Category Archives: Drugs and Drug Policy

Involuntary Hospitalization of Drug Users Is Bad Policy

Note: This essay was originally published in TruthOut, November 19, 2015. I’ve reposted it today because calls for involuntary hospitalization are again popping up around the country in response to the perceived opioid “epidemic.” The bill that was eventually passed by the Massachusetts House and then sent to the Senate did not include Governor Baker’s proposal to allow involuntary hospitalization of drug users. Click here for the text of the enacted AN ACT RELATIVE TO SUBSTANCE USE, TREATMENT, EDUCATION AND PREVENTION, signed by the Governor on March 14, 2016.

 

November 2015: Massachusetts appears to be on the cusp of adopting legislation proposed by Governor Baker (Republican) that would allow doctors to hospitalize drug users, involuntarily and without a court order, for 72 hours (H.3817). Previously, the power to order involuntary commitment of drug or alcohol users lay exclusively in the hands of judges under a Massachusetts’ law known as Section 35. At this time, few states give judges similar power to take away the freedom of individuals not accused of a crime. (1)

The proposed bill also would limit doctors to prescribing a 72-hour supply of opiate painkillers to patients receiving a first-time prescription for acute pain. While the second part of the plan has received criticism – concern that patients needing painkillers may not be able to reach their doctors for a refill in a timely manner – the first part of the plan has received virtual cross-the-board support. According to press reports, the majority of Massachusetts’ sheriffs as well as the association representing Massachusetts’ district attorneys have come out in favor of the bill. Hampshire County Sheriff Robert Garvey’s comments represent the growing opinion that, “The governor’s bill changes the attitude that addiction is not a criminal offense as much as it is a medical problem.”

Sheriff Garvey’s remarks are echoed around the country. For a variety of reasons – including a shift in media portrayals of the race of drug users — – we currently are experiencing a cultural and judicial movement away from criminalization and towards medicalization of substance abuse. Massachusetts might well be the vanguard of this movement. Not only is Massachusetts a relatively “white” state at a time in which the new face of drug use is Caucasian, but it also is the first state to have passed the healthcare coverage reform (“Romneycare”) that later became the law of the land nationally (“Obamacare.”)

Addiction Treatment and the Role of Physicians

Having worked for the past decade with criminalized women, most of whom struggle or have struggled with addiction issues, I am far from convinced that the Governor, sheriffs and district attorneys have got it right. While re-categorizing addiction as a medical rather than a judicial issue certainly sounds like step in the right direction, giving doctors unchecked power to hospitalize people against their will opens the door for serious human rights violations. Our legal system, like that of other modern democracies, insists that an individual should not lose his or her freedom without the due process of law. A doctor, committing people without an opportunity for those people to be represented by counsel, will be asked to serve as both prosecutor and judge – a position that directly contradicts principles of American jurisprudence and places doctors in an uncomfortable and untenable position vis-à-vis their patients. Knowing that doctors have this power will, I fear, serve to discourage people who could benefit from immediate medical attention from seeking assistance.

More broadly, the proposed bill puts the onus on physicians to fix social problems.

I understand that the motives behind the proposed bill are benign. However, I assume that the image of the doctor – patient relationship in the minds of the governor, sheriffs and district attorneys is most likely the kind of relationship they have with their own family doctors – a doctor who knows their history and their families, who has a good grasp of their patients’ medical and social backgrounds. However, it is likely that the doctors who will be committing patients under Governor Baker’s plan are emergency room doctors or hospitalists; that is, doctors who meet the patient for the first time at the encounter that leads to the commitment. Asking doctors single-handedly to take away the freedom of patients whom they barely know is not a reasonable burden to place on doctors.

I have great respect for doctors and I understand their frustration at treating patients for overdoses, only to watch these same patients walk out the hospital door immediately following stabilization. However, the bottom line is that there is no evidence whatsoever to indicate that three days of treatment will have any impact upon drug users. (The three day proposal, I assume, is based on the three day commitment for psychiatric patients under Massachusetts General Law, Section 12, though, since no reason is articulated for the three day idea it might just as easily, although perhaps subconsciously, follow the three days between the crucifixion and resurrection of Christ). In any case, there is little to no evidence showing that coerced drug treatment is effective. (2)

When patients are released after their three-day involuntary commitment, there is no reason to think that they will not return to their former drug use. In fact, having abstained from opiates for several days may set them up to overdose when they return to their former level of drug use but with a reduced tolerance for the drugs. (3) If a plan were in place to provide long-term, multi-faceted support after the three days I might have a different take on the proposal. But I do not see that Governor Baker’s bill includes such a plan, or a way to fund it. As I’ve seen repeatedly among the women with whom I work, even the “good” – that is, three month or six month – rehab placements end with people going back out into poverty, unemployment, scarce community support and (often) homelessness. These are sure recipes for sending them back into the drug use / detox cycle.

Blind Faith

We Americans have great respect for physicians and we trust that their medical training is the best in the world. However, addiction treatment is not a substantial part of most medical school curricula, and even in instances where doctors took a course (typically an elective) in the subject, given the rapidity with which the field of addiction treatment is progressing, their knowledge in the field may well be outdated. (4) Anecdotally, I personally have spoken with physicians who know nearly nothing about Suboxone and have never administered a dose of Narcan. Few hospitals in Massachusetts, and even fewer in other parts of the country, have more than one or two addiction medicine specialists on staff, which means that non-specialists will be tasked with the responsibility of deciding whether or not to commit patients who, in many cases, are seen as a nuisance or “revolving door” patient group.

I also know from having spoken with doctors around the country that they, like politicians around the country, tend to believe that twelve step programs are effective for treating addiction when, in fact, there is no evidence showing that Narcotics Anonymous participation (and especially coerced NA participation) leads to long-term abstention from drug use. (5) Indeed, I suspect that lying behind the proposed legislation is the notion, propagated by twelve step organizations, that alcoholism and substance abuse are “diseases” that take over one’s life; that people living with alcohol or substance-abuse disorders lack the capacity to make sound decisions (which is why they must turn themselves over to a “Higher Power.”)

Race Matters

I do not doubt that the vast majority of doctors are thoughtful, fair and knowledgeable. But I do know that there is a sufficient history of medical abuses – including medical experiments on prisoners and on African American men (the infamous Tuskegee syphilis experiment) to require all medical research to undergo thorough vetting and oversight by ethics reviews boards (IRB). In the frenzied panic over opiate deaths in Massachusetts, Governor Baker’s bill lacks a requirement for any sort of oversight. Decades of research show that doctors may tend to treat patients differently depending on the gender or the race both of the patient and of the doctor. (6)

It certainly should raise eye-brows that the popular push to re-label addiction and send addicts to ‘treatment’ rather than prison is taking place at a time when public attention has shifted from Black crack users to White opiate users. At the same time, as I have argued before, redefining people as “sick addicts” rather than “criminal addicts” is not as significant a social shift as one may think. In both cases they are labeled as flawed individuals who have failed to take responsibility for their own lives. In both cases, the onus for “deviance” lies on the individual rather than on the society that creates and sustains social and economic conditions that lead far too many people to feel that mind-altering and mood-altering substances are the best – or the only – means of making it through the day, the week or their lives. And clearly, those people labeled as “addicts” or “drug abusers” are not all that deviant. Throughout the United States, the normative way for dealing with misery is through doctors’ prescriptions for attention challenges, for anxiety, for depression and even for low libido. (7)

And Class Matters

The “epidemic” of opiate related deaths is not spread evenly across White America. In fact, the new attention to white opiate users exposes an important and seldom discussed reality of American society: Class matters. The white opiate users in Massachusetts overwhelmingly come from poor and working-class white communities – mostly non-urban — where good jobs are scarce and where young people see little hope for ever attaining the American dream.

The criminalized women I have come to know over the past decade are, for the most part, poor and white, and I believe that they represent a tragic social trend. According to research published in 2014 by sociologist William Cockerham “For the first time in modern history, the life expectancy of a particular segment of the American population— non-Hispanic white women with low levels of education and income living in certain rural counties—is declining.” And the same decline is happening among white men. (8) Opiate abuse is one of the factors explaining declining life expectancies in these communities, but it is crucial that we understand that opiate abuse is a symptom of hopelessness, disaffection, powerlessness and marginalization. Unless we treat those social forces we are deceiving ourselves if we think that allowing physicians to commit drug users for three days is going to do anything other than intensify those forces.

Notes

  1. Testa, Megan and Sara G. West. 2010. “Civil Commitment in the United States.” Psychiatry (Edgmont). 7(10): 30–40.
  2. Urbanoski, Karen. 2010. Coerced Addiction Treatment: Client Perspectives and the Implications of Their Neglect.” Harm Reduction Journal. 7(13).
  3. Strang, John, Jim McCambridge, David Best, Tracy Beswick, Jenny Bearn, Sian Rees and Michael Gossop. 2003. “Loss of Tolerance and Overdose Mortality after Inpatient Opiate Detoxification: Follow Up Study.” BMJ (British Medical Journal). 326(7396): 959–960.
  4. Rasyidi, E, JN Wilkins and I Danovitch. 2012. “Training the Next Generation of Providers in Addiction Medicine. Psychiatr Clin North Am. 35(2):461-80.
  5. Dodes, Lance and Zachary Dodes. 2014. The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. Boston: Beacon Press
  6. Staton, LJ et al. 2007. “When Race Matters: Disagreement in Pain Perception between Patients and Their Physicians in Primary Care.” Journal of the National Medical Association. 99(5):532-8; Weisse, Carol S., Paul C Sorum, Kafi N Sanders and Beth L Syat. 2001. “Do Gender and Race Affect Decisions About Pain Management?” Journal of General Internal Medicine. 16(4): 211–217.
  7. Greenberg, Gary. 2013. The Book of Woe: The DSM and the Unmaking of Psychiatry. NY: Plume.
  8. Cockerham, William. 2014. “The Emerging Crisis in American Female Longevity.” Social Currents. 1(3): 220-227.

 

Acknowledgments: I wish to thank Barak Sered, MD for his expert advice and input into this paper. All opinions and errors are solely my own.

Eulogy for Nicole

By Maureen Norton-Hawk, co-author Can’t Catch a Break.

If you were to meet Nicole you would never imagine that she had been battling a drug addiction for years. I can still see her sitting cross-legged on the lawn at the Common during one of our meetings.  Her long auburn hair framed her slender face as she chatted away, oftentimes not pausing between sentences.  She would talk about her love of making jewelry, her efforts to start a business, and the antics of her tiny dog. She was young, attractive, energetic and kind. Her desire to volunteer with the elderly was just one of many expressions of her deep desire to help others.

Unfortunately her giving nature made her vulnerable to those who would exploit her.  The combination of her youth and desire to please others made her an easy target to be used and abused physically, emotionally and economically by traffickers, boyfriends and some family members.

Nicole tried to stay off heroin, and succeeded for substantial periods of time. “I don’t want any more heroin. I want to live, I don’t want to die,” she declared shortly before her death.

Nicole died with a needle in her arm. Even the drug she ran to for relief took advantage of her.

I’d like to think that you are making beautiful jewelry in heaven. Rest in peace, Nicole.

For more on drug-related deaths see ““White Women, Opiates and Prison”   “The Opioid Epidemic: Just the Facts Please”

For previous eulogies see  “Orange-frosted Hostess Cupcakes”   “Eulogy for Elizabeth”

 

The Opioid Epidemic? Just the Facts, Please.

FotorCreatedHeadlines 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?

FotorCreated2No 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.

See Thinking Outside the Cell: Concrete Suggestions for Positive Change and A Feminist Sociologist’s Thoughts on the Zika Virus.

Images taken from headlines of the following articles:

http://www.pbs.org/wgbh/frontline/article/how-bad-is-the-opioid-epidemic/
http://www.desmoinesregister.com/story/opinion/columnists/2016/05/24/grassleys-help-needed-fight-against-opioid-epidemic/84857302/
http://www.theatlantic.com/health/archive/2014/10/the-new-heroin-epidemic/382020/
http://www.reuters.com/investigates/special-report/baby-opioids/
http://www.nationalreview.com/article/431486/heroin-prescription-painkillers-new-drug-epidemic
http://observer.com/2016/05/the-opioid-epidemic-its-time-to-place-blame-where-it-belongs/
http://www.huffingtonpost.com/entry/opioid-epidemic-medical-students-harvard_us_573e35c9e4b045cc9a707ca0
http://www.huffingtonpost.com/kristine-scruggs-md/the-opioid-epidemic-where_b_10112096.html
http://republicanherald.com/news/heroin-opioid-epidemic-grabs-attention-of-lawmakers-1.2045645

 

 

Like the “Girl Who Hides a Razor Blade in Her Mouth,” Coerced Addiction Treatment Has Many Victims

This article was originally published on April 13, 2016 by The Influence.

Kahtia “acted out” from a young age. At least that’s what the counselors involved in her case said. The reality, Kahtia recounts, is that she wanted to get away from the horrific sexual abuse in her home. By age 12 she was in residence at a juvenile treatment institution. By age 13 she was tired of being locked up.

After running away she had a few good years, during which she was adopted by a New York City gang whose leader had heard impressive stories about “the girl who hides a razor blade in her mouth to protect herself.” Later on she contributed to the gang through some high-priced prostitution and exotic dancing at upscale clubs. “Then,” she explains, “I was dealing drugs and became my own best customer.” The high-end sex work descended to street work, and Kahtia spent the next 15 years or so in and out of prisons and jails.

By the time I met her in 2008 (I have come to know her as part of an ongoing project with formerly incarcerated Boston-area women) she was spending far more time in treatment programs than in jail. Over the years, Kahtia has been sent by the courts, social workers, child welfare workers and doctors to residential treatment both in and out of jail, to outpatient multi-service clinics, gender-sensitive therapeutic groups, methadone treatment and ubiquitous 12-step programs.

What Should “Alternatives to Incarceration” Mean?

As a national consensus seems to be building around the idea that people who use drugs problematically are mentally ill and need treatment rather than incarceration, Kahtia’s experiences shed needed light on the concept as well as the practicalities of the “alternatives to incarceration,” which are garnering more enthusiasm than critical examination around the country.

Conceptually, the term “alternatives to incarceration” takes for granted that we are talking about ways to handle criminals who otherwise would need to be incarcerated—that incarceration is a reasonable baseline against which to measure “alternatives.” In light of the over-representation of Americans of color and low-income Americans in jails and prisons, however, it’s necessary to be careful about any sort of presumption of correlation between criminality and incarceration. In fact, about a third of people locked up in the US are awaiting trial; that is, they have not been convicted of a crime. Another third are locked up because they violated the terms of probation or parole; that is, the “criminal” act was not sufficiently egregious to require imprisonment but a subsequent action—often simply not showing up for a meeting with a parole or probation officer, or failing to keep up restitution payments or money owed in court fees—was the reason for incarceration. And 97 percent of federal and state criminal prosecutions are resolved by plea bargain—often accepted by defendants out of fear that if they don’t accept the deal they will be locked up even longer—rather than by trial.

Logistically, most alternatives to incarceration involve various sorts of intensive monitoring. This includes electronic bracelets, probation, parole and drug courts. Kahtia, like many other women I know, explains that all of these are a “set up” to be sent to prison. The terms of the supervision tend to be so extensive and rigid that, in her experience, everyone is bound to violate the terms. In her case, her last incarceration—four years ago—was triggered by the parole violation of having a “dirty urine.” When she added up the jail time and the time she was on parole, the total came to more months than she would have served if she’d been sent to jail to begin with.

Criminalization and Medicalization: Two Sides of the Same Coin

For the past 40 years, the cultural logic behind the mass incarceration of drug users rested on framing drug use as a personal choice, with the implication that it is appropriate to punish drug users who could have “just said no” to drugs. A similar logic still lies behind nearly all treatment alternatives to incarceration.

The individualistic understanding of addiction that is the bedrock both of prisons and of most treatment programs has important consequences in terms of social policies. In both medical and correctional settings Kahtia has been told—repeatedly—that her problems are the result of the bad choices she has made: the wrong men, wrong friends, wrong ways of getting money and wrong drugs. Correctional staff and therapeutic staff alike have drilled her in the idea that her problem lies within herself, her flaws, her disease, her female propensity to be “too nice,” and her proclivity for “denial.” Neither while incarcerated nor in any treatment programs has she ever been told that her problems may be the consequence of the failure of the collective to address economic inequality, racism, or sexual violence.

Sociologist Peter Conrad explains that, “[S]ince the medical profession’s mandate to treat addiction is dependent on (and accomplished at the determination of) the state, medicine functions as a social control agent in the former’s behalf. The uneasy alliance between law-enforcement and medical systems has created a hybrid criminal-medical designation of addiction” (Conrad p. 144). For women like Kahtia medicalization and criminalization are two sides of the same coin. She has been treated by doctors and psychiatrists for the very same conditions (pain and fear) and with the same or similar psychotropic and pain medications for which she has been sent to prison.

The murky line between punishment and treatment has not been lost on some of the corporations involved in the prison industry. Correctional Healthcare Companies, for example, has expanded beyond providing medical services to prisons and now offers services for the “full spectrum” of “offenders” lives: “pre-custody, in custody, and post-custody,” a timeline that perhaps says more than the company intended about American understandings of criminality.

What Is Treatment?

Typically, treatment begins with a short (five- or seven-day) detox. Ideally, people are sent from detox to residential facilities. However, in Massachusetts, like in much of the country, that transition often does not happen because there are no appropriate long-term placements available. Kahtia has been through dozens, perhaps even hundreds, of detoxes. Francesca, a friend of Kahtia’s, describes detox as “spin dry”—people come in, dry out, and are spat out afterwards. Spinning dry is particularly problematic because tolerance for heroin or pain medication is lower right after detox, making post-detox a period of danger for overdosing.

While one might argue that this simply points to the need for more long-term residential facilities, it is far from clear that such facilities offer much of a solution. If residence is voluntary, many people will leave because like Kahtia, they have families whom they do not wish to abandon or because they are fed up with the many rules about making beds, eating times, dress codes, etc. that residential programs typically see as necessary to “recovery.” If residence is coerced, then we as a society are at risk of a mass return to the cuckoo’s nest.

Recently there has been more interest in opioid agonist therapies such as methadone and buprenorphine. To be clear, these drugs do not “cure” addiction but rather are used like insulin or other on-going treatments for chronic diseases. While many people find these therapies useful, others feel that they simply substitute one drug for another (Kahtia told me that she found detoxing from buprenorphine even worse than detoxing from heroin), put money into the coffers of pharmaceutical companies, and too easily are misused when people sell or trade their doses.

Kahtia currently is in an outpatient program that provides group and individual therapy, psychiatric medication and methadone. Unfortunately, the combination of psychiatric medication and methadone made her so groggy that the director of the day camp to which she sent her kids last summer reported her to child welfare services (DCF) for being on drugs. Eight months later her kids are still in foster care; in order to get them back Kahtia is required to attend a full-time program of therapy and classes.

While not all treatment programs prescribe psychotropic medication, virtually all incorporate—explicitly or implicitly—12-step ideology and practices. Treatment facilities tend to be plastered with 12-step slogans such as “Let Go and Let God” and “Cultivate an attitude of gratitude,” and formal AA/NA meetings typically are part of the treatment regime. With emphasis on admitting one’s powerlessness (Step One) and making moral inventories of one’s faults (Step Four), these programs do not seem to offer people like Kahtia a meaningful script for re-organizing their lives. Having been at the receiving end of physical, emotional and sexual abuse both as a child and as an adult, she already is quite familiar with her powerlessness. And having spent much of her life in correctional facilities, her faults have been inventoried more times than she cares to think about.

Most treatment programs in Massachusetts also include some sort of psychotherapy. Kahtia has been treated by multiple therapists in both conventional and gender-sensitive programs over the years. While Kahtia typically enjoys talking about her history and her problems, she is frustrated by the rapid turnover in therapists at community mental health centers, by the fact that therapy has been required by parole officer and caseworkers, and most of all by the fact that therapy addresses her attitude to life’s challenges but can’t address the challenges themselves.

But Does It Work?

Politicians, advocates and just plain folks tout treatment as if there is clear evidence that treatment for addiction works. Indeed, “work it til it works” is a popular 12-step slogan. But by the standards commonly accepted for medical and scientific research there simply is no substantial evidence that this is the case. Studies showing positive outcomes to treatment typically look only at participants who completed the program, do not track program participants for long enough time to establish meaningful rates of success, fail to control for confounding variables, or look at very small numbers of participants from the start. Indeed, a recent meta-analytic review of the effectiveness of continuing care for substance use disorders (the need for ongoing treatment is one of the few things that virtually everyone in the field seems to agree upon), the researchers concluded, “Limited by [the] small number of [methodologically sound] studies, analyses did not identify any significant moderators of overall effects.”

Studies of addiction treatment tend to focus on retention rate in programs rather than on how the program impacted participants after they finished. The notion of treatment being measured by sticking with the program rather than by actually being cured seems bizarre. In cancer treatment we wouldn’t consider long-term treatment to be good. Yet, in the world of addiction research we find studies like this one that conclude that “Consistent with a sustained benefit for 12-step exposure, abstinence patterns aligned much like attendance profiles.” Despite the researchers’ use of the word “benefit,” all that their study showed is that there is some correlation between attendance and abstinence. Their data do not show that one causes the other. (In other words, it could just as well be that people who are not using drugs—for whatever reason—are more likely to continue attending 12-step meetings.)

Every Statistics 101 student learns that correlation does not prove causation, that two phenomena can be related with one causing the other. Yet studies like this one on “engagement” in treatment seem to remember that wisdom only in the “Limitations” section at the end of the article.  After pages of numbers showing that people who remain engaged in treatment are also less likely to be arrested, the authors acknowledge that “clients with stronger motivation at entrance to treatment may have both higher engagement and better outcomes.”

Very few studies follow the people who have left the treatment program, though in many studies more than half of the initial participants have left before the end. And even the best studies, the ones that make efforts to follow-up with all participants, typically cannot find half or more of the participants thus have no idea what has happened to them or whether the half (or less) they have managed to find are in any way representative of the full participant cohort.

For example, an otherwise strong study that compared methadone with buprenorphine (Suboxone) looked at 1267 opioid-dependent individuals participating in nine opioid treatment programs between 2006 and 2009 and randomized to receive buprenorphine or methadone for 24 weeks. But perhaps the most important finding is that the treatment completion rate was 74 percent for methadone versus 46 percent for buprenorphine. The researchers have no idea what happened to the half of the participants who dropped out. In short, while the study ostensibly found better patient retention with methadone but lower continued use of illicit opioids with buprenorphine, it’s difficult to conclude anything meaningful about the efficacy of treatment.

Even the best studies, the ones that that make efforts to follow-up with everyone who started the study, typically limit the follow-up to three months, six months, or at the most a year or 18 months post-program. However, as in Kahtia’s case, it is common for people who use drugs to have periods in which they use heavily, periods in which they use occasionally, and periods in which they don’t use at all. And while I suspect it is likely that many forms of treatment do have a short-term positive impact on participants, without a double-blind random study in which some people are treated and some are not and then everyone is followed-up for a substantial period of time, we really cannot know which, if any, treatment modalities actually work.

The absence of evidence for the success of treatment programs is especially glaring when the treatment is coerced or carried out in a coercive situation. It may be tempting to believe that even if treatment doesn’t help everyone, at least it doesn’t hurt. Yet, as we’ve learned from past efforts to “cure” homosexuality, treatment that is ostensibly for the patient’s own good may be used to bring the “deviant” individual back into line when their ideas or behaviors challenge social hierarchies of race, gender, sexual orientation or class. Those of us old enough to remember Jack Nicholson’s performance in One Flew Over the Cuckoo’s Nest can attest to the reality that therapeutic interventions aimed at “getting inside” the patient’s head can carry heavy costs indeed.

A Real Alternative

As the treatment-industrial complex gathers steam, there is need for critical thinking regarding not only the effectiveness but also the goal of treatment. Is the goal necessarily abstinence (an ideology promoted by the 12-step movement), as opposed to temperance or moderate drug use? More broadly, is abstinence or even temperance really the ultimate aim, or is the true goal a life of purpose, meaning and dignity? In Kahtia’s case the absurdity is that she would now be considered a “success” by treatment researchers because she has not had a dirty urine in many months. But the reality of her life is that she spends all of her weekdays in various classes and groups, she is not able to work, she is always broke, and her kids are still in foster care with no set date for her getting them back. Is that a success story?

Last month President Obama gave a strong speech about drugs. Yet even this thoughtful man, a president who has demonstrated his ability to hold onto competing ideas and live with ambiguity, offered the same uncritical promotion of treatment that has started to replace the uncritical promotion of mass incarceration. There was, however, an intriguing kernel of insight in his allusion to his own drug use in his younger days and his implicit acknowledgment that not everyone who uses drugs becomes addicted. I would have liked him to examine his own experiences a bit more and move beyond his uncharacteristically superficial analysis that, “I was lucky because, for whatever reason, addiction didn’t get its claws into me.” Could it be that his strong political and social views and commitments—his deep belief that the world can be made better and that he can be part of that process—made drug use less appealing?

If so (and I think it’s pretty likely that this is so) then we should be talking about social factors in addition to medical ones.

If, as President Obama has articulated many times, reckless use of violence by the United States cannot cure the violence that plagues the Middle East, then surely he can recognize that uncritically escalating our use of medical treatment cannot cure the problem of America’s massive overuse of drugs. Just like we need to put more thought and resources into understanding why people become suicide-bombers and into preventing disaffected young people from joining terrorist organizations, we need to put more thought and resources into understanding why so many Americans feel the need to use large amounts of mood-altering and sense-numbing substances. At this point we barely know what prevention of problematic drug use would entail.


 

Alternatives to Incarceration: Be Careful What You Wish For

As awareness is growing of the financial and human costs associated with mass incarceration, we’re hearing talk from politicians on both sides of the aisle (and, believe it or not, even from the Koch Brothers) about the need for “alternatives to incarceration” (ATIs).

The term “alternatives to incarceration” takes for granted that we are talking about ways to handle criminals who otherwise would need to be incarcerated — that incarceration is a reasonable baseline against which to measure “alternatives.” In light of the over-representation of Americans of color and low-income Americans in jails and prisons, however, it’s necessary to be careful about any sort of presumption of correlation between criminality and incarceration. In fact, about a third of people locked up in the US are awaiting trial; that is, they have not been convicted of a crime. Another third are locked up because they violated the terms of probation or parole; that is; the “criminal” act was not sufficiently egregious to require imprisonment but a subsequent action – often simply not showing up for a meeting with a parole or probation officer, or failing to keep up restitution payments or money owed in court fees – was the reason for incarceration. And 97% of federal and state criminal prosecutions are resolved by plea bargain – often accepted by defendants out of fear that if they don’t accept the deal they will be locked up even longer — rather than by trial.

Given these numbers, it’s easier to make a case for abolition than for “alternatives to incarceration.” But that is not the direction in which public discourse seems to be moving. To the contrary, the increasingly popular sentiment goes something like this: A whole lot of people sitting in jails and prisons are mentally ill; they are drug users who need treatment more than they need punishment. Echoing this sentiment, Los Angeles County – the US county with the largest number of incarcerated people – recently approved a $1.9 billion proposal to tear down Men’s Central Jail and construct a 4,885-bed “Consolidated Correctional Treatment Facility”. And while “treatment” certainly sounds beneficial, the content of that treatment has yet to be spelled out.

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Over the past five years I followed a cohort of Massachusetts women who cycle in and out of prison as well as a variety of treatment programs. All of the women, at some point in their lives, have been diagnosed with a psychiatric disorder (most commonly substance abuse, bipolar disorder, PTSD). Overall, these twenty-six women spent far more time in treatment than in correctional settings. Yet, at the end of five years only three women had settled into reasonably secure housing, stable employment and long-term desistance from substance abuse.

Typically, treatment programs include some combination of pharmaceutical, twelve-step and psychotherapeutic components. Most of the women I have come to know are prescribed mind-boggling assortments of psychotropic medication, some of which make them, as Elizabeth (a white woman in her early forties, Elizabeth was homeless for a decade) used to say, into “a space shot” who shuffles around in a daze that puts her at elevated risk for being robbed or assaulted. Whether anti-anxiety, anti-depression or anti-psychotic drugs, these medications are not intended to cure the underlying problems such as sexual assault and homelessness that lead to anxiety, depression and substance abuse. Rather, psychotropic medications are prescribed in order to manage the individual’s response those problems.

While not all treatment programs prescribe psychotropic medication, virtually all incorporate – explicitly or implicitly — twelve step ideology and practices. Treatment facilities tend to be plastered with twelve step slogans such as “Let Go and Let God” and “Cultivate an attitude of gratitude,” and formal AA/NA meetings typically are part of the treatment regime. With emphasis on admitting one’s powerlessness (Step 1) and making moral inventories of one’s faults (Step 4), these programs do not seem to offer the women I have come to know a meaningful script for re-organizing their lives. When I visited Joy, who has been homeless for nearly fifteen years and nearly died as a consequence of a brutal sexual assault, several weeks into her stay in a treatment facility she enthusiastically explained to me that, “I’m learning that my problems are in my head.” Unfortunately, her problems also were in the real world: Less than a year later she was back on the streets where she was sexually accosted by a police officer who then arrested her for solicitation.

Most treatment programs in Massachusetts also include some sort of psychotherapy, and nearly all of the women I know have been treated by multiple therapists over the years, sometimes beginning in adolescence or even childhood. With its focus on the individual psyche, psychotherapy addresses personal flaws such as poor impulse control, allowing oneself to be a victim, and struggles to “get over” past traumas. But as Elizabeth explains, “I don’t need to talk about my problems. I need a place to live so that I won’t be scared all of the time.” This does not mean that therapy is useless; it does mean that “talk is cheap” without the material conditions that permit women like Elizabeth and Joy to build a secure life.

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There is little evidence pointing to long-term success for any particular drug treatment modality. Studies showing positive outcomes typically fail to track program participants for long enough time to establish meaningful rates of success, look only at participants who completed the program, fail to control for confounding variables, or look at very small numbers of participants from the start. The absence of evidence for the success of treatment programs is especially glaring when the treatment is coerced or carried out in a coercive situation. It may be tempting to believe that even if treatment doesn’t help everyone, at least it doesn’t hurt. Yet, as we’ve learned from the past — from efforts to “cure” homosexuality to the tranquilizers (“mother’s little helper“) of the 1960s,  when a patient’s ideas or behaviors challenge social hierarchies of race, gender, sexual orientation or class, treatment that is ostensibly for the patient’s own good may be used to bring the “deviant” individual back into line. As those of us old enough to remember Jack Nicholson’s performance in One Flew Over the Cuckoo’s Nest can attest, therapeutic interventions aimed at “getting inside” the patient’s head can carry heavy costs indeed.

The murky line between punishment and treatment has not been lost on some of the corporations involved in the prison industry. Correctional Healthcare Companies, for example, has expanded beyond providing medical services to prisons and now offers services for the “full spectrum” of “offenders” lives: “pre-custody, in custody, and post-custody,” a timeline that perhaps says more than the company intended about American understandings of criminality.

Read more: Incarceration by Any Other Name: A Return to the Cuckoo’s Nest?

Aswirl in a sad spiral, women in detox face human rights violation

Reprinted from the Boston Globe, August 19, 2014

The Aug. 14 editorial “Women get unequal treatment in court-ordered detox” underscored an egregious violation of human rights in the Commonwealth. Due to a lack of treatment beds, drug users who have not been arrested, tried, or sentenced may be sent to MCI-Framingham if a judge deems that they are dangerous to themselves or others.

Women committed to a prison setting do not receive the treatment afforded those who are sent to the Women’s Addiction Treatment Center, which is licensed by the Department of Public Health. Most damning, women of color are three times more likely than white women to be committed to prison rather than to the treatment center.

The way out of this mess, according to Governor Patrick and others, is to fund additional substance-abuse treatment beds in non-prison facilities.

However, many of the women who are civilly committed are not only dealing with addictions but also with poverty, homelessness, serious health problems, and intimate partner violence. One DPH official estimated that 20 percent of civilly committed women do not meet the criteria for commitment; rather, they are committed because no one knows where else to send them.

As a nation, we’ve gone the route of building more prisons in unsuccessful efforts to manage the devastation caused by economic and racial inequalities. Building more “staff-secured” treatment centers will not prove any more successful unless we also address the poverty, gender and racial discrimination, and violence that lead so many residents of the Commonwealth to turn to drugs in the first place.

Susan Sered

Boston

The writer is a sociology professor and a senior researcher at the Center for Women’s Health and Human Rights at Suffolk University.

Suicide is Painful, Update

Last week I wrote about my friend Joy, a woman who has dealt with sexual violence, homelessness, substance abuse, humiliation and criminalization since she was in her early teens. A few days earlier she had tried to end her life. Precipitating the suicide was her realization that if she kept using heroin she would not survive. She made the tough decision to go onto methadone, and enrolled in a methadone clinic. Though she told the clinic  about the extent of her heroin use, she was given too low a dose to stave off painful withdrawal symptoms. (Clinics sometimes give doses that are too low to be effective out of fear that patients are trying to trick the staff into giving them more methadone than they really need.) To supplement the methadone she went back to the streets and sex work for the money to buy heroin. The day she tried to kill herself she felt, as she told me later, “What’s the point? I try to do the right thing, go on methadone, and that doesn’t work. There’s nothing left for me.”

Today Joy called me again. She sounded great. She’d had two weeks of a safe bed to sleep in and nutritious meals to eat in the psych ward of a hospital near my house, and the doctors there had gradually raised her methadone dose to a point at which she was no longer dope sick.

“How did you get them to keep you for so long?” I asked, reminding her that last week the hospital had told her that she couldn’t stay there for more than a few days. “They tried to find a place to send me,” Joy explained, “but the social workers couldn’t find anyplace willing to take someone who is on methadone and coming from a psych ward. So they tried to send me to a homeless shelter but I told them that if I went into a shelter I’d be back on the streets and I’d jump off the roof, so they had to keep me because I said I was suicidal. I actually wouldn’t jump off the roof, but sometimes,” Joy added, “you’ve got to finagle a bagel.”

“What now?” I asked. “Well they just gave me my phone back and I’m waiting for the detox [facility] to pick me up.” “What are you detoxing from?” I asked. “You haven’t used drugs. You’ve been in the hospital for the past two weeks.” “Methadone,” she replied. “They decided to send me to detox to get me off methadone because that is the only way I can get a placement in a halfway house or rehab.”

Sounds crazy? Yes, it is. But those are the rules.

Joy has been around this block before, and she doesn’t expect the system to make sense. I, far more naïve than she, repeatedly find myself hoping that this time the doctors, the social workers, the nurses and the caseworkers who advocate for Joy will be able to arrange an appropriate, permanent placement. But even the best medical and social service personnel (and she has been assisted by many wonderful professionals) cannot create a rational plan out of the current hodgepodge of short-term public and private programs.

No Magic Bullet – But Some Sensible Recommendations

There is no magic bullet that will cure Joy. The social conditions — and especially the gender inequality and sexual violence that cause her misery continue to be our reality. But there are steps we can take both at the policy and the programmatic levels that can increase Joy’s odds of survival.

One, we must bring the jumble of programs for people who are struggling with substance abuse into a coherent system in which a given individual can know that she has a therapeutic “home” that she can turn to, a home that knows her history and in which there is at least a fighting chance of developing some level of mutual trust. Joy cannot even remember all of the programs she has been sent to over the years, but when we tried to brainstorm we came up with a list of more than three dozen different facilities and programs — each with its own intake and assessments, each with its own medical protocols, each with its own rules. Right now, I am still fuming over the idiocy of putting Joy on too low a dose of methadone in an outpatient clinic, increasing her dose in an inpatient psych ward, and then sending her to a detox facility to withdraw from methadone so that she can get into a “holding” program while waiting for placement in a rehab program.

Two, we need to change the criteria for participation in mental health programs and in substance abuse programs in order to serve the needs of people like Joy with “dual diagnoses” (mental illness and addiction). The fact is that the majority of people who overuse psychoactive substances are, in one way or another, self-medicating their misery. The ersatz distinction between mental illness and addiction reflects out-dated ideas about what constitutes criminal behavior. It is neither realistic nor helpful.

Three, we need to know when to say “enough” to drug treatment programs. Joy has been through so many programs that, as she once told me, “I could teach the classes myself.” Rather than send Joy to detox and still another program, it would be far more sensible to provide her with secure housing where she will have access to on-going healthcare and emotional support, where she won’t be kicked out for breaking the rules or for “relapsing” (which, I acknowledge, she likely will), and where she will have at least a fair shot at putting down the roots and building the social networks that, in the long run, may be more salutary than methadone.

Over the next few weeks I will post additional recommendations for addressing the suffering experienced by Joy and other women I have come to know in Massachusetts over the past decade.You can read more about my work in Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility.

Suicide is Painful

The week that Robin Williams’ suicide hit every media outlet in the country, my friend Joy drove into the woods, shot herself up with enough heroin to kill a horse, and sat on a rock waiting to die. Unlike Williams, Joy survived (though the person who found her and called 911 first stole all of the cash from her wallet). And while I’m not surprised or even hurt that Joy’s intentional overdose has not received the media attention of Williams’ hanging, I do feel the need to acknowledge and share the knowledge of what led her to that rock and what happened after she was “rescued”.

The youngest daughter of a white, middle-class couple, Joy recalls that, “Until I was seven everything was normal – white picket fence, father went to work, mother stayed home with the children. Then everything fell apart.” Her parents divorced, her mother received custody and her mother’s boyfriend molested Joy and her older sister. Joy saw therapists and was given psychiatric medication throughout her childhood. Eventually she was removed from the home and placed into the child welfare system where she lived in various foster homes and juvenile programs. “None of these placements worked. I was an early drug abuser.” When I first met her crack cocaine was her drug of choice; a few years ago a boyfriend introduced her to heroin.

As an adult, Joy has never held a job that pays a living wage, never had secure housing, and never had custody of her daughter (her father is raising her daughter.) She suffers from impaired hearing, diabetes, insomnia, Hepatitis C, chronic hip and shoulder pain, lumps in several lymph nodes, and neuropathy in her feet. Joy’s sole legal income is her monthly SSI check of approximately $740, which she supplements through sex work. For the past twenty years she has moved among drug rehabilitation programs, motel rooms, shelters, jail and psychiatric hospitals. During the years I have known her she has been prescribed the following psychiatric medications: Trileptal, Seroquel, Neurontin, Abilify, Remeron, Buspar, Celexa, Wellbutrin, Neurontin, and Effexor.

…..

I’d last seen Joy a few months ago right after she was released from jail. She had been held while awaiting trial on a prostitution charge and then let go on “time served.” After losing track of her for a while, a few days ago I heard that she was in the locked psychiatric ward of a local hospital and I went to visit her. Although brightly painted and staffed by cheerful nurses, the ward gave off a “One Flew Over the Cuckoo’s Nest” vibe. Most of the patients were wearing hospital gowns, and since they are not allowed shoes they shuffled back and forth in the corridors in slippers or socks. Some gave off unpleasant odors; many had the blank “zombie” look of heavy psych medication.

Joy was delighted to see me (and delighted with the chocolate and magazines I brought). I asked her how she ended up on the ward. She explained that she’d been drifting around between stints of jail time and realized (not for the first time) that she needed to make a change in her life if she is going to survive and “be there for my daughter”. She made the decision try methadone and see if she could kick her drug use once and for all. The methadone clinic put her on a dose that was too low for the amount of heroin that she had been using, and she became extremely dope sick. “They moved up my dose but it wasn’t enough so I kept using dope together with methadone. I realized it wasn’t working and I already tried everything else – you know Susan I’ve been in so many programs that I could teach them — so I decided to end it all.” The last thing she remembers is feeling the heroin start to work. When she woke up in a hospital close to where she was found, she was told that she very nearly died and that the medical staff worked on her for a significant amount of time to bring her back.

…..

Two days later the hospital released her. She was told that they had tried to place her into the detox facility with which the hospital works, but that facility only takes people on Suboxone (another drug that is used to treat opiate addiction), not methadone. The nurse handed Joy a piece of paper with some phone numbers for her to call to find a detox program for herself, and told her to leave. Joy said to the nurse, “Are you kidding me? I tried to kill myself less than 48 hours ago.” The staff claimed they didn’t know that, but in that case she could stay in the hospital.

The next day they transferred her to the hospital at which I met her. Joy was assigned a doctor whom she liked, but after one day a “fill-in doctor” took that doctor’s place. The fill-in doctor looked at her chart and cut in half the medication for the neuropathy in her feet and stopped her anti-anxiety medication without talking to her or seeing her. A nurse told Joy that she’d try to speak to the doctor on her behalf, but the doctor made it clear that “I am the doctor and you’ll get the medication I give you.”

Joy was not assigned a therapist but was told to meet with a social worker who tried to find a rehabilitation program for her. Joy told the social worker that she had thrived at a facility she had been in a few years ago, but that program only lasted for five months, after which she was sent back to the streets.

Two days later when I called Joy told me that the doctor felt a large lump in her stomach and was sending her for an ultrasound later that day. Also, a lump on her neck had grown and she was being sent for a scan. I told her I’d drop by but I could only come in the morning. Because visiting hours start at 4:00 the nurse would not let me in (although Joy told her that I was the only person visiting her and that my visits help her want to live.)

Later that day Joy and I talked again on the phone. “It’s good you didn’t come, Susan, because they had me packed up and ready to go to a detox program in [another city]. I was literally going out the door when the program called and said they can’t take someone from a psych ward. So I’m just waiting for them to find a holding place for me where I can wait for a halfway house placement.” I asked her about the results of the ultrasound and scan. These tests had not been done nor had the doctor written up orders for them to be done at her next placement.

…….

The U.S Centers for Disease Control and Prevention (CDC) recently reported substantial increases in suicide rates among middle-aged adults in the United States. Based on National Vital Statistics System mortality data from 1999–2010, CDC researchers found that the suicide rate among American men aged 35–64 had increased 27.3 percent from 1999 to 2010, and among American women aged 35-64 the rate had increased 31.5 percent. A variety of theories have been proposed to explain these increases. Psychologist and author Bruce E. Levine notes that while it is popular to blame chemical imbalances in the brain for suicide, according to the CDC, “Possible contributing factors for the rise in suicide rates among middle-aged adults include the recent economic downturn (historically, suicide rates tend to correlate with business cycles, with higher rates observed during times of economic hardship).

One would assume that our current partiality to theories regarding the biological and chemical bases of mental illness would lead us beyond blaming the individual for his or her pain. But that is not the case – as witnessed by the estimate that nearly two-thirds of people sitting in jails and prisons are mentally ill.

And that is what I find so difficult to swallow.

Within forty-eight hours of Joy’s almost fatal suicide experience she had to fight to stop the hospital from releasing her to the streets where she’d surely be re-arrested for drugs, prostitution or simply loitering. Then she was confined in a locked ward where her visitors were limited and where she was prescribed different medication regimes by two different doctors (one of whom refused to listen to anything she or her nurses had to say). She knows she needs to stay off the streets but she has been told that there is no placement available for someone who is both suicidal and on methadone so the best she can hope for is a temporary “holding” facility until a place can be found in a slightly-less-temporary halfway house from which (as she and I know from her past experiences) she will be kicked-out if she “relapses”. And all of this happened in a very reputable treatment setting, which, Joy told me, is not all that different from jail.

…….

Now, it may be tempting to chalk Joy’s experiences up to bureaucratic run-around or an episode of particularly egregious institutional incompetence. But when the run-arounds and incomeptences are built into the laws, the regulations, the policies and rules and protocols, then they must be understood as manifestations of “the system” rather than as haphazard or idiosyncratic exceptions.

I don’t know if Joy will die from being raped or beaten by a trick, from a bullet one day when she can’t hear the police tell her to stand still, from whatever is causing the mass in her stomach and the lump on her neck, from the chaotic cocktails of prescription medication she receives, or from an unintentional overdose or another try at suicide. I don’t know if she’ll die in prison, a violent and oppressive setting that gives rise to high rates of suicide, or after her next prison release – a time in which suicide rates again rise. I don’t know if she’ll die in a detox facility or a homeless shelter. But each time I say good-bye to her, I have a sick feeling that this may well be for the last time.

You can read more about Joy in Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility.

White Women, Opiates and Prison

Author’s note: Race is hard to write about; so is class; so is gender. I struggle with articulating — especially in a short essay —  two truths. Broad social forces and inequalities impact life experiences. And, each individual has her own unique life experiences framed by the particular ways in which class, race, gender, sexual orientation, ethnicity, nationality, citizenship status and other social categories intersect for her. I thank Robin Yang and Lois Ahrens for helping me try to get it right here. I accept sole responsibility for bits where I’ve missed the mark.

Black men have been the face of incarceration in America for decades, and black men continue to be locked up at rates far exceeding those of other gender and racial demographic groups. But, over the past few years, just as the pace of incarceration finally began to decline for men and for black women, incarceration rates have risen by 47.1% for white women. Opiate use seems to be driving much of that increase.

CDC Director Tom Frieden, in a 2013 briefing, announced that rates of opiate use, abuse, overdose and death are rapidly increasing among women. Aside from age (those in the 45-54 year age group have the highest rate of opiate related death), Frieden did not offer demographic details beyond the rather meaningless “mothers, wives, sisters, and daughters.”

Research published last week by the Boston Globe found that the number of babies born in Massachusetts with opiates in their system is more than triple the national rate, and that the numbers in Maine and Vermont are even worse. This research did not track race, but we do know that Maine and Vermont are two of the whitest states in the county – 95% white, Massachusetts is 84% white, and that many of the opiate hot spots in these states are poor, white communities. In Fall River, for instance, approximately 72% of residents have received a prescription for opiates, a rate well above the state average of 40 percent.

While the media seems shocked to “discover” that white women make illicit use of drugs, we really should not be surprised. Indeed, over the same years in which black men were the face of incarceration, white women were the face of medicine. White women take more prescription and over-the-counter medication, are prescribed more pain medication, undergo more cosmetic surgery, and make more doctor visits than any other major demographic group. White women are the greatest users of commercial holistic healing (alternative and complementary medicine). And white women are over-represented on pharmaceutical commercials and in high profile “war on illness” campaigns such as the pink ribbon breast cancer extravaganzas.

Just as higher incarceration rates do not necessarily mean that black men are especially wicked, higher medication rates do not necessarily mean that white women are especially sick. They do mean that white women tend to be portrayed as particularly in need of — and deserving of — expert medical care, and that the health challenges of white women are treated with more attention than the health challenges of other groups. Think, for instance, of how the natural aging process becomes seen as a medical problem (medicalized) when millions of prescriptions are written for hormone replacement therapy (HRT) for women who do not have any disease other than not being young. And think of the racial implications of these findings from a large government study released in the 1990s: HRT use among white women was 89% higher than among black women and white women were 54% more likely than black women to receive HRT counseling from their doctors.

Women – and especially white women – are prescribed more psychiatric medication (especially for depression and anxiety) than men. Jonathan Metzl, in Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs, traced advertisements for psychiatric medication in the American Journal of Psychiatry over a period of decades. He found that marketing to doctors disproportionately addressed women’s problems. Advertisements for Milltown and then Valium featured women’s unhappiness with their husbands, family responsibilities and sex, and offered medication as a way to make them more compliant with expected gender roles. Overwhelmingly, the pictures in these advertisements were of white women benefiting from treatment provided by white male doctors.

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What does all of this mean for white women’s experiences of opiates today? Continue reading White Women, Opiates and Prison