The drug crisis is hard to ignore in the South – and not just in the rural areas. People keel over waiting for buses or lie slouched and zoned out in cars, as if some zombie-inducing viral contagion out of a horror flick suddenly descended. Overdosing has become such a part of the fabric of everyday life here that, like the weather, taxes and homelessness; it no longer elicits a reaction, “it is what it is.” Last year on the job, an elderly woman fell and broke her hip. The ambulance crew apologized for coming so late, but said they had been dealing with one OD after another all night, including a man who had fatally OD’d in a nearby Walmart parking lot. Alabama has the highest opioid prescription rate in the country and for every 100 people in the state, 121 prescriptions are written (1).
Oxycontin (I’m going to leave crystal meth, which is still the South’s preferred drug of choice, to the side) is not only a drug of abuse, but also a form of alternative currency, which is yet another reason for its stubborn persistence. It works like this. People on low income, many times elderly or disabled, get a script filled for chronic pain. They need extra money; SSI or Social Security isn’t enough to survive. Supplementing their insufficient incomes, they then hawk pills by word of mouth for extra cash. Some, depending on their pain levels, sell their whole allotment; others just part. For a long time, it was possible for those, mostly younger or middle-aged, with ambition or voracious habits needing to be fed to transition from dipping and dabbling in informal pill-selling by word of mouth to extended family members and friends into more lucrative pill markets. Although mostly shut down now, for a long time, there was a veritable diaspora of “pill mills” in the South, especially in strip-mall Florida, set up by sketchy doctors fleeing more intense northern regulatory scrutiny.
In these “pill mills,” masquerading as pain centers, someone hopping from one to another, a budding pharmaceutical entrepreneur as it were, without much effort could rack up scripts sometimes for hundreds of pills. Since black market street rates for Oxys run roughly a dollar a milligram, selling pills on the black market made rational economic sense; a perfect example of the homo economicus so beloved by bourgeois economists. I heard of a couple who did just this. Both were on SSI and heavily strung-out. To feed their habits, they would make bi-weekly runs to Florida strip-mall clinics to stock up on pills both for sale and personal use (they eventually broke up over mutual accusations of stealing each other’s “capital.”)
I knew a woman who had been kicked off social services because she was too high to keep the appointments and, as a result, temporarily without income. She instead used her Oxy scripts to trade for food stamps and to pay for child-care in the interim (I shudder to think about the quality of the child care if the babysitter was paid in Oxys and Xanax). While her case of pharmaceutical barter might be an outlier, it is undeniable that Oxy derived income streams unacknowledged in the formal economy
Because Oxycontin is obtained legally – unlike heroin and cocaine, there’s no real street corner drug trade; it’s all done covertly and discretely with willing sellers and buyers – I think, except for the black market rates, the trade in Oxycontin and other opioid derivatives roughly approximates what a real-life drug decriminalization policy might look like. Yet while decriminalizing now illegal drugs would stop the tremendous waste of lives left in the wreckage of a decades long failed War Against Drugs, harms such as mass incarceration, destruction of families and community bonds, I believe, from personal observation, that decriminalization would just shift the problem elsewhere.
Just because Prohibition ended, alcohol didn’t stop being a “problem” because it now was legal. On the contrary, many still drink in ways that hurt themselves and others. Contrary to libertarian dogma, alcohol and unwise drug use is not a victimless crime, a consensual act between a buyer and a seller : the families and children involved are always victims, the unacknowledged collateral damage, a damage measured in intimate partner violence, child abuse and neglect, and constant financial stress, if not actual homelessness, to list just some of the many non-consensual harms visited on the families of hard-core addicts.
In narrowing drug use to a legal or public health problem, as many genuinely concerned about the legal and social consequences of addiction will argue, I believe a larger politics and political critique gets lost (This myopia is not confined to drug issues. From what I’ve seen, much of the “social justice” perspective in the professional care industry is deeply conservative; what gets argued for amounts to little more than increased funding for their own services and endless expansion of non-profits). Drug use, broadly speaking, doesn’t take place in a vacuum. It is a thermometer for social misery and the more social misery, the greater the use. In other words, it’s not just a matter of the properties of the drug or the psychological states of the individual user, but also of the social context in which such actions play out.
If we accept this as a yardstick, then it’s no accident then that the loss of the 1984-1985 U.K. Miners’ Strike, with the follow-on closure of the pits and destruction of pit communities’ tight-knit ways of life, triggered widespread heroin use (2). What followed the defeat of the Miners’ Strike only telescoped into a few years the same social processes that in much of the U.S. were drawn out, more prolonged, insidious, and harder to detect. Until, that is, the mortality rates – that canary in the epidemiological coalmine -sharply rose to everyone’s shock.
US doctors have coined a phrase for the underlying condition of which drug use and alcoholism is just part: “shit-life syndrome.” As Will Hutton in the Guardian describes it,
“Poor working-age Americans of all races are locked in a cycle of poverty and neglect, amid wider affluence. They are ill educated and ill trained. The jobs available are drudge work paying the minimum wage, with minimal or no job security. They are trapped in poor neighborhoods where the prospect of owning a home is a distant dream. There is little social housing, scant income support and contingent access to healthcare. Finding meaning in life is close to impossible; the struggle to survive commands all intellectual and emotional resources. Yet turn on the TV or visit a middle-class shopping mall and a very different and unattainable world presents itself. Knowing that you are valueless, you resort to drugs, antidepressants and booze. You eat junk food and watch your ill-treated body balloon. It is not just poverty, but growing relative poverty in an era of rising inequality, with all its psychological side-effects, that is the killer”(3).
This accurately sums up “shit-life syndrome.” So, by all means, end locking up non-violent drug offenders and increase drug treatment options. But as worthwhile as these steps may be, they will do nothing to alter “shit-life syndrome.” “Shit-life syndrome” is just one more expression of the never-ending cruelty of capitalism, an underlying cruelty inherent in the way the system operates, that can’t be reformed out, and won’t disappear until new ways of living and social organization come into place.
(As a closing aside, I should say I tried crack several times in the 1990s – or rather I should more accurately say, was treated to it, because I am too cheap to spend money on illegal “escape” drugs of any sort. It brought on a pleasant, transient high, but nothing I was going to give up what I was doing in my life to chase. On the other hand, I knew many people that went on crack runs so severe that they wasted away to near-skeletons; it was only getting locked up that forced an unwilling pause in their run. You could always tell when someone like this had been to jail; they came out with a healthy glow and increased weight. It’s a sad comment on U.S. society to note that jail is less detrimental to many than “freedom” on the outside)
Notes
1) National Institute on Drug Abuse (NIDA) Alabama Opioid Summary. Downloaded fromhttps://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/alabama-opioid-summary
2) BBC (2002). Mining Towns Hit Hard By Heroin. Downloaded from http://news.bbc.co.uk/2/hi/uk_news/england/2338623.stm
Will Hutton (2018).The Bad News Is We’re Dying Earlier In Britain – And It’s All Down To Shit-Life Syndrome. Downloaded from https://www.theguardian.com/commentisfree/2018/aug/19/bad-news-is-were-dying-earlier-in-britain-down-to-shit-life-syndrome
Thank you Curtis for sharing this piece. I think you capture quite well how opioids are an aspect of this “shit life syndrome” that will not go away with more drug treatment centers and call for decriminalization. The root of the problem goes way deeper and entails a complete reorganization of society. It seems that white privilege (getting more access to prescription drugs in ways that perhaps blacks latinos cannot) actually has harmed white people in the long run.
I read this study published by these economists who look at mortality rates in the US and argue that life expectancy rates for whites has declined as a direct result of the opioid epidemic (the decline in rates began in 1998 two years after Oxycontin was approved by FDA). As you write Oxycontin is a huge business. In West Virginia for instance, a town was flooded with pills (20.8 million pills were shipped to a town of 3,000). Is there a target population that drug companies etc are going after? It seems that way. Even for instance in the marketing of buprenorphine (to treat narcotic addiction) https://www.youtube.com/watch?v=wAztT1eeEM4
Buprenorphine from my understanding is not widely covered by public insurance, which makes it that only certain people can afford it. This is a very different population from those that can be seen outside of methadone clinics. I wonder if Buphrenorphine is being targeted to more the white middle class professionals in all of this. What I am getting at is that even as the opioid epidemic is seen as a “white people thing”, there are important class differences in who receives what treatment, etc.
To go back to how opioids being framed as a “white people’s issue” I think this is very important for any potential movements. The reality is that when we look at drug addiction–this is not an issue that affect only whites. I have been reading that while on a national scale opioid addiction affects more whites, the rates of overdoses from opioids are higher for blacks (2x the rate of whites). Also, there is other research that shows that cocaine addiction in the black community has skyrocketed.
This leads me to think about the different response to drug addiction. In the 1970s when drugs addiction was concentrated in the black community the response was incarceration not treatment (though this is such a simple story of state coming down on black communities, other scholars have shown how often working class and middle class black community leaders and politicians demanded a swift response to drug addiction that was really tearing apart people, communities, etc). Today, arrests for the sale of manufacturing drugs are still lower than possession and sale of cocaine and heroin. So here we see another way in which there is difference in the state responds to drug addiction in whites and blacks. How do we address those (who righteously so) raise the point that only when opioid affect white people are we seeing more of a call for a public health response (Lets not forget Trump drove this home during his campaign).
What would be our response to these issues?
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Thank you Curtis for this piece. There is another term that is gaining some currency in the media when the opioid crisis is mentioned and that is “deaths of despair.” Alcohol and opioids are seen as the two leading causes for the decline in US life expectancy. There is the famous study done just a couple of years ago by economist Anne Case and Angus Deaton that found that life expectancy is dropping among middle-aged whites in America and that the gap between whites and blacks is actually closing in on this very issue. Here is NPR covering the study: https://www.npr.org/sections/health-shots/2017/03/23/521083335/the-forces-driving-middle-aged-white-peoples-deaths-of-despair
I think on the one hand we can see that there has been such a heavy marketing my pharmaceutical companies. I read somewhere that in one small town in West Virginia 20.8 million pain pills were shipped to a town with fewer than 3,000 people (see https://www.wvgazettemail.com/news/health/drug-firms-shipped-m-pain-pills-to-wv-town-with/article_ef04190c-1763-5a0c-a77a-7da0ff06455b.html). That is just insane!
There is a sense that also not only there is more prescription drugs but also that they are now more dangerous because they are being mixed, etc. Some localities have even pursued law suits against the pharmaceutical companies. But as you point out there is this large informal market that has been created.
I guess one question see come up a lot is the concern that many have raised with opioids being framed as “a white problem” and thus eliciting more sympathy on the part of the state towards treating addiction. So now drug addiction necessitates a “public health response” or is framed as “an epidemic” with calls for more funding and a public health response as opposed to how the war on drugs in the 70s and 80s hit urban communities where the response to addiction in black and latino communities was more punitive (policing, incarceration). I am not sure this new response to opioids is because this country has learned anything about ineffectively of the war on drugs. Drugs and drug addiction in America have been historically racialized (long history of just how drugs have been linked to migration patterns, etc).
Having said all of this I also think that it seems unlikely that small rural counties can find the funding for treatment centers that such severe addiction would require. In fact, I wonder if some of the county jails are being repurposed and expanded to address growing addiction, etc. White working class and lower middle class people have now perhaps more than ever a vested interested in local fights against criminalization, policing and incarceration which can be important ways of seeing their struggles connected to that of black and latinos who have long been affected and punished for addiction, drug trade etc. For instance, I read that in Bell County, Kentucky is running out of space in prisons and the local jail population is 300 percent over capacity. The state in the past to deal with opioid addiction has increased tougher penalties for drug dealers. https://www.wcpo.com/news/government/state-government/kentucky-state-government-news/kentucky-official-state-prisons-to-run-out-of-space-by-2019
Also I think its interesting too how opioid gets framed as “white” and I am still thinking through this. But the overdose death among blacks is still twice as high (even though opioids affects more whites I believe). And there has been a spike in cocaine-fentanyl spiked-related deaths among black Americans. I cant help but think how marketing also helped to frame opioids as white. I think back to those buprenorphine ads that were mostly geared at white professionals, very different from the people that would be receiving methadone treatment.
-Z
I agree with your general assessment and conclusion. But there is one point I’d nitpick. You write that, “Just because Prohibition ended, alcohol didn’t stop being a “problem” because it now was legal.” That is sort of true while missing the point. What Prohibition does is make the problem worse. This is for several reasons.
It turns the situation into a primarily legal and criminal act, and that causes the trade to be taken over by violent gangs. Also, in needing to covertly transport the substance, it becomes more concentrated and potent. For example, during alcohol prohibition, the alcohol content became extremely higher and variable, which caused people to get drunk easier and more likely to die — also because without regulation alcohol was cut with various dangerous substances, as seen as well with the illegal drug trade.
If you want to understand what I’m talking about, read Johann Hari’s Chasing the Scream. His discussion of the successful drug decriminalization in Portugal demonstrates the dynamics. What the Portugal government did was made the use of drugs legal but not the sale.
So, drug users were incentivized to go to doctors where they got safe products. It turns out this drastically decreased drug use and even for those who didn’t quit it led to less dysfunction. Many people were able to maintain a safe level of drug use while holding down jobs, maintaining marriages, taking care of kids, and because it was all legal there was no worries about prison time to destroy their lives. The criminalization of drug use was the primary cause of the problem.