As I’ve written about the opioid epidemic, I’ve come to expect one specific type of response from readers.
I get emails telling me that I should stop caring about the crisis because the only people dying are those who “deserve” to die because they can’t stop using drugs. Here’s an example, which I’ve used in stories before: “Darwin’s Theory says ‘survival of the fittest.’ Let these lost souls pay the price of their criminal choices and criminal actions. Society does not owe them multiple medical resuscitations from their own bad judgment, criminal activity, and self-inflicted wounds.”
Yes, it can get nasty. And while I first wrote this off as trolling, these types of emails have become a serious concern for me — more and more so as the year has gone on.
Over 2017, I committed to focusing as much of my reporting time as possible on the opioid epidemic. I had seen the overdose death toll grow year by year, and, frankly, I didn’t think any major media outlet had given it adequate, consistent coverage.
So my wonderful editor, Michelle Garcia, and I decided to make that change at Vox. I reported from New Jersey, Vermont, and British Columbia, Canada, for some of my bigger pieces. I talked to a lot of experts and looked through a lot of research, putting together an in-depth review of the best policies to tackle the crisis. Because of my reporting, I even changed my mind on some pretty big policy issues — particularly legalizing all drugs.
With the year coming to a close, I’ve been reflecting on what I’ve learned. I keep going back to those emails and what they represent: the stigmatization of addiction not as a disease but as a moral failure.
Before this year, I just didn’t appreciate how much stigma towards addiction still colors America’s approach to drugs. That’s not because I didn’t know that stigma plays a big role, but because I didn’t expect stigma to be nearly as all-consuming as it really is.
Yet it came up again and again in my reporting. Why don’t we widely embrace opioid addiction medications, despite decades-old research supporting them? Stigma. Why do we resort to the criminal justice system to deal with addiction, even as that’s proven ineffective? Stigma. Why do we close down needle exchange programs that are proven to save lives? Stigma. What is the one thing Vermont had to overcome to build up its addiction treatment system? Stigma. Why won’t Congress approve the money experts agree is needed to address the crisis? You get the idea.
It’s absolutely everywhere. It explains so much of why America’s policy response to the opioid crisis is insufficient and broken. This abstract cultural force may be the one thing letting this opioid epidemic continue — and in that way, it’s literally killing people, allowing more than 170 drug overdose deaths a day and more than 64,000 in 2016 alone.
Table of Contents
Stigma is everywhere
On drug policy issues, over the past year I found myself frequently asking, “Okay, so we have the research and evidence here. Why don’t we do what’s being proposed?” At this point, you should be able to guess the answer time and time again.
Sarah Wakeman, medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, summarized the problem: “For 100-plus years as a society, we’ve punished and criminalized people who use drugs.”
This has fostered an environment in which people who are addicted to drugs are seen not as victims of a disease who need help, as we would see, say, someone with cancer. Instead, they’re viewed as wrongdoers and perpetrators of their own illness.
So when someone is sick with addiction, she’s seen as someone who needs to get her life together. When she doesn’t seek help, it’s assumed that she just need to hit “rock bottom” — even though for opioid addiction “rock bottom” often means overdose and death. When someone refuses treatment, it’s not that the care that was offered was the wrong approach or improperly suggested; it’s that the person with addiction has failed and deserves what’s coming to her.
Stigma is a problem even in a progressive state like Vermont. In September, I went to Burlington and the surrounding area to find out how the state built up its “hub and spoke” model, which integrated addiction treatment into the health care system. I expected to hear about money — building up treatment is expensive, and that is a hurdle for any cash-strapped state.
To my surprise, John Brooklyn, an addiction specialist in Vermont who helped shape and implement the hub and spoke model, pushed back on this. Money was important, sure, but the bigger problem was overcoming stigma.
Even people with opioid addiction perpetuated such stigma. Before he got into care, Charlie C. of Vermont, who asked I not use his last name, said he thought of using buprenorphine as replacing one drug with another. “It’s just the same,” he said he thought at the time. (He’s now a big proponent of the medication’s effectiveness.)
This is a popular misconception, but it misunderstands how addiction works. The problem with addiction isn’t necessarily drug use. Most Americans, after all, use all kinds of drugs — caffeine, alcohol, medication — with few problems. The problem is when that drug use begins to hurt someone’s day-to-day function — by, say, putting his health at risk or leading him to steal or commit other crimes to get heroin.
Medications like buprenorphine let people with drug addiction get a handle on their drug use without such negative outcomes, stabilizing the dangers of addiction, even if the medication needs to be taken indefinitely.
This is proven: Systematic reviews of the research have found these medications cut all-cause mortality among opioid addiction patients by half or more, and the drugs are recommended by health groups like the Centers for Disease Control and Prevention, National Institute on Drug Abuse, and World Health Organization. Experts consider such medications the gold standard in opioid addiction care.
With every other disease, using a proven medication would be a no-brainer. Not so with addiction. The results can be deadly; take, for example, a 2013 case in New York state in which Judge Frank Gulotta Jr. refused to let Robert Lepolszki stay on methadone treatment because Gulotta saw medications as “crutches” — and Lepolszki died of an overdose months later. Because people see addiction as a moral issue, lifesaving medication suddenly becomes a sign that someone is too weak to deal with addiction on his own.
This is still a problem in relatively liberal states like New York and Vermont. Imagine the rest of the country.
Stigma holds everything back
Stigma has real, measurable consequences around the US.
Look to Lawrence County, Indiana, for an example. In October, county officials there ended a needle exchange program.
A needle exchange program, based on the empirical evidence vetted separately by Johns Hopkins researchers, the World Health Organization, and the Centers for Disease Control and Prevention, should be one of the least controversial ideas in public health. For decades, studies have repeatedly found that needle exchanges help prevent the spread of diseases, such as HIV and hepatitis C, that can spread through used syringes, while not increasing overall drug use.
So why did Lawrence County officials end the local needle exchange program? In their words, morals and the Bible. County Commissioner Rodney Fish, who voted against the program, told NBC News, “My conclusion was that I could not support this program and be true to my principles and my beliefs.” He quoted the Bible before casting his vote.
We know what will happen due to this: As Chris Abert of the Indiana Recovery Alliance told me at the time, “People will absolutely die as a result.”
Yet because drug use and addiction are viewed primarily as moral failures and not medical problems, commissioners pushed forward with their repeal anyway. A lifesaving policy was killed off due to stigma, plain and simple.
Another example: the criminal justice system. The White House’s opioid epidemic commission summarized, as one example, how prisons view medications for opioid addiction (“MAT,” which is short for medication-assisted treatment):
[A] national survey of corrections staff in 14 states found very limited use of MAT. While 83% of prisons and jails offered some form of MAT, its use was limited mostly to detoxification or to maintenance treatment for pregnant women. One study found that nearly 60% of jail personnel surveyed strongly disagreed with the statement that their tax dollars should support methadone treatment. The same survey found that nearly 55% of jail security personnel agreed with the statement that “people who overdose on heroin get what they deserve.”
Again, medications are considered the gold standard of care for opioid addiction. Yet in much of the criminal justice system, they’re rejected because people addicted to drugs are blamed for their condition. As the commission explained, “The authors noted that negative attitudes regarding MAT appeared to be related to negative judgments about drug users in general and heroin users in particular.”
As Charlie’s story in Vermont shows, this can all trickle down to an individual level — pushing people away from getting treatment they know they need. It took years of struggles — including joblessness and homelessness — to get Charlie to finally seek treatment in a Vermont hub, largely because he had stigmatized buprenorphine.
Stigma is everywhere. It’s in policies. It’s in doctor’s offices. It’s in individuals, even those suffering from addiction. And it holds everything back.
Americans need to understand addiction is a chronic, relapsing disease
My takeaway from all of this: To confront the opioid epidemic, the public and policymakers need to understand that addiction truly is a chronic, relapsing disease.
Everyone needs to understand, as Stanford psychiatrist and Drug Dealer, MD author Anna Lembke put it to me, “If you see somebody who continues to use despite their lives being totally destroyed — losing their jobs, losing loved ones, ending up in jail — nobody would choose that. Nobody anywhere would ever choose that life. So clearly it is beyond this individual’s control on some level.”
Many Americans may understand this with, say, depression and anxiety. We know that people with these types of mental health problems are not in full control of their thoughts and emotions. But many don’t realize that addiction functions in a similar way — only that the thoughts and emotions drive someone to seek out drugs at just about any cost.
People like Charlie in Vermont don’t want to go to prison. They don’t want to lose their jobs. They don’t want to burden their friends and families. They don’t want to spend all their waking moments thinking of ways to chase down a drug — just to feel okay for a few minutes or hours. They don’t want to spend their lives taking from more than giving to society. This is something that, for whatever reason, has afflicted them — and they need help to deal with it.
Once Americans understand this, a lot of the policy recommendations proposed to combat the opioid epidemic quickly become obvious. Of course you would give people naloxone, the opioid overdose antidote, to revive them from an overdose — just like you wouldn’t hesitate to use a defibrillator to revive someone who suffered cardiac arrest.
Of course you would give people medications for their opioid addiction — just like you would give insulin to someone suffering from diabetes. Of course you would take preventive measures like needle exchange programs to make sure people don’t spread dangerous diseases — just like you would provide condoms to prevent the spread of sexually transmitted diseases. Duh!
But until then, much of the public and policymakers will hesitate — troubled by proven interventions because they seem to, in their eyes, “enable” a moral failure. The result is the opioid epidemic will continue, and more people will die of preventable causes.
My 2017 journey in opioids
I put a lot of my time, work, and thought into the opioid epidemic this year. Here are some of my big pieces that came out of it all:
- How to stop the deadliest drug overdose crisis in American history: Much of the media coverage about the opioid epidemic has focused on its causes. I wanted to figure out how to solve it. The experts I spoke to all gave a fairly similar answer: Much more federal funding is needed to boost access to treatment (particularly highly effective medications for opioid addiction), pull back lax access to opioid painkillers while keeping them accessible to patients who truly need them, and adopt harm reduction policies that mitigate the damage caused by opioids and other drugs.
- I looked for a state that’s taken the opioid epidemic seriously. I found Vermont: Okay, what experts told me sure sounds nice. But has any state done anything like it? That’s when I uncovered what Vermont was doing — and was surprised by the results. One fact to consider: The state was the only one in New England to have a drug overdose death rate below the national average in 2015.
- The case for prescription heroin: I also went to Vancouver, British Columbia, to check out a program that prescribes heroin to people with opioid addictions in a highly supervised environment. The rationale is that it’s better to supply them with a clean, reliable source of the stuff — not only because it reduces the risk of overdose, but also because it mitigates the chances they’ll commit crimes to obtain heroin. It’s not for everyone — the Vancouver clinic’s head told me it’s needed for maybe 10 to 15 percent of people addicted to opioids — but it suggests we need to dramatically expand our thinking in order to tackle the opioid crisis.
- When a drug epidemic’s victims are white: Much of the reporting above is rooted in the expectation that drug overdose epidemics should be treated primarily as public health crises, which has become a popular sentiment, at least rhetorically, during the opioid epidemic. But this wasn’t always the case — with the crack cocaine epidemic of the 1980s and ’90s offering a stark contrast to the rhetoric around the current opioid crisis. I set out to find out why, and it turns out that race — racial segregation in particular — likely plays a big role.
- The new war on drugs: For all the talk about treating the opioid epidemic as a public health issue, the public health approach isn’t always what policy looks like on the ground. I found that at least 16 states since 2011 have passed punitive anti-drug laws that focus on harsher punishments for opioid possession and trafficking. As Ezekiel Edwards, director of the pro-reform ACLU Criminal Law Reform Project, told me, “[I]t seems inevitable in this country that when we try to find ways to deal with addiction and drugs … we can’t help ourselves in ultimately responding with a criminal justice framework instead of a public health framework — notwithstanding some improved rhetoric.”
- “If it wasn’t for insurance, I wouldn’t be here”: how Obamacare’s end would worsen the opioid crisis: At the federal level, President Donald Trump and Republicans in Congress spent much of the year pushing to repeal the Affordable Care Act. But as Jessica Goense in New Jersey made clear to me, the law was hugely important to her recovery — with the Medicaid expansion in particular helping her get into treatment. For all of Trump’s talk about taking the opioid epidemic seriously, his first serious attempt at major legislation would have made the crisis worse if it had passed.
- I used to support legalizing all drugs. Then the opioid epidemic happened: In the middle of all this reporting, I slowly came to a realization: I don’t feel comfortable with legalizing all drugs anymore. The argument, in short, is that the opioid crisis came about when big companies pushed a legal product — their painkillers — and got a lot of people misusing and addicted to the drugs. And we’ve seen that same playbook with other legal drugs, particularly tobacco and alcohol. Unfortunately, America doesn’t seem capable of legalizing drugs without letting greedy, for-profit companies corrupt the idea.
This isn’t everything I wrote on the opioid crisis. (You can find all of Vox’s coverage in our story stream.) And I still feel like I have a lot to learn. But hopefully, these stories will give more people a bit of clarity on what, exactly, is going on with the deadliest drug overdose crisis the country has ever faced.
My take? Stigma is HUGE! Medication-Assisted Treatment (MAT) IS the gold standard because it works so well. I disagree with prescribing heroin, but buprenorphine with the 12-step program has the best track record that I have seen. We need to do more of this! We need to STOP IMMEDIATELY the requirement for “prior-authorizations” that insurers and 3rd party payers put on the medication; it’s a tier-1, generically available medication. We need more manufacturers to bring the cost of it down and fewer restrictions on prescribers with better compensation for our time. How do you get more people doing something desirable like prescribing buprenorphine? Make it economically attractive to do so–reward it!
We need to recognize addiction as it is; simply a disease that is passed down through families, a disease characterized by relapse and great suffering.