The Coming Crisis in Opioid Nation

OPEN SOURCE WITH CHRISTOPHER LYDON 7.20.17

(Google Images)

PART I

I’m Christopher Lydon. This is Open Source. Here’s a short list of what’s strange and different about this opioid epidemic. The poisons of choice and convenience are cheaper, laced with synthetics like fentanyl, much more powerful and more available than poppy heroin ever was. The problem is everywhere — rustic New Hampshire a spike on the national map. And the devastation is almost out of control: deaths on the order of 50,000 a year, drug dependency for 2,000,000 Americans, 10 percent of them getting treatment. An aggressive, expanding marketplace is choking on a 30-year promotion of pain meds, like Percoset, addiction warnings long muffled and unheard. For most new users of illegal opioids, the gateway is an array of prescription painkillers like Oxycontin. The racial profile and the enforcement culture around drug abuse are markedly changed: opioids can be blamed for a shocking turn down in life-expectancy for white males in the US; but the stigma and the racialized rage around drugs are much reduced. We speak of drug addiction more realistically now, more humanely perhaps, as a disease, no longer a crime.

And so our crash course begins this week, to feel the size and shape and hear the sound of a full-blown public health nightmare in a circle of purgatory or possibly hell, known as the opioid epidemic.

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CL VO: Jesse Gaeta is the medical doctor that addicts meet at the Boston Healthcare for the Homeless next to Boston Medical Center on Albany Street. Her patients, she says, are the furthest “downstream” in the opioid crisis — literally collapsing from overdose — or in horrible fear of withdrawal. They come back and back, needing a safe space or maybe emergency treatment, like oxygen and a drug called Narcan, which revives people who are unconscious and at risk of death… Doctor Gaeta walked us around the block the main drag of the opioid crisis in Massachusetts… She calls it Recovery Road, but it’s better known as “Methadone Mile”…

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Jesse Gaeta: Sometimes we respond to overdoses right here on the front walk, that are really significant overdoses. It’s a place where lots of folks have been actually sleeping at nighttime and there are moments where it almost feels like an open air drug market. I don’t know if you’ve noticed one person smoking cocaine from a crack pipe.

Person 1: It’s an epidemic.

Person 2: This is out of control around here.

Woman 1: We need more help in here.

Man 1: I’ve been homeless two months. Due to circumstances I became homeless and I came out here to South Hampton Street.

Christopher Lydon: What’s working for you?

M 1: Well I’m not really a heavy drug addict. Technically I do K2. I like K2. That’s what I smoke.

CL: What kind of treatment or help do you want?

M 1: I just want…housing.

CL: And what do we hear from family?

M 1: My family is out of the book. They’re written out of the book for the time being.

Man 2: I’m by myself right here. The first years I was doing good. I got a job, nice job and then I started hanging out with the wrong crowd. And look what I ended. With no place no family. My wife left me and everything. Because the drugs.

Female Addict 1: Um, I’ve been using for 10 years. I’ve — no, no, not ten years. My daughter’s nine. I didn’t get high when I was pregnant. Never touched a drug. I didn’t get high until she was a year and a half, so…

Dr. Jesse Gaeta: [You’ve] been doing really well though…

FA 1: I’ve been doing five months until two weeks ago I relapsed and then I got into a car accident two days ago. My car…I took off. My daughter, I was taking her to school every day, picking her up these past five months. I’ve been a mother, I’ve been doing so good, and then… [audible crying]. Just two weeks ago I relapsed.

JG: Tell them just how hard it is to, ah…

Dr. Jessie Gaeta of Boston Health Care for the Homeless

FA 1: It’s so hard. It’s gross. I’ve never seen anything like this. I thought I was in a movie when I came out here. ’Cause I never got high out here. I just got high back… — you know what I mean? Like, to myself, I never really…then I came out here two days ago. I slept out here. It’s just disgusting.

CL: What treatment do you want?

FA 1: I’m on, so I was on Suboxone for five months. I’ve been doing great, and then two weeks ago, I don’t know why, I don’t know what happened, I lost it. I used. I left the house. You know? I just took off. I haven’t seen my daughter since.

CL: Are you getting high now?

FA 1: Yes, I am.

CL: How hard is it to find what you need?

HW 1: Extremely hard. Everything’s hard. This whole life is hard. It’s like a full time job to get high. It’s just… It’s like, it’s out of control.

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CL: Kathleen Frydl is a political historian at the University of California, Davis. Her book is The Drug Wars in America, 1940-1973: they were the gateway, she argues, to our contemporary crisis.

Kathleen Frydl, welcome. Once upon a time, you write, we had a pretty effective drug enforcement regime. What happened?

Kathleen Frydl: Yeah, our effective drug enforcement regime, including out policing of illicit drugs, was premised on a regulatory model of taxes and tariffs. So, we tracked all opioids, including heroin which was once a licit painkiller, as soon as they came into the country by virtue of a tariff. And then, by following them through a tax stamp at every location, we tracked those drugs, including their diversion. But in the 1940s and the 1950s, the Bureau of Narcotics and Drugs, which is the predecessor to the Drug Enforcement Agency, landed on this “great idea”, and great idea there is in quotes, to actually prohibit heroin because there was a such a problem with diversion of the drug. And, by ever increasing steps, slowly and surely, we’ve wound up into a place where drug prohibition greatly compounds the harms of the drug crisis itself. So, drug prohibition has turned what was once a regulated drug and a known risk, into an unregulated drug, and an unknown risk.

CL: In the 80s, Kathleen, and we remember it, suddenly pain doctors appeared and pain medications galore and without warning, without warning of addiction. How did this happen?

KF: Yeah. Well there are some features of the opioid crisis, you know, the sounds of which you just ran through, which are heartbreaking to hear. There are some features of the current opioid crisis, the worst drug crisis in US history, by the way, that are very typical of other drug crises that we’ve had in the past, in the sense that it’s been widely acknowledged that they were preceded by the abandonment of government policy in certain places and also the disappearance of work. But there are some things, there are some features to our current opioid crisis that are kind of a failure of politics specific to our current moment. In particular, there are two things: Drug prohibition, which we just ran through, and the second one is global neoliberalism.

That neoliberalism specifically is characterized by three things. One is deregulation. The second is austerity, which usually involved the privatization of some government functions. And the third is unrestrained free trade. Remarkably, all three of those things play a role in the opioid crisis. In particular, what you were just mentioning, the kind of mass marketing of pain pills have a lot to do with the transformation of the institutional culture of the Food and Drug Administration as a result of deregulation and privatization.

Kathleen Frydl

CL: Kathleen, the most interesting number I’ve read, in a sort of crash course of my own, is that four-fifths of new heroin users today are coming off prescription painkillers. Just how does that transition happen?

KF: Ok. So that number came to us in 2013 and it was a huge wakeup call at least within the community of practitioners. This opioid crisis has unfolded in kind of successive waves, and you can kind of think of it as Big Pharma laying the foundation for the broad prescribing of opioid pain pills, especially for chronic pain, but for acute pain prescribing as well. They laid a foundation that was kind of built upon by illicit drug cartels. So throughout the first ten years, the first decade of the new century, we steadily increasing opioid overdoses largely as a result of opioid pain pills. Then around 2009, we started to heroin illicit markets feed off of the very same people and the very same places that were most susceptible to prescription pain pill overdoses.

CL: How different, Kathleen, is the deregulation of drugs and of pain medicines from the deregulation of banking? Glass-Steagall, that separated speculative banking and service banking.

KF: It’s a great comparison in my eyes because a lot of the dangers can’t be predicted at the moment of deregulation. There is a danger of unintended consequences that are involved in these kind of structural reformulations, like the repeal of Glass-Steagall for instance. Nobody could have predicted the way in which financial derivative products could destabilize the global economy. Well, likewise, when Bill Clinton thought it was a great idea to modernize the FDA and transition half of its budget over to industry. So the Food and Drug Administration now gets half of its money directly from the government and half of its money directly from the pharmaceutical industry. The ways in which — I mean, pain pills and pain pill over-prescribing was relatively new at the time. Nobody could have predicted that it would lead to the worst drug crisis in US history, and yet, here we are.

CL: Again, the worst banking crisis in modern memory, too. I keep wondering why they don’t just reenact Glass-Steagall, but I also wonder why the FDA and the industry don’t just say, “Oops! Bad mistake, we’re going to reimpose the old rules.”

KF: Yeah. It’s actually tremendously disheartening to be active in this space because we are at a point where, in March 2016, the Los Angeles Times published an investigation that disclosed previously sealed court documents. These court documents came from a West Virginia lawsuit against Purdue Pharma and those documents made it clear that Purdue Pharma advocated for the approval of OxyContin based upon misleading information and that the FDA was aware of that and knew of that misleading information. And yet, just last week the National Academy of Sciences released a report on opioid pain pills and the opioid crisis more generally. And I was hoping the recommendations would be, specifically, to reinvestigate the legitimacy of opioid pain pills for prescribing for chronic pain, which is one of the largest markets that we’ve seen Purdue Pharma exploit. And we do, in a broad sense, encourage the FDA to review opioids as a class of drugs, but there’s a huge reluctance on the part of the political establishment to revisit some of these decisions because people are still making a lot of money from them.

CL: Woah. Everybody knows somebody whose kid had a football injury, got a bad steer toward pain pills, and got into trouble. I was prescribed OxyContin, without my knowing it, for a tooth implant. No pain of any consequences, completely unnecessary. We all know that these things get way over prescribed. What would it take to cut through the financial power of that industry?

KF: Well, that’s exactly it. I think you’ve put your finger on it. A lot of people are under this impression that we can walk ourselves out of the darkest days of the opioid crisis, purely via voluntary messages and education.

CL: Kathleen, stand by. We’ll be back.

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Coming up: White-Out by Michael Clune stands out in the opioid literature for taking readers inside the experience of addicts, both high and crashing. Addiction is a memory disease, he says, a failed mechanism when it comes to sorting the past. This is Open Source.

Part II

The writer Michael Clune was born in Ireland, raised in Chicago, with a yen for books. He was studying at Johns Hopkins in Baltimore for his Ph.D. in English when he met the high of heroin and then the black hole that he decided over and over was inescapable. He got out 15 years ago with a qualified ‘reverence’ for what heroin does. He begins here from his book White-Out:

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Michael Clune, from his book White-Out: In Baltimore that summer the best heroin was sold in little glass vials with white stoppers. White tops. The color of the stopper was like a brand. If it was good, its reputation would spread. (“Where’s Dom?” “Dom’s dead.” “What was he doing?” “White tops.” “Who’s got ‘em?” “Fathead.” “Where’s Fathead?”) Eventually dealers with inferior product would start using the good color, and then the people with the hot dope would have to change to red or blue stoppers. It was a cycle. I’d been off the stuff for almost six months, but as soon as I saw that empty white-top, I got a funny, destiny feeling.

You might think the whiteness of the white tops isn’t that important. After all, over the past few years I’d bought red tops, blue tops, black tops, and even yellow tops. Of course, the drug itself is often white, but it can also be brown, and the white is really just an effect of the cut. But the first stuff I ever did was in a vial with a white top, and its whiteness showed me dope’s magic secret.

The secret is that the power of dope comes from the first time you do it. It’s a deep memory disease. People know the first time is important, but mostly they’re confused about why. Some think addiction is nostalgia for the first mindblowing time. They think the addict’s problem is wanting something that happened a long time ago to come back. That’s not it at all. The addict’s problem is that something that happened a long time ago never goes away. To me, the white tops are still as new and as fresh as the first time. It still is the first time in the white of the white tops. There’s a deep rip in my memory.

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MC: What I would say with my experience of addiction, I think the aspect that a lot of people have a difficult time understanding is that it is a memory disease. Now the actual experience of taking heroin even the first time, it is euphoric, but it’s no more so than a whole variety of other kinds of experiences I’ve had. Ranging from falling in love, walking in a beautiful landscape.

But here’s the crucial difference: For the addict that experience in your memory grows so large and intense and unforgettable and omnipresent that it dominates you and almost forces you to worship it in a way that those other experiences really don’t. There’s no other analogue to it. So I always want to draw a sharp distinction between the way the addict feels when they take it and the way that the addict remembers it.

During my using days I had a friend named Dave. And Dave was not an addict, but he did heroin with me one day a couple of times and every time we did heroin you know he would say the next morning, “Hey that wasn’t that great.” And I would be saying what are you talking about it’s the best thing ever. So one time we did an experiment. I got a pen and a pad of paper and we both did heroin together. I said Dave write down on the pad in the paper what you’re experiencing. And he wrote down this is the best feeling ever. This is amazing. I feel so relaxed I feel like I’m floating all of this like euphoric stuff. The next morning, he said, “Oh, it was an ok time, but I basically remember it being kind of sleepy and throwing up a bunch of times and that’s it.” And I showed him the the paper and he said, “Well that’s weird but I don’t really remember it that way.”

For me, when I think about heroin or look at any of the objects associated with heroin, whether it’s a spoon or a straw or a vial or the white powder, instantly what flashes back as if no time at all had elapsed was the memory of the euphoria of the first time. For me, the first time I did it was on a roof in Soho in New York in the summer and that’s the experience right that roof comes back, the sky looks, the people I was with. That’s what I see when I look at dope.

CL: We spent some time, and you can’t avoid it these days in a big city or even in the countryside, you meet all kinds of addicted people. Can you put us in the heads of those people? They’re homeless. They’re poor. They’ve got complicatedly screwed up backgrounds and histories.

MC: I can relate and empathize with addicts and I also work with, on a volunteer basis, with addicts here in Ohio today. Anyone who’s had the experience of addiction I think can relate.

On a day to day basis, my life was essentially all about getting money and getting the drugs. From the moment I wake up in the morning I’m hustling. How am I going to get some money? What can I do in terms of bouncing checks? What stores can I steal from? How can I come up with this with this cash right? Because the thing is it’s like an hourglass you’ve got about four to six hours from every dose until the withdrawal symptoms start.

The best thing that ever happened to me was getting arrested on a felony charge in Chicago on New Year’s Eve in 2001. That arrest and putting me in jail over the next days in in jail I got some of that distance from that rat race, that insanity. That made me think, “Hey, maybe you know I need to get some more serious help for this.”

The cover of Michael Clune’s new book

CL: A woman that sounded like you, Michael, talked to us yesterday and she said, as you’re saying, “This is insanity I’m in a bad movie. I got to get out here but I’ve been in it for a long time.” That sort of thing, but she’s she’s the privileged one. So many more don’t seem even aware of where they’re at. They’re numb and say it.

MC: This is the million dollar question which is why was I able to find recovery when so many people that were smarter than me, less addicted than me that I’ve known in my life are now dead or serving life life sentences in prison because of the things they did in their addiction? I have no idea what the answer to that question is. I went to, probably, I think I added it up one time I went to 13 detoxes in my years of addiction. I went through withdrawal 13 times, went through the worst of it 13 times. The vomiting, the shakes, the chills, and so forth. The depression. I was fortunate to get arrested with a serious enough charge to take off the street for long enough for that moment of clarity to take hold as it finally did. Very very fortunate. I’m sure I would be dead by now if it wasn’t for that.

The message I’ve got to give is you can be happier than you’ve ever been, more peaceful than you’ve ever been not on drugs. Because when you’re an addict if you can imagine life without drugs it just seems to you like this boring endless, pleasureless expanse. This desert. Freedom from that grind, Freedom from that depression, that despair. That is a huge, I mean, it’s amazing it’s like a high everyday for me to be honest. And then it just opens the door to all the ordinary pleasures of life, right?

I remember after I was clean for about a few months and the depression subsided, just the taste of food right. The pleasure of walking outside and being in nature really minor pleasures that ordinary people take for granted. For the addict, that comes as a revelation.

Part III

That’s Michael Clune’s version. Michael Patrick MacDonald has another in his memoir All Souls of South Boston in the 1980s, a proud old Irish-American community coming apart around poverty, crime, drugs, and then gentrification. I never forget your line, Michael, that addiction is about trauma, trauma and trauma…

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CL: Explain what you mean.

Michael Patrick MacDonald: Well, in my experience anyways, with the populations I’ve worked with, what I’ve seen over and over is that people that are struggling — especially with any kind of pain killing addictions — are coming from a life of trauma, basically post-traumatic stress. The population that I come from in South Boston, for people who don’t know, growing up there in the ’70s, 80s, and ’90s it was the neighborhood with the highest concentration of white poverty in America, and it was also controlled by organized crime. Whitey Bulger was there, large-housing projects, mostly Irish-American community. You had a lot of death. You had a lot of trauma. You had a lot of people disappearing. You had murders. You had people getting involved in truck hijackings and bank robberies, people being incarcerated. A lot of families with a lot of trauma, and basically world-shattering trauma in their lives.

During the years we were controlled by organized crime, Whitey Bulger was confirmed in the trials, the Whitey Bulger trials a couple of years ago, during those years he oversaw the influx of cocaine into the community. We had the highest death rate from cocaine and crack, higher than any other neighborhood in Boston other than perhaps Charlestown, the other small, Irish-American, working-class, and poor community at the time. We were always competing for highest death rates. But these weren’t discussed at all, these weren’t in the news. These were kind of our secret because these were things that only I would find in the public health statistics. And the neighborhood was kind of invisible, in terms of people wanting to work on those issues and the issues that might lead to that level of addiction and death.

Now, we also have this code of silence, so nobody in the neighborhood talked about. Media weren’t really getting information, and if they would come into the community nobody would speak to the media. This was the effect of having someone like Whitey Bulger in a tight grip on that stuff.

So you come out of those years, Whitey Bulger goes on the lamb in the mid-90s. Now he did, it is true that he kept heroin out of South Boston. That’s something that he bragged about in court. And that is true, and we all always knew that and it was always as if, well, you know, heroin’s particularly dirty. Meanwhile, all our deaths that were happening throughout the ’80s were pretty much as a result of cocaine and crack. Now when he went on the lamb, that’s when you had this community left behind with immense pain, and then you had an influx of heroin into the community. We had a huge explosion of heroin deaths in the mid to late ’90s and one that has continued with the diaspora of this neighborhood.

CL: I’m remembering, Michael, that your tribute to heroin is that “it works!” You quote medical authorities, real ones, that say it may be the only thing that works against Post Traumatic Stress Disorder. Explain that, and what are the alternatives?

MM: One of the things in the mid to late ’90s, there was a huge upsurge in suicides in our neighborhood from hanging and there were lots of attempts, people being cut down every day. For about six months, we had this huge suicide epidemic among teenagers. At the same time you had the beginning of the heroin epidemic. In both situations, you were dealing with people who had all the experiences I had in my family, you know, coming from a family of 11 and losing four siblings, very young, to the effects of poverty and violence and incarceration and drugs. So all the people I saw that were dying in those years were coming from the exact same experiences I come from with the same levels of trauma.

Now the problem was that the City of Boston, the solution that they had for this epidemic was to send in teams of psychiatrists who were giving people prescriptions for pills. Basically, I had — a good friend of mine’s the head psychiatrist at Bellevue and she’s always talking about how there is no pill for Post-Traumatic Stress. There’s one thing that “works”, and she’s only saying this to account for why people turn to it and that is Heroin. Heroin works. People with PTSD will have a natural gravitational pull towards heroin. Not to say that everybody on heroin has huge adverse childhood experiences, but it is true, statistics show that people with highly adverse childhood experiences are way more likely to become addicted long-term and to die as a result.

CL: Michael, I want to draw Kathleen Frydl back. She’s talking policy. You and Michael Clune are talking emotional pain. What’s the meeting here, Kathleen?

KF: You know, what rings out for me, in terms of what Michael just shared with us, is the mid-1990s influx of heroin. That’s one of the things that jumped out at me when he was talking just now. The mid-1990s was a time when NAFTA as a trading agreement tremendously increased the flow of goods into this country. And I can tell you, most of the time no one mentions it, but not a single thing has influenced the stream of illicit substances into this country more than the NAFTA agreement.

Drugs are a trade. Anything that increases the flow of goods and people across borders is going to lead to an increase in drugs. So I’m not surprised at all with the timing of the first heroin epidemic that hit South Boston.

CL: But are you advocating walls, Kathleen? [Laughs] Should we stop trade all together?

KF: No, but I’m not surprised that people are. I think that Trump’s kind of ludicrous suggestion was greeted with a kind of coastal snobism and a kind of dismissing of it. It’s important to realize that a lot of counties from which he drew his votes have been so heavily ravaged by the opioid crisis, that they have reason to look towards Mexico, even if they don’t have a lot of immigrants living amongst them. They have reason to look at Mexico with a lot of anxiety.

CL: Michael, over to you. How do you stand on trade?

MM: You know, I totally agree that neoliberal global capitalism has had a huge part to play in all of this. It’s just a matter — I think that Trump has kind of tapped into one aspect of this truth and turned it into a xenophobic rage, nationally. And that’s unfortunate because there is some aspect of that that we have to address, which has everything to do with globalization. But, of course in his rhetoric it turns into a racial profiling.

CL: I want to question the branding of this word pain. You’ve said and written, Kathleen, there was a move on to make pain the fifth vital sign, along with your blood pressure, your temperature, your respiration. The confusion of chronic pain, physical pain, emotional pain, real pain, imagined pain, what about pain, Kathleen? Is it a legitimate reason to be dropping regulation?

KF: No, certainly not, but it is a legitimate medical crisis. In the field of chronic pain, what we have now is chronic medical failure. Remarkably, in the midst of the broad overprescribing of opioid painkillers, we still in many respects stand in a health system that actually undertreats and poorly treats pain. I return again and again to the simple fact that opioid painkillers have not been proven to be clinically useful for chronic pain patients. That is often neglected and, of course, Big Pharma, which sort of owns a lot of real estate in the political and media establishment, wants you to forget it. But we have yet to prove the utility of these drugs. That’s to say nothing of the realities of pain. A lot of the things that Michael was describing, and another one of the comments that he made that jumped out at me, is pain is often accompanied by other ailments, especially depression, PTSD. I’m not saying that people imagine they feel worse, I’m saying that pain is literally worse when you have those conditions. That’s how funny our brain is wired. Once again, it’s really not surprising to me that when you have neighborhoods and communities exposed to trauma, what we’re seeing in red county and red state America, entire swaths being exposed to the disappearance of work, you know, Rust Belt America, so on and so forth. It’s really not surprising that we should find a pain crisis, where we find the abandonment of communities.

Michael Patrick MacDonald

MM: Right, and I would say when you have this community in immense emotional pain and having suffered huge catastrophes that they weren’t allowed to talk about, then turning to, at first the hanging epidemic. Around that time, I was talking to a lot of newspapers about the role of trauma in all of this and it was pretty much being ignored because people wanted it to just go away and they just wanted to put these kids on pills. I bumped into a point person for the City of Boston who became a good friend of mine, a point person working on this stuff, and she said to me, “Please keep speaking out!” Now I thought she was going to be angry at me for all the stuff I saying in the papers, she said “Please keep speaking out because every single one of those kids that tried to hang themselves, we locked up and put them on pills and everyone of them today is a heroin addict.”

CL: Wow… Michael, I want to hear more from you when we come back about your alternative therapy of talking. Tell the story, find the story, transform the story, make the story and keep telling it. Coming up: The color line that runs between the crack epidemic in the 1980s and opioids today. Media storytelling, law enforcement, lasting consequences are conspicuously different. This is Open Source.

Part III

A primer on the Opioid plague before it engulfs us. How like, how unlike, the flood of crack cocaine that hit black America in the 1980s? That epidemic accelerated the War on Drugs, the quasi-military transformation of policing, and 40 years of mass incarceration. I asked Donna Murch, Drug War historian at Rutgers, to tear and compare two drug crises:

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Donna Murch: What was really striking to me about the opioid crisis is that it continues that white users are seen in entirely different lense. The article that came out in the New York Times, it had a picture of a mother and a child and was talking about the problems of a child born addicted to buprenorphine, which is a drug that’s used to help wean people from their opioid addiction. It was an incredibly empathetic account of mother and child and the challenges they faced and I think everyone who read that of a certain age immediately thought of the discussion of crack mothers and crack babies and the development of a whole generation of people, essentially, who were not human, who would not have powers of reason, who would be unable to function in society, would be capable of incredible amounts of violence and the only thing that could be done would be to warehouse them. That’s when you see how purely this was about race and had nothing really to do with discussions of addiction, dependence, or public health.

CL: How would you apply that, that hindsight? I mean, will we ever go back and look at black families who were being devastated by crack and say we’ve got to make it up. They were in desperate need of income, help, treatment, counsel, housing.

DM: Yes, I think that that’s very well said. I think that thinking about a kind of truth and reconciliation about what happened in the drug war, and having that kind of discourse — I want to be clear, the drug war continues. People are still being arrested and prosecuted, especially for marijuana possession. So, stopping what’s happening now, it’s not only past tense. It is continuing throughout the country.

I think what we need to continue to talk about is people that have had inordinate sentences, getting people out of prison, breaking down the line between violent and nonviolent offender. So, I think using the racial contrast, the way these two different problems are being treated, to really highlight the deep role of structural racism and to think about, most urgently, how to get people out of prison and to ensure they’re not being put in prison in the future.

Donna Murch

CL: Correct me if I get this wrong, but what I’m hearing is that the response to crack in the ’80s was hyperpolicing and mass incarceration. The response to the opioid crisis includes a lot more empathy, not big incarceration of users. It’s a disease, not a crime. Is that racism at work or is it also progress?

DM: It’s hard to disentangle the two, but I mean there’s no question it was racism. I mean the intense racial discourses that were used, like superpredator, the language of a people that essentially were not human. You almost have to use the counterfactual, what would be happening now if we imagined that the opioid crisis was primarily African-Americans? Given the scale of punishment, the mechanisms for stop-and-frisk still exist in many places throughout the country. So in that sense, I don’t think it’s just been a transformation from one to the other. The media coverage has been specifically about white opioid addiction as it’s been called, but that doesn’t mean the whole punishment apparatus hasn’t been directed at not only African-Americans, but also Latino populations, the undocumented. So maybe we’ve made some progress. I’m not sure. I think that the status of the opioids because it was linked to prescription drugs also does matter.

CL: How so?

DM: Well, I think it’s part of the class composition of this crisis. It’s people that had health insurance, right? There’s the discussion about these are middle and upper middle class people, there is also a discussion about adderall. The drugs that are killing people now are prescription medications.

CL: Donna, make what you can of the Trump politics of all of this. We associate the hillbilly counties that voted for Trump as part of the problem. What is the connection?

DM: It’s a very good question. I think it’s well into a narrative. The narrative is that this reflects white suffering. I think that’s how it links into the Trump base. So even Republicans, who are absolutely hard line stance on the drug war are talking about we need to find monies within ACA repeal and reset specifically within opioid addiction. That has to do with how they see their base. It’s also happening in the context of people with a radical deregulatory regime. That’s why they can’t talk about pharmaceutical companies. These are big powerful companies that are crucial to the American economy. I think that’s why we’re getting a much narrower discussion on the focus on the people themselves, rather than to ask ourselves policy questions. How did this happen?

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CL: Donna Murch has written her book, forthcoming, titled Crack in Los Angeles: Policing the Crisis and the War on Drugs.

Back to you Kathleen Frydl, who wrote A History of the Drug Wars and the Policies Since the 1940s. What do you make of the racial key to the differences here?

KF: Yeah, I think Donna is completely right that the stereotype of addiction has changed dramatically from the crack-cocaine epidemic to the opioid crisis now. I think she’s also right, in fact the published work of my own agrees with her, that racism was a major driver of drug prohibition and all of the kind of subsequent mass incarceration bills that we saw from 1984 to 1990 and 1994. But I do want to raise…I think it’s important to draw similarities between the various drug crises. I think it’s important to also distinguish them. The way in which the stereotype on addiction has changed is one contrast. Another is the crack-cocaine epidemic inflicted its worst damage in homicide rates, and it inflicted it’s worst damage in cities among young African-American men. In fact, the homicide rate among them actually paralleled some of the worst opioid overdose death rates that we’ve seen in Rust Belt and rural America. So it was actually a massacre.But I think people react to homicide very differently and I think there was actually a lot of support for mass incarceration and punishment policies from the same African-American communities that the crack epidemic was raging in. So that was one point of distinction.

Another thing that I think is worth keeping in mind is that the drug war has not been dismantled. I think the addiction stereotype has changed, but we still have opioid users who are incarcerated. In fact, a lot of the rhetoric, and some of the programs of treatment are coexisting alongside a move toward greater punishment. And that’s not just Donald Trump and Jeff Sessions. Across counties, among and throughout the various states, we’re now seeing punishment and mandatory minimum sentencing coming back. So I think, to look at it with a historian’s eye, it’s really too soon to say that we’ve changed the discourse and we’ve changed the approach.

MM: I was going to totally agree with that. I get alerts on heroin and Massachusetts in particular, so everyday you get multiple stories and most of them are about arrests and if you pull up the pictures most of them would be users. The drug war is on. Again, they would be, at least in Massachusetts, they would be white. I come from poverty and I tend to be able to identify class and I tend to identify that they come from poverty. The other aspect of this that I just wanted to mention, I did a lot of community organizing over the years, most of my work has been in poor and working class black communities, latino communities, white communities. It is true, I agree that the manifestation of the crack epidemic was in shootings and that’s the huge massacre that you see, I totally agree and we’re seeing something that’s totally on parallel with that.

I also want to say that the perception that this is a white, i.e. rich people problem, or even a middle-class, upper-middle-class problem, is a myth that’s been out there. White and suburban tends to mean middle-class to people and that’s just not true. If you look at the CDC reports for heroin abuse and the Massachusetts reports, if you look at the health insurance reports, it’s overwhelmingly people with no health insurance coverage or Medicaid, but also overwhelmingly people that come from households that made $20,000 or less. If you look at Massachusetts it’s overwhelmingly people with a high school education or less, so that’s, those are some indicators that point to the class that’s disproportionately impacted. It doesn’t mean that we don’t all know people from wealthy families who have lost their son, or that it’s spreading, because all this stuff spreads.

CL: Michael, I want to know about the “new empathy”, the nonjudgmental treatment and the empathy for addicts is striking, but I wonder how deep does it go between your generation in South Boston, for example, and the black families of the crack epidemic, who went through mass incarceration and are still going through it.

MM: It’s true that the response to the crack epidemic was totally racist and all about dehumanization, the superpredator and all that, I totally agree. I was there for all of that and I remember all of that and I worked with families of homicide victims who were dealing with all that. What we dealt with in South Boston — because I was working in both communities at the time — But in South Boston what we were dealing with was an invisibility. So I would say places like South Boston throughout the country, including a lot of the Rust Belt states — and by the way, when you look at the map of the worst of the opioid epidemic, the Rust Belt states are the worst along with Massachusetts and Rhode Island, which is really interesting —

CL: Explain that. Explain that. Massachusetts and Rhode Island, on the national map.

MM: Well, you look at the map and that’s what’s colored in the darkest for the opioid epidemic. I would say that a lot of — in Massachusetts and Rhode Island a lot of the class indicators would be invisible to most people. I would say we’re always perceived to be Harvard and upper-class liberalism and all that kind of stuff. So the perceptions are different from the reality, and I would say there is a lot of paranoia in terms of the disappearance of work and things like that. But what we experienced was more of an erasure and it’s really not as bad — I hate to say that one thing is worse or better than the other — it’s really not as bad as dehumanization and superpredator and all that. People do know people who are friends, middle-class, upper-middle-class whose son is addicted and got hooked first on pain pills and then got worse. So everybody knows someone like so I think the perception is that it’s becoming more affluent white, you know, it’s becoming more in the press more. When it was happening to us — and it’s an ongoing thing, along with drug war. It’s an ongoing thing that I’ve seen over the past two and a half decades. Over the years, we were kind of missing from the story. Now we might be in those stories, but the newspapers will call it white suburban and that looks middle class to people.

CL: Kathleen, I’ve got two quick questions on fentanyl, which is sort of new to me. One, have we not missed a huge opportunity in the dreadful death of Prince, the entertainer, to surface the danger? To do for the fentanyl problem what Rock Hudson did for AIDS?

KF: Yes, we have. In fact, fentanyl, illicit fentanyl is largely produced in China and sent directly to the United States or to Mexico. I don’t understand, having said before that drugs are a trade, I don’t understand why the United States government has not raised China’s unregulated chemical manufacturing —

CL: — I wonder, too! But here’s my second question about fentanyl and China: what if fentanyl is history’s revenge for Britain’s Opium Wars in the 1830s and ‘40s? It was all about forcing Indian opium into China, the Chinese resisted and the British whacked them and said, “No, you’re going to take it in the name of free trade!”

Kathleen Frydl’s book

KF: Exactly. In so many ways, and what I’ve tried to underscore in my remarks is that this opioid crisis is a karma boomerang coming back. It’s not just global neoliberalism and extended free trade, which, by the way I also don’t understand why heroin and fentanyl-laced heroin is not a part of the NAFTA renegotiation. It should be. It should be one of the things that’s on the table. But what I want to say is that Donna is right about the stereotypes and I think Michael is right about the erasure, I know he’s right about it. All of this is changing as a result of fentanyl. Fentanyl will now more broadly distribute the harms of heroin across regions. We, in Washington, D.C., the place where I live, we have actually seen our opioid deaths double within the past three years. And that has had it’s own form of silence. Our response to it has not gotten anywhere near the attention that it should. Whatever the harms were in the past, and I think it’s important to discuss those, everybody is going to be at this table eventually. I think it’s incumbent on us all, now, to start to point to the pain that’s behind this opioid crisis and the policies that produced it.

CL: Could I ask you both, before we’re done: do, not that we want to bring even more militarization to our police forces, but are we paying enough attention to the peddling of drugs, including fentanyl, to our kids? I mean, we don’t seem to — we used to, in the crack epidemic we had “drug-free” zones around schools and a lot of talk about it. Where has that vigilance gone in the opioid crisis?

KF: I can’t speak for Michael, but for myself here in D.C., one community I don’t understand is not more affected is methadone clinics. Methadone clinics are a known target for illicit heroin dealers and now with white-powder heroin I’ve seen laced with fentanyl, I don’t understand why our police resources — I mean I do understand it — but I raise this in community meetings to say I don’t understand why our police resources and proactive and protective policing can’t be extended to our most exposed and vulnerable populations.

CL: Michael MacDonald.

MM: I agree with that absolutely. We’re seeing a lot of that around methadone clinics in Boston as well, but we need to be careful, of course, with asking for more law enforcement at the little guy level and more action on the part of the Feds. A lof of our problems in South Boston, we had a drug lord that was in cahoots with law enforcement so we have to be careful with what we’re asking for there.

I think that we could do more on all levels, and certainly with getting people to be aware of the trauma that they come from, and be able to tell their story in a safe way and be able to transform that into a lifelong mission.

CL: And while we’re at it, Michael, we could ask the Food and Drug Administration to rethink the licensing of production of this stuff, and reinstituting the severe restrictions on what drug companies can produce.

MM: Absolutely. In terms of things growing, spreading, let’s remind ourselves what happened with the gun violence epidemic which was perceived to be isolated in black communities and has become a national epidemic as well.

CL: Are we going to remind ourselves of the time limits of the hour, too.

~~~

Thank you Michael Patrick MacDonald, Donna Murch, Jessie Gaeta and the very helpful people at Boston Healthcare for the Homeless. Thanks also to Kathleen Frydl. If you’d like to reach Kathleen she encourages you to contact her on twitter: @kfrydl.

Our show this week was produced by Conor Gillies, Zach Goldhammer, Becca DeGregorio, Susan Coyne and Kevin Doherty. George Hicks is our engineer. Mary McGrath is our executive producer. I’m Christopher Lydon. Join us next time for Open Source.

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