For nearly forty years a perfect storm has been building to create an opioid epidemic. Economic instability has plunged huge portions of the country into poverty with no escape in sight. An evolution in the way doctors considered patient pain–egged on by profit-hungry pharmaceutical companies–has flooded the country with opioids. Those in power turned a blind eye to the increased risk of addiction, and those who spoke out were ignored. Journalist Beth Macy has become the great chronicler of Mid-American turmoil through her books Factory Man and Truevine. In Dopesick: Dealers, Doctors, and the Drug Company that Addicted America, released last month, she turns her gaze to the opioid epidemic. The stories she uncovers are shocking and horrifying, but the most surprising thing she finds amidst those whose lives have been ruined by opioids is hope. It can be easy to think of the opioid epidemic or the War on Drugs theoretically. Many people do not personally know anyone who uses heroin or who is incarcerated for selling drugs. They might not have ever spent time in former mining towns or rustbelt cities devastated by economic depression, high unemployment, and skyrocketing rates of opioid overdose deaths. In recent years, books such as In the Realm of Hungry Ghosts and Dreamland have offered readers a ground-level perspective. Their stories help us understand how addiction can consume and destroy lives, and how many government policies in the name of the War on Drugs only make things worse. Dopesick is the latest addition to that pantheon, explaining the rise of opioids in America and why it has been so difficult to break their hold. What makes Macy’s exploration of the opioid epidemic so effective is its comprehensiveness. She begins by digging into the origins of the epidemic, shining a harsh light on the tactics of pharmaceutical companies like Purdue Pharma in promoting OxyContin. Bribing doctors and lying about data, Purdue relentlessly pushed the prescription of opioid painkillers, making hundreds of millions of dollars in the process. Ultimately, Purdue was sued for blatantly untrue claims that the opioid painkillers they marketed were non-addictive. After failed attempts to bully the plaintiffs and get the lawsuits thrown out, Purdue was eventually forced to pay over $600 million in fines. It amounted to a drop in the bucket for the wildly profitable company, and Macy pulls no punches in painting it as a hollow victory. The damage was already done. Next, Macy looks at the War on Drugs, following a group of law enforcement officers tracking high-profile traffickers in Virginia and Maryland. Men like ATF Agent Bill Metcalf embody the worst instincts of law enforcement, attempting to stamp out opioid addiction through aggressive policing. Even with good intentions, the police officers and federal agents who think that we can arrest our way out of the opioid epidemic are only making things worse. Their tactics play out like a bad TV procedural, dehumanizing both addicts and dealers, all of whom are victims of a broken system. By shining a light on how law enforcement views and treats those caught up in drugs, Macy makes it clear why the War on Drugs has been such a fiasco. If Macy is far more concerned with harsh truths than easy answers, it is because there are far more of the former than the latter. But in following a group of those struggling with opioid use disorders, and those who love them, she helps us understand why some are successful and others aren’t. It almost never has to do with the individual, and far more often is about the opportunities and support provided to them. Medication-assisted treatment typically involves treating addiction with an opioid substitute such as methadone or buprenorphine. It is by far the most effective form of treatment for opioid use disorder, yet it is heavily stigmatized. Many rehabilitation programs refuse to accept those on MAT, demanding complete abstinence from drugs. There is a reason Macy chose to title her book Dopesick: those forced to endure the brutal symptoms of opioid withdrawal are driven to relapse, while medication provides much-needed stability, increasing the likelihood of recovery. Fortunately, MAT is becoming more common. Doctors and public health advocates are learning to treat people where they are, rather than enforcing unrealistic standards of behavior. Dopesick does not offer a happy ending, though. There are still too many people dying because they cannot get the help they need. What it provides, instead, is a path forward. There are alternatives to opioids, to opioid addiction, and to overdose deaths. The strategies are not easy or simple, requiring coordination between multiple levels of government and the public, as well as a complete reframing of the causes of and solutions to addiction. There are going to be more stories like those told in Dopesick. Maybe someday soon, those stories will end in triumph. Tom Houseman
Politics should not dominate science. When researchers propose studies about the medicinal value of a drug or substance, research funding should be determined neither by the whims of politicians nor bureaucratic self-interest. Yet, when it comes to medical cannabis research, politicians and federal officials have an iron grip that have serious consequences on the lives of millions of Americans. The passage of the Controlled Substances Act in 1970 is one of the most important events in the history of the War on Drugs. Fueled by anti-drug rhetoric, the Controlled Substances Act established the Drug Scheduling System. This system, based more in already debunked drug myths, has determined the legality of various substances for medicinal and research purposes for decades. The most egregious category placement in the scheduling system is undoubtedly cannabis. Congress categorized cannabis as a Schedule 1 drug, deeming it to have a high potential for abuse and no accepted medical use. Incredibly, this placement meant that marijuana was considered as dangerous as heroin, and more dangerous than cocaine and meth. This scheduling placement has suffocated progress on cannabis research for decades. The regulatory hurdles that must be overcome are currently so complex and burdensome that they would be funny were the ramifications of such regulations not so serious. Reading through a recent report from The National Academies of Sciences, Engineering, and Medicine on the barriers to cannabis research are both dizzying and infuriating. Proposals for research involving cannabis must be submitted to the Drug Enforcement Adminstration, the National Institute of Drug Abuse, and any relevant state agencies. Some of these agencies brazenly display their biases in the types of research they approve. In 2015, more than eighty percent of cannabinoid research funded by the NIDA was on the harmful effects of marijuana, rather than any potential medicinal effects. Who could expect that the Drug Enforcement Administration would support research on cannabis as medicine? Yet its approval is required. The DEA in 2016 stated its intent to permit marijuana to be available from approved registries. But it has yet to approve a single application. The only acceptable source for marijuana used in research is the University of Mississippi. Many researchers have pointed out that the samples provided are not nearly as potent as the product sold legally in many states, hampering the effectiveness of research. That researchers in California cannot use marijuana legally grown and sold in California is absurd. As a result, research that could save and improve lives is difficult to perform. The first ever trial of the effect of medical marijuana on Post-Traumatic Stress Disorder in Military Veterans was only approved after seven years. Then, after another twenty months, the NIDA-approved cannabis was finally delivered, and was found to be contaminated with mold. Many medical researchers have been vocal about burdensome regulations. Sachin Patel, who studies cannabis at Vanderbilt University, has spoken publicly about the medical community’s desperate need for “well-controlled unbiased large scale research studies into the efficacy of cannabis for treating disease states.” Researchers also point out the absurdity of the claim that cannabis has a high potential for abuse and no accepted medical value. “In the biomedical research community,” Eckard College’s Gregory Geredemann has said, “it is universally understood that cannabis is a very safe, well-tolerated medicine.” Despite these regulations, and the anti-marijuana bias of the NIDA, research continues to prove that the medical value of cannabis is vast, and that access to it will reduce pain and save lives. Studies have shown that smoking cannabis can help reduce chronic pain in HIV-positive patients, symptoms of multiple sclerosis, and the development of Alzheimer’s. Earlier this year, two studies provided evidence that access to medical marijuana can help stem the rise of the opioid epidemic, potentially saving thousands of lives. More and more states are legalizing marijuana for both medical and recreational purposes, acknowledging that the potential for abuse is low and that there is undoubtedly medical value to the drug. Yet over the last decade attempts to downgrade cannabis from its Schedule 1 placement have been stymied by the federal government. In 2011, DEA Administrator Michele Leonhart rejected a petition to reclassify marijuana on the basis that the “risks of marijuana use have not been shown to be outweighed by specific benefits in well-controlled clinical trials.” The irony of this statement is, of course, that well-controlled clinical trials are almost impossible to run unless marijuana is reclassified. In 2016, the federal government was given another opportunity to reclassify the drug, and again chose to maintain the status quo. Statements in favor of reclassifying marijuana have come from The American Medical Association and the American College of Physicians. Earlier this year, a report from the Senate Appropriations Committee on barriers to marijuana research stated that “At a time when we need as much information as possible about these drugs, we should be lowering regulatory and other barriers to conducting this research.” Given the aggressive anti-drug stance of both President Trump and Attorney General Sessions, it is unlikely that such barriers will be lifted any time soon. For now, researchers must continue navigating highly burdensome regulations in order to study cannabis, including storing cannabis in a safe or a vault. It seems that knowledge about the medical benefits of cannabis is also being kept in a vault, one that lawmakers who cling to debunked claims about the dangers of marijuana refuse to open. Tom Houseman
When the General Assembly of the Presbyterian Church U.S.A. held its biennial meeting in late June, that body approved a report calling for an end to the 47-year-old War on Drugs. Stating unequivocally that the “cure has been worse than the disease,” it set forth an agenda of “healing before punishment.” As clergy and people of faith appalled by the human and social costs of this five-decade-long “war,” we should be encouraged that a mainline denomination with nearly 1.5 million members took this stand. Yet ultimately this report is a disappointment. On the most important issue related to drug policy today–whether marijuana should be legalized for recreational use–the report hedges and ultimately declares itself “ambivalent.” Legalization of recreational marijuana will be a central issue this November in state elections around the country. If the Presbyterian Church U.S.A. had taken a strong stand on legalization, this report would have been immediately relevant. Instead, it simply calls for more research. (It also decries the commercialization of marijuana without a balanced consideration of this important question.) Would more research be helpful? Of course. But is it necessary in order to evaluate the merits of legalization? The answer is clearly no. Advocates of legalization know that heavy adolescent (and into their 20’s) use is potentially damaging to brain development. It is becoming tiresome to hear medical experts repeat what we readily acknowledge to be the case. We also know that legalization is the best way to limit adolescent use. It is more effective than the half-measure of decriminalization, where marijuana is easily available to young people, delivered by a black market with no regulation or age limits. To use one of the report’s most far-fetched examples, we know that commercial airline pilots should not be permitted to fly with marijuana in their system. No kidding! Nor should people drive while high. But these are not unsolvable problems. We can safeguard against these concerns on the basis of current knowledge, even as further research will provide more sophisticated techniques. The report suffers from a second, subtler flaw. In calling for an end to the War on Drugs, the authors say nothing about strategy. There is no indication that they understand, or have even thought about, how the important goals they espouse will ever be achieved. Their “ambivalence” about legalization assures us that this is the case. The War on Drugs is doing immediate, concrete damage to our society. The federal drug war bureaucracy has stymied marijuana research by classifying it the Schedule 1 most dangerous category, deeming it as dangerous as heroin. Only with legalization will this absurd classification — and the barriers to research — disappear. The Presbyterian Church U.S.A. report contains the seeds of strong ideas. It cites the devastating impact that the enforcement of drug laws has on minority communities. It makes the very good recommendation that those convicted for low-level marijuana possession have their records expunged. But decriminalization has existed in many states for years, and does not eliminate a black market in drugs. Nor does it expand economic opportunity for the communities and individuals that have been disproportionately harmed by the drug war. With legalization, most notably in California, white entrepreneurs are becoming wealthy selling a product that African-Americans and Latinos have long been given a criminal record for selling and using. The racial injustice and rank hypocrisy inherent in years of criminalizing marijuana are thus clearly exposed. This has begun a conversation about the need to heal these communities devastated by the War on Drugs. It has taken legalization for this conversation even to begin. Finally, the report calls for decriminalizing not just marijuana, but all drugs, accompanied with proper regulations. On this point, the report is profoundly right. Getting to this point is the lynchpin in finally ending the War on Drugs. What the authors fail to realize is that change occurs step-by-step, and is driven by public perception. When marijuana is legalized the public will see that the myths surrounding its use are overblown. Only then can we progress to educating the public about the fact that decriminalization of all drugs would be far more beneficial to society than prohibition. Merely decriminalizing marijuana only reinforces the stigma surrounding it, freezing the debate in place. This nation has a long way to go before “healing before punishment” drives drug policy. The Presbyterian Church U.S.A. has given us a valuable document. But there are times to be cautious, and times to be bold. The authors of this report failed to recognize the difference. They have been careful and safe when they could have been prophetic. Rev. Alexander Sharp
Guest Blog by Kim Brown, President, QC Harm Reduction On May 25th, 2011 my world came to a crashing halt. My thirty-three-year-old son Andy died from an accidental heroin overdose. We knew he was in trouble, we knew he injected drugs, and most of all, we knew we were at risk of losing him…and then we did. I was a single mom working as a nurse, and I adored my kids. Now one was gone. The damage done to a family when a child and sibling dies is staggering, especially when the death is caused by a drug overdose. The shame and stigma directed your way after losing a child to an overdose is quite debilitating. In any event, there were no neighbors with casseroles or offers to help and very few condolences. I was introduced to harm reduction when I sought support for my grief online. I discovered GRASP, Grief Recovery After A Substance Passing, and found other mothers to whom I could talk. GRASP literally saved my life. While pouring out my heart to these mothers I’d met, I was struck by their absolute certainty that our children’s deaths could have been prevented. Had we been able to access harm reduction tools, including naloxone, clean needles, and safe spaces for them, maybe our kids would still be here. With this knowledge, I began to turn my grief into advocacy. We founded QC Harm Reduction, our 501(c)3, non-profit organization in 2015, but had been seeking allies to support naloxone training and distribution since 2012. Iowa did not have a naloxone access bill, so we began to advocate for one at our state capitol. Finally, in 2016, after four grueling years, our law was passed. As we attempted to build support for training and distribution in our community, we continued to get pushback from many stakeholders. Stigma, shame, and a focus on abstinence were sadly still the rule of the day. My dear friend, a former Catholic Worker, Michael Gayman, introduced me to some folks in the faith community who operate The Center, Love in Action (LINK). They listened as I explained how a simple harm reduction tool, such as naloxone, could save the lives of people who use drugs. Our mission was well received, and they invited QC Harm Reduction to be a partner organization. As a result, we have been able to reach those directly impacted by drug use at The Center, in Davenport, Iowa, and through our street outreach. We have partnered with the homeless shelters in our community and have expanded our street outreach and services. QC Harm Reduction, in addition to distributing naloxone, now provides HIV and Hepatitis C testing, all free of charge. Unfortunately, Iowa has yet approved needle exchanges. We are working to change this. We also distribute food, clothing, backpacks, and other items necessary for survival, including, importantly, love and acceptance to those who are often discarded and forgotten. I am deeply grateful to The Center and their faith community for the love and support they’ve shown me, QCHR, and those individuals we are helping to serve. We are trying to get people to connect the dots. People on the streets are put in jail for low-level drug offenses, and they are often parents. This is disrupting the lives of children and families, and the human costs are too great. The Center and QCHR believe strongly that harm reduction is a human right and that everyone is entitled to safety and compassion. Love is love. Every life is worth saving.
I live in Illinois. My state has received a B- in its approach to the War on Drugs and how it aligns with a “health not punishment” response to drug use. This grade tells me that we have some important changes we can and must make. We must move to taxing and regulating marijuana, legalizing low level recreational use. I am pleased that we have decriminalized marijuana so that low level possession is treated as a civil offense, like a traffic ticket. However, marijuana arrests continue, especially in poor neighborhoods of color. The illicit drug market encourages gang activity and violence. Prohibition of marijuana breeds a War on Drugs mentality. Police continue to be seen as a hostile presence just over marijuana. We must seek to do more than reform civil asset forfeiture. We must abolish it. With the ACLU taking the lead, Illinois has reversed a laughable part of a bad law. When police seize property allegedly related to a drug crime, the burden of proving guilt now rests with the government rather than the accused. But our grade is still a D+. The standard of proof is too low: “preponderance of evidence,” rather than “beyond a reasonable doubt.” The government does not even have to establish that a crime has been committed. Police retain and fund their budgets with the proceeds they seize. Conflict of interest continues almost unabated. I am heartened that we are finding ways to ways to save lives, ease suffering, and help people restore their lives through harm reduction policies. We no longer insist upon the “abstinence only” demand that has dominated this country’s approach to drug use and recovery. But I do not understand why we do not provide Medicaid coverage for access to methadone. This could permit many people struggling with a heroin abuse disorder to work and remain with their families while receiving treatment. Fortunately, we do not have private prisons in Illinois, nor do we send prisoners to private prisons out-of-state. Thus, we do not support an industry that lobbies for laws that wants as many people in prison as possible. But even after those convicted of drug felonies have paid their debt to society and been released from prison, they are denied access to key benefits, including nutrition assistance. If we can change this, our grade will be an A rather than a B+. Our state map does not yet track some important things we are working in Illinois. Sentencing reform is critical. We are hoping for a bill that would reclassify most low-level drug offenses as misdemeanors rather than felonies. We are about to become one of the first states to pass legislation that provides a roadmap for police departments to divert drug abusers to treatment rather than jail or prison. And we may well be the first state to make it possible for our medical marijuana program to help those suffering from opioid abuse. We are making progress in Illinois. This new map shows me where we should concentrate our efforts. What does the map tell you about what you can do in your state? Reverend Alexander Sharp