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The terms “opioid crisis” or “opioid epidemic” have come to be used as political buzzwords, but what does it really mean to say that America is in the grip of an “opioid epidemic”? According to the Centers for Disease Control, more than 72,000 people in the United States died as the result of an overdose in 2017, and approximately 30,000 of these were from the use of fentanyl and other synthetic opioids — that comes to around 100 per day! Fentanyl, a powerful opioid designed to treat severe and chronic pain, is roughly 100 times stronger than morphine, and is currently being used to adulterate other abused substances, making these overdoses likely to increase.
From the perspectives of policy, policing, and public health, this rash of deaths is worthy of further consideration. John Jay College scholars from across disciplines and research areas tell us what they think has contributed to the trend of deaths from opioid abuse and what approaches may be best suited to tackling the problem.
What is different about the pattern of drug abuse we are seeing today that has caused it to be referred to as the “opioid epidemic”?
Jeff Coots (Director, From Punishment to Public Health Initiative): One main reason for concern around opioids today is that they are simply more deadly than the other drugs we consume. However, the rates of overall illicit drug use are actually quite steady — especially when we remove cannabis consumption from the conversation. The latest results from the National Survey on Drug Use and Health show steady illicit drug consumption from 2002-2013 at about 4%, with those aged 18-25 using a bit more than twice the rate of other age groups. We do see a slight increase in heroin consumption as prescription opioids become less available, but this doesn’t impact the overall rates of illicit consumption.
Heidi Hoefinger (Visiting Scholar, Anthropology): The situation is considered an “opioid epidemic” due to the size of the problem now, and its potential for growth. But this issue is also getting more attention than past drug “epidemics” because it’s a white, middle-class problem, particularly here in New York, with Staten Island and Long Island having some of the highest rates of use and overdose. There has definitely been a “softer” approach to this epidemic as opposed to the “crack epidemic” of the 1980s, which saw much more aggressive law and order efforts resulting in mass incarceration. Many poor people of color are still sitting in prison because of that heavy-handed approach. It’s definitely a good thing that opioid addiction is currently being viewed as more of a public health issue, but it’s extremely problematic that Black and Latinx folks continue to suffer the consequences of racist applications of drug policy.
Can you point to a few of the key factors that you believe are to blame for the current public health crisis?
Jeff: The origins of the current crisis began with the marketing of OxyContin as a non-addictive painkiller in the 1990s followed by the introduction of “pain” as the fifth vital sign in 2001. This led to higher rates of opioid prescription drug use and related overdose fatalities in the early 2000s. The second “wave” of opioid-related deaths are attributed to increased heroin consumption starting in about 2010, following a crackdown on prescription opioid distribution — consumers simply switched to the cheaper and more available opioid. The third wave is attributed to the increased presence of synthetic opioids like fentanyl in the market, starting in about 2013. These synthetics can be much more potent and make it difficult for users to control their dosage, leading to more overdoses.
Marta Concheiro-Guisan (Assistant Professor, Forensic Toxicology): Other socioeconomic factors like unemployment and economically-depressed areas should also be considered in trying to understand the whole problem and the populations most affected by it.
Heidi: The biggest drivers are probably Big Pharma and corporate greed because pharmaceutical companies were deceptive about the true effects of opioids, claiming they were non-habit inducing. They also offered incentives to doctors for prescribing, which led doctors to over-prescribe opioids instead of safer alternatives. Insurance companies typically cover opioids as opposed to alternative therapies, so they’ve played a role in this as well. It’s encouraging to see that NYC (among other cities) is suing some major pharmaceutical companies for their role in the epidemic, but there still needs to be more accountability on the part of Big Pharma.
What are the implications for American society should this systemic issue continue unabated?
Jeff: I think we are having a really important debate in the country right now about how our collective response to drug use differs along racial lines. Drug Policy Alliance and Columbia University co-hosted a conference in 2016 to highlight how the white opioid user who may have started on prescription drugs and then switched to heroin is considered a victim of circumstance and provided overdose treatment, rehabilitation and a call for compassionate public health responses. Meanwhile, black and brown heroin addicts who may not have had health insurance and access to prescription drugs tend to get jail cells, court-mandated treatment and moralizing “just say no” campaigns grounded in personal responsibility. Obviously, the the shift towards funding treatment and reducing criminal justice involvement is welcome, but the carnage reaped in the previous regime of zero tolerance and deterrence must be acknowledged and reconciled at the local and national levels.
Heidi: It has been compared to HIV in some arenas, in that it’s affecting a marginalized and stigmatized population (e.g., drug users) but it’s not getting the same attention and funding it deserves. The numbers of overdoses and deaths will likely continue to rise as long as the stigma exists, and as long as pharmaceutical companies continue to operate unchecked, as long as doctors continue over-prescribing, as long as insurance companies don’t see the value in covering alternative treatments, and as long as harm reduction remains undervalued and underfunded.
Marta: The biggest impact on American society is, of course, the tragedy of the families affected by this unprecedented health issue, and the loss of so many young people’s lives. The Centers for Disease Control and Prevention estimates that the total “economic burden” of current opioid misuse alone in the United States is $78.5 billion per year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.
The Opioid Crisis Response Act of 2018 was recently signed into law. It authorizes new funding and grants to address the crisis, advances initiatives to raise awareness and to get more first responders to carry naloxone, and drives increased coordination among federal agencies to stop drugs like fentanyl at the border, among other measures. Do you think this bill takes the right approach to dealing with the crisis? Does it go far enough?
Heidi: Many of these are welcome changes, and are actually similar to Obama’s opioid plan from 2016, but the problem is that this plan doesn’t allocate much more funding — which is needed. If this is a serious public health problem, it should receive funding and attention similar to that provided for HIV/AIDS or Ebola, as well as a similarly concerted, multi-organizational response. But addiction is still a very stigmatized condition, and not taken as seriously as it should be. People with addictions are still often blamed for their own demise, and not viewed in the same light as people with other chronic illnesses.
Marta: From my point of view, one critical element in addressing this crisis is the treatment of addiction as a health issue rather than as a stigma, and a drastic improvement of current services and their accessibility. Another important aspect is education for the general population and among professionals such as medical doctors. More funds are also necessary for the forensic sciences to develop a clearer picture of the current crisis, to know all the opioids that are involved, to monitor future crises, and to research addiction.
Jeff: We need to invest heavily in reducing demand and mitigating the risks associated with consumption, rather than focus on interrupting supply. Efforts to control access to drugs have failed for over a century. In reducing demand, we need to do a better job of addressing pain and trauma, take a hard look at our overreliance on pharmaceuticals and reduce the number of people who become addicted in the first place. In working with those already experiencing opioid dependence, we need to provide competent and evidence-based care including Medication Assisted Treatment (MAT), which is the gold standard for treating those with opioid disorders. In terms of mitigating risks, increased naloxone access is crucial, but increased use of other Harm Reduction strategies is needed as well.
What do you believe is the best way to address this epidemic?
Marta: This epidemic has to be addressed with a multidisciplinary approach, as indicated by the National Institute on Drug Abuse (NIDA) and other governmental agencies. Promoting the use of naloxone, the improvement in the accessibility of medical assistance and addiction treatments, the expansion of prevention programs in schools and for the general public, and increasing funds for the forensic sciences and addiction research are among what I consider the priority areas.
Jeff: The best way to reduce the impact of opioid overdose fatalities is to focus on saving the lives of those who choose to consume opioids. This strategy, more commonly known as Harm Reduction, focuses on reducing the negative side effects associated with illicit drug use, rather than punishing and/or moralizing at those who engage in use. These strategies include needle exchange programs, peer-based education, MAT programs, and safe consumption facilities, all of which treat those who consume illicit drugs as human beings worthy of compassion and competent medical care for their medical issues. As I noted earlier, our previous strategy of interrupting supply and punishing consumption — i.e., the War on Drugs — has not reduced the rates at which our citizens consume illicit drugs. It has, however, made that consumption more dangerous and more damaging for those communities with higher rates of use and criminal justice presence.
Heidi: Societal attitudes towards drug users and people with addictions need to change. For this to happen, people need to understand that drug use has always been a part of human history, drug users are not inherently bad people, and people will continue to want to alter their consciousness or treat pain through drug use. People also need to understand the racialized history of drug policy in this country, and that laws against drug use (which are unevenly applied across race and class) were implemented for racial, class and economic reasons (and because of who was using the drugs), not necessarily because of the harmful effects of the drugs. When people are exposed to this history, and these realities, then perhaps stigma against drug use will change, and people affected by the current epidemic will get the proper help that they need.
In addition, we need more funding for harm reduction and evidence-based drug education programs in middle schools, high schools, college and universities. Not the “Just Say No” type, because those don’t work. But the kind where students can ask open, honest questions and get factual, evidence-based, non-biased, non-moralistic responses so they can know the potential effects and risks and make more informed decisions. And there also needs to be more support for medication-assisted treatment programs (like methadone and buprenorphine), as well as harm reduction programs like DanceSafeNYC that provides factual, evidence-based drug education and drug checking kits at music festivals and events. These types of initiatives take harm reduction beyond syringe exchange programs and make them more accessible to a diverse range of young people, which ultimately saves lives, and may start to turn the tide of this epidemic.
Marta Concheiro-Guisan, Ph.D., is Assistant Professor of Forensic Toxicology at John Jay College. She has experience in the development and validation of new analytical methods and toxicological analysis of different types of specimens–including plasma, blood, urine, oral fluid, hair, sweat and other tissues. She has participated in Drugs and Driving Research Projects, including the ROSITA (Road Site Testing Assessment) and DRUID (Driving Under the Influence of Drugs) European Projects, to study alternative matrices to detect drug impairment, and in clinical protocols involving different types of drugs of abuse and drug exposure during pregnancy. Dr. Concheiro-Guisan has more than 40 publications in peer-reviewed journals.
Jeff Coots, JD, MPH, serves as the Director of the From Punishment to Public Health (P2PH) initiative based at John Jay College. Prior to joining P2PH, Mr. Coots completed a joint Juris Doctor/Masters of Public Health degree program at Northeastern University School of Law and Tufts University School of Medicine, where he focused his studies on the social justice and health impacts of mass incarceration. While in Boston, he served as an Albert Schweitzer Fellow and delivered dialogue-based “Health Reentry” workshops to introduce strategies for working in collaboration with a primary care provider to prevent new infections and mitigate the effects of chronic disease.
Heidi Hoefinger, Ph.D., is a Visiting Scholar in John Jay College’s anthropology department, where she teaches a course on gender and sexuality within the social and cultural contexts that exist in an increasingly integrated but unequal global world. She also works on a large European Research Council (ERC) project led by Kingston University in London, in which she is the New York-based ethnographer looking at anti-trafficking efforts in New York City, and their effect on sex work/ers and migration policy. Among her areas of interdisciplinary research interest are gender and sexuality, globalism and transnationalism, and drug use.