Opioids in New Hampshire and beyond

Last week, the New York Times ran a piece about a family in New Hampshire and their struggle with their adult son’s opioid addiction. Based on almost a year’s worth of interviews and other interactions with the family, the piece details the crippling impacts of drug addition for individuals, families, and communities, and, along with another piece published the same day, highlights the limits of current strategies for intervention, support, recovery, and care for addicts. One of the major questions underlying this pair of articles is, why New Hampshire? It doesn’t fit the profile as defined by other states and localities in the US facing the most difficult challenges of opioid abuse, such as West Virginia and Ohio, where economic stagnation, deindustrialization, and easy access to painkillers, among other factors, have created the conditions for a crisis. Yet as the second article points out, a recent poll indicated that over 50 percent of New Hampshire residents, a relatively small but prosperous state of just over 1.3 million people, view drug abuse as the state’s most pressing issue. New Hampshire ranked third in the US in 2016 for drug-related overdose deaths, and the release of transcripts last summer revealed that President Donald Trump called the state “a drug-infested den” during a conversation with Mexico’s president shortly after taking office. I’ll let you read the multiple reasons why the opioid crisis has so deeply scarred New Hampshire in particular, but want to point to two specific contributing factors as a way of talking about the geography of addiction, treatment, and recovery. The first of these is the question of New Hampshire’s place in geographic networks of illicit drug trade and distribution, which has made opioids and other drugs relatively accessible. The second is the ideological component of treatment and the social management of addiction, and the scale at which we (and that’s a big ‘we’) articulate and locate responsibility in relation to drugs and addiction.

First is New Hampshire’s position relative to drug production and distribution networks that are both global, tied to the international pharmaceutical industry and illicit production of narcotics, and intimately local, at the street level where casual users and addicts procure drugs from dealers or other retail points that they often know well. As the last link above and the story from the Times indicates, one of the major causes observers postulate for New Hampshire’s addiction crisis is the proximity of major urban centers, all of which lie in the southernmost part of the state, to the city of Lowell, Massachusetts, not far over the state line. Lowell and many neighboring communities on the north side of the Boston metropolitan area are former mill towns that have been ravaged by decades of deindustrialization and disinvestment, and along with Boston have become major transhipment points for drugs communities across New England. But proximity alone is not enough to produce a crisis of the magnitude that has occurred over the last few years. In neighboring Maine, current Governor Paul LePage made national headlines with inflammatory and racist remarks in January 2016, and again in August of that same year, when he claimed first that Maine was being flooded with drugs by “guys with the name D-Money, Smoothie, Shifty” who “[h]alf the time … impregnate a young white girl before they leave,” then followed by arguing that “90-plus percent of [drug dealers arrested in Maine] … are black and Hispanic people from Waterbury, Connecticut, the Bronx and Brooklyn.” As PBS reported, these claims are unsubstantiated and draw on familiar but harmful and inaccurate stereotypes about minorities, drugs, and the diffusion of crime, addiction, and other social ills from broken-down places to supposedly more innocent people and places.

Meanwhile, the highly competitive and lucrative distribution network for prescription painkillers operates openly, profitably, and without similar social stigma, for now at least. In West Virginia, for example, reformers, advocates, and pharmacists have debated the merits of carrying Narcan and other emergency overdose drugs for opioid addicts, revealing and deepening rifts between actors in the pharmaceutical supply chain. Fortune featured former doctor and prescription painkiller addict Raj Masih, who now assists with interventions and argues for stronger regulation of drug distrbituors and pharmacies, in a June 2017 Fortune piece on McKesson, which along with two other large drug wholesalers, was sued by several local governments in West Virginia for not appropriately detailing large and suspicious shipments of prescription painkillers to federal drug regulators and the DEA. In the piece, Masih:

“counters that the resistance by pharmacists is another example of stigmatizing addicts. ‘Some have an attitude, “These people did this to themselves. Just let them die. Why do we want to bring them back from an overdose?”‘ he says. The same pharmacies, he points out, have no qualms about carrying highly addictive painkillers such as oxycodone. Says Masih, ‘We need a change of community mindset.’

In a different part of West Virginia, McDowell County Sheriff Martin West stated that large transnational pharmaceutical companies also bear responsibility for the opioid epidemic, pumping far more prescription drugs into community than is warranted, making them “no different than drug dealers selling on the street.” So the forces that bring drugs to addicts in places like rural West Virginia and small-town New Hampshire are part of much larger and far-reaching networks that are both legal and illegal, a core part of the health care economy on one hand, moving factory-manufactured and lab-standardized doses of prescription drugs by the millions and from numerous far-flung sites around the world, and the product of illicit economies that produce heroin and other hard drugs in Asia, Africa, and Latin America and transport them through a variety of means to consumers in a very lucrative global market.

So the question of ‘why New Hampshire?’ needs a multifaceted answer that relies not just on arguments about poor economic conditions and lack of social services and supports for addicts, or even about the geographic proximity to socially destructive forces and places for drug transshipment or retail. These are important factors, of course, though how they are framed, particularly the way we understand and approach addicts and addiction more broadly is important for guiding our actions within these networks and for trying to solve the problem of drug abuse and the ‘opioid epidemic.’ This brings me to my second point, the ideological component of addiction and treatment and the location of responsibility for its management as a social problem. This is closely tied to the issue of why this place or these people. I would argue that this responsibility is both overwhelmingly individualized and destructively bundled and cut loose from its particular geographic settings and conditions. The cumulative effect is that the systems put in place to handle addiction and assist addicts instead often treat them simply as abstracted and pathologized bodies, to be moved through a series of bureaucratic processes that often punish as much as they help and do little to undo or alter the conditions identified in answering the question of ‘why this problem in this place for these people?’ This is not to say that those groups and individuals addressing drug abuse and the current epidemic in treatment centers, in homes and schools, and on the streets aren’t doing good work. But there are competing ways of understanding addiction and addicts, and they pull in very opposite directions, isolating the responsibility in individual addicts. Others point to the larger systemic forces, which are impersonal and overwhelming and impossible for any individual, family, or even a community to control or ignore. In both, addiction is naturalized as a kind of logical result of an essential pathology – there are simply irresponsible people, who cannot be trusted to take care of themselves properly, or there are global forces that just operate and are too difficult to buffer oneself against or to alter through collective action. Thus you get addicts who are addicts because they simply don’t make good choices, or you get addicts because that’s simply what happens when broad economic forces turn on you. It is also, I would suggest, the archetypal framing and understanding of social pathology under the four-decade ascendance, dominance, and decay of neoliberal ideology in government and daily life. The famous but often-shortened quotation from former British PM Margaret Thatcher comes to mind – there is no such thing as society. But the full quotation, from a 1987 interview with Woman’s Own magazine, is worth repeating here:

“They are casting their problems at society. And, you know, there’s no such thing as society. There are individual men and women and there are families. And no government can do anything except through people, and people must look after themselves first. It is our duty to look after ourselves and then, also, to look after our neighbours.”

This individualizes responsibility for social problems without acknowledging either the social context in which individuals must operate and make their lives, and on the other hand, does very little to acknowledge the individuality of people, locating the individual as a repository of essential, inherent qualities that are either good (in which case we take them to the market) or bad (in which case we try to isolate and contain them). This isn’t a relic of the past; read again the quote from the doctor/advocate/former addict Raj Masih above and what some pharmacists in West Virginia tell him, or the commentary by the governor of Maine (who, by the way, is in his second term, so let’s not pretend he’s not saying something people don’t want to hear). And read again the articles from the New York Times, about how addicts get shuffled through court, prison, and treatment systems, about how health care institutions deflect on one end while another arm of the industry manufactures and distributes opioids at a massive scale, about how local institutions like firehouses and churches must try to fill in the cracks, about how governance of addiction is based (largely but not always) on seeing addicts as merely bodies to be moved around until they no longer present a problem. There must be better ways, and these are often tried at a small scale, but if they are to work it seems they must not only address the geographies of addiction that have historically been attempted, things like continuing the failed ‘war on drugs’ or controlling the precursor supply chain for illicit drugs or cracking down on drug manufacturers and distributors or criminalizing drug use and imposing hefty fines and lengthy prison sentences. It must also build from the bottom up, from recognizing addicts as individuals, and places as alive with possibilities for those individuals. These must be tailored to the nuances of local places and people, and they must give agency to addicts and their communities. In fact, that seems to be the common thread across most of the stories I read of the opioid epidemic – people feel stripped of agency over their own lives, and drug use gives them a sense of control, even if that is ultimately illusory and destructive. I don’t have good answers but I am hoping to start seeing success stories soon instead of those like I have linked here, where families, communities, and people are ripped apart by opioids.

Not long after posting this a friend and colleague from Manchester, Cristina Temenos, noted that the terminology used in research on drug use and drug users is increasingly moving away from labeling people as addicts, and she pointed me to a useful article in the Boston Globe about the changing style of Associated Press and other media usage of terms such as addict, addiction, and alcoholism. The article notes: “‘Addict’ defines a person by his illness. ‘Substance abuse,’ with its echo of ‘child abuse,’ suggests that a person is misbehaving rather than ill, advocates said.” This is a subtle but important distinction, and one that I was a bit careless with in the post above, but it does reinforce the idea I hoped to get across, namely, that substance use and drug dependence and the geographies of social solutions to these problems, too often locate responsibility on the individual, and do so in ways that essentialize drug use as an inherent moral failing of the user. So thanks to Cristina for the helpful rejoinder, and check out her research on this topic at her official University of Manchester site.