Flawed Perceptions Result in Fatal Policies

May 2024

By Nikki Tierney, JD, LPC, LCADC, CPRS
NCAAR Policy Analyst

“A system cannot fail those it was never meant to protect.” – W.E.B. DuBois

Historical records of lives lost in wars do not include the specific weapon which caused the deaths.  There is no indication if lives were lost to a bomb, gunfire, or drone strike.  Additionally, there is no demographic information about the people killed in war.  The people are simply gone.  Yet, in terms of drug-related death and harm, those results are often categorized according to the specific substance that caused it (directly or indirectly) and the demographic information about the individual.  Certain drugs are deemed to be acceptable by society, while others are unacceptable.  Alcohol versus heroin, for example.  Where substances fall on this spectrum is often equated with the people more likely to use those substances.  This framing has resulted in draconian and ineffective penal policies, which have exacerbated the death and harm from substance use.

Dehumanization and stigma of people who use drugs, especially drugs labeled as ‘illegal’, has played a significant role in the inhumane ways various government systems treat those people.  A recent study highlighted that this skewed depiction from media coverage, anti-drug awareness campaigns, and academic research has resulted in systematically biased policies, harsh penal responses, discrimination and stigma, and suboptimal healthcare. ¹ For example, in the 1980s and 1990s there was a fixation with the supposed ‘arrival’ of ‘crack’, which is always distinguished from cocaine even though they are the same substance. ² The active ingredient in crack is cocaine, with the only difference being the route of administration, and of course, the skin color of the people who used the drug.  The media added substantially to this rhetoric.  More specifically, there was the now infamous 1986, Newsweek cover story entitled “Kids and Cocaine” which quoted a supposed addiction treatment entrepreneur as stating crack caused “instantaneous addiction” and was “the most addictive drug known to man.” ³ There were also false claims that people who used crack were violent and predatory and repeated references to ‘crack babies.’

The sensationalist perception of crack and people who likely used it contributed to the 100:1 sentencing disparity between crack and powder cocaine in the Federal Sentencing Guidelines.  It was not until 2007 that the United States Supreme Court ruled in Kimbrough v. U.S. that the crack/powder cocaine sentencing disparity was racially biased and fundamentally unfair.  Next, the Fair Sentencing Act of 2010, decreased the sentencing ratio to 18:1.  It was not until late 2022, that Attorney General Merrick Garland issued new guidance (effective within 30 days) that finally declared the crack/cocaine sentencing disparity was “simply not supported by science, as there are no significant pharmacological differences between the drugs.” ⁴

Next, in the 2000s, the ‘opioid epidemic’ was attributed to the overprescribing of opioid pain relievers by doctors across the country.  Media coverage, elected leaders, and awareness campaigns all contributed not only to the purported significance of drugs being used but also to which people were using which drugs.  The following are some examples of the new perspective the media and public ascribed when opioid related harms and deaths began amongst White Americans:  Fox News “The New Face of Drug Addiction” (Lee, 2013), on NBC News “Painkiller Use Breeds New Face of Heroin Addiction” (Schwartz, 2012), on Today “Hooked: A Teacher’s Addiction” (Carroll 2014), and on ABC News “Heroin in Suburbia: the New Face of Addiction” (Michels, 2008) and “The New Face of Heroin Addiction” (ABC News 2010). ⁵ Much like the sensationalism around crack cocaine, the narrative about prescription opioids influenced policies that had unintended consequences. This led to a reactive idea that by decreasing supply, in this case prescription for opioids, the multifactorial challenge of the crisis would be miraculously solved.  As the American Medical Association explained, opioid prescriptions decreased by 44.4 percent between 2011-2020, including a 6.9 percent decrease from 2019-2020.” ⁶ When interdiction efforts were directed toward pain management and healthcare clinics, untreated pain and supply shock increased suicides and forced people who were already struggling with addiction and/or chronic pain to turn to the unpredictable potency of the illicit drug market.  Most tragically, media, researchers, and leaders continued to concern themselves with the ‘what’ and ‘who,’ but not the critical ‘why.’ What drug and who was being harmed remained the focus rather than why people were using drugs in the first place.

Then, a new villain was identified: fentanyl. More specifically, fentanyl analogues.  There was a plethora of pictures and articles about the massive volume of deadly fentanyl analogues seized and how it could destroy humankind and yet there continued to be significant increases in deaths.  Again, the sensationalism contributed to the one-dimensional supply side interdiction response that had been failing for years. Moreover, which populations were being impacted was always lurking in the background.   Research and data from the National Institutes of Health, U.S. Substance Abuse and Mental Health Services Administration, and Indian Health Service underscore the continued challenges and inequities for Black, Latinx and American Indian/Native Alaskan populations. Increasing deaths and inequities not as a result of drugs but resulting from America’s response and policies related to drugs and the people who use them. ⁷

More recently, there has been a media frenzy and governmental interest in xylazine.  Again, the public misperception and media coverage not only resulted in additional stigma, but the familiar ineffective policy responses, including a race to ‘schedule’ xylazine as opposed to employing evidence-based harm reduction strategies that have worked with so many other public health challenges, such as HIV and AIDS.  The headlines associated with the proliferation of the animal anesthetic xylazine in the already adulterated supply leveraged stigmatizing rhetoric around xylazine and compared humans to monsters: “Skin-rotting drug ‘tranq’ infiltrates big cities: Zombifying bodies” (Kato, 2023); “Xylazine fears grow as ‘zombie’ drug spreads across US” (Phillips, 2023);  CBC News (2024) How a flesh-rotting ‘zombie drug’ is complicating the overdose crisis; and Forbes (2023) White House Promises More Research into Deadly ‘Zombie Drug’ Xylazine.⁸

The latest media obsessions have been related to alcohol, a historically ‘acceptable’ drug, despite a 29 percent increase of alcohol-related deaths from 2016 to 2021. ⁹ As with other changes in substance use data, some reporting highlighted the demographics of the people most impacted, in this case younger women.  For example, one recent report noted that among adults under 65, more people died from alcohol-related causes in 2020 than from COVID-19 (White, A. M., et al., JAMA, Vol. 327, No. 17, 2022) ¹⁰ One article provided welcomed insight into the real challenge facing so many Americans, as opposed to the name of the substance or race and identity of those impacted: “[a]lcohol can be a cause of harm, but it’s also a barometer for other issues. Mental health in this country is in meltdown mode,” said Aaron White, PhD, a biological psychologist at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). “It’s common for people to drink excessively in an effort to cope. Alcohol use might be on the death certificate, but what’s often killing people is loss of hope.”

This conceptualization that mental health and social vulnerabilities are critical in framing and responding to the current health crisis is essential if we are to make progress.  Researchers are increasingly focusing on the powerful effects of social context and environment on substance use initiation and disorders and this shift will result in evidence-based responses and policies instead of a continuation of the responses that have cost America billions of dollars and immeasurable number of lives and suffering. ¹¹

Policies and approaches that focus on downstream factors such as individual-level interventions, medical care, and treatment address the consequences of using substances, the substance used, and the population involved are a necessary but incomplete strategy.  These responses and policies do not eliminate risks or increase protective factors.  On the other hand, approaches that focus on upstream factors, the reason people are using substances, seeks to improve the conditions in which people live via changes in policies, housing, neighborhood conditions, and increased socioeconomic status, and will likely be more powerful. ¹²

Animal models have provided evidence of potential protective factors that may help as they consistently reveal that purpose, connection and social interactions reduce substance use. This finding has been consistent across drug class, drug dose, gender, sex, and abstinence duration. ¹³ To date, much of the American response and policies related to drug use have focused on the exact opposite things, such as harsh penal consequences, dehumanization and deprivation.  Seeking to address drug use primarily by reducing supply through a law enforcement approach has proven costly and less effective than hoped, both within the United States and internationally. ¹⁴ Conversely, there is data and evidence to show that harm reduction is the most humane and effective way to respond to people who use substances.  More specifically, more than 40% of fatal opioid overdoses are witnessed and therefore preventable if naloxone is readily available. ¹⁵ Merely preventing deaths is not sufficient though.  Drug policies must also be an agent of change and support physical and mental wellness, again through purpose, connection, compassion, and evidenced-based services.

Dynamic modeling strategies have revealed that peer recovery support and harm reduction can play a critical role in reducing harms, caused not just by opioids, but other drugs as well.¹⁶ Whether it is crack or fentanyl or alcohol, data reveals that trauma, external stressors, persistently high unemployment, poverty, and imprisoning large numbers of people only multiplied the deaths and loss from substance use.  The stigmatizing narrative put forth by media and other reporting results in the belief that certain substances make harm reduction paradoxical, and punishment seem prudent, but there are decades of increasing deaths and harms from every single substance to dispute this.  In the classic public health parable credited to medical sociologist, Irving Zola, a member of the local community sees a man caught in a river current. She saves the man, only to be drawn to the rescue of more drowning people. After many have been rescued, she walks upstream to investigate why so many people have fallen into the river. She discovers a beautiful overlook along the river’s edge without any warning signs or protective barriers. (National Collaborating Centre for Determinants of Health, 2014, p. 1).

To relate the analogy of Irving Zola, if one were to investigate why so many people are falling into the river of substance use, it is because they are sucked in by a vacuum of structural inequities in our social, health, legal, and economic systems that are built by policies that misattributed the failure solely to the individual rather than the system. The way to change that is to readily and intentionally prioritize the health of everyone, including people who use drugs, and acknowledge those who have been forced to the margins. If we build our systems on the foundation of data rather than discrimination, real stories rather than stigma, and collaboration rather than separation, perhaps the devastation of the War on Drugs (and the people who use them) will finally be considered our greatest teacher rather than our longest war.