“Political language is designed to make lies sound truthful
And murder respectable, and to give the appearance of solidity
To pure wind.” – George Orwell
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, sansStaten 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?
Written By Dr. Jack Carney
Originally published at: http://www.paddlingupstream.org/america-addiction-a-primer-from-the-war-on-drugs-to-the-opioid-epidemic/
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