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 20thcntury, 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.
Written By Dr. Jack Carney
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