As the bodies of opioid users pile up in morgues across America, one newspaper columnist wonders if we should stop "accommodating" these "cunning" addicts:
Kevin Small, who used Naloxone kit to save a friends life, poses for portrait at his apartment in Manhattan, New York, U.S., April 20, 2018. SHANNON STAPLETON/REUTERS/Newscom
Many years ago, I was in the home of a relative whose husband was a heroin addict, and hanging on a wall in the hallway was a poster that read: "Signs of a drug overdose." It went on to list symptoms such as passing out, disorientation, shallow breathing, vomiting and muscle spasms. It instructed them to call 911 immediately. I was aghast. It was like saying to the addict and their children that it's OK to use drugs as long as you make sure someone knows how to save your life if you take too much. Today's version of that poster might read, "Make sure you've got naloxone in your medicine cabinet."… Placing so much attention on accommodating the drug addict does nothing to address the underlying problem of addiction. The truth is that America doesn't know how to fix this opioid problem and meanwhile, it's getting worse. But we cannot allow Narcan to become a crutch that allows us to shirk our responsibility to figure it out. Of course, throwing drug users in jail isn't the answer either. But there has to be something between locking addicts up and giving them a license to use drugs freely.
When I see a liberal newspaper columnist like the Chicago Tribune's Dahleen Glanton parroting the arguments of Maine Gov. Paul LePage—who made national headlines in 2016 by vetoing over-the-counter access to naloxone, on the grounds that making the overdose reversal drug widely available would simply enable opioid users to get high again—I wonder how we can move the conversation about drug addiction out of the late 1980s and into what should be a more compassionate present.
One way to do that might be to put opioid addiction in the context of some other conditions that lie at the intersection of psychology and physiology. Consider Type 2 Diabetes. There's evidence that people are genetically predisposed to developing insulin resistance, but we also know it's possible to reverse symptoms with behavioral modifications. Should we stop "accommodating" type 2 diabetics by providing them with access to insulin and metformin? Probably not: Behavior modification "works" in less than two percent of the type-2 diabetic population (and not at all for type-1 diabetics, who require insulin medication to stay alive regardless of what they eat or how much they exercise).
What about hypertension? It's also reversible with dietary changes and exercise! But just as with diabetes patients (and metabolic diseases in general), long-term compliance with lifestyle changes is poor. Increasing cardiovascular exercise can lower cholesterol. Are we excessively accomodating people by giving them statins?
If you have any of those diseases and are offended by the suggestion that your sickness is your fault, or by the idea that providing you with medications allows you to continue living in such a way that makes medication necessary, imagine how you'd feel if I or someone else—your governor, say, or a prominent columnist at your city's most widely read newspaper—suggested that your medicines are a crutch and making them available to you sets a bad example for people who don't already have your condition.
You'd probably be angry, and maybe scared. You might wonder if people know how hard it is to replace deeply entrenched behaviors that started not with a declaration of "I'm going to live in such a way that I am more likely to develop a serious health problem" but more slowly and subtly, over years and under the influence of your environment, your community, your genes, and a thousand small choices that, taken alone, seemed inconsequential when you made them.
Despite everything we know about the neurological aspects of addiction, this is exactly how we talk about opioid users. Safe injection sites "would encourage and normalize heroin use, thereby increasing demand for opiates and, by extension, risk of overdose and overdose deaths," U.S. Attorney Christina E. Nolan complained when local leaders in Burlington, Vermont, called for opening such facilities. "Government-sanctioned shooting galleries won't solve the drug crisis," Glanton wrote in her column just last week.
It is absolutely true that supervised injection facilities make intravenous drug use less risky. That is the entire point. Countries that allow them do so to reduce the danger for people who will die without them. It's why we have seat belts in cars and lifeguards at the beach and condoms at college health centers and those glow-in-the-dark tabs in car trunks. The idea behind all these inventions and policies is that if we can make an activity less dangerous, we should, because helping people stay alive is morally and ethically preferable to the alternative. This is also why we give people statins and Metformin and hypertension medication!
And in all those cases—save unapproved opioid use—we accept the trade-off without even realizing that's what we're doing. Whether it's because we can imagine ourselves benefitting from those forms of insurance, or because we all drive cars and expect to get old and develop cardiovascular disease, we support policies and technologies and social contracts that shield us from the most dire consequences of our own risky behaviors.
But for some awful reason, we have allowed prohibitionists to draw the line at drugs. Tens of thousands of our family members and neighbors die each year because of that concession. As Jacob Sullum wrote in March:
Naloxone indisputably saves people's lives, and it would be unconscionable to block access to it based on speculation about how the availability of that lifesaving option might affect other people's behavior. That is like banning seat belts or HIV treatment because the extra assurance they provide might encourage some people to behave more recklessly. This is the logic of prohibition, which endangers the lives of drug users to deter people who otherwise might join them. One way it does that is by making drug potency unpredictable, which makes overdoses more likely, thereby increasing the need for naloxone. LePage is not wrong to think that making naloxone hard to get is consistent with this plan. He is wrong to think the plan is morally defensible.
By criminalizing both their behavior and the methods proven to help opioid users live longer—supervised injection facilities, easy access to opioid agonist treatments, clean needle exchanges—lawmakers have marked opioid addicts as lost to their disease, useful only as cautionary tales to people who are not sick with that particular disease. Can you imagine the uproar if officials talked about elderly, hypertensive swing-state voters the same way?
Glanton says we don't know how to tackle this problem, but that's absolutely wrong. France lifted provider restrictions on the opioid treatment buprenorphine, and in just four years reduced opioid overdose deaths by nearly 80 percent. The supervised injection facility in Vancouver, British Columbia, has reduced both opioid overdose deaths and the transmission of HIV in the surrounding area. In the 1970s, New York City's methadone-on-demand program saved countless lives.
These policies keep more people alive longer than prohibition does. As a bonus, they don't require people like Glanton, Nolan, and LePage to forfeit their prejudices against people they see as admonitory, or economically useless, or "cunning." They can keep their contempt so long as they allow opioid users to access the health care their neighbors wish to provide. The real miracle of modern medicine is not that it fixes us; it's that it allows broken people the chance to live normal lives.
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