The drug strategy of the Trump administration is going to look a lot like that under John Walters, head of the Office of National Drug Control Policy (ONDCP) under President George W. Bush, ADAW has learned. The three key issues are prevention, treatment and border control. According to an administration official, speaking on background, “This administration is working to develop a comprehensive approach to addressing drug use and its consequences that will address preventing drug use before it starts, getting people who are struggling with substance use disorder the help they need and stopping the flow of illegal drugs into the country. We will provide further information in a timely manner as these policies are developed and implemented.”

At the stroke of noon on January 20, President Donald Trump became the nation’s leader. But despite the swirling uncertainties about the future of the Affordable Care Act (ACA) and other questions, prevention and treatment of substance use disorders are still a part of the national drug control strategy.

There were initial concerns in the field because the ONDCP website had disappeared, but that’s because everything that was EOP (Executive Office of the President) had been replaced by the new White House. Michael Botticelli, the beloved ONDCP director who had championed recovery and, along with Gil Kerlikowske, President Obama’s first drug czar, a focus on treatment and away from the drug war, was also gone. But the programs are still there, as is the ONDCP itself, with Kemp Chester the acting director. Chester joined ONDCP as associate director for the National Heroin Coordination Group in October 2015. He retired from the Army, where he worked for 27 years; his last tour was at the Defense Intelligence Agency, working on counternarcotics. 

We asked Andrew Kessler, principal with Slingshot Solutions, about how the changes will affect the SUD field. “We are in a situation that is not unique to our field,” said Kessler, who lobbies on behalf of behavioral health providers. “A lot of people across government are very curious to see how this plays out.”

Kessler zeroed in on community policing as a key question going forward. Community policing is recommended for elimination from the Department of Justice budget by the Heritage Foundation in a report the Trump Administration appears likely to consider. However,  Sen. Jeff Sessions, nominee for Attorney General, has in the past been a big supporter of community policing – as is Kessler. “I think community policing can play a huge role in working with the treatment community on diversion programs, prevention programs, any number of programs,” he said.

SAMHSA leadership team

In addition, the leadership team at the Substance Abuse and Mental Health Services Administration (SAMHSA) consists of career officials with longtime experience in the programs of that agency (see organization chart, SAMHSA.pdf). As Kana Enomoto, deputy assistant secretary for mental health and substance use in the Department of Health and Human Services (HHS), told SAMHSA staff last fall, “SAMHSA’s work remains critical and behavioral health continues to be a top priority” (see ADAW, Nov. 21, 2016). The HHS assistant secretary for mental health and substance use will be appointed by President Trump. The move from SAMHSA administrator to the new position of HHS deputy assistant secretary, as well as the new position of HHS assistant secretary, were created by the Cures Act, which incorporated some changes to SAMHSA organization (see ADAW, Dec. 12, 2016, and Jan. 23).

Charles Curie, SAMHSA administrator from 2001 to 2006, gave us a sense of perspective about how the transition will work. “I know some of the people who are in acting positions at HHS — all have been in transitions before, all are highly competent, all SES [Senior Executive Service] with institutional knowledge, and are in a good position to inform stakeholders,” Curie told ADAW last week. For example, Acting Secretary of HHS Norris Cochran was at the Office of Management and Budget (OMB) when Curie was waiting to be confirmed as SAMHSA administrator. Cochran’s expertise is the health budget, and he has experience in Congress as well.

Curie, now a consultant in behavioral health, also has great confidence in the SAMHSA career officials — many of whom worked there when he was administrator. “These are very strong people,” he said. “Kana is an example of someone who is SES, key advisor on my team, and has demonstrated that she can work with a range of administrations.” A note on SES: it’s not based on seniority alone. A federal employee has to go through a review process, under which competence must be demonstrated. Also, Curie doesn’t think the title change is going to make much difference, noting that the SAMHSA administrator position always reported to the HHS secretary.

The transition

“In a transition, in the very early part of a new administration, you have a situation where prior to cabinet officials being confirmed and being in charge, you have senior executive career people who are in acting positions who are working with White House liaisons and counselors who are working for the new administration,” said Curie. These people are likely to be part of the HHS secretary’s new leadership team once the secretary is confirmed. (Tom Price, congressman from Georgia, is Trump’s nominee for HHS secretary.)

As for Medicaid and ACA changes, Curie cautions this is not a time to panic. “During a transition, where there’s been a major process to put into place, the assumption needs to be to continue with that process,” he said. For example, the treatment providers who have learned how to bill Medicaid and commercial insurance for services need to keep doing this, he said. “Any new process coming in is not going to be implemented quickly,” he said.

It’s still very early in the administration. More will be known when the secretary gets confirmed and when agency heads are put into place, said Curie. This doesn’t happen quickly. In Curie’s case, he was nominated in July 2001 — six months after the inauguration took place — and not confirmed until October.

Curie’s advice to new appointees is to “make sure what you are doing is aligned and transparent with what the White House wants,” he said. “Make sure stakeholders have had the opportunity to engage and have some ownership, and as you move forward, you can put new ideas on the table, facilitating trust for the administration.”

And everyone needs to “think about what is sustainable positive change, not just a quick win here or there,” Curie said. From his administration, he cited the Strategic Prevention Framework, Access to Recovery, the New Freedom Commission and the National Outcome Measures, all “readily embraced by the secretary and the White House.” Not all survived the Obama administration, which had other plans. But if the new drug strategy is any key, some of the same ideas — especially a focus on primary prevention — may come back.

ACA, parity and Medicaid/IMD

The National Association of Psychiatric Health Systems (NAPHS) is committed to three priorities as the Trump administration sets its policies: health insurance, parity for mental health and addiction, and increasing access for Medicaid patients by continuing progress in the Institutions for Mental Diseases (IMD) exclusion, according to President and CEO Mark J. Covall. “We recognize that there will be changes in the ACA, anything from total repeal to replacement, but we’re going to make sure that people have coverage however it plays out,” Covall told ADAW last week.

NAPHS will also “continue to preserve and protect the parity laws and regulations that are in place across the board,” said Covall. This includes those that apply to Medicaid as well as those that apply to the small business and the individual market, he said. “There’s strong bipartisan support for parity, and we’re going to keep the pressure on that one,” he said. Covall is co-chair of the Parity Implementation Coalition, and works with many partners on parity, including the Kennedy Forum and the American Psychiatric Association.

The IMD exclusion, under which Medicaid could not pay for treatment in a residential facility with more than 16 beds, was relaxed last year, allowing larger SUD and psychiatric facilities to obtain Medicaid payment for 15 days per calendar month (see ADAW, Aug. 1, 2016).  “We want to continue to break down the barriers to access, and a good example is the IMD exclusion, where we made some progress last year,” said Covall. “As part of that, we’re going to be very focused on Medicaid.”

The focus on Medicaid, as there is discussion of possibly changing the program to a block grant program, is an essential part of making sure there is health coverage for everyone, said Covall. “Maybe there will be changes — we’ll see,” he said. “But we want to make sure that individuals receiving Medicaid are protected.”

The interviews for this story were conducted before President Trump had been in office for even a week. The transition is still in transition. What is in place is what was in place before: a cadre of experienced staff at SAMHSA; an ONDCP in the process of developing a drug strategy that is not unlike those of the past; and plenty of funded programs and grants, laws and regulations. Above all, what remains regardless of politics: substance use disorders.

Bottom Line…

In the first few days of the Trump administration, we have learned that the new drug strategy will resemble that in place before Obama’s: primary prevention, treatment and sealing off the borders from illegal drugs.