Understanding the Trump Administration’s Drug Policy Changes

The new administration released a Statement of Drug Policy Priorities last week.

What’s in the White House Statement of Drug Policy Priorities?

It’s not a long document — just a few pages, and it identifies 6 priorities listed below. I’ve also called out specific references to treatment, prevention, harm reduction, and research.

Reduce the Number of Overdose Fatalities, with a Focus on Fentanyl
- Objective: Decrease the number of drug overdose deaths nationwide.
  - OD prevention education
  - Access to emergency services
  - Law enforcement diversion programs to treatment
  - Naloxone and drug test strips
  - Prosecution for provision of drugs involved in OD death, pursuing the “harshest available penalties”
Secure Global Supply Chain Against Drug Trafficking
- Objective: Decrease the global movement of illicit drugs, including precursor and related chemicals, through all shipping modalities.
Stop the Flow of Drugs Across our Borders and into Our Communities
- Objective: Decrease the domestic availability of illicit drugs.
Prevent Drug Use Before It Starts
- Objective: Reduce the initiation of drug use, particularly among young people.
  - Educational campaigns and evidence-based prevention programs
  - Collaborate with state and local organizations promoting youth resilience and health
  - Media education campaigns, including social media, on OD prevention and accessing treatment
Provide Treatment That Leads to Long-Term Recovery
- Objective: Increase the number of individuals receiving evidence-based treatment and achieving long-term recovery from addiction and substance use disorders.
  - Emphasis on community-based programs
  - Goal of “recovery and lead(ing) productive, healthy lives”
  - “Effective, timely, and evidence-based treatment” available to all who need it, including MOUD and mental health care
  - Strengthening peer Services, the infrastructure that deploys it and Recovery Community Organizations
Innovate in Research and Data to Support Drug Control Strategies
- Objective: Obtain and apply high-integrity data to address the crisis.
  - “prioritize the continuous collection and analysis of accurate, timely, and relevant data to inform policy”
  - “modernize Federal, state, and local technologies and systems for data collection and sharing”
  - “closely monitor trends and available data to identify and rapidly address emerging threats”

Analysis of the statement

This analysis is focused solely on the statement and does not integrate actual events since the inauguration.

Big emphasis on supply interdiction and law enforcement

The document emphasizes border control, international sanctions, and law enforcement.

Supply reduction is one important element of effective drug policy, and one could argue that its importance has been underacknowledged in recent years. However, its emphasis in this document stirs memories of the war on drugs. Those concerns are reinforced by the references to pursuing the “harshest available penalties” against people connected to OD deaths and people disseminating drugs.

It also references “encourag(ing) state and local efforts facilitating law-enforcement-assisted diversion to connect people who use drugs with supportive services that divert them from incarceration and reduce recidivism.”

An important question is where the emphasis will be — prosecuting people who exploit addiction, or prosecuting behavior that is associated with addiction itself?

It does include prevention and treatment

While supply interdiction is centered, prevention, treatment, and research are explicitly included.

As mentioned above, it references diversion to treatment.
Emphasizes community-based care.
Specifically mentions access to MOUD.
There’s no reference to harm reduction, but it does specifically mention distribution of naloxone and drug testing supplies.
Specifically mentions peers and RCOs.
Equates recovery with “productive and healthy lives.”

All of these are welcome elements for a drug policy model, and they seem to be given something approximating equal weight.

To me, the clearest signals of change relate to harm reduction and recovery.

The absence of reference to harm reduction but the inclusion of naloxone and drug testing supplies may signal an openness to some harm reduction interventions, but a movement away from integrating harm reduction as a philosophy. This will be something to watch. The first potential casualties that come to mind are programs like drug consumption sites and syringe exchanges. Another big question is who would be delivering interventions like naloxone and drug testing supplies — would it be harm reduction specialists, public health departments, treatment providers, law enforcement, or some combination? I suspect harm reduction specialists may have reasons to fear their exclusion.

The linkage of recovery to productive and healthy lives signals the possibility of ambitious endpoints for addiction care — beyond harm reduction, symptom reduction, and remission, to something more like “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” Centering this model of recovery as an endpoint could have benefits, as long as we’re respecting patient rights to self-determination, respecting multiple pathways, and acknowledging partial recovery.

What about research?

Priority #6, related to research and data, includes a reference to “supporting drug control strategies” but makes no specific reference to research on treatments for addiction or public health. It does talk about modernizing data collection and sharing.

This implies that the intention here may be to collect and share data to support interdiction and law enforcement. That kind of data collection isn’t bad, and it might provide some benefits to public health, prevention, and treatment, but it’s a fraction of the knowledge we need to generate.

Maintaining a crisis response orientation

One criticism of drug policy in recent years is that it was stuck in a crisis response mode focused on death prevention. Of course, preventing death is of supreme importance, and we should have a robust public health response to reduce mortality. AND, that shouldn’t come at the expense of restoring lives and facilitating recovery. We should be able to walk and chew gum at the same time.

These priorities seem to maintain a crisis orientation but shift the primary frame from a public health crisis to a border security and law enforcement crisis. There is a long history of enormous harm inflicted on vulnerable people and communities in the name of protecting communities and young people from drug threats. The language in the document does not include any signals that those lessons were learned and integrated.

A disconnect with Trump administration actions

^{Prior to Medicaid expansion, people seeking publicly funded treatment in Wayne County, MI, had to line up at the Herman Kiefer Center for an assessment. To ensure they got an assessment, people used to sleep outside the building, waiting for it to open.}

The inclusion of prevention and treatment, as well as the specific references to peer support and recovery community organizations (RCOs), might provide some reassurance for people who care about people with addiction and the families and communities they touch. However, this doesn’t comport with the actions the administration has taken in its first weeks in office.

What are those actions?

There are credible threats to cut Medicaid funding, which is estimated to fund 30-40% of all substance use disorder treatment in the US.
The federal freeze on grants is currently stalled in the courts, but the implications for the federal Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG) are unclear. The block grant is estimated to fund 20-25% of all substance use disorder treatment in the US.
SAMHSA staff were cut by around 10% in February, and there were reports of an effort to increase those staff cuts to around 50%. These initial waves of cuts included about half of the staff in the Office of Recovery. Now, it’s been announced that SAMHSA will be absorbed into the new Administration for a Healthy America, meaning that there will no longer be a department dedicated to addiction and mental health.
At a local level, two addiction treatment programs received abrupt “stop work” orders and funding cuts last week. This meant layoffs of 20 staff, the closure of a crisis center for people under the influence of alcohol and other drugs (used by local law enforcement, EMS, human service programs, and emergency departments), and recovery support for custodial parents and their children.
Across the country, these abrupt (previously budgeted) cuts resulted in the closure of the kinds of peer support services explicitly named in the White House priorities and crisis mental health support.
Despite the references to data collection and sharing, the administration abruptly laid off all 17 people running the country’s only nationwide survey on substance use and mental health.
In North Carolina, the administration cut funding to collegiate recovery programs and treatment, with rural areas being especially affected.

Advocacy is critical

As an addiction professional for 31 years, I have not seen systems of care and our patients’ well-being threatened like this. It’s not hypothetical, it’s happening today.

Advocacy is essential to protect access to care for people with addiction. Here are some sources of information that help make advocacy easy for you: