After Trump's Declaration: The Social Conditions Driving the Opioid Epidemic

Yesterday, President Trump declared the opioid epidemic a public health emergency. In his speech, he addressed the scale of this crisis. “Last year we lost at least 64,000 Americans to overdoses,” he said. “That's 175 lost American lives per day. That's seven lost lives per hour in our country. Drug overdoses are now the leading cause of unintentional death in the United States by far. More people are dying from drug overdoses today than from gun homicides and motor vehicles combined.” As I listened to the speech, I watched an outpouring of reactions on social media. They ranged from gratitude for the symbolic step in the right direction, to deeply critical of the failure to declare a national emergency, which would have unlocked a substantial amount of funding and provided a broader range of opportunities for action on the issue.

I’ll say up front that my response to the declaration was the later, one of deep frustration and disappointment. On a basic level, I don’t believe symbolic steps are enough when we're staring down 175 deaths a day from opioid overdoses. Beyond this, I cringe when solutions like “just say no” and “getting tough on bad guys” are suggested as answers to this crisis. We’ve been down this road before, and we have a deep body of evidence that shows these approaches, at best, don’t work, and at worst, ravage our nation’s most vulnerable communities, primarily communities of color. But the real source of my frustration is rooted in the fact that we're largely failing to talk about the social conditions that created the fertile bed in which the seeds of this epidemic were planted.

Much smarter people than I have written at length on the individual factors that have contributed to this epidemic. In light of this, I don’t want to focus on the distinction between a “national emergency” and a “public health emergency”, nor do I want to explore the role of big pharma, insurance companies, prescribing practices, or drug cartels. These components of the epidemic are crucial, but I believe the conversation is failing to look at the fact that our nation and its people are suffering for a variety of reasons, and I believe the kind of suffering we’re experiencing (outside of the opioid crisis) is the spark that started this fire in the first place. We need to talk about treatment, naloxone, pharmaceutical companies, doctors, and all of the other gears driving this epidemic, but I don’t think we will make much headway in solving the big issue of addiction unless we also begin to look at it from a broader angle.

People in recovery have long suspected that addiction is largely rooted in social factors that impact our sense of belonging, wellbeing, safety, and hope for the future. The science is finally beginning to show we’ve been right all along. A recent article in Scientific American references several studies that confirm an increase in addiction and overdose deaths in places where individuals experience low levels of “social capital”, meaning people in these communities lack connection to one another and have little or no opportunity to participate civic life. Ultimately, these studies back up the idea that social isolation, unemployment, lack of access to education, lack of safe places to live, lack of transportation, lack of healthcare, lack of spaces that promote wellbeing, lack of meaningful ways to give back, and so forth, increase our levels of emotional and physical pain. And this pain is the place where addiction begins.

If we consider addiction from this angle—as the result of pain caused by social conditions—and at the same time reflect on the current state of our nation, it should come as no surprise that this epidemic has unfold with such ferocity. Over the past ten or fifteen years we’ve witnessed a perfect storm. As pharmaceutical groups pushed painkillers on doctors, who then pushed them into our communities, our nation was also experiencing a tremendous amount of social strife. Since 2000, we’ve experienced a devastating economic collapse, high levels of unemployment, two wars, significant issues with healthcare and medical costs, cuts to education budgets, cuts to social services, class struggles, racial tensions, political divides, significant occurrences of violence, and media pumping all of it our living rooms. This, of course, is an incomplete overview of the past two decades, but I think it’s enough to make my point. What I’ve listed are just a few sources of pain that everyday Americans were grappling with across the nation as painkillers flooded our communities. Unfortunately, they’re conditions we’re still grappling with as fentanyl and heroin take the place of prescribed painkillers. Yes, the availability of these drugs plays a significant role, and must be addressed, but we must not ignore the role our current social conditions have played in creating and perpetuating this crisis. We need to recognize that this epidemic signifies a larger crisis in the fabric of our nation. 

While we absolutely need an immediate response to this crisis that includes broader access to treatment, widespread availability of naloxone, education for doctors and the general public, tighter restrictions on prescribing practices, consequences for drug companies, and so forth, these actions will not end the epidemic. I’m sorry to say this, but I believe it's true. Although these measures may stop the bleeding, which is crucial, they will not make a real dent in the issue of addiction. Why? Because these solutions do not address the pain from which addiction stems. These actions are a necessary tourniquet that will save lives, but just because you get a tourniquet on a bleeding limb does not mean the injury goes away. It is a first step, but the healing process takes time, and more importantly, it requires the correct conditions.

If we’re going “overcome addiction in America”, as President Trump suggested in his speech, we have to begin thinking beyond the limits of the current conversation. We have to think bigger that “bad guys” and “border walls” and “just say no”. Honestly, I believe we need to think bigger than detox beds and naloxone, bigger than prescribing practices and pharmaceutical companies. Again, treatment and naloxone are incredibly important, but the folks saved by naloxone and treatment need to return to communities that allow them to develop the social capital necessary to maintain recovery. Likewise, those kids President Trump was talking about in his speech, the one’s who will “just say no”, need the same kind of opportunity. From a place of isolation, fear, and hopelessness, it’s nearly impossible to say no to something that promises an opportunity for relief.

In light of our president’s actions, his proposed policies, and his seemingly endless striving to keep the American people divided, hateful, and afraid, his words rang absolutely hollow. He was right in saying that, “addressing [the opioid epidemic] will require all of our effort and require us to confront the crisis in all of its very real complexity.” The problem is that I don’t believe he, or many of our representatives, actually grasp the complexity of the issue as it stands. Or perhaps they do, but they aren't that interested in actually solving it. If they did understand it, they’d realize that throwing money and encouraging words at the problem will not fix it. Instead, along with funding treatment and taking on big pharma, they’d be working to correct the broad social conditions that have left many in our nation isolated, unwell, unsafe, afraid, and hopeless. Unfortunately, it seems to me that they’re moving in the opposite direction.

So, why are we not talking about social conditions? Why are we not talking about the necessity for individuals to have opportunities to develop and possess social capital? We know this is a significant piece of the puzzle, so why are we skating the issue? Well, the simple answer is that we’re focused on stopping the bleeding, and this is exactly what we should be doing. But, I think there is another reason, and it has to do with the fact that addressing the big issue of addiction in America is going to require us to take a good long look at ourselves. We’re going to have to ask why, in this shining city on the hill, so many are suffering so deeply that they find themselves addicted to opiates. We're going to have to confront racism and misogyny. We’re going to have to confront the fact that as a nation we’re in big trouble. What we find in our looking will not be pretty—I know because I’ve been looking—but we need to see it in order to correct it. We must find a way to address the underlying pain for all of our citizens. I’ll be the first to admit I’m not sure how to do this, but in the depths of my heart, I know that this work will begin when we find the courage to face ourselves.