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.
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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