, according to the Centers for Disease Control and Prevention. Overall drug overdose deaths declined from more than 70,000 in 2017, the highest overdose death toll on record, to more than 67,000 in 2018.

After decades of a worsening drug overdose crisis that’s now tied to nearly 770,000 deaths since 1999, the 4 percent decline is a welcome development. It does come with caveats: 2018’s overdose death toll was still the second highest in US history (after 2017), and there are red flags in the data that suggest things could still get even worse. Still, it’s good news.

But Trump doesn’t deserve the credit for the drop. The policies that likely led to a drop in overdoses largely preceded him, and Trump, despite all his talk on the campaign trail, just hasn’t done much on the crisis overall.

Trump’s drug policy and health care proposals could even make the opioid crisis worse, not better. From his calls for repealing Obamacare and cutting Medicaid to his advocacy for a wall at the US-Mexico border and the death penalty for drug dealers, his administration’s ideas range from the harmful to ineffective when it comes to addressing the opioid crisis.

That America is now seeing some good news in the opioid epidemic, then, may very well be in spite of Trump, not because of him.

The overdose numbers expose Trump’s failures

Trump’s failure is made clear in the actual overdose data.

The bulk of the decline in overdose deaths seems to be linked to a drop in painkiller overdose deaths of nearly 16 percent. That’s likely a result of government and other efforts to get doctors and other prescribers to cut back on opioid prescriptions. Although the US still generally prescribes far more opioids than the rest of the world, these efforts have been somewhat successful, with prescriptions steadily falling since 2010.

But that’s the thing: These efforts have been successful since 2010 — seven years before Trump took office. Much of the government messaging regarding overprescribing, like the CDC’s 2016 opioid prescribing guidelines, preceded Trump, even if he has kept such efforts going.

Rep. Robert Dold speaks to Nikkina Hankins and other student pharmacists from Howard University before an event unveiling a multi-state program to combat opioid abuse in Washington, DC, on February 9, 2016.
Gabriella Demczuk/Getty Images

Meanwhile, overdoses in other areas are actually going up. Drug overdose deaths linked to synthetic opioids excluding methadone — particularly illicit fentanyl, which is increasingly replacing heroin on the black market — increased by 10 percent. Overdose deaths involving stimulants with misuse potential, particularly meth, increased by nearly 22 percent. Cocaine overdose deaths increased by nearly 5 percent.

If these increases continue and prescription opioid overdose deaths plateau, as experts warn is possible, the overall overdose numbers could continue their climb up again. This wouldn’t be unprecedented; drug overdose deaths seemed to plateau around 2012 before reaching new record highs in the ensuing years.

This is where Trump’s failure becomes clear: Especially as people lose access to painkillers, some of them, particularly those still addicted to opioids, will seek out other, cheaper highs. That’s one reason why experts have long advised that it’s not enough to pull back on opioid prescriptions but to also make investments in addiction treatment, harm reduction policies, and other efforts that can address underlying causes of drug addiction.

Yet Trump has long neglected these areas. While Congress did reach a deal to increase spending on the epidemic, particularly treatment, by $3 billion each year and tweak some regulations to speed up responses to the opioid crisis, that’s still far from the tens of billions experts say is needed to truly scale up addiction care. The efforts also have done little to improve regulations and oversight on the addiction treatment system, which often fails to follow evidence-based practices yet loads patients with as much as tens of thousands of dollars in bills and debt — if they can afford treatment at all.

The result is the primary defense to America’s addiction problem is failing, with only one in 10 people with a drug use disorder seeking specialty treatment on any given year, based on federal data. And Trump hasn’t done much to change that.

In fact, what Trump has proposed would make addiction treatment even less accessible. He’s repeatedly called for repealing the Affordable Care Act (“Obamacare”) and advocated for cutting Medicaid. The ACA alone expanded access to health care, including addiction treatment, to hundreds of thousands of people with addictions. A recent study in JAMA Network Open linked Obamacare’s Medicaid expansion to a 6 percent reduction in opioid overdose deaths.

On harm reduction, Trump’s record is as weak. His surgeon general, Jerome Adams, has pushed more people to carry the opioid overdose antidote naloxone — a good step. But Trump’s administration hasn’t done anything significant to expand needle exchanges, one of the most proven harm reduction strategies with decades of evidence behind it. And his administration has actually fought some cities and states on their plans to establish the first legally sanctioned safe injection sites in the US (although, in fairness, the evidence for these sites is still a bit weak, if promising).

Other Trump ideas would be largely ineffective

One thing Trump has done is declare a public health emergency over the opioid crisis. But that led to almost nothing, as the Government Accountability Office concluded in a report. (The emergency declaration even lapsed for nine days in January, as Dan Diamond reported for Politico, and no one seemed to notice.)

Otherwise, Trump has boasted about the ability of a wall at the US-Mexico border to stop the flow of drugs into the US — an idea that experts have widely panned, not least because most drugs actually come through legal ports of entry that a wall does nothing about. He also called for using the death penalty on high-level drug dealers, which is discredited by the body of research showing tougher criminal penalties don’t slow the flow of drugs into the US.

President Trump delivers his State of the Union address on February 4, 2020.
Mandel Ngan/AFP via Getty Images

Trump’s administration has done some good things about the opioid crisis. The Food and Drug Administration in particular has taken steps to increase oversight and research on opioid painkillers, while encouraging more access to addiction treatment and more development of anti-addiction medications. The White House’s opioid epidemic commission also put out some good recommendations for addressing the overdose crisis, some of which were adopted in subsequent legislation.

Asked for comment, the White House also referred me to a list of the administration’s policy efforts in the past three years, including law enforcement programs and regulatory changes as well as the launch of FindTreatment.gov.

But what the administration has actually implemented and done falls short of the massive response that advocates and experts argue is necessary to reverse the deadliest overdose crisis in US history. When we’re talking about a public health crisis that kills more people in the US annually than gun violence, car crashes, and HIV/AIDS ever did, a few billion dollars and some regulatory tweaks and laws “tinkering around the edges” of the issue just aren’t going to cut it.

So it’s good news that drug overdose deaths fell in 2018. But it doesn’t mean victory over the opioid epidemic yet. And Trump can’t really take credit for what happened, anyway.

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