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Treatment, as it exists, is treatment for the few

Updated: Aug 29, 2023

Editor’s Note:  Today’s post comes from contributing editor Brooks Hudson, a PhD student in history at Southern Illinois University.

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If you look at recent coverage of opioid epidemic, media outlets admit that in the past they added gasoline to the fire during the “crack epidemic” and want to apologize for those mistakes. The New York Times editorial board gave a belated “whoopsie-daisy” for feeding the American people a steady diet of bad science and race-baiting incitement several decades ago. In their mea culpa they wrote:

“Today, with some notable exceptions, the nation is reacting to the opioid epidemic by humanizing people with addictions — depicting them not as hopeless junkies, but as people battling substance use disorders — while describing the crisis as a public health emergency. That depth of sympathy for a group of people who are overwhelmingly white was nowhere to be seen during the 1980s and 90s, when a cheap, smokable form of cocaine known as crack was ravaging black communities across the country.”

The Times’ statements are true, at least when compared to its own media coverage in the 1980s. Today the newspaper avoids the kind of inflammatory statements used during the “crack epidemic,” such as how they once asserted that mothers “were giving birth to a generation of neurologically damaged children who were less than fully human and who would bankrupt the schools and social service agencies once they came of age.” While a casual reader can still stumble across op-eds connecting marijuana use to homicide and psychosis to this day, overall, there is less hysteria in drug coverage–a positive step forward for sure. I even applaud some of the more progressive suggestions found in the Times and other venues, including giving ER doctors the ability to provide buprenorphine (brand name Suboxone), asking whether we should abolish the DEA (given its contribution to fueling the crisis by refusing to license mobile methadone clinics and arresting doctors for prescribing Suboxone, and preventing cities and states from opening safe injection sites).

Even if these policies could be brought about with the wave of a magic wand, however, I am skeptical that even the best coverage is doing little more than providing false hope. Everyone talks about “humanizing” individuals with a substance use disorder, and framing the problem within a public health framework. But treatment only exists for the affluent few, people with families willing to take on tens of thousands of dollars of debt, or therapies that might not work at all, or just temporarily. Sympathy and humanizing are nice, but let’s not mistake a disposition for action. I recently finished reading Beth Macy’s Dopesick and Chris Hedges’s America: The Farewell Tour. Both hit home for me the reality that treatment only reaches 10% of those looking for it.

Hedges documents the life of Christine Pagano. Her heroin use began “when she was sixteen years old after a school counselor learned Pagano’s stepfather was sleeping with one of Pagano’s classmates.” Her “mother’s marriage, and whatever stability it provided in Pagano’s life, imploded.” The story of her stepfather and the student became public: “She felt humiliated. She began to snort heroin. She dropped out of school.” She then turned her life around, “enroll[ing] in a drug treatment program in 2007. She got sober. She worked in a diner and got a cosmetology certificate.” She later relapsed, turned to prostitution, and was raped several times. On the first occasion, she was raped by a police officer, who “stuck his gun up [her] vagina,” threatened to pull the trigger and degraded her by calling her a whore and a dirty prostitute. Unfortunately, things got worse from there.

It was only because her mother found a private detective that she had another shot. Still, the methadone program she entered cost her mother $20,000. As she told Hedges, “The system is set up for us to fail. Ten years from now I’m still just going to be a number. I’m always going to have an SBI [State Bureau of Identification] number. I’m always going to have mug shots all over the internet.” For Hedges, this is a much larger problem than opiates; it’s a failure of society. He writes:

“The poor in America get only one chance. Then it is over. Those who were the street with Pagano in Jersey City or Camden will most likely never have a private investigator rescue them, or have a mother pay for their drug rehabilitation. Most will live, suffer, and die within the space of a few squalid city blocks. No jobs. No hope. No help. They blunt their despair through alcohol or drugs. And if they do get out, as did Pagano, they carry the chain of their past wrapped around them. Employers do not want them. Landlords will not rent them an apartment. Real estate agents will not deal with them if they seek to buy a house. Banks and credit card companies will not give them credit. They never have enough money. They probably never will. They live one step away from hell. And they know what hell feels like.”

He also documents the life of Shannon Miller, who died from an overdose. She had a condition called Chiari malformation, a “condition that caused her brain tissue to extend into her spinal cord, resulting in crippling headaches.” She took pain medication because her condition was so debilitating that she struggled even to walk. Later she used heroin. She told her parents about her heroin use, and they got her into treatment. Her parents told Hedges, “Just to get her in a program was $6,000. After the detox, they shipped her down to another place. That was another $5,600.” A week after she returned, she relapsed. Her parents put shipped her off to a Florida rehab, at the cost of $10,000.

Miller got better. She saw a therapist who gave her samples of Abilify, an antipsychotic medication, and her parents said she seemed to act like her normal self. The monthly cost of the medication was $1,000, however, and insurance wouldn’t cover it, nor did alternative therapies work. As her parents told Hedges, “They put her on Topamax. But it wasn’t the same—when she was on Abilify it made her feel normal. All she wanted was to feel normal. But the insurance wouldn’t pay for it.” For a while, her family used the money they had inherited from a relative, “spending $8,000 to $10,000 a month on out-of-pocket expenses, medications, and insurance premiums. By the time Shannon died, her family had spent $100,000 trying to save her.”

In Dopesick, Macy documents the same phenomenon. As she tells in the story of another person struggling with financing her access to medication-assisted treatment, “The buprenorphine made her ‘feel normal,’ with insurance covering 80 percent of the medication’s costs. Visits to her addiction doctor were cash only, though, requiring $700 up front and $90 to $100 per follow-up visit, as many as four a month, in order to be monitored and receive the buprenorphine.”

Macy calls for a “New Deal for Addiction.” If you subscribe to modern monetary theory (or MMT) like me, the question “how are you going to pay for it?” doesn’t matter. But for those who do care, it’s simple: we already pay, just in the most counterproductive ways imaginable. On an individual level, two researchers broke down the cost of individuals that suffer from heroin use disorder today: “Heroin users who are locked up are particularly expensive to society. The scientists estimate each bears a cost of to the United States of nearly $75,000 per year. This figure is mostly driven by productivity loss ($29,000), incarceration costs ($31,000) and, perhaps surprisingly, treatment for hepatitis C (a chronic condition with a treatment tab of $9,000). HIV, spread via heroin use, also takes a large toll; the condition is estimated to cost $300,000 to treat over a lifetime.” On the macro level, enforcing the current drug control system in the United States costs somewhere in the ballpark of $100 billion a year. To put that into perspective, the projected cost for universal higher education proposed by Bernie Sanders had a price tag of $70 billion per year.

There are several good ideas on both the left and the right about what to do. There is an appetite among both the democratic socialist Left and the libertarian Right for major drug reform legislation. While legalization would be better than decriminalization, decriminalization would be a huge advantage. As Nicholas Kristof wrote about Portugal: “It’s not a miracle or perfect solution. But if the U.S. could achieve Portugal’s death rate from drugs, we would save one life every 10 minutes. We would save almost as many lives as are now lost to guns and car accidents combined.”

For the budget hawks and deficits scolds, Kristof continues, the comparison between Portugal cost-per-capita and the United States is stark: “One attraction of the Portuguese approach is that it’s incomparably cheaper to treat people than to jail them. The Health Ministry spends less than $10 per citizen per year on its successful drug policy. Meanwhile, the U.S. has spent some $10,000 per household (more than $1 trillion) over the decades on a failed drug policy that results in more than 1,000 deaths each week.”

The United States doesn’t even have to look around the world for solutions. Instead, we can look back to our own brief experiment with morphine maintenance clinics in the 1920s and our successes like Shreveport—but the goal today would be to make these programs available to anyone, at no cost at all. And I don’t want to pretend like libertarians or those on the right are not proposing ideas that solve similar problems through different means, but I do think that we should consider all options. 

And there are many. Jessica Flanigan’s Pharmaceutical Freedom: Why Patients Have a Right to Self-Medicate, makes a strong case for abolishing prescription laws, which restrict patient choice and often preclude access to substances like Suboxone, methadone and other substitutions therapies that have proven effective in treating opioid use disorder. Flanigan’s thesis is that “drugs are not morally different from other products and that the same considerations that justify other rights, such as informed consent, the right to make intimate and personal decisions, the right to die, bodily rights, economic freedoms, freedom of expression, and rights of self-preservation, also justify rights of self-medication.”

She touches on several problems patients face, from the money and time wasted to see a doctor to receive a prescription, to the hurdles and obstacles that exist under the current system for patients that would like to try Suboxone. Flanigan offers a novel approach that might find a constituency on both the left and right. Taken together, there are a lot of potential solutions, some tried in the United States, some in other countries, and others are well thought out but not tried. What all agree on is that acknowledging past mistakes is good, but the system as structured today cannot provide treatment. To do that would require a dramatic restructuring, and there are many ways to get there.



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