Headlines decrying the “opioid epidemic” have been in the news on a daily basis lately. Politicians, public figures and journalists here in Massachusetts as elsewhere around the country are practically trampling each other in their haste to jump on the “addicts are not criminals, they are sick and need treatment” bandwagon.
This sort of speedy 180 degree shift in public opinion calls out to me as a sociologist. How did it happen that after decades of quietly locking up people (disproportionately men of color) for drug crimes we now are approaching across-the-political-spectrum consensus in favor of treatment rather than punishment?
I’ve argued elsewhere (“White Women, Opiates and Prison“) that part of the impetus lies in recent spates of high-profile drug overdoses in white communities and an unspoken consensus that while it’s okay to send Black kids to juvenile detention “our” kids deserve better. While the poster-child for drug use in the 80s and 90s was – literally — African American, over the past decade, whites have experienced a greater rise than African-Americans or Latinos in drug-related death rates. According to the CDC, in 2000, non-Hispanic black persons aged 45–64 had the highest rate for drug-poisoning deaths involving heroin. In 2013, non-Hispanic white persons aged 18–44 had the highest rate.
Is There Really a Growing Epidemic?
No and yes.
No, there has not been an increase in drug use overall, with the exception of marijuana (which is not implicated in drug deaths.) According to statistics released by the National Institute on Drug Abuse:
Marijuana use has increased since 2007. In 2013, there were 19.8 million current users—about 7.5 percent of people aged 12 or older—up from 14.5 million (5.8 percent) in 2007. Use of most drugs other than marijuana has stabilized over the past decade or has declined. In 2013, 6.5 million Americans aged 12 or older (or 2.5 percent) had used prescription drugs nonmedically in the past month. Prescription drugs include pain relievers, tranquilizers, stimulants, and sedatives. And 1.3 million Americans (0.5 percent) had used hallucinogens (a category that includes ecstasy and LSD) in the past month. Cocaine use has gone down in the last few years. In 2013, the number of current users aged 12 or older was 1.5 million. This number is lower than in 2002 to 2007 (ranging from 2.0 million to 2.4 million).
Yes, there has been an increase in the number of drug-related and particularly opiate related deaths. At this time, it is unclear whether that uptick whether that uptick is caused by bad drugs, stronger drugs, lower tolerances in people who cycle in and out of detox, or something else entirely. What we do know is that, according to researchers at the CDC, the primary culprits are prescription pain medication and poly-drug use:
[Our study highlights] the predominant role opioid analgesics play in pharmaceutical overdose deaths, either alone or in combination with other drugs. It also, however, highlights the frequent involvement of drugs typically prescribed for mental health conditions such as benzodiazepines, antidepressants, and antipsychotics in overdose deaths.
The issue, then, is not more drug users but rather higher rates of death from particular drugs and drug combinations. That distinction should be critical in terms of policy yet typically is overlooked. Take for instance, a recent article in the Boston Globe: “Boston Globe Game Changers: Four Innovative Ideas for Fixing the Opioid Crisis.” Three out of the four “innovative ideas” are aimed at helping individuals stop using drugs and assume that “treatment” (whatever that means) is effective, an assumption that, I have argued elsewhere, has little basis in evidence-based research. I respect Gloucester Chief of Police Leonard Campanello for recognizing that arresting drug users is not helpful and I applaud CeltiCare for reducing bureaucratic hurdles for people struggling with addiction and I think it’s great that Massachusetts General Hospital recognizes that people struggling with addiction can use support – even when dealing with addiction treatment institutions. Yet only one of the four innovative ideas actually targets drug-related death: Healthcare for the Homeless has opened a safe space for people who are using drugs to sit down and get help — including Narcan (nasal spray for emergency treatment of suspected opioid overdose) – when they feel unwell.
The emphasis on treating people for drug use (in order to get them to stop using drugs) rather than minimizing drug-related deaths (harm reduction) is, I suspect, not going to change anytime soon. As a society we are far too invested – financially, politically, morally and culturally.
How (Not) to Treat an Epidemic
Ironically, despite public reiterations of the word “epidemic”, our public responses are not in line with standard protocols for tackling epidemics. Take this article which recently appeared in the local Wellesley Patch :
A change to Massachusetts Interscholastic Athletic Association regulations aims to encourage high school athletes struggling with substance abuse to undergo treatment. Under the new rule athletes can come forward and seek help for substance abuse without being penalized for violating the MIAA’s drug policy. “We wanted to change the rule for people who recognize that there’s a problem,” Norfolk District Attorney Michael Morrissey, who spearheaded the change, told Patch. “We don’t want to discourage people from coming forward.” Morrissey said athletes in particular are susceptible to abuse if they’ve used prescription drugs while recovering from sports injuries.
Now let’s break this article down.
First, readers unacquainted with Massachusetts need to know that Wellesley is one of the wealthiest and whitest towns in the state and that Norfolk County is the 28th highest-income county in the United States with a median household income of $81,899. In other words, we learn that substance abuse is a disease that afflicts even the most respectable people (student athletes in wealthy, white suburbs) and that requires treatment.
Second, while individual student athletes with substance abuse issues are urged to seek help, the MIAA did not question why so many athletes are injured. Are there particular teams in particular towns that are more injury-prone? If so (and I believe that to be the case), what is it about these teams and towns that make them fertile for the spread of opiate overuse? Are severe injuries due to the culture of hyper-masculinity in the sports world driving boys (and coaches) to reckless behavior? Are kids learning that real men should suck up pain? Alternatively, given the widespread use of prescription pain medication, are they learning that every pain needs to be medically treated? Maybe they are learning that only those who are the best at something really count? Or are they picking up the message that success in high school sports may be their last chance in life to shine, that from here on it’s all down hill? Full disclosure – I do not know if any of this is the case, and that is the problem. No one knows because these sorts of social and cultural questions are not being studied.
Follow the Money
There are huge profits to be made in drug treatment, though there is very little rigorous evidence showing that addiction treatment of any sort actually works. Not so much money, however, to be made in changing social values.
Given the public consensus that addiction is a manageable yet essentially incurable disease (“once an addict, always an addict” is a mantra promulgated by the 12 Step movement; there is no actual evidence for this notion), the treatment-industrial complex stands to be even more profitable than the prison-industrial complex. Prison sentences and parole eventually end; the treatment of chronic disease can go on forever.
According to the American Civil Liberties Union:
As incarceration rates skyrocket, the private prison industry expands at exponential rates, holding ever more people in its prisons and jails, and generating massive profits. Private prisons for adults were virtually non-existent until the early 1980s, but the number of prisoners in private prisons increased by approximately 1600% between 1990 and 2009. Leading private prison companies essentially admit that their business model depends on high rates of incarceration. For example, in a 2010 Annual Report filed with the Securities and Exchange Commission, Corrections Corporation of America (CCA), the largest private prison company, stated: “The demand for our facilities and services could be adversely affected by . . . leniency in conviction or parole standards and sentencing practices . . . .”
Fortunately for their stockholders, private prison companies are moving into the lucrative treatment field. Take a look at this excellent article by Deirdre Fernandes in the the Boston Globe:
The $35 billion-a-year addiction treatment industry is gaining more attention from investors of all sizes, including private equity giants like Boston-based Bain Capital, which owns the largest chain of detox clinics in Massachusetts. Large investors are capitalizing on the increasing demand, changes in health care law, and opportunities to scoop up smaller facilities, reduce their costs, and sell them at a profit. American Addiction Centers, a Nashville addiction treatment company, went public in late 2014, raising $75 million. Its profits climbed from $871,000 in 2011 to $11.2 million last year, a more than twelve-fold increase. So it’s no surprise that individual investors are piling in, too, said Philip Levendusky, the director of psychology at McLean Hospital, an affiliate of Harvard Medical School. “Everybody is chasing the pot of gold at the end of the rainbow of the opioid issue,” Levendusky said. “There’s an epidemic of opioid abuse, so there’s a tremendous demand.”
A Real Response to an Epidemic
In order to get a sense of what a real public health response to an epidemic looks like I turned to the CDC’s webpage on Zika. Medical attention for affected individuals is part of the picture, yet the CDC focuses more on understanding the underlying causes of the problem, tracing how it spreads, and taking pro-active measures to prevent its proliferation. This includes identifying exactly where there are clusters of Zika-carrying mosquitoes and clusters of affected humans, pinpointing exactly how transmission occurs, and taking concrete steps to minimize the possibilities of transmission.
Imagine if efforts to stop the Zika virus were limited to offering individual treatment (the treatment consists of rest, water and Tylenol since there is no known cure for the Zika virus) and counseling sufferers about the importance of staying away from mosquitoes (where exactly does one go to hide from mosquitoes in the tropics?)! Imagine if there were no efforts to assist communities in removing stagnant water from yards and streets or to encourage governments to build systems that distribute safe water (so as to minimize mosquito larvae survival as well as the need for households to store water in buckets and pools)!
Yet that essentially is how Massachusetts, like other states, is tackling its opioid epidemic. For instance, just a week ago, Marian Ryan, district attorney in Middlesex County, issued a press release addressing the epidemic by offering a list of resources for people struggling with addiction and for “their loved ones.” The list turns out to be a hodge-podge of treatment and support agencies and organizations, many of which are not licensed by any local, state or federal office and some of which are for-profits corporations (LLCs or others) while others are entirely lay-led quasi-religious 12-Step groups. (The statuses of the agencies and organizations are not indicated on the list.)
In terms of opiate over-use, what would be the equivalent of cleaning up the pools of stagnant water in which mosquitoes breed? The equivalent of wide-scale public investment in safe water for all communities?
Having spent the past decade working closely with women who are former or current illicit drug users, I have seen how gender inequality (machismo and sexual abuse), crummy schools, reiterated messages that ‘if you are not wealthy and beautiful you are a failure,’ and over-reliance on pharmaceuticals of all kinds (licit and illicit) play the role of mosquito-breeding pools of standing water. In line with these observations, I believe that public investment in good schools and in facilities for worthwhile leisure time activities for people of all ages, legislation ensuring living wages and paid family leave, and a fair economy in which the majority of people can realistically strive for good and meaningful lives, play the role of investment in safe water.
If we really are in the midst of an opioid epidemic then it is foolishly short-sighted for us to focus our efforts on individual rather than public measures. To be clear, I am not suggesting that drug users who wish to stop using should not receive appropriate, evidence-based support and treatment. I am, however, pointing out that giving drug abusers the equivalent of rest, water and Tylenol will not protect them — or anyone else — from the stagnant pools of sexism, poverty and hopelessness.
Images taken from headlines of the following articles: