The United States is in the midst of the worst drug crisis in its history, a toll measured in fatalities on a scale we have never seen before.
Death is not usually the leading indicator of a drug epidemic. Only the horrors of the crack-cocaine crisis, when homicide rates peaked at 80 per 100,000 citizens in Washington, D.C. in the early 1990s, come close enough for comparison. In a frenzy of violence that targeted predominantly black, urban communities, the crack epidemic took an average of 2,000 lives from New York City, the country’s most populous city, in each year of its most brutal phase.
We now count close to half a million lives lost to drug overdoses since 2000, a figure driven by the long-running opioid epidemic, and one that exceeds the number of American lives lost to combat during the Second World War. Counties in many states register death rates of 30 or 40 per 100,000; some surpass death rates of 70 per 100,000; and a small number, in states like West Virginia, approach 100 or more. Opioid overdose deaths in 2015 rival the total number of lives lost during the entire crack-cocaine epidemic. Sadly, though the Centers for Disease Control and Prevention (CDC) has yet to finalize overdose fatalities from 2016, when it does we will reckon with numbers far worse than those of the year before; 2017 is on track to be worse still.
Only very recently, as we suffer the darkest days of the country’s most lethal drug crisis, has the opioid epidemic commanded the kind of public attention commensurate to its damage. Most notable is the Donald Trump’s executive order, issued at the end of March, to convene a long overdue blue-ribbon commission to address drug addiction, with a special focus on opioids.
But what has so far escaped notice is that in the magnitude and duration of the opioid crisis, in fact in the very nature of its lethality, we confront a problem of our own creation. While this observation holds for every drug epidemic—indirectly measuring dislocation or the disappearance of work; unobtainable idylls of performance or body; and very often, the policing of race, class, and “subversive” activities—opioids in particular lay bare specific policies and philosophies of state power that have proven disastrous for the American people.
The Failure of the Regulators
Chief among these is neoliberalism: government austerity, unrestrained free trade, and the deregulation of markets. All of these present dangers that have played a role in the opioid crisis, but none has been more pernicious than austerity, an obsession over government deficits and debt that favors the privatization of public assets and services—and one that has exacted steep costs from the institutional culture and operation of the nation’s drug safety watchdog, the Food and Drug Administration (FDA).
Though accounts of the opioid epidemic typically start with the FDA’s approval of Purdue Pharma’s OxyContin in 1995, a better chronology would go back to President Bill Clinton’s Prescription Drug User Fee Act of 1992, initiating a process by which drug companies would become a major funding stream for the FDA. An adequate political account would also include the 1997 FDA “Modernization Act,” part of Clinton’s far-ranging initiative to “reinvent government,” as well as the recent “21st Century Cures Act.” The sum total of this legislation has transformed the FDA to the point where the pharmaceutical industry provides almost half its budget, and most members of Congress have come to regard drug approval requirements as corporate burdens rather than public protections. It is certainly true that, as economists Anne Case and Angus Deaton write in the latest installment of their research examining the surge in “deaths of despair,” that there are “reasonable questions about an FDA approval system that licenses a class of drugs that has killed around 200,000 people.” But few in Washington, D.C. show any interest in asking them.
To call the FDA “missing in action” on the opioid crisis would be charitable. It is closer to the truth to say that the agency launched and continues to abet it. From the misguided approval and branding of OxyContin, on the basis of information the FDA knew to be faulty, to the puzzling approval of the similar single-entity, extended-release opioids of Opana in 2006 and Zohydro in 2013, the FDA operates on the belief that opioids are beneficial in managing chronic pain, although there is to date no persuasive evidence of their effectiveness, and only mounting proof of their morbid risk. Also damning is the fact that most of the criminal and civil prosecution of drug companies for “misbranding” their opioid products as less addictive has come at the hands of U.S. Attorneys and whistleblowers, even though the law that defines the violation, the Food, Drug, and Cosmetic Act, falls well within the purview of the FDA. Aggressive in opioid approvals, the FDA has been lethargic in responding to the consequences.
It turns out “running the government like a business” in practice amounts to running the government on business’s behalf, at the expense of the public good. It is a troubling and pointed irony that the new commission formed to address opioids will reside within Jared Kushner’s new White House venture to “reinvent government,” a coincidence of placement that underscores Donald Trump’s uncanny ability to identify a problem neglected by the political establishment, and propose as a solution the very thing driving the problem in the first place.
The Lost Drug War: Is Anyone Keeping Score?
But neoliberalism is not alone in propelling the opioid epidemic. Alongside it falls the U.S. government’s commitment to drug prohibition, a failure unmatched in the annals of public policy. Prohibition results in, among other things, an unregulated drug, and an unregulated drug poses an unknown risk to its user. That heroin is formulated with increasing potency, and illicitly produced synthetic opioids like fentanyl and carfentanil circulate in the drug market, is principally the result of criminal prohibition.
The drug war, like neoliberalism, is a relatively recent government project. Even many historians make the mistake of attributing prohibition to the 1914 Harrison Narcotics Tax Act, but in fact heroin—the drug at heart of what we think of as the modern drug war—was not contraband until 1956, when the U.S. federal government demanded the dwindling licit supply be turned over to the government in return for payment. In the interim and especially before the Second World War, European drug companies overproduced a number of opioid painkillers, including heroin, and turned a blind eye to diversion and non-medical use. Because all opiates and semi-synthetics derived from the opium poppy were imported into the country (something that remains true today), lawmakers fell prey to facile promises from the Bureau of Narcotics, a predecessor to the Drug Enforcement Administration, that prohibition was both feasible and desirable.
What followed attests to the inability of the U.S. government to monitor the flow of relatively minuscule amounts of goods and relatively small numbers of people across its borders—not unusual, for a prosperous trading nation—as well as the perverse incentives established when trying to punish a market out of existence. In the end, prohibition only adds to profit margins, and renders irrelevant the licit regulations and medical judgment used to manage a drug’s formulation and potency.
In every possible sense, the opioid epidemic is a creature of our creation. As overdose deaths spiral to horrifying new heights, we owe it to ourselves to set more ambitious terms for discussing the crisis. But rather than inaugurating the discussion the country needs, Donald Trump’s commission promises nothing more than to repeat a discussion we’ve already had, replicating its worst errors.
It is not widely known that President Kennedy formed his own blue-ribbon panel to tackle drug addiction in 1963. The interim and final reports of the Kennedy commission rebuked the previous twenty years of drug policy, which had veered from drug regulation via taxes and tariffs into punishment and de facto prohibition. The commission’s chair, Judge E. Barrett Prettyman, stepped into the breach between the government’s strident policies and the emerging consensus which called for their rejection. Addicts were the victims, not the knowing creators of crime, he insisted, to the chagrin of the nation’s zealous drug warriors, and the commission followed suit by endorsing treatment over punishment. At the same time, Prettyman and his commissioners argued that tougher penalties for sales and production, and more effective tools to detect and intercept these, were long overdue. The preface of the committee’s final report noted with obvious satisfaction that the group had rejected the extremes of either an exclusively militant or, as they viewed it, an overly permissive approach—an attractive appearance of compromise that closely resembles President Obama’s position on the drug war, as well as the presumed intent behind Donald Trump’s commission.
History’s verdict on the Kennedy commission has not been kind. Long forgotten, its half-measures proved palatable, but temporary and easily rescinded. Yet we continue lavish praise and regard as aspirational the very same posture, even in the midst of the worst drug crisis in our history. Unless and until we accept the failures of prohibition and neoliberalism, we will trapped by their logic and will perpetuate, however unwittingly, their injustice and harm.
Elsewhere both philosophies have come in for much deserved criticism. When Guatemalan President Otto Pérez Melina took his call for drug decriminalization before the United Nations in 2013, he joined others in the region who have called for a major reconsideration of drug prohibition. Outside Latin America, which has long borne the brunt of American drug war foreign policy, support for legalization and decriminalization grows apace, emboldened by decriminalization’s notable success in Portugal. In a world that is converging on official recognition of the drug war’s failure, the United States refuses to entertain any serious discussion of alternate approaches.
Much the same is true for neoliberalism writ large. Last year the International Monetary Fund published a study by researchers who questioned whether projects to privatize government and tilt political economy in favor of global finance actually resulted in real gains for ordinary people. This was a remarkable turn for an institution long devoted to promoting a neoliberal agenda; the IMF’s findings on economic inequality reinforced those of Thomas Piketty, who issued grave warnings about rising inequality in his landmark Capital in the Twenty-First Century. Nevertheless, neoliberalism registers in mainstream U.S. political discussion mostly under the guise of euphemism, if at all, and the Democratic Party’s embrace of its fundamental principles has deprived it of an organized opposition, allowing it to escape a reputation of failure. When it comes to drug regulation, all of the major components of the neoliberal agenda passed with bipartisan majorities in Congress and under Democratic presidents.
And so in facing the opioid crisis, we are in reality wrestling with the catastrophic consequences of other policies, and the limits of our politics in naming and addressing those problems. We have fallen prey to facile proposals before; let us at least be able to recognize them. Treatment facilities will not expand or become more effective in response to rhetoric and block grants; they will flourish only when other, antagonistic and more entrenched interests disposed toward punishment are rejected. The FDA will not become more diligent in its service to the public when it undergoes thorough review or hires more staff; it will return to safeguarding the public interest only when its corporate capture comes to an end. In this sense, the opioid crisis is a problem of power. Channeling resources into alternative approaches does little when forces directly injurious to them remain untouched—or, under the stewardship of Trump and appointees like Jeff Sessions, grow emboldened.
Kathleen J. Frydl is an award-winning scholar of the U.S. state. Her latest book is The Drug Wars in America, 1940-1973 (Cambridge University Press, 2013).
An earlier version of this article appeared at Medium.