Sun. Oct 25th, 2020

The deadliness of the opioid epidemic has roots in America’s failed response to crack

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https://www.vox.com/identities/2017/10/2/16328342/opioid-epidemic-racism-addiction

The US could have used previous drug crises to prepare for the current one. But it didn’t.

Vials of crack cocaine.
 New York Daily News via Getty Images

The death toll from the opioid epidemic ravaging the US has been climbing by the thousands for years: In 2015, opioid overdose deaths killed more people in the US — 52,000 — than guns, car crashes, and even HIV/AIDS at its peak, and overdoses since the epidemic began in the late ’90s had killed more people than the entire population of Atlanta. Based on preliminary data, 2016 will be worse. And 2017 could be even worse than that, as the deadly synthetic opioid fentanyl continues to spread across the US.

Public health officials at every level of government have been unable to reverse or even stabilize the rising death toll from the crisis, which was sparked by the widespread misuse of highly addictive prescription painkillers. This stark inability to manage the crisis shows just how unprepared America is to deal with such a massive epidemic of addiction.

But that’s not because America has never dealt with a drug crisis in the past. Since the 1980s, for instance, devastating and prolonged crack cocaine and methamphetamine epidemics have destroyed and destabilized communities across the country. Rather, the opioid crisis has gotten so far out of control because of the spiraling effects of America’s flawed response to those previous crises. And that has a lot to do with who the victims of those crises were, and how that informed the way Americans viewed their struggle.

Consider a hypothetical scenario, raised to me by Atlantic writer Ta-Nehisi Coates: Back in the 1980s and early ’90s, America was ravaged by the crack cocaine epidemic, with thousands of overdoses a year and thousands more murders associated with the drug trade at the time. If the US had responded to this crisis by investing in drug addiction treatment, there would be an infrastructure for dealing with such a crisis that could have endured to this day. This may have prevented one of the biggest challenges in the current opioid crisis — that only about 10 percent of people with a drug use disorder get specialty treatment, according to a 2016 report from the surgeon general.

Today, white Americans are the ones disproportionately suffering in the opioid crisis. The largely empathetic rhetorical response to their addiction, compared with the way black people addicted to crack were treated decades ago, has been noted many times over. But you can draw a direct line between the fact that the people suffering in this crisis can’t get the help that they need and society’s failure, 30 years ago, to view black people as worthy of the same help.

“There weren’t signs on the billboards and the subways that said save people at all costs,” Heather McGhee, president of the left-leaning public policy group Demos, told me. “White Republican politicians weren’t saying that this is a national crisis, and ‘there but for the grace of God go I,’ as Chris Christie has said. There is a difference. There absolutely is a difference.” She added, “Racial bias distorts our response and … made it so we did not create the infrastructure and the policy understanding during the earlier drug epidemics.”

This is just one of the many ways that systemic racism ultimately hurts not just those who are the targets of bigotry, but society as a whole. Time and time again, politicians have deployed explicit racism and dog whistles to justify policies to white constituents who harbor racial resentment. But these policies can lead to outcomes that ultimately hurt the white constituents who are activated by racial calls. The opioid epidemic, as the country’s deadliest drug overdose crisis in history, is a concrete example of this trend.

“In our interconnected society, racism — both interpersonal and institutional — is the flaw in the machine that often stymies our democracy and our economy,” McGhee, who’s working on a book on this topic, said. “Racism and bias against full portions of the population color the policy responses of elected officials.”

The US was totally unprepared to handle the opioid epidemic

The opioid epidemic is not America’s first drug overdose crisis, although it is so far the deadliest. In 2016, preliminary data suggests that 59,000 to 65,000 people died of drug overdoses — the highest death toll from overdoses ever recorded in the US. In the next 10 years, as many as 650,000 people could die from opioid overdoses alone — a death toll that totals more than the entire population of Baltimore.

Policymakers and the public are widely in agreement that people addicted to opioids need treatment. But there is little existing addiction treatment infrastructure in the US, and systems like that cannot be built overnight.

It’s common to hear stories across the US, particularly in places hit especially hard by the crisis (such as West Virginia and New Hampshire), about weeks- or months-long waiting periods to get into treatment — if patients can get into care at all.

Take Dean Lemire of New Hampshire: In 2012, as reported by NPR, Lemire was finally fed up with his heroin addiction. He tried to sign up for a state-funded treatment center but was put on a waiting list. He called multiple times a day for three weeks, but after repeated denials, he gave up. He drank some whiskey, got into his car to find heroin, and got into three car crashes before waking up in a jail cell. Only then could the treatment center let him in, apparently deeming his case serious enough.

And Lemire is one of the lucky ones — he survived and ultimately got into care.

States that want to treat a growing wave of newly addicted people just don’t have the resources in place to act quickly. That’s because they’re largely starting from scratch. And starting from scratch is expensive — New Hampshire, which is second in overdose deaths after West Virginia, still doesn’t have treatment centers in swaths of the state, especially in rural areas.

Drug policy experts have told me that the US as a whole will likely need to spend tens of billions a year to seriously boost addiction treatment. That may lead to financial savings in the long term, given that studies show addiction treatment prevents all sorts of negative, costly outcomes. But it’s a big upfront investment, and it will take years to implement and build on.

Meanwhile, people will continue to die — and so states may be tempted to use their existing criminal justice systems to deal with their overdose crises. Some states have, for example, begun asking prosecutors to bring more drug-induced homicide charges against people who supply opioids to someone who overdoses and dies.

A drug user prepares heroin.Universal Images Group via Getty Images

Criminal justice experts widely agree this is not only costly but ineffective. A 2014 review of the research by Peter Reuter at the University of Maryland and Harold Pollack at the University of Chicago, for example, found that while simply prohibiting drugs to some extent does raise their prices, there’s no good evidence that tougher punishments or harsher supply-elimination efforts do a better job of driving down access to drugs and substance misuse than lighter penalties. So increasing the severity of the punishment doesn’t do much, if anything, to slow the flow of drugs.

As ineffective as that may be, states already have the means to carry out this kind of response. They have enough prisons to make the US the world’s leader in incarceration. They have old laws in place that allow prosecutors to pursue stiffer penalties. And they have an incentive to use these systems, because it makes them look like they’re doing something about an epidemic that kills tens of thousands of people a year.

America “built up this massive incarceral state, which is a hungry critter,” Keith Humphreys, a Stanford drug policy expert, told me.

Put another way, the table is set so that America responds in the same way it has before to drug crises: not much on the public health side, but a lot more on the criminal justice side. And people will suffer and die as a result.

It didn’t have to be this way. In the 1980s, America had a chance to implement the sort of public health infrastructure for addiction that states are scrambling to put in place today. Under pressure from the public to do something about the crack epidemic, policymakers could have invested in a serious drug addiction treatment system that could have been scaled or retooled for other drugs, from meth to opioid painkillers and heroin.

Humphreys gave a concrete example of how this could have worked: “Something we could have done then, which is what we’ve done now, is we could have mainstreamed addiction treatment benefits into the Medicaid system.” That, he said, would have let patients more easily afford treatment today — and since health care providers would know those customers are around and now able to pay, they would have been more likely to scale up treatment to match demand even before the opioid epidemic got so bad.

Of course, that didn’t happen in the ’80s and ’90s.

The differences between the response of today and that of the 1980s and ’90s

In the 1980s, crack cocaine came to America. Taken up disproportionately by black and poor neighborhoods (while the original powdered version of cocaine remained popular in wealthier, whiter areas), crack quickly became the center of the illicit drug trade — contributing to thousands of overdose deaths as well as a spike in murders and violent crime in the ’80s and ’90s. As crack addiction strangled black communities in particular, policymakers didn’t reach to more treatment to deal with the problem; instead, the response to the crack epidemic was built almost entirely around the criminal justice system.

The media reflected this. There was not a day that the nightly news didn’t tell a new, horrifying story of a gang shooting related to crack. The New York Times ran headlines like “New Violence Seen in Users of Cocaine.” Stories of “crack babies” dominated much of the news, warning that crack use by single black mothers in particular would lead to a new wave of addicted, stunted, violent youth later called “superpredators” — warnings that later research found to be severely exaggerated.

“The media portrayals during the crack epidemic were exceedingly hostile,” Rachel Godsil, co-founder and director of research at the Perception Institute, previously told me. “When they talked about mothers who were crack-addicted, there wasn’t, ‘What kind of treatment can we provide for them?’ but, ‘What kind of criminalization can we impose upon them?’”

The prejudiced ties between race and drug use had a long history in America. In 1914, for example, the New York Times ran an article headlined “Negro cocaine ‘fiends’ are a new southern menace,” in which an actual physician claimed that cocaine made black men uniquely violent and even impervious to bullets. Many Americans can now look back at this kind of claim with scorn at its obvious absurdity, but it shows the sort of attitudes that have dominated American views on drugs for decades.

Policymakers responded in kind. Across the country, states passed tougher prison sentences for drugs. The federal government enacted with its own “tough on crime” laws, such as the Anti-Drug Abuse Acts of 1986 and 1988. Republicans backed these measures, but Democrats played a big role too — with former Vice President Joe Biden even helping write some of the “tough on crime” laws of the ’80s and ’90s while he was a senator. It was a time when it was bipartisan to treat drugs as a moral failure and a criminal justice issue.

A crack pipe.Bettmann via Getty Images

Take former President George H.W. Bush, who used his first televised national address in the Oval Office to warn of what he called “the greatest domestic threat facing our nation today”: drugs. He held up a bag of crack cocaine — purportedly bought near the White House, though later the story was found to be a bit more complicated — and vowed to escalate the war on drugs.

“Drugs are sapping our strength as a nation,” Bush said. “Who’s responsible? Let me tell you straight out: everyone who uses drugs, everyone who sells drugs, and everyone who looks the other way.” He was as brutal in describing the consequences, arguing that crack is “turning our cities into battle zones” and “murdering our children.”

There were also some treatment-focused programs in response to crack, such as the creation of drug courts. But the great majority of the response was punitive.

The opioid epidemic has inspired a different response. Media coverage of the epidemic is much more sympathetic of people struggling with drug addiction, with the New York Times now running headlines such as “In Heroin Crisis, White Families Seek Gentler War on Drugs.”

In a rarity in today’s politics, the compassion is even bipartisan. Michael Botticelli, President Barack Obama’s former drug czar, repeatedly stated that “we can’t arrest and incarcerate addiction out of people.” New Jersey Gov. Chris Christie, who’s leading President Donald Trump’s opioid commission, in 2015 gave a passionate speech urging Americans to treat addiction as a medical issue, drawing from a friend’s story to argue that “we need to start treating people in this country, not jailing them. We need to give them the tools they need to recover, because every life is precious.”

And the one major piece of legislation that Congress has passed related to the opioid epidemic, the 21st Century Cures Act, put $1 billion toward addiction treatment over two years — far from what experts say is necessary, but remarkable in that it approached the crisis exclusively as a public health problem.

Some states have passed laws toughening prison sentences related to opioids, and more have encouraged police and prosecutors to use old “tough on crime” laws to crack down on drug addiction. But these kinds of actions have not reached the all-consuming fervor, at least yet and at least not rhetorically, that engulfed the nation during the crack epidemic in the 1980s and ’90s.

Of course, a change in the public perception of addiction — a disease we still don’t fully understand but understood even less in the 1980s — has something to do with this disparity. But racism does too.

A key explanation in all of this is race

Consider this chart, which shows that until the early 2000s, black Americans tended to suffer more drug overdose deaths when controlling for population — and now white Americans have taken the lead by far, due to the opioid epidemic:

Chart showing that white Americans have disproportionately died from drugs in the last 16 years, but that might be changing given spikes in 2014 for black and Hispanic Americans

The trend is central to understanding why America’s drug addiction treatment system remains woefully inadequate — to the point that as many as 90 percent of people with drug use disorders won’t access it.

Drug addiction was widely seen in the past as a problem that afflicted mostly racial minorities, especially black Americans. So a lot of Americans felt more comfortable treating it not as a medical problem but more as a criminal justice issue, with surveys of the era showing greater support for arresting drug dealers and, to a lesser degree, drug users than later surveys have found.

As an example of how this can work, consider a 2007 study that examined the aftermath of Hurricane Katrina in 2005. In that study, researchers found that people tended to believe that victims in racial groups they don’t belong to suffered fewer “uniquely human” emotions like anguish, mourning, and remorse than victims in racial groups they did belong to. And in the aftermath of a natural disaster, that perception of fewer “uniquely human” emotions led participants to be less willing to help victims of a different race.

A 2009 study similarly found that when participants looked at images of people in pain, the parts of their brains that respond to pain tended to show more activity if the person in the image was of the same race as the participant. Those researchers concluded that their findings “support the view that shared common membership enhances a perceiver’s empathic concerns for others.” Other studies reached similar conclusions.

Really, it seems like common sense: Once someone can relate to the person who’s suffering, it becomes much easier to empathize. And when it comes to federal and state legislators — the majority of whom are white — empathy can then translate to more sympathetic policy preferences and outcomes.

So it’s not hard to understand why America didn’t have much in the way of serious discussions about scaling up drug addiction treatment in the 1980s and ’90s but is suddenly discussing the value of treatment in response to the opioid epidemic.

A man using heroin in Vermont.Spencer Platt/Getty Images

Ithaca, New York, Mayor Svante Myrick, who’s black, previously told me the disparity in how crack was approached in previous decades and how opioids are now viewed has led to resentment in much of the black community in his predominantly white town.

“It’s very real,” he acknowledged. The typical response from his black constituents, he said, goes something like this: “Oh, when it was happening in my neighborhood it was, ‘Lock ’em up.’ Now that it’s happening in the [largely white, wealthy] Heights, the answer is to use my tax dollars to fund treatment centers. Well, my son could have used a treatment center in 1989, and he didn’t get one.”

Still, Myrick added, “I’m as angry about this as anybody. But just because these are now white kids dying doesn’t mean we shouldn’t care, because these are still kids dying.”

Now, race isn’t the only reason these systems turned out as they are today. For one, the crack epidemic was associated with more street violence — there were more shootings and murders during the crack epidemic, as the homicide statistics show, than there have been during the opioid epidemic. To some degree, that justified a criminal justice response at the time. (Although the greater levels of violence in minority communities can also be blamed on institutional racism.)

Class likely plays a role too. The recent meth epidemic was predominantly linked to white Americans, yet it also invited a punitive “tough on crime” response. That may be because it was also linked to poor white Americans, while the opioid crisis is associated more with middle-class white Americans.

And society’s understanding of addiction was simply much worse in the 1980s. As Humphreys has noted, activists in the addiction treatment and recovery fields have done a lot to boost the view of addiction as a medical problem in recent years. This kind of awareness simply wasn’t around in the ’80s, especially as racism colored how Americans viewed addiction.

The result, however, is that America is better suited to deal with drug addiction as a criminal justice, not public health, problem as it faces an extremely deadly overdose crisis.

Racism affects policy outcomes for everyone in all sorts of ways

The response to drug epidemics exemplifies just one way in which race can shape so much of American politics and policy.

A prominent example is President Donald Trump. Several studies suggest that racial resentment was a big predictor of support for his candidacy, which was launched with an infamous speech explicitly attacking Mexican immigrants. Yet his legislative policy agenda so far has focused on efforts to repeal Obamacare, a budget that slashes social services to the poor, and a tax reform package that will mainly benefit the wealthy. As Dylan Matthews explained for Vox, the cuts hit programs that help millions of white Americans and keep millions out of poverty — yet through racial resentment, Trump managed to get people to support this agenda.

“People’s level of racial resentment … was the single best indicator of whether they were against the ACA, or Obamacare, in the outset,” Godsil told me. “It is clear that the right used racial resentment and racism and this idea of who’s benefiting from certain kinds of government programs to undermine support for [Obamacare].”

There’s a lot of social science research behind this idea. As researchers Sean McElwee and Jason McDaniel explained for Vox, racial attitudes are a very strong predictor for beliefs about government spending. “For decades, social scientists have found that attitudes about race, particularly toward African Americans, persistently impact political attitudes and opinions toward government services, spending, and welfare,” they wrote.

McElwee and McDaniel measured racial resentment, economic peril, and support for more government spending. They found that higher measured racial resentment correlated with a preference for decreased government spending and services, while more economic insecurity appeared to correlate — but not at a statistically significant level — with more support for increased government spending.

Government services vs. government spending tradeoffs when layered with economic peril and racial resentment

A recent study is particularly illustrative in this regard. In a survey, white respondents were asked about their beliefs on housing assistance. (The researchers only used data from white respondents because support among minority groups for Trump was too low to be statistically reliable.) With the question, survey takers were primed with a subtle image of either a black or white man.

The two images used in the study: one of a white man in front of a foreclosure sign, and another of a black man in front of the same sign.

The results were striking: Greater favorability toward Trump highly correlated with more opposition to a federal mortgage aid program, higher levels of anger that some people receive government assistance, and a greater likelihood to say that individuals who receive assistance are to blame for their situation. In contrast, favorability toward Hillary Clinton, Trump’s 2016 opponent, did not have a statistically significant effect.

The researchers concluded, “These findings indicate that responses to the racial cue varied as a function of feelings about Donald Trump — but not feelings about Hillary Clinton — during the 2016 presidential election.” Trump was clearly attracting people with high levels of racial resentment.

Much of this is driven by the perception of who gets these benefits. If critics can paint a policy as benefiting black people, that makes white people more likely to oppose it. This is why coded rhetoric about “welfare queens” and other recipients of government benefits can be so effective: It suggests the government is taking money from white taxpayers and redistributing that money to people of color who are, McGhee argued, seen as “lazy at best and criminal at worst.” Never mind that, as just one example, the plurality of food stamp recipients are white.

This has been a trend for decades, going back to Richard Nixon’s “Southern strategy,”Ronald Reagan’s original use of the term “welfare queen,” and now Trump’s own coded rhetoric. It’s what some experts call the identity politics of the right, and perhaps the big reason, McGhee argued, that a majority of white voters have rejected Democrats in presidential elections after 1964, when the Civil Rights Act passed.

We see this consistently throughout American politics: Race plays a tremendous role in how people respond to certain policy issues and how people vote. That lets politicians like Trump leverage race to get white voters in particular to go along with an agenda that could actually hurt them — whether the issue is housing, welfare, Obamacare, or drug addiction treatment.

“It scapegoats and vilifies people of color,” McGhee explained. “It sets up a response among many white people that sees policies that benefit people of color as suspect, regardless of the fact that those policies would also benefit similarly situated white people.”

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