Warren Refloats $100 Billion Opioid Plan

Analysis: Big spending offers few new ideas on fighting crisis

Elizabeth Warren
Elizabeth Warren / Getty Images
• May 13, 2019 5:00 am


Presidential contender Elizabeth Warren (D., Mass.) floated a proposal Wednesday to combat America's ever-growing overdose crisis.

The proposal would allocate $10 billion per year primarily for treatment and harm reduction. However, some experts argue that that might not be enough.

Warren debuted her proposal in a Medium post, highlighting the year-on-year decline in life expectancy attributable to opioids, as well as suicide and overdose deaths involving drugs like methamphetamine and cocaine.

Her proposed response is the reintroduction of the Comprehensive Addiction Resources Emergency (CARE) Act, a bill co-authored with Rep. Elijah Cummings (D., Md.). If passed, the bill would allocate $100 billion to fund "first responders, public health departments, and communities on the front lines of this crisis," divided up into ten $10 billion payments over ten years.

Each year states and territories would receive $4 billion in funding; an additional $2.7 billion would go to the "hardest hit counties and cities." $1.7 billion would go towards public health surveillance and research, $1.1 billion will support nonprofits, and $500 million will expand access to naloxone. This spending will be paid for with Warren's "ultra-millionaire tax," which is now estimated to fund outlays totaling $129 trillion.

The CARE Act "also works to strengthen our addiction treatment infrastructure," Warren wrote, "demanding states use Medicaid to its fullest to tackle the crisis, expanding access to medication-assisted treatment, and ensuring treatment programs and recovery residences meet high standards."

Warren is correct in claiming that America is currently facing an opioid crisis: more than 40,000 Americans were killed by drug overdose deaths involving opioids in 2017, the highest rate on record. The added spending would be an enormous boost to harm reduction and treatment efforts. By comparison, Congress put $3.3 billion towards fighting the crisis in its most recent omnibus spending bill; the Department of Health and Human Services has allocated $1.4 billion to states to combat the opioid crisis under its State Opioid Response grant program.

"Senator Warren's proposal is the only one right now in Washington that is at the needed scale," Dr. Keith Humphreys, a health policy and addiction expert at Stanford, told the Washington Free Beacon. "The opioid epidemic isn't a small problem that will go away with short-term grants or through a few billion dollars. We need to go big, as we did for AIDS, and she (and Rep. Cummings) deserve credit for putting forward a solution that recognizes the severity of the problem."

The CARE Act is focused primarily on improving access to treatment and "harm reduction" methods, both of which would likely save lives in the long run. At the same time, it is not clear how effective the impact of expanding such resources would be on the current crisis. A 2018 study, of which Humphreys is a co-author, used statistical modeling techniques to estimate the number of lives that would be saved over 10 years by the introduction of eleven different policy interventions.

Their analysis projected some 500,000 opioid-associated deaths through 2025. The expansion or introduction of tools like naloxone, needle exchange, medication-assisted treatment, and psychosocial therapy would reduce this number by 47,100, or 9.4 percent. In other words, increases to treatment availability would have some mitigating effect on the crisis, but not categorically address it.

Humphreys emphasized to the Free Beacon that this conclusion is a product of his paper's assumptions. "Our paper showed only modest benefits to a group of policies in the range we estimated they might be scaled," he said. "But this proposal goes beyond those ranges (we did not expect Congress to go this big) so the impact should be larger than what we estimated if this bill is passed."

Still, Humphreys et. al.'s finding highlights the insufficiency of a drug strategy which focuses exclusively on funding more treatment, as opposed to additionally offering novel ideas for combatting the new realities of the overdose crisis. For example, a treatment-focused plan will struggle to cope with the rising cocaine and methamphetamine crises, as neither drug has an associated effective medicine a la buprenorphine or methadone for opioids.

"A plan on overdose deaths cannot just be opioid-specific. Opioids are very unusual in that we actually have medication-assisted therapy," David Murray, a drug policy expert at the Hudson Institute, told the Free Beacon. "But in America, we have an overdose crisis that is not just opioids. We have an emerging and rising cocaine epidemic of overdose. We have an emerging and rising methamphetamine abuse and overdose. And they are not susceptible to medication-assisted therapy."

Warren's plan does not necessarily constrain funding to just fighting opioid dependence; but its generality belies what Murray sees as a willingness to throw more money after the problem rather than thinking critically about new solutions.

"I'm always kind of skeptical about more money for a system that is not capable now of delivering what is needed—it is like insisting on better deck chairs [on the Titanic]," Murray said.

Also conspicuously absent from Warren's comprehensive plan is a proposal for supply-side intervention, either domestically or abroad. Recipients of CARE grants are constrained to spending no more than 20 percent of their funds on prevention services, including both education and diversion.

This may be because Warren preferred to blame American pharmaceutical firms, whose role in perpetuating the crisis has waned since 2012. In her Medium post, Warren took shots at the infamous Sackler family, arguing that overdose deaths were a product of their lust for wealth.

"Here's the truth: fueling addiction is big business," Warren wrote. "This crisis has been driven by greed, pure and simple."

Totally absent from her essay was any mention of the role of Mexican cartels in producing methamphetamine and heroin, nor of Chinese producers who fabricate the fentanyl that killed 28,000 Americans in 2017. Also absent is any proposal for tightening oversight of unscrupulous doctors or dangerous prescribing practices.

"The policies we most need are currently not being implemented because of a lack of political will rather than a lack of funding," Humphreys told the Free Beacon. "These include reforms at FDA as well as in state medical boards to promote a return to careful opioid prescribing. We also need international engagement with and cooperation from China, Mexico, and with chemical manufacturers to disrupt the supply of fentanyl."