First, Do No Harm

Responding to the Opioid Crisis

For the first time in its 95 year history, Time magazine has devoted an entire issue to the photography of one person: James Nachtwey. Time asked Nachtwey, whose pictures are, in his words, his “testimony” to events that “should not be forgotten and must not be repeated,” to bear witness to the opioid epidemic that is ravaging the United States.

The pictures are difficult to look at. Their cumulative effect brings to mind what Ron Weasley said after his first encounter with the Dementors: “It felt . . . like I’d never be cheerful again.”

It’s not only that what Nachtwey is documenting is depressing – it’s also that it’s difficult to imagine things getting better for a long time, if ever.

A few years year ago, I wrote about the heroin epidemic in what’s often called America’s “heartland.” The occasion for that piece was an HIV outbreak in a rural Indiana county linked to intravenous drug use. Austin, Indiana, population 4200, had 150 confirmed HIV cases, which, according to the Centers for Disease Control, gave it “a higher incidence of HIV than ‘any country in sub-Saharan Africa,’” and “more people infected with HIV through injection drug use than in all of New York City last year,” which has 2,000 times as many people as Austin.

As I pointed out, heroin is a “fallback drug,” in this case, a fallback to semi-synthetic opiates like OxyContin and Opana. These drugs, as Sam Quiñones, the author of “Dreamland: The True Tale of America’s Opiate Epidemic,” has pointed out, are “molecularly very similar to heroin,” and, as everyone who has been paying attention knows, have ravaged small towns, rural communities, and “Rust Belt” cities like Portsmouth, Ohio for more than a decade.

The switch to heroin occurred when opiate addicts found it harder and more expensive to maintain their pill habit. Heroin was cheaper, more potent, and often delivered much like pizza.

The prevalence of these opiates, whether “semi-synthetic” like the pills or “natural” like heroin, means overdoses, lots of overdoses. In 2016, an estimated 64,000 Americans died from drug overdoses, up from an estimated 52,000 in 2015 and 47,000 in 2014.

Put another way, drug overdoses killed more than twice as many Americans than automobile accidents or firearms. It’s one-and-a-half times as many Americans as died annually at the height of the AIDS epidemic. The sharp increase in overdose deaths is why life expectancy has declined the past two years in a row, which hadn’t happened in more than fifty years.

Opiate overdoses are by far the leading “accidental” cause of death in the United States, except, of course, there’s nothing “accidental” about them. “Accident” doesn’t describe the way that the heroin got into the bodies of  the 28 people in Huntington, West Virginia who overdosed in a four-hour period any better than it describes how the Fentanyl got into Prince’s.

The obvious question is “what do we do about it?” If by “it” you mean stopping the flow of drugs and keeping people from using them, the most honest answer is “beats me.”

Since President Nixon first declared “war on drugs,” the United States has spent approximately $1 trillion dollars on that war, the vast majority of it on interdiction and law enforcement. Yet, heroin is cheaper, more potent, and more readily available than it probably ever has been. And the body count is steadily rising. So, going on the evidence, interdiction and law enforcement really isn’t the answer.

Likewise, no one, least of all me, has a clue about what to do about the circumstances that predispose people to seek solace from these dangerous drugs. We don’t know how to revive the economies of these communities, at least not beyond the occasional feel-good story about a plant reopening in Ohio or Indiana. The sad truth is that very few of the low-skill, good-paying-with-benefits jobs that made a middle-class lifestyle possible in these communities are coming back, no matter which party controls the government.

And while it’s true that faith can provide people with hope and solace in even the most trying of times, if that’s all we have to offer it brings to mind the words of James: “If one of you says to them, ‘Go in peace; keep warm and well fed,’ but does nothing about their physical needs, what good is it?”

Of course, there are Christians doing a great deal more than this, and we should support them. But we shouldn’t suppose that these kinds of programs are anything more than the proverbial drop in the bucket. There simply aren’t enough of them to make much of a difference.

Even if they expanded to the point where we could be confident that they were saving, say, 2000 people from dying from drug overdoses every year, which is a very optimistic-to-the-point-of-being-incredible goal, that would be three percent of all fatal drug overdoses in 2016, the last year for which we have complete data. Given that the number of such deaths is rising by more than five percent, the impact is probably even smaller than I’m stipulating for purposes of discussion.

All of this leads me to the inescapable conclusion that our emphasis must increasingly be on harm reduction. Our ability to reduce opioid abuse, at least without serious unintended consequences, is limited, at best. But there are things we can do to reduce the likelihood that living in a place whose best days are 50-plus years in the rearview mirror doesn’t become a death sentence.

These include things like opioid substitution therapy, e.g., methadone maintenance, which, while not addressing the underlying addiction, at least keeps that addiction from killing the patient. The person may still be an addict, but a live addict at least has a chance of kicking their habit, while a dead one doesn’t.

There’s Narcan, an effective opioid overdose medication that has been proven to save lives. An increasing number of police departments are training their officers and other first responders in the use of Narcan. When coupled with “Good Samaritan Laws,” which shield people reporting overdoses from prosecution, Narcan can make a difference.

Harm reduction strategies are, to put it mildly, controversial. There are legitimate concerns about possibly enabling drug users and, in so doing, making the problem worse.

Portugal is no stranger to these concerns. In 2000, the country, infamous for sky-high rates of drug addiction and the health problems that accompany it, such as HIV infection and overdoses (sound familiar?), decided to go the harm reduction route. It decriminalized the possession of all drugs, from marijuana to heroin. (The sale and distribution of drugs remains illegal.)

Instead, offenders “receive a citation and are ordered to appear before so-called “dissuasion panels” made up of legal, social, and psychological experts.” Repeat offenders are “prescribed treatment, ranging from motivational counseling to opiate substitution therapy.”

Sounds soft, doesn’t it. That’s what critics said sixteen years ago. They predicted that drug use would skyrocket and that Lisbon would become “a haven for drug tourists.”

None of this happened. Instead, “With some exceptions, including a marginal increase among adolescents, drug use has fallen over the past 15 years and now ebbs and flows within overall trends in Europe,” and the number of heroin users has been cut in half.

“The rate of new HIV infections in Portugal has fallen precipitously;” and “Portugal’s current drug-induced death rate, three per million residents, is more than five times lower than the European Union’s average of 17.3, according to EU figures.” By way of comparison, the United States’ is 135 (!) and West Virginia’s is 324 (!!!) per million.

So, not only is the Portuguese approach actually reducing harm, it seems to also have had a possible impact on the actual usage rate. But there is a downside: talking about harm reduction, dissuasion, treatment, and counseling isn’t as emotionally satisfying and politically popular as talking about personal responsibility and “getting tough.”

But it’s the right thing to do. Just ask Mike Pence.

As governor of Indiana, the Vice President struggled with what to do about the aforementioned HIV outbreak in Austin, Indiana.

On the one hand, there was the legitimate concern that passing out clean needles was enabling intravenous drug users. On the other hand, there was the legitimate concern that, without such an exchange, HIV would spread even faster and farther.

In the end, after praying about it, governor Pence gave the go-ahead. He made it clear that his decision was in response to a “public health emergency.”

I would call 64,000 deaths (and growing) annually a “public health emergency.” Perhaps we should consider treating it as such.


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  • Gloria Rigali

    Why is there no mention of drying up the supply of drugs but sealing up our borders with much more protection in the ways of fences, radar, border guards, and drones while still implementing all of the measures being applied that have helped to lower deaths caused from overdosing and HIV from dirty needles??? Our immigration laws must be enforced as part of the safety measures needed!!!

    • hisownfool

      The author here: You ask a good question. The answer is that the vast majority of drugs entering the United States does not enter via methods that the technologies and approaches you cited could affect. They are smuggled in our ships, in trucks, and, in the case of marijuana, via tunnels.
      Every day, nearly 5000 trucks cross the World Trade Bridge from Nuevo Laredo to Texas. That’s one every fifteen seconds. The vast majority are carrying legitimate goods. A few aren’t. We can’t search all or even most of them. To try and do so would be economically disastrous for both countries. This is just one point of entry. Multiply this times every port on the West Coast and the Gulf of Mexico. Multiply this times every international airport.