Support for President Trump is highly correlated with living in a region stricken by what are being called “deaths by despair”: skyrocketing rates of suicide, alcohol-related fatalities and most notably, relentlessly rising deaths from opioid overdose. These often-rural areas have been hit hard by job losses, with high unemployment and shredded social fabric. Not surprisingly, the overdose epidemic came up repeatedly over the course of the election — largely through questions from voters — starting from the very first primaries.
Unfortunately, what might be seen as a form of political correctness has long stymied America’s reaction to the problem. To take the most egregious example, we actually know how to cut opioid overdose deaths at least in half with existing treatment, but we fail to do so because much of the rehab establishment is philosophically opposed and because stifling regulation cripples the ability to rapidly expand evidence-based care.
If President Trump wants to help these suffering constituents, he needs to take bold action against these ideological and regulatory roadblocks. There are five critical components to improving drug policy, which do not require radical legislative change.
First, we need to fight the real problem, which is addiction and other harmful drug use, not simply drug supply. Second, we need to massively expand access to evidence-based treatment, which is currently rare. Third, more evidence-based prevention is needed, which is again currently in short supply. Fourth, drug risks need to be prioritized in context, which means fighting the most dangerous drugs first and foremost.
Finally, for any of this to help in a sustained way in the most vulnerable communities, people need decent, adequately paid stable jobs. This series will explore each of these policy ideas in greater depth over the course of this week.
The addictions field is too PC to acknowledge that the vast majority of drug use — even of cocaine and heroin — occurs without doing harm. Most of it doesn’t involve addiction, overdose, or other damage.
Though many in society would obviously prefer for there to be no drug use, in a world of limited resources, it makes sense to focus policy on fighting the most harmful use first. That means recognizing that the main problem we need to address is addiction — and that addressing addiction requires a whole different perspective than fighting a war on drugs.
When the modern war on drugs was first declared by Richard Nixon in 1971, thinking about addiction was simplistic: it was caused by the body developing a physical need for drugs after repeated exposure to them. People who chose to continue to take drugs until this occurred were hedonists, driven first by a desire for unearned pleasure, then by a desire to avoid withdrawal pain. Consequently, cutting the drug supply would solve the problem.
Now, however, science has shown that addiction is much more complex. For one, only about 10-20% of people who take drugs non-medically — even drugs like heroin and cocaine — become addicted to them. Second, this group is different from those who don’t get hooked before they even try substances: at least half have mental illness, 2/3 suffer from the after-effects of child trauma and most of the rest have also experienced some recent form of distress or dislocation, often unemployment.
Physical withdrawal symptoms can also occur with drugs that are not linked with addiction (like blood pressure medications) and highly addictive drugs (like cocaine) do not leave people physically ill when they quit, though they certainly will be irritable. Seeing addiction as drug dependence was a mistake.
Consequently, today’s experts, like the National Institute on Drug Abuse and the diagnostic manual of psychiatry, the DSM 5, recognize that addiction isn’t just physically needing a drug to function: it is compulsive use of a substance to cope with a problem, despite negative consequences. Essentially, it’s a learning disorder, in which the brain does not change harmful drug-related coping behavior even in the face of horrific losses like job loss, being cut off from family, losing friends, prison.
As a result, cutting supply without addressing the root of the problem tends to merely shift people from one addiction to another. It’s like expecting a ban on soap and hand sanitizer to stop obsessive hand-washing: if the underlying issue isn’t dealt with, alternative means of engaging in compulsive behavior will be sought.
In fact, this is why the Obama administration and states’ efforts to cut prescribing and prosecute pill mills have actually increased overdose deaths. The pill mills had lists of everyone who received these drugs directly from doctors — in order to get controlled prescription drugs, you need to show real ID. But rather than being offered evidence-based treatment when law enforcement shut these doctors down, addicted customers were left to fend for themselves.
That left a market opportunity for gangsters, who rapidly supplied far more dangerous drugs — fentanyl and its derivatives, which are dozens of times more potent than heroin. This followed a pattern seen so often during the drug war — where more dangerous drugs pop up when police crack down on one source or route of supply — that it has an academic name, the Iron Law of Prohibition.
Another key fact about addiction that makes the drug war approach ineffective is that its very nature is defined by resistance to punishment. That’s what compulsive use despite negative consequences means: if you don’t stop even when you lose your house, your job, your friends, your spouse and your health, it’s unlikely that other punishing experiences like prison sentences will deter or change you. When we understand that addiction is learned behavior that resists punishment, it’s obvious that we need a whole different approach.
If our new president can move beyond the old, failed strategies by rethinking addiction, there are concrete steps he can take to save lives now. In the next four days, I’ll explain each of them and how these changes can finally start cutting the death toll.