Is the White House’s drug policy office worth the money?
A Trump administration proposal to cut the $388 million budget of the Office of National Drug Control Policy by 95 percent has given new urgency to that question, with some administration officials arguing the ONDCP simply duplicates work already done by other agencies. They have also said the proposal is only preliminary.
But Regina LaBelle, who worked in the office from October 2009 to January 2017 for the Obama administration, says slashing the office’s budget would be “penny-wise and pound-foolish,” arguing that it makes work at agencies across the government more efficient.
STAT spoke with LaBelle, who was most recently the office’s chief of staff, about tackling the opioid epidemic, the early days of the Trump administration, and what ONDCP actually does.
The conversation had been condensed and edited for clarity.
What’s your reaction to the proposal to cut the office’s budget?
It’s the type of office that sometimes goes unnoticed, but the importance of it is that it really coordinates drug policy across the federal government and can save money. I mean, that’s what it’s supposed to do — the purpose of it is to have one entity that can oversee everything going on in drug policy.
Because it’s in the executive office of the president, it does have authority to go to other agencies and dissuade them from spending their money in a way that might not be the best way. So I think [the proposal is] penny-wise and pound-foolish. ONDCP wrote the first strategy to deal with the opioid crisis back in 2011 when the issue hadn’t really been on other agencies’ radar screens. They were aware of it, but there wasn’t a concerted effort by the federal government to deal with the issue.
What would be lost if the budget was cut in this way?
Two years ago, we did a reorg and reduced staff by about 20. And we did it in what we thought was a thoughtful way to make it a more nimble and more coordinated entity instead of being divided by topics, because drug supply obviously has an effect on demand, and vice versa. The problem with a hatchet job — a cut across the board — is that you don’t get to do it strategically.
The budget cuts would wipe out grants for the drug-free communities program and the high-intensity drug-trafficking area programs. What do those do?
With the drug-free community coalitions, the grants seek to reduce substance use in local communities generally, so alcohol, tobacco, and illegal drugs. And the evidence bears it out. Communities with coalitions have lower rates of substance use than without. And then the HIDTA program is a law enforcement grant program that goes to at-risk areas. The program allows state, local, and federal law enforcement to work together on drug trafficking. They also have some discretionary grants, and with one, regional HIDTAs get together for a heroin response team. They are focusing specifically on the heroin issue by hiring both a public health and public safety person in each of these areas to look at the heroin issue and share data. Law enforcement and public health aren’t always at the same table. HIDTA can allow for creativity in the area to deal with the drug problem.
The administration has said that it is trying to reduce duplication among drug control policy efforts, but it sounds like you’re saying that’s what the office does?
We were constantly seeing things that one agency wanted to do that another agency was already doing, so communicating that to the different agencies was really important. That’s the purpose of the office.
What do you think about President Trump’s opioid commission led by New Jersey Governor Chris Christie?
I hope that they are drawing on a lot of the things that we have done over the last several years, and I hope that they draw on the surgeon general’s report that was released last year. That was very comprehensive and was about substance use across the board. The most important thing is that we are leading with science. We know that people who are on medication-assisted treatment have better outcomes. We need to make sure more people have access to evidence-based treatment and recovery support. I hope there’s an effort to learn from all the work that has already gone into it.
It seems like you’re making a point that this issue has been studied and you already have outlines for what you need to do.
I mean if the commission’s purpose is to continue a lot of the work that’s been done, and to look around the corner at the new consequences we’re seeing, then that’s great.
I’ll give you an example of two consequences that I don’t think we have a handle of what to do yet. The first is the stark increases of hepatitis C and HIV in rural areas. That is an issue we have to deal with and that could have really devastating consequences. The second is instances of neonatal abstinence syndrome, accompanied by an increase in foster care rates. And then there’s the increase in fentanyl.
This is a moving problem, and we can’t say the plan we had seven years ago is the plan that has to be implemented now. The issue has morphed. Prescription drug misuse is down, but now we’re seeing more heroin use and younger people injecting drugs. We’re seeing a faster movement from prescription drugs to heroin. This is a moving target.
What else has President Trump done that could either help with the epidemic or that worries you?
On the positive side, a lot of people who voted for Donald Trump are from areas that are most affected by the opioid problem. Maybe that will get more public attention to this issue.
But I’m very concerned about the [GOP health plan] and how that will affect outcomes, because of the number of people who are on Medicaid and have opioid use disorders. Treatment is not a washing machine, you don’t go in for 21 days and you come out and you’re better. It’s a continuing process. The changes that could be made to health care could be really devastating for people with substance use disorders.
You used to work for the city of Seattle, where the country’s first safe-injection sites might open. What do you think about those?
I’m not in a position where I have to formulate or pursue a policy. But if I were advising the mayor of Seattle, I’d say, have you done everything you can to make sure that everything else is in place? Do you have enough treatment access? Do you have prevention in your schools and communities? Do you have enough naloxone out there? Do you have enough syringe exchange? And they have a lot of that, but it is very complicated.
Sometimes we look at this shiny object, but will that solve the problem? I’m not sure. I really don’t know. The problem is not just in urban areas, where people might be in proximity [to a site]. It’s in a lot of outlying areas as well. From a public health standpoint, obviously we need to look at saving lives. But I think the stumbling block is that heroin possession is still illegal. I don’t think that the federal government could ever fund it because of heroin being an illegal drug.