WASHINGTON (Good Medical) – President Donald Trump has stated that the opioid epidemic was a public health emergency at the national level and urged prosecutors to seek the death penalty for drug traffickers. Congress has provided targeted grants for treatment, recovery and prevention, and has made numerous policy changes to help people with addictions access services. From National Institutes of Health to Veterans Affairs and the Department of Agriculture, government agencies deploy their own specialized expertise. Nevertheless, the drug crisis will not easily leave the country, even if progress is made in terms of resources and improved coordination.

Here is an overview of the magnitude of the epidemic and what the federal government has done.



Some 47,600 Americans have died from opioid overdoses in 2017, according to federal figures. It's more than dying as a result of a road accident. Opioid deaths have increased by 13% over 2016, an increase of one notch in 20 years. Fentanyl (street drug) – an extremely powerful opioid – is the deadliest killer today, replacing heroin and painkillers. But prescription pain medications remain a problem, contributing to 14,495 deaths in 2017.

It is too early to say, but experts are observing a potential indicator that the number of opioid overdose deaths could peak. The monthly data reported to the Centers for Disease Control and Prevention showed a stabilization in the number of deaths, said Bob Anderson, Chief Statistician of the CDC. However, these figures are considered preliminary because the surveys have not been completed in all cases.

"We can start to see a decline," said Anderson. "It reminds me of what we saw with HIV in the 1990s." Final figures for 2018 will not be available before the end of the year, and the situation may also worsen, but not improve.

Although overdose deaths receive the most attention, this is not the only way for users to die. People who inject drugs can contract heart infections, HIV and hepatitis C. The risk of infection is higher than the risk of dying from overdose.

Counting all fatal overdoses, not just opioids, CDC put the number at 70,237 for 2017.



Many people have embarked on the path of painkiller addiction, prescribed by a physician for the treatment of injuries, post-surgical pain or chronic condition, or illegally purchased from a dealer. Much of the heroin sold in the United States comes from Mexico and the drug is more potent than in the 1970s, during a previous crisis. China is the main source of fentanyl, which is used as an additive in illicit drugs.

The multitude of opioid drugs, the increasing lethality of certain drugs and the diversity of their marketing routes make the crisis particularly difficult. Some effective responses may be surprisingly simple: In a recently reported experiment, doctors received a letter from the medical examiner's office telling them the deadly overdose of a patient. They responded by prescribing fewer opioids.



Since the beginning of former President Barack Obama, the government has provided grants to states to help treat people addicted to opioids and prevent others from becoming addicted. The extension of the Medicaid Health Program under Obama's Health Care Act also played a role in funding treatment.

With the exception of the Medicaid expansion – which Trump and the Republican Congress have tried unsuccessfully to repeal – the federal response to the opioid crisis has been bipartisan.

Various federal agencies provide specialized expertise. The CDC is closely monitoring the epidemic's record. NIH is studying pain management and how to treat addiction. The Department of Agriculture focuses on opioid abuse in rural areas, where treatment resources are scarce. And Veterans Affairs is maintaining an initiative on opioid safety dating back to 2013 to help its doctors reduce the number of unnecessary prescriptions.

On the side of the crackdown, the detectives of drugs, cybercrime and money laundering target the main suppliers. In the 1980s, cocaine from Colombia was smuggled by speedboats and marijuana bullets were airlifted, but fentanyl from China can now be marketed online and shipped by mail. The Food and Drug Administration is deploying more and more inspectors to international postal facilities to intercept fentanyl packages.



It is difficult to obtain complete and reliable accounting as expenses are spread among many organizations and programs. This includes rights such as Medicaid, which does not require annual approval of congressional funding, as well as dozens of other programs that do – in addition to specific grants. Experts say that the government spends billions of dollars, there is no doubt that it is increasing, and that is probably still not enough.

In its last year in power, the Obama administration has committed to expanding treatment, and Congress has earmarked $ 1 billion for grants to the states . Last year, Congress provided an additional $ 1 billion to states under a new grants program. The Trump administration has recently granted these grants. That adds up to nearly $ 1.9 billion for the government's largest program of treatment, recovery and drug prevention, according to the National Association of Alcohol and Drug Abuse Directors.

Additional funds are allocated to other agencies and programs. A study sponsored by the nonpartisan foundation Robert Wood Johnson highlighted the role of Medicaid. It shows that the federal-state health care program for low-income people covers more than one-third of opioid addicts. Even before the expansion of Medicaid, researchers estimated that it spent more than $ 9 billion in 2013 on the care of low-income opioid-dependent people.


What is all this money for?

States spend grants on treatment, antidote kits for overdose, recovery services, training of doctors and awareness campaigns. The goal is to have more people treated with opioid addiction medications such as buprenorphine and methadone. There is strong evidence for these drugs when used in conjunction with counseling and ongoing support.

States began reporting to the federal government that thousands of people had started treatment with a grant, including hundreds of pregnant women. Pennsylvania, for example, reported treating 11,423 people in fiscal 2017, including 86 pregnant women. Michigan says it has treated 2,974 people, including 30 pregnant women. Tennessee: 3,075 people, including 55 pregnant women.



With little or no training, third parties can reverse an opioid overdose with a nasal spray with naloxone or by injecting the drug. States have distributed thousands of naloxone kits to first responders, schools, family members and addicts themselves.

The Health and Social Services Department has several programs to help states and communities pay for the antidote, but with the number of overdose deaths still high, it's hard to say what the impact of naloxone was. A working paper published in 2017 by the National Bureau of Economic Research suggests that laws promoting naloxone could have a minor effect on reducing the number of deaths.

People struggling with the epidemic say that the number of deaths would be even higher without the antidote.



Administration officials say they are making progress on a daily basis by deploying more resources and strengthening coordination of government efforts between agencies. Some experts in the field discuss the role of the administration.

"When you look at the actions of the administration as a result of this public health emergency, I have not been overwhelmed by any of these things," said Rebecca Farley David of the National Council for Behavioral Health, which defends organizations who offer drug treatment.

She pointed to Trump's attempt to cancel the Medicaid extension: "It would have had a devastating impact on drug addicts."

But Jessica Hulsey Nickel, founder of the advocacy group, Addiction Policy Forum, said, "Whether you're an R or D, this administration has ensured that every element of government that has a role in play be involved. "

Trump's opioid commission made 56 recommendations, including more drug courts, physician training, and wider use of treatment drugs in the criminal justice system.



In some ways, the opioid epidemic is just the latest manifestation of drug-related problems that are deeply rooted in American history. Public health experts say that a major difference today is that drug addiction is increasingly recognized by experts and non-specialists as a brain disease, not a moral failure. This could pave the way for the construction of an infrastructure for what is known as the "continuum of care" – prevention, treatment and recovery.

For many people, the path back from addiction is a multi-year journey and relapses are common. Deborah Richter, a Vermont doctor who treats drug addiction, says that there is no clear timetable for declaring a patient "cured". "They are not ready unless they can say," I would not know where to get heroin unless I bite, "Richter said.



The fight against drugs in the United States is traditionally part of the fight against drugs. The importance of treatment has been recognized recently.

Former Presidents Ronald Reagan, George H. W. Bush and Bill Clinton argued for the death penalty for drug sponsors in the most serious cases. Reagan said that even though he thought drug traffickers deserved the death penalty, their application could create counterproductive political divisions.

Trump hypothesized that countries like Singapore had less addiction problems because they were doing cruel justice and said he wanted the Justice Department to ask for the "ultimate sentence" as far as possible. The US drug law already allows federal prosecutors to apply for the death penalty in cases where someone is killed intentionally during a transaction or promotion of a business. drug. Former Attorney General Jeff Sessions vowed to ask for the death penalty "whenever it would be appropriate".

Warning: Many judges, prosecutors, criminal law experts and lawmakers on both sides now consider the intransigent approach of the 80s and 90s as a drift that has led many people in prison to long sentences, particular African-Americans.

"If it's important to make the prohibition a priority, we need to make sure we do not criminalize addiction disease," said Jessica Hulsey Nickel of the Addiction Policy Forum.