In a strange Monday afternoon speech on opioid policy, President Donald Trump dedicated the bulk of his time to ideas that would be likely to worsen the crisis.

Reporters who had been briefed on the administration’s plans ahead of time wrote that the White House seeks to put force behind a 12-point guideline for the proper, safe prescribing of opioids that has languished for two years after the Centers for Disease Control and Prevention released them. The move would be a rare thing for Trump’s opioid policy so far: a novel move rather than a continuation of existing policy, and one that appeals to treatment-oriented groups rather than just law enforcement advocates.

Gary Mendell, an addiction and recovery expert who runs the organization Shatterproof, told ThinkProgress the guidelines are “the single most important thing we could do to prevent tens of thousands, hundreds of thousands of our loved ones from becoming addicted to opioids.”

Trump’s team reportedly plans to require that doctors adhere to the CDC best-practices list if they want to receive payments from Medicare, Medicaid, or other publicly-financed health services. Elsewhere in the speech, he even suggested his team is looking to file major federal litigation against the companies that have made billions of dollars off of prescription drugs that drag people into addiction — another potentially major shift in policy that would be in harmony with expert coalitions.


But Trump didn’t lead with these substantive policy change on Monday. If you blinked at the wrong moment, you’d have missed either of them. He spent the top of the speech reiterating his desire to see major drug dealers put to death, extolling the virtues of such bloody example-making to bursts of applause from his audience, mentioned the two promising initiatives briefly, then pivoted to familiar railing against immigration policies he hates.

“Our Department of Justice is looking very seriously into bringing major litigation against some of these drug companies,” Trump said after winding down the executions talk. “We’re going to cut nationwide opioid prescriptions by one-third over the next three years. We’re also going to make sure that virtually all prescriptions reimbursed by the federal government follow best practices for prescribing.”

Then, just as quickly as he’d brought up the long-awaited move on CDC’s guidelines and the surprise prospect of corporate accountability, he shifted subjects again. The government will soon be “spending a lot of money on great commercials showing how bad it is, so that kids seeing those commercials during the right shows, on television or wherever, the internet, when they see these commercials they, ‘I don’t want any part of it,'” he said. “That’s the least expensive thing we can do, where you scare them from ending up like the people in the commercials.”

Soon after, he was back on the subject of executing dealers, jumping between it and immigration policy rambles and occasionally inviting one or another attendee up to the microphone for an ad-libbed cameo.

Standing in front of a wall labeled “OPIOIDS: THE CRISIS NEXT DOOR,” Trump railed against so-called “sanctuary cities,” blasted Democrats’ negotiating positions on his border wall proposal and citizenship options for undocumented young people, and rambled about MS-13 gang members’ preference for using knives rather than guns.


Eventually, Trump wound his way back to the death penalty again, again praising other countries that execute their drug dealers.

“Now maybe our country is not ready for that,” the president said, seemingly ad-libbing in his signature loose, rambling, contradictory style. “It’s possible, it’s possible that our country is not ready for that, and I can understand it, maybe, although personally I can’t understand that.”

The chaotic nature of Trump’s remarks undercut the administration’s pre-speech marketing of a major policy platform rollout.

Here are the big things you need to know about Trump’s approach to opioids:

On prescriber rules and ‘major litigation’

The CDC’s list contains a dozen specific requirements for prescribers that would radically restrict the flow of legitimate doctor-provided opioids as a pain management strategy. The doctors who crafted the list hoped to split the difference between a status quo where the pills are given too freely and an overcorrection where patients in serious pain would be expected to just rub some dirt on it and move on.


“The implementation of these guidelines is going extremely slow,” Mendell said, noting that the policy is a relatively cheap, simple way to tackle the demand side of the drug problem by shrinking the number of people who will slide from legitimate, safe, and short-term use of painkillers into a more dangerous relationship with narcotics.

Trump’s approval of changes to Medicare and Medicaid to require compliance with the CDC rules would mark a significant shift in medical practice. But his administration is also seeking sweeping cuts to those programs which would make it harder for people to seek and obtain treatment for addiction, making it unlikely his policies would produce a net-positive change in America’s drug problem.

Trump’s suggestion of a federal suit against drug marketers opens further interesting doors. When Purdue Pharmaceutical first marketed Oxycontin, the opioid formulation most directly associated with the 20-year surge in addiction to such drugs, the company knowingly misled doctors about what their patients could expect from the pill. The gap between Purdue’s marketing copy and its own clinical trials helped fuel numerous lawsuits from state governments seeking to recoup the costs of grappling with mass opioid addiction, most of which the company has quashed or settled.

A federal pursuit of accountability for such marketing swindles would mark a genuinely new direction. But other, lengthier moments in the speech tacked away from Trump’s brief mention of a possible crackdown. He mentioned a proposal to develop less-addictive painkiller alternatives, referencing a proposal in his most recent budget that would funnel hundreds of millions of research dollars to the same industry that created the current crisis by pretending that their products were not likely to generate dangerous addiction cycles. His philosophical predisposition to trust the industry cropped up again as he introduced Health and Human Services Secretary Alex Azar. “Who knows better than the guy running the drug company?” Trump said of the secretary, who was a top executive at drug-making company Eli Lilly.

‘Great commercials…where you scare them’

Trump’s fascination with War on Drugs advertising is well-documented. He’s been proposing dedicated funding for scared-straight advertising for months, mirroring Attorney General Jeff Sessions’ repeated calls to return to Reagan-era “Just Say No” campaigns with young people.

But we already know that those ad campaigns failed to reduce youth drug experimentation — and maybe even backfired by triggering greater use of certain drugs. Trump either hasn’t seen any of that research or doesn’t feel obligated to explain how his new ad push will be different. After a lengthy description of the coming media buys, he pivoted to attacking Democrats over their negotiating stance toward border security and immigration reform.

The big talk on executions has only one easy outlet. A 30-year-old law allows federal prosecutors to seek the death penalty in prosecutions of senior members of a “continuing criminal enterprise” that moves mass quantities of drugs. This so-called “kingpin law” has barely been used since Congress passed it in 1988. Its use raises constitutional questions the Supreme Court has never answered. In theory, the Trump administration can already seek death sentences for traffickers they can prove participated in a ring that moved at least 24 kilos of fentanyl or 60 kilos of heroin, or generated at least $20 million in profits in any given year.

But while that’s the only ready-to-use federal provision for imposing death sentences on dealers, a corresponding ramp-up in prosecutorial aggression in general following Trump’s lead would have a bunch of other serious consequences. The federal “drug-induced homicide” statute, for example, allows prosecutors to seek sentences of 20 years to life in cases where they can prove the drugs someone sold caused a specific overdose death.

Several states have their own drug-induced homicide laws that trigger harsh sentences. In Colorado, Florida, and Oklahoma law, drug-induced homicide convictions can even confer the death penalty — with none of the “kingpin” requirements in the federal law Trump wants to dust off, meaning that a destitute addict who sells a baggie to a friend to support their own habit could get the needle if that friend dies in Denver, Miami, or Tulsa.