Earlier today, Politico provided a preview of what’s believed to be the broad contours of Trump’s grand plan for addressing the opioid crisis. But while some of the details include common sense measures embraced by public health and opioid experts, others are setting their nerves on edge.
The proposal, which might be fully revealed as soon as Monday, according to Politico, is expected to be a mix of law enforcement and health care policy changes.
On the health side of things, Trump reportedly proposes repealing a Medicaid rule that bars it from being used to pay for addiction treatment at large facilities, will ask the majority of Medicaid and Medicare providers to revamp how they decide to pay for opioid prescriptions to fit “best practices” within three years, and will call for the mandatory screening of new federal prisoners for opioid use along with providing avenues for treatment at halfway houses. Following the lead of many state agencies, Trump would also make it a priority to expand the access first responders have to naloxone, the medication used to rapidly reverse overdoses.
Ideas like expanding naloxone availability and giving Medicaid patients access to more treatment centers have received almost universal support from opioid researchers and doctors. But Stefan Kertesz, a clinical researcher in addiction at the University of Alabama at Birmingham, is suspicious of the proposed changes to Medicare and Medicaid prescription payment criteria.
“What is ‘best practices?’” he said in a email to Gizmodo. “Based on the last few years, I am worried that this expression is code for strict adherence to certain dose and duration thresholds for patients with pain, in violation of the CDC Guideline.”
Kertesz and many of his colleagues have already harshly criticized a proposal by the Centers for Medicare and Medicaid Services to impose mandatory restrictions on opioid prescriptions that would come into effect in 2019. These restrictions, while intended to prevent misuse, would also affect stable chronic pain patients on long-term opioid therapy, Kerterz says, and depend on a disingenuous reading of the CDC Guideline on prescribing opioids that was released in 2016.
“The CDC Guideline does NOT say to reduce such patients’ doses against their will, but legislators, health systems, and quality metric agencies have read it that way,” Kertesz said. “What it did say was to reduce our tendency to rely on opioids as first or second line responses to chronic pain and to be very cautious with dose escalation. That’s wise, and doctors had been making that shift since 2010.”
Kertesz is similarly worried about the White House’s claim that their plan will reduce opioid prescriptions by one-third within three years.
“I really do fear that the only way to reduce prescribing by one-third in a few years is forced dose reductions in currently stable patients,” he says. “Forced dose reductions have no data to support them whatsoever and in a number of instances they result in the death of the patient, sometimes due to suicide, sometimes due to overdose as the patient goes into crisis, sometimes due to medical deterioration.”
Kertesz himself has met with and studied some of these patients.
When it comes to law enforcement, Trump’s proposal is said to contain language that would call for the increased use of the death penalty in “certain cases where opioid, including Fentanyl-related, drug dealing and trafficking are directly responsible for death,” according to Politico. The policy reflects rhetoric Trump had spouted earlier this month during an White House Summit on opioid abuse. Another policy would try to make it easier to hand out mandatory minimum sentences for drug traffickers who are believed to knowingly distribute potent, synthetic opioids like fentanyl.
These ideas are unlikely to win much support from those like David Herzberg, a historian at the University at Buffalo who has studied past US drug policy.
“It would be hard to overstate how misguided and destructive the death penalty (and mandatory minimum sentences) idea is,” he told Gizmodo via email. “We’ve tried harsh punishments (including mandatory minimums and, at least on paper, the death penalty) repeatedly over the past century—in the 1920s, in the 1950s, in the 1970s/80s/90s—and every time, they have wreaked more harm rather than helping the communities they were supposed to serve/protect. Total disasters all.”
While some other ideas would be a step in the right direction, Herzberg says it’s unlikely Trump and his administration are capable of pulling them off.
“We clearly need supply-side clampdowns to rein in an out-of-control pharmaceutical industry and to repair medical and pharmacy institutions warped by their influence,” he said. “However, blunt, broad, one-size-fits-all versions of these policies could be incredibly damaging in a variety of ways, and very little that Trump has said makes me think he is interested in careful, nuanced policy implementation.”
And for those living with addiction who lose their suppliers or prescription drugs, Herzberg says, they’ll need more than just expanded access to naloxone or screenings at prisons.
“Even more important would be dramatic (yet careful) expansions of buprenorphine treatment, safe injection sites, etc. Putting more money into treatment is great—but we need to make sure those resources go towards public health approaches proven to save lives and protect health rather than pursuing abstinence (becoming ‘clean’) at any cost,” he said. “A lot of terrible things are done to drug users in the name of ‘treatment’—not just ineffective but, in some cases, tantamount to torture. It matters a lot what kinds of treatment they will make available.”
“And again, Trump does not inspire confidence that he is ready to set aside macho moralism and follow where the public health evidence leads,” he added.