How Addiction Became a Public Health Problem Instead of a Criminal One

Over the counter Narcan sales are an important step in America's war on heroin, but they won't address the racialized aspect of drug abuse and public health.
Publish date:
February 22, 2016
heroin, addiction, drug abuse, Harm Reduction, Public Health

Opioid addiction — including dependence on controlled substances as well as illegal drugs — is booming in the United States, according to the Centers for Disease Control and Prevention. With politicians debating the best way to address the problem in an election year when all eyes are on them, some states are getting proactive with the simple step of providing naloxone (better known as Narcan) over the counter through partnerships with stores like Kroger and CVS. These moves will save lives, creating an environment in which overdoses can be treated quickly and effectively without special medical knowledge — anyone can administer a Narcan nasal spray.

The story of the heroin problem in the U.S. is a long and circuitous one. Many claim that it originated in the explosion of abusive use of prescription narcotics, an issue that constantly made the news in the 1990s and early 2000s. Members of the public were warned that such drugs were dispensed carelessly and in excessive numbers by pill mill medical offices, and the result was a storm of laws designed to crack down on opioid pain medications to make them more difficult to obtain. For every scaremongering primetime news report on the pill-laden perils descending upon us all, lawmakers took to the drawing board.

Two unintended consequences occurred as a result of the crackdown, which didn't address the fundamental problem: People had become addicted to opioids, and they would continue to seek that high however they could.

The first consequence is that pain patients actively suffered — and continue to — when states and the federal government put measures in place to limit controlled substance prescriptions. Patients living with chronic pain, a disproportionate number of whom are women, who are often ignored when they report severe pain, struggle on a daily basis with pain levels that are most adequately controlled with narcotic medications, and the most effective way to manage pain is to remain on a steady dose rather than trying to treat as needed.

These patients often run out of medication before they're legally allowed to refill it thanks to restrictions on their physicians' abilities to manage their cases, and they have to jump through hoops every time they renew their prescriptions. This can include having to make an in-person visit to the doctor's office, which is not enjoyable for patients dealing with debilitating pain, along with having to show up in person at the pharmacy with a prescription written out on security paper, and a matching identification.

For them, there's nothing addictive about the drugs they use, and this isn't a dependency. It's a basic need to function, which can be nearly impossible without adequate pain control. The shaming that surrounds the use of opioids in any setting doesn't just make it technically harder to get these drugs — it also makes it more difficult for pain patients to be open about their conditions, to seek treatment, to take their medications as directed, fearing that they will develop dependencies or addictive behaviors. And when patients do experience opioid addiction, they're put in a terrible position if they decide they want to access rehabilitation services.

The second consequence hit the very drug users these laws were supposed to be targeting. Instead of magically getting over their addictions and moving on to a brave new world of sobriety, patients turned to the next most readily-available option. It was cheap, it was plentiful, and it was accessible. Heroin began flooding the streets of America — and it was primarily used by white youth, some of whom were wealthy and in positions of privilege, putting paid to the notion that drug abuse is restricted to the lower classes. (Something that was already painfully apparent when wealthy people used cocaine with few consequences while poor people and people of color used crack and faced aggressive mandatory sentencing laws.)

Between 2002 and 2013, deaths due to heroin overdoses almost quadrupled in number, many in cases where patients were mixing multiple drugs, which can be a recipe for disaster. States like Vermont, which hadn't really been high on the list of narcotrafficking zones, suddenly began experiencing a horrific heroin problem that they didn't know how to deal with. In Ohio, parents explicitly named a heroin overdose as the cause of death in their daughter's obituary, defying the convention that these things should be left unmentioned. Especially in low-income communities, heroin became a serious problem.

Policymakers and public health officials are struggling with what to do, but while criminalization seems to be entering some minds, it's thankfully not the first resort. It would be nice to credit this solely to developments in substance abuse treatment — harm reduction is growing more and more high profile, and more and more accepted. Now, addiction is a public health concern, rather than a criminal one. The idea that perhaps we should treat people instead of marginalizing them is gaining ground. There's a growing awareness of the fact that you can't treat addiction if someone is dead, that in the short term, survivability needs to be the most important thing.

In some ways, it's akin to "housing first" policies used to address homelessness in some communities: Solve the most immediate challenge, and then move on to deconstruct the others. Someone with a substance abuse problem can survive with the help of naloxone and use drugs more safely through a needle exchange. Meanwhile, a larger framework of counseling and rehabilitation can swing into place to provide addicts with the services they need to stop using and start rebuilding their lives. That includes methadone clinics, job and housing support, counseling, and other services addicts find useful.

To do this, though, we need to destigmatize drug use, which remains a taboo subject in American culture. Stereotyping about "junkies" and "addicts"makes it difficult for people to seek treatment, because they fear social reprisals, and it's hard to adhere to treatment programs. Addiction, as anyone with a substance abuse problem will tell you, is a lifelong problem, and in a world where people can be open about their history of addiction, they can ask for support from the people around them. They also don't have to fear being outed in settings where they could lose access to jobs, housing, and other basic social needs. That's what harm reduction is all about.

But along the way, we need to openly talk about the elephant in the room, that while harm reduction measures are important and it's fantastic to see them in use, because of pervasive racism, they likely wouldn't have been made available if the heroin problem was primarily an issue in communities of color. Instead, we would have seen a resurgence of criminalization laws and more discussion about mandatory sentencing, a practice that absolutely destroyed Black communities in the 1990s and still reverberates today. There's a reason so many Black men are victims of felon disenfranchisement, and why so many once-thriving communities are struggling, and we should not hide from that legacy.

This kind of short-term harm reduction followed by thoughtful long-term approaches to preventing and treating addiction needs to be available to everyone as a free and open right in American society. The fact that innovative and aggressive public health-oriented approaches are only available to some is very troubling, and it reflects poorly on us as a nation. As we take on our heroin problem, we would be wise to take lessons from earlier failed drug initiatives, and to take reparative steps to undo the damage they left behind.

Image credit: Torbakhopper/CC