“Political language is designed to make lies sound truthful
And murder respectable, and to give the appearance of solidity
To pure wind.”
I — Introduction:
This is a “how-to”, or primer, for persons addicted to opioids or persons in recovery and for their families to help them negotiate a treatment system that is often opaque, unwelcoming and punitive. It’s also an admonition directed at the treating professionals who work in addiction treatment programs and at the government officials who establish and fund them to think “outside the box”, to put the addicted persons whom they purport to help at the very center of treatment or risk continued failure.
To clarify that last contention, I’ve purposefully included a critique of the long prevailing theories about addiction and its causes – that it is consequent to an individual’s character or moral failures or to her or his brain dysfunction and genetic predisposition – and I suggest alternatives: that the former or moral model is rooted in stereotypical notions assigned to groups of individuals, principally those who are poor and those who are persons of color, and the latter, the medical model, is not supported by any scientific evidence. In contrast, I review the theories advanced by Maia Szalavitz that addiction is a learning and development disorder, and by Johann Hari that addiction is directly related to social disconnection or alienation. Simply put, addiction, according to Szalavitz and Hari, is not an individual but a social problem and requires a village or a tribe to resolve it.
To provide historical context, I review the War on Drugs from its roots in Lyndon Johnson’s Safe Streets Act of 1968 to the present, when the President’s drug control budget continues to allocate more money to law enforcement and drug interdiction than to treatment. If the latter produces questionable results, I argue that the former, the criminalization of drug possession and sales and the incarceration of those caught doing so, has done little to prevent or put an end to the current opioid onslaught. The attempt by the Federal government to re-cast our opioid epidemic as a public health problem is more a reflection of opioid abuse as a problem for white Americans and less so for blacks than it is a concrete commitment by all levels of government to assist addicted persons become drug-free. The question for white Americans, which I address throughout, is whether being white will allow white Americans to more easily access better treatment. In sum and to date – and the opioid epidemic can be dated from 1999 – much talk, too little action.
This is illustrated in the primer’s final sections, devoted to “Opioid Abuse in the North Country,” i.e., the Adirondacks of northern New York state where I live, which contains a description of the efforts by local and State governments to address opioid abuse and prevent deaths related to opioid overdose. Despite the unique demographics of the North Country, the most sparsely populated area of the state, the rate of opioid overdose deaths per 100,000 is essentially the same as that for New York City’s four largest boroughs – Manhattan, Brooklyn, Queens and the Bronx. For reasons which I explore at length, Staten Island’s opioid overdose death rate is twice that of the other boroughs and third highest in the state, behind Genesee and Dutchess counties. Nonetheless, there is only one opioid treatment program in the Adirondacks, an area 400 miles in diameter, and virtually no outreach in an area where isolation is a commonality. Perhaps more importantly, there is only one needle exchange program in the Adirondacks, located cheek by jowl with the one treatment program. It’s a wonder that the area’s towns and communities have not been struck by an upsurge in the incidence in HIV and Hepatitis C.
Improvement in the form of treatment programs that will be more accessible and that will be effective, i.e, not only provide their patients the medication-assisted treatment that will facilitate their detox but the coping skills necessary for them to become and remain drug-free, will come not from the interventions of cautious politicians and bureaucrats but only from the demands made on them by North Country residents. My concluding recommendations are that all those affected by the epidemic organize, town by town, community by community, forums or grass-roots discussion groups whose participants can educate themselves about the issues of greatest concern to them, discuss and problem-solve them, and develop plans to bring the solutions at which they have arrived to the attention of their fellow citizens and the aforementioned politicians and bureaucrats. I intend to attempt to get a citizens forum up and working in my own home town of Long Lake sometime this Fall.
II – The Opioid Epidemic — Facts & Figures:
Perhaps the most startling aspect of today’s opioid epidemic is the overwhelming preponderance of white victims. In 2013, three times as many whites as blacks and Latinos died of heroin overdoses and four times as many whites died of overdose from opioid analgesics. The second fact that astounds is that the principal supplier of the opioid analgesics that has produced the great majority of overdose deaths is an American pharmaceutical corporation, Purdue Pharmaceuticals, a private family-owned company founded 64 years ago by the three Sackler brothers, psychiatrists by trade, the eldest of whom, Arthur, proved to be a master marketeer. More on this below. In 2015, the net worth of the Sackler family was reported by Forbes to be $14 billion, the 16th largest fortune in the country. Thirdly, the on-the-ground distributors or pushers, if you will, have been the victims’ own personal physicians, exemplars of a profession readily induced by Purdue and other pharmaceuticals to violate their Hippocratic oaths and do great harm to their patients. White Americans who managed to survive this malfeasance, as well as the families and friends of those who died or became addicted, have found themselves stunned and dismayed that their status as white, upstanding citizens no longer appears able to protect them or their family members from the grave damage done by the professionals they presumed to trust and by the addictive substances the latter had prescribed. What is going on?
Forty-five years ago, Richard Nixon launched his War on Drugs. As his chief presidential aides, H.R. Haldeman and John Erlichman, later attested, the War on Drugs was actually a war on black Americans, a war which continues today. Its ostensible purpose was to arrest and remove from poor black urban neighborhoods the drug dealers and users who preyed on those who lived there; more importantly, it gave the Federal government direct entrée to those areas most susceptible to urban unrest and rebellion. Federal money poured into large cities and the states to enable them to beef up their police forces, i.e., equip them with military grade weapons, and to construct more jails and prisons. Despite those efforts – some would contend that due to them – heroin, later followed by crack cocaine, flooded black urban communities and swept an ever-increasing cohort of young black men into prison.
Well-respected writers and academics, notably Peter Dale Scott (American War Machine: Deep Politics, the CIA Global Drug Connection, and the Road to Afghanistan, [November 2010]), compiled data bolstering their contention that the importation of heroin into U.S. communities, most notoriously into Harlem, was facilitated by the CIA — from the Golden Triangle (Thailand, Laos, Burma) where it was cultivated by the remnants of Chiang Kai-shek’s Kuomintang army, through Marseilles and the Corsican mafia, into East coast ports. The French Connection (1971), with Gene Hackman starring as Popeye Doyle, accurately portrays the last leg of that journey. When the American army left Vietnam in 1973, followed by the CIA in 1975, heroin production moved west to Afghanistan, which, to this day, thanks to American protection and consumption, remains its largest producer. Through the year 2000, the rate of deaths via heroin overdose in the country was highest among African-Americans, even though, since 1970, white Americans had used heroin in far greater numbers .
Unlike the War on Drugs, America’s opioid epidemic was not pre-meditated. It was largely happenstance, filled with ironies and opportunism, motivated at its outset by health professionals who wanted to ease people’s suffering. In the early 1990’s, the American Pain Society began advocating for a change in health policy, urging that “pain” be regarded as a patient’s vital sign, equal in importance to her or his heart rate, blood pressure, body temperature and respiration rate. The Federal government ensured the permanency of this practice in 2006 when it tied hospitals’ Medicaid reimbursement rates to the consistent review of all five “vital signs.” For most of the 20th century, opioids such as morphine had been the most potent pain killers, but fear of their addictive character limited their use. Research results published in 1986 in a study since debunked for its small cohort of study subjects appeared to minimize that risk; which served to open the door for Big Pharma and Purdue Pharmaceuticals. In December, 1995, the FDA approved Purdue’s opioid OxyContin, granting the company the drug’s patent until 2013, with the drug marketed in a time release form designed purportedly to mitigate its addictive potential. Within ten years, Purdue had cornered 30% of the opioid analgesic market and had realized $3.1 billion in profits. During the course of those ten years, persons addicted to the drug had discovered that pulverizing OxyContin so it could be dissolved in liquid and injected removed its time release effect. In 2014, 28,647 Americans died of opioid overdoses, a four-fold increase over the year 2000: opioid analgesics accounted for approximately two-thirds or over 18,000 of the opioid overdose deaths, with heroin implicated in over 10,000 overdose deaths, a three-fold increase since 2010.
In 2014, while my wife and I were still living in New York City, the torrent of deaths by opioid overdose by white New Yorkers began making front page news. At least once a week, reports came through about another Staten Island resident dying of an opioid overdose – mainly OxyContin or another opioid analgesic, increasingly heroin – a total of 71 in 2014. Throughout the other four boroughs, other New Yorkers were dying of opioid overdoses, but nowhere near the rate of Staten Islanders – 14.2 per every 100,00 residents, as per data released this year by the Commission for Disease Control (CDC). To put this in context, Staten Island’s overdose rate was third highest in the State, behind Genessee County’s 15.9 per 100,000 persons and Dutchess County’s 15.0. All three counties are very similar demographically: predominately white, middle class, politically conservative and non-urban in character. Genessee, the smallest of the three, has a population of approximately 60,000; its nearest big city is Rochester. Dutchess County, with a population of nearly 300,000, presents a rural/surburban mix and is home to an ever-increasing number of New York City commuters. And Staten Island, an area dotted with one- and two-family homes, is the least dense of all New York City’s boroughs, with a total population of nearly 500,000 but with a population density less than one-third that of Manhattan’s.
When my wife and I moved to Long Lake in July of last year to live year-round in the house we had built ten years earlier, we found similar headlines and stories in the local papers. (Long Lake is a town with a year-round population of 700. It’s nestled in the Adirondacks of northern New York, the North Country as it is locally known.) I remember last November’s elections, with candidates for district attorney in several North Country counties vowing to put a halt to heroin sales and jail the dealers. Those abusing opioid analgesics , i.e., OxyContin, fentanyl, or heroin, were nowhere near as evident as they might be in New York City. Nonetheless, according to current State data, they’re here and in large numbers but spread over a far larger expanse. The State Office of Addiction & Substance Abuses Services (OASAS) reported that 60% of 120,000 admissions to its opioid addiction treatment programs in 2014 were from outside New York City, i.e, upstate New York and Long Island.
Further, while the average number of opioid overdose deaths of 35 persons per year in the nine North Country counties from 2009 through 2013 appears relatively low, particularly when compared to the annual average of 654 deaths in New York City from opioid overdose during the same period, the overdose death rates per 100,000 for the two areas were remarkably similar. Discounting the outlier, Hamilton county, with a population of only 4,000, the lowest of any county in the State and no reported opioid overdose deaths, the remaining eight counties of the North Country had an average annual opioid overdose death rate of 7.0 per 100, 000 residents. New York City’s five counties, sans Staten Island, averaged 7.4 annual opioid overdose deaths per 100,000. Across the State, upstate and downstate, from 2008 to 2013, heroin overdose deaths increased three-fold, to 637 annually, and overdose deaths via opioid analgesics by 25%, to 952 annually. The individuals most vulnerable to heroin overdose deaths proved to be those aged 25 to 34, with 210 individuals dying annually, and with persons aged 45-54, who continued to suffer the largest numbers of opioid analgesic overdose deaths, 279 persons annually.
The most jarring statistic was that whites were dying annually of heroin overdoses in numbers nearly three times that of blacks and Latinos – 447 to 159 — and of analgesic opioid overdoses in numbers four times greater– 735 whites to 180 blacks and Latino. What was going on? What could have caused this phenomenon?
III – Causes, Consequences, Questionable Remedies
Contrary to everything I was ever taught about drug addiction twenty-five years ago, the opioid analgesics, led by OxyContin, are now the gateway drugs to all other addictive drugs, particularly heroin. According to data the Center for Disease Control (CDC) has been collecting since 2000, three-fourths of all first time substance abusers now report being repeat users of opioid analgesics, which puts them at high risk for opioid addiction. The second key risk factor identified by the CDC is that individuals who eventually become addicted to opioids invariably abuse multiple drugs. In the main, opioid abusers’ second drug of choice has come from the benzodiazepenes, a class of drugs that has sedating, anti-anxiety and muscle relaxing properties. Ativan and Xanax are examples. Increasingly, those abusing heroin and their dealers are cutting their heroin with fentanyl, the most powerful opioid analgesic in use today, reputedly forty to fifty times as powerful as pure heroin. Prince, the pop music star, recently died from an accidental overdose of the fentanyl he had been prescribed for severe hip pain. Much of the illicit fentanyl sold on the streets today is manufactured in China and Mexico and smuggled into the U.S. via Mexico. Among the states hardest hit by street fentanyl is Ohio, which saw a 500% increase in fentanyl overdose deaths, 92 to 514, in only one year, from 2013 to 2014.
Perhaps the single most immediate risk factor is the availability of opioids, initially OxyContin, et al, and now heroin, which is cheap and high in quality.
The response by the Federal and New York State governments in curtailing heroin’s ease of access has consisted of a variety of interdiction programs. The DEA, as expected, doubled down on its efforts to stop heroin shipments at the U.S.-Mexican border, succeeding in quadrupling the kilograms of heroin confiscated from 500 kgs. during 2000-8 to over 2,000 by 2012. Jack Riley, acting deputy administrator of the DEA, downplayed the significance of this accomplishment, acknowledging the increase in the amount of fentanyl smuggled into the country: “This goes to the heart of the marketing genius of the [Mexican] cartels. They saw this coming” (NY Times, June 10, 2016).
The CDC got into the act by issuing opioid prescription guidelines in March of this year, advising physicians to avoid prescribing opioids and to seek alternatives whenever possible and, when prescribing, to provide the lowest possible dose of the opioid for no longer than seven days rather than the 30 days which had become standard practice. The Federal Drug Administration (FDA) endorsed the CDC recommendations and decreed that all opioid medications carry a warning about their addictive capacity, but, bowing to Big Pharma pressure, issued no regulations that would oblige prescribing physicians and state health agencies to comply with the CDC’s guidelines. In New York, one of the few states to do so, Governor Cuomo signed into law this June legislation that established the CDC guidelines as mandated practice procedures for New York M.D.s, updating the I-STOP or Prescription Drug Reform Act of 2012 which had revised the manner in which prescription drugs that are prone to abuse are dispensed and monitored. I-STOP has been credited with having had an immediate impact, reducing the number of opioid prescriptions written in the State by 32% by 2014. Ironically, that very success may well have contributed to the dramatic increase in heroin abuse in New York.
Research published by Drs. Cunningham and Finlay of Tulane University in March, 2013, appears to validate the belief that, with addiction, one door opens when another closes. Their study examined the impact of U.S. interdictions of crystal meth in 2004, when the FDA issued a ban on the use of pseudo-ephedrine, the key ingredient in the manufacture of the drug, and in 2006, when cold medicines such as Sudafed could only be sold directly by a pharmacist and only after the consumer produced identification which the pharmacist recorded. The immediate effect of these interventions was to dramatically reduce the availability of the drug and increase its cost. Yet within a few years, pseudo-ephedrine could be located and purchased over the internet, and, within a few more years, was available in a more refined and potent form from Mexico. In short, the drug user rules, albeit at great personal cost, and persons addicted to drugs will invariably find a substitute when their drug of choice is denied them. Which should prompt us to question the cost-effectiveness of the DEA, the indiscriminate criminalization of addictive and other substances, and the very purpose of the War on Drugs. Further indicative of the Federal government’s unwillingness or, at the least, inability to fully confront our opioid epidemic is that none of the Big Pharma suppliers of opioids, particularly Purdue, has been subjected to any FDA sanctions. The only penalties Purdue and the other suppliers are due to face is a probable deluge of civil lawsuits brought by private U.S. citizens.
One final irony, which I’ll discuss at greater length below, is that few if any of the alternative pain interventions – meditation, yoga, exercise, marijuana, to name just a few – that physicians are being urged to recommend to their patients are covered by existing insurance plans and are, accordingly, neither easily affordable or readily accessible. Further, the long-term effectiveness of any of these alternatives to ameliorate the very severe pain that many aged persons, to name just one group, are prone to experience has yet to be studied and no money to do that has been allocated by the Federal or interested state governments.
Immediate answers to these issues are needed since drastic and far-reaching consequences are in the offing. Austin, Indiana, for example, is a small, largely white, economically depressed town of 4000 just south of Indianapolis which, by 2014, was overrun by opioid abuse and had the highest per capita OxyContin abuse rate in the state. One year later, given the rampant use of needle sharing, the first HIV cases began surfacing, and by early 2016, due to town and state inaction, the number of Austin residents infected by HIV had risen to nearly 200. That steady rise has been checked, due to the initiation of a needle exchange program which could have easily been started as soon as HIV made its first appearance. Perhaps better late than never, but a cautionary tale for every community in the country assailed by opioids. Coincidentally, the death rate in the United States, a key indicator of quality of life, which had been declining for years for all age and ethnic groups, rose for the first time in ten years, as per CDC report in 2015, attributable to dramatic rises in deaths among older white Americans due to Alzheimer’s disease, suicides by middle aged and older whites, and opioid overdose by young white adults 25 to 44 years of age (NY Times, January 16,2016).
The Times article proceeded to quote Dr. Ian Rockett, an epidemiologist at West Virginia University, who stated that death rates from drug overdose and suicides by whites “are running counter to those of chronic diseases” like heart disease. Conversely, the Times reported, deaths by opioid overdose by blacks have edged up only slightly and the overall death rate for blacks has been steadily falling in accordance with the declining number of deaths due to AIDS in the black community. Dr. Andrew Kolodny, a drug abuse expert at Brandeis University, adds that African-Americans have been spared the worst of the opioid epidemic because physicians are reluctant to prescribe opioid analgesics to patients of color fearing the latter might sell them or become addicted to them. “The answer,” Dr, Kolodny states, “is that racial stereotypes are protecting those patients from the addiction epidemic.” Irony of ironies.
In a search to understand why whites have been most heavily impacted, the Times reported that many researchers are speculating that there is a cohort of whites who are left out of the economy and the larger society and who have had ready access to cheap heroin and to medically prescribed opioids like OxyContin. Dr. Eileen Crimmins, from the University of Southern California, contends that the causes of death in younger people are largely social, i.e., “violence and drinking and taking drugs. For too many, and especially for too many women, they are not in stable relationships, they don’t have jobs, they have children they can’t feed and clothe, and they have no support network. … it’s life,” Dr. Crimmins concludes. “There are people whose lives are so hard they break.”
IV – Déjà Vu All Over Again:
Let me begin with an analogy between working class black Americans’ experiences with American society fifty years ago and those of white working class Americans today.
On February 29, 1968, the Kerner Commission, or the National Advisory Commission on Civil Disorders, which had been named seven months earlier by President Johnson, issued its “Report …” Johnson had been obliged to establish the Commission by Congress in the aftermath of the disastrous riots that occurred in Los Angeles (Watts, 1965), Chicago (1966) and Newark (1967), which left the country in a state of fear and anger similar to that in which we find ourselves today after the shootings by and of police in Baton Rouge, St. Anthony, and Dallas. Just as I was returning in the summer of 1967 from a three-year stint in the Peace Corps in South America, Detroit was erupting. The Kerner Commission was headed by Otto Kerner, Governor of Illinois, and included such luminaries as John Lindsay, Mayor of New York, Edward Brooke, Senator for Massachusetts and the first black American elected to the Senate since Reconstruction, and Roy Wilkins, head of the NAACP.
Johnson had been reluctant to establish the Commission and with good reason, since its report ripped his Great Society programs and labeled the War on Poverty and its programs as mere tokenism, incapable of addressing what the Commission saw as the fundamental causes of black Americans’ rebellion in large Northern cities: severe poverty and unemployment, inadequate and totally segregated schools and housing, and relentless police brutality, incidents of which had triggered the recent riots. The report concluded that institutional racism was embedded in the structure of American society and that “Our nation is moving toward two societies, one black, one white — separate and unequal.”
Johnson’s and the Congress’s response was to ignore the Kerner Report and to move to enact the Omnibus Crime Control and Safe Streets Act in June of 1968. “Safe Streets” laid the foundation of what Julian Zeizer of The Atlantic (July 8, 2016) and others term the “carceral state,” establishing the Law Enforcement Assistance Administration (LEAA) and funding the expansion of the nation’s police and police armaments and the construction of Federal and state prisons, the latter via grants to the states through the LEAA. Only three years earlier, in 1965, Daniel Patrick Moynihan, later Senator from New York, published his controversial The Negro Family: The Case for National Action, now simply known as the Moynihan Report. While he acknowledged many of the same causes for social unrest among black Americans that the Kerner report later cited, viz., continued racism and discrimination, he denied their centrality and advanced a psychological or characterological explanation. “The gap between the Negro and most other groups in American society,” he wrote, “ is widening,” noting the collapse of the nuclear family among poor and working class black Americans and concluding that black families comprise a “tangle of pathology … capable of perpetuating itself without assistance from the white world. It is the fundamental source of the weakness of the Negro community at the present time.” He also contended that black men were being undermined by the matriarchal structure of the black family.
In retrospect and even when the Moynihan Report was first issued, it is almost unfathomable that someone as knowledgeable as Moynihan would ignore the fact that many of the Industrial Belt jobs that fueled the black American exodus from the South to the Midwest in the first part of the 20th cntury, particularly in steel and manufacturing, began to disappear rapidly by 1960. The unemployment rate among black men to that for white men doubled in the ‘60’s, a phenomenon that continues today. As William Julius Wilson, U. Of Chicago and Harvard sociologist has thoroughly documented, precipitous unemployment in black communities in Chicago was the chief cause of their eventual fragmentation (The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy, 1987, 2012). Ten years later, white Americans would begin to be similarly knocked off their feet. Just listen to Billy Joel’s Allentown, which he wrote in 1971 to mark the loss of the promise of the American Dream for many Pennsylvania steel workers and coal miners and from which that state has yet to fully recover. As Joel notes, they worked hard, followed the rules and nonetheless lost what they most valued, i.e., their livelihood and their self-identity..
Ironically, when the Moynihan Report was published, it was used by Johnson to justify the War on Poverty, providing the rationale for Head Start, a program aimed at children from poor families and one of the few poverty programs regarded as successful. After Johnson’s Safe Streets program was launched, it was used to bolster the newly prevailing argument that black men had forsaken the American work ethic – wouldn’t work hard, were untrustworthy, angry, prone to violence and criminal behavior. How else to explain the urban riots and the simmering black rebellion? Hence, job programs to replace lost jobs or training programs to help displaced black workers learn new skills would simply not change their blighted circumstances. All this, of course only five years after the March on Washington in August, 1963, the March for Jobs and Freedom, whose principal objectives, to secure the economic and civil rights of black Americans, have never been realized. All this at a time when one-third of the American army fighting in Viet Nam consisted of black Americans.
During the 1968 presidential campaign, Richard Nixon, ever the opportunist, seized on white Americans’ fears, pronounced himself the “law and order” candidate and the conduit or voice of the “silent majority.” Sound familiar?
In 1971, prior to the 1972 presidential campaign, Nixon promulgated his War on Drugs, proclaiming “America’s public enemy number one in the United States is drug abuse. In order to fight and defeat this enemy, it is necessary to wage a new, all-out offensive.” As I wrote at the very outset of this essay and at great length in my book of essays, Nation of Killers … (2015), his War provided Nixon with sufficient cover to begin incarcerating as many black American men as quickly as possible, to remove them from American society rather than re-incorporating them, believing that they represented the greatest revolutionary threat to the U.S. government. This thinking has colored American criminal justice and social policy for the past forty years, when the sheer numbers of Americans under criminal justice supervision, black, white and Latino, has grown to approximately three million men and women, and the social and financial costs associated with doing so have become unsustainable.
The opioid epidemic, which has gained increasing public and political attention over the last several years, has contributed mightily to the emerging public conversation about the War on Drugs and the burdens it imposes on all Americans, and it has raised concerns about how the Federal and state governments will address this new surge in opioid addiction and related overdose deaths. Let’s not forget that the War on Drugs continues, with the Federal government, less so an increasing number of states, its foremost proponent.
By 2014, 50% of all inmates in Federal prisons had been convicted of drug offenses, in contrast to 16% in State prisons. While the Obama administration has shifted its rhetoric to characterize drug use as a health rather than a criminal justice issue, the Drug Policy Alliance, a critic of Federal drug policy, has pointed out that Obama’s budget and his drug policies “continue to emphasize enforcement, prosecution and incarceration at home, and interdiction, eradication and military escalation abroad” (“The Federal Drug Control Budget: New Rhetoric, Same Failed Drug War,” Feb., 2015). Specifically, as illustrated by Obama’s 2017 drug control budget request, funds allocated for treatment have increased significantly since 2013, from $7.9 billion in 2013 to $14.3 billion for 2017. At the same time, the sum requested to control drug supply, i.e., enforcement, incarceration and interdiction, domestic and international, has gone from $15.9 billion in 2013, or two-thirds of the drug control budget, to $16.7 billion in 2017, or 54% and still the larger part of the budget. Further, approximately half of Federal treatment funds go directly to the criminal justice system for drug courts and the treatments they mandate and for detoxification in criminal justice facilities, sites that have been found to have less salutary results than treatment provided in non-forensic or public treatment facilities. Federal monies have also gone largely to abstinence-only programs, which tend to be costly, punitive, and of limited effectiveness. The current 2016 drug control budget marks the first time that monies have begun to be earmarked for drug treatments such as methadone and suboxone. The Drug Enforcement Agency (DEA)/Law Enforcement lobby is entrenched and powerful, and the political risks involved in reducing the role of criminal justice agencies are great.
V – “Best Practice” Treatments – or Are They?
Working class white Americans are now finding themselves caught up in adverse circumstances comparable to those in which working class black Americans, indeed all poor Americans, regardless of ethnic heritage, have been mired for the past 50 years. Methadone was first used on a large scale in New York, particularly in New York City, during the early 1970’s when the first wave of heroin abuse swept over the City’s black neighborhoods. In the New York State plan to combat the current opioid epidemic announced by Governor Cuomo in June, $189 million of the State’s $1.5 billion drug treatment budget will be dedicated to improve and extend opioid abuse outpatient and inpatient treatment programs throughout the state. Methadone, together with suboxone, will be the treatments of choice, known as medication assisted treatment or MAT, employed in OASAS’s new opioid treatment centers and in its expanded treatment programs.
Methadone is a synthetic opioid and, as such, is addictive. The medical rationale for its use was and continues to be its apparent efficacy in the detoxification of persons addicted to heroin and opioid analgesics and as a deterrent to opioid overdose since it is administered orally, not intravenously, under medical supervision. Suboxone is a drug comprised of two other drugs: buprenorphine, another synthetic and addictive opioid purportedly designed to disrupt the brain’s dopamine receptor system and thereby curb craving for the illegal opioid on which the addicted person has become dependent; and naloxone, brand name narcan, which is an opioid antagonist and is increasingly employed nationwide, either nasally or intravenously, to offset opioid overdose and prevent death. The latter is a drug regarded as a life saver by emergency services personnel, and was used to revive Prince from a life-threatening fenatyl-induced stupor at the stopover his private plane made as he was heading home to Minneapolis after a concert in Atlanta. The use of these drugs is regarded as a step forward by many treatment professionals, since OASAS programs have historically followed the AA 12-step or drug-free treatment model and required that all patients cease using all psychoactive medications, including anti-depressants and neuroleptics, upon admission.
When methadone was initially introduced, it was presented not so much as a treatment option but as a tool of social control, whose objective was to put a clamp on the addicted person’s craving for her/his illegal drug of choice and so reduce the incidence of crimes committed by the addicted person to support her/his habit. I had friends in the 1970’s who lived in New York’s East Village, then a poor neighborhood ravaged by drugs, who always carried a few dollars in their jeans, particularly late at night, to give to anyone who stopped them and demanded money. They referred to the small change in their pockets as “mugging money.” Interestingly, research later conducted revealed no statistically significant effect for methadone maintenance in reducing crime, only for the suppression of an addicted person’s use of heroin. The latter, i.e., suppression of use, is reportedly enhanced when methadone is combined with traditional individual psychotherapies, particularly cognitive behavioral therapy. Finally, methadone is far from risk-free. In 2011, methadone poisoning or overdose accounted for over 4,000 or 26% of all deaths from opioid overdose, mainly from methadone sold on the streets.
Little is yet known about the long-term outcomes associated with suboxone, save for anecdotal reports from patients and professionals that it does reduce
craving. This presumed outcome puts “craving” front and center as key to understanding the nature and causes of addiction. It supports the popular notion that persons who become opioid dependent are those whose long term use of an opioid has altered their brains’ dopaminergic receptors, i.e., the brain’s pleasure center, to the point where their craving for the illegal opioid never ceases. Like most assertions regarding the centrality of brain functions in determining behavior, to the exclusion of environmental influences, there are no long-term controlled studies to substantiate that which seems to make intuitive sense. Similarly, most Americans continue to give credence to the belief that persons who become addicts suffer from character or moral defects, particularly if those persons are black or Latino. It is certainly easier to believe that black Americans have fundamental character deficiencies and come from pathological families after the assertions made in the Moynihan Report have gained unassailable credibility since its publication. Who can forget the scene in The Godfather, Part I (1972) when one of the Mafia dons gives his OK to sell heroin to blacks since “they’re all animals”? And what about the strength of moral character of persons, black or white, who willingly exchange one addiction for another? Interestingly, both drugs, methadone and suboxone, including its component drugs, buprenorphine and naloxone (narcan), are products of America’s Big Pharma, perhaps explaining their appeal to government funding agencies and the American treatment establishment despite their equivocal or uncertain outcomes.
Will white Americans, unlike black Americans, escape moralistic judgments? Once again, little mention is made of the structural changes in American society that appear to be a root cause of many Americans’ opioid addictions. Cuomo’s recommendations designed to combat opioids do make passing reference to employment and job training services, but indicate little awareness of the difficulty facing those in recovery in finding jobs and the consequent need to create them and the job training that will actually teach pertinent skills. In short, the key interventions recommended by Cuomo’s Heroin & Opioid Task Force are all medicalized and require the continuation of the addicted person’s addiction for an indefinite and possibly prolonged period of time. Will addicted Americans, white and black, be designated as superfluous to the American economy and consigned to a future as permanently disabled individuals living on Federal disability payments? Such has been the fate of many Americans unfortunate enough to have been designated as seriously mentally ill.
Fortunately, some folks, professionals and persons who have been addicted, have begun thinking outside the box. Often the first question they ask is
why those seeking help with their opioid addiction must trade one opioid addiction for another, i.e., methadone or suboxone. The rationale invariably offered is two-fold, both related to the unceasing “craving” addicted persons are presumed to have for the class of drugs to which they first became addicted. First, without a substitute opioid, the addicted person would continue using his or her drug of choice and run the risk of overdose and death; which contention appears to be supported by the high relapse rate, as high as 80%, for those who participate in drug-free treatment programs. Accordingly, an opioid delivered under the supervision of a physician systematically, i.e. same dose at the same time or times day in and day out, is necessary to reduce those risks as well as the risk of overdose.
Let’s consider the latter argument first. It’s hard to argue with the life-saving potential of methadone or suboxone when provided under medical supervision, which could well be essential before and during the first days of a person’s sobriety; but I regard it as unconscionable that treatment providers believe and communicate to their patients that they might be taking suboxone or methadone for a long time, perhaps a lifetime. Or, once an addict always an addict. Ironically, Maia Szalavitz, author of Unbroken Brain (2016), which I’ll discuss at some length below, reports that as many as one-third of all methadone providers fail to provide their patients with doses adequate to achieve successful detox, neglecting to individualize their patients’ treatment. She recounts that, during her first methadone detox, her provider started her on half the dose necessary and titrated it down so quickly that she found herself increasing her heroin use on her own to relieve her withdrawal symptoms. Her methadone provider explained that the relatively modest length of her heroin addiction warranted the lower dose and shorter detox.
Suboxone is not without its critics. To cite just one example, Mark Mitchell, the police chief of Lebanon, Virginia, questioned, in a Times article (NY Times, May 29, 2016) the modus operandi of his town’s suboxone clinics: “I know people suboxone has helped , but unfortunately a lot of the clinics are not forthright in trying to taper people off.” The Times reporter concluded that “for some clinics, losing customers means jeopardizing profits,” a charge often leveled at methadone clinics. One of the three clinics in the town was shut down for poor record-keeping and excessive prescribing. Chief Mitchell goes on to ask, “for a town of 3,000 people to have three clinics? That’s absurd.” Some enterprising patients have learned to separate buprenorphine, or the opioid half of suboxone, from the naltrexone, or opioid antagonist part, dilute the former in water and inject it, creating a suboxone black market in the process. Oh, capitalism! Accordingly, Judge Jack Hurley, who chairs the operations committee for Virginia’s statewide drug court advisory committee, allows suboxone to be prescribed for only those applicants screened by the court’s psychiatrist. Which effectively limits the number of persons prescribed suboxone, as the court intends. To quote The Times, “In a region where suboxone seems to have replaced coal as the economic driver, 80 to 90 percent of all crimes in Russell County are drug-related, most involving black-market suboxone …” In sum, the MAT drugs may be effective and even essential for an addicted person’s recovery and survival, but they must be administered in a manner that is respectful of the person and her/his right to fully informed consent if the addicted person’s cooperation is to be secured.
During my own 40 years+ experience in the public mental health system, I witnessed the same indifferent treatment approach with virtually all persons who are presumed to have a serious mental illness and are given a pejorative or socially-damning diagnosis, usually schizophrenia. They are invariably prescribed powerful psychoactive drugs, usually a neuroleptic like zyprexa, seroquel, or risperdal, and are advised by their treating psychiatrists that full compliance with their prescribed medications is essential to their well-being. The price of non-compliance is a return of the psychotic symptoms that got them into a psysch hospital and earned them pariah status with family and friends. Folks caught up in the mental health system are rarely if ever told that the meds they’re prescribed scramble their brain chemistry and are addictive, and that non-compliance doesn’t result in a resumption of psychotic symptoms but rather in symptoms of withdrawal. Bob Whitaker, in Mad in America: Anatomy of an Epidemic (2002) and in all his subsequent books, describes this phenomenon in depth. Long-term compliance with neuroleptics is known to cause metabolic syndrome – diabetes, heart disease, impaired kidney and liver function – and reduce life expectancy by up to 25 years. The individuals prescribed these meds are never told of those risks. No psychiatric treatment program and only the rare methadone treatment program holds out as a treatment goal for their patents the attainment of a drug-free life. Only very knowledgeable and determined individuals, assisted by the few empathic and progressive drug counselors, physicians and psychiatrists, pursue and attain these goals while in treatment. Most of their comrades are more likely to stop taking their meds and to drop out of treatment, with many never returning.
Rarely do drug treatment programs set as a priority the teaching of addiction management or coping skills that would lessen their reliance on medications and promote their pursuit of discontinuing all medications. I’m referring to yoga, exercise and the skills of emotion regulation taught in Dialectical Behavior Therapy, which include meditation mindfulness and distress tolerance and interpersonal effectiveness. As I indicate below, the latter, which promotes the capacity of an addicted person to make decisions that support one’s sobriety and one’s ability to connect with others, are consonant with Ms. Szalavitz’s theory of addiction as a developmental and learning disorder. Unfortunately, and the complaint of many private practitioners seeking to introduce these skills to their patients, neither commercial insurance nor Medicaid or Medicare provide coverage for them. More significantly, drug treatment programs never offer explanations as to why their patients became addicted in the first place beyond the habitual craving theory. Perhaps the new opioid treatment programs being established by the state, despite their reliance on methadone and suboxone, will be driven by a more patient-centered philosophy.
VI – Outside the Box:
A Developmental Learning Disorder: Again, folks other than medical providers have begun to think outside the box. The afore-mentioned Ms. Szalavitz, a journalist and a person who has overcome heroin and cocaine addictions, and who, as a child, suffered from what she describes as an autism spectrum disorder, argues in her new book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction (2016), that persons who become addicted – to drugs, gambling, sex, etc., — do not have addictive personality disorders, do not have disordered brains, but are primarily suffering from developmental learning disorders. How else to explain the vulnerability of younger people, those in their teens and twenties, to addictive behavior and the ability of the majority of them to simply stop the behavior without medical intervention as they grow older and mature.
As Szalavitz explains, addiction is best understood as a learning and developmental disorder for the following specific reasons:
- the behavior that follows from addiction has psychological purposes: emotional protection and social comfort;
- it is a coping strategy that becomes maladaptive when the behavior persists in the face of negative consequences;
- specific learning pathways in the brain become engaged to make the addictive behavior nearly automatic and compulsive;
- addictive behavior doesn’t stop when it is no longer adaptive;
- ultimately, overlearning makes addictive behavior resistant to change.
She reminds us that her understanding of addiction from a developmental perspective is not new but has been studied and known by addiction researchers and scientists for years. What has been ignored are the implications of such an understanding. Specifically, it doesn’t fit into either of the two historical models for conceptualizing addiction: the moral or characterological model, which is highly stigmatizing and usually reserved for individuals and groups viewed as defective or depraved, usually poor persons, persons of color and persons considered mentally ill; and the medical model, or addiction as a disease model, erroneously regarded as normalizing and as de-stigmatizing the addicted person’s behavior. Unfortunately, it’s ultimately indefensible since addiction’s symptoms are behavioral and “no unique neurological or genetic pathology has [yet] been identified” as causative (Szalavitz, 2016). In short, there is no scientific evidence that addiction is an illness. If anything, addiction as learning disorder resolves this dialectic of moral vs. medical by discarding both models in favor of a developmental model, which sees addiction not as a choice but as profoundly affected by cultural factors and the addicted person’s own life experiences, both of which can impair effective decision-making. Implicit in this model is the understanding that free will in the addicted individual does exist, that decision-making varies from person to person and situation to situation, and that one continues to have control over one’s behavior but less than a non-addicted person. Finally, addictive behavior is more likely to appear in adolescents and young adult at a time when the brain is beginning to change and to prepare for adult sexuality, adult responsibilities and the development of commensurate coping strategies (Szalavitz, 2016).
As regards treatment, Szalavitz favors a harm reduction approach, more about which below, and the need for strong social supports, similar to that sometimes found in the rare 12-step groups that are non-judgmental, to enable persons in recovery to maintain their sobriety and fashion a satisfying, even happy, life.
Social Alienation: If you live a happy life, believe yourself to be a good person living a purposeful life and have those beliefs validated by others whom you trust; and if you have a strong network of family and friends on whom you can count in times of trouble, you will not become addicted to drugs. Johann Hari, contends in Chasing the Scream: The First and Last Days of the War on Drugs (2015), that “It isn’t the drug that causes the harmful behavior—it’s the environment. Addiction isn’t a disease. Addiction is an adaptation. It’s not you—it’s the cage you live in.”
A notion not too far removed from Maia Szalavitz’s learning disorder theory; but here, Hari starts not from his own personal experience with drugs but with experiments with rats exposed to heroin or cocaine. In the early 1980’s, Partnership for a Drug-free America circulated an ad advancing the “craving” theory of addiction. The ad depicted a rat in a cage with two water spigots, one laced with cocaine, the other with only water. Time and again, the rat chose the cocaine water and drank from that spigot incessantly until it died. The narration accompanying the short video intoned, “Only one drug is so addictive, nine out of ten laboratory rats will use it. And use it. Until dead. It’s called cocaine. And it can do the same thing to you.” A good dose of fear, which appeared to have little impact on the general public.
About the same time, Bruce Alexander, a professor of social psychology in Vancouver, conducted a controlled study, again using lab rats, but with two significant twists. First, he housed the rats in a setting he called Rat City – a cage replete with everything a rat might need to live a good rat life, equipped, as in the Partnership experiment, with two drinking spigots, one just water, the other containing cocaine mixed into the water. Next, he put one rat alone into one Rat City and, in another, several rats. The solitary rat replicated the behavior of the Partnership rat, drinking the cocaine water incessantly until it died. In the second cage, all the rats tested both spigots, but soon ignored the cocaine spigot and drank only the uncontaminated water. As Hari describes it, Bruce concluded that “an isolated rat will almost always become a junkie. A rat with a good life almost never will, no matter how many drugs you make available to him.” Again, “It’s not you—it’s the cage you live in.”
When it comes to human beings, Hari learned, after speaking to the researchers, treatment providers, government officials and ordinary people he met during thousands of miles of travel, understanding addiction is a bit more complicated. Yet, it still remains directly connected to addicted persons’ life experiences and the environments in which they find themselves. To list some of the quotations from his book that have become popularized aphorisms …
“ … for each traumatic event that happened to a child, they were two to four times more likely to grow up to be an addicted adult.
… child abuse is as likely to cause drug addiction as obesity is to cause heart disease…”
He has little confidence in America’s addiction treatment system, which he views as punitive — and, in my own professional experience, culturally quite similar to our penal and mental health systems …
“ … punishment — shaming a person, caging them, making them unemployable — traps them in addiction. Taking that money and spending it instead on helping them to get jobs and homes and decent lives makes it possible for many of them to stop… ”
And … “Wouldn’t it be better to spend our money on rescuing kids before they become addicts than on jailing them after we have failed?”
As the subtitle of his book suggests, The First and Last Days of the War on Drugs, he is opposed to the War on Drugs and finds the amount of resources devoted to it and to the criminalization of drugs now branded illegal as wasteful, fundamentally discriminatory and racist…
“ … More than 50 percent of Americans have breached the drug laws. Where a law is that widely broken, you can’t possibly enforce it against every lawbreaker. The legal system would collapse under the weight of it. So you go after the people who are least able to resist, to argue back, to appeal—the poorest and most disliked groups. In the United States, they are black and Hispanic people, with a smattering of poor whites… ”
And … “When alcohol was legalized again in 1933, the involvement of gangsters and murderers and killing in the alcohol trade virtually ended. Peace was restored to the streets of Chicago. The murder rate fell dramatically, and it didn’t rise so high again until drug prohibition was intensified in the 1970s and ’80s.”
Finally, to return to the theme he cites throughout …
“The opposite of addiction isn’t sobriety. It’s connection. It’s all I can offer. It’s all that will help [you] in the end. If you are alone, you cannot escape addiction. If you are loved, you have a chance. For a hundred years we have been singing war songs about addicts. All along, we should have been singing love songs to them.”
That last line – “love songs to them” – is probably hard to fathom, particularly when we’ve been fed such lurid pictures and stories of persons addicted by the media and from friends and acquaintances. Perhaps many of us have had sad and bitter experiences with family members or others close to us. The message of the War on Drugs is to shun persons addicted who won’t change their ways, send or put them away, declare them irrelevant to us, so as to relieve our own pain and discomfort. In his post on The Power of Humanity, “The Likely Cause of Addiction Has Been Discovered and It Isn’t What You Think” (Jan. 25, 2016), Hari references Bruce Clark, creator of the Rat Park, who had told him that to talk about individual recovery from addiction is to go down the path that reinforces the addicted person’s isolation and, accordingly, her/his addiction. It is also to fail to recognize and accept that it’s our collective social recovery that’s at issue here – “how we all recover, together, from the sickness of isolation that is sinking on is like a thick fog.
That’s essentially the message of Sebastian Junger’s new book, Tribe: On Homecoming and Belonging (2016). Junger is not a researcher or treatment provider. He’s a journalist and the Academy award-winning co-producer of Restrepo (2010), a documentary that depicts the experiences of a group of soldiers posted to a remote mountain area in Afghanistan and explores the intense bonding that occurs between them as they seek to support one another and survive in a thoroughly hostile environment. Junger uses Restrepo as his starting point and describes the sense of loss that the soldiers who fought there experienced once they returned home: they came home changed by their war; felt themselves unwelcome and unwanted in a world they found strange and unknowable; found no one willing to extend a welcome or a helping hand. Offered only the innocuous “Thank you for your service” by strangers, they found themselves alone, unable to sustain relationships with wives and family and friends, unable to find gainful employment, without their tribe and unable to find or make or join a new one. Remember, 22 veterans of all our wars dating from Viet Nam kill themselves daily; 1 Iraq or Afghanistan vet kills herself or himself daily. According to a National Institute of Drug Abuse study released in 2013, 30% of those suicides were substance abuse-related, principally involving alcohol and, to a lesser extent, prescribed opioid analgesics. The report also estimated that 11% of all returning Iraq and Afghanistan veterans are misusing or abusing intoxicants, highly co-morbid with depression and post-combat duty trauma. (The latter is officially and popularly known as post-traumatic stress disorder, a descriptive term I regard as problematic.)
Junger’s message is that many if not most Americans find themselves in the same fix. Parallel to the surge in opioid abuse that I referenced above, data show a dramatic surge in suicides by middle aged white American men and women largely attributable to the loss of their workplaces, or their tribes, after they were laid off, and of family and friends after they grew despondent and isolated. From 1999 to 2010, the suicide rate among white Americans aged 35-64 increased by 28% and for those aged 55-64 by 40%. Ironically, the suicide rate for black Americans is much lower than that for whites; the rate of opioid addiction and overdose deaths is substantially lower; and life expectancy for black Americans has risen.
Junger’s anti-dote for those alone and isolated is simple and direct — connectedness, very much like the two authors whose books I just described, an indication to me that many folks are arriving at the same conclusion at the same time. Family and friends must reach out to those they’ve lost touch with and who they know or suspect might be troubled. Churches and community-based service organizations must do the same for absent members and seek and welcome new ones. Social welfare organizations cannot let any of their clients go missing. The VA and the Federal government must help our veterans and we must insist on it. The only persons addicted to drugs that I know personally who gained and have maintained their sobriety were surrounded by family and friends who never abandoned them no matter how odious their behavior, who never stopped singing songs of love and acceptance.
I’ll leave the final word on American anomie or alienation and the marginalization of returned vets to Matthew Crawford, who wrote an impassioned review of Junger’s book, entitled “No Place for Warriors,” in the May 29, 2016, issue of The NY Times Book Review:
“ … A society with less false consciousness about these matters would reintegrate soldiers returning from battle by putting them to work (emphasis mine). Doing so would tacitly affirm the continuity in their contribution to the common good. Instead, Junger points out, such is the misalignment of our culture and military service that someone who has fought is regarded as fundamentally damaged (emphasis mine). The way we receive combat veterans returning home is by treating them as victims and putting them on disability (emphasis mine). Victim status confers the only form of moral redemption we know, and we offer this freely – on condition that a veteran submit to therapy. If the therapy is successful, he will come to accept the obsolescence of precisely those traits that made him a good fighter. With the help of a little medication, they will wither, like a limb that has been tied off to prevent an infection from spreading. Only then can the veteran hope to claim his prize, which is to become a well-adjusted consumer and cog in the corporate economy… ” (emphasis mine).
VII — The North Country:
“Denial ain’t just a river in Egypt.”
Mark Twain, apocryphal
“It’s the longest river in America, making its way throughout the entire country.
Let’s hope that its North Country traverse will be short and easily crossed.”
Jack Carney, 2016
In the context of the opioid epidemic that has swept the North Country and the nation, the dilemma that persons who have become addicted have to confront is whether their status as white Americans will allow them to choose the best of all possible outcomes, viz., that of getting their lives on track. Or will they, by default, be limited to those less than optimal choices available to the majority of Americans – victim or pariah status; probable life-long Federal disability vs. the kindness or ingenuousness of strangers; survival on the fringes of society or an eventual slow but steady cancellation of membership in it? Will there be sufficient resources? Will the treatment be beneficial? Will the needed social support be there? Will anyone still love and respect me?
Over the past thirty and more years, free market or unregulated capitalism has come to dominate the American economy and American culture. As a consequence, America’s way of life has become a zero-sum game, of winners and losers, with fewer winners – those whom I refer to as the one-percenters – and an increasing number of persons branded as losers – for starters, the 47 million Americans living in poverty. Since our corporatist economy can’t provide living wage jobs for all Americans, more and more of us are being labelled as “others” and stigmatized as throw-aways, as superfluous or no longer capable of contributing to the larger society – black American men, particularly those who’ve been incarcerated; poor Americans, regardless of skin color or gender; persons labeled as mentally ill, particularly those who’ve been involuntarily hospitalized; immigrants here illegally, most of whom have lived here for more than eight years, when illegal immigration peaked; American Muslims, all presumably potential jihadists; and persons addicted to intoxicants, particularly opioids, and derided as junkies. And whomever else you’d care to add.
The list keeps growing. The best that many of those consigned to it can hope for, as Michael Crawford contends in his NY Times Book Review article (5/29/16), is to be considered a victim, be assessed as disabled, attend the required rehab or treatment program, be found eligible for Federal disability (DIB) payments, and exercise the one right that all Americans with a little bit of cash can, i.e., consume. Since 1985, when free market capitalism began its ascendancy, Americans receiving Federal disability payments – Supplemental Security Income (SSI) and Social Security Disability (SSD) – grew four- and five-fold. By 2012, according to a recent National Public Radio (NPR) report (June, 2016), 14 million Americans were receiving SSI or SSD.
The following provides further corroboration …
- The rate of SSD applications by former workers doubled from 1985, when 1.0 of 100 former workers applied, to 2011, when 2.0 per 100 filed Disability (DIB) applications;
- DIB applications have mirrored the rise and fall of the unemployment rate – as the latter rises, so do DIB applications; conversely, when the unemployment rate falls, so do DIB applications;
- In 1980, 3 million former workers were receiving Federal DIB; by 2011, that number had almost tripled to 8.5 million;
- In 1980, 4 million persons received public assistance; by 2011, consequent to Clinton’s ill-advised welfare reform of 1996, the number of persons receiving public assistance dropped to two million. Conversely, the number persons receiving DIB benefits in 1980 was two million; by 2011, that number had tripled to six million, which included persons who were formerly eligible for welfare.
Persons found ineligible for DIB payments face two possible outcomes: those who are alone, disconnected and without social supports, are likely to go or return to prison or a mental hospital; to become or remain homeless; to initiate or resume maladaptive behaviors – criminal, anti-social, including addictive; and eventually die by their own hands, at the hands of others, or from illness or drug overdose. On the other hand, those with good social supports, particularly with solid family support, stand a good chance of reclaiming the positive identities and productive lives they had before going off the rails and becoming socially alienated — after two steps forward and one back, eventually building both from scratch.
None of the questions I posed above can be answered with certainty, much as I suggested in preceding sections of this article (available in full on my website, www.paddlingupstream.org). Nonetheless, it is worthwhile reviewing the observations I made and revisiting the data and analyses I referenced in an attempt to come up with some plausible answers. Remember, the latter are more likely to come from the bottom up, i.e., from those individuals who have experienced and/or witnessed firsthand opioid addiction and the pain and suffering that are its consequences. A summary of those observations grouped by pertinent category follows below.
- Opioid Epidemic in the North Country: Yes, there is an epidemic of opioid use and destruction. Despite protestations that the “demographic here is different,” code to mean different from New York City, the death rate from opioid overdose per 100,000 persons in the Adirondacks, according to the Federal Commission of Disease Control (CDC), is essentially identical to that in four of the City’s most populous boroughs, Manhattan, Brooklyn, Bronx and Queens – 7.0 per 100,000 in the North Country vs. 7.4 in the four boroughs. Of course, total deaths per annum from opioid overdose in New York City are 20 times greater; but if there is a true demographic difference it lies in the fact that opioid use and abuse, much like widespread alcohol abuse and poverty, is hidden, unlike the much higher visibility of addicted – and intoxicated and poor — persons in New York. It comes to light here only when addicted persons overdose, die from drug overdose, or cause the rare public incident when intoxicated. Folks in the North Country live by the dictum common in most of the City’s older neighborhoods, viz., “Don’t put your business on the street.”
- Nature & causes of addiction: Addiction is not indicative of a defective moral character, nor is it a disease caused by a defective brain: the former is invariably applied to individuals who are despised, i.e., it’s a form of stigma; and there is no scientific evidence that supports the disease model of addiction. Persons who are addicted can commit immoral, criminal acts; they can also seem or act crazy or out of control, but those are addiction’s consequences not its causes. Addiction is best understood as a social disconnection, as maladaptive behavior overlearned to the point of compulsion by alienated, isolated individuals. Your drug will always love you even when no one else does.
- Treatment: Rooted in the disease model of addiction, treatment is medicalized, i.e., supervised by a physician. Suboxone — and to a lesser extent, methadone — is the drug of choice in the detoxification of addicted persons. It is usually an effective drug, weaning the addicted person off the illegal opioid and relieving him/her of the intense pain and anxiety that accompany detox. However, suboxone or methadone, when used as a maintenance or post-detox medication, is problematic since it involves the continued addiction of the person with an opioid and interferes with the attainment by the addicted person of a drug-free life. Accordingly, its use post-detox appears to have as its objective social control rather than treatment: the addicted person’s drug use and dosage are predictable and regulated by a physician, and anti-social, particularly criminal behavior, is minimized. The addicted person will no longer be subjected to the anxiety of pursuing his drug; but she/he will remain addicted to an opioid and her/his social functioning – the ability to connect with others; hold a job; go to school; care for children – will in all likelihood remain impaired.
- Alternatives: As for alternatives to maintenance suboxone/methadone, physical therapies to curb anxiety, such as mediation, yoga, supervised exercise, are not covered by Medicaid, Medicare or private insurance providers. Maybe one day. In the interim, virtually all treatment providers house and promote 12-step recovery groups; but, as Maia Szalavitz points out in the Unbroken Brain (2016), many of these 12-step groups can be punitive towards a person who relapses; are mired in the past, emphasizing past associations with persons, places and things as triggers for relapse and the consequent necessity of avoiding them; and rarely, if ever, address the loss of the pleasure that addicting drugs bring, and the greater opportunities for joy that await the person who is drug-free. Szalavitz says that hearing a guest speaker at a 12-step meeting raise that possibility turned her life around.
- Family Involvement: Why do families continue to be excluded from their family members’ treatment? Fifteen of the nineteen years I spent at Maimonides Community Mental Health Center in Brooklyn were spent working with patients who had been labeled with serious mental illness diagnoses and their families, meeting with them, often on a weekly basis, in what we termed multi-family groups. In fact my doctoral dissertation was concerned with the therapeutic impact of multi-family groups conducted over a two-year long period with persons diagnosed as having schizophrenia and their families. With great success, I might add. Ditto, albeit anecdotally, for the patients and families that were not included in my study.
The exclusion of families from addiction treatment is a long-outdated hangover from the founding days of Alcoholics Anonymous (AA) and Bill W., where much effort was made to ensure AA members’ confidentiality. To continue that practice today is to exclude those persons who comprise the addicted person’s key support group and to do little to promote her/his post-discharge connectedness. During my, my wife’s and our Maimonides colleagues’ long experience working with families – my wife and I are trained family therapists – breach of patient confidentiality never proved to be an issue. I’m confident that addiction treatment professionals can address this issue successfully with their patients and with their patients’ families. I will address family advocacy regarding this and related issues below.
- Post-Detox: Szalavitz is a college grad and a writer and was able to return to that profession once she re-gained sobriety. What of those folks who never got through or even to college, or through high school and have no marketable skills? Detox into a purposeless life will promote continued alienation and isolation and resumption of drug use. As I mentioned above, no plans and no resources to address this appear anywhere in the Federal government’s or New York State’s master plans to roll back the opioid epidemic.
- War on Drugs: At the root of this is the continuing War on Drugs mindset developed when the War’s targets were black men, regarded then and now as lazy, deficient and criminal. Can a new, “public health”, non-demonizing perspective be developed now that the great majority of persons addicted are white? Not likely, since the greater part of the Federal Drug Control budget still goes to law enforcement and drug interdiction, which, despite the many kilos of illegal drugs Drug Enforcement Agency (DEA) agents have confiscated, has done little to stem the steady increase of drug use in the country. Even half the treatment dollars in the Drug Control budget go to law enforcement for use in the detox and treatment facilities housed in prison and jails.
- De-Criminalization: Is de-criminalization of all drugs the answer? Yes, in the very long run, no, in the here and now. When you think you’ve solved one problem, new problems invariably arise. The experiences of the several states that have legalized marijuana for recreational use – Colorado, Alaska, Oregon, Washington and the District of Columbia – will provide some answers. I’ll discuss in some detail below Johann Hari’s description the de-criminalization of drugs in Portugal and what’s transpired there in the past 15 years.
- Barriers to Treatment: The barriers to access treatment for opioid addiction in the Adirondacks are consequent to geography and inadequate planning by the State’s Office of Addiction and Substance Abuse Services OASAS). Specifically …
The one opioid treatment program in the Adirondacks is located in Plattsburgh, in the northeast corner of the region on Lake Champlain; the one needle exchange program is also located in Plattsburgh. The entire area, essentially one large circle, has a diameter nearly 200 miles long. Even though State officials surely know that addiction and its related problems are more often than not hidden from view in a rural area, no provisions in the State plan have been made for outreach, often best accomplished via needle exchanges. On the plus side, while there is an excellent network of emergency services in the area – most towns have at least one emergency service vehicle staffed by well-trained volunteer crews – the latter are not equipped to do outreach, i.e., uncover those persons who are using and possibly addicted. How will addicted persons access treatment if it’s readily available in only one area — at the very edge or circumference of the circle? Where can they exchange needles and reduce the risk of HIV and Hepatitis C infection? I have some ideas, again largely borrowed from my outreach mental health experience, that I’ll present in the next and final section.
VIII – Final Considerations:
North Country Forums: Answers to the questions I’ve posed above will come from the bottom-up, from friends and family and neighbors, not from government bureaucrats or politicians or treatment providers stuck with commonplace solutions that don’t work. The third page on my website, www.paddlingupstream.org, which is currently being re-fashioned, is entitled North Country Forum. It’s where I post my blogs, my opinions on the issues of the day, and where I invite readers to post their reactions to what I write so a discussion can ensue between us. I harbor the ambition to establish a “live” Forum in Long Lake sometime in the Fall; and, if that does get up and running, I’d like to see folks from nearby communities pay us a visit and bring the idea of a forum, a venue to discuss problems like the opioid epidemic, back to their own towns. It strikes me as ironic and shortsighted that the folks who live the problems are rarely, if ever, asked by politicians and government officials what their take is on those problems, and equally infrequently, have the opportunity to debate and discuss possible solutions. It’s the only way out of the box.
In the interim, three key issues likely to spark a spirited debate at a North Country community forum are outlined below. Their presentation will serve to conclude my primer on and summary description of the opioid epidemic afflicting the North Country and the nation.
1st – Overcoming barriers to treatment: Outreach is the ultimate answer. It remains to be seen if the State will fund it to connect addicted persons to treatment. The original NY State outreach program in mental health was Intensive Case Management (ICM), whose objective was to assist individuals presumed to have serious mental illnesses and discharged from State and acute care psychiatric hospitals to re-settle in their home communities. I directed a large ICM program preceding my retirement in 2010, since which time all ICM programs throughout the State have been replaced by computer-driven Mental Health Homes, whose case managers monitor their clients’ treatment compliance via internet software and intervene with them personally only when they fail scheduled appointments with their treatment providers. The direct antithesis of Intensive Case Management.
The one State-sponsored program that has continued is Assertive Community Treatment (ACT), whose presumed mentally ill clients within a specified catchment area are served by an ACT Team , the latter comprised of several mental health professionals, each with her/his own area of expertise – psychiatry, nursing, social work, etc. It is regarded as a “Best Practice” program, i.e., approved by third-party insurance payers, primarily Medicaid, as providing a re-imbursable service. While used extensively in New York City, ACT was originally developed in Wisconsin to serve rural areas of the state that lacked necessary community-based resources, particularly those related to medication maintenance, social and financial support and drug and rehab counseling.
Needless to say, an ACT Team would appear to have the capacity to reach those persons in the State’s many rural areas, including the North Country, who are abusing opioids and other addictive drugs or have become addicted to them, who, until some calamity befalls them, rarely seek treatment at their own initiative. It’s my guess that these are the individuals at greatest risk of overdose. The ACT Team’s job would be to visit various small communities within a given area, its visits advertised well in advance, and render the assistance needed and make necessary referrals. Although again a guess or speculation on my part, the Team could be comprised of a nurse practitioner (NP), a nurse case manager and a drug treatment specialist, perhaps a social worker, at least one of whom would be CASAC–certified (Credential in Alcoholism and Substance Abuse Counseling), and all of whom would have familiarity with opioid abuse and related treatment medication. The NP would have chief responsibility in this area and would be licensed to prescribe needed medications.
Most importantly, and key to any outreach operation, the Team would provide a needle exchange for those who are using drugs intravenously, usually a great attractant that will serve to facilitate a connection between the IV drug users and the team and have the added benefit of reducing the risk of HIV or Hepatitis C infection. (For additional information on needle exchanges, readers are directed to the Injection Drug Users Health Alliance (IDUHA), www.iduha.org, and to St. Ann’s Corner of Harm Reduction (SACHR), www.iduha.org/st-anns-corner-of-reduction, a Bronx-based drug treatment program and IDUHA affiliate.)
Since the foregoing would involve the use of ACT in a novel – or out-of-the-box – enterprise, i.e., outreach to persons abusing drugs, the State and OASAS will resist mightily. The biggest obstacles will be how to pay for it and will it be worth the cost, answers to which can only be provided via a pilot program, i.e., placing ACT teams in two or three locations for 1-2 years and tracking their effectiveness or success in attracting and helping their prospective clients; determining the ideal staff composition; identifying unforeseen barriers; and obtaining an on-the –ground estimate its cost. In short, a pilot program will cost money; and a determined advocacy campaign will have to be organized and political support mustered from fellow Adirondackers, our State representatives and experts. A very tall order but an illustration of the enormity of the task in effecting necessary change.
2nd – De-criminalization & ending the War on Drugs: This is where the money will have to come from, an even taller order of business.
Frankly, I can’t wait until the phony War on Drugs is ended – too little gained at too high a cost for black men, for men and women of all ethnic backgrounds, for all the people of the Americas, North and South. It’s time to surrender our international title as prison capital of the world. Yet, while de-criminalization of all drugs considered illicit is many years off, the legalization of recreational marijuana seems right around the corner. California was among the first states to legalize the medical use of marijuana, in 1996. My sister who, together with her wife, cultivates a small crop of medical marijuana in Mendocino county, reports a recent upsurge in the number of medical marijuana purveyors, accompanied by tighter government regulation, both setting the stage for California’s ballot initiative this November to legalize recreational marijuana. It’s seen as likely to pass. Six other states have the same initiative on their ballots, but California holds the key to opening Pandora’s box of legalization, which, if the ballot initiative carries, is expected to set off a wave of legalizations by other states and pressure the Federal Government to do likewise.
Fortunately, legalization and its correlative de-criminalization won’t catch the State and Federal governments unaware and unprepared. Colorado, which approved recreational marijuana use in 2012, appears to have very quickly established a thriving and well-regulated recreational marijuana industry in the State. My niece, who lives in Aurora just outside of Denver, tells me that marijuana retail stores have the appearance of well-appointed boutiques, with the many varieties of cannabis and their dosages clearly labeled and each’s finer points highlighted. It will offer a business model and regulatory guidelines for other states to follow. My niece reports that the State’s coffers are filling with marijuana tax monies, and large quantities of cash from retail sales are accumulating but can’t be deposited and safeguarded in local banks due to the Federal government’s anti-drug laws. With California leading the charge, it’s inevitable that the growing number of states that have approved the use of recreational marijuana by their residents will begin lobbying the Feds and the Congress to repeal the laws that legislate criminal penalties for use. It’s equally certain that Big Pharma, with its very large pocketbook, will join and take a leadership role in the lobbying effort. It’s only a matter of time, perhaps 10 years, maybe longer.
I confess to some ambivalence about legalization – probably more than half of all Americans are walking around with their brains altered by pharmaceuticals and intoxicants at a time when clear-headedness would seem to be a valuable national commodity. I guess that beats reality, and it’s either that or Pokemon-go. The one consolation is that fewer people will get incarcerated for marijuana possession and selling. I’m also curious about where all those marijuana-generated tax dollars, surely the carrot for most states, are going to go. A recent article in “Marijuana Politics” (February, 2016) informs that, in Colorado in 2015, nearly $1 billion in sales generated $135 million in tax revenue, $35 million of which will be invested in capital improvements to local schools. And what about the other $100 million – where will that go? Will any money go to drug treatment or to providing the employment, training, housing and related resources required to re-integrate persons recovering from addiction back into the social fabric? I’m too well versed in the reigning philosophy of denigrating the “other” and throwing her/him away to have any confidence that government will invest money in “junkies”, even if they happen to be white.
De-criminalization of cocaine, the opioids and methamphetamine is an entirely different matter. Still associated with the “other” these days, despite the realities of the opioid epidemic – I’m referring to black Americans and poor Americans, who continue to be stereotyped as those more likely to become “junkies” – de-criminalization of drugs that carry higher risk is an entirely different matter. It would represent the de facto end of the War on Drugs and, as a consequence, the Drug Enforcement Agency (DEA), which, together with its law enforcement, Congressional and corporate allies, can be expected to protest the loudest. The DEA just reiterated its opposition to the Federal legalization of medical marijuana, citing the FDA’s contention that marijuana has no scientifically validated medical use (National Public Radio [NPR], August, 2016). Which is like throwing a rock into a rising torrent. The DEA was also on the verge of conducting forays into local pharmacies that were filling large numbers of opioid scrips until President Obama ordered it to stand down. I can just picture SWAT-suited DEA agents storming into my Rite Aid pharmacy in nearby Tupper Lake and scaring everyone to death. In any event, the DEA budget will be $30 billion for FY 2017 and promises to continue to grow annually, as it has since the DEA was legislated into existence in 1973. That’s a lot of money and it represents enormous power and political influence.
In short, de-criminalization of the more dangerous drugs is a very long shot, and, should it happen, will occur gradually over a long period of time. By way of endorsement, Johann Hari cites the Portuguese experience, where, over the course of 15 years, Portugal went from having 1% of its 8 million residents addicted to heroin in 2000 to a 50% reduction in IV drug use by 2015. The government de-criminalized the use of heroin, stopped its fruitless war on drugs and transferred its entire drug enforcement budget to treatment and social remedies, i.e., subsidized jobs and housing. A British Journal of Crimology study of the Portuguese initiative reported a dramatic reduction in overall addiction rates. Portugal, of course is not the United States, and the use of controlled substances has never been as politicized as it is in the U.S.
It’s important to clarify that de-criminalization need not necessarily equal legalization, It might best be employed, given the opposition it is certain to stir, as a gradual or transitional strategy that would lead, one far off day, to legalization. Specifically, it could involve the reduction of criminal penalties, as has been done in several large U.S. cities, notably New York, with the possession of small amounts of marijuana reduced from a low level felony to a misdemeanor. Such an approach readily complements the objectives of advocates of criminal justice reform and their political allies here in New York, who are working to secure the early release from prison of persons sentenced for drug possession under the harsh penalties of the Rockefeller laws, and to restore sentencing discretion to criminal court judges.
The Law Enforcement Assisted Diversion (LEAD) pilot project initiated by Seattle in 2011 represents a promising example of a gradualist approach, and was prompted by the large number of young, homeless IV heroin users and addicts who were flooding Seattle’s downtown business district and committing a slew of petty crimes, often victimizing the area’s workers or tourists. The HBO documentary program, VICE, featured LEAD in its April, 15, 2105, program, which is how I learned of its existence. Law enforcement before LEAD was largely a revolving door operation — the Seattle P.D. would dutifully stop and arrest those openly using or selling illicit drugs, usually heroin, or those committing petty crimes and found with drugs in their possession ; would bring them in for arraignment, where those arrested were given the option of serving jail time or entering a methadone detox program and having their sentences reduced. Members of both cohorts eventually returned to Seattle’s streets and continued their pre-arrest behavior, repeating the process.
LEAD was designed to interrupt the revolving door. It is described by those who originated it as a harm reduction program that is rooted in client choice and the close cooperation between the Seattle police, the Seattle municipal court and LEAD case managers. Accordingly, it attracts those individuals who are ready to make the changes that will take them off the streets and lead to their social re-integration. In essence, LEAD’s clients self-select, but they can also be referred by the cops on the beat who have gotten to know them. The only conditions they have to agree to comply with are to accept the services of a case manager and to not commit any petty crimes or person-on-person crimes, i.e., steal from or assault or mug anyone. Violation of the latter will automatically revoke the agreement they made with the municipal court judge and result in their immediate remand to jail or prison to complete their sentences. Once they’re in the program, their case managers can help them to develop a plan to pursue a purposeful life: link them to housing and employment, help them re-connect to estranged families and friends, and assist them to enter treatment and drug rehab programs. The choice to enter treatment or not is solely theirs to make, increasing the likelihood that they will take responsibility for and follow through on their decisions.
The VICE report characterized LEAD as largely successful, with much satisfaction expressed by its clients and by the case managers and police officers working with them. Seattle has decided to continue the program, which is funded, at least in part, from savings accrued from reduced municipal jail and court costs.
Whatever the eventual outcome of de-criminalization and legalization v. the War on Drugs and business as usual, there is sufficient money at hand, in the form of Federal tax dollars, to secure effective treatment for those who want it and provide the social reintegration resources that are the key to drug-free lives for those who are addicted to opioids and other substances. Yet it appears the Congress cannot be trusted to do that. In May, the grandiose-sounding Comprehensive Opioid Abuse Reduction Act, aimed at bolstering law enforcement programs, was enacted but funded at only $103 million annually over 2017-2021. A relatively paltry sum, given the need, but one that raises the question as to why almost nothing for treatment and over $400 million for a system that does not need the funding. War on Drugs knee-jerk response, I suppose. Then in July, the House passed a bill designed to redress that grave oversight and fund new addiction treatment and prevention programs. However, as The New York Times noted in a July 12, 2016 editorial, no funding was appropriated. In response to a dispute with the President over money – Obama wanted a $1 billion treatment appropriation, the House leadership one-half that amount – the House tabled that discussion until September. So much for the urgency of the opioid epidemic.
The putative criminal justice reforms that social justice advocates and sympathetic politicians are beginning to push will complicate matters further. If enacted, increasing numbers of inmates, most convicted of low-level drug offenses and many of whom former addicted persons, will be released back home. What resources will be provided for them to effect successful community re-integration? Will they just be allowed to revert to old habits and over-learned criminal and addicting behaviors? Just to refresh readers’ memories, we do have a tried but not so true template for sending long-term institutional inmates back to their communities without the necessary resources. Remember “de-institutionalization”, the social experiment initiated over 50 years ago when long-term patients of State mental hospitals, the largest single contingent of which, approximately 250,000 persons, was here in New York State, were abruptly discharged from the hospitals and sent home to families and to communities ill-equipped to help them. That’s why my ICM program and the ACT teams came into being, over twenty-five years too late. The presumed mentally ill persons sent home are to be considered the first institutional throw-aways. Those prison inmates released early will likely constitute the second wave. Will addicted persons, regardless of ethnic identity, be treated any differently? The mother lode of tax dollars is be found in the $30 billion DEA budget, and the struggle to re-order its expenditures from interdiction and law enforcement to the type of effective treatment and social re-integration programs that actually work will be long and fierce and will entail dismantling the DEA and its long-failed War on Drugs.
The keystone goal of the North Country Forums will be the reclamation of the throwaways – of those presumed to be mentally ill and abandoned; of those presumed to be dangerous drug addicts and abandoned to unconscionably long prison sentences; of those persons addicted to opioids and other drugs and running the risk of being abandoned to disability, social isolation and the comfort of addicting drugs. Self-education on the relevant issues as well as unrelenting advocacy directed at those with the power of the purse or access to it will be the tools used by Forum members. Their primary task will be to join the advocates that are beginning to coalesce to confront the DEA and its political and corporate supporters. Family involvement will be essential.
3rd – Families & Social Connectedness: Family members are crucial to their loved ones’ treatment, and will help them make the social connections necessary to break their social isolation. Who will most addicted persons turn to when they return home from their treatment programs? Who are most likely to love them and validate their efforts at recovery? Treatment staff will object to family involvement in the addicted person’s treatment, mired as they are in antiquated notions of confidentiality that serve to isolate rather than protect their clients. Sharp and determined advocacy will be needed to overcome this barrier to effective treatment.
Family members will learn how to be advocates. They will not learn the needed skills at Nar-anon groups – loosely affiliated with Narcotics Anonymous and modeled on Al-anon – designed to be attended by friends and family members of the addicted persons so they can monitor their recovery and provide support. These groups have as their focus the addicted person and can tend to be punitive and traumatizing for those who attend them, emphasizing, as they do, the errors the family has committed that have contributed to their loved one’s addiction. As such, they tend to look backwards rather than hold out hope for a future where neither they nor their loved family member will be held prisoner by the past and by their shame and can escape their isolation and re-join their extended family and the larger community.
Family advocacy organizations have yet to be organized – at least Google doesn’t list any. Treatment professionals are much more comfortable with quiet, compliant families, those who will do as they are asked and no more, fearful they will cause their loved one’s relapse. Rather, the focus needs to be on unsettling complacent and patronizing professionals and obliging them to listen to families’ analyses of problems afflicting the treatment system and interfering with their loved one’s recovery. Ditto patronizing politicians, who don’t want to be exposed to families’ anger and pain.
In short, families must do the unexpected and say to those who hold the power in the treatment system exactly what’s on their minds, decorum be damned. It’s your family’s and your love one’s lives that hang in the balance and you must be heard if no else is to die. I would hope that the North Country Forums could serve as the venues for families to practice and hone these new skills, and receive the support and validation of their fellow Forum members that they are on the right track.
In conclusion, I’ve used the opioid epidemic to illustrate how such a process might unfold in a future forum in Long Lake or other North Country communities; outlined the questions that might well be asked; and suggested possible responses and the actions Long Lakers and others might undertake to bring their ideas to the public. I welcome meeting with my fellow Adirondackers sometime soon, debating and devising solutions to the problems besetting us.
I’ll close by offering the advice, perhaps apocryphal, put forward by the murdered I.W.W. labor organizer, Joe Hill, one hundred years ago but still pertinent today – When the going gets hard, “Don’t mourn, organize.”
Hari, Johann, Chasing the Scream: The First and Last Days of the War on Drugs, 2015
Hinton, Elizabeth, From the War on Poverty to the War on Crime: The Making of Mass Incarceration in America, 2016
Junger, Sebastian, Tribes: On Homecoming and Belonging, 2016
Szalavitz, Maia, Unbroken Brain: A Revolutionary New Way of Understanding Addiction, 2016