Why do people use drugs? It’s one of those neglected questions with answers right in front of our noses. We just refuse to look.
Getting high—and overdosing—is after all, as American as apple pie. Over 46 million people in the U.S. have an alcohol- or drug-use disorder. Everyone knows someone who died, or who lost a son or daughter, mother or father, to a drug overdose, one of the 100,000-plus now yearly recorded nationwide.
Lost in today’s raging debate over drug policy and how to curb this spiraling mortality is the deep malaise that lies at the root of substance use in America. We are stuck on a loop, veering from “drug war” to legalization to backlash against legalization, without a record of improving lives and setting people on a successful path of recovery. And that’s because we are frankly unwilling to fix the economic cruelty that drives and keep people locked in dangerous drug use.
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In a 2022 photographic-ethnography published in the journal Criminology, investigators did the obvious thing and asked people using meth in rural Alabama how they made sense of their tumultuous lives. Rather than gathering post-hoc justifications for using meth, the study aimed to hear people who use drugs tell their own stories. The results painted a remarkably vivid portrait of poverty and drug use in 21st-century rural America.
Across small towns in the northern tier of Alabama, a state with the sixth lowest median household income and seventh highest poverty rate, the researchers observed lives caught in repetitive and destructive patterns. Women felt trapped in relationships that were volatile and often violent. They would flee but have nowhere to go. People felt a pervasive sense that they lacked freedom and agency to improve their circumstances. If you feel boxed in by the absence of opportunity and mobility, then daily meth use, adding a synthetic buzz and thrill to otherwise boring or dreadful moments, isn’t such a stretch.
One of the study’s most arresting images was a selfie-silhouette taken by a 22-year-old named Alice. It shows her “in the dark where I felt I belonged,” she said, expressing the shame and stigma draped over her life. The study captures how substance use fills a void in a world drained of meaning.
The unhoused person smoking fentanyl in Portland, Ore., or the couple injecting methamphetamine in isolated ruins in northern Alabama, need much more than what current policy options can deliver. That’s because the dominant policy models are utterly divorced from the emotional pain flowing out of today’s social and economic structures that fuel compulsive use of highly lethal substances.
It’s no coincidence that drug overdose deaths have been rising exponentially in America since the 1980s. That’s when more and more of life’s vital necessities, from housing to health care and education, were left to the whims of the marketplace. Corporations squeezed more and more profit at the expense of consumer protection and public safety. Ever since the American economy deindustrialized, the gap in wealth and education inequality, along with measures of well-being like life expectancy, grew wider. Economic and social conditions like what we’re living through fuel a sense that people are being screwed over, resulting in rampant distrust of American institutions, breeding loneliness and despair and thus an urge to escape.
That pain is felt even sharper when systemic failures are internalized as personal ones. People who lose control of their substance use have long been deemed constitutionally weak-willed, doomed to a life of moral turpitude. That dim view of human compulsion thankfully has shifted in recent decades. During the 1990s “Decade of the Brain,” addiction came to be viewed through a neurobiological framework that promised to unleash the power of neuroscience and technology on the mysteries of brain disorders, unlocking new treatments.
Three decades later, it’s no longer the case that addiction is so difficult to treat. For opioid use, in particular, there are highly effective medications that relieve withdrawal, stabilize opioid-starved receptors and drastically reduce the risk of a fatal overdose. These drugs––from naloxone to methadone and buprenorphine––were designed in the 20th century, well before the technological leap of neuroscience and brain imaging. Naloxone was first patented in 1961. It can miraculously stop an overdose in its tracks and rapidly restore life. And yet, naloxone distribution is nowhere close to where experts say it needs to be. That’s largely a consequence of distribution bottlenecks and pharmaceutical companies’ efforts to repackage and profit off the surging demand for an old, generic drug.
Thanks to a disjointed and profit-driven health care system, other crucial medications rarely make it to people who need them. Many jails and prisons—places where people with substance-use disorders endlessly cycle—refuse to prescribe methadone and buprenorphine. Unless, of course, they’re sued into doing so.
People outside the prison system don’t fare much better. A June article by RAND researchers found only a third of outpatient mental health facilities offer medication to treat opioid addiction. Despite the high prevalence of co-occurring mental illness, the same study found only about half of such facilities even screen patients for opioid use. Another recent study uncovered a dismaying number of missed opportunities to treat opioid use among Medicare beneficiaries who experienced a nonfatal drug overdose. The researchers found that only 6 percent had filled a naloxone prescription and just 4 percent received medications like methadone or buprenorphine. If that medication was administered, that lowered the likelihood of fatal overdose.
A lack of scientific knowledge or clinical skill is not to blame for these abysmal findings. Instead, it’s our Kafkaesque health system, littered with holes, gaps and silos, that is incapable of administering the best treatments science has to offer. People struggling with addiction are repeatedly failed by the institutions meant to help them.
Arresting, prosecuting and incarcerating people struggling with addiction has become incredibly unpopular and widely seen across the political spectrum as a costly failure. And yet attempts to decriminalize drugs and create robust systems of health care and social services trigger ferocious backlash. The policy pendulum swings between liberalizing and relaxing drug laws to more aggressive and harsh enforcement. Caught in the middle is a well-meaning, albeit quixotic, techno-optimism seeking impractical moonshots like a fentanyl vaccine and brain-stimulating implants.
Reading about the lives of people using meth in rural Alabama, I couldn’t help but think about the other end of the addiction spectrum. Studies repeatedly find that recovery rates among doctors, airline pilots and other professionals are much higher than in the general population. Some attribute their success to the intensity of the treatment: long-term, strict monitoring and frequent drug tests. But there’s another crucial element at work. These well-paid professionals have something to lose, and therefore, something to live for. More than their future livelihood is on the line; their identity and entire life’s work is contingent on their recovery.
So long as our drug policies fixate on treating symptoms, the downstream manifestation of an economy, society and culture that has left so many behind, then the actual disease will go untreated.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.