Trump's Attacks on the ACA Could Worsen the Opioid Crisis

Trump’s Attacks on the ACA Could Worsen the Opioid Crisis

Trump advisor Kellyanne Conway seemed to be playing damage control last week during a press call highlighting the White House’s efforts to address the nation’s opioid woes. While President Trump was busy defending his decision to declare a “national emergency” on the southern border, his administration came under fire for its milquetoast response to the overdose crisis. Trump declared a public health emergency back in 2017, but the White House did not release a national drug control strategy until January 2019, and federal auditors said it lacked measurable objectives for reducing opioid-related deaths and other hard numbers required by Congress. Lawmakers were furious, demanding the administration explain just what it is doing about the epidemic.

Conway rattled off statistics about public awareness campaigns and controversial new federal guidelines for prescribing painkillers, but the meat of Trump’s public health response to opioids comes from a $6 billion package passed by Congress last year. With new authority from Congress, the Trump administration is expanding public spending on addiction treatment through Medicaid and other federal programs, according to senior administration officials. For example, one reform lifts restrictions on Medicaid funding for opioid disorder treatment in mental health facilities.

“This is huge because it supports victims in the opioid crisis by removing a decades-old barrier to care by allowing state Medicaid programs to provide treatment at an institute for Medicaid patients with substance-use disorder for up to 30 days,” Conway said.

Conway didn’t mention that civil rights and mental health groups had opposed this section of legislation because they fear it would misdirect badly needed treatment resources. The next day, the National Academies of Sciences reported that 80 percent of people living who needed treatment for an opioid use disorder in 2017 did not receive it, largely because institutional barriers make it difficult for patients to access federally approved addiction medications. In fact, about 80 percent of people living with any type of substance abuse disorder went without treatment, with 30 percent citing a lack of health coverage or ability to pay, according to federal data. That same year, drug overdose deaths peaked at around 70,000, and preliminary data from 2018 suggest that fatal overdose rates remain sky-high.

Medicaid covers nearly 40 percent of nonelderly adults living with an opioid use disorder. In the years following its expansion under the Affordable Care Act (ACA), the program drastically increased spending on medication-assisted treatments (MAT) for opioid addiction, including methadone and buprenorphine. Still, the National Academies of Sciences insists that too many institutional barriers to these lifesaving treatments remain in place, which may explain why Conway highlighted modest moves to remove some of them.

Then, a week later, the Trump administration threw a giant wrench in any effort to tackle opioids with Medicaid when the Justice Department announced that it would ask federal courts to throw out the ACA entirely. This would include popular provisions expanding Medicaid coverage to 12 million people and protecting patients with preexisting conditions, such as opioid use disorder. Critics quickly pointed out that Trump is threatening to undercut his own health policies in his quest to undo President Obama’s signature achievement.

“Medicaid expansion has greatly increased access to methadone and buprenorphine to treat opioid use disorders,” said Jeremiah Goulka, a senior fellow at Northeastern University’s Health In Justice Action Lab, in an interview. “Even though we still have a long way to go to ensure that people who want MAT can receive it, dismantling the ACA would be a turn in the wrong direction.”

This is the story of the Trump administration’s response to the overdose crisis: Efforts that address opioid addiction with compassion and medical treatment are overshadowed and even undermined by Trump’s agenda, pitting public health advocates against right-wing ideologues intent on gutting the social safety net and waging the war on drugs. Trump is using overdose deaths to justify lavish funding for law enforcement and his precious wall on the border with Mexico, but critics say this heavy-handed approach is making the illicit drug supply more dangerous and reinforcing stigma that drives people living with addiction away from services.

Standing in the Way of Public Health

Perhaps nothing sums up the Trump administration’s approach to opioids quite like its effort to derail Safehouse, a proposed safer drug consumption site that would serve people living with opioid addiction in Philadelphia’s Kensington neighborhood. Safehouse is a faith-based nonprofit that wants to provide a range of overdose prevention and harm reduction services that are badly needed in Philadelphia, where rates of fatal drug overdoses are some of the highest in the country. The Trump administration has responded with aggressive legal action in an attempt to criminalize the entire project.

After commissioning a study and examining the issue for months, city officials declared that they would not stand in the way of facilities like Safehouse, where people would use their own opioids under medical supervision with easy access to clean syringes and referrals to addiction treatment. While Safehouse would be the first facility of its kind in the U.S., studies on safer consumption sites in other countries show they reduce overdose deaths, prevent the spread of disease and help people living with addiction to stabilize their lives, making it easier to take steps toward recovery when they are ready. Safe consumption or “supervised injection” sites are often located in areas similar to Kensington, where addiction and homelessness are intertwined and public drug use is common.

With rates of fatal overdose remaining stubbornly high despite the government’s multibillion dollar attempts to contain them, approaches once considered unconventional are making sense to policymakers in Philadelphia. Former mayor and state governor Ed Rendell sits on Safehouse’s board, and last week he announced that an anonymous developer who lost a loved one to an overdose agreed to donate a building in a strategic location for the project. Philadelphia’s district attorney has pledged not to intervene.

The logic behind a space like Safehouse is simple. People living with opioid use disorders must use opioids to avoid debilitating (and potentially fatal) withdrawals, so they are likely to continue using in the absence of medical treatment. Opioid use disorder is a chronic disease, and relapse into drug use after a period of recovery is common. With drug use comes social stigma and the very real fear of arrest. Using in a space where medical staff are on hand to reverse a potential overdose and treat health problems that can result from injecting drugs is drastically safer than, say, shooting up in a quiet alley or a private bathroom.

The Trump administration is having none of this. In February, U.S. Attorney William McSwain filed a civil lawsuit against Safehouse that asks a federal judge to declare the proposed facility in violation of a section of federal law written during the anti-drug hysteria of the 1980s to target “crack houses.” Last year, Deputy Attorney General Rod Rosenstein threatened legal action against any city or state that pursues safer consumption facilities, putting a chill on efforts in California and Seattle. Still, Safehouse is pushing forward with its plans, confident that safer consumption will win in both federal court and the court of public opinion.

Like President Trump, McSwain says the feds are doing plenty to combat the overdose epidemic, even as they attempt to block groundbreaking harm-reduction projects. When announcing the lawsuit against Safehouse, McSwain highlighted the aggressive prosecution of several people accused of distributing opioids, including Emma Semler, a 23-year-old who gave a fatal dose of heroin to a friend while they were using together. The two women met in rehab, according to reports, but the government has responded to the tragic death of one by jailing the other. Does holding Semler responsible for her friend’s death make sense when both women struggled with the same chronic illness and the social stigma that comes with it?

“If the Trump administration is going to pretend to support a public health response, then it should support actual public health responses, and it should stop undermining them through drug-induced homicide prosecutions and threats against cities looking to open safe consumption facilities,” Goulka said.

The Iron Law of Prohibition

So, what is Trump doing about opioids? The White House is primarily focused on reducing painkiller prescriptions, preventing drug use through youth education programs, and aggressively pursuing the black market supply of opioids. Not only do these strategies fall squarely into decades of conservative tradition (think Nancy Reagan and “Just Say No”), they also aid Trump’s push to militarize the border with Mexico and build “the wall.”

Fentanyl, the powerful synthetic opioid driving overdose rates, has become cannon fodder for Trump, allowing the president to blame death in the U.S. on foreign drug traffickers supposedly crossing the southwestern desert. No matter that most drugs are thought to enter the country at legal ports of entry, a fact Trump has repeatedly denied, or that the war on drugs has made the U.S. the most incarcerated nation on the planet. Trump has repeatedly hauled drug agents and border police in front of the press to make a case for enhancing border security, but that could make the epidemic even deadlier.

Since 2017, federal agents have seized 16,000 kilos of heroin, and in 2018, border agents have seized enough fentanyl to kill 90 million people along the southern border, according to a White House fact sheet released after Conway’s press call. Does this mean Trump’s obsession with border security is saving lives? While these numbers look good on paper, people living with opioid disorder remain dependent regardless of the amount of drugs seized at the border or the number of traffickers arrested. The war on drugs was built around such “supply reduction” strategies, and over the decades experts have concluded that they are not cost-effective and potentially harmful.

A paper published in the International Journal of Drug Policy examines the parallels between the current fentanyl crisis and the era of alcohol prohibition, when gangsters circumvented law enforcement to supply a thirsty public with its favorite intoxicating drug. As cops cracked down on alcohol, bootleg liquor became much easier to produce and transport than beer and wine, so the price of strong booze dropped relative to weaker spirits (if consumers had a choice in libations at all). Prohibition certainly didn’t keep Americans from drinking, but it did force consumers toward stronger (and potentially adulterated) drinks — and all the health problems that come with them. This is known as the The Iron Law of Prohibition; when demand for illicit drugs remain steady, tougher law enforcement means harder drugs on the street.

Fast forward to today. Crackdowns on prescription painkillers are pushing people with chronic pain and opioid use disorders toward street drugs like heroin, and heightened law enforcement efforts to interdict the heroin is pushing traffickers to smuggle more concentrated products in smaller packages. This helps explain the rise of synthetic opioids like fentanyl, which contributed to a 45 percent increase in opioid-related deaths from 2016 to 2017 while deaths from heroin and prescription painkillers remained stable, according to the Centers for Disease Control and Prevention.

“If you add substantial barriers and costs to the drug supply but fail to take adequate efforts to reduce demand, the effect is to create direct incentives for traffickers to minimize the volume of the trafficked goods while maximizing their potency, so you can maximize profits,” Goulka said.

It’s simple, deadly economics, and it’s supplied Trump with plenty of ammo for his beloved wall, even as law enforcement agencies embrace the same drug war policies that have failed to reduce both the supply and demand for drugs over the past four decades. For Trump, opioids are the perfect bogeyman, a scourge smuggled over porous borders by foreign advisories in China and Mexico that conjure up the racist, anti-drug hysteria of yesteryear. Unfortunately, such propaganda ignores that fact that even potent opioids like fentanyl can be useful medicines, and plenty of people are able to use them without becoming addicted.

For those who do develop opioid disorders, there is still much more that the administration can do. The National Academies of Sciences reports that heavy restrictions on methadone and buprenorphine are no longer supported by medical evidence. Drug overdose is the most common cause of death among people recently released from jail or prison, but many sheriffs and wardens still refuse to provide MAT behind bars to anyone besides pregnant people. Trump could demand they stop dragging their feet, but what’s the point in incarcerating people with opioid disorders to begin with? If Trump was serious about stopping the overdose epidemic, he could join other world leaders in calling for the decriminalization of drugs instead of attempting to arrest his way out of a public health dilemma.

All of this is unlikely because drug criminalization remains at the heart of Trump’s worldview and agenda. Conway said the opioid crisis is a “legacy issue” for the president. As it stands today, Trump will be remembered for undermining the health care system and fighting a war on drugs that should have ended years ago.