It is 10 a.m. on a spring day in 2009, and already a heavy reggaeton beat fills the air. Rico, our baby-faced, wheel-chair bound, teenage neighbor is working the coveted morning shift selling $10 baggies of heroin to the constant stream of mostly young, white addicts that have been pouring into our North Philadelphia block since dawn.* “The dope moves fast in the morning because when the fiends wake up they are already in withdrawal,” Rico explains.
“Let me get two!” shouts a young man, still several car lengths away. Rico peels two postage-stamp-sized baggies from a fresh fourteen-pack bundle arrayed like a miniature deck of cards and held together by a ring-sized elastic band. He hands them over and stuffs the $20 in his jeans. In between sales, he hides his thinning dope bundle in the ripped armrest of his refurbished wheelchair. Two years ago, his brother, high on PCP, accidentally shot him in the back, partially paralyzing him. The injury led to him dropping out of high school and eventually selling heroin full-time.
After copping, the block’s customers disappear into nearby abandoned row homes or descend into the overgrown, garbage-filled railroad tracks that for decades have been one of the neighborhood’s most popular open-air injection sites. Some cannot wait and peel open their small baggies to inject just steps off of our block. The anticipation of pleasure, or, more frequently, simple relief, overwhelms fear of arrest. Others, more patient because they are not yet in the agony of full-blown withdrawal, walk the two blocks to one of the neighborhood’s crumbling factories. Three lonely row homes border the lot, which, littered with scattered fragments from previous demolitions, recalls the aftermath of an aerial bombing.
Later, as Rico is wrapping up his shift, two men come shuffling up to ask if they can get “eight [bags of heroin] for seven [$70].” Rico agrees and the two men are ecstatic. As they are leaving, Rico tells them that he will be out at 6 a.m. again tomorrow morning and will “get them well [with the first dose of the day].” When Rico tells them that they can work for him as steerers, fetching other addicts to come buy from him, the two men beam with gratitude and say, “Thanks for putting us to work!” After another older white addict hurriedly strides past us, Rico says pensively “I guess they must have been born to be that way. It must be horrible to inject into your veins six times a day, 365 days a year.”
Rico’s words now strike me as sadly ironic. Today, a largely sympathetic media portrayal of a younger, whiter, less urban, less poor group of addicts has helped spark a much needed, yet enormously inadequate, reconsideration of the failed War on Drugs that has mostly left poor black and Latino communities out of the spotlight of concern. This despite the fact that recent research shows that from 2001 to 2014, deindustrialization and hyperincarceration were responsible for a two-and-a-half-year reduction in life expectancy overall and may also fully explain the growing gap in life spans between the poorest and richest quartiles in the United States. Cedric Richmond, a U.S. Representative and the leader of the Congressional Black Caucus, in a 2017 interview, commented on the contradiction: “So we now have this loving, nurturing medical response to opioid addiction. . . . However, 1988, 1989, and the ’90s, what we did with crack . . . we said we’re going to declare war on drugs and we’re going to lock everybody up. . . . The only difference is who is addicted and the response that we’re giving.”
Far worse, the still tentative turn to a gentler public health approach for white drug users is actually masking a regressive recommitment to punishment for the black and Latino dealers who are arrested for selling to them. In the most extreme form, some states are passing laws that would hold dealers like Rico criminally responsible for homicide if their customers overdose. Even more states are implementing new mandatory minimums for selling fentanyl—a fully synthetic opioid fifty to a hundred times the strength of heroin—which became a common heroin contaminant in 2013.
These initiatives represent an incredible return to outmoded criminal-justice policies at a time when we seemed to be heading for reform. They perpetuate historic injustice against the communities of color that, for decades, economic marginalization, over-policing, and hyperincarceration have already traumatized. They also indicate a misreading of both the roots of the current wave of addiction as well as the factors that sustain it. Instead of allowing growing sympathy for one population to drive misguided retribution against another, we ought instead to firmly locate blame for the opioid crisis where it belongs: unrestrained corporate greed, a broken, market-based healthcare system, and the growing chasm of American inequality.
The heroin trade between two eras
In 2008 I moved to Rico’s block, in the heart of Philadelphia’s predominantly Puerto Rican ghetto and at the epicenter of the city’s thriving open-air heroin, crack, and cocaine trade. Over the next four and a half years I worked as part of an ethnographic research team conducting hundreds of interviews with the dealers selling on our block, their families and their customers, as well as our neighbors not involved in the drug trade. My goal was to document and contextualize the intimate reverberations of the War on Drugs and the street-drug market it targeted, along with the poverty, violence, and hyperincarceration in which it was embedded. I spent time with my neighbors in their homes, on their stoops, at baby showers, birthday parties, and funerals. I accompanied mothers to court to witness their young sons sentenced to lengthy prison terms for drug crimes, shootings, and parole violations; and years later, I welcomed some of these now older men home, to the same busy drug corner where they had grown up and been arrested, and where they had seen friends shot and killed.
Once upon a time, my neighbors would have cycled between factory shop-floors rather than in and out of prison. Unfortunately, these are precisely the jobs that began disappearing after the industrial boom of the Second World War, just as African Americans and Puerto Ricans were migrating to northern industrial cities in increasing numbers. Driven by crushing poverty in the Jim Crow South and Puerto Rico, they sought opportunity that would prove, for many, to be no more than a mirage.
Back when Philadelphia was still a thriving industrial city, the factories that now serve as heroin and cocaine shooting galleries employed thousands of neighborhood residents. The row homes on our block were built to house these workers, but only a couple of our neighbors, now in their seventies and eighties, have nostalgic stories to tell of walking onto a job at one of these now decommissioned factories. The street-drug trade replaced manufacturing over thirty years ago as the neighborhood’s most accessible, equal-opportunity employer. The dealers that hustle retail doses of heroin, crack, and cocaine, often literally in the shadow of these empty factories, don’t even dream of those long-gone union jobs.
Between 1960 and 1980, when Puerto Ricans first started moving into this particular corner of the city, the neighborhood lost 40 percent of its population. In 1970, when the neighborhood was still predominantly white, the employment rate for school dropouts with less than nine years of formal education had been 67.5 percent. In 1988, it had dropped to 18.4 percent. At the last census, in 2010, only 27 percent of neighborhood residents held a high-school diploma and 56 percent lived below the poverty line. My neighbors, like ghetto residents across the country, increasingly suffer geographic, educational, and job-skill mismatches with the meager opportunities that remain, while crumbling public-school systems permit only the most exceptional students to attain the credentials that might allow them to break into the middle echelons of an ever more stratified U.S. economy.
Work in the neighborhood street-drug trade, on the other hand, is always readily available and sales on our block have been booming. For the last several months it has been open for business twenty-four hours a day, seven days a week. As we watch Rico serve his customers, Johnny, another of our teenage neighbors, recounts his own initiation into heroin selling when he was just fourteen:
It ain’t hard to start hustling [selling drugs in the street]. You see Gordo [one of the boys playing basketball]. He is thirteen years old, little as shit. If he go to Tray [the block’s drug boss] and says, “Can I hustle?” Tray gonna say “Alright,” ‘cause Gordo gonna put money in Tray’s pocket. That’s all Tray care about.
I like workin’ legit but I ain’t got time to be a momma’s boy no more. It’s not like I ain’t tried to get a job. It’s time for me to grow up now. My mom can’t take care of all of us.
Johnny’s mom, Marisol, raised him and his two brothers, Luis and Tito, on the block. She managed to acquire their house when the city was selling abandoned row homes for a dollar each. When they moved in, there was no heat or electricity, the floors were partially ripped up and several of the windows were broken. They made do, happy at least not to be in a shelter, and slowly worked the house into a more livable condition over the years. Johnny’s mother was one of the few residents on the block who had managed to secure a long-term full-time job, working for over ten years behind bulletproof glass for minimum wage at a gas station in another poor corner of Philadelphia. Over my years of fieldwork, Johnny, Luis, and Tito talked to me about their anxieties and triumphs and tried to make sense of their lives as they navigated the mean North Philly streets while Marisol watched on helplessly. “I lost them to the streets. How was I supposed to be home and at work at the same time?”
Although the neighborhood heroin trade employing Rico and Marisol’s sons has been well established for decades, in 2008—at the start of our fieldwork—no one had yet declared an “opioid crisis.” Nevertheless, we saw what appeared to be a new generation of heroin initiates. This cohort was younger and whiter than the mostly African-American and Latino users of the previous generation. We interviewed dozens of users from different ethnic and generational backgrounds and found a clear distinction, which national epidemiological studies have subsequently confirmed. Nearly all of the older users initiated heroin directly in early adulthood, often first by sniffing, and then injecting, the powdered form long available in the neighborhood.
Younger users, in contrast, almost uniformly began by abusing prescription opioid painkillers stolen from family members or purchased from friends. Immediately prior to switching to heroin, a very large number of these younger addicts were using OxyContin—Purdue Pharma’s proprietary continuous-release formulation of high-dose oxycodone, a powerful synthetic opioid relative of heroin.
Peter, Purdue Pharma, and the three phases of the opioid epidemic
A man named Peter, one of the neighborhood’s heroin customers whom we came to know well, straddled these two generations of opioid users. When we met him in 2011, he was in a long stretch of recovery and volunteered at the neighborhood’s only needle exchange. He was in his mid-forties and balanced recovery and relapse with a deep commitment to HIV and harm-reduction activism. He had a warm personality and boundless energy. Eventually, he became one of our research assistants, helping us recruit other heroin users for interviews. When he began using drugs as a young man, prescription painkillers were not widely accessible. He used alcohol, marijuana, cocaine, and methamphetamines before becoming addicted to heroin. But after a long stretch of recovery from the heavy drug use of his youth, he was re-exposed to opioids, this time in the form of prescription painkillers after an injury. After his pills ran out, he began purchasing heroin and, as he put it, he was again “off to the races.”
In his second phase of drug use, Peter joined the contemporary wave of opioid addiction that started to surface in 1999 with increasing prescription-overdose deaths. This inflection point followed Purdue Pharma’s introduction of OxyContin four years earlier and the subsequent aggressive, and criminal, campaign to maximize its market. The company advertised OxyContin as a safe, non-addictive alternative to other nearly identical opioid painkillers on the market. OxyContin’s trademark continuous-release mechanism was designed to smooth the peaks and troughs of instant-release formulations that, Purdue argued, led users to addiction by alternating euphoria and withdrawal. Its high-dose, slow-release mechanism also promised to increase the convenience of administration by supposedly providing pain relief for a full twelve hours rather than the four to six of other formulations. Then, in 2010, after more than a decade of rising opioid-overdose deaths, FDA concerns prompted Purdue to discontinue its highest-dose formulation of OxyContin and introduce a new deterrent mechanism against crushing and injecting the pills.
At around the same time, federal and local agencies ramped up the targeting of “pill mills” illegally selling prescriptions as well as other high-volume prescribers. The sudden introduction of tamper-proof mechanisms and the crackdown on prescribing—both criminal and legal—pushed already addicted individuals to seek black-market heroin to stave off withdrawal. (The new tamper-resistant formulation also conveniently renewed Purdue’s proprietary ownership over continuous-release oxycodone, and after years of arguing that their product as originally formulated was safe and non-addictive, they began militating against the introduction of generics because they lacked OxyContin’s new abuse-deterrent.)
If, at this second critical inflection point in the opioid epidemic, there had been the necessary commitment to expanding access to addiction treatment to absorb the predictable impact from these double shocks, it is likely that many opioid-pill addicts, like Peter, would not have progressed to heroin. Abandoning moralization and investing in harm-reduction strategies like expanding access to the overdose-reversal agent naloxone and creating medically supervised safe-injection facilities (SIFs) would have saved many of the lives of those who did transition. Peter, at least, had thought that had he had access to high-quality addiction treatment, it may have made a difference for him. He said that he would certainly use a SIF if one were available.
Instead Peter relapsed, and at an importune moment: it was the beginning of the third—and deadliest phase—of the opioid epidemic, which has been marked by the flooding of ultra-powerful fentanyl into the heroin street supply. The year 2016 set a record of roughly 64,000 deaths from fatal overdoses. Since 2009, overdoses have been the leading cause of accidental deaths in the United States. They have long since surpassed the deaths inflicted by AIDS at its peak before the availability of effective therapy. And if, as predicted, the toll is even higher in 2017, the United States is set to experience an unprecedented three successive years of declining life expectancy for the first time in over a century, just over twenty years since the introduction of OxyContin.
Peter was one of these victims, but perhaps he didn’t need to be. At a time when he was actively campaigning to establish a SIF in the neighborhood, Peter overdosed and died on the filthy train tracks near my house.
Corporate greed, Big Pharma, and American healthcare
Observers have justifiably assigned Purdue a large share of the responsibility for the opioid crisis. The company’s success in pushing OxyContin, the cover-up of its misleading marketing, and its continued evasion of meaningful punishment provokes apt comparisons to Big Tobacco. But the opioid epidemic is more than an outrageous and tragic example of the harm done by one “bad-apple” company. It is also a powerful condemnation of our market-dominated, profit-driven, and highly fragmented healthcare system, which failed people like Peter.
Perhaps most obvious is the freedom of companies like Purdue to market medications as if they were merely commodities. Purdue did not invent these sales practices, but it implemented them in a ruthless fashion with OxyContin, a medication with an unusually high potential to harm public health. They hired the highest-paid and largest group of sales representatives in Big Pharma history to “educate” physicians about the undertreatment of pain and offer the company’s solution to this problem. The company was particularly sophisticated in targeting medical curricula to help establish pain as the “fifth vital sign” (in addition to the traditional four—heart rate, blood pressure, respiratory rate, and temperature). This concerted campaign to spread the use of opiate painkillers liberalized prescribing patterns among physicians and provided cover for criminal pill mills, which together flooded the country with narcotics.
Yet as spectacular as the pill-mill phenomenon has been, negligent opioid prescribing frequently takes place in otherwise unremarkable clinical encounters. The rapid uptake of opioid prescribing among physicians has dovetailed with the erosion of the therapeutic relationship by a market-driven healthcare system. Patients have become customers to satisfy, and the doctor-patient relationship has become ever more transactional as a result. Perhaps the focus on satisfaction rather than on health outcomes would have had a different effect had frontline providers in primary-care clinics and emergency rooms not simultaneously been subject to increasing pressure to see more patients, and bill for more services, or spend less time with ever more onerous administrative burdens such as filling out paperwork and fighting with insurance companies. Physicians spend less time with patients, rendering them less able to meaningfully engage with their complex pain and suffering. Faster, simpler interventions, like heavy-duty opioid prescriptions that will leave their patient at least temporarily relieved, short-circuit the comprehensive primary care and pain management necessary for long-term healing.
When so many of these trends contributing to the opioid epidemic are directly traceable to our dysfunctional healthcare system, I can’t help but wonder how different it would be if we instead had a system that dramatically reduced corporate influence, realigned incentives toward quality care and positive health outcomes rather than revenue generation, promoted the integration of our current system’s many fragments, and simplified, standardized, and facilitated regulatory oversight. That a majority of physicians polled now support a single-payer system suggests I am not the only one wondering this.
But that is not the system we had at the start of the opioid epidemic, and it is not the system we have today. It should be no surprise, then, that profiteering is distorting the response to the opioid epidemic as much as it shaped its origin. Also unsurprising is that Big Pharma is again at the forefront, profiting from a disaster it helped initiate and exploiting a newly captive market of addicts.
Take, for instance, the dramatically increasing cost of naloxone, the overdose-reversal agent that the opioid epidemic has made into an essential medicine. Even the cheapest generic formulation shot up from $1.84 for two vials in 2005 to $31.66 by 2014. But this pales in comparison to the cost of Evzio, the privately-held Kaléo pharmaceutical company’s talking naloxone auto-injector. In 2017, Kaléo increased the price of an Evzio two-pack to an astronomical $4,500 from an already high $690 just three years earlier. We need not speculate whether a different healthcare system would combat this rapacious profiteering at the expense of a vulnerable public. The Veterans Health Administration, America’s oft-forgotten single-payer insurance system and the only public entity authorized to negotiate directly with pharmaceutical companies, covers the auto-injector for its patients at far below sticker price. Of course, a national single-payer system would have greater negotiating power for the benefit of far more patients.
Another example is the high cost and aggressive marketing of Vivitrol, a monthly injectable formulation of the opioid receptor–blocking agent naltrexone. Like both OxyContin and Evzio, the packaging—and not the novelty of its active ingredient—distinguishes Vivitrol. (The active ingredient, naltrexone, was approved for medical use in 1984 and is available as a generic one-a-day pill at a wholesale cost of $0.74 per day. Vivitrol’s monthly injectable formulations costs $1,267.) In a detailed investigation published last year, ProPublica documented how Alkermes, the manufacturer of Vivitrol, exploits and inflames the perception that treatment with methadone and buprenorphine is just substituting one drug for another, rather than promoting full abstinence, and lobbies to try and out-compete these more affordable and established therapies.
The opioid crisis does not simply reveal cracks in the healthcare system, though. It uncovers even larger fault lines in American society. The rapid rise in opioid overdose deaths, many observers tell us, signals a paroxysm of thwarted aspirations for a downwardly-mobile white working class. Drug addiction is the most visible of the “deaths of despair,” as the Princeton economists Anne Case and Angus Deaton put it. These include suicide, depression, and heart disease, which first dragged down the life expectancy of poor whites, and are now responsible for the first nationwide back-to-back drop in life expectancy in over four decades. The fallout from opioid addiction spreads far and wide, but its intensity continues to track economic exclusion. Some of the most affected zones are where white poverty is the most concentrated, like the Appalachian region that includes Western Pennsylvania, West Virginia, Eastern Kentucky, and Southern Ohio, as well as deindustrialized Rust-Belt cities like Philadelphia, which has both the highest poverty and overdose rates of any American city with a population over 1 million. The Brookings Institute, in a 2017 analysis, confirmed the link: across the United States, counties with already high or increasing poverty rates are among the hardest hit by overdoses.
Here again, we would do well to remember Representative Richmond’s admonishment that the color of despair is provoking a caring conversation that neither the public nor the government afforded black and Latino communities, whose poverty was and continues to be criminalized. Decades of thwarted aspirations drive young black and Latino ghetto residents to earn money and respect in the street-drug trade, suffering violence and incarceration in return. The national discourse on addiction brings much-needed, but still frustratingly partial, attention to the ravages of American social and economic inequality. So far it has had a remarkable ability to cloud our analytical lens with racial blindspots. A fuller analysis can guide us toward the common roots of suffering afflicting the poor of our increasingly unequal country, while reminding us of the key role race plays in shaping our concern and understanding.
But a structural diagnosis requires a structural intervention, and those are hard to come by without a movement behind them. That is why since leaving North Philadelphia in 2012, my understanding of engaged scholarship and equity-driven medicine has evolved toward trying to organize powerful new constituencies for positive social change. In my case, that has meant starting a campaign to push Harvard teaching hospitals—some of the most prestigious and richest in the world—to include the formerly incarcerated in their workforce so that they are not locked out of one of our fastest-growing economic sectors. Other colleagues—medical students and practicing physicians—organize side by side with active drug users to establish lifesaving safe-injection facilities. Still others are leading a national movement for a single-payer healthcare system that would reign in the profiteering that condemns our country to costly and unequal care, and that facilitated the birth of the opioid epidemic, impedes its solution, and continues to create grotesque opportunities for cashing in on despair. Other doctors are forming a white-coat bloc for the growing Poor Peoples’ Campaign that Reverend William Barber of North Carolina’s Moral Mondays is heading, picking up the unfinished work of Martin Luther King, Jr. when he was assassinated while organizing with striking African-American city sanitation workers in Memphis. Each of these is only a small contribution to the fight for a more just world. But by bringing varying constituencies into new alliances, they gesture toward the type of organizing that might help overcome the exploitation and public abandonment that manifests in the devastated bodies of our patients.
Almost ten years after first setting foot onto the North Philadelphia dope block I called home, I make my way back to visit Johnny and his brothers, Luis and Tito, who have just returned from five- and eight-year prison stays. As I wait for Luis to pick me up from the airport, I wonder if it might be too hopeful to think that physicians can play a role in ushering in a more just world, especially given American medicine’s tendency to stand on the wrong side of history. But as a new wave of addiction refocuses our attention on the social and economic exclusion that our country has long suffered, it is at our peril, both in medicine and beyond, that we ignore the call to action and continue to abandon people like Peter, Rico, Marisol, Luis, and Tito.
I have plenty of time to think, because Luis is over an hour late picking me up. In the middle of a snowstorm, Luis is driving to the airport for the very first time and he leaves late, misses the exit, and gets confused between arrivals and departures. Apart from his time incarcerated, he has rarely had the opportunity to leave the ghetto that has penned him in his whole life. I am overjoyed when he finally pulls up, jumps out of the car with a huge grin, and greets me with a hug. He starts pouring his heart out, like I never left: it is so strange to be back home after five years locked up, he says. Overwhelming, really. In the six short months since he has been back, seven friends have been shot to death. There are three drug crews on the block now and it’s crazier than ever. He has never seen so many addicts in the neighborhood before. Rico is in and out of jail. His two brothers are back to selling drugs. It’s so hard to find a job.
Lost in conversation, we take a wrong turn and his electronic surveillance anklet starts vibrating, indicating he is out of range. Before Luis has a chance to correct his course, parole dispatch rings him to check on his whereabouts. As he brings the phone to his ear, my heart sinks a bit as I catch sight of the rubber band around his finger, like a black elastic wedding ring, from a recently sold bundle of dope.
George Karandinos is an MD/PhD student in anthropology at Harvard University. He is currently co-authoring a book, Cornered (forthcoming from Princeton University Press) based on fieldwork in the open-air narcotics markets of inner-city Philadelphia, where he lived for four years.
* All names have been changed and identifying details withheld to protect the privacy of the individuals concerned.