Are You in Pain and Getting the Help You Need? The Opiate Addiction Dilemma That Obama Truly Grasps
Throughout the 20th, and now the 21st, centuries, public health officials and politicians have announced new drug scares. These scares have usually—but not always—involved opiates, also known as narcotics, but they’ve also in recent decades included cocaine and its derivative, crack, methamphetamines, Ecstasy, and other substances.
Today, the villain is prescription painkillers, as deaths associated with them reach new heights. And, so, once again, politicians and public health officials want to make it harder for people to receive legitimate prescriptions for painkillers.
Does this sound familiar? As painkillers proliferated in American society throughout the 1990s and 2000s restrictions were placed on the prescription and purchase of painkillers, making it both harder to obtain drugs such as oxycodone (OxyContin) and fentanyl, while also making these drugs more expensive relative to illegal narcotics. Guess what happened next? Many painkiller users turned to ... heroin.
And, so, we got a phenomenon not previously observed. Whereas health professionals (like CNN’s Sanjay Gupta) tended to see one form of narcotics as replacing the other, we managed to create the unprecedented situation in the U.S. of having simultaneous epidemics of both heroin and painkiller deaths—and, while we were at it, adding in a record number of tranquilizer-related deaths.
Not a good result. And, yet, here we go again.
We can go back a hundred years to see how our policy was formed, to 1914 and the passage of the Harrison Act, technically a taxation bill, but one that had the effect of making narcotics (and cocaine) illegal. The result? Whereas heroin users had been supplied the drug by individual physicians or at hospital clinics, previously ordinary citizens habituated to heroin were now thrown onto the streets to seek their drug supplies, becoming the “addicts” who created the drug underworld Americans came to fear and loathe.
Along with this shift, heroin use became lodged in inner cities, creating drug ghettos, whereas earlier opiate use was more likely to be found among middle-class and white Americans. Much is now being made that the narcotic addiction tide has been partially reversed to include more white, and perhaps somewhat more middle-class, users. But heroin addiction is still heavily concentrated in inner cities, like Baltimore, while painkillers are rampant in impoverished white enclaves, like Appalachian West Virginia.
This is the United States on drugs, the United States of heroin/narcotic addiction, which Yale psychiatrist David Musto termed “The American Disease.”
Flash-forward to the present. The opioid death epidemic “unexpectedly dominated” the bipartisan governors’ conference this year, with the governors passing a resolution to make it harder for people to obtain and use prescription painkillers. Finally, something both Republicans and Democrats agree on!
Only one notable political figure, not up for re-election, opposed the governors’ consensus:
“If we go to doctors right now and say ‘Don’t over-prescribe’ without providing some mechanisms for people in these communities to deal with the pain that they have or the issues that they have, then we’re not going to solve the problem, because the pain is real, the mental illness is real,” President Obama said during his meeting with the governors. “In some cases, addiction is already there.”
What the hell?!
This statement is prescient and nostalgic at the same time. Prior to the Harrison Act, those addicted to narcotics were supplied their drug by medical providers. Currently, prescribing heroin, or providing sites where heroin can be safely administered under medical supervision, is the leading edge of drug policy reform in Britain, Denmark, the Netherlands, Switzerland, Germany, and—in North America—Vancouver.
Why not in the United States? Because “heroin is bad, and injecting heroin is bad, so how could supervised heroin injection be a good thing?” This question was asked rhetorically by Ithaca’s Democratic Mayor, Svante Myrick (age 29). Rhetorically, because Mayor Myrick was actually proposing a plan for establishing a site where people could legally shoot heroin.
But the plan is a nonstarter, because probably every other politician in America who mouthed the words Myrick did would actually mean them. Keep in mind, however: Virtually no deaths have ever occurred at supervised heroin injection sites or in places where heroin is provided by prescription.
Which brings up a strange anomaly. While heroin deaths have reached a peak, heroin purity has declined since the 1990s. And as painkiller deaths slowly rose in the 2000s, the use of painkillers did not rise. And while somewhat more people are using tranquilizers, deaths associated with their use have quadrupled. In other words, the problem isn’t in the drugs, but in how we use them.
Heroin use, in itself, is not toxic. People have taken opiates safely for centuries. The ratio of strength for a fatal injection of heroin relative to a typical street dose is 50-1, or more. Drug users die, in over 90 percent of cases, from combining depressant drugs, including different narcotics (which may have caused Prince’s death) or tranquilizers or alcohol or other drugs. Amy Winehouse drank alcohol while using tranquilizers. Philip Seymour Hoffman died from taking heroin mixed with benzodiazepines, amphetamine, and cocaine.
At the same time that they assure drug purity, drug-administering sites (where drugs are tested) and drug-providing sites offer ready access to treatment for those who want to remit or reduce their drug use. No such assisted remission is available to street users—although many do ultimately outgrow narcotic addiction—“mature out”—on their own.
So, in rejecting injection sites, or prescribed heroin, our concern obviously isn’t to reduce drug fatalities or to support people in quitting drugs. It’s a way for us to repeat, as we have been for a hundred years, the mantra that “drugs are bad.”
Let’s return to Obama’s remarkably prescient statement. He recognizes that people have reasons, whether physical or mental (as though we can separate the two), for using painkillers—including perhaps their having become addicted to them. The president’s keen insight is that the greater damage occurs when people are denied a reliable supplier and are forced to ferret drugs out for themselves, on the street or from multiple medical sources.
Or else the users are forced to deal with pain and emotional problems without them. What gives us the right to force this choice on them?
Assisting people safely to take drugs, on the other hand, represents the policy of harm reduction. This isn’t American drug policy—harm reduction is backed by neither drug czar Michael Botticelli nor the director of the National Institute on Drug Abuse, Nora Volkow.
Yet, President Obama enunciated this harm reduction perspective in his response to the governors’ seat-of-the-pants action plan for prescription painkillers. We’re going to miss a person able to form such a calm, rational, empathic perspective on drugs—one that neither Donald Trump nor Hillary Clinton is capable of. (Is it too late for Svante Myrick to run for president?)