To the Teacher:
America is in the grips of a nationwide epidemic. Currently, nearly 2 million people in the U.S. are addicted to opioids—drugs that work on the opioid receptors in the brain to produce feelings of euphoria and extreme relaxation. According to the Centers for Disease Control and Prevention (CDC), 91 people die every day from opioid overdoses. The scale of the crisis—which cuts across class, race, age, and geographic boundaries—has led politicians on both sides of the aisle to recognize the need for immediate action.
Often, government officials have approached drug addiction as first and foremost a criminal justice matter—seeking jail time for addicts and dealers alike. This approach is seeing a resurgence under the Trump administration. However, critics of this approach point to the inadequacy of the U.S. government’s 40–year "War on Drugs" and contend that there is a need for new thinking about how to address drug crises. They argue that we should see the opioid epidemic as a primarily a public health issue.
This lesson consists of two readings designed to have students think critically about the opioid crisis, its origins, and potential solutions. The first reading provides background on the crisis, examining its origins, scope, and magnitude. The second reading looks more closely at the different perspectives and approaches for fighting the epidemic—including criminal justice and public health perspectives. Questions for discussion follow each reading.
The Opioid Crisis––Its Scope and Origins
America is in the grips of a nationwide epidemic. Currently, nearly 2 million people in the U.S. are addicted to opioids—drugs that work on the opioid receptors in the brain to produce feelings of euphoria and extreme relaxation. Taken in large enough quantities, opioids produce extreme respiratory depression, which can result in death. Some commonly–known opioids include morphine, fentanyl, and oxycodone, which are primarily used in medical settings for pain relief.
As CNN Medical Producer Nadia Kounang reported in a June 29, 2017, article, the number of people addicted to opioids has increased rapidly since 2010, and the number of deaths by overdose has reached an alarming level. Kounang wrote:
An analysis from Blue Cross Blue Shield of its members found that from 2010 to 2016, the number of people diagnosed with an addiction to opioids – including both legal prescription drugs like oxycodone and hydrocodone, as well as illicit drugs – climbed 493%. In 2010, there were just 1.4 incidences of opioid use disorder among every 1000 members. By 2016, that rate had climbed to 8.3 incidences for every 1000 members. Yet, at the same time, there was only a 65% increase in the number of people getting medication–assisted treatment to manage their addiction...
These numbers illustrate the continued difficulty of trying to get control of this public health epidemic. According to the U.S. Centers for Disease Control and Prevention, 91 people die every day from an opioid overdose. In 2015, more than 33,000 lives were lost to opioids. In fact, drug overdoses—most of them from opioids—kill more people than guns or car accidents.
The deaths from prescription drugs alone have more than quadrupled since 1999. Added to that is the threat of heroin and synthetic drugs like illicitly made fentanyl. Deaths from synthetic opioids alone, such as illicit fentanyl, jumped 72% from 2014 to 2015.
As Vox.com senior reporter German Lopez wrote in an Oct 26, 2017, article, experts trace the roots of the current opioid epidemic to the early 1990s, when pharmaceutical companies began a marketing blitz. These companies promoted these highly addictive drugs as safe and effective for the treatment of pain patients. Doctors, in part convinced by the marketing campaigns, began prescribing the drugs more freely. Lopez writes:
The opioid epidemic began in the 1990s, when doctors became increasingly aware of the burdens of pain. Pharmaceutical companies saw an opportunity, and pushed doctors — with misleading marketing about the safety and efficacy of the drugs — to prescribe opioids to treat all sorts of pain. Doctors, many exhausted by dealing with difficult–to–treat pain patients, complied — in some states, writing enough prescriptions to fill a bottle of pills for each resident.
The drugs proliferated, making America the world’s leader in opioid prescriptions. As Stanford drug policy expert Keith Humphreys previously noted, "Consider the amount of standard daily doses of opioids consumed in Japan. And then double it. And then double it again. And then double it again. And then double it again. And then double it a fifth time. That would make Japan No. 2 in the world, behind the United States."
Lopez notes that there are a variety of reasons for the higher rate of opioid prescriptions in the United States, citing the role of both pharmaceutical companies and doctors. He writes:
First, there were the pharmaceutical companies. Wanting to make as much money as possible, these companies marketed their drugs as safe and effective for treating pain — even though the evidence for opioids shows that, particularly for chronic pain, the risks outweigh the benefits in most, but not all, cases. Many doctors and patients were convinced by this campaign. (Purdue Pharma, the maker of OxyContin, and some of its higher–ups later paid more than $600 million in fines for their misleading marketing claims, and opioid makers and distributors are now facing many more lawsuits on similar grounds.)
Then there were doctors. On one hand, doctors were under a lot of pressure from advocacy groups (some pharma–backed), medical associations, and government agencies to treat pain more seriously. On the other hand, doctors faced increasing pressure to see and treat patients quickly and efficiently.
The latter is a result of what Stanford addiction specialist Anna Lembke, author of Drug Dealer, MD, describes as "the Toyotazation of medicine — tremendous pressure on doctors within these large integrated health care centers to practice medicine in a certain way and get patients out in a timely fashion to be able to bill insurers at the highest possible level and to make sure that their patients were satisfied customers."
When some patients become dependent on these highly addictive drugs and can no longer obtain them with legitimate prescriptions, they may seek to obtain them illicitly. Others turn to street drugs such as heroin, which provides a nearly identical high to prescription opioids. Indeed, as the National Institute on Drug Abuse noted in a December 2015 report, abuse of prescription opioids—or taking prescription drugs more than is medically necessary—is a major risk factor for future heroin use:
A study of young, urban injection drug users interviewed in 2008 and 2009 found that 86 percent had used opioid pain relievers non–medically prior to using heroin, and their initiation into nonmedical use was characterized by three main sources of opioids: family, friends, or personal prescriptions. This rate represents a shift from historical trends. Of people entering treatment for heroin addiction who began abusing opioids in the 1960s, more than 80 percent started with heroin. Of those who began abusing opioids in the 2000s, 75 percent reported that their first opioid was a prescription drug. Examining national–level general population heroin data (including those in and not in treatment), nearly 80 percent of heroin users reported using prescription opioids prior to heroin.
The recent explosion of opioid addiction in the United States has caused an undeniable problem that demands response from our country’s political leaders. The question, however, is what the best approach to address the crisis might be.
- How much of the material in this reading was new to you, and how much was already familiar? Do you have any questions about what you read?
- According to the reading, what are some of the origins of the current opioid crisis in the United States? What are some of the flaws in the U.S. system of medical care that contributed to the problem?
- What groups do you think must claim the most responsibility for the crisis: pharmaceutical companies, doctors, or opioid users themselves? Explain your reasoning.
- How do you think the opioid crisis might be affecting your community? Is this a problem that you feel has visible impacts locally?
Handling the Crisis: Criminal Justice vs. Public Health
The scale of the opioid crisis—which cuts across class, race, age, and geographic boundaries—has led politicians on both sides of the aisle to recognize the need for immediate action.
In an October 26, 2017, speech, President Donald Trump addressed the crisis and declared it a public health emergency. As political analyst Julie Hirschfeld Davis reported for the New York Times:
President Trump on Thursday directed the Department of Health and Human Services to declare the opioid crisis a public health emergency, taking long–anticipated action to address a rapidly escalating epidemic of drug use.
But even as he vowed to alleviate the scourge of drug addiction and abuse that has swept the country — a priority that resonated strongly with the working–class voters who supported his presidential campaign — Mr. Trump fell short of fulfilling his promise in August to declare "a national emergency" on opioids, which would have prompted the rapid allocation of federal funding to address the issue.
His directive does not on its own release any additional funds to deal with a drug crisis that claimed more than 59,000 lives in 2016, and the president did not request any, although his aides said he would soon do so. And he made little mention of the need for the rapid and costly expansion of medical treatment that public health specialists, including some in his own administration, argue is crucial to addressing the epidemic...
To combat the epidemic, the president said the government would produce "really tough, really big, really great advertising" aimed at persuading Americans not to start using opioids in the first place, seeming to hark back to the "Just Say No" anti–drug campaign led by Nancy Reagan in the 1980s.
"This was an idea that I had, where if we can teach young people not to take drugs," Mr. Trump said, "it’s really, really easy not to take them." He shared the story of his brother Fred, who he said had struggled with alcohol addiction throughout his life and implored Mr. Trump never to take a drink — advice the president said he had heeded.
Often, government officials have approached drug addiction as first and foremost a criminal justice matter—seeking jail time for addicts and dealers alike. This approach is seeing a resurgence under the Trump administration. As justice correspondent Carrie Johnson reported for National Public Radio on June 6, 2017, both members of the Senate and officials in the Justice Department have signaled their intent to renew a "tough on crime" approach to address the opioid crisis. Johnson notes that for nearly four years, a coalition of Republicans and Democrats had worked to reduce mandatory prison terms for many federal drug crimes. However, some senators now support a bill that would create tough new penalties for people caught with synthetic opioid drugs:
A draft of the legislation reviewed by NPR suggests the plan would give the attorney general a lot more power to ban all kinds of synthetic drugs, since criminals often change the recipe to evade law enforcement. It would impose a 10–year maximum sentence on people caught selling them as a first offense. That would double if they do it again...
The problem is getting attention at the highest levels of the Justice Department. Attorney General Jeff Sessions has called for a return to a tough approach on drug crimes. Sessions recently directed prosecutors to seek more mandatory minimum penalties...
Deputy Attorney General Rod Rosenstein appeared at the Drug Enforcement Administration. He warned police about the deadly risks of exposure to various forms of fentanyl and synthetic drugs like it. Rosenstein said people are dying in record numbers. And overdoses, he said, represent the leading cause of death for people under 50.
"There's a horrifying surge in drug overdoses in the United States of America," Rosenstein said. "Some people say we should be more permissive, more tolerant, more understanding about drug abuse. I say we should be more honest."
To critics of the "tough on crime" approach, the fact that the federal government has waged a "War on Drugs" for 40 years and yet has failed to head off a drug epidemic is evidence of the need for new thinking to address the opioid problem. These people see the epidemic as a primarily a public health crisis. From this perspective, opioid abusers should first be viewed as people with medical conditions who need treatment, rather than simply as criminals who should be locked up. Moreover, the government should focus more on pharmaceutical companies who overzealously promote drugs and doctors who overprescribe them, rather than on punishing individual users.
As healthcare reporter Casey Ross wrote in an April 23, 2016, article for the Cleveland Plain Dealer, public officials in Ohio, one of the states hardest hit by the opioid crisis, are calling for a more comprehensive approach to address addiction:
Ohio's spike in opioid overdoses and deaths is a public health problem that requires an urgent influx of resources to treat addiction, stem the supply of prescription narcotics, and educate children and parents about the dangers, law enforcement officials and health experts said Friday.
That conclusion was hammered home repeatedly during an extraordinary three–hour hearing in Cleveland hosted by the U.S. Senate Committee on Homeland Security and Governmental Affairs.
Typically, such a gathering would be laced with law–and–order rhetoric and a sharp focus on combating crime. But Friday's event was punctuated by broader questions about the nature of addiction, and how public perceptions surrounding it are undermining efforts to save lives...
Law enforcement leaders said they will continue to crack down on drug dealers and opioid traffickers, but they emphasized that the state's rising tide of fatalities will never be reversed by focusing strictly on punishing the users and suppliers of drugs.
"We cannot arrest our way out of this problem," Ohio Attorney General Mike DeWine said. "This takes a holistic approach. We have to have education. We have to have prevention. We have to have treatment."...
Promoting this approach, Republican Senator Rob Portman has drafted legislation that would favor treating drug addiction like other diseases, rather than addressing it primarily through a criminal justice framework. Casey Ross reported that the bill "includes a raft of measures that would increase funding for prevention and treatment. It would increase the distribution of Naloxone, a drug used to reverse opioid overdoses; it would provide more funding to help treat the addictions of incarcerated people; and it would also expand the number of disposal sites for unwanted prescription narcotics, among other measures."
People in the fields of public health and criminal justice propose very different solutions to the opioid crisis. Politicians are divided about which approach is best, making this a topic on which public input could be critical.
- How much of the material in this reading was new to you, and how much was already familiar? Do you have any questions about what you read?
- What constitutes a criminal justice or "tough on crime" approach to the drug crisis? How does this perspective propose to address skyrocketing rates of opioid abuse?
- How does a "public health" perspective on the drug crisis differ from the "tough on crime" approach? What solutions does this second perspective propose?
- What do you think? Should the "War on Drugs" framework be extended to combat opioid abuse, or should the epidemic be treated more like a disease whose victims need medical help?
- What do you think of President Trump’s statement that, "This was an idea that I had, we can teach young people not to take drugs... it’s really, really easy not to take them"? Do you think that the president is pointing toward an effective approach to decreasing drug abuse? Why or why not?
As homework, ask students to research the degree to which opioid addiction is a problem in their area. (This interactive map is a place to start.) Have students look for local stories about:
- the extent of the problem in their area
- what local government and organizations are doing about it
In the next class, discuss students’ findings. Ask students to consider what they think should be done to address the opioid epidemic, and what they might do to advocate for that action.