How are healthcare practitioners engaging with the ‘opioid crisis’? How can we understand addictions differently, and therefore step up to this moment in ways that transform dominant narratives around addiction, reduce harm, save lives, and help build the world we believe in? Someone overdoses on opioids every 20 minutes in the US, and overdose is now the leading cause of death for people under the age of 50.
At Casa de Salud, we are working to write a different story about addiction. Casa de Salud is a cozy, integrative medicine primary care clinic in the South Valley of Albuquerque NM. We see mostly uninsured Spanish speaking migrants, folks dealing with heroin and prescription opioid addictions, and trans folks seeking gender affirming care. We have a large syringe exchange alongside a harm reduction based recovery program. Our Strong Roots recovery program is a creative, visionary and deeply politicized recovery program integrating suboxone-based treatment with healing circles, primary care, traditional medicine and curandismo, peer support and popular education. We are weaving a new network of what harm reduction, recovery and healing can look like for folks dealing with opioid addiction in one of the hardest hit geographies in the country.
I have the profound honor to regularly meet with a group of folks in our Strong Roots recovery program, our curandera-nurse practitioner, our peer recovery coach and a health apprentice to develop workshops on ‘Criminalization the Drug War’, ‘Root Causes of Addiction’, and ‘Resilience and Social Change’. In addition to prescribing suboxone to folks in treatment, I get to work with them to develop the leadership and facilitation skills to lead the workshops with other people dealing with addictions. We are building a shared understanding of addiction as a community issue, a narrative that counters the pervasive shame and stigma society imposes on individuals. We are humanizing and politicizing its origins, and showing the inherent worth and dignity of people who use drugs, as well as their role in creating social transformation. My understanding of addiction has been deepening through these workshop series and through the wisdom, stories, and experiences of people directly affected by addictions as they unravel the structural inequities that set them up, the buried pains, and the desire to help each other out. As healthcare practitioners, I think it’s our responsibility to understand the broader context within which we practice medicine. And so, I think it is our duty to understand the structural and social determinants of health for folks who use drugs, and how we can engage with people who are in recovery in ways that reduce harm and promote healing. If we want to be effective at addressing opioid addiction and overdose, we have to understand the nature of the demand for drugs, rather than policing or trying to control the supply.
I was raised in the “Just Say No” to drugs era (though I didn’t adhere to it), and then was indoctrinated into the individualized medical model of addiction as a brain disorder in PA school. Reaching beyond these dominant narratives, I have come to understand that addition is rooted in structural inequities; in poverty, capitalism, colonialism, intergenerational trauma and the emotional pain that is engendered by these structures as they play out in communities, families, and individuals. With others, I’m working to see and name how these structural inequities cause social distress, chronic stress, and trauma. Chronic stress and trauma often underlie the emotional pain that is at the root of addiction as people try to escape, mask or mitigate that pain. Dr. Gabor Mate explains addiction is neither a choice nor an inherited disease, but a human condition arising out of emotional pain and suffering. Dr. Mate reminds us that there is nothing unique or special about opioid addiction, and that we are a society of addicts because we are a suffering people seeking escape from that pain through substances, sex, shopping, or technology.
The Adverse Childhood Experience (ACEs) study based on 17,000 patients confirms what people working in the field of trauma have known experientially—that early experiences of violence and trauma are harmful to health in a myriad of ways. The ACEs study demonstrates the direct correlation between severe childhood stress such as neglect, abuse, domestic violence, a mentally ill or substance using parent and various types of addiction. A child with four or more adverse experiences was found to be 5 times more likely to be addicted to alcohol, and 46 times more likely to inject drugs than children that didn’t have any adverse childhood events. The Racing ACEs publication expands on this work by explicitly naming racism- personal, structural and historical- as a root cause of modern trauma. We have ample research connecting trauma to addiction, we know that addiction changes the brain and impairs one’s ability to make rational choices, and yet our society and the medical field scrutinizes, pathologizes and blames folks dealing with substance use disorders unlike those living with asthma, rheumatoid arthritis or other chronic relapsing health conditions. Uniquely, the medical field interacts with substance use in ways that has implications for criminalization, as seen in the mythic “crack baby” frenzy (there is a whole other conversation here about the ways that the medical field scrutinizes and blames people for their chronic health issues such as diabetes or ‘obesity’ as they relate to fatphobia, classism, racism and sexism). As one of the participants in the workshop series who’s been incarcerated over twenty times exclaimed in a moment of revelation, “they should be helping us with treatment and instead they just lock us up or let us die”.
The impacts of opioid overdose and the state neglect that enable it are detrimental to all of our communities, albeit experienced differently based on one’s relationship to power. We have high rates of addiction across all sectors of people in this country- wealthy, poor, white, Indigenous, people of color, queer and trans folks, and straight people. (We are a suffering people). However, our society disproportionately criminalizes those who are already marginalized- especially poor people, people of color, migrants and LGBTQ folks at the intersections of those identities. The ‘opioid epidemic’ is increasingly seen as a public health crisis as more white folks are being impacted, yet the response to the ‘crack epidemic’ in the 80’s and 90’s had nothing to do with public health, and everything to do with the criminalization of people of color and dissidents through the drug war. In the 1970’s, Nixon called drugs “public enemy number one”, and declared a “War on Drugs” at a time when the rate of drug use was actually decreasing. A top aid for Nixon, John Ehrlichman, later admitted:
“You want to know what this was really all about. The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying. We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”
The war on drugs created a media frenzy and punitive state response to drug use, boosting mass incarceration via mandatory minimums and the like instead of treatment programs. And here we are now, decades later with another substance use crisis, with no tools to respond appropriately because of racism and the pervasive culture of punishment.
Addiction is rooted in pain, and that pain is connected to larger histories and social contexts that we must grapple with in order to heal it. For many, the pain is emotional. For others, it is physical pain rooted in over-work and injuries, and the ways that stress and trauma manifest physically through the nervous system. Land dispossession and the trauma of colonialism and capitalism lead to broken interdependence from self, land and each other. Lorenzo Candaleria, a farmer, recovering heroin user and participant in the workshop series says it best,
“We lost the language because we lost the need to converse to mother earth. When you lose a language, you lose a culture, when you lose a culture, you lose identity… a lot of addiction I see around me and the addiction I experienced was directly correlated to that loss of identity because we no longer have the need to refer to the sacred. So in losing the culture, we have no identity, without identity we have poverty, and that has led to despair, and it’s generational.”
As healthcare practitioners, how can we hold the big picture, the structural and social with the most delicate experience of individual human connection? How can we better challenge the stigma and judgement that arises in us and each other as we work with folks dealing with addictions, instead holding the complexity of trauma and suffering, and also of resilience and potential of the people we work with? As in organizing for social change, how we can honor that people who are closest to the problems are best positioned to create the solutions? How can we get out of the way and make room for folks who use drugs to determine the conditions of their continued drug use or their treatment, and to envision the policies to reduce harm and to end criminalization? There is so much that we can do together, and in collaboration and solidarity with folks directly affected by addictions. The new recovery movement is one example of people in recovery sharing their stories as tools of empowerment and organizing, which includes storytelling as well as direct action. There are so many opportunities to organize for policy changes. We can get trained as suboxone / methadone (MAT) prescribers. We can join harm reduction efforts to end discrimination against drug users, to prevent opioid overdoses through the distribution and access of naloxone (opioid antagonist medication used to reverse opioid overdoses), to pass good Samaritan laws so users are protected when they call in medical support for overdoses, to advocate for medical and mental health first responders to 911 calls instead of police, and expand access to syringe exchanges. We can join efforts to reallocate funds from prisons and policing into treatment programs. We can invest in treatment programs that are grounded in an understanding of trauma, healing, and the nervous system, and that use effective tools like acudetox ear acupuncture, somatic therapies, and peer support. We can work to make these programs available for free for everyone, not just the elite who can pay forty to seventy thousand dollars a month for quality inpatient treatment. Let’s move towards wholeness, humanity and dignity, towards a new drug users union, an activist recovery movement, and healthcare practitioners participating in meaningful ways.