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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.
Hundreds of thousands of immigrants to the United States who arrived as children were protected by the Obama-era Deferred Action for Childhood Arrivals program, which allowed them to live, study and work in the country. Shortly after entering office, Donald Trump put a (currently defunct) deadline on phasing out the program and asked Congress to create a permanent solution which has not yet emerged, making these hundreds of thousands of immigrants into a political football and creating extreme anxiety about their futures. Despite professed political will on both sides of the aisle to keep DACA program beneficiaries (often conflated with Dreamers, or supporters of a Development, Relief, and Education for Alien Minors Act) in the country, the process of creating a legislative solution to protect these individuals has gotten bogged down amid new debate over levels of legal as well as illegal immigration, discussion of building a wall on the US’s southern border, and related issues. As a case makes its way through the courts, there are currently no signs of progress being made, whether on a short- or long-term solution for Dreamers, or for comprehensive immigration reform more broadly.
The fight over Dreamers is ongoing, thanks to a court order staying the Trump Administration’s directives to terminate the Deferred Action for Childhood Arrivals (DACA) program and continuing Congressional inaction toward creating a path to citizenship. What do you think is the ideal fix for Dreamers?
Jamie Longazel (Associate Professor, Political Science): Some may argue that blanket citizenship for Dreamers is not possible, but I’m a firm believer in working to expand the realm of possibility.
Isabel Martinez (Assistant Professor, Department of Latin American and Latina/o Studies): The ideal legislative fix for Dreamers is a pathway to citizenship that is not punitive and takes into account the many years that they have lived in the United States. This means eliminating the conditional permanent resident provisions that have been included in several versions of the “Dream Act” that in some cases mandate thirteen total years before the ability to apply for citizenship; lowering application fees; and widening the ability to regularize status. Better legislation would raise the limit on the age of arrival (now sixteen) and remove the maximum age (currently thirty). It would also include a way for Dreamers’ parents to regularize their statuses, either via sponsorship by Dreamers or other citizen children, or on their own. It is wholly punitive to grant children of immigrants a pathway to citizenship and not their parents.
Dan Stageman (Director of Research Operations, Office for the Advancement of Research): Dreamers are a particularly sympathetic class of immigrants because they fit into the American narrative of meritocratic achievement, and because they were too young to be seen as culpable for the “crime” of their unauthorized presence in the US. In a moral sense, however, they are no more deserving of citizenship than low-wage immigrant workers who underpin significant sectors of the American economy, who pay taxes, and contribute to their communities of residence in countless ways. Perhaps more importantly, Dreamers are connected to this supposedly less deserving segment of the undocumented population through family ties and social bonds. So no legislative fix that focuses narrowly on Dreamers is intrinsically good for them – it is simply seen as more politically possible than a genuinely inclusive and comprehensive approach to legislation.
Part of the problem with making a push toward legislative change is that issues tend to fall out of the news cycle or be supplanted by newer and bigger issues. How can activists keep DACA at the forefront of legislators’ minds and continue to push for change?
Isabel: Immigration activists have been fighting for a Dream Act for sixteen years, but what is hopeful is that we are currently seeing the highest percentages of voters supporting a way for Dreamers to remain in the country legally. Activists and allies must be media and politically savvy and ensure that this support continues and grows, and is continuously broadcast to legislators. This means that DACA activists and allies must be media and politically savvy. Media and legislators must also do the right thing to build further support to get a law passed.
Jamie: I think activists deserve a lot of credit for keeping this conversation going, despite the media’s tendency to get bored and move on. My sense is that, within activist circles and immigrant communities, this issue hasn’t gone away at all, even if the national media has stopped covering it and we have temporarily lost legislators’ attention.
One helpful tactic for activists to consider as they try to build the power necessary to enact meaningful change is issue linking. DACA is about immigration, but it’s also about economic injustice, race, and unequal access to certain rights and privileges. By bringing DACA recipients and other undocumented folks into the conversation on, say, universal healthcare (and vice versa), not only does the issue stay on the agenda, but it also helps to boost cross-issue solidarity where we’d otherwise have activists working in silos.
Dan: What is striking is when you see groups like United We Dream – an undocumented youth grassroots organization – shifting their focus to providing practical support for immigrants facing deportation. It’s an indication that the faith these groups place in the political process to solve their very real and immediate human problems is at a low ebb.
Can you state the case for allowing Dreamers to stay in the United States?
Isabel: Dreamers are already Americans! They have assimilated – the only thing that separates them from other young people is a piece of paper. Removing Dreamers would be removing Americans, as well as much-needed talent and potential in which this country has already invested. Additionally, sending Dreamers back to countries and communities that they do not know and where they do not possess social ties is setting them up for failure. These countries have limited plans to receive and integrate them.
Jamie: I don’t think Dreamers are especially deserving because they are high achieving or assimilated. Claims like these can reinforce notions of “us” versus “them” that have long plagued the immigration debate. I think they are deserving because they are human beings, because no one deserves to live in fear, because no one deserves to be denied access to basic rights. I think Dreamers should be permitted to stay in the United States because it is the right thing to do.
Isabel: The other case is rooted in the United States’ obligations as an imperialist state: the majority of DACA recipients are Mexican, approximately 79%. Their arrivals to the United States coincided with the shocks or aftershocks of economic deals, including NAFTA, made between the US and Mexico that had losers as well as winners, namely many poor Mexican families who could no longer survive due to conditions of the deals. If we look at other countries of origin including the Dominican Republic, Guatemala, and El Salvador, we see immigration as the effect of failed or highly lopsided bi-national policies enacted with the United States. This is considered alongside increased border militarization that made the conditions of circular migration deadly and expensive for adult migrants like these young peoples’ parents. The United States has had its hand in the conditions that pushed many families from these communities to enact strategies that let them survive together; as such, the United States has a moral obligation to right these wrongs by receiving and integrating Dreamers and other immigrants.
Dan: I would again broaden the lens to include all “unauthorized permanent residents,” a group that includes any individual who has built the kinds of social and economic ties to the US that are the essential features of establishing long-term community membership, but is unable to legalize their presence. That definition in and of itself makes the case: the ethical framework for community membership goes back at least to Rousseau’s Social Contract, and the mutual obligation it establishes between the individual and their society. Dreamers and other unauthorized permanent residents are fulfilling their end of the social contract through their economic and cultural contributions to American life; unfortunately, the federal government has not reciprocated. Congress passed the last comprehensive immigration law in 1996 – over 20 years ago. The heartbreaking stories that have recently become so common, of individuals deported after 20, 30 or 40 years of US residency, are the direct result of Congress’s historic refusal to address the instability and vulnerability these immigrants have faced throughout their time in the country.
The reality is that vulnerable people are easy to exploit – illegality is, in effect, an informal guest worker program that allows the US economy to benefit from Dreamers and other unauthorized permanent residents without providing for their welfare. This is also why local governments and private prison companies have been able to take increasingly entrepreneurial approaches to their involvement in immigrant detention and deportation. The simple case for a path to citizenship is that these forms of exploitation are morally repugnant and un-American.
What is the best thing others can do to support the Dreamers?
Jamie: If we are talking about folks who are not immigrants, or immigrants who do not have a precarious legal status, then my suggestion would be to stay active – attend rallies, share information, or join an organization. And I think folks should think hard about how our struggles are intertwined. Solidarity is how otherwise powerless groups become powerful. But it is important that Dreamers and other affected immigrants lead the way, because sometimes well-intended actions and words from unaffected people can do more harm than good.
Dan: Give generously to advocacy organizations like the New York Immigration Coalition or the Immigrant Legal Resource Center. Write and call senators and congresspeople in support of DACA legislation. Most importantly, learn about the needs and vulnerabilities of immigrant communities where you live and work, and intervene in whatever way you can.
CUNY has one of the largest populations of Dreamers of any university system in the country, and while it would be irresponsible for any institution to tell these students that we can keep them safe from deportation, we can find other ways to help alleviate the incredible stress they’ve been under since the 2016 election; for example, establishing scholarships and emergency support funds, holding regular legal clinics, providing physical and mental health services, and ensuring the confidentiality of their education data are some of the things that CUNY has taken on to support our Dreamers.
Isabel: Individuals can follow our lead at John Jay for local-level support. For college-going Dreamers, we will be opening an Immigration Student Success Center in the fall that will centralize resources – academic, financial, social and legal – that are essential to their success. This is the culmination of two and a half years of work that focused on creating systems to protect, support, and empower our John Jay Dreamers.
In addition, according to a variety of polls the majority of Americans support a pathway to citizenship for Dreamers. Voters need to turn that passive support into active support and pressure their representatives to vote on a bill ASAP, with calls, emails, visits, op-eds and town hall testimonials that share how important it is that this issue is resolved. This pressure should be placed at all levels of government and in the private sector. Private citizens and corporations can advocate for state and local government to support Dreamers by passing bills that provide in-state tuition, state financial aid, and drivers’ licenses; allow them to obtain professional licenses to practice medicine and law, or teach; and restrict cooperation with DHS and ICE.
Some states and institutions are instituting limited solutions for DACA recipients, like a bill proposed in Rhode Island to allow DACA recipients to obtain drivers licenses and work permits despite expired federal status, or certain universities helping with DACA renewal fees or offering special opportunities for non-citizenship-dependent research and educational opportunities. How helpful do you think these solutions are in mitigating the current circumstances Dreamers find themselves in?
Isabel: These are very helpful, but aren’t enough. In-state tuition and financial aid can mean the difference between DACA recipients enrolling or not in college, and, once enrolled, stopping frequently to save money or paying by semester. And of course, there are significant wage differentials between those with and without college degrees or professional development opportunities. Providing funding for internships and research enables DACA recipients to position themselves to procure better (status and –paying) jobs during school and after graduation.
Dan: While state and local-level solutions are not a replacement for comprehensive federal immigration reform including a path to citizenship, they are absolutely necessary in its absence. Most important among these solutions are the ones that, like California’s recent SB-54, limit law enforcement data sharing and cooperation with Immigration and Customs Enforcement (ICE). It’s important for states and localities to announce their intentions to protect their communities from arbitrary detention and deportation, and follow through with legally binding statutes that prevent local law enforcement agencies from contributing to the process in any way.
Jamie: What I appreciate most about measures like this is their symbolic power. These places are leading by example. They’re showing us what inclusion could look like, showing us that they are not afraid, and expanding our collective sense of what is possible.
Does the focus on DACA recipients in the news and policy debate overlook other undocumented immigrants, or ease their own paths toward citizenship? Do you believe this debate will end up helping all undocumented residents?
Dan: I think overall the focus on DACA recipients does a disservice to other undocumented immigrants. It sets up a contrast between the supposedly achievement-oriented, ‘model immigrant’ Dreamers, and their hard-working (but often low-wage) parents and neighbors who are no less deserving. This is a false dichotomy, and not one that anyone who supports immigrant rights should be playing into.
Jamie: I think the focus on DACA recipients has overlooked other undocumented immigrants, but only because of the way the issue has been framed (i.e., depicting DACA recipients as deserving in contrast to other undocumented folks). There are plenty of other ways we can frame the issue that are actually favorable to immigrants across the spectrum of legal statuses.
For instance, I think talking about children who were brought to the United States without authorization can complicate what is otherwise a rather simplistic immigration debate. People talk about “legal” and “illegal” immigration as though there is a binary that is synonymous with “good” and “bad.” But here we see that the reality is far more complicated. DACA also opens up an opportunity to talk about nuances that many non-immigrants are unaware of: mixed-status families and the unique experiences of “1.5 generation” immigrants, to name a couple of examples.
What I’m saying is that so much of our public debate has relied on stereotypes and myths! With DACA, I think we have an opportunity to confront and challenge those myths, but we have to be very careful not to reinforce them.
(Answers may be lightly edited for clarity.)
Dr. Jamie Longazel is an Associate Professor in the Department of Political Science at John Jay College. His research examines issues of race and political economy, typically within the contexts of immigration and imprisonment. His recent book, Undocumented Fears: Immigration and the Politics of Divide and Conquer in Hazleton, Pennsylvania, uses the debate around Hazleton’s controversial Illegal Immigration Relief Act (IIRA) as a case study that reveals the mechanics of contemporary divide and conquer politics and makes an important connection between immigration politics and the perpetuation of racial and economic inequality.
Dr. Daniel Stageman is the Director of Research Operations of John Jay’s Office for the Advancement of Research. His academic work examines political economy and profit in the detention of American immigrants, and the economic context surrounding federal-local immigration enforcement partnerships.
Dr. Isabel Martinez is an Assistant Professor of Latin American and Latina/o Studies and the Founding Director of U-LAMP, the Unaccompanied Latin American Minor Project, a research and service project that focuses on providing academic, social and legal support to recently arrived immigration minors in removal proceedings. She also serves as the faculty adviser to the JJay DREAMers club.