President Trump walked through core elements of his administration's three-pronged attack on the opioids epidemic during a visit to New Hampshire, while simultaneously pushing for voter support in the next election.
"This is about winning a very, very tough problem ... I don't want to leave at the end of 7 years and have this problem," he said.
The president declared the opioid epidemic a public health emergency in October, but has been criticized for not offering tangible support for it.
Under the new approach, the government will expand education and awareness about the dangers of opioid addiction, stop the flow of illegal drugs into the country, and increase access to evidence-based treatment.
At times, the President's speech had the air of a campaign rally, as Trump ticked items from a punchlist of familiar themes: reducing unemployment, building a border wall with Mexico, and allowing patients' access to treatments before the FDA approves them through so-called "Right To Try" legislation.
Trump framed his border wall plan as part of the opioid fight, saying it was needed "to keep the damn drugs out."
Similarly, eliminating "sanctuary cities," another frequent Trump target, is critical to "stopping the drug addiction crisis."
The president's comments directly addressing the opioid crisis focused primarily on law enforcement.
"Whether you are a dealer or doctor or trafficker or a manufacturer, if you break the law and illegally pedal these deadly poisons, we will find you, we will arrest you and we will hold you accountable," he said to booming applause.
Tougher Penalties for Traffickers
President Trump again raised the spectre of capital punishment on Monday, as he had previously at the White House Opioid Summit on March 1.
"Take a look at some of these countries where they don't play games. They don't have a drug problem," he said speaking of some country's "zero tolerance" approach to drug dealers.
The Department of Justice will be "seeking much tougher penalties than we ever have ... That penalty is going to be the death penalty," he said.
"Maybe our country's not ready for that ... I can understand it maybe, although personally, I can't understand it," the president continued.
Prior to Trump's speech, a White House aide said the death penalty would be sought for drug traffickers "when it's appropriate under current law," although officials were unable to identify the specific circumstances when that could happen.
The president brought Adapt Pharma president Mike Kelly to the stage, applauding his company's offer to provide free naloxone to all high schools, colleges, and universities. He also thanked another pharmaceutical company, Kaléo Pharma, for donating hundreds of thousands of naloxone products to first responders.
Trump did also speak about prevention briefly, saying the government would be "spending a lot of money on great commercials" as part of a new public awareness campaign.
"So that kids seeing those commercials... say 'I don't want any part of it.'"
The White House is also launching a new website called , he announced, where families can share their stories.
"This epidemic can affect anyone and that is why we want to educate everyone."
In a phone call with reporters on Sunday, senior White House officials outlined the new initiative.
"The president will call on Congress to pass legislation that reduces the threshold amount of drugs needed to invoke mandatory minimum sentences for drug traffickers who knowingly distribute certain illicit opioids including fentanyl [in] their lethal and trace amounts," said Andrew Bremberg, assistant to the president and director of his Domestic Policy Council, on the phone call with reporters.
A White House fact sheet also noted that the DOJ will "aggressively deploy appropriate criminal and civil actions to hold opioid manufacturers accountable for unlawful practices."
In addition the initiative will expand the DOJ's Opioid Fraud and Abuse Detection Unit's work in "prosecut[ing] corrupt or criminally negligent doctors, pharmacies, and distributors," the fact sheet noted.
Increasing Education, Awareness
With regard to prevention of addiction, the administration plans to launch a national public awareness campaign to highlight the dangers of prescription and illicit opioid misuse.
The administration also set a goal of cutting nationwide opioid prescription fills by one-third in 3 years and ramping up the use of "best practices" in all federal health programs including Medicaid, Medicare, TRICARE, the Department of Veterans Affairs, the Veterans Choice program, and the Department of Defense, noted Bremberg.
The administration aims to see half of all federally employed healthcare providers using best practices for opioid prescribing within 2 years and all such providers following such standards within 5 years, the fact sheet noted. However, the document did not specify those "best practices" nor indicate how they would be determined.
In addition, the president will direct agencies that provide money for states' opioid-related programs to use such programs to incentivize a shift from a state-based to a "nationally interoperable prescription drug monitoring program network," Bremberg noted.
The president's initiative also supports research and development efforts aimed at identifying new treatments to prevent addiction -- including a possible vaccine -- and at producing non-addictive pain management options, as noted in the White House fact sheet.
Expanding Treatment
Lastly, Bremberg said the administration will save the lives of those with substance use disorders by ensuring that first responders have access to naloxone. The proposal also aims to expand access to evidence-based medication-assisted treatment (MAT) in every state.
The administration's plan also includes "leveraging federal funding opportunities" to improve the overdose tracking system to ensure that "resources can be rapidly deployed to hard-hit areas."
The president will also urge Congress to change a decades-old law (known as the Institutions for Mental Diseases (IMD) exclusion), which blocks Medicaid from offering reimbursement for mental health or substance abuse treatment in facilities with more than 16 beds, Bremberg said.
While waiting for such a change, the administration will continue to approve demonstration waivers that bypass the IMD exclusion; the Centers for Medicare & Medicaid Services has already approved five of these waivers, he noted.
Bremberg also explained that, with the new initiative, all active duty service members, veterans, and their dependents -- anyone who qualifies for healthcare from the Department of Veterans Affairs or the Department of Defense -- will have access to evidence-based treatment "on demand."
For those involved in the criminal justice system, Bremberg described a plan to screen "every federal inmate for opioid addiction at intake."
Those who test positively for addiction will be linked to "post-release access to treatment at residential re-entry centers," he said.
Ex-offenders would also be connected to community treatment centers, and the initiative will expand state, local, and tribal drug courts in order to "use the leverage that comes from the sentencing process to connect people to treatment as an alternative to incarceration or as a condition of supervised release," Bremberg said.
Stakeholders Respond
The American Society of Addiction Medicine agrees with efforts aimed at expanding access to treatment and prevention, said Yngvild Olsen, MD, MPH, the group's public policy committee chair, the idea of tougher penalties for drug dealers could have unintended consequences.
"When you look at the people who have been incarcerated and look at the percentage of them who have a substance use disorder and who have an opioid use disorder, it's very high in some places, it's over 50%," Olsen said in a phone call with MedPage Today.
"The people who end up getting incarcerated may not really be the people that we want to go after," she said, meaning those "at the top of the chain."
Olsen also stressed the importance of adequately funding the epidemic.
When responding to the HIV/AIDS epidemic in the 1980s and early 1990s, Congress appropriated about $24 billion a year, Olsen said.
For opioids, the response has been less substantial -- $1 billion here or $6 billion there, over a 2-year period, she noted.
"If you just look at the comparison between the AIDS epidemic and where we are currently with opioids... we've had more deaths with the opioid epidemic than HIV and AIDS and yet the funding is really not commensurate."
Fred Wells Brason II, president and CEO of Project Lazarus, a community based opioid overdose prevention model in Moravian Falls, N.C., echoed Olsen's concerns about strengthening law enforcement's role in the crisis.
"It's one thing when you're talking about the Mexican cartel, but what if you're talking about the local person who may get three or four bags of heroin and sell one or two to feed his habit," Wells Brason told MedPage Today. "You're putting someone in jail who's got an addiction problem and we clearly know that does not solve the problem."
While he was pleased to see that the administration is stepping up efforts expand access to naloxone, he questioned why it hasn't done more to increase co-prescription of naloxone "on the front end."
Wells Brason also argued that access to treatment and to reversal drugs should be reimbursible and easy to access.
"If we're in an epidemic, there should be no co-pay and there should be no prior authorization for whatever [is] necessary, the naloxone or the [medication assisted treatment]," he said.
Sally Satel, MD, a resident scholar at the American Enterprise Institute and a psychiatrist at a Washington methadone clinic, said she found the proposal "very comprehensive."
"If money is put into treatment infrastructure then it could make a difference," she wrote in an email to MedPage Today.
But she said she worried about "a sweeping mandate to reduce prescriptions by one third in a year," citing concerns that chronic pain patients who have been functioning well on opioids "may be swept into this net."
Already the CDC's guidelines "have been misinterpreted as a mandate to discontinue or reduce opioids in all patients -- and the potential for problems is significant."
Satel said she would like to see federal efforts to collect better data on heroin and fentanyl users.
The Substances Abuse and Mental Health Services Administration's "door-to-door survey is not cut out for that task," she wrote.
She also suggested re-introducing the . Knowing how many heroin users are out there could help gauge treatment need and naloxone need too, she explained.
Patrice Harris, MD, chair of the American Medical Association's Opioid Task Force, said the AMA was "encouraged" to see some of its own proposals embraced by the president, including the administration's focus on expanding medication assisted treatment.
"We also are pleased the administration is interested in expanding access to those incarcerated who have opioid use disorder. Patients need help during the transition from prison back to the community. If treatment does not start before release, the availability of heroin and other street drugs can prove deadly to those who are not being treated," she wrote in an email.
Harris said the AMA believes physicians "should be prudent" when prescribing opioids but she also stressed that patients need access to non-opioid alternatives to treat pain.
"We are ready to offer our expertise on behalf of all our patients," she said. "We don't have time to lose."