The most striking thing about the first meeting of President Trump’s
Commission on Combating Drug Addiction and the Opioid Crisis, last
Friday, in Washington, D.C., was how normal it was, like a throwback to
some earlier, more rational Administration. Recognized experts on
addiction gave considered testimony, for which the commission’s
chairman, Chris Christie, politely thanked them. The physicians and the
advocates who testified made consistent, coherent points: We can’t
incarcerate our way out of the overdose epidemic, which now kills more
Americans than car accidents or gun homicide. Addiction is a chronic
brain disease, not a moral failing, and we need a national messaging
campaign to spread that idea. We should implement treatment that is
evidence-based—in the case of opioid addiction, this means opioid-based
medications, such as methadone and buprenorphine, which help curb
cravings and ease withdrawal symptoms, combined with psychosocial
support to help people rebuild their lives. We need to invest in
training medical professionals to handle addiction. People need health
insurance that allows them access to treatment.
Jared Kushner and Kellyanne Conway, representing the White House, sat
silently through the proceedings, but most speakers weren’t shy about
saying that the repeal of the Affordable Care Act would be a disaster.
Dr. Joe Parks, the medical director of the National Council for
Behavioral Health, pointed out that “Medicaid is the largest national
payer for addiction and mental-health treatment,” and that the Medicaid
expansion had been crucial to getting people into treatment in the past
few years. “We’re kidding ourselves if we don’t think that what is
happening over in Congress, regarding issues of health care, matters to
this issue,” Roy Cooper, the governor of North Carolina, who sits on the
commission, said, adding, “If we make it harder and more expensive for
people to get health-care coverage, it’s going to make this crisis
worse.” Another commission member, the former congressman Patrick
Kennedy, acknowledged that the fate of the A.C.A. is “the elephant in
the room.”
Unfortunately, almost nothing that the Administration has done so far to
address the opioid crisis reflects the commission’s welcome
reasonableness and seeming respect for expertise. It’s true that Trump’s
proposed 2018 budget includes five hundred million dollars for the
Health and Human Services department to fund opioid-addiction treatment
and prevention, but that amount was already allotted by the 21st Century
Cures Act, which Congress passed under President Obama. And the
Administration’s over-all message has been spotty and misleading. In
April, Trump fired the surgeon general, Vivek Murthy, who, last October,
had produced that office’s first report on drug addiction and helped
publicize the scientific evidence for medication-assisted treatment.
(Murthy probably got on the President’s wrong side because the N.R.A.
doesn’t like him—he has spoken often about gun violence as an important
public-health issue.) Trump has yet to appoint a new surgeon general.
Nor has he appointed a director of the Centers for Disease Control and
Prevention to replace Dr. Tom Frieden, who resigned on Inauguration Day,
or a new “drug tsar,” the head of the Office of National Drug Control
Policy. (The Administration originally proposed cutting almost all of
the office’s funding.)
Meanwhile, Attorney General Jeff Sessions has announced a reversal of
Obama Administration policy—and a good deal of bipartisan consensus—by
calling for a return to harsh prosecution and mandatory-minimum
sentencing for drug crimes. And Tom Price, the Secretary for Health and
Human Services, has floated some unnecessarily confusing notions about
the value of medication-assisted treatment. On a stop in West Virginia
during Price’s recent opioid-epidemic “listening tour,” the Charleston
Gazette-Mail quoted him as sounding skeptical about methadone and
buprenorphine, and bullish on “faith-based” approaches and the
opioid-antagonist drug Naltrexone, which is marketed under the brand
name Vivitrol. “If we’re just substituting one opioid for another, we’re
not moving the dial much,” Price said. “Folks need to be cured so they
can be productive members of society and realize their dreams.” That’s
the kind of talk that drives most addiction experts crazy, because it
stigmatizes medications that often work, and upholds the idea of “cure,”
instead of acknowledging that addiction is more like a chronic disease
that may need life-long management. Nearly seven hundred researchers and
clinicians signed a letter to Price, urging him to “set the record straight—medication-assisted
treatments meet the highest standard of clinical evidence for safety and
efficacy.”
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.” Feinberg also could see why some drug users would prefer it,
as it only has to be taken once a month, whereas methadone and
buprenorphine are administered in daily doses*, but she doesn’t
think that it should be promoted to the detriment of those medications.
Alkermes, the company that makes Vivitrol, has been promoting it
aggressively, as the Times recently reported, spending “millions of
dollars on contributions to officials struggling to stem the epidemic of
opioid abuse,” supplying “thousands of free doses to encourage the use
of Vivitrol in jails and prisons, which have by default become major
detox centers,” courting doctors, and buying billboards and other
advertising. Dr. Daniel Ciccarone, a professor at the University of
California San Francisco School of Medicine, who studies opioid use,
told me that Vivitrol is “a good tool in the tool box but its rapid
adoption and promotion are moving beyond the evidence base.”
It didn’t seem completely naïve to imagine that if Trump were elected he
might do something meaningful about the opioid crisis, if only because
it has struck the heart of his constituency—rural whites in Appalachian
states—especially hard. He spoke about the crisis fairly often on the
campaign trail, promising, on a stop in Columbus, Ohio, last August, for
example, that, “we’re going to take all of these kids—and people, not
just kids—that are totally addicted and they can’t break it. We’re going
to work with them, we’re going to spend the money, we’re gonna get that
habit broken.” But his efforts so far have been weak and scattered, and
his obsession with ending Obamacare could doom even those.
As many of the speakers at last week’s commission hearing testified, the
biggest setback in the fight against opioid addiction could come if
congressional Republicans succeed in carrying out Trump’s plan to gut
the A.C.A.’s Medicare expansion, which has insured so many low-income
people in states struggling with the
epidemic,
such as Ohio and West Virginia. Speaking about Ohio’s addiction crisis
earlier this year, Governor John Kasich said, “Thank God we expanded
Medicaid, because that Medicaid money is helping to rehab people.” A
new study by Eric Seiber and Micah Berman, public-health researchers at Ohio State University, found that, if the A.C.A. were repealed, almost no one in
Ohio who is currently covered by the Medicaid expansion would have any
viable insurance option. Other research,
from the Substance Abuse and Mental Health Services Administration
(SAMHSA), has found that people who have no health insurance are more
likely to misuse prescription pain medication.
Judith Feinberg is the infectious-disease physician* at an outpatient addiction program in Morgantown, West
Virginia, that currently treats five hundred and fifty people with
buprenorphine, and has six hundred people on its waiting list. Feinberg
says that ninety per cent of the program’s patients get their insurance
coverage through Medicaid. She asked, “What are they going to do if they
lose that? What happens to those people?” If the opioid commission is to
do any real good, it will have to answer those questions.
*An earlier version of this story misstated the frequency of dosage for medicated opioid-addiction therapy and Feinberg’s role in the outpatient clinic.