Over the past decade, the US has undergone an opioid epidemic. Republican presidential nominee Donald Trump has called it a “tremendous problem,” while Democratic presidential candidate Hillary Clinton has called it a “quiet epidemic.”

As has been well-documented, the widespread prescription of opioids to treat pain and the subsequent diversion of said drugs for illicit uses created a sizable new population of users addicted to opioids.

Many of them turned to heroin, which became cheaper and more available, as the government cracked down on opioid prescribing.

The crisis has hit a number of states hard, including New Hampshire, Ohio, Pennsylvania, and West Virginia. It has made the epidemic — among other issues related to substance abuse and addiction — a hot-button issue in this presidential election.

Curtailing heroin abuse

Heroin use in the US has grown exponentially in recent years. The UN's "World Drug Report 2016" estimated that the number of heroin users in the US reached about 1 million in 2014, almost three times as many as in 2003.

Trump’s plan to combat heroin use in the US is built around his plan to build a wall on the border with Mexico, which he blames as “the source” of America’s opioid problem.

The expansion of heroin use has coincided with a shift in the source of heroin — from primarily Southeast Asia in 1994 to almost completely Mexico and South America by 2012. Yet experts say the heroin crisis has been primarily fueled by the explosion in demand for opioids as a whole, caused primarily by widespread overprescribing of opioids by doctors.

In the few times Trump has talked about the issue — specifically in hard-hit states like New Hampshire and Ohio — he has said that he will "stop the inflow of opioids into the US." But he has failed to go into further details.

“We’re going to have borders again, and we’re going to work with you people to help you solve that very big problem,” Trump said during his primary-victory speech in New Hampshire in February, referring to plans to secure “the Southern border.”

Clinton’s plan, called the "Initiative to Combat America’s Deadly Epidemic of Drug and Alcohol Addiction," would allocate $10 billion over the course of 10 years to combat the issue from multiple points. That figure would be divided between a $7.5 billion fund to help states create programs tailored to the issues specific to their area and $2.5 billion allocated to the Substance Abuse Prevention and Treatment Block Grant, which directly funds substance-abuse treatment and prevention programs.

Clinton specifically mentions LifeSkills Training, a three-year program for middle-school students targeting substance abuse and violence, as a type of successful program that can prevent substance abuse later in life.

In contrast to Trump, Clinton calls for approaching the substance-abuse issue from a public-health perspective, rather than a criminal-justice one.

Her policy statement on the issue proclaims that “we cannot arrest and incarcerate our way out” of the problem. Notably, she cites criminal-justice reform as one of the main ways she wants to combat substance abuse. She specifically calls for increased investments in diversion programs, which connect addicts with treatment and services rather than prison, and drug courts, which incentivize addicts to stay in treatment by sanctioning them when they fail to live up to obligations.

Fixing the overdose crisis

A nasal injection containing the overdose-reversing drug naloxone is seen at the police headquarters in Quincy Thomson Reuters

In 2014, deaths from drug overdoses reached a new high of 47,055, according to a January report from the US Centers for Disease Control and Prevention — more than the number of people killed in car crashes or from gun violence.

The overdoses haven’t slowed. Synthetic opioids — such as fentanyl and carfentanil, which are 50 and 5,000 times more powerful than heroin, respectively — have become increasingly popular since 2014. This summer saw a flood of overdoses — likely involving synthetic opioids — overtake Ohio, Indiana, West Virginia, and Kentucky.

Clinton’s plan is similar in scope to a law that President Barack Obama signed in July that aimed to make naloxone, a drug that instantly reverses overdoses, more readily available to the public, as well as to police officers and first responders. Clinton specifically calls for creating a state fund to help police, fire departments, and EMTs purchase the drug, and to create naloxone training programs for first responders.

While Trump has not addressed concerns over overdoses in his stated policies, he tweeted in August that “heroin overdoses are taking over our children and others in the MIDWEST. Coming in from our southern border. We need strong border & WALL!”

Neither candidate has addressed concerns over the skyrocketing price of naloxone.

Public-health reforms

James Ingemi picks up Suboxone prescription as part of his treatment regimen for opiate dependency at the pharmacy at Boston Healthcare for the Homeless Program in Boston, Massachusetts January 14, 2013. REUTERS/Brian Snyder

As noted in Clinton’s policy fact sheet on addiction, nearly 23 million Americans suffer from a substance-use disorder, while only about one-tenth of those addicted receive treatment.

Clinton has announced a number of policy proposals to eliminate the treatment gap. Her plan calls for allocating $2.5 billion to “immediately expand” in-patient and out-patient treatment options at hospitals, residential facilities, health centers, and recovery organizations. In addition, she has called for federal action to more aggressively enforce requirements that Medicaid and private insurance companies cover substance-abuse treatment, as well as encouraging Medicare and Medicaid to remove obstacles to substance-abuse treatment coverage.

One of the biggest factors in the current opioid epidemic is poor prescribing practices and an overreliance on opioids for pain treatment. For years, pain specialists have advocated using alternative treatments to alleviate patients' pain.

In her policy statement, Clinton addresses this, calling for the Department of Veterans Affairs and the Centers for Medicare and Medicaid Services to promote pain-treatment guidelines that identify treatments other than opioids. In addition, she calls for the use of state prescription-drug monitoring programs, which can flag patients who are “doctor shopping,” and calls for imposing a training requirement to obtain a license to write prescriptions.

At a town hall in Columbus, Ohio, in August, Trump spoke at length about the drug-addiction issue. While he focused his remarks on the heroin issues and its ties to Mexico, he did touch upon the need for treatment, saying: “It’s very hard to get out of the addiction of heroin. We’re going to work with them, we’re going to spend the money, we’re going to get that habit broken.”

Trump has not said where or how that money would be spent in treatment, nor has he addressed issues related to prescribing or treatment in healthcare.

But the 2016 Republican Party platform acknowledges the link between overprescription of drugs and the current opioid epidemic. It cites Republican-backed legislation that limits patients on certain Medicare plans to a single pharmacy and coming out in support of the Comprehensive Addiction and Recovery Act, which was signed by Obama in July. The platform also calls for CMS to ensure that physicians are not penalized for limiting opioid prescriptions.