Through my thirties, my nights were insomniac fever dreams of pain and restless movement. Until well into my second decade with ankylosing spondylitis, no treatment was able to calm the maddening stiffness and spine pain of this degenerative autoimmune disease – at least not without equally unpleasant side effects.
Then at last, my doctors and I settled on an effective dose of an opioid – that notorious palliative of last resort. Now I sleep almost through the night. Despite militant adherence to exercise and other self-management techniques, and along with immune-suppressant medications that at least partially address the underlying cause of AS, it’s fundamentally this drug that makes life bearable – that allows me to write, earn a living and raise my family.
That’s not a reality that makes good drama. So, as governments do little or nothing to stem a crisis that has killed 24,000 Canadians through opioid-involved overdose since 2016 (and taken nearly 50,000 Americans lives in 2019), a truly undying War on Drugs offers a series of reliable tropes: the downward spiral, the demanding pain patient, the pharma-dupe doctor, the violent dealer, the corruption-fighting narcotics agent and the “junkie” who embodies horror movie archetypes barely inspired by reality.
Opioids thrillingly frighten viewers of Danny Strong’s popular miniseries Dopesick, based on Beth Macy’s book of the same name, and readers of Sam Quinones’ 2015 book, Dreamland: the True Tale of America’s Opiate Epidemic. Both characterize people like me as the weak, white and deluded prey of the Oxycontin-pushing Sackler family. (Although pain tends to be undertreated in Black communities, among whom overdose rates have nevertheless risen very quickly, as in Indigenous communities.)
Over the years, I have gone from fearing addiction, to strenuously distinguishing myself from “addicts,” to at last acknowledging that, like virtually every other human being, I use one of a range of psychoactive drugs to get by – coffee, tea, antidepressants and alcohol included. And I’ve come to understand my drug use as occupying one node in a pattern of prohibition and medicalization that, for just over a century, has privileged legal and illegal profit over public health, created unnecessary harm and codified indifference to human suffering.
A small group of writers are likewise thinking more deeply about substances. Like the producers of Dopesick, they address such intimate issues as dependence, desire and corruption. Unlike them, they also address the policies that spawned a violent, devastating U.S.-led War on Drugs and unregulated industries devoted to incarceration, surveillance and “treatment.” They explore the dire impact these have had on the lives of people who use substances, whether to feel pleasure or to relieve pain.
A drug by any other name
In White Market Drugs: Big Pharma and the Hidden History of Addiction in America (The University of Chicago Press: 2020), historian David Herzberg offers a U.S.-focused overview of the medicalization of some drugs (the so-called “white market”) that has ensured their access for mostly white, comfortably well-off patients – with profit all too often outweighing public safety – and the prohibition of others. The latter encourages the development of increasingly strong and compact illicit drugs that are easier to smuggle and offer greater return for risk.
Thus, overdose deaths now overwhelmingly involve an illicit opioid in combination with other drugs. And, because they’re not regulated like pharmaceuticals, these substances contain unknown and therefore dangerous potencies. Prohibition typically doesn’t make drugs vanish, but it does criminalize poor and racialized users who lack access to the pharmaceutical market.
“Instead of emphasizing differences between people with dependence and people with addiction, I emphasize differences between consumers with access to more or less safe drug markets,” Herzberg writes. “This acknowledges both the gravity of addiction and the possibility of safe long-term drug use. It also emphasizes that drug consumers’ safety has been determined as much by social and political forces as by consumers’ own inherent qualities.”
After years of daily use, my body has adapted to the painkiller and I physically cannot skip doses without experiencing withdrawal (becoming “dopesick”). Still, I don’t meet any normal criteria for addiction because, in part thanks to my white-market access to effective pain treatment and medical care, I lack the symptom of “continued use despite harm.” The War on Drugs nevertheless touches all pain patients with stigma and taints the patient-doctor relationship with mistrust on both sides. The white-market access Herzberg describes is not what it was.
Since roughly the early-2010s, an enthusiastic, poorly managed backlash against opioid prescribing for chronic pain has resulted in previously stable, long-term pain patients such as me losing function and hope, with some applying for Medical Assistance in Dying. In the U.S., and sometimes in Canada, patients have been stripped of this palliative even when it best balances risks and benefits for a particular person, after alternatives have failed. Meanwhile, patients with acute leg fractures may refuse painkillers in the ambulance lest they wake up in an alley, injecting illicit fentanyl in their jugular vein.
In 2022, it’s odd to see the Dopesick-led resurgence of societal anxiety about prescription opioids, even as COVID-19 represents a mass disabling event that will result in greater need for opioids to ease both life and death. After all, the once-plausible positive association between opioid prescribing and overdose deaths has been definitively cut for years now. Although changes to opioid prescribing have been less brutal in Canada than in the U.S., patients like me tiptoe to every medical appointment, fearing this will be the one where we’re told that, contrary to experience, our drugs don’t work.
Meanwhile, overwhelming racism and classism that determine whether drug use is considered rational and judicious, or weak, reckless and indulgent, persist within the illicit market. Take crack cocaine, the use of which was associated with the Black community, resulting in criminal penalties that have torn families apart; while a white stockbroker who sniffs powder cocaine at a party is unlikely to suffer any penalty at all, either health-wise or legally.
Herzberg traces historical shifts from medicalization to criminalization and back. He carefully outlines the multiple factors that led to reckless opioid prescribing around the turn of the millennium and, while he doesn’t address the current plight of pain patients, he argues effectively for policies to limit the distorting effect of profit-motivated drug provision. This could include everything from decriminalizing illicit drugs to nationalizing Big Pharma: turning drug companies into public utilities.
Readers might like to pair White Market Drugs with neuroscientist Carl Hart’s Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, published last year, which convincingly argues that racist policy leads us to see addiction wherever the drug used is illegal. Hart relies on estimates derived from the U.S. government’s National Survey on Drug Use and Health data suggesting some 90 per cent of all drug use, even of illegal “hard” drugs, is non-problematic and better characterized as responsible and for rational ends (including recreation).
Global markets, local impacts
Many people are aware of the catastrophe of overdose deaths, but few understand that Canada could effectively eliminate most such deaths and effectively open up lives cramped by pain, criminalization or compulsive drug use. For an indispensable overview, I’d recommend More Harm Than Good: Drug Policy in Canada (Fernwood Publishing: 2016), an accessible look at the entire spectrum of drug policy issues in Canada by advocates and academics Susan Boyd, Connie I. Carter and Donald MacPherson.
They critique Canada’s unregulated, poorly evidenced approach to addiction treatment – a point borne out in later research showing clearly that in the case of opioid use disorder, in-patient and abstinence-based ”treatment” actually increase risk of overdose. One of the many strengths of this exhaustively researched little volume is that it addresses the full spectrum of drugs, from pharmaceutical opioids taken for chronic pain to illicit market methamphetamine. It also addresses a wide range of solutions to drug-related harms, including harm reduction, decriminalization similar to Portugal’s 2001 model and legal regulation of currently illegal substances.
“In this book we argue that drug use is a health, not criminal, matter and should be treated as such. We also note that not all drug use is problematic and cultural and social factors shape drug use. Prohibition does not deliver on its intended goals, but it does result in the marginalization of whole groups of people and in some cases their deaths,” the authors write. “It is time to consider an approach that helps to contain the negative effects of drug use, provides a variety of treatment modalities and harm reduction services and avoids criminalizing those who choose to use drugs.”
A similar story of persecution-based policy, leading to tragedy in Mexico, is told in Cristina Rivera Garza’s Grieving: Dispatches from a Wounded Country (The Feminist Press: 2020). “It is the forgetting of the body, in both political and personal terms, that opens the door to violence,” she writes.
Grieving is a poetic, experimental work, reminiscent of Maggie Nelson in that Rivera Garza combines language and feeling with highly intellectual concepts (and the occasional academic overreach, where the lay reader trips over un-contextualized terms such as “discourse,” “materiality,” “ekphrastic” or “ontological”). And yet Rivera Garza bridges the accessibility gap more effectively than Nelson does in her own recent book on freedom and drugs (which left me with no clear sense of her views on drug policy), and does so with an urgent, palpable sense of connection to the people she writes about.
While pop culture, drug war rhetoric, and outright racism prime Canadians and Americans to see drugs as malevolent forces from countries such as Mexico and China, Mexicans more often think of the American guns that power a violent illicit drug trade, the insatiable American and Canadian demand for drugs, and the violent war on cartels nominally led by Mexican politicians who seem even more indifferent to the suffering they cause than murderous narcos.
Rivera Garza weaves together several issues typically though incorrectly seen as discrete: as in Canada, murders and disappearances of poor and working-class women, often Indigenous, investigations into which stall because of neglect and corruption; the pain of family and friends of people disappeared or tortured by cartels or government security forces; and the suppression of wages and labour rights in the service of a neoliberal state that can be seen as a net producer of emotional and physical pain through its inexorable demands, while incentivizing participation in a drug trade made lucrative by its very illegality.
In The Dope: The Real History of the Mexican Drug Trade (W.W. Norton and Company: 2021), another historian, Benjamin T. Smith, notes that harm-producing prohibition policies and economic policies such as the North American Free Trade Agreement (“The modern drug business was now about riding the explosion of globalized trade,” Smith writes of the post-NAFTA era) run southward from the U.S. This incentivizes increasing violence between and collusion among security forces and an exceptionally adaptable and entrepreneurial illicit drug trade.
I spent part of the holidays watching Narcos: Mexico, and appreciate Smith’s critique of how the hugely enjoyable miniseries portrayed its real-life protagonists. On the killing of “border-born Mexican,” U.S. narcotics agent Kiki Camarena by Mexican drug traffickers, a founding myth of the War on Drugs-waging DEA, the Drug Enforcement Agency, Smith writes: “The story was simple, persuasive, and played nicely to a host of U.S. anxieties. It conveniently cleansed the DEA of accusations of corruption, torture and prejudice; it succinctly divided the world into good cops and bad traffickers; and it did so in a way that tiptoed delicately around the United States’ changing racial makeup.” It’s the genesis of a stock character: the border-sneaking, youth-poisoning, corruption-feeding “bad hombre” – a hazy, malleable scapegoat – infamously invoked by Donald Trump.
Breaking bad habits
A writer may get at part of the story without making all the necessary connections. Poor people who use illicit drugs (and, incidentally, often live with chronic pain) and low-level dealers may be characterized in ways that reflect neither the reality that they are often the same people, nor that drug dealers can practice harm reduction in important ways.
Together, prohibition and uneven medical or profit-focused access (think alcohol or cannabis) make up a sort of morality play in which we each play a role. Drug users at the very bottom of the socioeconomic pyramid are blamed for the “insatiable demand” that keep cartels in business, families in mourning and patients resorting to alcohol, illicit fentanyl or suicide. But demand won’t ease so long as emotional, social and physical pain – effectively eased by opioids and made less tolerable and more prevalent by a punitive, unequal society – persist.
The Urge, psychiatrist Carl Erik Fisher’s combined memoir and history of addiction, released on Jan. 25 from Allen Lane, addresses a missing piece of the puzzle: Why does some drug and alcohol use become disordered, out of control – what we call a substance use disorder or addiction? Fisher explores and rightly trashes attempts (including by the American National Institutes on Drug Abuse, which funds perhaps 90 per cent of research on addiction globally) to define addiction as essentially a brain disease. He argues instead that craving – the urge to ingest a substance that eases distress or emotional or physical pain – sits on a spectrum of fundamentally human desire, and must not be treated purely as a disorder.
I’d like to see Fisher (who does acknowledges the value of medication in treating opioid use disorder) dig deeper into what I see as the most interesting evidence on recovery from opioid addiction, and thus on the nagging question of addiction’s relationship to physical dependence, social conditions, self-control and relief of pain.
Indeed, anyone investigating the urge to use these powerful palliatives must ask why it is that, when an already physically dependent person with disordered, compulsive patterns of use and a train-wreck of a life is able to access basic needs (such as decent housing) plus legal, pharmaceutical versions of the opioid they seek, long-standing, self-destructive patterns of chaotic use fall away. (Despite alcohol’s greater intrinsic health harms, severe alcohol use disorder can also become relatively “un-disordered” with managed alcohol programs, an Ottawa invention that inspired Canada’s managed opioid programs.)
As much as I’d love to depend on nothing and no one, reliance on my thrice-daily dose seems to me a fair trade-off for enhanced quality of life after years of ultimately meaningless engagement with suffering. Managed opioid programs tell a similar story: a reasonable trade-off that, far from being a slippery slope toward a mythical rock bottom, represents meaningful recovery in every sense save abstinence.
Depending on the substance a drug-seeker is seeking, the best, safer, legal version might be heroin, as in the U.K.’s decades-long take-home prescribing program; fentanyl patches as in Vancouver pilots; morphine or hydromorphone across Canada; or methadone in countries around the world. When it comes to opioids and the relief of pain, it may be that to purge severe addiction, it’s best to satisfy the urge.
Carlyn Zwarenstein is the author of On Opium: Pain, Pleasure, and Other Matters of Substance (Goose Lane Editions, 2021).
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