The opioid crisis and the 2020 US election: crossroads for a national epidemic
Authors: Leana S Wen, Nakisa B Sadeghi
Journal: The Lancet (2020)

Health care is a major point of differentiation in the upcoming US presidential elections. One priority area is the opioid crisis. In 2019, reported deaths from drug overdose in the USA reached an all-time high of almost 72 000, with opioids involved in more than two-thirds of the total deaths.1US Centers for Disease Control and PreventionVital statistics rapid release; provisional drug overdose death counts.https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htmDate: Sept 16, 2020Date accessed: September 22, 2020Google Scholar The COVID-19 pandemic has exacerbated an already difficult situation by reducing access to life-saving treatment, harm reduction, and recovery support services, while increased stress and isolation might increase the risk of addiction and substance use disorders (SUDs).2Associated PressVirus outbreak creates new challenges for addiction recovery.Los Angeles Times. April 1, 2020; Google Scholar As of July, 2020, deaths from drug overdose in the USA rose by an estimated 13% in the first half of the year compared with 2019, according to data compiled from several local and state governments. In some states, drug-related deaths climbed by over 30%.3Katz J Goodnough A Sanger-Katz M In shadow of pandemic, US drug overdose deaths resurge to record.The New York Times. July 15, 2020; Google Scholar The pandemic has also triggered an economic recession that threatens the survival of some addiction treatment centres,4Sokolow A Opioid overdoses have skyrocketed amid the coronavirus, but states are nevertheless slashing addiction treatment program budgets.Stat News. July 16, 2020; https://www.statnews.com/2020/07/16/opioid-overdoses-have-skyrocketed-amid-the-coronavirus-but-states-are-nevertheless-slashing-addiction-treatment-program-budgets/Date accessed: September 30, 2020Google Scholar and is expected to exacerbate social barriers such as housing instability, which can further hinder treatment of SUDs.5Yamamoto A Needleman J Gelberg L et al.Association between homelessness and opioid overdose and opioid-related hospital admissions/emergency department visits.Soc Sci Med. 2019; 242112585Crossref PubMed Scopus (73) Google Scholar Against this backdrop, the presidential candidates propose divergent policy solutions to counter the opioid epidemic. There are three major differences. First, the policy proposals differ in how they will treat addiction. Just one in five people with opioid use disorder in the USA are able to access treatment at the time they need it, and fewer than half of community health centres in the country have the capacity to provide medication-assisted treatment (MAT).6Corallo B Tolbert J Sharac J et al.Community health centers and medication-assisted treatment for opioid use disorder. Kaiser Family Foundation, Aug 14, 2020https://www.kff.org/report-section/community-health-centers-and-medication-assisted-treatment-for-opioid-use-disorder-issue-brief/Date accessed: September 22, 2020Google Scholar Medicaid expansion through the Affordable Care Act (ACA) has been instrumental in increasing coverage of mental health and SUD services.7Wen LS Behrle EB Tsai AC Evaluating the impact of Affordable Care Act repeal on America's opioid epidemic.PLoS Med. 2017; 14e1002380Crossref PubMed Scopus (3) Google Scholar Nationally, Medicaid expansion was associated with a 6% reduction in total deaths from opioid overdoses in states that underwent expansion compared to non-expansion states.8Kravitz-Wirtz N Davis CS Ponicki WR et al.Association of Medicaid expansion with opioid overdose mortality in the United States.JAMA. 2020; 3e1919066Google Scholar In West Virginia, the state with the highest rate of deaths from opioid-involved overdose as of 2018,9National Institute on Drug AbuseOpioid summaries by state.https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-stateDate accessed: October 1, 2020Google Scholar buprenorphine prescriptions for patients with opioid use disorder increased by an estimated 42% between 2014, when Medicaid was first expanded in the state, and 2016.10Saloner B Landis R Stein BD Barry CL The Affordable Care Act in the heart of the opioid crisis: evidence from West Virginia.Health Aff (Millwood). 2019; 38: 633-642Crossref PubMed Scopus (17) Google Scholar Treatments with buprenorphine and methadone were associated with 38% and 59% decreases in opioid-related mortality, respectively, according to one study in Massachusetts; all forms of MAT should be made accessible.11Larochelle MR Bernson D Land T et al.Medication for opioid use disorder after nonfatal opioid overdose and association with mortality.Ann Intern Med. 2018; 169: 137-145Crossref PubMed Scopus (616) Google Scholar US President Donald Trump has repeatedly called for the repeal of the ACA, which would roll back Medicaid expansion.12Katkov M Obamacare must "fall," Trump administration tells Supreme Court.The Washington Post. June 26, 2020; Google Scholar Repeal of the ACA would not only cause millions of Americans to lose their health insurance coverage, but it would also eliminate the coverage of SUDs under essential health benefits, making treatment unaffordable even to insured Americans. As a result, people on SUD treatment could suffer from withdrawal or resort to alternative methods of obtaining opioids such as heroin or street fentanyl, resulting in increased overdose deaths. By contrast, the Democratic Party presidential candidate, Joe Biden, has proposed an expansion of the ACA to "achieve universal coverage" and accelerated integration of SUDs into standard health-care practice under Medicare, the Indian Health Service, the Veterans Health Administration, and other health plans.13Harris Biden The Biden Plan to End the Opioid Crisis.https://joebiden.com/opioidcrisis/Date: 2020Date accessed: September 22, 2020Google Scholar Second, the candidates' proposals will determine the strength and capacity of the nation's public health infrastructure to curb the opioid crisis. Public health infrastructure to prevent and treat addiction has been chronically underdeveloped and underfunded in the USA.14Trust for America's HealthThe impact of chronic underfunding on America's public health system: trends, risks, and recommendations, 2020.https://www.tfah.org/report-details/publichealthfunding2020/Date: April, 2020Date accessed: September 30, 2020Google Scholar In October, 2017, Trump declared the opioid crisis a public health emergency. However, the current administration's budget proposal that year included a 95% cut to the central coordinating entity for the federal government's response, the Office of National Drug Control Policy, although this cut was not ultimately implemented.15Rappeport A White House proposes cutting drug control office funding by 95%.The New York Times. May 5, 2017; Google Scholar In 2018, the Trump administration secured US$6 billion to address opioid use disorder over 2 years through the Initiative to Stop Opioid Abuse.16White HousePresident Donald J. Trump's Initiative to Stop Opioid Abuse and reduce drug supply and demand.https://www.whitehouse.gov/briefings-statements/president-donald-j-trumps-initiative-stop-opioid-abuse-reduce-drug-supply-demand-2/Date: Oct 24, 2018Date accessed: September 22, 2020Google Scholar This represented an additional $5 billion to the $500 million distributed to states in 2017 to prevent and treat opioid use disorder, and another $500 million was allocated to drug addiction through the 2018 budget,17Office of Management and Budget, US GovernmentAn American budget. fiscal year.https://www.whitehouse.gov/wp-content/uploads/2018/02/budget-fy2019.pdfDate: 2019Date accessed: September 30, 2020Google Scholar although the impact of this funding remains to be seen as overdose deaths have increased into 2020.1US Centers for Disease Control and PreventionVital statistics rapid release; provisional drug overdose death counts.https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htmDate: Sept 16, 2020Date accessed: September 22, 2020Google Scholar Public health experts have warned that the funding in Trump's Initiative to Stop Opioid Abuse is insufficient to turn the tide, and have called for tens of billions of dollars for the prevention and treatment of opioid use disorder.18Goodnough A $45 billion to fight opioid abuse? That's much too little, experts say.The New York Times. June 30, 2017; Google Scholar The Comprehensive Addiction Resources Emergency (CARE) Act of 2019, a monumental piece of legislation that was introduced in 2019 and remains in the introductory stages at the House of Representatives, proposes $10 billion per year in federal funding to address the opioid crisis.19House Committee on Oversight and ReformCummings and Warren introduce landmark legislation to combat opioid epidemic.https://oversight.house.gov/news/press-releases/cummings-and-warren-introduce-landmark-legislation-to-combat-opioid-epidemicDate: May 8, 2019Date accessed: September 22, 2020Google Scholar This legislation would target funds to counties and cities hardest hit by the opioid crisis, reflecting the importance of funding that is sustained and proportional to the severity of the epidemic.20Wen L We must provide sustained funding proportional to the severity of the opioid epidemic.The Hill. Sept 9, 2018; https://thehill.com/opinion/healthcare/405415-we-must-provide-sustained-funding-proportional-to-the-severity-of-theDate accessed: September 25, 2020Google Scholar Aligned with these recommendations, Biden's campaign has proposed a $125 billion federal investment in prevention, treatment, and recovery services over the next 10 years, with 60% of funds distributed in the form of flexible grants to state and local communities.13Harris Biden The Biden Plan to End the Opioid Crisis.https://joebiden.com/opioidcrisis/Date: 2020Date accessed: September 22, 2020Google Scholar Third, the coming election will determine whether SUDs and overdose will be treated as diseases, rather than as moral failings or crimes. Addiction is a complex brain disease. Studies have shown that the criminalisation of SUDs is ineffective and harmful,21Joudrey PJ Khan MR Wang EA et al.A conceptual model for understanding post-release opioid-related overdose risk.Addict Sci Clin Pract. 2019; 14: 17Crossref PubMed Scopus (105) Google Scholar diverting attention away from treatment and prevention. Moreover, drug-related arrests and incarceration disproportionally impact people of colour with long-term consequences that perpetuate health inequities.22Ferrer B Connolly JM Racial inequities in drug arrests: treatment in lieu of and after incarceration.Am J Public Health. 2018; 108: 968-969Crossref PubMed Scopus (9) Google Scholar One focus of Trump's plan to address the opioid crisis is the reduction of illicit drug supply; he endorses policies to secure ports of entry and land borders, such as through investment in a US–Mexico border wall, increasingly stringent criminal penalties for dealing and trafficking opioids, and institution of the death penalty for drug traffickers.16White HousePresident Donald J. Trump's Initiative to Stop Opioid Abuse and reduce drug supply and demand.https://www.whitehouse.gov/briefings-statements/president-donald-j-trumps-initiative-stop-opioid-abuse-reduce-drug-supply-demand-2/Date: Oct 24, 2018Date accessed: September 22, 2020Google Scholar While Biden's plan also targets drug supply by attempting to reduce the overprescribing of addictive pain medications, it proposes to end incarceration for drug use alone with diversion to drug courts and treatment, and supports investment in partnerships with mental health specialists and social workers, in addition to resources to address social barriers to recovery like housing instability.13Harris Biden The Biden Plan to End the Opioid Crisis.https://joebiden.com/opioidcrisis/Date: 2020Date accessed: September 22, 2020Google Scholar On the cusp of the presidential election and in the midst of the COVID-19 pandemic, the nation finds itself at a crossroads with a crucial opportunity to decide the trajectory of the opioid crisis. Will the nation's next leader continue to fall short and tinker around the edges while many tens of thousands die, or will he commit to urgent, robust, and science-based action? The consequences of this decision will persist for generations to come. LSW is an unpaid member of the advisory committee of the non-profit organisation Shatterproof and receives advisory board fees from Behavioral Health Group, a company with a network of outpatient opioid treatment and recovery centres in the USA. NBS declares no competing interests.