Addiction experienced in the first-person feels like watching a movie shot entirely in extreme close-ups. No matter how hard you try, you can’t see the world beyond the frame. A tolerance builds after a while and you grow used to the shaky, nauseating ride. We couldn’t have possibly known it at the time, that we weren’t the stars in our very own drama. The content of our stories differed in the details, but the tone was uncannily similar: how prescription painkillers first took hold; after pharmaceuticals became scarce and expensive, how we, as a generation in unison, playing a fucked up game of Red Rover, beelined toward heroin. Another thing we had in common was a lot of dead friends.
Really, we were just extras in a vast plot. Data points in a decadeslong “mass casualty event.” Epidemics are sort-of defined after the fact. After enough emergency room physicians start connecting the dots, after economists quantify labor participation and all-cause mortality, after a small hamlet’s population begins to shrink, after the morgue runs out of freezer space, after the president goes on TV.
What kicked off addiction on such an enormous scale has become an Odyssey for epidemiologists and journalists (like me), as well as parents and siblings who’ve lost loved ones. Grieving families and activists have turned up the heat on politicians and cops, urging a unified public health response that would reverse course. But how we define the origin of the crisis, its root causes, invariably informs which solutions are prioritized. Decades in, with each year deadlier than the one before, and no end in sight, what’s it going to take? The answer depends on who’s asking the questions.
The real tragedy of Dopesick isn’t that young people are using drugs. It’s that when they’re drowning and begging for help, they’re callously thrown deflated life preservers. The numerous attempts at treatment throughout the book — typically at abstinence-based facilities, a dangerous move for someone with an opioid use disorder — become maddening. These are places that prefer to give patients heart-shaped rocks instead of the two FDA-approved medications that reduce the risk of fatal overdose by 50 percent or more.
All the treatment failures in Dopesick read like screams into the void of America’s outdated patchwork of shoddy care. Macy finds just the right details that’ll make you pull your hair out. A police officer picks up Jesse’s cellphone at the scene of his fatal overdose, and on the other end is a treatment center (that he’d already been to once before, that doesn’t believe in medication) calling to confirm Jesse’s arrival. If you’re wondering why so many of us are still dying, in-patient, residential “treatment” is one place to start looking. (...)
The villains in Dopesick are the usual suspects. In 2015, Los Angeles Times crime reporter Sam Quinones wrote one of the first major books about the modern day opioid crisis, Dreamland, in which he sketches out the mechanics that drove the first wave of painkiller overdoses in Ohio and the Rust Belt. Quinones calls Ohio the epicenter of the crisis; Macy calls Virginia the epicenter of the crisis. But both Macy and Quinones find the same culprit: Purdue Pharma’s false marketing, which assured doctors that their time-released opioid analgesic rarely addicted patients.
Central to the origin story of the crisis in both Dreamland and Dopesick is the over-supply of OxyContin, dulled out by sometimes well-intentioned but misinformed doctors, or in bulk at greedy pill mills diverted for street sale. Either way, in the late ’90s and into the aughts, during a climate of deregulation and a “patient-centeredness” movement obsessed with smiley-faced rate-your-pain scales, these drugs flooded vulnerable regions of America.
Both Macy and Quinones look intently at the supply of drugs. But did flooding the market with opioids create the demand? Drugs, after all, are like any other product: people have to like and want it or they won’t buy it. So, can a doctor create addiction in their patients? Can a drug company addict an entire country? Only if you believe opioids are like mosquitos carrying Malaria, and whoever touches them comes down with the disease.
The vast majority of people who use opioids do not become addicted to them. A conservative estimate for rates of addiction among pain patients is less than 8 percent (still much higher than Purdue’s < 1 percent claim). But among those who do become addicted, they’re typically using diverted medications that were never prescribed to them, or had misused illicit drugs and were well on their way to addiction prior to receiving a prescription, thanks to trauma, mental health, and other factors that increase one’s risk. Nobody walks into a doctor’s office with a clean slate. (...)
As satisfying the feeling is to rail against Big Pharma and unenlightened doctors, the iatrogenic (doctor-caused) narrative isn’t without caveats and shortcomings, which are becoming painfully evident as the government rolls out strategies to rein in the supply of opioids. A recent study out of Stanford that modeled public health policy shows that aggressively controlling the supply of prescriptions, in the short-term, is actuallyincreasing overdose deaths by the thousands. Other strategies to reschedule drugs like Vicodin also backfired, new studies are finding. In a powerful commentary by public health experts, “Opioid Crisis: No Easy Fix to its Social and Economic Determinants,” they argue wrangling the supply of opioids fails to address root causes. Targeting supply is important, the authors of “No Easy Fix” agree, but doing so without addressing people’s pain is one of the reasons things are this bad. (...)
America’s draconian conception of drug policy has life and death consequences. Jesse, the football player in Dopesick, preferred to inject pharmaceutical oxycodone. This was true for my friends and me. Jesse, like my friend Alex, didn’t survive the leap to heroin. This isn’t retold to condone the misuse of prescription painkillers. The moral world of addiction is shaded with greys. And the fact is, injecting a regulated pharmaceutical of known dose and purity is less risky than injecting a bag of white powder purchased on the street. Bags of dope come with no proof of ingredients. At the end of the day, an 80 milligram OxyContin is always 80 milligrams. It may not be pretty, and Purdue executives might be dead-eyed ghouls, but at least there was measure of safety. That safety’s gone now. Hello, fentanyl.
Unfocused anger at Big Pharma also winds up harming a different vulnerable group, one that’s typically an afterthought in stories about opioids: chronic pain patients. In the name of “battling the epidemic,” patients who need opioids are being abandoned by their doctors. With Jeff Sessions and the DEA breathing down their necks, they’re afraid of prescribing any narcotic. In response to the opioid crisis, the prescribing pendulum has rapidly swung. Doctors who treat pain are receiving threatening letters to prescribe fewer opioids, patient outcomes be damned. As a result, some of these patients are killing themselves, which has caught the interest of investigators at the Human Rights Watch, who are documenting patient abandonment in the new, restrictive climate. A sweeping package of opioid legislation recently passed by the Senate will also be studying whether opioid prescribing limits have led to patient suicide. (...)
Macy calls this game “Whac-a-Mole,” with new dealers and more dangerous products popping-up after each bust, otherwise known as the Iron Law of Prohibition: painkillers replaced by heroin, and heroin replaced by fentanyl. Choking off the supply of prescription painkillers early on in the crisis, without first installing a safety net to catch the fallout, was a major policy failure that worsened America’s opioid problem by orders of magnitude. What would such a safety net look like? In Fighting for Space: How a Group of Drug Users Transformed One City’s Struggle with Addiction, Canadian journalist Travis Lupick exhaustively details the architecture of a demand-centered strategy that prioritizes saving the lives of active drug users.
Lupick rarely mentions supply-side interventions in his book. Instead, he stays close to people actively injecting heroin and cocaine several times per day, learning what makes them desire drugs in the first place, listening to what they say they need. Fighting for Space, more than anything else, is a testament to the organizing power of drug users. In 1997, with the help of compassionate public housing and healthcare workers on the Downtown Eastside, where poverty and trauma are heavily concentrated, drug users came together to form a union called the Vancouver Area Network of Drug Users (VANDU). Rather than flinch at their drug use, Lupick portrays Downtown Eastside users as they truly are: fierce but flawed heroes. Like the manic energy of user-activist Dean Wilson, whose injection cocaine habit made him an untiring debater, dunking all over City Hall’s bureaucrats. He was one of VANDU’s early presidents.
For the uninitiated, Lupick’s harm reduction history might read like inside baseball. But as you slowly come to meet the activists, like the recalcitrant Ann Livingston and the mysterious heroin-poet Bud Osborne, you can’t help but root for them as they break all the undignifying rules that make life a living hell for those addicted on the street. From an American perspective, Lupick’s encyclopedic history also reads as a blueprint.
Treating addiction like the public health issue that it is didn’t happen because Canadians are naturally nicer and friendlier toward drug users. After decades of highly organized, politically strategic activism by a dedicated, at times disabled and tense group of drug users and health care providers, Vancouver’s most marginalized community was seen and heard. They didn’t merely get what they wanted; they got what they needed by fighting for their space: their space to do drugs with dignity, in the presence of radically compassionate nurses, but also space at the policymaking table where decisions about their fate are made. “Nothing about us, without us,” the saying goes. Canadian drug users had the insight to make their needs political, and had the stamina and support to sustain pressure on the city.
Reminiscent of ACT UP during the HIV epidemic of the ’80s and ’90s, VANDU targeted the media and politicians who seldom made a peep about their friends who overdosed alone behind dumpsters in the alley, or others who died from untreated AIDS and Hepatitis C.
by Zachary Siegel, Longreads | Read more:
Image: Jose A. Bernat Bacete / Getty, Illustration by Katie Kosma
Really, we were just extras in a vast plot. Data points in a decadeslong “mass casualty event.” Epidemics are sort-of defined after the fact. After enough emergency room physicians start connecting the dots, after economists quantify labor participation and all-cause mortality, after a small hamlet’s population begins to shrink, after the morgue runs out of freezer space, after the president goes on TV.What kicked off addiction on such an enormous scale has become an Odyssey for epidemiologists and journalists (like me), as well as parents and siblings who’ve lost loved ones. Grieving families and activists have turned up the heat on politicians and cops, urging a unified public health response that would reverse course. But how we define the origin of the crisis, its root causes, invariably informs which solutions are prioritized. Decades in, with each year deadlier than the one before, and no end in sight, what’s it going to take? The answer depends on who’s asking the questions.
***
Drenched in shame and broken by stigma, the impulse to blame ourselves for our addictions felt like a natural turn inward. Journalist Beth Macy’s new book, Dopesick: Dealers, Doctors, and the Drug Company that Addicted America, isn’t interested in victim blaming, as the title suggests. The villains, familiar to those following the news, are doctors cum dealers duped by Purdue Pharma’s marketing that downplayed the risk of addiction for their blockbuster drug, OxyContin. And after painkillers had their run, the story goes, enterprising heroin dealers tapped a hungry market outside the city, “picturesque” and “bucolic” markets demanding relief after years of physical labor and economic distress metastasized into despair. (...)The real tragedy of Dopesick isn’t that young people are using drugs. It’s that when they’re drowning and begging for help, they’re callously thrown deflated life preservers. The numerous attempts at treatment throughout the book — typically at abstinence-based facilities, a dangerous move for someone with an opioid use disorder — become maddening. These are places that prefer to give patients heart-shaped rocks instead of the two FDA-approved medications that reduce the risk of fatal overdose by 50 percent or more.
All the treatment failures in Dopesick read like screams into the void of America’s outdated patchwork of shoddy care. Macy finds just the right details that’ll make you pull your hair out. A police officer picks up Jesse’s cellphone at the scene of his fatal overdose, and on the other end is a treatment center (that he’d already been to once before, that doesn’t believe in medication) calling to confirm Jesse’s arrival. If you’re wondering why so many of us are still dying, in-patient, residential “treatment” is one place to start looking. (...)
The villains in Dopesick are the usual suspects. In 2015, Los Angeles Times crime reporter Sam Quinones wrote one of the first major books about the modern day opioid crisis, Dreamland, in which he sketches out the mechanics that drove the first wave of painkiller overdoses in Ohio and the Rust Belt. Quinones calls Ohio the epicenter of the crisis; Macy calls Virginia the epicenter of the crisis. But both Macy and Quinones find the same culprit: Purdue Pharma’s false marketing, which assured doctors that their time-released opioid analgesic rarely addicted patients.
Central to the origin story of the crisis in both Dreamland and Dopesick is the over-supply of OxyContin, dulled out by sometimes well-intentioned but misinformed doctors, or in bulk at greedy pill mills diverted for street sale. Either way, in the late ’90s and into the aughts, during a climate of deregulation and a “patient-centeredness” movement obsessed with smiley-faced rate-your-pain scales, these drugs flooded vulnerable regions of America.
Both Macy and Quinones look intently at the supply of drugs. But did flooding the market with opioids create the demand? Drugs, after all, are like any other product: people have to like and want it or they won’t buy it. So, can a doctor create addiction in their patients? Can a drug company addict an entire country? Only if you believe opioids are like mosquitos carrying Malaria, and whoever touches them comes down with the disease.
The vast majority of people who use opioids do not become addicted to them. A conservative estimate for rates of addiction among pain patients is less than 8 percent (still much higher than Purdue’s < 1 percent claim). But among those who do become addicted, they’re typically using diverted medications that were never prescribed to them, or had misused illicit drugs and were well on their way to addiction prior to receiving a prescription, thanks to trauma, mental health, and other factors that increase one’s risk. Nobody walks into a doctor’s office with a clean slate. (...)
As satisfying the feeling is to rail against Big Pharma and unenlightened doctors, the iatrogenic (doctor-caused) narrative isn’t without caveats and shortcomings, which are becoming painfully evident as the government rolls out strategies to rein in the supply of opioids. A recent study out of Stanford that modeled public health policy shows that aggressively controlling the supply of prescriptions, in the short-term, is actuallyincreasing overdose deaths by the thousands. Other strategies to reschedule drugs like Vicodin also backfired, new studies are finding. In a powerful commentary by public health experts, “Opioid Crisis: No Easy Fix to its Social and Economic Determinants,” they argue wrangling the supply of opioids fails to address root causes. Targeting supply is important, the authors of “No Easy Fix” agree, but doing so without addressing people’s pain is one of the reasons things are this bad. (...)
America’s draconian conception of drug policy has life and death consequences. Jesse, the football player in Dopesick, preferred to inject pharmaceutical oxycodone. This was true for my friends and me. Jesse, like my friend Alex, didn’t survive the leap to heroin. This isn’t retold to condone the misuse of prescription painkillers. The moral world of addiction is shaded with greys. And the fact is, injecting a regulated pharmaceutical of known dose and purity is less risky than injecting a bag of white powder purchased on the street. Bags of dope come with no proof of ingredients. At the end of the day, an 80 milligram OxyContin is always 80 milligrams. It may not be pretty, and Purdue executives might be dead-eyed ghouls, but at least there was measure of safety. That safety’s gone now. Hello, fentanyl.
Unfocused anger at Big Pharma also winds up harming a different vulnerable group, one that’s typically an afterthought in stories about opioids: chronic pain patients. In the name of “battling the epidemic,” patients who need opioids are being abandoned by their doctors. With Jeff Sessions and the DEA breathing down their necks, they’re afraid of prescribing any narcotic. In response to the opioid crisis, the prescribing pendulum has rapidly swung. Doctors who treat pain are receiving threatening letters to prescribe fewer opioids, patient outcomes be damned. As a result, some of these patients are killing themselves, which has caught the interest of investigators at the Human Rights Watch, who are documenting patient abandonment in the new, restrictive climate. A sweeping package of opioid legislation recently passed by the Senate will also be studying whether opioid prescribing limits have led to patient suicide. (...)
Macy calls this game “Whac-a-Mole,” with new dealers and more dangerous products popping-up after each bust, otherwise known as the Iron Law of Prohibition: painkillers replaced by heroin, and heroin replaced by fentanyl. Choking off the supply of prescription painkillers early on in the crisis, without first installing a safety net to catch the fallout, was a major policy failure that worsened America’s opioid problem by orders of magnitude. What would such a safety net look like? In Fighting for Space: How a Group of Drug Users Transformed One City’s Struggle with Addiction, Canadian journalist Travis Lupick exhaustively details the architecture of a demand-centered strategy that prioritizes saving the lives of active drug users.
Lupick rarely mentions supply-side interventions in his book. Instead, he stays close to people actively injecting heroin and cocaine several times per day, learning what makes them desire drugs in the first place, listening to what they say they need. Fighting for Space, more than anything else, is a testament to the organizing power of drug users. In 1997, with the help of compassionate public housing and healthcare workers on the Downtown Eastside, where poverty and trauma are heavily concentrated, drug users came together to form a union called the Vancouver Area Network of Drug Users (VANDU). Rather than flinch at their drug use, Lupick portrays Downtown Eastside users as they truly are: fierce but flawed heroes. Like the manic energy of user-activist Dean Wilson, whose injection cocaine habit made him an untiring debater, dunking all over City Hall’s bureaucrats. He was one of VANDU’s early presidents.
For the uninitiated, Lupick’s harm reduction history might read like inside baseball. But as you slowly come to meet the activists, like the recalcitrant Ann Livingston and the mysterious heroin-poet Bud Osborne, you can’t help but root for them as they break all the undignifying rules that make life a living hell for those addicted on the street. From an American perspective, Lupick’s encyclopedic history also reads as a blueprint.
Treating addiction like the public health issue that it is didn’t happen because Canadians are naturally nicer and friendlier toward drug users. After decades of highly organized, politically strategic activism by a dedicated, at times disabled and tense group of drug users and health care providers, Vancouver’s most marginalized community was seen and heard. They didn’t merely get what they wanted; they got what they needed by fighting for their space: their space to do drugs with dignity, in the presence of radically compassionate nurses, but also space at the policymaking table where decisions about their fate are made. “Nothing about us, without us,” the saying goes. Canadian drug users had the insight to make their needs political, and had the stamina and support to sustain pressure on the city.
Reminiscent of ACT UP during the HIV epidemic of the ’80s and ’90s, VANDU targeted the media and politicians who seldom made a peep about their friends who overdosed alone behind dumpsters in the alley, or others who died from untreated AIDS and Hepatitis C.
by Zachary Siegel, Longreads | Read more:
Image: Jose A. Bernat Bacete / Getty, Illustration by Katie Kosma
