While Baltimore’s opioid epidemic has proven pervasive, questions perpetually arise as to why. For some, this “why” is answered with a slew of systemic and historical problems— the War on Drugs, mass incarceration, institutionalized racism; for others, this same “why” is answered through a paradoxically individualized yet homogenized lens: bad people doing bad things.
For Baltimore City Health Commissioner Leana Wen, the opioid epidemic demonstrates the notion that “addiction is disease.” Such a notion reflects the push towards a medicalization of opioid usage. While medicalization of opioids risks de-contextualization of a highly contextual issue, medicalization simultaneously promotes more equitable, less stigmatized treatment of this opioid issue. Dr. Leana Wen prioritizes the latter.
In 2014, 303 Baltimore City residents died from a drug or alcohol overdose; 192 of these 303 deaths were due to heroin. Such shocking statistics reflect a 19% increase in overdose deaths from the prior year and a higher number of Baltimore deaths from heroin than homicide, respectively.
Dr. Leana Wen’s response has been two-fold. First, she has established widespread naloxone training that has permeated Baltimore’s nonprofits, its community groups, and its universities; second, she has implemented policy that now allows the purchase of naloxone without a prescription. This response stems from Dr. Wen’s push towards the medicalization of opioids, as she stated: “Nobody has to go to a doctor to explain why they need to use a defibrillator if somebody’s heart has stopped beating…so why should we treat overdose any differently from something that is killing our citizens?”
Here, cardiac arrest is compared to an overdose; likewise, a defibrillator is compared to naloxone. However, this compelling comparison exists against a societal backdrop that has sought, and continues to seek, the antithesis—to distinguish overdoses from, rather than equate overdoses to, more ostensibly medical phenomena. This societal backdrop is a function of the stigmatization of opioids.
While naloxone and its ensuing policies and programs have been successful in saving 1,600 lives and training even more Baltimore City residents in its distribution, the stigma surrounding opioid usage and overdose remains.
This month, House Bill 771 was presented in the Maryland Legislature. Rather than advancing the medicalization of opioids and their treatment, this bill seeks to implement punitive measures of such usage and treatment instead. Under this bill, those who are treated with naloxone at least three times are mandated to either pay back naloxone’s cost or obtain treatment. Failure to fulfill this mandate will result in incarceration and a court hearing. This bill epitomizes a modernized perpetuation of the War on Drugs—it seeks to penalize overdose and subsequent use of naloxone due to preconceived notions of individualized wrongdoing rather than attempting to understand the contextually systemic and evidentially medical issue at hand.
One justification for House Bill 771 is the preservation of taxpayer dollars— that is, why are taxpayers paying for naloxone when those being treated with naloxone continue to overdose? This question probes at an issue of enabling: Does the accessibility of naloxone create a mental safety net, thereby enabling opioid users to continue using?
Such questions of enabling are not only presumptive, but are also misguided and rooted in ignorance. First, they assume that individuals are overdosing more because of naloxone. However, research rebukes this assumption, demonstrating that naloxone has reduced death without increasing overdoses. Thus, it is not that individuals are overdosing more, but rather that those who are overdosing now have the capacity to live notwithstanding such overdoses. Second, such questions problematically focus on the notion of individual responsibility rather than the life-saving value of naloxone: while it is important to understand the causes of opioid use and overdose—be it individual or systemic—it is nonetheless more important to maximize lives saved through this treatment. The penalization of overdose will only further impoverish and incarcerate Baltimore residents, while the treatment of overdose, through tools such as naloxone, can instill hope and mobilize change.
Our questions must shift from concerns regarding enabling to concerns regarding the saving of lives.
Our questions must also concern contextualization—while the medicalization, and consequent individualization, of opioid usage has reduced stigma and augmented treatment, the context of such opioid usage should not be overlooked. Recently, salient context regards the Gun Trace Task Force trial, in which Baltimore City police officers were convicted of stealing money and drugs from local drug dealers and profiting from such actions through reselling the drugs back onto Baltimore’s streets. While conversation surrounding this trial has largely been rooted in policing and our criminal justice system, and rightly so, another crucial conversation emerges regarding that of opioids in Baltimore City.
This trial may serve as a rebuke against the widespread, yet problematic conjecture that the opioid crisis is a function of “bad people doing bad things.” This trial demonstrates that Baltimore City’s police force is culpable of permeating its city with the same dangers it is tasked with removing. Moreover, this trial unearths misplaced blame. While stigma has resulted in the placement of blame on those who use drugs and overdose, here we see that such blame is neither simple nor linear. Our police force is to blame, our history of racism and segregation is to blame, and our inability to erase stigma from our purview is to blame.
With the Gun Trace Task Force trial as our immediate context, Dr. Leana Wen’s biomedical approach to “addiction as disease” is both progressive and warranted. Logically, if our police are charged with perpetuating the opioid crisis, health policy should support, not penalize, those impacted by such a crisis. Moreover, if we defibrillate a heart without question, the distribution of naloxone should likewise exist without question based on the understanding that addiction is a disease rather than a character flaw.
The opioid crisis spans many arenas—public health, law, history, science, bioethics— all of which embody the intersection of individuals and society; likewise, our response to this crisis should integrate an individual, biomedical focus with a systemic, institutionalized context so as to instill concrete change.
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