While opioid policy is complicated, taking concrete action on it is not.
Experts have a dozen different ideas for tweaking the relationship between powerful prescription drugs and the people who sometimes fall into cycles of addiction. A government that is serious about addressing addiction could throw money and manpower at any or all of them, and in time receive a concrete sense of what works and what doesn’t.
But instead of actual movement, President Donald Trump has opted for theater.
His command of television as a medium for elaborate fakery, honed so carefully over decades of professional wrestling cameos and reality-show stardom, was on full display in October when he declared prescription drug abuse a national public health emergency. Flanked by dozens of dignitaries from the politics, law enforcement, and addiction-assistance communities, the president gave a grandiose speech in his typically rambling style. To a neutral eye, it was the picture of authority and action. On scrutiny, it was a speech full of fluff and little meaningful change.
“A lot of talk, little action,” National Council for Behavioral Health executive Chuck Ingoglia told Vox. “His thoughts and prayers have helped,” West Virginia Public Health Commissioner Rahul Gupta told Politico, “but additional funding and resources would be more helpful.” Trump’s blue-ribbon commission on opioid addiction is a “sham,” a “charade,” and “reshuffling chairs on the Titanic,” commission member (and former Rhode Island Democratic Congressman) Patrick Kennedy told CNN. When the network questioned the White House about the do-nothing commission and fake-news emergency declaration, it responded with a 30-point list of executive actions — several of which are actions former President Barack Obama initiated and for which Trump now seeks credit, and just four of which were initiated after the theatrical East Room announcement last fall.
Trump continued the show late last week when the federal government was on the verge of shutting down. The emergency declaration he’d issued in the fall was set to expire that same Friday. The White House announced it was extending the emergency — another example of Trump’s pattern of hitting the “continue” button on things that are already in place and then calling it action.
The political calculus here is simple. Reporters tend to cover announcements, unveilings, groundbreakings — something “new” is almost inherently “news.” Trump is betting that he can get large bumps of coverage — much of it positive, if perhaps caveated with a few paragraphs of “remains to be seen” language acknowledging that his words haven’t yet congealed into actions.
Even if things don’t change in material terms, these serial blips of coverage will conjure and reinforce an image of action, authority, and aggressive engagement. The truth of the thing won’t ultimately matter to most people if it feels like he’s acting. And who can blame him? He’s simply bringing the same playbook he has always used, in his born-rich business career and throughout the 2016 campaign, to a new venue.
Time and again, Trump has proven able to pull wool over enough people’s eyes enough of the time to gather real power. A large number of Republican operatives and voters were willing to believe he’s a loyal American rather than a xenophobic racist. A large share of the public is willing to believe he’s a master businessman, rather than just a guy who played one on TV while wriggling out of paying his contractors and ruining Atlantic City to pad his own pocket. Another share of the electorate refused to believe he is the serial sexual predator he described himself as being on audio tape he acknowledged, at the time at least, as legitimate. Brute or not, lout or not, he’s good at this one specific trick.
In playing the same old trick with opioid policy, Trump isn’t just seeking political profit from tragedy. Opioids policy is a space where material dithering on which strategies should be tried and which ones shelved could make things worse — and actively so, not merely by allowing bad trends to continue at their current, organic rates.
Not all opioid policy proposals are created equal. Some physicians recommend drastic changes to how the medical community views patients’ reports of pain. The same research evidence used to back up that proposal in fact indicates that only about 1 percent of people who get prescribed opioids after surgery end up misusing them. The causality of the research on the connection between emergency room visits and opioid abuse is fuzzy even in the most prominent studies. It could be that “getting a refill may be a result rather than a cause of a higher addiction risk,” as reason’s Jacob Sullum put it. Stringently restricting ER prescribing policies in response to the belief that such practices create addicts would mean leaving huge numbers of people to suffer in pain that has no therapeutic value.
At the same time that Trump’s gaudy shrug of an opioid policy is opening the door to greater human suffering among non-addicts, he seems prepared to close it on other ideas that enjoy significant support from the research community. Early research suggests that medical marijuana — a drug with none of the boom-bust chemistry of heroin derivatives like Oxycontin — can be a valuable tool to getting people off of pills. But Trump’s top law enforcer, Attorney General Jeff Sessions, is so hidebound in his beliefs about pot that he has made it a point to reject the idea as he tours the country giving speeches. Trump’s commission didn’t even mention the possibility of relaxing restrictions on medical cannabis, let alone propose funding for a pilot treatment program that could test cannabis advocates’ claims.
Tuesday afforded another example of the administration’s habit of seeking out positive press coverage for microscopic, incremental, and sometimes inherited changes to policy regarding opioids. The administration took one small but substantive step toward changing the ground-level reality of the fight against addiction, unveiling a new Drug Enforcement Agency regulation making it easier for nurse practitioners to prescribe the maintenance drug buprenorphine to addicts. The move was greeted in some quarters with the same kind of relieved finally-some-good-news fanfare that Trump’s October speech received from many observers.
The DEA move, however, was hardly evidence of a shift in Trump’s politics-over-substance pattern.
The change in DEA regulations was required by a law passed in 2016 and a regulatory change adopted at the Department of Health and Human Services that same summer. The “final rule amends the DEA regulations only to the extent necessary to be consistent with current federal law,” the agency rule announced Tuesday said. This is a small, lagging change mandated under a law signed by Trump’s predecessor, not a forceful or novel step by the new bosses in Washington.
It is not even as far-reaching as it may sound on its face, as drug policy expert Mike Riggs discovered after initially praising the move. The affected medical professionals “do not have independent prescribing power in the states hardest hit by the opioid crisis,” he wrote.