The Washington PostDemocracy Dies in Darkness

Trump said solving the opioid crisis was a top priority. His drug office’s track record suggests otherwise.

President Trump holds hands with former baseball player Mariano Rivera during an event at the White House highlighting the U.S. opioid crisis Oct. 26, 2017. (Alex Wong/Getty Images)

President Trump on Thursday expressed his deep support for Americans facing drug addiction in a proclamation of National Substance Abuse Prevention Month and renewed his administration’s “unyielding commitment to breaking the grip of alcohol and drug addiction.”

Trump’s expression of empathy came just two days after he mocked Joe Biden’s son’s history of drug addiction during the chaotic presidential debate.

The president’s contradicting sentiments are reflected in the way his administration has responded to the nation’s drug crisis over the last four years, with its irregular commitment exemplified by the unsteady performance of the Office of National Drug Control Policy (ONDCP), the government’s flagship agency in the fight against drug abuse.

Trump has run the office much the way he has approached governance in general, showing skepticism, ambivalence and a lack of focus according to government audits, documents and drug policy specialists. Under his leadership, ONDCP employees have cycled out and failed to marshal a cohesive and measurable anti-drug plan. It served as a way station for political appointees, documents and interviews show.

For most of Trump’s administration, the office, created by Congress to lead efforts related to illegal drugs, has not delivered on a central mission: an annual strategy to guide more than a dozen federal agencies and hundreds of billions of dollars in federal spending, government auditors wrote in 2019.

With opioid deaths now surging during the pandemic to their highest level in five years, critics say the office is falling short again during its greatest challenge under Trump.

Lawrence “Chip” Muir, who served as general counsel and acting chief of staff in the administration’s first year, said ONDCP officials faced daunting odds early on because of the opioids epidemic. But the White House marginalized the office and did not follow through on other coordination efforts. Muir said ONDCP should have done more to help drug abusers, doctors, hospitals and others during the covid-19 pandemic.

“Everyone knows what economic and psychological depression does to at-risk populations,” Muir told The Washington Post. “There was an opportunity for real-time strategy and guidance during the pandemic that could save lives, and I just didn’t see it.”

Josh Sharfstein, a physician and vice dean for public health practice at Johns Hopkins University, gave the ONDCP’s coronavirus response a “middling” grade. Some measures were helpful, such as waiving regulations so people in treatment did not have to make in-person visits to get buprenorphine, a medication used to treat addiction. But, Sharfstein said, the office did not make as generous allowances for people being treated with methadone, which he said is easily prescribed by physicians for non-drug treatment uses.

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Though Trump repeatedly claimed success in its management of the opioid crisis, the ONDCP struggled to coordinate more than a dozen other agencies in a multibillion-dollar counterdrug effort. Last summer, the administration took credit for ending what it said was a 29-year streak of rising deaths from opioid overdoses. Within weeks, the death toll began to rise again.

A spokesperson for the ONDCP stood by its record, citing a range of achievements over the years that encompass the administration’s focus on drug use prevention, treatment and recovery. The office took credit for expanding availability of the overdose reversal medication, naloxone; increasing anti-opioid misuse education campaigns for young people; and securing historic funding levels for anti-trafficking efforts and addiction recovery.

A spokesperson for ONDCP cited its Rural Community Toolbox issued in June as one way the office has taken action to address opioid use during the pandemic. Some of what is included in the toolbox is guidance from other agencies, but much of it focuses on efforts like increasing access to telehealth so patients can access treatment remotely.

Notably, telehealth does not appear in the office’s 2020 Drug Control Strategy, released in February. It’s an inconsistency critics say is emblematic of the office’s management.

Sharfstein compared it to the way the Trump administration has responded to the coronavirus pandemic.

“It’s disorganized at the top and they’ll just let the states do what they’re going to do,” Sharfstein said. “There’s an analogy in this. You can really set an agenda and drive toward the policies and programs that are proven to work, and away from the ones that aren’t proven to work.”

A tumultuous transition

Despite the erratic management that has plagued ONDCP since the start of the Trump administration, the office tallied important achievements in the first year.

Muir, the former acting chief of staff, said Trump shifted planning the administration’s response away from the office and closer to political appointees close to him, with former White House adviser Kellyanne Conway leading the charge.

The administration’s early plans focused on states hardest hit by the opioid epidemic, like Ohio and Pennsylvania, yielded success, with opioid deaths falling by roughly 20 percent in each state, Muir said.

“We wanted effective plans with measurable reductions in overdose deaths,” he said.

But ONDCP became caught up in the upheaval that defined Trump’s first year in office, where staff turnover was high, top roles sat vacant and inexperienced Trump loyalists were rewarded with influential positions.

As opioids flooded tribal lands across the U.S., overdose deaths skyrocketed

Trump’s first nominee to be the new drug czar, Rep. Tom Marino (R-Pa.), withdrew after an investigation into his ties to opioid companies and work in Congress on their behalf. That same year, a 24-year-old former Trump campaign employee was elevated to third-in-command at ONDCP; he was later fired when a Post investigation raised questions about his qualifications.

In May 2017, the Office of Management and Budget proposed cutting 95 percent of ONDCP's budget, but the White House reversed course over complaints from lawmakers who saw the opioid epidemic raging in their communities.

By 2018, at least seven political appointees had already left and the office had no permanent director until James Carroll, a lawyer who served in the George W. Bush administration but has no drug policy experience, was confirmed in early 2019. The most experienced staff member is assistant director Kemp Chester, a retired Army intelligence officer and holdover from the Obama administration.

Sharfstein, of Johns Hopkins University, said the tumult has undermined the influence the office had grown during the Obama years, when ONDCP shifted its emphasis away from ’90s-era drug enforcement to focus on harm reduction and treating addiction as a brain disease rather than a moral failing.

In the waning days of the Obama era, the office released an influential memorandum that updated federal terminology around substance use, which was later adopted by the Associated Press Stylebook. It calls for terms that separate the person from the disease — “a person with heroin addiction” rather than “heroin addict” — and less stigmatizing language around drug use, favoring “substance use” over “drug abuse.”

Sharfstein noted the name of the Trump administration’s recent proclamation.

“If they’re calling it ‘Substance Abuse Prevention Month,’ they’re violating their own style guide,” he said.

Inconsistent strategies

Under Trump, ONDCP did not publish a Drug Control Strategy, the office’s annual blueprint for the government’s drug policy, until 2019. A spokesperson for ONDCP said incoming administrations are not required to issue a drug control strategy during the first year in office.

The office’s first report, in 2019, was 23 pages; under the Obama administration, the strategy reports from 2012 to 2016 averaged almost 103 pages long.

A December 2019 audit by the Government Accountability Office, Congress’s watchdog agency, found the report lacked basic data required for “the development and implementation of U.S. drug control policy across the federal government.”

It also did not meet requirements in the Support Act, October 2018 legislation aimed at confronting a national opioids scourge. Though the office hired five coordinators, as required by the act, the strategy document offered none of the congressionally mandated details about how to achieve the legislation’s goal, including the reduction of opioid abuse, the GAO auditors said.

When questioned about the shortcomings, ONDCP leaders did not demonstrate even a basic grasp of the issues, the GAO said.

“ONDCP could not provide in writing or otherwise describe its planned steps, interim milestones, resource investments, or overall time frames — all key planning elements — that would provide assurance it can meet these requirements,” the GAO said. “Further, ONDCP officials had no information on next steps for fully meeting the requirements.”

The office “fell short” again with strategy report issued in February 2020, GAO auditors said. That report, just 44 pages long, also lacked information and planning required by law. ONDCP later supplemented the report with one that did “address all of the statutory requirements that GAO noted as missing in their March 2020 report,” a spokesperson said.

A GAO auditor told The Post that it examined the recent strategy reports after lawmakers raised questions about the Trump strategies. “We did not conduct a similar exhaustive analysis of the earlier strategies,” wrote Triana McNeil, a GAO director involved in the reviews.

Muir, the former acting chief of staff, said when ONDCP resumed publishing the National Drug Control Strategy in 2019 after missing the previous year, the strategy report “had no numerical metrics, no rationales for objectives."

The 2019 Strategy Report boldly claimed, “The Trump Administration is matching the magnitude of today’s historic crisis with a historic level of focus and resources.”

But within the same report, ONDCP staff wrote that its annual strategy “focuses on outlining a high-level approach rather than enumerating all of the key tasks and activities that organizations at the Federal, State, local and Tribal levels must undertake to stem the tide of this crisis, it is important to employ some broad measures of performance and effectiveness to guide the Strategy’s implementation."

It also sidestepped performance metrics, as required by law, writing that its plan “requires that we focus on effects and not simply performance.”

In the absence of detailed metrics and objectives, Muir said, “predictably we have reentered the crisis.”

Reflecting on Trump’s comments about Hunter Biden’s past cocaine use during the debate, Sharfstein, the Johns Hopkins doctor, said the president’s words were harmful to the same efforts his ONDCP office is trying to advance.

“It was a gigantic step back for the idea that people with substance disorders are people first and are not defined by their use of the substance,” Sharfstein said. That continued inconsistency has filtered down to ONDCP and diminished its reputation in the broader public health and drug treatment community, he said.

“ONDCP hasn’t been nearly as much as a leader,” Sharfstein said. “I just don’t think the office has made any ripples. And more generally, there isn’t anymore coherent national strategy.”