key: cord-0051173-4s197gpv
authors: Wen, Leana S; Sadeghi, Nakisa B
title: The opioid crisis and the 2020 US election: crossroads for a national epidemic
date: 2020-10-06
journal: Lancet
DOI: 10.1016/s0140-6736(20)32113-9
sha: e6627099f9ad0fc0d3e9f6dda00e001baf908c83
doc_id: 51173
cord_uid: 4s197gpv

nan

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. 1 The COVID-19 pandemic has exacerbated an already difficult situation by reducing access to lifesaving treatment, harm reduction, and recovery support services, while increased stress and isolation might increase the risk of addiction and substance use disorders (SUDs). 2 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%. 3 The pandemic has also triggered an economic recession that threatens the survival of some addiction treatment centres, 4 and is expected to exacerbate social barriers such as housing instability, which can further hinder treatment of SUDs. 5 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 medicationassisted treatment (MAT). 6 Medicaid expansion through the Affordable Care Act (ACA) has been instrumental in increasing coverage of mental health and SUD services. 7 Nationally, Medicaid expansion was associated with a 6% reduction in total deaths from opioid overdoses in states that underwent expansion compared to nonexpansion states. 8 In West Virginia, the state with the highest rate of deaths from opioid-involved overdose as of 2018, 9 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. 10 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. 11 US President Donald Trump has repeatedly called for the repeal of the ACA, which would roll back Medicaid expansion. 12 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. 13 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. 14 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. 15 In 2018, the Trump administration secured US$6 billion to address opioid use disorder over 2 years through the Initiative to Stop Opioid Abuse. 16 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, 17 although the impact of this funding remains to be seen as overdose deaths have increased into 2020. 1 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. 18 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. 19 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. 20 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. 13 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, 21 diverting attention away from treatment and prevention. Moreover, drugrelated arrests and incarceration disproportionally impact people of colour with long-term consequences that perpetuate health inequities. 22 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. 16 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. 13 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. *Leana S Wen, Nakisa B Sadeghi lwen@gwu.edu

USA (LSW); and University of North Carolina at Chapel Hill School of Medicine

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