The Opioid Crisis Isn't A Metaphor

Drug users don't take heroin because of postindustrial despair — they do it because withdrawal feels worse than anything you can imagine.

There is a tendency, among those lucky enough to not be personally affected, to speak about the opioid epidemic in sweeping cultural and political language, declaring it a symptom of all that ails the country. People invoke shuttered factories and jobless towns, turning nationwide addiction to a deadly chemical into another front in the culture wars.

This penchant reached its peak in a recent New York magazine story about the opioid crisis. “The scale and darkness of this phenomenon is a sign of a civilization in a more acute crisis than we knew, a nation overwhelmed by a warp-speed, post-industrial world, a culture yearning to give up, indifferent to life and death, enraptured by withdrawal and nothingness,” Andrew Sullivan warned. “America, having pioneered the modern way of life, is now in the midst of trying to escape it.”

Wait a second. What?

Opioid addiction isn’t a metaphor for the ills of modern life. It is not a medieval morality play. It is an affliction that leads to real people — about 42,000 a year in the US — dying because of the brutal biochemistry of the drugs they’re addicted to: the opioid compounds found in painkillers, heroin, and fentanyl.

People end up with an opioid use disorder because human beings like to get high and they like to avoid pain — two things that opioids are great for, at least in the beginning. And opioids are now readily available across the country, for a fairly straightforward reason: Greedy pharmaceutical companies recklessly distributed pain pills and created a vast new group of drug users. Those users began looking for an illicit alternative when authorities cracked down on the legal stuff. And Mexico’s Sinaloa drug cartel stepped in to meet all that new demand, stretching out its supply of heroin by cutting it with fentanyl.

I have no doubt that if the beer I drank as a teenager, or the weed my friends smoked, had been spiked with the heroin now readily available across the country, some portion of us — perhaps a fifth or so — would have ended up addicted.

And once you’re addicted, you don’t take a hit because you’re surrounded by postindustrial despair. You do it because not taking a hit makes you feel worse than you could have ever imagined. If you go long enough without it, you’ll vomit, crap your pants, and want to die, just for starters. So of course you'll do anything to get another hit.

If that next hit is too strong, it will stop you from breathing. Then, after a few minutes, you die.

The metaphorical side of all this can make for beautiful prose — and Sullivan is just one of many, many writers to make opioids a symbol of America in 2018 — but the problem with this kind of writing isn’t just that it’s self-indulgent. It’s dangerous. When we overlook the terrible chemistry of opioids in favor of abstract narratives of despair, we make some incredible mistakes.

Here’s one of them: To this day, authorities refuse to do real-time testing of the amount of fentanyl in illicit street drugs — stuff that anyone can buy, anywhere, right now — and publish warnings if they’re found to be full of deadly poison. When an egg salad causes salmonella, the CDC broadcasts the hunt for the culprit carton nationwide, but the fentanyl killing dozens of people daily isn’t broadcast until months after blood is drawn from the body on a morgue table.

By overlooking deadly molecular reality, we also spend scandalously little on the replacement molecules, and counseling, that can end addiction and stop deaths. Only 1 in 10 people who need the medication-assisted treatment programs endorsed by the government can actually get them, and the two-year, $6 billion package that has been promised in the recent budget deal is about what we spent on the Ebola crisis, which killed fewer people in its worst year.

We’re spending nowhere near the kind of money needed to rebuild addiction and pain treatment in the country to what is needed. The costs pile up in the meantime: New Jersey alone — not the hardest hit state — spends $300 million a year responding to the opioid crisis, and West Virginia is estimated to lose about $8 billion. The economy as a whole may lose $500 billion a year from the costs of the opioid epidemic; the social cost is impossible to quantify.

Prince, perhaps fentanyl’s best known victim, died with liver concentrations more than six times higher than a fatal dose. He was reportedly a casualty of counterfeit pain pills. He certainly wasn’t a victim of “a culture yearning to give up.” He died because the opioid receptors in his brain wanted pills, but his liver was unable to clear out the toxic dose he unwittingly took.

Today’s crisis is all about that chemistry, just like it was a bit more than a century ago, when morphine was peddled alongside heroin and nearly 0.5% of the US population — hardy Victorian folks, living in an America that had not yet succumbed to withdrawal and nothingness — were addicted to the stuff. Availability combined with endless demand adds up to a tragedy.

The much misunderstood argument that overdoses are one face of “deaths of despair” recognizes this: Opioids are just deadly drugs sprinkled on a bad situation, like cinders dropped on a dry forest. People need jobs and meaning in their lives, relief from pain, all the good things whose absence, according to the more complicated explanations for the opioid crisis, leads to addiction.

But any solution begins with putting out the fire. Taking on the chemistry that is driving this crisis will cost huge amounts of money and require the kind of commitment and focus our government seems virtually incapable of these days. But at the same time, all of us need to understand that this is first and foremost a problem of chemicals.

You can even put that understanding into practice. Not long ago, after a late day at work, I came across a young couple passed out in the stairwell of my parking garage. My first thought was they had been beaten in a mugging and left for dead. They didn’t look like they were breathing. But when I knelt down I saw that they were, very slowly — one breath, and then a count to four or five, then another. They had overdosed.

What you are supposed to do in this situation is try to stir people, rasping their breastbone with your knuckles if you have to. If they are turning blue or frothing at the mouth, they are well on their way to dying, and they need the overdose reversal drug naloxone immediately.

So I gave them both a shake. The man opened an eye after a few long moments, looked at me sleepily, and started pushing at his companion, who stirred. I ran to alert nearby staff to the problem. They were doubtless only mildly overdosed — every trip is an overdose, honestly speaking — and would have lived without the shaking. But it’s not like I could have just blithely stepped over them.

A nudge on a stairwell doesn’t change much, but it’s another kind of beginning: seeing overdose victims simply as people in trouble who need help, not as symbols of national decay that we need to argue over.

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