In his First Inaugural Address, President Trump used an evocative phrase — “American Carnage” — to describe the misery of the US heartland: communities racked by the China trade shock and afflicted by opioids and related social crises. Fast-forward a decade, and tucked into his “big beautiful” budget bill is a proposal to slash more than $1.2 billion from the Substance Abuse and Mental Health Services Administration, and some $30 million from the Centers for Disease Control and Prevention’s opioid-monitoring programs.
The move would eliminate more than 20,000 jobs: case workers, public-health researchers, Narcan distributors, Medicaid rehab staff — the very professionals and programs, in other words, that serve the victims of American Carnage. It is among the gravest betrayals of Trumpian America in a second Trump term that undeniably favours Reagan-style austerity over popular domestic policy.
Since Oxycontin emerged on the market in 1996, more Americans have died from accidental opioid overdoses than were killed in the Vietnam War, the Korean War, and the Second World War combined. The bloodshed of the opioid epidemic is the worst conflict in America this century; and its architects — the Sackler family — still live in luxury and wealth.
For decades, the crisis only got worse, prescription meds giving way to fentanyl-laced pills; the Covid pandemic isolating people from their support systems; hundreds dying every day. Yet recent successes were undeniable. This year, overdose deaths plummeted by nearly 30,000, the first such drop since the Nineties. This progress owed to a combination of expanding Medicaid rehab, making the anti-overdose drug Narcan free and ubiquitous in rural counties, and establishing data systems to track where spikes were happening in real time. In other words, thanks precisely to the programs now on the chopping block.
Yet, even as Team Trump destroys the tracking programs that rendered the crisis visible, American literature has served up the first great opioid novel, The Emperor of Gladness. The 36-year-old author, Ocean Vuong, grew up in the ruins of the crisis in Connecticut, where Oxycontin was created, lending him the firsthand experiences that form his tender Bildungsroman. It follows his fictional stand-in, Hai, rescued from suicide by an older Lithuanian woman who makes him her carer.
The book is infused with the grim, perpetual reality of post-industrial America — the words “pills” and “war” recur in every chapter. Hai describes the bloodshed around him as his adolescence unfolds: “It did not have a name, this slaughter, and yet your loved ones were being slowly erased, even teachers and lunch ladies overdosing overnight, then cremated without ceremony, their faces soon existing only in your mind.”
When I went to his book launch in New York, Vuong moved himself to tears three times. He gets a lot of flak for being too emotional, and his earnestness can be exhausting (watch him on Oprah). But it reveals something profound: he believes his success is born from the fluke that he is still alive. He is “no better than the friends I’ve lost, just lucky that when I tried the pills, they made me feel like I was drowning; and that I didn’t like that.” In this part of the country, lucky means he was addicted to cocaine, instead of the Oxy and “fent-dope” his friends took.
That sense of arbitrary survival, just brutal luck, is threaded through the novel. Hai tries rehab, relapses, remembers the boy he loved who died from wanting “too much of one feeling.” He witnesses his first overdose at age 12, and thinks as he watches a woman saved by Narcan at work: “Her mouth was open like a Scream mask.” One of Hai’s coworkers at the local fast-food chain thinks the world is run by lizards that are “feeding off our negative energy.” She’s crazy, Hai thinks, but kind of right.
It’s a reptilian twist on a capitalist reality: Vuong watched his friends die from fentanyl and OxyContin that billionaires had bribed doctors to prescribe.
The pain exhaled throughout Vuong’s book stores enormous political capital that Trump once tapped into. In 2016, he campaigned on a platform of expanding access to Narcan, cutting opioid prescriptions by a third, and securing “billions” for opioid treatment. Then, in 2024, he started to mine support from an even more politically rewarding angle: revenge, by promising to shut the borders through which chemicals for fentanyl come into America and threatening the death penalty against dealers. Vuong, who worked picking tobacco and at the fast-food chain Boston Market, wasn’t “surprised” by Trump’s win either time. The “slaughter” around him wasn’t being talked about by the Democrats, and Trump swooped in.
“The opioid crisis radicalised people for Trump, turning grief into politically divisive fury.”
When they started to market OxyContin, Purdue Pharma’s sales reps targeted communities with high cancer rates, which were mostly white, working-class, and rural. They told doctors that OxyContin was “non-addictive,” encouraged high dosages, and launched “pain-management seminars” with steak dinners and bonuses. By 2012, opioid use in those areas was 50% higher than in similar economic regions, and overdose deaths were twice as common. Communities hooked on prescriptions have since turned to fentanyl bought from dealers.
In 2016 and 2020, the counties that had been hit hardest by Purdue’s marketing became some of Trump’s most loyal voting blocs. A 2023 study by economists Carolina Arteaga and Victoria Barone traced a direct line from Purdue’s targeting to the ballot box: people who lost their families to pills also lost faith in the status quo, and when conservative media paid more attention to their pain than liberal media did, they chose their side. The opioid crisis radicalised people in favour of Trump.
He blamed border enforcement, whilst spinning his own Justice Department’s choice to go easy on the Sacklers as a big win. Since then, CNN’s coverage has helped his case, with the network interviewing cartel members who move fentanyl across the border. But these have a powerful point when addressing Trump: “the problem is the consumers are in the US. If there weren’t consumers, we would stop.”
Yet the second term has seen Trump attacking anti-opioid policy and abandoning even the pretext of addressing the deeper social crises that drive addiction. His attorney general, Pam Bondi, claimed a few weeks ago: “Since your last 100 days, we’ve seized 22 million fentanyl pills, 3,400 kilos … which saved — are you ready? — 258 million lives.” The number is suspect, but it doesn’t matter, her onlookers cheered.
The bigger point is that fentanyl is not a thing you “win” against by merely seizing it. The crisis will be stopped by addressing why people want to use it in the first place. Funding housing, health care, and treatment. Asking why Americans, alone among wealthy nations, keep dying by the tens of thousands. In 2023, there were still more than 125 million opioid prescriptions written. I tested it myself. I found an online health site, and 20 minutes later, with nothing but a call and some claim to vague back pain, I was offered a way to get a prescription for Oxycodone. America is still manufacturing this crisis; still pretending it’s a foreign invasion, not a domestic product.
A boy I went to elementary school with in California, with whom I’d exchanged love notes with under the table, was prescribed Oxy after a high school football injury. He died in 2020 of an accidental overdose, at age 18, alone in his car. His funeral was held on Zoom, and his mother wept into a screen. He’s not a statistic, but he is one of a generation; a vanished cohort that Vuong writes about with unblinking clarity. And the systems that were just beginning to try to save kids like him are now being dismantled by Trump.
Vuong does not pretend that addicts will always choose redemption, but he offers something stranger: mercy. “How strange,” Hai thinks, “to feel something so close to mercy… and stranger still that it should be found here of all places, at the end of a road of ruined houses by a toxic river.” We’re back at that river again. A brief drop in death and a flicker of institutional compassion, but now, a sudden turn back to cruelty and abandonment. The real question isn’t whether Trump’s budget cuts will let more people die, but whether he’ll get away with saying this is about safety, instead of feeding the fantasy of revenge. The opioid epidemic is not a mystery. We know how to fight it and what works: research, Narcan, Medicaid and funding.
This crisis has always been about pain, who gets to treat it, who gets punished for it, and whether America is willing to recognise that the people who are suffering most are still worth saving.
