America On Opioids: The Many Faces Of The Country’s Addiction Crisis
A fire chief in West Virginia is haunted by a child, “staring at us with a blank face,” as she attempted to revive his father.
In the small New Mexican town of Rio Arriba, one man has lost his brother and much of his social circle to overdose deaths and prison. He blames poverty, hunger and insecure housing ― a constellation of injustices that he sums up as “historical trauma” ― on the high rates of addiction in his majority Native and Latino community.
During HuffPost’s Listen to America tour at the end of 2017, reporters encountered stories ― some heartbreaking, some triumphant ― of opioids and their effects. The fearsome impact of this public health crisis weighed heavily on people’s minds in every town HuffPost’s bus visited. It is a truth so universally acknowledged as to seem cliche: Overdoses are sweeping the country.
Opioid overdose deaths more than quadrupled between 1999 and 2014, and have only continued to rise in recent years. In total, more than 63,000 Americans died of drug overdoses in 2016, according to the latest data from the U.S. Centers for Disease Control and Prevention. And that is likely an undercount, due to investigations that delay results.
“This crisis has been brewing for a long time,” said Nancy Campbell, a professor at Rensselaer Polytechnic Institute in Troy, New York, who has published several books on drug policy and treatment.
“We have to ask ourselves why it came in the form that it did, when it did,” Campbell said. “Those answers do not lie entirely with the medical profession and with changes in how we treat and think about chronic pain. We have to look at deindustrialization and the changes in our lives in different regions in the country.”
To that end, HuffPost sent reporters to the front lines of the opioid crisis across the country, to talk with people in the throes of addiction, as well as the men and women trying to pick up the pieces in a landscape devoid of widespread and accessible treatment options.
There were some reasons to hope things would get better: A nurse who became addicted to Percocet after knee surgery found an outpatient program that has her clean for the first time in 20 years; an east Tennessee native who used to drive several hours a day to North Carolina to get a dose of methadone now has a clinic closer to home, thanks to a relenting local zoning board.
Previously resistant communities are enacting policies that save lives: equipping local emergency personnel with Narcan, the opioid overdose reversal drug, and enacting “Good Samaritan” laws in which those who report overdoses to the police will not be charged with drug-related offenses.
The Affordable Care Act’s Medicaid expansion provision has made addiction treatment affordable for many people who couldn’t pay for it in the past. And medication-assisted treatment, like methadone and buprenorphine, once rejected by abstinence-only treatment programs, are gaining support among lawmakers in states that have been hit hard by opioids.
Still, Campbell doesn’t think policy has progressed much.
“We’ve evolved all kinds of new strategies, which are actually based on old strategies, like drug courts and diversion,” she said. “We’re trying to meet that problem with slightly more benevolent, but still quite punitive, responses.”
In the meantime, people keep dying.
How We Got Here
While the opioid crisis has been getting steadily worse for the last several years, many experts identify the 1990s as the inflection point.
The movement then to treat pain patients more compassionately dovetailed with aggressive opioid marketing from drug companies, which touted the drugs as safe and non-addictive.
“There is a growing literature showing that these drugs can be used for a long time, with few side effects and that addiction and abuse are not a problem,” Dr. Russell Portenoy, then a pain specialist at the Memorial Sloan-Kettering Cancer Center, told The New York Times in 1993.
That turned out to be untrue ― and not based on much evidence to begin with.
“Everybody kind of got on that bandwagon before adequate research was done to really understand the long-term consequences of opioid use,” said Dr. Michael Hooten, an anesthesiologist and pain clinic physician at the Mayo Clinic.
Doctors across the country increasingly prescribed painkillers to patients, with annual non-cancer prescriptions for OxyContin, a popular opioid, increasing almost tenfold between 1997 and 2002, from 670,000 to 6.2 million prescriptions.
But in many cases, opioid prescriptions weren’t well suited to the conditions for which they were being prescribed. In long-term studies of opioid use for lower back pain, for example, opioids don’t work very well at relieving pain.
As opioids became much more prevalent in society, many who took them also noticed and enjoyed the obvious side effects. Opioids have intense effects on the brain, including facilitating sleep and reducing anxiety, leaving many people to feel a sense of well-being after taking them.
“Those may be the people who need the most help,” Hooten said, about those who use opioids for emotional relief or mental health reasons. “Suffering is a part of chronic pain. Opioids are great at treating that suffering component.”
It’s that relief from suffering that appealed to many Americans, who perhaps didn’t realize they were plagued by more than a physical injury. One man in recovery who spoke to HuffPost described the first time he took a painkiller ― a half dose of Lortab, he said ― as a revelation. “Not only did it make me feel better, it made me feel good,” he said. “I had a lot of energy ― I was walking on clouds, euphoric.”
Medical professionals argue that unaddressed mental health challenges ― from mild depression to schizophrenia ― coupled with a lifetime of poor access to proper health care underlies much of the current crisis.
“Most of the drug users I meet here and everywhere I’ve been, have underlying mental health stuff that’s not being treated,” said Hillary Brown, the founder of Steady Collective, a harm reduction program based in Asheville, North Carolina. “And if they had more money, they would be getting legal versions of the illegal stuff they’re using.”
“We don’t live in a country that sides with the poor,” Brown added. “So we don’t have health care and we don’t have mental health care.”
Finding Treatment That Works
The punitive social response to the crack-cocaine era of the 1980s favored by politicians and law enforcement casts a shadow on the present-day approach to the opioid epidemic. Back then, fear about crime and drug-addicted babies fueled a series of drug policy changes that targeted city-dwelling black Americans, and filled jails and prisons with drug offenders.
In addition to the racial injustice of disproportionately incarcerating black Americans, the carceral response to drugs in the 1980s meant that the United States never developed addiction treatment systems to adequately address the current opioid epidemic.
What that infrastructure would look like is a tougher question. Integrating addiction treatment into general health care settings, where addiction could be treated like other chronic conditions, would be ideal, but it’s a big lift, explained Tom Hill, vice president of addiction and recovery at the National Council for Behavioral Health.
Treatment is also completely counter to the way the medical system traditionally framed recovery from addiction.
“Initially the treatment systems were designed with addiction as an acute illness,” said Hill, who has been in recovery for 25 years. “You get people in, you fix them up and you get them out.”
Today, the consensus of health care professionals is that’s not a realistic depiction of addiction, which is a chronic, often lifelong, condition.
“There’s no one-size-fits-all approach,” Campbell said. “Oftentimes people don’t know what treatment approach will work for them and they have to try more than one, and more than one time. Very few people find an approach that puts them into long-term recovery the first time.”
Given that the majority of people with addiction will need to attempt recovery multiple times, accessibility and affordability are key.
The biggest takeaway from HuffPost reporters during the Listen to America tour was that the story of opioid addiction in America isn’t a monolithic narrative. In some places, like in New Mexico, opioid addiction has been raging for decades, long before doctors started overprescribing pain pills. In other areas, like Montana, opioid addiction is a concern, but not as big of a crisis as meth addiction, which started in the 1990s and never left.
Addressing the unique addiction profiles of different states, cities and among different demographics is something that keeps Campbell up at night.
“Historically most drug crisis situations have been local,” she said. “They’ve been confined to particular areas, particular places, particular populations. Whenever we represent them as national, we probably lose our best chance to understand them.”