As we head into the New Year and mark less than a month until Donald Trump is officially sworn in as our 45th U.S. President, questions still abound as to how his background, beliefs, and personal qualities will translate into policies that may shape our country for years to come. Many are still recovering from a sense Trump simply wasn’t supposed to be in this kind of driver’s seat. To be sure, he evolved from a candidate few believed would stay in the race to a kind of bullet-proof political persona who overcame multiple missteps to win the GOP nomination and eventually a seat in the White House. Some also believe that, if not still a bit of a mystery and contradiction, he might at least be unpredictable. Certainly, in spite of his propensity to talk and tweet up a storm, Trump revealed little in the way of concrete policies in the lead up to the election – choosing instead to broadly brand himself a “Washington outsider” committed to shaking things up in Washington. These factors, paired with a spirit of nervous anticipation as to the big challenges we face in the coming years, are fueling a great deal of conjecture, worry, and wonder as to what making “America great again” really looks like.
As the Surgeon General’s special report on addiction recently underscored, few issues have more immediate and long-term consequence than the way in which the incoming president addresses substance abuse and treatment. Yet, in this area too, the crystal ball under a Trump Administration is a bit foggy. Recent cabinet-level appointments and campaign trail comments by the President-elect offer some valuable clues and hints, but there is still a lot that simply has to play out. In other words, as another famous Donald – in this case, Rumsfeld – once famously said, there are a number of “known unknowns” (things we know we do not yet know) about what the addiction and recovery landscape will look like under Trump. Here are four key features of the new commander in chief’s drug policies we’ll be watching with interest…as we wait to see how they land:
- How efforts made to de-stigmatize, and humanize, addiction will be met and managed. Most experts agree that a big part of how we treat – in both the literal and figurative sense – those who suffer from substance use disorders flows from how we, as a society, view the problem. An increasingly compassionate, and disease- based dialogue regarding our nation’s continuing struggle with addiction in the last year or so has been encouraging and overdue. And, whether prompted as much by an expanding opiate crisis as by their own personal convictions, both President Obama and Hilary Clinton have promoted a more solidly prevention- and public health-based approach to America’s drug problem in recent months. That approach has gained bi-partisan support – and now at least partial funding – in the form of the Comprehensive Addiction and Recovery Act (CARA). Donald Trump has expressed support for CARA as a positive step forward, and he clearly wants to save lives that may be in the balance if people pick up again, or accidentally overdose. He has indicated he wants to expand the reach of naloxone and “make it easier for doctors to prescribe ‘abuse-deterring drugs.’” While campaigning in New Hampshire, Trump also advocated for expanding drug courts that would emphasize treatment and accountability over automatic criminal penalties for users. But beyond simple stump speech statements that recognize the immediate fallout we currently face, Trump has said little to suggest a full appreciation for how addiction impacts human brains and behavior. This might seem surprising from a guy who has a close personal connection to the issue. His older brother Fred’s advanced alcoholism and early death clearly made a lasting impression on the President-elect, prompting him to steer clear of drugs and alcohol completely. But even in this deeply personal context, Trump seems to be “all business” and little emotion, choosing to discuss that very powerful event as one that caused him to be more self-disciplined and determined –rather than compassionate and empathetic.
- Where education and treatment will fit into an approach to curtail use. Hilary Clinton’s proposed $10 billion plan to combat opioid and other addiction issues focused pretty squarely on reducing demand through targeted treatment, intervention, and education. She favored funding to improve existing treatment facilities and supported treatment facility expansion. She also consistently advocated for reducing childcare – and personal costs – for adults in treatment, requiring more guidance and stricter regulations for drug prescribers, and more expansive anti-drug education programs for young people. In contrast, most of Trump’s strategies (which do not yet have an attached budget) seek to snuff out drug supply. Clearly, trafficking is a problem. Up to 79% of the heroin seized in 2014 was found to have come from Mexico – and the largest source for fentanyl and carfentanil is China. Trump, who ran on a strong border control platform, argues that the wall he proposes to build on the Mexican border will not only reduce illegal immigration, but will cripple the passage of illegal drugs into the U.S. He also says that he will work with law enforcement to target shipping loopholes that permit international transport of drugs into the U.S. through the postal service. The question is whether this strong, but rather singular, stance favoring interdiction will be enough – and how he might enlarge his policies to focus on a growing user market for substances if it is not.
- How changes in the insurance landscape may impact access, coverage, and care. Trump campaigned on the promise of repealing the Affordable Care Act (ACA). While Trump’s position may have appealed to some who still view a broad healthcare mandate as intrusive or unconstitutional, ACA has become the law of the land and has made insurance coverage a reality for many who previously relied on limited personal savings – or Federal help – to cover larger health expenses. Trump has stated that he would dramatically expand access to drug treatment and alter Medicaid policies that obstruct inpatient treatment, such as the Institutions for Mental Diseases (IMD) exclusion. But he recently appointed Tom Price to lead the Department of Health and Human Services. Price, a former physician and long-time, fierce opponent of Obamacare, favors a rollback of Medicaid expansion. Thirty-two states have adopted measures to expand Medicaid coverage since ACA was signed into law and many believe such measures are critical in ensuring that low- income individuals have access to substance abuse programs. Many also believe that Price’s alternative to ACA, which would encourage the purchase of health insurance through tax credits and pricing incentives, will not necessarily prompt the broad-based coverage that ACA (which penalizes a lack of purchase through penalties)– like it or not – has. And that could mean many citizens who are currently in the “treatment gap” would lack insurance to defray the cost of needed addiction care.
- How a strong prosecutorial stance towards drug offenses, dealers, and the continuing momentum towards marijuana legalization might impact availability and social acceptance. In the face of mounting evidence to suggest that criminalization and mandatory minimums for drug offenders fills prisons more than it fights drug abuse, Donald Trump wants to be tough on drugs. Which is fine, good even. But the President-elect still seems to link that idea to aggressive legal and punitive approaches that many criticize as the next chapter in a historically ineffective war on drugs. In a campaign rally, Trump drew the connection explicitly saying, “Over the last few years, this [Obama] administration has been steadily dismantling the federal criminal justice system. Tens of thousands of drug dealers have been released from prison early…regardless of their history of violence or ties to transnational gangs and cartels.” In addition to using language that seems to promise longer sentences for dealers, Trump recently appointed Jeff Sessions (R-AL) to serve as Attorney General. Sessions, a former Federal prosecutor, has a record of being intensely conservative and morally intolerant when it comes to users (“good people don’t smoke pot”). He also exhibits a clear nostalgia for the “Just Say No” days of Reagan, and has a similarly simplistic zeal for the punitive that suggests he’ll be none too sensitive to civil liberties in the pursuit of setting an example. While Trump is less extreme, favoring state decisions about marijuana legalization and being careful not to suggest that we can arrest our way out of the drug problem, most recognize the appointment of Sessions as a strong move towards criminalization that does little to address the underlying problem. As Dr. Hakique Virani, an addiction specialist in Edmonton, Vancouver noted, “So long as there continues to be a large unmet demand…because we aren’t treating people with addiction, the illicit market will find ways to meet that demand… In the meantime, people die.”
So, we have what we have in the Trump presidency. And we have some things to look for in terms of how he meets this undoubtedly huge challenge. The challenge for us now is to have the patience to wait and see how it turns out.