US Drug Policy: 2020
Drugs and addiction play a fascinating role in American society. Specifically, their impact on our political system and public policy. Modern US drug policy has been largely punitive. Although public opinion on addiction began changing during the rise of the “opioid epidemic” in the early 2000s; government policy largely remained the same until the election of Donald Trump in 2016. This post examines the changes the Trump Administration made around drug policy, as well as the Biden campaigns response on handling the topic. We will compare the two approaches while providing analysis on potential shortcomings in what’s ahead.
Donald Trump’s Drug Policy
If you type “President Trump drug policy” into a Google search the first thing you’ll notice is the critical tone directed towards President Trump’s drug policy. Included among the first page of results are the headlines Opioid Crisis: Critics Say Trump Fumbled Response; RNC 2020: Trump failed on the opioid crisis; and Too Little, Too Late just to name a few. What’s interesting is that it was President Donald Trump, in the wake of a nationwide opioid epidemic, who started shifting away from the draconian “War on Drugs” policies of years past. In fact, according to newly released federal statistics overdose fatalities declined in 2018 for the first time in 28 years. The Trump Administration’s approach to the opioid epidemic followed a three pronged approach:
“(First step) reducing demand and over-prescription, including educating Americans about the dangers of opioid misuse. (Step two) cutting down on the supply of illicit drugs by cracking down on the international and domestic drug supply chains that devastate American communities. (Third step) helping those struggling with addiction through evidence-based treatment and recovery support services.”Whitehouse.gov
Some of the criticism directed at Trump’s handling of the opioid crisis is the pushing of a partisan agenda, however some critiques are valid. Specifically, Trump’s proposal to enforce the death penalty for drug dealers, as well as attempting to use the opioid epidemic as validation for his US-Mexico border wall, have been rightfully questioned on their effectiveness.
Joe Biden’s Drug Policy
During the 2020 presidential campaign Joe Biden outlined an impressive plan to combat the opioid epidemic. Biden’s plan calls for $125 billion in funding over the next ten years to ramp up addiction treatment, along with other methods of prevention, to be funded through increased taxes on the profits of pharmaceutical companies. That figure made for the largest funding commitment from any of the presidential candidates during the 2020 campaign (vox.com). Biden’s plan effectively breaks down his response to the crisis into five categories:
- Hold accountable big pharmaceutical companies, executives, and others responsible for their role in triggering the opioid crisis.
- Make effective prevention, treatment, and recovery services available to all, including through a $125 billion federal investment.
- Stop overprescribing while improving access to effective and needed pain management.
- Reform the criminal justice system so that no one is incarcerated for drug use alone.
- Stem the flow of illicit drugs, like fentanyl and heroin, into the United States – especially from China and Mexico.
An area of strength to this proposal are the expansions in prevention, treatment, and recovery services. The $125 billion in federal funding not only goes towards traditional approaches like medically assisted treatment (MAT), in-patient and out-patient programs, but also towards prevention. For example: increasing accessibility to naloxone (the opioid overdose antidote), new education campaigns, recovery coaches, and peer support networks.
While the financial commitment of $125 billion is massively important, the proposed reform to the criminal justice system might be of even greater significance. In short, the plan aims to end incarceration of anyone convicted of strictly drug use. Instead of imprisonment the proposal will guide people with a substance abuse disorder towards treatment. This will be adone via social services such as drug court among others. Marking a monumental shift in US drug policy.
Drug Policy: Biden vs Trump
How will policy change now that Biden’s elected? In short, there are three major differences between Trump’s policy and Biden’s. Some of this being speculative since President Trump never released a comprehensive plan in as great of detail as Biden’s.
First, the policies diverge from the candidates support/opposition of the Affordable Care Act (ACA). Biden has advocated for broadening the ACA to “achieve universal coverage” and streamlining the inclusion of addiction into customary health-care practice under Medicare, Medicaid, the VA, and various other health plans. Conversely, Trump’s proposed repeal would have left a significant portion of the population without viable treatment options (potentially). Of course, this is a moot point since Joe Biden was elected President.
Second, resource allocation to build up the country’s infrastructure around substance abuse treatment and prevention. Historically, this infrastructure has been an embarrassment both in terms of funding and development in the United States. We finally started beginning to see some changes in 2018 through programs such as the Initiative to Stop Opioid Abuse. The Trump administration devoted $6 billion over two years towards the opioid epidemic. Previously (2017) the federal government distributed $500 million to states for addiction treatment. Biden’s proposal calls for $125 billion in federal funding over the next ten years.
Third, Biden’s policy promotes the disease model on substance abuse disorder (SUD) rather than a choice or moral shortcoming. President Trump’s initial focus appeared to center on helping people struggling with a SUD. However, the more we saw, the more punitive his policy became. This was evident both in the US-Mexico wall and proposing the death penalty to dealers and traffickers. Biden’s proposal calls for ending imprisonment for offenses that are entirely related to drug use.
Analysis: The Good
Take a moment and allow yourself and let yourself digest all of that information. We ought to recognize and commend President Trump for initiating the shift in drug policy as a result of the opioid epidemic. With that being said, the proposal Joe Biden outlined during the election campaign offers a far more comprehensive approach to addressing the issue. Essentially, Biden’s proposal takes everything that worked from President Trump’s drug policy and expands on it. For example: limiting supply through restrictions on the amount of opioids doctors prescribe, pressuring foreign countries (in particular China and Mexico) into halting illicit drug production, increasing the availability of Narcan (the opioid overdose antidote), and launching new ad campaigns around drug abuse.
In addition to this, President Biden’s proposal calls for massively increasing resources allocated to treatment and prevention when compared to present policy, while tossing out aspects that don’t seem to be working. The Comprehensive Addiction Resources Emergency (CARE) Act, introduced in 2019 and presently in the introductory stage at the House of Representatives, advises on $10 billion of federal funding annually to combat the opioid crisis. This figure is far more aligned with the federal investment of $125 billion over ten years we see in Biden’s plan.
Analysis: The Bad
Then there’s the bad… While the policy Biden’s proposing is without a doubt better than anything seen before in modern US politics, it still has significant shortcomings. We will examine five potential areas that could be expanded upon or are of concern:
- Narrow Scope of Opioid Centric Approach
- Possible Shortcomings to Supply & Demand Approach
- Potential Vacuum from Prescribers Drastically Reducing Prescription Practices to Current Patients
- Neglecting Evidence: Expansion of Treatment/Separation of Treatment & Recovery
- Disconnect with Public Opinion
Narrow Scope of Opioid Centric Approach
Notice how both the policies laid out by newly elected President Biden as well as the one implemented previously under Donald Trump narrowly focus on addressing opioids. This highlights one of the significant shortcomings to this sort of public policy.
Ideally the policy around addiction would, by extension, cover drugs. Such a policy should aim to be proactive rather than reactive. This might be earth shattering for some; but the reality is that addiction isn’t about drugs. Addiction is an obsessive compulsion for pleasure inducing (or pain avoiding) external stimuli. More importantly, given the significant data indicating the next drug epidemic will center on stimulant abuse, it would make sense to expand the scope of our approach. Which brings us to our next point…
Shortcomings to the Supply & Demand Approach
The aspects of Biden’s proposal aimed at addressing supply and demand falls into two different tiers. Domestically, focusing on the number of prescriptions given out by doctors. While internationally focusing on making reductions to the illicit drug market out of Mexico and China. These approaches are well and good in their intent, but are they practical?
First off, there’s the apparent issue in this approach abroad. China has no incentive to crack down on their drug manufacturing. Even if they could police supply (which they probably can’t), these chemicals are adjusted to skirt around international law faster than laws can be made. A fact reflected in reality that it’s still apparently stupid easy to buy powerful opioids like fentanyl online. As for the issues to this approach domestically…
Potential Vacuum Created Out of Immediate Reduction in Prescription Practices
Biden, much like Trump, promises to “stop overprescribing while improving access to effective and needed pain management,” with regard to the opioid crisis. The problem with this approach, as we’ve seen over the last four years, is that it creates a vacuum.
This vacuum effect forces patients now physically dependent into seeking out unpredictable illicit alternatives. These folks may very well need the medications. While the alternatives, like street heroin for examples, are much more likely to be fatal. This isn’t to say we shouldn’t push for decreasing opioid prescriptions. In fact we should return to no longer giving them out for chronic conditions. Nonetheless, this should be done gradually.
Neglecting Evidence: Expansion of Treatment/Separation of Treatment & Recovery
Now the solutions focused aspect in Biden’s policy: making effective prevention, treatment, and recovery services accessible to anyone in need. The truth of the matter is that we aren’t particularly efficient when it comes to treating substance abuse disorders. What’s missing here are the details as to what the administration would do to ensure treatment be evidence-based. We need to reassess the treatment industry as a whole. The industry requires stronger oversight, as well as regulation, to establish the highest level of care as well as success for patients receiving treatment.
Experts, activists, and providers have all voiced this area as concerning. According to drugabuse.gov anywhere from 40% to 60% of patients relapse after treatment. Approximately 74% of inpatient treatment facilities implement the 12-Step philosophy of Alcoholics Anonymous. What’s interesting is that addiction specialists claim 12-Step programs like AA and NA have a success rate between 8% and 12%. One might speculate industry norms allow for lazily developed curriculum based on the teachings of an almost 100 year old support group rather than advances in science. In short, we sorely need to expand on differentiating treatment from recovery.
Disconnect with Public Opinion
In a healthy, well run society public policy reflects public opinion. A shortcoming in democratically run political systems are the delays, or disconnects, between public policy and public opinion. Perhaps no topic better illustrates this reality in our country than the conversation around drugs and addiction. The latest Gallup poll shows support for the legalization of marijuana to be a record high sixty-eight percent. In fact, thirty-five states now allow for medicinal marijuana. Fifteen states, accounting for one third of the country’s population, have legalized recreational use. Every state that had the legalization of pot (for either medical or recreational use) on the ballot saw voters approve the initiatives.
No state took the discussion around drugs further than Oregon, where voters decriminalized personal amounts of virtually every drug. Offenders caught with a personal amount can either pay a fine or be accessed on whether or not they suffer from a substance abuse disorder. In which case the fine can be avoided in place of attending treatment. That’s not all, Oregon also legalized Psilocybin (magic mushrooms) for medical use. Whether or not you believe that to be a good idea is up for debate, it’s impossible to argue against it serving as an amazing social experiment on society.
If Not, Then What?
Anything that helps contribute to removing the veil of stigma around addiction provides a tangible benefit to society. Biden’s plan has three primary focuses: criminal justice reform, healthcare accountability, and supply & demand.
Both healthcare accountability as well as supply & demand have two parts. Regarding healthcare, the first makes effective prevention, treatment, and recovery services widely accessible to the public. The second holds large pharmaceutical companies responsible for their contribution to the opioid crisis. As for supply and demand, the first objective centers on ending practices of overprescribing; and the second on reducing the flow of illicit drugs, like fentanyl and heroin, into the country.
Shifting from a punitive drug policy towards one of supply and demand is no doubt an improvement, however it lacks significant comprehensive components. The narrow opiate focus, unrealistic expectations towards handling supply and demand, and silence on the expansion of evidence based treatment are only a few areas of concern. Not to mention we can’t have a healthy society if public policy doesn’t align with public opinion. Therefore, we’re still missing a significant piece to the puzzle that is federal drug policy.
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