content warning: drug-related death, addiction
Say you’re locked in a room with a glass of water.
The water has a small amount of poison in it.
Hours pass, then a day or two. Some may be able to resist their thirst for a time, but as dehydration begins to rear, most will go for the water, though they know it to be dangerous.
This is the comparison Dr. Josiah Rich, a Professor at the Alpert Medical School, and Infectious Disease Specialist at Miriam Hospital, offers to describe the process of opioid withdrawal. As he told the Independent, “If you think that you’re going to die, you will do desperate things to survive.”
Opioid withdrawal occurs when someone who has been regularly taking an opioid—either a prescription drug, like Vicodin or OxyContin, or an illicit one, like heroin—stops taking that drug. When opioids bind to receptors in the body, they alter the perception of pain, producing a pleasurable sensation instead. The brain begins to expect this feeling of pleasure, and stops producing as many of its own, naturally-occurring opioids. At the same time, the brain develops a tolerance for the drug, meaning that it requires more of the opioid to experience any sort of high.
“Someone who uses regularly will no longer be using to get high, they will use to avoid withdrawal and craving,” Patricia Cioe, a professor in Brown’s Department of Behavior and Social Sciences, told the Independent.
According to the American Addiction Center, withdrawal often begins with muscle aches, fever, insomnia, and high blood pressure. As it progresses, symptoms include nausea, diarrhea, and cravings. The brain is struggling to acclimate to the abrupt absence of opioids, and to regulate pain, which was previously altered.
It is in this state of mind—this moment of neurological tailspin—that most low-level crimes related to opioid use occur, said Dr. Rich. The opioid crisis reveals the extent to which our criminal justice system prioritizes retribution over rehabilitation, and makes visible how we—as individuals and as communities—respond to basic human suffering.
With the third highest use of non-heroin opioids in the country in 2015, Rhode Island has been hit especially hard by the opioid crisis over the past decade. According to the state’s Department of Health, opioid overdose is the leading cause of accidental death, accounting for more fatalities each year than all homicides, suicides, and car accidents combined.
Put simply, “every single community has been affected,” said Dr. Brandon Marshall, from the Brown School of Public Health, in an interview with the Independent. With this in mind, it is important to analyze the image of the typical opioid user painted by most national coverage: a younger to middle-aged white man.
According to statistics from the Kaiser Family Foundation, of the 254 total opioid overdose deaths in Rhode Island in 2015, 210 were of “white, non-hispanic” individuals, 10 were of “black, non-hispanic” individuals, and 30 were of “hispanic” individuals. Although these statistics demonstrate that the majority of in-state opioid overdoses are of white people, one should not ignore the deaths of non-white Rhode Islanders by treating this as an exclusively white phenomenon. Close attention should be paid to how the different identities of an individual who uses opioids might impact their access to treatment, and their likelihood of seeking it.
The portrayal of opioid use as a “white thing” is laden with racism, as Georgetown sociology professor Michael Eric Dyson explores in his recent book Tears We Cannot Stop: A Sermon to White America.
“White brothers and sisters have been medicalized in terms of their trauma and addiction,” Professor Dyson writes. “Black and brown people have been criminalized for their trauma and addiction.” As the New York Times has reported, the city faced a surge of heroin and crack use beginning in the 1970s. This use was largely pinned on communities of color, and then demonized as causing crime and handled with harsh mandatory-minimum laws. Addicts were treated as criminals; there was no effort to portray opioid dependency as a medical condition, requiring treatment rather than punishment.
In today’s epidemic, most people begin using opioids with a prescription for a pharmaceutical opioid—like Vicodin or Oxycodone—given to them by a doctor to manage pain.
Prior to our current understanding of opioid dependency, most prescriptions did not include warnings about their addictive nature. This narrative of this ellision of their addictive nature can be traced to a short, oft-cited letter, entitled “Addiction Rare in Patients Treated with Narcotics,” which was published in a 1980 edition of the New England Journal of Medicine. The authors, Jane Porter and Dr. Hershel Jick, stated that, in their study of 11,882 patients, they found “the development of addiction...[to be] rare in medical patients with no history of addiction.”
Following this publication, other studies were conducted—such as one by Dr. Russell Portenoy, with a test group of just 38 patients—and the incidence of addiction was found to be low. Simultaneously, as Professor Cioe explained, a new emphasis was placed on pain management. In 1996, the well-known painkiller OxyContin came on the market, from the company Purdue Pharma, and was advertised as having few lasting health complications. Purdue circulated 15,000 copies of the promotional video “I Got My Life Back” in doctor’s offices across the country. The video chronicled the success stories of six individuals taking OxyContin.
Eleven years later, in 2007, three executives from Purdue faced criminal charges that they had misled doctors and patients in downplaying the addictive nature of their product. However, by this point the market was already flooded with narcotic painkillers.
Purdue eventually released an “abuse deterrent” version of OxyContin, known as Targiniq ER. However, according to a study from the New England Journal of Medicine, 66 percent of patients who abused OxyContin had moved on to another opioid by the time Targiniq ER was approved. The most common choice was heroin, which is cheaper and more accessible. The same study indicates that no OxyContin abusers were deterred from their habit by the alternative.
A lot of stigma emerges from the refusal to understand addiction as a disease, which contradicts our increasing awareness about the genetic nature of addiction. That is to say, if you have a history of addiction in your family, you are genetically predisposed to it, just as someone might be predisposed to cancer.
If a person with the right combination of genetics and circumstances is exposed to an opioid, they can quickly run into trouble, Dr. Rich explained to the Independent. He added that many who begin with a prescription say the drug genuinely helped alleviate their pain at first. For someone who has experienced chronic pain, this relief is incredibly significant.
The seeds are sown in this way: a patient who may have a genetic predisposition to addiction, coupled with pain, is given an opioid pharmaceutical by their doctor. The patient may recall the narrative, developed over the past 40 years by big companies like Purdue, that drugs like OxyContin help people regain control of their lives. They begin to take the painkiller, which helps at first, but soon experience the symptoms of substance use disorder. While this is of course not the case for every patient prescribed an opioid by their doctor, it is the case for thousands of Americans. These thousands face a world of misconceptions, and a criminal justice system that funnels individuals with substance use disorder into prisons rather than treatment centers.
“If drug use was to truly be taken as a public health concern, personal possession of drugs would have to be decriminalized,” said Diego Arene-Morley, a recent Brown graduate who now works for RICares, a non-profit focused on creating a community for individuals affected by substance abuse disorder. As it currently stands, he added, police are called again and again to deal with the same group of people, with the same motivations—getting money for drugs. This cycle indicates how ill-equipped the police are in handling the issue.
In Rhode Island, to address increasing use and addiction rates in the state, Governor Gina Raimondo signed the Overdose Prevention and Intervention Action Plan in 2015. This initiative was co-written by many medical and community leaders, including Dr. Marshall and Jonathan Goyer, manager of the community recovery center Anchor MORE and statewide advocate for peer recovery programs. The initiative’s goal was to reduce deaths caused by opioid overdose by one third within three years by focusing on four major areas: prevention, rescue, treatment and recovery.
In terms of prevention, a push was made to enroll 100 percent of in-state prescribers in the Prescription Drug Monitoring Program, a database that previously was not well utilized. Before prescribing an opioid, Rhode Island doctors must now consult the database to see if a patient has received any prescriptions from any other doctors. This, Goyer told the Independent, helps prevent “doctor shopping.”
Another aim of the initiative was to increase the prescription and use of Naloxone, an opioid antagonist that, if administered quickly, can reverse an overdose.
An overdose, explained Arene-Morley to the Independent, is a respiratory phenomenon that often results from mixing substances. Naloxone reverses the depressant effects on the user’s respiratory system by crowding out opioids and binding to the receptors in their place.
Most opioid overdoses that occur today in Rhode Island are due to the presence of fentanyl, a synthetic compound that is used to cut other products, including heroin, said Dr. Marshall in an interview with the Independent.
Fentanyl is cheap, easy to transport, and dangerously potent. If an individual takes their typical dose of a substance, and is unaware of the presence of fentanyl—even miniscule amounts—they can overdose within minutes. Dr. Marshall is currently leading a study in which he and his team have asked 90 participants to test their drugs for the presence of fentanyl, using special test strips, and to report back their findings. If participants do find traces of fentanyl present, Dr. Marshall has instructed them to either throw away the drugs, or to use cautiously, with a friend, who is trained to use Naloxone.
Many owe their lives to Naloxone, including Goyer, who overdosed in 2013, and was saved by a peer in recovery who had the drug on hand. In Rhode Island, Naloxone can be picked up at a pharmacy, without a prescription; the closest such pharmacy to College Hill is the CVS in Wayland Square. Naloxone comes as either a nasal spray, or an injectable, which a pharmacist can show you how to use.
The Good Samaritan Overdose Prevention Act of 2016 legally protects anyone who administers Naloxone to an individual experiencing an overdose. The 2015 initiative also pushed to fund the outfitting of all police departments in state with the drug, although a handful of departments still do not supply their officers with it. This hesitation around using Naloxone, despite the funding and increased awareness, stems from the same conviction that criminalizes users by saying that they deserve whatever they get.
The second half of the 2015 initiative focused on treatment and recovery, areas in which understanding addiction as a disease is especially important. When addiction is taken as a judgment of an individual’s character, detox is the expected solution, which means suddenly going off opioids without medical treatment.
“A lot of people think detox is treatment, and it’s not,” said Dr. Rich. “90 percent of the time [after detox] people relapse. If that’s your treatment, and it fails 90 percent of the time, you’re in trouble.”
Dr. Rich is a major advocate for access to medically-assisted treatment in state, especially for incarcerated individuals. Medically-assisted treatment, or MAT, combines long-term counseling and the careful administration of drugs such as Methadone, Suboxone, and Vivitrol to help individuals resist cravings and take crucial steps towards recovery.
There are important differences between the different MAT drugs. For example, Methadone, which makes the brain think the opioid is still present and alleviates some of the symptoms of withdrawal, can only be administered by a federally licensed clinic. Daily trips to the clinic can be an added burden in the recovery process. Suboxone, in comparison, can be prescribed by any licensed medical professional and picked up as an over-the-counter prescription, which is a major step in providing easier access to treatment.
These drugs, though they have the potential to be abused, allow many in recovery to return to full, self-directed lives. However, according to a recent New York Times article, less than a third of “conventional drug treatment centers” in the country currently offer MAT. Even in Rhode Island, where the 2015 initiative pledged to expand access to medically-assisted treatment, Goyer reported that there is currently not enough long-term treatment available to residents.
Not everyone is ready to begin treatment, often due to traumatic past experiences with medical professionals. In these instances, harm reduction practices—which include everything from clean needle exchanges to supervised injection sites—can provide spaces that are, as Dr. Rich explained, “patient-centered and non-judgmental.” Harm reduction should not be viewed as opposed to MAT; rather, the two complement each other.
Supervised injection sites are considered one of the more radical harm reduction practices, and, as of now, they mostly exist in literature alone. The aim of supervised injection sites is to provide safe, clean facilities where individuals can inject their drug of choice with the supervision of a team of medical professionals. This space lessens the odds of overdose and exposes users to non-threatening, supportive environments with the hopes of opening the door to a discussion about MAT.
Insite, in Vancouver, Canada, is the first legal injection site operating in North America.
“There are people sitting at their own little booths,” said Dr. Rich, describing his visit to Insite. “[It’s] almost like a hair salon.” Nurses give out clean syringes and alcohol wipes. Other medical professionals talk with clients about possible treatment options; some go right upstairs and begin their treatment.
Supervised injection sites, although promising, have a long way to go before they become established in Rhode Island. “I don’t think [they] would pass in Rhode Island, because of the conservative impulse that if you invite people to a place for safe use, more people will start using,” said Arene-Morley. Here again, stigma interferes with advances in opioid dependency treatment.
Our state and our country must recognize that opioid addiction is a disease that continues to be penalized as a choice. To right this wrong, the voices of peer recovery coaches and individuals with experience of substance abuse disorder must be centered in conversations about addiction. This means calling out the myths sold by major pharmaceutical companies, and being frank about how incapable our criminal justice system is of handling a public health situation. Medical care—not more cages—must be the path forward in the national approach to addiction.
NORA GOSSELIN B’19 thinks you should visit the interfaith memorial tree for the lives lost to overdose at Roger Williams Park Community Garden.