This decade’s explosion of deaths in white communities from opioids has, predictably, altered mainstream attitudes toward people who use these drugs. Those deaths have generated public sympathy, including the belief that people with problematic drug use need to be helped, not hunted; that deep addiction is neither a free choice nor a moral failing; and that addiction can be conquered with respectful, empowering treatment.
At many public gatherings to address the opioid crisis, citizens and mainstream politicians speak of those with addictions compassionately, and refer to drugs with street slang familiarity. While I have become hopeful about the chance of real reform, these gatherings — and the fact that it took the deaths of white people but not those of people of color to spur them — still continue to frustrate.
In addition to a sprinkling of success stories, they invariably begin with sobering statistics and parents who recall their child’s sudden distance, withdrawal and tragic death. We learn that, despite a long history of targeted stereotypes, everyone is susceptible, and though individually unpredictable, emotional trauma is a powerful predictor, particularly childhood abuse. We meet adult survivors who have lost jobs for failing drug tests, who can’t find work because of an arrest record, or with long histories in the foster care and penal systems. We note the inadequacies of available treatment combined with the stigma, chaos and isolation of illicit drug use.
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These are the faces of despair, and the despair continues, commonly presented as a deadly interaction of two factors: The first is our very nature. We are graphically reminded of our hard-wired, animal craving for dopamine and the chemical Velcro found in opioids and similar drugs.
This approach is often underscored by a video of lab mice compulsively dosing themselves with illicit drugs to satisfy what cannot be satisfied. Addiction itself is presented with frightening, unrelenting force. It is defined without nuance or hesitation as a disease that can strike anyone, anywhere.
The second factor of addiction, we are told, is the deadly advent of heightened drug potency controlled by foreign and domestic “traffickers.” This isn’t your father’s heroin. The synthetic opioid known as fentanyl is now the common denominator in virtually all such deaths. Emerging from hidden factories — once in Mexico, now in Asia — its power, speed and ability to hide from detection is staggering: the physical equivalent of two grains of salt can quickly kill.
International cartels and amoral street dealers familiar to viewers of “The Wire” bootleg these drugs, and we now know that their origin story also involves the domestic traffickers — Big Pharma. Most often, it’s Purdue Pharma that generates the most intense heat in addiction awareness presentations — the company whose sales reps convinced doctors to flood communities with the addictive pre-cursors to heroin, yielding a devastating wake of addiction.
The audience is saddened by the victims and angered by the villains, but when they seek more than perfunctory calls for better treatment and drug education, mainstream leaders serve up ineffective, safe harbor bromides such as “getting more involved in our kids’ lives,” “watching for the classic warning signs” and “cracking down on dealers.”
I am frustrated because these broad-based narratives distort the drug policy universe and thwart real reform. The audience goes home with unnecessary resignation or misdirected anger. I want to reframe the issue for the audience so they emerge every bit as enraged, but neither hopeless nor unproductively sidetracked.
Targeting Symptoms, Not Causes
Clearly our biochemistry, newly potent drugs and motivated sellers are meaningful factors. But these targets are more symptoms than causes and obscure the causal center of the crisis, which has nothing to do with our brains, cartels, Purdue or even the drugs themselves.
Neuroscience reveals universal vulnerability, but fewer than 1 in 10 people succumb to drug use disorder. Our chemical infrastructure awaits the conditions that exploit it. How can it be that our brains are unchanged over the past century, yet deaths related to drugs continue to fluctuate? Newer experiments with mice and illicit drugs changed their environment to a less stressful one, and the mice showed only minor interest in the easily available cocaine. To attribute addiction to our wiring is a sinkhole that replaces political indignation with a resigned, it’s-the-nature-of-the-beast shrug.
It’s also not the cartels air-mailing fentanyl from hidden factories. While sharing the drug warriors’ desire to rain holy terror on those sources, our decades-old drug interdiction policy has a nearly perfect failure rate and as the pills get smaller and easier to conceal, it is inconceivable that we will have any more luck going forward. We are stuck with the fact that any demand for fentanyl will be met.
Admittedly, some crave the scary heights of greater potency, but they are not looking to kill themselves. A heroin overdose is significantly more reversible than a fentanyl one, not to mention one with super-potent carfentanil (tomorrow’s fentanyl). As soon as addicted and non-addicted users have supervised access to regulated heroin of known dosage, the “demand” for such synthetic enhancements will dwindle, and the death rate will decline. But railing against foreign “traffickers” only deflects a motivated audience’s attention and misplaces their energy.
Likewise, it’s also not Purdue, despite the behemoth’s deserved reputation. In addition to personal trauma or personality type, the societal conditions were ripe for any pharmaceutical interest with the moral compass of a drug cartel; a condition not unique to Purdue. Today, Oxycodone is sold in huge quantities by other pharmaceutical firms, though regulations make it somewhat harder to misuse. The hyper-focus on Purdue is yet another deflection which misses the point that these villains are replaced the minute they are eliminated.
Lastly, it’s not, ultimately, even the drugs. It’s the circumstances of their use — and the circumstances of those who use them. I would highlight two factors as having primacy in the opioid crisis: The first is the overall “war on drugs,” though we’ll focus on the specific illegality of heroin; and the second is the class- and race-based nature of how that illegality plays out.
Stigma and the Criminal Legal System
As stated, trauma-related depression is a major predictor of addiction. And while most addiction-related presentations provide examples of how an individual’s involvement in the criminal punishment system thwarted their ability to conquer addiction, they rarely reveal the incredible scope of such entrapment.
Tens of millions of Americans have suffered drug-related arrests, disproportionately in the African American community. Predictable outcomes include the stress of job insecurity and inability to get student loans, drivers licenses or secure housing. Much of the stigma, far worse than for those addicted to alcohol, stems from heroin’s outlaw status.
Today’s drug awareness campaigns invariably stress the cross-racial nature of the problem, including the lack of insurance required for treatment, but they rarely expose the larger reality that over half of the non-elderly uninsured are people of color. They also seldom reveal the frustration and disempowerment experienced by millions of people of color denied the right to vote because of a police record, largely due to the racially skewed enforcement of drug policies. Stress, hopelessness and neighborhood disinvestment is often mentioned but rarely placed at the doorstep of the illicit drug market’s inevitable requirement that disputes must be settled out of court, on the streets. In the absence of that analysis, many can only shake their heads at the “inevitable” connection between violence and poverty.
The public’s new soft-landing empathy for those with opioid addictions must have skipped the inner city.
More than any single cause (and there are many others), current U.S. drug policy creates and augments the stresses associated with addiction. A recent Lancet Public Health Journal study confirms a greater than 50 percent increase in drug mortality in U.S. counties with higher incarceration rates, and cites a University of Massachusetts analysis which says, “Our findings indicate that the 3,000 local jails in the USA are an overlooked but important independent contributor to overdose deaths and may help to explain the geographical differences in drug-related deaths — identifying a potential cause that has remained elusive until now.”
All of this should be enough to energize a sympathetic audience, which is why it remains critical that we demand realistic reforms that still challenge the familiar world.
What Does Real Reform Look Like?
We must seek reforms that give people access to a full range of proven medicines provided in a respectful, supportive environment that includes freedom from the criminal punishment system. In fact, needle exchanges, chill-out spaces and street administration of Narcan depend on law enforcement ignoring the obvious trail to federal illegality, and thus depend on the continued willingness of the state to look the other way. This fragile truce must suffice — for now.
Ultimately, though, those with serious addictions require the same routine support and access to medications that people with diabetes or tooth decay expect. It means always knowing what they are consuming, or being surrounded by competent help — both in terms of having a safe supply and safe space to use drugs.
For instance, at the Insite clinic in Vancouver, a supervised injection site, more than 6,400 life-threatening overdoses have been reversed. These overdoses mostly occur because users are restricted to unregulated street drugs, but unlike many of their friends, they survive — typically with an instantly available hit of Narcan or oxygen. Far fewer overdoses need to be reversed at the safe supply clinics in Canada, the U.K., Switzerland, Germany and the Netherlands, where clients are provided medical-grade heroin under the same supervision as with Insite. If preventing unnecessary deaths could be described as routine, these clinics would be prime examples.
The contrast between the devastation caused by the status quo and the availability of such lifesaving reforms should motivate today’s sympathetic audience to eagerly confront the “What do we do now?” question.
There are two specific reforms that should find widespread support: 1) An end to the penal-like approach that requires cumbersome clinic visits for methadone and puts endless, prohibition-inspired roadblocks in the way of all forms of medically assisted treatment — which is a proven path to recovery with a multi-decades international track record; and 2) safe consumption spaces where people can use street-provided illicit drugs or clinic-provided medical-grade heroin under supportive supervision, another proven path to recovery with a multi-decade international track record.
These reforms boil down to safe supply and safe space. They provide a life-affirming glimpse of a post-prohibitionist world in which drug users are treated with routine decency and common sense. And as these programs become part of the woodwork, public frenzy will diminish along with stigma: People with difficult addictions will be recognized as humans with troubles in need of support. These programs will help create a society with less death, disease, law-breaking and addiction. They provide a glimpse of drug policy that works.
There are many paths to addiction; a burden unfairly distributed across class and race lines but experienced individually. Those in its thrall have forever been treated as the lowest of the low, with racist and ethnic slurs piled on top of character assassination.
The medical model is a welcome wedge against the worst of such false notions. This model removes drug users’ demonization by referring to addiction as a non-punishable disease of the brain. Yet, the medical model still leaves little room for nuance. People addicted to cigarettes, for example, repeat their self-destructive behavior despite full knowledge of its effects. We do not thereby call them “mentally ill.” And some folks who use drugs, even heroin and cocaine, are not addicted or even deeply troubled by it. Blanket use of the medical model borders on an enlightened form of stigma: “They are evil” has now become “They are sick.”
Nevertheless, these targeted reforms remind us that those with addictions are simply just those with burdens — some or none of their own making.
And so now, with proven, lifesaving tools at our disposal, we can ask two questions: How can we help? And what’s stopping us? As rural death rates start to drop and urban rate rise, we must strike while the iron is hot — before the mainstream’s newfound sympathy cools.