President Donald Trump insisted that drugmakers that helped fuel the opioid epidemic should face federal litigation. But when it comes to dealers of illicit substances, like fentanyl, Trump demanded an even harsher punishment — declaring they should pay the "ultimate penalty."
"The drug dealers, the drug pushers are really doing damage" and "kill hundreds and hundreds of people, and most of them don't even go to jail," Trump said at a March 1 White House summit dedicated to examining the opioid crisis.
"If you shoot one person, they give you life, they give you the death penalty. These people can kill 2,000, 3,000 people and nothing happens to them. And we need strength with respect to the pushers and to the drug dealers. And if we don't do that, you're never going to solve the problem," he said.
But Trump made it clear that even though illicit drugs are now driving much of the epidemic, prescription opioid makers remained in his sights.
He said he had talked with U.S. Attorney General Jeff Sessions about bringing a lawsuit against some of the opioid companies.
"Hopefully, we can do some litigation against the opioid companies," Trump said. "I think it's very important because a lot of states are doing it, but I keep saying, if the states are doing it, why isn't the federal government doing it? So that will happen."
Sessions revealed Feb. 27 the U.S. Department of Justice planned to file a so-called statement of interest in a lawsuit against a number of drug manufacturers and distributors accused of using false, deceptive and unfair marketing practices.
"I believe it will be filed today," Sessions said at the White House summit. "And we're looking to see if there's additional civil litigation that the Department of Justice can take independently of the state lawsuits."
The attorney general said he sent the head of the Drug Enforcement Administration a directive on March 1 telling the agency to look at its regulatory capabilities to reduce the number of drugs being prescribed in America.
"We want the death rate down and we'd like to see the amount of drugs prescribed down," Sessions said. "We have Medicare, Medicaid, [Veterans' Affairs] and private insurance paying for these drugs to make people sick. It makes no sense whatsoever — actually killing people — so we've got to tighten that up."
At the summit, Health and Human Services Secretary Alex Azar was more focused on ensuring access to treatment facilities and medication-assisted therapies, or MATs, for Americans addicted to opioids — which "are essential to this fight" — and on lifting the stigma associated with those products and services.
Azar noted that shortly after Trump declared the opioid crisis a public health emergency in October 2017, the administration unveiled a way for states to get waivers on a 1970s rule that prevents their Medicaid programs from providing care at substance-use disorder treatment facilities with more than 16 beds.
The Centers for Medicare and Medicaid Services on Nov. 1, 2017, notified states that the agency had created a streamlined process to make it easier to obtain the waivers. The agency has since approved five waivers, Azar said, adding that "I want more."
The Obama administration had previously approved waivers for California, Maryland, Massachusetts, Virginia and New York.
"We're open for business on them," Azar told those gathered at the White House for the opioid summit.
A commission Trump convened last year to examine the opioid crisis recommended that the government immediately grant the waivers to all 50 states.
Barriers and stigma
Several people at the White House summit described the barriers they faced in getting treatment for themselves or for their loved ones, with some relating stories of how a family member had died of an overdose while waiting to enter a treatment facility.
"Until it becomes as easy to get treatment as it is to get the drugs, we're not going to win the battle," said Housing and Urban Development Secretary Ben Carson.
Other administration officials made similar remarks earlier in the day at a forum hosted a block from the White House at the U.S. Chamber of Commerce.
"There is a stigma associated with people who require life-long treatment with replacement therapy," Food and Drug Administration Commissioner Scott Gottlieb said at the Chamber's forum. "Those people are not addicted anymore."
The FDA chief said there was a mistaken perception that people using MATs are simply replacing one opioid with another.
"That is not the case," Gottlieb said.
National prescribing system
At the Chamber forum, Gottlieb acknowledged that he has long advocated for some sort of a national prescribing system for opioids and other controlled substances and said the political and career staff at the FDA are behind such a concept.
"I think it's a good idea," he said. "I think it could provide for a much more robust system."
While Gottlieb said he has long expressed concern about federal regulation of the practice of medicine, that is not the case when it comes to controlled substances.
"There's no more clear articulation of the aspects of the federal regulation in the practice of medicine than the Controlled Substances Act, where you not only have the scheduling process for how doctors can prescribe drugs, but you actually have very clear parameters for how those drugs can be dispensed and prescribed," he said.
A national prescribing system should incorporate an interoperable prescription drug monitoring program into it "so doctors can look across states to see where their patients are getting access to drugs," Gottlieb said.
"If we had these systems in place, I think it could help lead to much more rational prescribing and health systems would have much more opportunity to see how drugs are being dispensed, how doctors are dispensing and also how patients are receiving" the opioids and other controlled substances, he said.
While there would be some up-front costs, in the long run the system would save money because it would reduce the use of opioids and other controlled substances and reduce overdose deaths, Gottlieb said.