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Ending the Opioid Crisis

Trump finally declared mass opioid addiction a national emergency. But he won’t take on big pharma and the social roots of the crisis.

Hydrocodone. Frankie Leon / Flickr

The Portuguese communist José Saramago once imagined a plague sweeping through an otherwise functional society. In his novel Blindness, a mysterious contagion traverses an unnamed city in tendrils, striking citizens blind with no regard for social class or political disposition.

The ailment metastasizes quickly. The first victim, blinded while he sits in traffic, explains to a throng of irritated strangers that he has “fallen into a milky sea.” An opthamologist, eager to get to the bottom of the outbreak, finds his research interrupted by a curtain that descends cruelly over his own eyes. A women awakens in a hotel room after exactly twenty-two minutes of rapturous sex, seeing nothing but mist.

From there, the novel unfolds along a pretty standard dystopian trajectory — the afflicted are placed into camps, petty tyrants emerge from amongst the sequestered, and a callous government withdraws from its responsibilities, opting for authoritarianism over creativity. It’s less a meditation on illness than a sober warning about what can happen when social problems are placed outside the realm of politics, when fatalism forecloses the possibility of a positive solution.

Blindness crossed my mind earlier this summer because, in the town I grew up in, there were thirty-six opioid overdoses in twenty-four hours. The next day, there were fifteen more.

A National Emergency

A little more than a week ago, months overdue, the White House’s commission on opioids finally issued an interim report. The group’s “first and most urgent recommendation” for Trump was to declare a national emergency. Noting that “with approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks,” the commission addressed Trump directly. Declaring a national state of emergency is “completely within your control,” they wrote. “You, Mr. President, are the only person who can bring this type of intensity to the emergency.”

On Thursday, after sending some mixed signals, Trump took the advice. “We’re going to spend a lot of time, a lot of effort and a lot of money on the opioid crisis,” Trump told the White House press pool.

Such a declaration is long overdue. Over the past decade or so, a flood of prescription opioids has inundated the country, irrigating the money-trees of major pharmaceutical companies while quadrupling overdose rates. Last year, opioid overdoses killed fifty thousand people, far outpacing car accidents as the country’s leading cause of preventable death. In 2015, 12.5 million people reported misusing prescription opioids like hydrocodone or OxyContin. Close to a million more reported using heroin, which is often cheaper and more easily available than prescription pills.

People in my hometown, and in communities across the United States, are dying at alarming rates. These people tend to live in disinvested rural or peri-urban areas, and they tend to be white — though this is not always the case. You wouldn’t know it from the news coverage, but rates of overdose deaths among black, Latino, and Native Americans, while still lower than rates for whites, have also increased dramatically over the past few years, as national data reveal.

But because so many of its victims are white, the opioid epidemic has so far attracted a degree of empathy from politicians that contrasts sharply with the draconian response to the crack epidemic of the 1980s. That earlier epidemic, which disproportionately affected black Americans, sparked the launch of an unhinged War on Drugs that visited interlaced horrors of criminalization, incarceration, and public disdain on black America, while leaving the drug problem to fester. But today’s epidemic, as plenty have pointed out, inspires hand-wringing even from tough-on-crime conservatives like Chris Christie and Trump himself.

Hand-wringing, however, doesn’t necessarily translate into political action.

What Trump’s state of emergency will mean in practice remains to be seen. Six states with high addiction and overdose rates have already declared states of emergency of their own, but the concrete policies they’ve advanced have varied widely — ranging from merely establishing a standing order for naloxone, the miracle drug that can pull overdose patients away from the brink of death (Alaska), to implementing mandatory prescription tracking and hardball restrictions on drug companies, including the outright banning of certain products (Massachusetts).

The attorneys general of several states have even advanced legal action against large companies that manufacture and distribute opioids. The state of West Virginia has sued a number of corporate drug distributors — including major wholesalers like McKesson (the fifth largest company in the United States), as well as household-name pharmacies like CVS — after drug companies shipped a staggering 780 million doses of opioids to the small state between 2007 and 2012. In some counties, that amounted to as many as 400 pills per resident.

Ohio pursued a similar tactic in May, suing drug manufacturers like Johnson & Johnson and its subsidiary, Janssen Pharmaceuticals, for helping “to unleash a health care crisis that has had far-reaching financial, social, and deadly consequences in the State of Ohio.” Just a few days ago, New Hampshire became the latest state to throw its hat in the ring by suing Purdue Pharma, the American drug company that invented OxyContin and spent nearly a decade serially understating its addictive properties.

These suits join a slew of other legal actions brought against drug companies by states, municipalities, and indigenous nations — including Illinois, Mississippi, several New York counties, Orange and Santa Clara counties in California, the city of Everett, Washington, and the Cherokee Nation. These suits allege that drug manufacturers and distributors were well aware that enormous quantities of prescription opioids were being funneled into the black market, yet did nothing to staunch the flow.

But so far, Trump has given no indication that he intends to discipline, or even aggravate, the pharmaceutical companies that bear the brunt of the responsibility for today’s spiraling crisis. Instead, he has pandered to law enforcement, surrounding himself with tough-on-crime sycophants like Attorney General Jeff Sessions, who inaugurated his tenure by promising a return to some of the drug war’s most draconian (and discredited) methods.

To make matters worse, Trump routinely mischaracterizes the drug epidemic as an issue of border security, ascribing the outbreak of a domestic public health crisis to some nebulous foreign menace that shape-shifts according to the political winds — sometimes China, sometimes Mexico, but never, notably, Purdue.

If Trump’s state of emergency signals a ramping up of drug arrests and the intensified militarization of border areas, then the expansion of executive power it entails could be a disaster for the epidemic’s most vulnerable victims, not to mention the many other people who will be caught in the president’s crosshairs.

The two most meaningful steps for actually solving the drug crisis are very likely located over lines the Trump administration simply won’t cross. First, Trump should follow his own commission’s advice and eliminate the federal Institutions for Mental Diseases restriction that prevents Medicaid recipients from accessing addiction treatment. “This is the single fastest way to increase treatment availability across the nation,” according to the report. But, unfortunately, Trump’s assault on Medicaid is ongoing, and it is unlikely his administration will green-light an expansion of the program.

Second, Trump should lay the blame where it belongs: at the feet of pharmaceutical manufacturers and drug distributors whose malfeasance is, at this point, well-documented, and even validated by legal settlements at the state level. In fact, with someone stronger and more principled in the executive branch, it wouldn’t be too much of a stretch to imagine something akin to the Tobacco Master Settlement Agreement of 1998 — in which four leading tobacco producers were forced to foot some of the bill for the social cost of tobacco-related illness — applied to companies like McKesson and Purdue.

As Trump’s own commission acknowledged outright (before backpedalling with some soft-shoe language about “lack of education”), “one out of every five new heroin users begin with non-medical use of prescription opioids.”

Unfortunately, it seems Trump, against the advice of his own experts, intends to continue down the dead-end path he has already laid out: punitive prosecutions of addicts, coupled with milquetoast educational efforts that don’t amount to anything close to what we need.

Meanwhile, overdose rates continue to climb. A deadly opiate derivative called fentanyl circulates like a covert wildfire, disguised in bags of white powder only to be revealed later in autopsy-room toxicology reports. And in a suburb of my hometown, parents and teachers are closing out the summer by discussing how to get naloxone into classrooms in time for the coming school year.

Williamsport, PA

The town I’m from is called Williamsport, Pennsylvania. My parents live in Lewisburg, about forty minutes south of there, in a county where the coroner documented twelve overdose deaths between 2014 and 2016. A pipeline of out-of-town leisure dollars, routed through local Bucknell University, gives Lewisburg the new-money polish of some Poconos destination towns, but sets it apart from its immediate neighbors. This makes the enclave attractive to a certain kind of resident — in two Lewisburg census tracts, the median household income exceeds $100,000 a year. That number struggles to get above $50,000 everywhere else in the county, and just north of town, in a hamlet called West Milton, it’s less than $25,000.

My father, a minister, has a small church right across the river from Lewisburg in a village called Montandon. Montandon isn’t much to look at, with none of the big-city hubris of Williamsport (population: 30,000) nor the glitter of nearby Lewisburg. There’s a chain diner, a state police barracks, some railroad tracks on which I’ve never seen a train. Median household income is about $40,000 a year and unemployment is just over 10 percent. It’s situated in Northumberland County, where there were twenty-seven overdose deaths in 2016, up 80 percent from the previous year.

But it’s in Williamsport, the closest thing we have to a city, where the problem is most pronounced. The forty-eight-hour rash of overdoses earlier this summer demonstrated that reality in gruesome detail.

A thirty-year-old man, cruising in broad daylight down the highway where I learned to drive, suddenly nodded out behind the wheel of his SUV. He was saved by his grandfather, who managed to snatch the wheel from the passenger’s seat and pilot the car to the shoulder.

Later in the day, two men stepped out of a pickup truck only to slump immediately to the pavement. One of them required a breathing machine to stay alive; the other, once resuscitated, was justifiably “uncooperative” with the local cops, who have set a precedent for arresting and charging survivors who happen to be present for overdose incidents.

Medical staff at the local hospitals, by now used to one or two overdoses a day, responded admirably to the incidents, using naloxone to save dozens of lives. But there were deaths, too, sprinkled among the close calls, intensely private tragedies that spilled into the public realm by virtue of the grisly tableaux they left behind.

On Thursday, June 29, one day after the forty-eight-hour spike, a young man was found dead in his apartment in town. A few days later, on Saturday, a young woman named Delaney Marie Ferrell was discovered in a bathroom at the hotel where she worked. She was two weeks away from her twenty-fourth birthday.

In her obituary, Ferrell’s family included a poem she had written about her addiction. The obituary found readers far beyond the river towns of my upbringing — in the months since her death, Farrell’s poem has been shared by people all over the country whose lives are affected by the American epidemic.

The story of Williamsport resonates with the stories of a great many towns and cities across the country, places “long tethered to the vagaries of hard industry,” as the Washington Post put it in one post-election profile, and today afflicted by poverty, joblessness, and mass opioid dependency.

Williamsport sits alongside the west branch of the Susquehanna River, a tributary that once ran thick with prized Pennsylvania lumber. There was a time when there were more millionaires per capita here than in any other city in the country. In the heady days between the Civil War and the 1873 financial panic, lumber-magnate-turned-mayor Peter Herdic transformed the waterside community into a petty fiefdom for robber barons, even constructing a string of Gatsby-like mansions along a stretch of Fourth Street that is still known locally as Millionaires’ Row.

Today, the city has a poverty rate of 27.3 percent, higher even than Philadelphia’s (25.8 percent) and almost double the national average (14.7 percent). Millionaires’ Row still exists, but now it forms the edge of one of the city’s most persistent pockets of poverty, and its mansions are almost all split up into apartments. Yet the high school mascot remains the Williamsport Millionaire, represented on flags and posters by an old-timey top hat and two sleek driving gloves.

Around 2008 or so, when I was in high school, a perpetual caravan of out-of-state license plates started snaking its way through town as natural gas speculation began in earnest. Williamsport sits above the Marcellus Shale, among the country’s most lucrative natural gas deposits. For a few years, fracking seemed to offer the promise of renewed prosperity — 309 new gas wells were drilled in 2011, with permits issued for more than 150 more. But now many energy companies have moved on to newer ventures elsewhere. Fitting a pattern matched in cities around the country, this latest round of disinvestment has coincided, hand in glove, with rising opioid addiction.

Williamsport, incidentally, went 71 percent for Trump. Mayor Gabe Campana, whose political career appears unthreatened by his wife’s credible allegations of abuse, became the first Pennsylvania mayor to endorse Trump in March 2016, when Ted Cruz was still the presumptive Republican nominee. Williamsport’s congressman, Tom Marino, was Trump’s first pick for drug czar (for a few days, at least, before his organized crime connections knocked him out of the running), and served on the president-elect’s transition team.

As the Washington Post dryly noted, “the America of Williamsport” is “the America that fueled the rise of Trump.”

It’s also, of course, one of the many Americas Trump has abandoned since taking office. But it’s not just Trump. Williamsport was failed by its political leadership long before him.

Tom Marino, the congressman and Williamsport native who Trump considered to lead the Office of National Drug Control Policy, responded to his hometown crisis by introducing a bill that actually slowed down DEA efforts to quell the flow of opioids through pharmacies, while making it all but impossible to prosecute pharmaceutical companies for their role in the epidemic. (He received over $63,000 in campaign contributions from big drug companies during his 2016 reelection bid.)

In Williamsport and similar cities across the country, members of the Trump coalition sit in positions of power in local governments — as well as in state houses and congressional chambers — selling snake oil to their constituents and standing in the way of a comprehensive, reparative solution to the drug epidemic.

If Trump’s national state of emergency means a new drug war — this time, with white addicts positioned as innocent victims and out-of-town or immigrant “drug pushers” in the role of villain — these are the foot soldiers who will put Trump’s policies into practice.

For Williamsport, unseating Trump surrogates like Tom Marino and Gabe Campana would be a vital step on the road to recovery. If a meaningful solution to the crisis is to be reached, Trump’s odious coalition must be roundly defeated, at every level of power they hold.

Hope

With alarming efficiency, the outbreak of blindness soon shreds the social fabric of Saramago’s imagined city. Torn between contradictory obligations — on the one hand, to serve the afflicted; on the other, to preserve social discipline in the face of creeping decay — state authorities soon prove themselves poor stewards of the general well-being. A profound lack of creativity from above transforms a public health emergency into a crisis of collective neglect. And it only takes a few days.

The Portuguese novelist’s point is clear: The disease may have been an act of God, but the apocalypse it wrought was wholly political.

The lesson of Saramago’s parable isn’t that apocalypse is preordained. Counterintuitively, it’s actually that solutions are possible. The danger lies in rejecting political action. Disaster only visits when politics is abandoned: the afflicted are sequestered in faraway quarantines, disintegrated from society and left to fend for themselves in the austerity of collective desperation.

Even in the face of a callous and destructive government response, even as drug addiction continues to tear a hot, bleeding swath through so many American communities, political intervention is still possible. More than that, it’s vital.

For the time being, Trump’s state of emergency could very well bring about some much needed ameliorative measures — like the mass dissemination of naloxone, which has the potential to save thousands of lives. But to the extent that Trump’s emergency means a return to the heightened paranoia and destructive scapegoating of the drug war, people in high-addiction communities must fight tooth and nail for a restorative (as opposed to punitive) solution.

This outbreak was borne of a profit-hungry pharmaceutical industry’s collision with a deflated manufacturing sector that left despairing minds and injured bodies in its wake. But Trump denies the social problems at the root of the disease ripping through the hollers of West Virginia and the hamlets of New Jersey.

Instead, he offers a nonsensical alternative explanation: mass opioid dependency is the result of an un-American pollutant whose origin lies in China, or in Mexico, or in a Salvadoran gang — shadowy interlopers against whom the president swears to protect our national integrity. In his scrambled narrative, the Border Patrol and ICE (both early Trump endorsers) are the first lines of defense against a public health crisis that was always homegrown.

We should dispute Trump’s dishonest narrative every chance we get. When this most recent of American drug epidemics comes to an end, it won’t be the result of police intervention or heightened border security. It will be because ordinary people across the country came together to combat the scourge of opioid addiction while demanding an end to the tough-on-crime policies that have proved so destructive in the past.