Connecting the dots

The recent spate of deaths in white communities from poisoned opioids has radically altered mainstream attitudes towards 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 subsequent public gatherings, citizens and mainstream politicians speak of the addicted with compassion, and refer to drugs with street slang familiarity. I become hopeful about real reform. Yet these gatherings continue to frustrate. Let me explain.

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 (identical twins; one a judge, one incarcerated), emotional trauma is a powerful predictor, particularly childhood abuse. We meet adult victims who have lost jobs for failing drug tests, or 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.

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. Some presentations include a video of lab mice compulsively dosing themselves with cocaine to satisfy what cannot be satisfied—behavior also found in the chronically obese, compulsive gamblers, and people termed sex addicts. Addiction itself is presented with frightening, unrelenting force. It is defined without nuance or hesitation as a disease that can strike anyone, anywhere. And when we combine the immature brain of impulsive youth with the cruelty of opioids' diminishing returns, addiction appears virtually unavoidable.

The second is the deadly advent of heightened drug potency controlled by foreign and domestic "traffickers." (They don't sell ounces of drugs, they traffic in kilos of narcotics). And this isn't your father's heroin. Synthetic heroin (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. These drugs are bootlegged by bigger than life international cartels and amoral street dealers familiar to viewers of The Wire. We now know that their origin story also involves the domestic traffickers—Big Pharma. Most often the real heat of these addiction awareness presentations is generated by Purdue Pharma, that poster child of heartless capitalism, whose sales reps convinced doctors to flood communities with the addictive pre-cursor to heroin, yielding a devastating wake of addiction.

We are besieged, vulnerable to the assault, awash in drugs.

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 (including some in the recovery industry) serve up ineffective safe harbor bromides such as Getting More Involved in our kids' lives, watching for The Classic Warning Signs, cracking down on dealers, and bemoaning the human condition. I am frustrated because these broad-based presentations distort the drug policy universe and thwart real reform. The audience goes home with unnecessary resignation or misdirected anger.

I want to re-frame the issue for the audience so they emerge every bit as enraged but neither hopeless nor unproductively sidetracked.

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. Rather:

 It's not our brains. Neuroscience reveals universal vulnerability to addiction, but far less than one in ten succumb. 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? Why are nearly a quarter of all opioid misusers in the construction and fishing industry? A genetic predisposition, or a lack of job security and health insurance on a dangerous job that requires quick (read opioidal) relief? Newer experiments with mice and cocaine changed the environment to a more challenging, less stressful one, and the mice showed only minor interest (almost as much as to sugar) in the easily available cocaine. To attribute addiction to our wiring is a sink hole that replaces political indignation with a resigned, it's-the-nature-of-the-beast shrug.

 It's not the cartels air mailing Fentanyl from hidden factories. While sharing the drug warrior's desire to rain holy terror on those sources, our decades old drug interdiction policy has a failure rate of some 90 percent, and as the pills get progressively 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 (or inevitable successors such as Dsuvia, ten times as powerful and soon to be FDA approved) will be met. Admittedly, some crave the scary heights of greater potency, but they are not looking to kill themselves. A heroin overdose is 100 times more reversible than a fentanyl one; and 1,000 times more reversible than with 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.

 It's not Purdue, despite their deserved reputation. Doctors and the get-well-quick insurance industry jumped at their fast acting magic trick. In addition to personal trauma or personality type, the societal conditions (long term unemployment or having a dangerous, uninsured, job) 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 threat to rain holy terror on Purdue is yet another deflection which misses the point that these bigger-than-life villains are replaced the minute they are eliminated. Again, the audience leaves without direction; seething with resigned anger.

 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 nature of how that illegality plays out.

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 justice system thwarted their ability to conquer addiction, they rarely reveal the incredible scope of such entrapment. Over 55 million Americans have suffered drug-related arrests, disproportionately in the African American community. Predictable outcomes include the stress of job insecurity, inability to get student loans, driver's licenses, or secure housing. Much of the stigma, far worse than for those addicted to alcohol, stems from heroin's outlaw status. Consider the stress on parents torn apart by incarceration, losing their children to foster homes. Consider the lower-income, pregnant minority woman struggling with addiction who doesn't seek help because of a reasonable fear that she might end up caged during her kid's childhood. Or shackled while giving birth. Consider people being forced into abstinence behind bars or as a condition of not being caged, only to die because their new equilibrium has rendered them incapable of handling what they used to tolerate. People are 122 times more likely to die of an overdose in the two weeks following their release than those using the same drugs but not imprisoned. Consider the paranoia and isolation of young people used as snitches by drug cops. Consider people dying alone—the most common circumstance—a predictable result of the furtive conditions of illegal consumption.

 These are some of the dots connecting addiction to a drug policy that is neither class- nor race-blind. It has, for example, become common to hear one of America's 900,000 underage drug sellers saying, "There were no jobs, so I sold drugs." Addiction presentations invariably include someone who lacked the insurance required for treatment, but they rarely expose the larger reality which is that over half of the non-elderly uninsured are people of color. They also rarely reveal the frustration and disempowerment experienced by millions of African Americans denied the vote because of a police record, mostly due to  drug policies. The stress, hopelessness, and neighborhood disinvestment caused by inner city violence 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.

It's as though the soft-landing empathy for those with opioid addictions hasn't fully reached the inner city.

More than any single cause, and there are many others, drug policy creates and augments the stresses associated with addiction. A recent Lancet Public Health Journal confirms that "Even after taking into account the role of opioid prescription rates, the association between incarceration and overdose mortality persists."  Many presentations hide this impact in plain sight—mentioned but not analyzed; protected by safe harbor bromides and misdirection.

All of which should be enough to energize a sympathetic audience, except for the obvious problem of scope. It's not exactly realistic to expect most folks to emerge from these presentations demanding income redistribution and drug legalization. It is, then, critical that we demand realistic reforms that still challenge the familiar world.  

Which makes this a good time to analyze the success stories.

The exceptions

There are success stories because there is an answer: access to a full range of proven medicines provided in a respectful, supportive environment that includes freedom from the criminal justice 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, those with serious addictions require the same routine support and access to medications that people with Diabetes or tooth decay expect even if they abuse their diet or health. It means always knowing what they are consuming or being surrounded by competent help—Safe Supply or Safe Space. At the Insite clinic in Vancouver, an example of Safe Space, over 2,500 life-threatening overdoses have been reversed (even in the age of Fentanyl). 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, England, 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 life-saving reforms should motivate today's sympathetic audience to eagerly confront the "what do we do now?" question.

And 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; a proven path to recovery with a multi-decades international track record, and (2) Safe Consumption Spaces where people use street-provided illicit drugs or clinic-provided medical grade heroin under supportive supervision; another proven path to recovery with a multi-decades international track record.

These reforms boil down to Safe Supply or Safe Space. They provide a life-affirming glimpse of a post-prohibitionist world in which drug users and misusers are treated with routine decency and common sense. And as these programs become part of the woodwork, hysteria will diminish along with crippling stigma. People with difficult addictions will be seen more as human and troubled, and less as exotic and frightening. These programs will help create a society with less death, disease, crime, and addiction. They provide a glimpse of drug policy that works.

 Going forward

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. Today's use of the medical model is a welcome wedge against the worst of that hysteria. We have removed their demonization by referring to addiction as a non-punishable disease of the brain. Yet the medical model has little room for nuance. People addicted to cigarettes, for example, slavishly repeat their self-destructive behavior despite full knowledge of its effects. We do not thereby call them mentally ill. And (under the public radar) most 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 ghettoization—of stigma: "They" are evil has become, "They" are sick.

These targeted reforms serve to remind us that those with addictions are just those with burdens—some or none of their own making.

And so now, with proven, life-saving tools at our disposal, we can ask two questions:

How can we help, and what's stopping us?

But as rural death rates start to drop and urban rate rise, we must strike while the iron is hot—before our newfound sympathy, cools.