Abstract
The opioid addiction crisis kills 130 Americans every day. Since the late 1990s more than 400,000 people have died from opioid drug overdoses in the United States (Centers for Disease Control and Prevention 2018). This is clearly a public health emergency, but under U.S. law opioid addiction is largely a criminal justice priority; therefore, responses to it are woven into the massive federal and state structures of probation, incarceration, and parole. Research shows that criminalization of opioid use does not reduce the prevalence of addiction or the number of overdose deaths (Wakeman et al. 2020). In fact, incarceration makes the problems of addicts worse in many ways. Treatment programs are often based on moral judgments rather than on research evidence, and as a result many addicts are treated with methods that simply do not work. People continue to die.
Two detailed and nuanced scholarly monographs published by the University of California Press and Johns Hopkins University Press address these timely issues. Their authors speak with authority from the points of view of social science, medicine, law, and public health policy. Kimberly Sue (Getting Wrecked: Women, Incarceration, and the Opioid Crisis) holds an MD from Harvard Medical School as well as a PhD in Anthropology from the Harvard Graduate School of Arts and Sciences. She works as a physician and medical director at Harm Reduction Coalition, a national nonprofit organization focused on improving the lives of drug users. Barbara Andraka-Christou (The Opioid Fix: America’s Addiction Crisis and the Solution They Don’t Want You to Have) is an attorney and assistant professor in the Department of Health Management and Informatics at the University of Central Florida. She holds a JD and a PhD in Law and Social Science from the Indiana University Maurer School of Law.
These books focus on the failed treatment of opioid addiction that takes place under the umbrella of criminal justice policy in the United States. Their authors describe the rise of the opioid epidemic and show how current treatment methods are ineffective. They investigate why proven methods, such as medication-assisted treatment (MAT), are met with resistance from treatment providers, physicians, judges, and government regulators. Along the way they offer carefully considered solutions to this seemingly intractable problem.
Sue and Andraka-Christou adopt similar and complementary approaches in their research. Sue details the stigma that American society places on those who abuse drugs, particularly women, and most particularly women of color. She situates the opioid crisis within society’s punitive approach to deviant behavior that utilizes incarceration as the predominant method of dealing with drug addiction. While raising many of the same issues, Andraka-Christou’s legal and public health approach directs the reader’s attention toward policy changes that could result in vast improvements over current strategies.
The authors build their analyses on ethnographic research that allows their readers to hear the plaintive voices of addicted persons. Sue focuses on the troubled lives of addicted women and the failure of addiction treatment in the prison setting. She interviews addicted women in and out of prison and follows them from family and home to jail to drug court to rehabilitation facility and often to death by opioid overdose. Andraka-Christou’s interview subjects are “current drug users, people in recovery, their family members, activists, criminal justice professionals, policy makers, and health care providers” (p. 15). Like Sue, Andraka-Christou focuses her research on the failure of non-medication-assisted treatment, and she proposes a detailed program of changes to public policy.
Neither author provides a detailed breakdown of the characteristics of their sample of interviewees or explains why particular individuals were chosen. Sue reports speaking with over thirty women in prisons, jails, and drug treatment programs in Massachusetts. Andraka-Christou’s sample includes over 120 respondents in thirteen states, but some ambiguity is introduced when she informs the reader that the details of some respondent’s stories have been changed and that sometimes two stories have been combined into one. Fortunately, neither author lets their micro-level ethnographic research overwhelm the insightful macro-structural focus of the rest of their work. Rather, the stories of addicted subjects, and their words, offer compelling and meaningful foundations for the works as a whole.
Sue’s anthropological field work allows the reader to become familiar with women who are trapped in the addiction/prison cycle, what she refers to as the “carceral-therapeutic state” (p. 22). We learn that they begin using drugs for the same reasons that people in all social classes do. They want to escape from trauma, they are trying to please a friend or lover, or they simply seek to escape boring everyday life and provide some excitement. Once addicted, however, they search for drugs primarily to avoid terrifying withdrawal symptoms. The urge to avoid becoming “dope-sick” is so strong that addicts will do anything to avoid it. Even after successfully completing a prison treatment program and being released, the probability of addicts returning to drug use and dying from an overdose is high. Society views their return to drugs as a moral failure that confirms their deviant status. Sue reminds us that the criminalization of drug use and addiction, and the subsequent imprisonment of addicts, reduces opportunities for released inmates to succeed in the non-deviant world. Employers don’t want to hire ex-inmates, family members withdraw their support, and interactions with police and parole officers make addicts fearful of being sent back to prison.
Sue questions the appropriateness of prisons as sites for rehabilitation. The number of women in state and federal prisons has risen sharply since the 1980s. Much of this increase can be explained by the disproportionate involvement of women in opioid addiction. Decades of research has clearly established the effectiveness of MAT (Wakeman et al. 2020). However, most prison programs do not administer effective medications, such as buprenorphine-naloxone or methadone—medications that ameliorate the feared effects of withdrawal from drugs. Instead, prison-based programs classify drugs as prohibited contraband, possession of which can result in solitary confinement and loss of days credited to early release.
For the women in Sue’s study, prison treatment programs are naïve and unrelated to the lives that they will return to after release. They see the prison as “an otherworldly reality in a space intended for punishment” (p. 81). This is primarily because correctional institutions do not address the structural factors that work against achievement of freedom from addiction. For women who have lived lives of recurrent trauma, the resources needed to reintegrate them into conforming lifestyles are unavailable. Opioids offer them a welcome respite from bleak and dangerous lives.
In the United States, most addiction treatment programs involve group counseling and peer support. This approach is based on the assumption that self-harming behaviors such as alcoholism and drug addiction stem from a failure of self-control on the part of the addict. Alcoholics Anonymous, Narcotics Anonymous, and other “12-Step” programs require that addicts acknowledge their personal failures and resolve to overcome them. Many have a religious or spiritual component.
The primary goal of these programs is abstinence: living a life that is drug-free. Once addicts have endured forced drug withdrawal and a period of abstinence in jail and prison, those who enter treatment programs find themselves in the group counseling and 12-step programs that correctional institutions provide. As a result, and despite their best intentions, most addicts continue to experience powerful drug cravings that lead many to return to opioid use immediately upon their release from prison. This is a vulnerable time for addicts since they have lost their tolerance to opioid drugs, and many die from overdoses.
But how are opioid addicts to succeed when only one quarter of these programs offer agonist medications that reduce powerful cravings, such as buprenorphine or naltrexone, and only a very few offer methadone? Counselors in 12-step programs are often unreceptive to the idea of MAT, seeing it as a counter to the goal of becoming drug-free. Many group counselors have received only rudimentary training and are less than knowledgeable about evidence-based treatment methods. For Andraka-Christou, 12-step group counseling programs and MAT approaches exist within a “strained relationship” (p. 55).
On its face, the opioid crisis is a public health emergency that would seem to require a medical response. There is irony in the fact that it was physicians’ overprescribing of synthetic opioids (based on false claims made by pharmaceutical companies) that generated the crisis in large part, yet many physicians have distanced themselves from participation in MAT approaches. According to Andraka-Christou’s respondents, physicians sometimes avoid MAT because of the unsavory reputation of addiction and for fear of becoming associated with a population of less-than-respectable patients (p. 145). To be sure, even those physicians who would prescribe methadone and other effective medications find their options constrained by a forest of legal restrictions.
The hands-off approach of medical doctors and the control of addiction treatment by criminal justice structures have resulted in treatment-related medical decisions being made by police officers, correctional facility staff, probation and parole officers, and drug court judges. There are currently over 3,000 drug courts in the United States, where rehabilitation is a stated goal. However, most drug court treatment teams do not include a physician. If one looks beneath the surface of attitudes toward rehabilitation that are held by drug court teams and the rehabilitation program staff they contract with, one will find negative attitudes toward MAT to be commonplace. Some judges are openly antagonistic.
Based on her extensive review of decades of treatment studies, Andraka-Christou offers a clear vision of how public policy should proceed. Addiction treatment teams should include physicians, and MAT should become the norm. Opioid addicts should be able to receive addiction treatment from their family doctor, and physicians should be enabled by law to prescribe effective medications such as methadone. Drug courts are to be preferred over imprisonment, but treatment decisions in drug courts should be made by trained medical personnel including physicians, nurse practitioners, and physicians’ assistants. Judges and non-medical personnel alone should not be making them.
Group counseling and 12-step support groups should stop stigmatizing medication-assisted treatment methods. If MAT programs were viewed as acceptable, then addicts would benefit from a combination of group counseling and MAT. Andraka-Christou proposes that all addiction treatment programs offer MAT as an option.
The results of their research lead both scholars to call for a harm-reduction approach to opioid addiction. Perhaps the most serious harm caused by the opioid crisis has been the number of deaths by overdose. A relatively simple means of preventing overdose deaths is to distribute the antidote medication naloxone widely to first responders, persons with opioid addiction, and their family members. “No one recovers from opioid addiction when they are dead,” Andraka-Christou reminds us (p. 234). She proposes the decriminalization of all drug possession along with educating the public to view addiction as a health condition rather than a violation of law. Sue suggests that public policy should shift opioid addiction from a criminal justice concern to a public health priority, and she calls for the “unlinking” of these structures (p. 136).
Andraka-Christou’s illuminating chapter entitled “Learning from Other Countries” compares the U.S. crime-and-incarceration approach to the harm-reduction policies adopted in the United Kingdom, France, and Portugal. For these nations, the U.S. approach to opioid addiction has served as a model of failed national policy. The United States hands out long prison sentences for drug-related offenses, has few needle-exchange programs, and provides no legal safe injection sites. In contrast, for several decades the European Union has favored evidence-based treatments that reduce stigma and greatly increase the likelihood of reintegrating opioid addicts into society. Portugal’s 2001 decriminalization policy eliminated criminal penalties for possession of up to ten days’ supply of all drugs, including heroin. Results have been highly positive, with more treatment centers available that provide medications proven to be effective, such as buprenorphine or methadone. In France, physicians are encouraged by government policy to treat opioid addiction with these medications, and the percentage of French physicians who prescribe them is seven times higher than the percentage of U.S. physicians who are legally allowed to do so.
If the United States truly wished to effectively treat opioid addiction, it would decriminalize drug use. Making drug use illegal is not effective in reducing drug use or, especially, in treating drug addiction. Given the blame-the-victim approach of current political and social climates, this is not likely to occur in the near future. In the meantime, opioid addiction treatment programs should use evidence-based treatment methods rather than the abstinence-based programs that are located in the prisons. This approach has achieved good results in other nations.
Perhaps the most extreme recent example of the criminalization of addiction is the proliferation of state laws that allow prosecutors to bring homicide or related charges against persons who provide drugs that result in an overdose death. This option has been exercised in nearly every state in the United States, with the number of overdose-homicide cases increasing from 2 to 75 per year during the 2000s and then rising rapidly to a high of 717 cases in 2017. According to the Health in Justice Action Lab (2019) at the Northeastern University School of Law, approximately 50 percent of those charged were the caretaker, family member, friend, or partner of the deceased, rather than a traditional drug dealer. Laws such as these may even increase the likelihood of overdose death because they provide an incentive for persons who are present at overdose incidents not to call 911 for fear of being prosecuted themselves.
Sue and Andraka-Christou have provided us with carefully researched and detailed examinations of the broad problem of opioid addiction treatment and policy in the United States, and their works represent important contributions to the literature on these issues. Nevertheless, readers will come away with feelings of despair for the women and men who use opioid drugs. At every level from the micro/interactional to the macro/structural, addicts face stigma, cruelty, and the crushing weight of the criminal justice system. These books show that a system that is primarily designed to punish will fail to provide effective treatment for addicts and will not succeed in preventing opioid-related deaths. Fundamentally, incarceration mitigates against the possibility of redemption for lives lived beyond prison walls. There is always the threat of being sent back to prison because using drugs and associating with people who use drugs are violations that can lead to immediate loss of freedom. Failure is as close as the next encounter with a police officer, and death lurks in the next overdose.