I can hear it now... "Just say NO!"

Trump vows to 'liberate' Americans from 'scourge of drug addiction'

But critics say his words won't mean much without the money to back them up.

By BRIANNA EHLEY and SARAH KARLIN-SMITH

President Donald Trump declared the opioid crisis a public health emergency Thursday and touted "really tough, really big, really great advertising" against drug use. But despite his August vow to spend "a lot of money” to combat it, he did not pump additional funds into an epidemic that has ravaged communities and claimed tens of thousands of lives.

Trump said he would swiftly "review and evaluate" recommendations due next week from his opioid commission and promised to fight illegal drug shipments from countries like China. But the declaration disappointed state officials and public health experts who say a lot more money is needed to respond to a deadly epidemic that is outpacing efforts to contain it. Policies, they said, won't accomplish much without substantial investments behind them.

“People are dying," said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing. "We have people dying of overdoses on waiting lists for an effective treatment.”

Public health and addiction experts say a multi-pronged approach is needed immediately — a national prevention strategy, greater access to substance abuse treatment and enough money for communities to stock up on naloxone, an increasingly costly drug that can reverse life-threatening overdoses.

Some experts had urged Trump to trigger another category of national emergency under the Stafford Act, which can unlock more federal resources and emergency powers but is usually used for more clearly delineated disasters like hurricanes or fires. That would normally be administered through FEMA, not the Health and Human Services Department.

In addition, they noted that several parts of his plan are already underway, from requiring training for those prescribing opioids to developing nonaddictive pain medications.

Trump’s declaration, formalized by acting HHS Secretary Eric Hargan on Thursday afternoon, allows public health agencies to swiftly redirect existing health resources to the crisis. It will also cut "bureaucratic delays" in hiring personnel and expand access to telemedicine, including remote prescribing of medication commonly used for substance abuse or other mental health treatment.

"We can be the generation that ends the opioid epidemic," Trump said at a White House ceremony attended by many Cabinet officials, lawmakers from affected states, people recovering from addiction and families who have lost relatives to overdoses. He emphasized his planned anti-drug advertising campaign, recounting how he himself had never had a drink because he heeded the advice of his older brother, Fred, who died young because of a drinking problem.

Some lawmakers from hard-hit states immediately said they would be open to appropriating more resources — but it's not clear how much of an appetite there is on Capitol Hill to significantly boost spending. As of now, the House and Senate appropriations bills for next year keep opioid funding levels flat. States already are getting $1 billion between 2017 and 2018 under the 21st Century Cures legislation to respond to the drug crisis.

But Trump's declaration relies largely on shifting existing funds, rather than putting up the extra money that state officials and some in Congress say is critical for a comprehensive response to the drug epidemic that the White House itself estimates is claiming about 175 lives a day.

"We're underwater," said Rep. David McKinley (R-W.Va.) during a congressional hearing earlier this week at which he criticized the federal response. "I don't understand why more resources aren’t flowing to help out a rural state like West Virginia." His state has the highest overdose death rate in the country.

The HHS public health emergency fund currently has only about $57,000 left in it, although Congress could replenish it and the department has some other emergency resources to draw on. An administration official said there are "ongoing discussions" with lawmakers about how much money is needed.

The spreading opioid crisis reaches from abuse of prescription painkillers to street drugs like heroin and the even more lethal fentanyl — which Trump said he'd bring up in his coming talks with China. Drug overdoses now kill more people than traffic crashes or gun-related deaths, and there's growing fear that IV drug use will set off waves of new HIV/AIDS infections in the heartland.

New Jersey Gov. Chris Christie, who attended the White House event praised Trump in a statement for taking "bold action." But the president's order will fall far short of the recommendations his Commission on Combating Drug Addiction and the Opioid Crisis made in its preliminary report in July. The final report is due next week and Trump pledged he'd act on it.

It's also not clear who will spearhead Trump's effort, given that there are vacancies or acting directors in several key agencies, including the Drug Enforcement Agency and HHS. Without clear leadership, "this is going nowhere," said Georges Benjamin, executive director of the American Public Health Association.

The Christie commission in its preliminary report recommended mandatory education for doctors and the waiving of a longstanding federal prohibition on using Medicaid funds to pay for inpatient substance abuse treatment — which the panel said is the single fastest way to increase treatment. Trump did call for some mandatory training for federal prescribers, such as doctors who work in the Defense Department or the Department of Veterans Affairs. Physician groups say some training has already been policy for a few years. The CDC has also put out prescribing guidelines.

Trump also said states could apply to lift some restrictive Medicaid rules for inpatient substance abuse treatment, again without many specifics or a commitment for more money, although officials said details would come soon. States are already able to seek waivers — without extra money — and it wasn't immediately clear whether Trump was expediting those waivers or suggesting a much more liberal policy.

Trump also highlighted public-private sector efforts underway through the National Institutes of Health to develop safer nonaddictive pain treatments.

Michael Fraser, executive director of the Association of State and Territorial Health Officials, urged Congress to act. "The lack of resources is concerning to us since the opioid epidemic is presenting lots of challenges for states' budgets," he said.

Advocates worry about redirecting other health funds administered by HHS, particularly from programs such as those for HIV prevention.

“There are some measures in the package that suggest states could shift money away from HIV to the opioid crisis, but the fact is patients who are suffering from the opioid crisis, they have other health concerns too," said Tiffany Kaszuba, deputy director of the Coalition for Health Funding. "It's not even robbing Peter to pay Paul anymore. It's robbing Peter to pay Peter."

Even without more cash, some experts noted that HHS and other agencies could use their emergency powers to act on some other recommendations of the Christie commission. "This could set the stage for something more to come," said Cynthia Reilly, director of the Pew Charitable Trust's substance use prevention and treatment initiative.

But the declaration as unveiled Thursday did not include other priorities identified by state and local officials. For example, it won't immediately address access to the emergency overdose treatment naloxone. The price of the drug has soared in the past couple of years, making it hard for cash-strapped emergency departments to stock it. And addiction experts say that's crucial, particularly in rural areas.

Ohio was able to negotiate a lower price of naloxone for emergency medicine agencies and police officers, but at a cost of $40 a vial, it’s still too high for many EMS agencies, particularly as some of the stronger opioids now require multiple doses per patient, said Carol Cunningham, medical director for the Ohio department of public safety’s EMS division and the chairwoman of the National Association of State EMS Officals.

Policy experts said the administration's decision to use a public health emergency fund instead of a national emergency declaration under the separate Stafford Act is insufficient.

"You show me in the past a national public health emergency declaration with no accompanying funds or even requests for funds, I’d be pretty surprised," said Andrew Kessler, who runs Slingshot Solutions, a consulting firm specializing in behavioral health and drug abuse.

Some states had hoped to see more help to build out programs that show promise. Rhode Island, for instance, wants to establish a pre-arrest diversion program so that law enforcement sends people using opioids to treatment instead of jail. "We know that prevents deaths, and criminalization does not,” said Rhode Island Health Director Nicole Alexander-Scott.

According to a summary released by the White House, but not mentioned by the president, the Department of Labor will be able to give emergency grants to states for workers displaced by the opioid crisis if funds are available. However, the administration has proposed a 40 percent cut to dislocated worker grants and training.

Trump said in August and then again last week that he would declare the crisis a national emergency, which would give the administration more tools to fight the crisis but also raise a host of legal and economic issues.

At the time, officials were considering using the Stafford Act. Former HHS Secretary Tom Price, White House budget director Mick Mulvaney and the White House Domestic Policy Council had objected to such a declaration because of its potential multibillion-dollar price tag, legal issues and questions about how it could be implemented.

The more measured response speaks to the complexity of a drug epidemic that is pervasive yet not isolated in a particular time or place like a hurricane or a fire.

Another official added the administration has spent $1 billion on the opioid crisis since the president took office. Roughly $500 million for drug addiction response efforts was provided under the 21st Century Cures Act signed into law by former President Barack Obama last year.

The declaration of public health emergency lasts 90 days, but it can be renewed.