WASHINGTON — Ahead of a 2020 race already focused on health care, President Trump is boasting that his administration played a huge role in achieving the first annual drop in overdose deaths in three decades. The drop, he crowed recently, is “tremendous.”

But behind the scenes, his administration’s efforts to address the opioid crisis are increasingly contentious. Two federal agencies are feuding over how to classify certain drugs too dangerous for public consumption. And in the two-plus years since his inauguration, his White House has yet to nominate a leader for the Drug Enforcement Administration.

Public health experts caution that not only is Trump claiming victory too early — his sometimes-chaotic approach might actually be setting back public health efforts to rein in a broader drug crisis that currently claims 70,000 lives per year.

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“They’re going to make the political argument that they’re winning,” said Regina LaBelle, the former chief of staff for the Office of National Drug Control Policy during the Obama administration. “Which they can say, since deaths are down. But I get concerned that we’re going to take our eye off the ball on the broader issue of addiction.”

Trump’s triumphant declaration he had succeeded in helping to lower the overdose death rate came a month ago, at an event touting the administration’s drug policy victories and the White House’s success in pushing major addiction legislation through Congress last year.

“This is a meeting on opioid[s],” Trump said then, “and the tremendous effect that’s taken place over the last little period of time.”

There’s a compelling sway to Trump’s political argument. The hard-hit states Trump advisers like Kellyanne Conway point to as beacons of progress last month in the Roosevelt Room of the White House include many critical to his reelection hopes: Pennsylvania, Ohio, Florida, and Iowa.

The braggadocio will set him up, too, to take on the slew of Democrats challenging the president in 2020, nearly all of whom have already unveiled ambitious plans to improve addiction and mental health care.

For Trump and even some of the Democratic candidates, too, tackling the country’s opioid crisis is part of a broader effort to appear tough on drug-related crime. He has proposed jailing pharmaceutical executives and, infamously, suggested some drug dealers should be executed.

His administration’s media strategy has echoed the intensity, with some television ads featuring people driving cars into walls or smashing their own fingers with hammers so as to obtain opioid prescriptions.

But for all the emphasis on prevention and enforcement, the administration is hardly united.

Already, tension between two drug policy camps — public health advocates and researchers on one end and law enforcement on the other — has spilled into public. The DEA itself has lobbied Congress to expand its authority, in an aggressive advocacy push the Trump administration has not formally endorsed.

At a closed-door briefing for Senate staff on June 20, a DEA chemist urged lawmakers to empower the agency to classify all fentanyl analogues as Schedule I, congressional aides told STAT.

A researcher from the National Institute on Drug Abuse forcefully opposed the legislation, saying the designation had little scientific basis and could threaten researchers’ ability to investigate fentanyl compounds and develop life-saving medications, including stronger equivalents of the overdose antidote naloxone.

The Senate briefing, which was first reported by Reuters, followed a DEA-only briefing on March 1 for House of Representatives staffers. Both presentations were met with skepticism, according to aides in both chambers. Though the Schedule I designation relies on chemical and public health analysis, the DEA has advocated to remove the Food and Drug Administration and the National Institute on Drug Abuse from the process.

A hearing last month on the proposal, ominously titled “The Countdown,” featured no representation from public health officials. Some lawmakers were openly wary of DEA’s advocacy, with Sen. Dick Durbin (D-Ill.) in particular vocally warning of potential research and public health implications.

Led by Durbin, eight members of the Senate Judiciary Committee — seven Democrats and a Republican — wrote to health secretary Alex Azar on Thursday to air those concerns again.

“We are concerned that the failure to engage necessary health experts vests far too much authority to a law-enforcement agency and may result in action that will deter valid, critical medical research aimed at responses to the opioid crisis,” the group wrote.

While the enforcement-heavy approach carries potential benefits, outside observers say it also represents the latest skirmish in a decades-long war between the DEA and the Department of Health and Human Services.

The DEA is “playing on people’s fear in order to make a power grab that predates the fentanyl crisis,” said Michael Collins, the director of the Drug Policy Alliance, a Washington advocacy group that has warned against enforcement-only approaches to the nation’s drug use and overdose epidemic.

Seized fentanyl
Bags of heroin, some laced with fentanyl, are displayed before a press conference regarding a major drug bust in September 2016. Drew Angerer/Getty Images

The DEA and the Department of Justice, its parent agency, have used aggressive tactics to advance the proposal, which was authored by Sen. Ron Johnson (R-Wis.). DEA representatives have claimed that unless Johnson’s bill passes, some forms of fentanyl could effectively become legal if Congress fails to extend an emergency order from 2018.

Amanda Liskamm, a high-ranking Department of Justice lawyer tasked with opioid prosecutions, warned reporters at a recent press briefing of “potential trial losses.”

The move is necessary to guard against highly sophisticated drug traffickers, she said, in which criminal fentanyl kingpins would make a marginal alteration to a drug compound for the sake of evading U.S. drug laws.

“Once we got a fentanyl-related substance permanently scheduled, the drug traffickers, who are very smart, would alter that molecular structure just by a tiny bit, and then obviously it wouldn’t be illegal in this country,” said John Martin, an assistant administrator for diversion control at DEA. “It was that kind of cat-and-mouse game we were playing.”

Public health experts — including several from HHS — point to existing law that provides for prosecution of chemical compounds that are similar in effect but not identical. Drug policy figures representing groups including the American Psychological Association and the American Society of Addiction Medicine have publicly opposed the measure.

“DOJ’s jobs are going to be a little bit more challenging,” Collins acknowledged. “We are being asked to give DEA control of the scheduling process and give up due process and allow more prosecutorial power — and give up researching these substances and potentially saving lives as a result of that research.”

But even ardent advocates of controlling drug supply cannot square the president’s rhetoric with his failure to appoint an official best equipped to do so. Asked about the DEA vacancy, a White House spokesman told STAT there were no impending personnel decisions. The Trump administration, he said, had full confidence in Uttam Dhillon, who has served as acting DEA administrator for the past year.

“The White House is so disorganized and dysfunctional that they can’t pluck an apple sitting at eye level in front of them,” said Gen. Barry McCaffrey, a retired Army general who served as “drug czar” in the 1990s under President Clinton. “Why wouldn’t you have a DEA administrator, for God’s sake? In 14 workdays, you could come up with a dozen superlative people with political chops who would take that job.”

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    • Julie – You do know that DEA sets the quotas every year for production of narcotics, right? And that every doctor must have a DEA number to prescribe narcotics, right? This is their lane.

  • Forget the Agencys that research and understand the drugs??? Sounds crazy DEA too much power! What happened to reason and research? Taking medication from those in need hasn’t stopped the Heroin or illicit Fentanyl this is crazy!

  • Why aren’t you worried about all the people on marijuana and alcohol? People have been dying from alcohol related problems for 100’s of years

  • The number of prescription opiate deaths are down but illegal opiate deaths are skyrocketing! This fact well documented! We also are not including the rampant increase in suicides among Chronic Pain patients, many of them Veterans!

    When will anybody start being honest about what is happening, by killing off an additional chronic pain patients every month, it helps to improve his overall economic numbers! This isn’t rocket science, this is the modern version of Hitler’s T-4 plan of culling the disabled.

    Isn’t funny how “right to try” doesn’t apply to us chronic pain patients, we want to try what has been proven to work for us, but we can’t.

    • I agree! He’s staring the truth ask anyone who knows addicts they haven’t been effected just us!!! It’s not never was a prescription medications crisis its a illegal heroin. Only 1% people taking opioids become addicted! Dependence to live not addiction!

  • Like they usually do, lawmakers have over-reacted now also in the opioid crisis, and that is resulting in torture for patients who NEED that level of pain control. Judging from the reactions, I would not be the only one who might be thinking that opiod abusers should be less important than those that need the opioids to have a half-decent life. Addiction boils down to bad choices made, and pain is no such thing. The time is long overdue for DOCTORS to start fighting for the well-being of their pain patients !!

  • The reason there are less opiate deaths is because they are not ending up in the morgue due to Narcan. The decline in opiate deaths although still far too many is not due to the lack of overprescribing or wrong prescribing of opiates. The bill in support of giving authority back to the DEA that was removed is HR 4084 S1960. I fully support passage of these bills. The case of DEA vs Walgreens can be read in the book STOPPNow (Stop the Organized Pill Pushers) Now. Changing a molecule in fentanyl removing it from unlawful status also occurred in Florida with bath salts. The passage of the Analog Act banned a substance for its pharmaceutical action not substance was effective. Our legislators are paid by the drug companies. Many of the pain society’s and government agencies are funded by Big PhRma. The swamp needs to be drained if we are to see an end to the opiate epidemic.

    • I agree but what about critically ill patients who are suffering? Can it be legislated? Can we legislate protection for them? If so I’m in. Check out dr William Bauer on Google. Treats the critical intractable patients. Thanks for listening.

    • I agree with you about the availability of Narcan slowing down the overdose deaths. However, if you really think more laws and regulations will slow this down, then you’re quite naïve.

      Frankly, I’m sick and tired of knowing that some of my fellow humans are being forced to suffer in silence because they can no longer get adequate pain relief in this country. Why?

      Because of people like you … People (like you) who are ignorant as to what substance abuse and addiction actually are and what they’re triggered by. (I’ll give you a hint – the substance has very little to do with abuse and addiction).

      People with constant pain – who once were stable and functioning and actually had some quality to their lives thanks to regulated opioid-based medication – are being punished for the actions of a small minority of those who are self-destructing as we speak.

  • Not one mention about severe chronic pain patients, cancer patients, terminally ill patients that this reclassification would hurt! Apparently the over 50 million chronic pain patients in America are expendable. No one seems to be hearing our cries for help. How can our leaders allow the forced suffering of their fellow Americans!? Government over reached in its response to opioid crisis and went after folks in pain instead of the drug cartels who easily flood our country with heroin, illicit fentanyl and illicit pills. Any addict with an email account can order illegal, illicit drugs through the mail, but a legit chronic pain patient who needs an opiate pain med to function and have a life, raise their families, they can’t find a doctor willing to help. The doc who prescribed their pain med safely and responsible for decades, had to drop their patients due to fear from the DEA. “First do no harm” is out the window. All turn a blind eye to the suffering and suicides going on everyday in America. What can we do to stop the suffering? We must all shout “no more” and let our elected officials know that it’s not ok to let Americans suffer!

    • Check out dr William Bauer on Google. He’s in Ohio defending the critically ill and is under attack. Grass roots campaign to support.

    • Amen, it doesn’t matter what lawmakers think. People are suffering, especially our veterans. Make a ” classification” for patients who are intractable. Problem solved.

    • Yes the Narcan reviving has cut down on deaths but problem not solved. This will just result in changes as some have stated! Already seen Narcan resistant in PA. Law enforcement got to go hard on illegal drugs and get out of doctors offices and chronic pain! We are going to have a PCP crisis soon if DEA isn’t stopped! The drug kingpin are living large as government funnels them new group customers!! Tired

  • Since most issues are initiated from the at-home medicine cabinet; should we not look deeper into proper disposal of unused medications? I believe Walmart and Walgreens are actively educating patients receiving these Rx’s about disposal when they pick them up.

    • Richard, you are incorrect that the issues stem from left over meds in the cabinet. Yes, some folks got meds that way, and some of those got addicted. But since 2012 prescriptions for opiate pain meds have declined and are at an all time low. So low that legit chronic pain patients suffer needlessly in agony because they can no longer find a doc willing to prescribe. The DEA put fear in docs and ruined the doctor/patient relationship. Docs now knowingly cause harm by force tapering their patients off pain meds that worked and allowed their patients to have a life. These folks now live in horrific, uncontrolled pain. Suicides are at an all time highly, mostly due to those suffering in unimaginable pain, and no doc will help. And despite the fact that prescriptions at an all time low, opioid overdoses are at an all time high proving once again, the opioid crisis is due to illegal street drugs, not legit prescriptions for pain. Alcohol causes more harm and deaths than any prescription opioid or illegal opioids combined. Yet folks can drink all they want. No one is worried about that. But somehow it’s wrong for a person suffering in pain to get a prescription for a med that’s been used effectively and safely for 4000 years! I don’t have all the answers to this tragedy, but I do know that as a proud American it brings me shame that my country allows the forced suffering of its citizens. To deny pain relief to those who suffer is a crime against humanity…and it’s allowed everyday. I’m at a loss…

    • Richard – Why not take measures to prescribe less so they don’t end up in the medicine cabinet. Implement CDC guidelines into law. Hospital ED’s to utilize ALTO (alternative to opiate prescribing) (government grants available).

    • Richard – Why not take measures to prescribe less so they don’t end up in the medicine cabinet. Hospital ED’s to utilize ALTO (alternative to opiate prescribing) (government grants available).

  • What about the suicide rate of chronic pain patients and veterans taken off their much needed medicine to function, bet that rate has not gone down. Who’s next after all the chronic pain patients, disabled veterans and senior citizens have been exterminated. sound familiar? check the history books. The DEA needs to go after illicit drug sellers not Doctors, even though Doctors are an easy mark. My life and others are being ruined because of the so called opioid epidemic. Someone in government please start caring and help the pain patients!

    • Disagree with the two previous posts. Propaganda driven statements. Science has proven that opiates lose their effectiveness over long periods of use in chronic pain patients, necessitating increased doses over time causing increased risk of ACCIDENTAL overdose due to tiny margins of difference between the deadly respiratory depression for which the threshold does NOT change due to opioid tolerance. The increased suicide rate is NOT because of uncontrolled pain but because of those who have inadvertently been overprescribed opiates. These individuals live their lives controlled by their next dose, RX or fix. Naturally, as regulations cause the decline in prescriptions for opiates, those who have become dependent or “addicted” are forced to turn to the street to acquire the drug. The result is? Increased use of heroin … cheaper, more potent and easier to acquire or black market (counterfeit) Opiate drugs. These have increased deaths or have been deliberately accessed for deliberate overdose. Do not counter with the typical testimonial pharmaceutical company agenda crap. I work in the health field and watch first hand what both legitimate and illegitimate opiates do to people, patients and loved ones. Doctors are careless, nurses use and Pharmacists are forced to police it. If doctors truly held to the “do no harm” they would diagnose appropriately, treat with modality driven treatments and STOP throwing a drug at every symptom that exists. The US is responsible for 85% of the worlds oxycodone use and 95% of the hydrocodone use. What does that tell you? We are the only country with the inability to handle pain! Watch TV! Every other ad is about a medication for a symptom “just ask your doctor”. Yes there are chronic pain patients but the ones I’ve worked with truly dislike the opiates and how they make them feel. They want relief not from a drug but from a combination of treatment approaches that improve their quality of life not just “mask pain”. They are willing to endure a certain level of pain, so long as they are able to function and do not want to have to “depend” on a pill as the only source of relief. I’d say the drug companies have too many paid BOTs out their flooding threads like these with their propaganda! Thanks to Sackler family. RIP to DT! I will always speak out for you. Choosing death over addiction is not the cause of increased regulation it is the cause of despair because the physicians caused the problem and then left you to your own demise. Advocate for prevention and recovery not for continued opiate use. Opiates should be reserved for severe, ACUTE, Cancer related or irretractable pain not for Chronic pain.

    • So true. Our veterans git whatever it took to help them in wartime. Hope my nephew , a medic, deployed in Iraq ,doesn’t have to get permission to save a soldier hit with a roadside device….it is ok to legislate but c’ Mon.

    • “Science has proven that opiates lose their effectiveness over long periods of use in chronic pain patients,”

      Bull crap. Science has not proven this in any way. In fact, there have been very few studies on the long-term “effectiveness” of opioid-based medication (just as there are very few studies on the long-term “effectiveness” of anti-depressants, anti-convulsants, anti-psychotics, and most other medications available). However, let’s talk about the millions of people who have taken prescription opioids for years, even decades, like my own dad did for over 20 years of his life.

      “Opiates should be reserved for severe, ACUTE, Cancer related or irretractable pain not for Chronic pain.”

      LOL … chronic pain includes “irretractable” pain (BTW the word is INTRACTABLE). Chronic pain includes pain associated with cancer and its various treatments. Acute pain can sometimes turn into chronic pain. So, according to you, unless someone is DYING, their quality of life is not important. When does QOL become important to you? When one is 3 months from their death? 6 months? What’s the number?

      Regarding “cancer pain” vs “chronic pain” –

      “[P]ain mechanisms do not discriminate between cancer and noncancer pathophysiology. Patients with cancer or those without cancer have essentially identical pain-generating physiologies, and thus the same mechanisms for the development of their pain (eg, inflammatory pain in a cancer patient will be the same physiological process as in a noncancer patient). Further, cancer patients are living longer and their original pain generators become chronic pain in and of themselves, little different from patients without cancer.”

      So, according to your philosophy, one who has been given a cancer diagnosis is “deserving” of pain relief while another who has been given a trigeminal neuralgia, chronic regional pain disorder, or interstitial cystitis (three of the most painful afflictions known in the medical world – in fact, the pain can be much more severe than pain caused by cancer and/or its treatments) is not deserving of pain relief.

      What about the patient whose cancer went into remission 5 years ago, but whose bones were permanently damaged by the chemo or radiation, giving them hellish bone pain 24/7? I guess they’re no longer “deserving” of pain relief. Their quality of life no longer matters to you since they no longer carry the cancer diagnosis. Right? (BTW many cancer patients – including terminally ill – are unable to receive adequate pain relief).

      One last thought – Just like everyone else, you are just a split second away from a cancer diagnosis or becoming disabled and left with a lifetime of severe pain from a car accident or a fall.

      My brother-in-law just learned this the hard way when just a few weeks ago, he fell from the 2nd floor onto concrete, landing on his back. Emergency spinal surgery and now stuck in a wheelchair for the rest of his life, pain plaguing him until the day he will die … but then his quality of life does not matter to you since he doesn’t have a cancer diagnosis.

      Seriously, you’d better think long and hard before spewing garbage about a substance that you literally know NOTHING about. Karma has a way of coming back, making you wish you could eat the words of your past. This has happened several times when I spoke about my kids BEFORE I even had kids. Every. Time.

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