We’re still far away from treating drug dependency like diabetes

Dawid Krawczyk: Opioid crisis in the United States is no longer a topic that you will spot only in medical journals. There are TV shows and reports about the victims of heroin or fentanyl in newspapers almost every day. When did the opioid epidemic start? And is it a crisis?

Michael Collins: The US has had challenges around heroin for around a decade now. But it used to typically be a challenge for big cities, like Chicago. In recent years we’ve observed the transition of heroin problems to rural communities and rural states like Kentucky, West Virginia, Ohio, and New Hampshire. It has happened for a certain number of different reasons – from job losses to challenges around prescription drugs. And yes, it is a crisis, so I won’t give one easy story that would explain all the reasons.

But I could get such an easy story elsewhere, right?

Obviously, you can find articles that will tell you that big bad pharmaceutical companies were overprescribing and they pushed these drugs on people that didn’t want them. It’s not entirely false but it is also not entirely true, it is a lot more complicated.

Look at West Virginia. It has suffered huge job losses over the last 5 to 10 years, people are mourning the loss of their jobs and looking for an escape. Drug use and escapism go hand in hand. It is way more problematic than this narrative about irresponsible doctors who ran the so-called pill mills and heavily overprescribed opioids. I’m also sceptical about this explanation because it’s based on this belief that we should just cut off the supply of prescription drugs and that it will solve the problem. There are people who were suffering in pain and took these drugs for legitimate reasons. If I offered you OxyContin today that doesn’t mean you will automatically become addicted to it.

Drug use and escapism go hand in hand.

I don’t have any sympathy for pharmaceutical companies, I don’t have any skin in that game, but I do think that we have to dive a little bit deeper to find the root causes of the opioid epidemic because only then will you have different solutions. Because there is not one solution, this crisis has multiple roots, therefore, it needs multiple responses.

We need to talk about injection facilities, expanding syringe exchange programs, and medication-assisted treatment. We need methadone and buprenorphine also in jails. But I know that the U.S. population is still caught in the drug war mentality when we hear about drugs the first thing we want to do is to stop the supply of drugs.

“Overprescribing doctors” and “pill mills” feature in almost every story about the opioid crisis. You say that we should focus on something else.

There is definitely a problem with legal pharmaceuticals that individuals were prescribed. The classic example is the high school athlete who gets injured, gets ankle problems or something like that and then is prescribed OxyContin, a serious painkiller that is highly potent and highly addictive. There wasn’t enough education around these very strong substances and therefore you have individuals who became addicted to these prescription drugs.

The high school athlete gets ankle problems and then is prescribed highly addictive OxyContin.

But it’s not that the doctors didn’t know what they were prescribing, right?

They did know, of course, and using stronger prescription drugs to deal with pain is not always a problem. But it may become one when you stop prescribing at some point. And when the person is addicted they will try to buy drugs on the streets. In most of the cases the drug they used is too expensive on the streets, so they go for a nearest affordable equivalent.

Heroin?

Exactly, heroin. six years into this and I see it is not getting any better. In fact, one of the things that has made it worse is the arrival of synthetic drugs, like fentanyl.

Fentanyl is another hot topic. According to some sensationalist stories, it is the deadliest drug ever.

It is a way more powerful opioid than heroin, like a hundred times more powerful. It’s a fact. It is dangerous and deadly, but you’re right that there are a lot of sensationalist approaches to this drug. I’d prefer to read more about what drives the sales of fentanyl.

Fentanyl is a way more powerful opioid than heroin, like a hundred times more powerful.

And what is that?

If you are a drug seller then you are always interested in making your product more potent and cheaper, it is as simple as that. And fentanyl does that unfortunate thing, it is more potent and therefore more desirable.

How does it get to the US?

The usual path, it is manufactured in a laboratory in China then it is taken to Mexico where it is added to heroin and then it is brought to the US. In some places, the only drug that is available is heroin cut with fentanyl. This is how things work when you deal with an unregulated drug market – people use the most dangerous substances, as far as they’re available and obviously, overdose rates go up dramatically. It’s not that there are no solutions, you have the Swiss model of heroin distribution (people who use drugs receive clean heroin under supervision) that drives overdose death rates down. But the US is not there yet, politically.

And where is it, when it comes to drug policy?

We have an absolute nightmare of a President, we have a nightmare of an attorney general. It is hard to see how long this nightmare will last. But such huge progress like heroin-assisted treatments or safe consumption spaces is highly unlikely in foreseeable future.

What in your opinion should be a priority in a public health response to the opioid crisis?

If I had a magic wand I would expand medication-assisted treatment especially to prisoners in jails. It is the number one priority. When people are using methadone and buprenorphine they are not using fentanyl, heroin and they are not putting themselves in dangerous situations.

But somehow you can’t expand it here in the U.S. It doesn’t matter what is happening in Portugal (decriminalization of all drugs), Switzerland (Heroin-assisted treatment) or the Czech Republic (decriminalization of most of the drugs). Americans just think they’re the number one country in the world: we are really the greatest country in the world and we don’t have anything to learn from other countries. The health care system is an absolute shambles here. So what? They don’t want to look at Canada or the UK or France or Spain or any other country, a list of those who have a far superior healthcare is quite long.

With drug war policies nothing happens unless you reach a certain level of public support or even public ignorance.

Do you think that it is the general approach in society or rather views shared by the president and attorney general Jeff Sessions who famously said that “good people don’t smoke marijuana”?

I think if you walked the streets and say “Hey, I am a politician and I want to reduce sentences for drug deals” most people will say “Why would you do that?”. With drug war policies nothing happens unless you reach a certain level of public support or even public ignorance. Let’s look at the induced homicide – the idea that if you sell drugs to somebody, and that somebody overdoses then you get charged with homicide. I see people eagerly supporting that stuff, even though it doesn’t work, it doesn’t drive overdose rates down.

We worked with the Obama administration on sentencing reform, President Obama himself was very invested in reducing sentences from drug sales. The same Obama administration had prosecutors on federal level doing drug-induced homicide cases.

Under this administration, the name of the game is damage limitation. We have to limit the damage, put up the defenses. Even if it means only making an impact in terms of peoples mentality. When Obama went to visit a federal prison, the first President ever, nothing actually changed but the symbolism of him humanizing prisoners, with hugs and all that is hugely important. Even though we may not change laws, there is still rhetorical and messaging winds that you can point to.

Actually, the rhetorical winds are blowing in an interesting direction when it comes to the current opioid crisis.

What do you mean?

We’re still far away from treating drug dependency like diabetes or any other disease.

It’s completely different narrative than the one we know from the 80s and 90s crack epidemic. Back then the focus was almost exclusively on black users of crack cocaine who were portrayed as criminals or living dead. With opioid crisis it’s different. It’s even hard to compare the stories about white middle-class users of heroin we get to read today to those from the 90s.

It’s a narrative that’s taken hold that white people get sympathy whereas black people go to prison. The current response to the opioid epidemic is generally more sympathetic and more understanding of drug addiction and drug use. This is true and that’s a race thing, that’s absolutely about race and that’s about who takes drugs. At the same time, it’s more complex than that.

Even though there is more sympathy for white people we still lack basic medical support. The sympathy hasn’t translated into concrete actions, and sympathy doesn’t help you so much when you’re overdosing. Even though there is more sympathy for drug users there is no sympathy for drug sellers and the latter are often drug users. It’s not a binary issue.

My fear is that if we say “oh, white people get more sympathy” it could mean “we don’t need to focus on the opioid epidemic anymore because we are in a good space”. White people and black people who use drugs are still treated absolutely terribly. The stigma is very heavy. We’re still far away from treating drug dependency like diabetes or any other disease.

Michael Collins is deputy director at the Drug Policy Alliance’s Office of National Affairs, in Washington, D.C., where he works with Congress on a wide variety of drug policy issues including drug war spending, syringe access funding, appropriations, and Latin America. He holds a Master’s degree from Georgetown University’s School of Foreign Service, where he studied international relations.