Blog No. 149 Politics and the Scourge of Opioids: A Primer

There can be little doubt that the nation is in the grip of a serious opioid epidemic. Overdoses have been reported to be the leading cause of death of Americans under the age of 50 and the New York Times further reported that, on the basis of preliminary data, “drug overdose deaths last year likely topped 59,000 –19 percent more than the year before.” By way of comparison, about 34,000 Americans die in car accidents each year, and about the same number die from gun violence. In addition to overdose deaths, 2.7 million Americans were reported to be suffering from opioid dependence or addiction in 2015, with only about a quarter of them in treatment.

Congress has not been indifferent to the problem, but responses have been scattered. In 2016, Congress passed both the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act. With that legislation, there are now 33 federal drug programs that will receive over $5 billion in funding in 2017. (See Addiction Policy Forum.) It is not clear how opioid treatment will fare under the embattled healthcare bill in the Senate or under whatever version, if any, is ultimately passed. Critics charged that the “Better Care Reconciliation Act of 2017,” released as a “discussion draft” on June 26, would result in less Medicaid funding for addiction and make the present crisis significantly worse. It was later reported that as a part of negotiations over the bill, $45 Billion may be added for opioid treatment over ten years—impressive sounding, but some experts have called even that an amount that is woefully inadequate.

In the meantime, President Trump has created a Commission on Combating Drug Addiction and the Opioid Crisis, headed by by Governor Chris Christie. The choice of Christie seemed a logical one: he has been credited with effective work on the drug problem in New Jersey and he had spoken eloquently on the subject as a Presidential candidate during the primaries. (Unfortunately, his reputation and his influence within the administration may have been somewhat tarnished by the political embarrassment he suffered from the recent “Beachgate” incident.)

The federal officials on the Commission are Attorney General Jeff Sessions, Health and Human Services Secretary Tom Price, Veterans Affairs Secretary David Shulkin, and Defense Secretary James Mattis. Members from outside the federal government include Republican Governor Charlie Baker of Massachusetts and Democratic Governor Roy Cooper of North Carolina, Patrick Kennedy, a former Rhode Island congressman who has spoken of his own addiction issues, and Bertha Madras, a researcher at Harvard Medical School and McLean Hospital in Massachusetts. When the Commission held its first meeting on June 16, Jared Kushner and Kellyanne Conway were silent onlookers.

According to a release from the White House, the Commission has been instructed to undertake these:

• Identify and describe existing Federal funding used to combat drug addiction and the opioid crisis;

• Assess the availability and accessibility of drug addiction treatment services and overdose reversal throughout the country and identify areas that are under-served;

• Identify and report on best practices for addiction prevention, including health care provider education and evaluation of prescription practices, and the use and effectiveness of State prescription drug monitoring programs (PDMPs);

• Review the literature evaluating the effectiveness of educational messages for youth and adults with respect to prescription and illicit opioids; and

• Identify and evaluate existing Federal programs to prevent and treat drug addiction for their scope and effectiveness, and make recommendations for improving these programs.

The commission is to make recommendations on improving the federal response to opioid addiction and to produce a final report by October. After the final report, executive agencies are expected to take administrative and regulatory action to implement the commission’s recommendations.

It is not clear whether the Commission will have the time and resources to evaluate the numerous existing programs directed at opioids and other drugs. It is also not clear how, if at all, the Commission will  relate to the existing Office of National Drug Control Policy (ONDCP). Over the years, the head of that office has often been referred to as the ‘Drug Czar” but the position is currently vacant and no one has been nominated to fill it. The Trump administration initially sought to reduce funding of the office by 95 percent, but was met by strong resistance from both Republicans and Democrats on Capitol Hill. One of the leaders of the resistance, Senator Rob Portman of Ohio explained his position this way:

I’ve known and worked with our drug czars for more than 20 years and this agency is critical to our efforts to combat drug abuse in general, and this opioid epidemic, in particular. We have a heroin and prescription drug crisis in this country and we should be supporting efforts to reverse this tide, not proposing drastic cuts to those who serve on the front lines of this epidemic.”

As a result of efforts by Portman and others, the Trump budget for 2018 proposed $369 million for ONDCP, a cut of only five percent.

There are three fundamental elements to dealing with the drug problem: law enforcement, treatment and prevention, each of which gives rise to different issues. Notably the focus of the Christie Commission is to be solely on matters of treatment and prevention and does not touch on issues of law enforcement.

Law Enforcement. Law enforcement responsibilities reside not only in the Department of Justice but in various state, local and federal agencies, all of which the ONDCP seeks to coordinate. Attorney General Sessions raised a significant law enforcement issue when he issued a May 10 memo instructing federal prosecutors to pursue the “most serious, readily provable” drug offenses, even if they are nonviolent. The memo effectively nullified a policy put in place by former Attorney General Eric Holder that had instructed prosecutors to avoid charging nonviolent drug offenders with crimes that carry mandatory minimum sentences.

On June 7, a bipartisan group of Senators, including Republicans Mike Lee of Utah and Rand Paul of Kentucky, sent a well-reasoned letter to Sessions telling him that his memo will “result in counterproductive sentences that do nothing to make the public safer.” The letter accepted Sessions’s premise that it is important to “enforce the law fairly and consistently,” but went on to explain:

The problem is that, in many cases, current law requires nonviolent first-time offenders to receive longer sentences than violent criminals. Sentences of this kind not only ‘[undermine] respect for our legal system,’ but ruin families and have a corrosive effect on communities, and are not likely to reduce recidivism.

The letter was unlikely to have any effect on Sessions: as a Senator, he had been known for his opposition to sentencing reform proposals that would ease the requirements of rigid mandatory minimums that had contributed to the dismal phenomenon of mass incarceration. Such proposals are supported by a broad coalition of Democrats and Republicans, but Senator Sessions had been unimpressed.

Trump’s proposed border wall also represents a law enforcement approach to drugs, and the evidence remains very dubious that the coast-to-coast wall described by Trump is necessary or would be effective. Moreover, the likelihood that Mexico would pay for such a wall, as Trump has repeatedly promised, continues to seem remote, and there is little enthusiasm in Congress for sending the bill to American taxpayers.

Some argue that the “War on Drugs” has been a failure and that legalization across the board—not merely marijuana—is the only answer. The argument finds some support in the experience of European countries and is not entirely without force but, whatever its merits, it is unlikely to be a realistic prospect in this country any time soon.

Treatment. There are effective drugs to treat opioid addiction, but sometimes there is controversy over competing products. Margaret Talbot, writing in the New Yorker on June 21, described one such controversy involving Tom Price, Secretary of Health and Human Services. As Talbot explained, Price had expressed a preference for one drug (Vivitrol) over others (methadone and buprenorphine):

Price’s enthusiasm for Vivitrol also struck many addiction experts as unhelpful. Vivitrol blocks opioid receptors in the brain entirely, rather than binding to those receptors, as methadone and buprenorphine do. It’s not possible to get any kind of high from Vivitrol, and it has no street value. But it also has significant drawbacks: it’s expensive—more than a thousand dollars for a monthly shot—you have to be completely detoxified to use it, and there is significantly less data to support its efficacy in treating opioid addiction than there is for buprenorphine and methadone. Dr. Judith Feinberg, an addiction and harm-reduction researcher at West Virginia University, told me, “I can see why institutions like drug courts and prisons like it,” because it embodies “a certain punitive, puritanical attitude towards people in addiction.”

One suspects that this may be another example of science being “Trumped” by ideology.

For opioid addicts and their families, finding and gaining access to effective treatment may be a daunting prospect. Such treatment may, for example, require costly residential care extending over weeks or even months and even then there is no guarantee against relapse. Support for addiction treatment under Medicaid was expanded by Obamacare, but it is not known what the impact of new legislation may be. Addicts not eligible for Medicaid must rely on private insurance, where coverage varies, or personal assets. Presumably the financial burdens of treatment will be among the subjects addressed by the Christie Commission.

Prevention. Efforts to prevent addiction have focused most notably on attempting to rein in the over prescription and abuse of opiate pain killers. In March of 2016, the Centers for Disease Control issued guidelines recommending limitations on opioid prescriptions. The guidelines are not mandatory but are influential within the medical community (and were vigorously opposed by many doctors and facilities specializing in pain treatment). In addition, several states passed laws or adopted regulations limiting opioid prescriptions. Even before most of these measures had taken effect, opioid prescriptions had declined significantly over the period 2010-2015. Nevertheless, as reported in the New York Times on July 6, the prescription rate remained three times as great as in 1999 when the tide of opioid addiction began to swell. For their part, manufacturers have begun to provide opioid pills that are more difficult to convert to liquid or powder, the forms that most commonly lead to overdosing. But that approach, though helpful, has encountered pitfalls along the way. (See the Washington Post, “A drug company tried to make opioids harder to abuse. It backfired.”)

The principal federal support for drug abuse prevention at the local level comes in grants from the Drug-Free Communities Support Program jointly operated by ONDCP and the Substance Abuse and Mental Health Services Administration. The Program has two statutory goals:

1. Establish and strengthen collaboration among communities, public and private non-profit agencies, as well as federal, state, local, and tribal governments to support the efforts of community coalitions working to prevent and reduce substance abuse among youth.

2. Reduce substance abuse among youth and, over time, reduce substance abuse among adults by addressing the factors in a community that increase the risk of substance abuse and promoting the factors that minimize the risk of substance abuse.

In FY2016, the program awarded 698 grants totaling $85.9 million. The Christie Commission should evaluate the effectiveness of the efforts supported by the grants and consider whether the program should be modified or expanded.

One thing that the federal government does not appear to do, is to create, or fund the creation of resources that could be made available to communities all across the country for their use in drug education. One hopes that is something that the Christie Commission will consider: there is no reason why every community should have to re-invent the wheel in developing effective materials. More than thirty years ago, Nancy Reagan made famous the slogan “Just say no to drugs,” and some version of that message is timely and badly needed today. In Nancy Reagan’s day, the message was often conveyed simplistically and it was sometimes effective and sometimes not. But surely modern communications skills can be brought to the task of impressing upon young people and their parents the perils that drugs inevitably hold.

Just one example of the kind of thing that might be done was developed by a local organization in Ventura County, California, Not One More, that now has thirteen chapters around the country. Without benefit of federal funding, NOM produced a short video, “Poison,” dramatizing the story of an overdose victim and her family. It is not easy to watch, but I found it compelling and I recommend it to readers of RINOcracy.com. It might stimulate you to take an interest in finding out something about the drug situation in your own community.