Gloucester's plan for their opiate crisis

May 5, 2015 6:58 PM

Lives are literally at stake. I have been on both sides of this issue, having spent 7 years as a plainclothes narcotics detective. I have arrested or charged many addicts and dealers. I've never arrested a tobacco addict, nor have I ever seen one turned down for help when they develop lung cancer, whether or not they have insurance. The reasons for the difference in care between a tobacco addict and an opiate addict is stigma and money. Petty reasons to lose a life. As of June 1, the police department of Gloucester, Massachusetts will no longer be charging drug addicts who turn themselves in and ask for help. Instead, they will be fast tracking them into a recovery program.

The department has also partnered with a local pharmacy to provide Narcan, a drug that reduces deaths due to overdose, without prescription and at low or no cost to those without insurance. The police department will pay for this with money seized from drug dealers.

posted by Adridne (73 comments total)

Finally. Thank you, Chief Campanello.
posted by OnTheLastCastle at 7:01 PM on May 5, 2015 [2 favorites]

Here's hoping this is massively successful.
posted by Windopaene at 7:03 PM on May 5, 2015 [11 favorites]

What could the Drug Warriors in Congress do to shut this down?
posted by Faint of Butt at 7:10 PM on May 5, 2015

Damn Yankees and their logic!
posted by clavdivs at 7:11 PM on May 5, 2015

Who is in prison? Drug users. Who isn't? Dealers of drugs.
Graft explains many things.
posted by Mblue at 7:11 PM on May 5, 2015 [2 favorites]

Saw this on some news a day or two ago and thought maybe the PD got hacked. SO glad that is not the case.
GO FISHERFOLK!
posted by vrakatar at 7:35 PM on May 5, 2015 [1 favorite]

Meanwhile in Indiana.
posted by entropone at 7:45 PM on May 5, 2015 [1 favorite]

A bit more about the the town and the fish.
posted by vrakatar at 7:47 PM on May 5, 2015 [3 favorites]

Well Colorado GOP managed to shut down a massively successful program that provided IUDs to teenagers and reduced the abortion and pregnancy rate. Their reason (IUDs=abortions) is completely untrue, but it didn't stop them! So I'm sure they could find a way to stop this too by coming up with some handwavy "science" against it.

I hope they don't of course. We should be taking this approach everywhere.
posted by emjaybee at 7:56 PM on May 5, 2015 [3 favorites]

This is a very good thing. The opiate problem in this area is astoundingly bad. (I live not far away and have witnessed it myself, though thankfully no one I know).
posted by Miko at 8:12 PM on May 5, 2015 [1 favorite]

Thank Freaking God.
posted by benito.strauss at 8:39 PM on May 5, 2015

I've been having a bit of a debate with some friends about this, so for Miko or anyone else with local knowledge: are contraband seizures a sustainable source of funding for this kind of program, or would it be more in the nature of startup money to let the concept prove itself over a couple years? I've been having doubts that there could be enough seized drug money in the municipality to pay for the medication, counselors, and programs, but I don't actually know what the bust rate is like in that area.
posted by Errant at 8:57 PM on May 5, 2015

There is a difference between tobacco and opiate addicts, unfortunately. Nicotine does not have the same short-term and long-term effects on behavior that opioids do, to say nothing of crack, PCP, etc. Marijuana occasionally provokes psychosis, which nicotine does not. Marijuana can also cause an amotivational syndrome in some people and may lead to impaired cognitive development in adolescents. There is not evidence that nicotine does the same thing. You will not get lung cancer from heroin addiction and smoking undoubtedly kills more people, but false equivalency is not helpful. Rational public health and drug policy approach have to weigh all of the competing data. Acute alcohol intoxication is not the same as chronic nicotine dependence and policy has to take into account these differences. Even if we adopt a purely harm-reductionistic method of dealing with psychoactive substances, there are still troubling existential questions that need to be addressed about allowing people to be chronically in an altered state. When we treat addicts some stabilize and eventually get off substances but there are some individuals who may truly prefer to live in a state of constant intoxication. Even if the medical harm to such persons is minimized and some costs to society are minimized by not treating them as criminals, there may still be a type of harm being done by allowing people to continually self-medicate in this way. A purely harm-reductionistic and individual self-determination approach is not adequate to answer these questions. Even if such individuals are able to support themselves and not cause harm to society, is there not some other harm taking place that needs to be addressed to promote authentic human flourishing? Reasonable individuals may disagree and certainly we have demonstrated the harm of drug policy in this country, but trying to boil all the differences between types of substance use down to "stigma and money" is really missing some important points.
posted by fraxil at 9:03 PM on May 5, 2015 [4 favorites]

> .... is there not some other harm taking place that needs to be addressed to promote authentic human flourishing?

You may not have intended it, but this is exactly what concern trolling looks like.
posted by benito.strauss at 9:10 PM on May 5, 2015 [37 favorites]

A purely harm-reductionistic and individual self-determination approach is not adequate to answer these questions. Even if such individuals are able to support themselves and not cause harm to society, is there not some other harm taking place that needs to be addressed to promote authentic human flourishing?

So you think an individual self-determination approach isn't sufficient to promote authentic human flourishing? Is there some other way to promote authentic human flourishing than self-determination?
posted by bleep at 9:39 PM on May 5, 2015 [10 favorites]

Refuse to convict on non-violent drug crimes
Tell everyone to do the same.
Make it known its time to stop this failed experiment.
posted by bottlebrushtree at 10:26 PM on May 5, 2015 [4 favorites]

Way to go, Gloucester! This is an example of why I love the gritty, Massachusetts coastal cities- they are still full of old-school Democrats, hard working people who think that the government should help the less fortunate members of society, not punish or abandon them. See also- New Bedford (who elected Barney Frank for years)
posted by emd3737 at 10:31 PM on May 5, 2015 [8 favorites]

trying to boil all the differences between types of substance use down to "stigma and money" is really missing some important points.

This is actually very important. For example beyond a certain dose and frequency of use dopaminergic stimulants have a deleterious effect on physical and mental health that is inevitably well above zero, though education about these inherent limitations is certainly part of good harm reduction practice. On the other hand the inherent health effects of long-term opiate use - which happens to be the subject of this story - are not particularly dangerous as far as we know, just as the "short-term and long-term effects on behavior" tend to be minor, other than behaviors directly related to the urgent need to acquire expensive and illegal substances.
posted by atoxyl at 12:32 AM on May 6, 2015 [3 favorites]

(Even in the case of opioids, which I think is a fairly ideal one for harm reduction and medicalization if not full legalization I have to admit there are some problems that never completely go away. How many people manage to accidentally kill themselves with pills that have the dose right there on the tablet? Note that this is in fact fairly hard to do with opioids alone - people just don't listen when you say you shouldn't take them with alcohol or benzos.)

HOWEVER
there may still be a type of harm being done by allowing people to continually self-medicate in this way.

nah dude, not really
posted by atoxyl at 12:41 AM on May 6, 2015 [9 favorites]

A thoroughly harm-reductionistic approach would be preventative in aim and would mostly be geared towards reducing poverty and inequality. Since that's not so much in the cards atm, it's arguably less harmful than not to let people cope with what's given to them, in the ways available to them, without criminalizing them.
posted by cotton dress sock at 1:03 AM on May 6, 2015 [3 favorites]

there are still troubling existential questions that need to be addressed about allowing people to be chronically in an altered state.

No more coffee for you!
posted by telstar at 1:31 AM on May 6, 2015 [9 favorites]

"Even if such individuals are able to support themselves and not cause harm to society, is there not some other harm taking place that needs to be addressed to promote authentic human flourishing? "

That line of thought creeps me out. What is "authentic human flourishing"? What if not every person wishes or chooses to flourish? Must everybody flourish? What is the harm in individuals choosing not to flourish? If flourishing is desirable are those who choose not to flourish deemed undesirable or at least diminished or lesser? Why must there be an ideal posed of "human flourishing" and why must dissent regarding the need to strive for that ideal be considered "damage"?
posted by Hairy Lobster at 1:34 AM on May 6, 2015 [17 favorites]

generally in America "authentic human flourishing" refers to a lifestyle in which one works 40–60 hours a week for a fairly well known employer
posted by DoctorFedora at 1:39 AM on May 6, 2015 [19 favorites]

there are still troubling existential questions that need to be addressed about allowing people to be chronically in an altered state

Such as?

Even if such individuals are able to support themselves and not cause harm to society, is there not some other harm taking place that needs to be addressed to promote authentic human flourishing?

No.
posted by flaterik at 2:24 AM on May 6, 2015 [7 favorites]

As of June 1, the police department of Gloucester, Massachusetts will no longer be charging drug addicts who turn themselves in and ask for help. Instead, they will be fast tracking them into a recovery program.

Not really impressed. If people want treatment, why wouldn't they just turn up at a treatment provider? Why do they have to turn themselves into the cops to get it?

If they were no longer charging people they'd arrested in drugs raids, this might be notable. As it is, its a great big meh as far as I'm concerned.

As for the narcan thing -- well, do they really need praise for doing what they're supposed to fucking do?
posted by PeterMcDermott at 3:20 AM on May 6, 2015

But you're not a better (er, more "authentic") person for not smoking week or drinking beer or even shooting up opiates.

But, but, lotus eaters!
posted by Wolof at 3:34 AM on May 6, 2015 [2 favorites]

I'm pretty sure the current crisis is not conducive to "authentic human flourishing," since dead people can't flourish.

I think the point here, Peter McDermott, is that there's a systemic failure, and this one guy is trying to use his limited power to do what he can do and to call attention to the failure. If a long-term drug cop in a badly-affected town says this isn't working and we need to try something different, people might listen. He's also lobbying his political representatives, because that's where systemic change is going to have to come from. The police chief can't order treatment facilities to admit people who show up at their door. He could, I think, position his "angels" in less-threatening places, which is something I might suggest to him.
posted by ArbitraryAndCapricious at 3:35 AM on May 6, 2015 [2 favorites]

As for the narcan thing -- well, do they really need praise for doing what they're supposed to fucking do?

Yes, because evidence-based harm reduction is not the used by the majority of police departments in the US (much less other government service providers). Of course it should be standard practice, but it is not.
posted by Dip Flash at 4:17 AM on May 6, 2015 [4 favorites]

there are still troubling existential questions that need to be addressed [...] A purely harm-reductionistic and individual self-determination approach is not adequate to answer these questions [...] is there not some other harm taking place that needs to be addressed to promote authentic human flourishing?

You're absolutely right. People are being prevented from reaching their full human potential. Down with capitalism!
posted by Faint of Butt at 4:18 AM on May 6, 2015

there are still troubling existential questions that need to be addressed about allowing people to be chronically in an altered state.

No more coffee for you!

And no religion, too.
posted by Kirth Gerson at 4:19 AM on May 6, 2015 [1 favorite]

is there not some other harm taking place that needs to be addressed to promote authentic human flourishing?

yeah man I always chose the eudaimonic future society in alpha centauri too
posted by Rustic Etruscan at 5:08 AM on May 6, 2015 [4 favorites]

Not disagreeing that our current drug policy is crazy and we are seriously undertreating drug use and people are dying as a result. Not at all. But people are so reluctant to examine even a little bit where this "stigma" comes from and whether it has any ethical basis. Instead, I see people invoke "concern-trolling", silly people who pray to sky gods and petty moralizing. I am actually speaking from experience in treating people who are in long-term treatment for opioid addiction, and what I have seen is that a proportion are not able to successfully transition off maintenance opioids and they have associated chronic side effects, both cognitive and medical. More importantly, having your day revolve around taking opioids and dealing with the related side effects, and doing so without your full cognitive abilities does lead to limitations in their ability to flourish as humans. I doubt any of the casual users in this forum have such problems and am sure you all feel perfectly in control of your use, but others are not so lucky. Stigma can absolutely cause harm and prevent people from getting needed help, but it can also prevent suffering if vulnerable people avoid harmful things as a result. But I realize it's hard to swallow if you want to live by the mantra "nothing is forbidden".
posted by fraxil at 5:54 AM on May 6, 2015 [5 favorites]

We have decades of evidence that points to criminalizing addiction doesn't actually work. So, dorm-room philosophizing about actualizing authenticity or whatever aside, what is your policy suggestion? That we continue to criminalize and stigmatize? Even though we know it doesn't work?
posted by rtha at 6:01 AM on May 6, 2015 [8 favorites]

> I am actually speaking from experience in treating people who are in long-term treatment for opioid addiction, and what I have seen is that a proportion are not able to successfully transition off maintenance opioids and they have associated chronic side effects, both cognitive and medical.

Stigmatization and the threat of prison apparently did not keep them from becoming addicts. Do you believe more stigmatization and criminal punishment would have?

I'll point to this excellent comment by Eyebrows McGee over in the Indiana HIV outbreak thread a few doors down, which reads, in part:

But I also recognize that my feeling is not actually a logical or moral argument, and that if a law regulating the sale of fur in my state is up for debate, I shouldn't let my moral gut reaction override my actual moral reasoning abilities. As I understand myself to be human and therefore fallible, I don't require total philosophical coherence of myself ... just that I work hard at interrogating the parts where I discover I'm incoherent, until I understand my incoherence as well as I can and I'll remember it's there.

posted by rtha at 6:13 AM on May 6, 2015 [11 favorites]

Stigma can absolutely cause harm and prevent people from getting needed help, but it can also prevent suffering if vulnerable people avoid harmful things as a result.

You just give us a list of the vulnerable people and we'll take care of the rest.
posted by yerfatma at 6:14 AM on May 6, 2015 [2 favorites]

I doubt any of the casual users in this forum have such problems and am sure you all feel perfectly in control of your use, but others are not so lucky.

I think it is very weird to assume that people who criticize current drug policy are motivated by a desire to keep casually using heroin or prescription opiates. I'm always a little suspicious of folks who assume that everyone who wants drug policy reform is him or herself a drug user. I'm not, and I wonder about the personal ethics of anyone who can't imagine another reason to be critical of the current situation.

The War on Drugs has failed. Stigma has failed. As far as I can tell, the only effect that stigma has is to shift people from one drug to another. Where I live, there's a whole lot of stigma on meth, so respectable kids start with prescription pills instead. (Ultimately that often leads to heroin, but nobody realizes that at the outset.) I'm sure soon there will be stigma on prescription opiates, and the kids will move on to a different drug. But you can't fight the underlying problem with stigma. You fight it by keeping addicts alive until they decide to get clean. You fight it by adequately treating mental health issues, so people don't self-medicate. You fight it by providing people with economic opportunity and creating a more just society. And then you have to realize that we will never totally eradicate drug addiction, any more than we can eradicate currently-legal forms of substance abuse like alcoholism, and the best we can do is minimize the harms and maximize the chances that people will figure out how to get better. We don't, as a society, have the capability to ensure that everyone achieves "authentic human flourishing" as defined by you, so I think we should pursue other, better, more-realistic goals.
posted by ArbitraryAndCapricious at 6:38 AM on May 6, 2015 [22 favorites]

If people want treatment, why wouldn't they just turn up at a treatment provider? Why do they have to turn themselves into the cops to get it?

Having done several years of needle exchange volunteering: At least where I live, and at least as of a few years ago when I was more actively involved, they can't just turn up at a treatment provider because it is incredibly hard to get treatment. Some injection drug users don't have the money or health insurance for such things. Some have no idea where to even start finding out what treatment providers might be available to them. Some providers have very specific requirements for who they will take, or have long wait lists, and people get turned away in that critical window when they were ready to ask for help, and may never get up the courage to ask again. Some people are not good at advocating for themselves, especially to a system that thinks they are worthless because they use drugs.

If you show up at our exchange, and want treatment, we hook you up with our caseworker who is sympathetic, thinks you are a human being and inherently worthwhile whether or not you are using drugs, knows exactly what the local resources are, knows who has a waitlist at that specific time, knows about harm reduction, knows who takes what insurance, knows how to advocate for you, and may even know the right people to jump you up a waitlist if it's a special situation.

The right person helping you get treatment can make a giant difference in whether you actually get help.

Now, I am wildly skeptical of whether any police department, anywhere, is the right person to help someone get drug treatment. I really hope they are getting some special training in this stuff and not just throwing the nearest totally untrained cop at whoever walks through the door. But I think this could be a really good thing, done properly.
posted by Stacey at 6:48 AM on May 6, 2015 [9 favorites]

This is amazing news. Good on 'em.
posted by etherist at 7:01 AM on May 6, 2015 [1 favorite]

Stigma can absolutely cause harm and prevent people from getting needed help, but it can also prevent suffering if vulnerable people avoid harmful things as a result. But I realize it's hard to swallow if you want to live by the mantra "nothing is forbidden".
posted by fraxil at 5:54 AM on May 6 [1 favorite]

Do you really believe this? That people want to set up needle exchanges because we're all a bunch of hippies who want to turn America into some kind of heroin-fueled love-in where "nothing is forbidden"?

Also, who are you quoting when you say "nothing is forbidden"? Do actual social liberals say that or just the ones made of straw?
posted by Avenger at 7:03 AM on May 6, 2015 [5 favorites]

First of all, stigma is not a policy. It can be a response to policies such as drug illegalization, because (and in general, for good reason), illegal activity is stigmatized. But stigma can also arise simply from the firsthand experience of seeing people using substances to get intoxicated, particularly repeatedly. What I have seen is that nobody hates drug users more than the family members of drug users, not even the police. It is profoundly unsettling to have a parent or a child in the grip of addiction, and I think it is reasonable for families and communities to stigmatize drug use to prevent it from happening rather than adopting a judgment-free approach that says "try what you want, we'll make sure you can get into treatment if you need to".

I also think that making it as easy as possible to access mental healthcare and substance abuse treatment rather than jailing drug users is essential. But stigma can also be a very helpful tool for helping the person in recovery change their behavior. It can be a powerful motivating tool. We need to ensure that people who need care have access to it, but stigma can help people keep from developing problems in the first place and also help them get sober again. It is not all or nothing. And practically speaking, stigma against substance use is never going to go away, because there will always be some people for whom it interferes with their duties to themselves and to others, and you cannot medicalize that away.
posted by fraxil at 7:11 AM on May 6, 2015 [2 favorites]

It is profoundly unsettling to have a parent or a child in the grip of addiction, and I think it is reasonable for families and communities to stigmatize drug use to prevent it from happening rather than adopting a judgment-free approach that says "try what you want, we'll make sure you can get into treatment if you need to".

Literally no one is advocating that. Literally no one would tell their kid "oh yeah, go ahead and shoot up for funsies. No judgement here!" You're arguing against some sort of bizarre straw-person.

But you know, my grandfather died of lung cancer, and that's a shitty way to go, so I wouldn't say that about tobacco, either. I think there are ways to deter use without throwing people in jail or hampering HIV-prevention efforts.
posted by ArbitraryAndCapricious at 7:18 AM on May 6, 2015 [8 favorites]

Fraxil, I think you're stating largely uninformed opinion, not fact. There are many studies that show you to be mostly wrong. I don't know what drives you to push an agenda that's counter factual, but it is only a little amusing that you think you can have any success doing so here.
posted by five fresh fish at 7:21 AM on May 6, 2015 [3 favorites]

...and I think it is reasonable for families and communities to stigmatize drug use to prevent it from happening rather than adopting a judgment-free approach that says "try what you want, we'll make sure you can get into treatment if you need to".

Ok, once again, who the hell are you quoting?
posted by Avenger at 7:46 AM on May 6, 2015 [1 favorite]

> I think it is reasonable for families and communities to stigmatize drug use to prevent it from happening

And it literally does not work! Even you know this, because you know people who are addicts whose families hate and stigmatize their use. So in what way is it "reasonable"?

Stigma kills more people than it saves. It creates fear and hatred, and it thrives on ignorance and lies. That is what you are specifically advocating. It is stigma and fear and dehumanization that have driven the HIV outbreak in southern Indiana among injection drug users. Proponents of "stigma" as a useful tool did not prevent this from happening: they helped cause it.
posted by rtha at 8:05 AM on May 6, 2015 [2 favorites]

I am not trying to make straw man arguments. I am trying to refute the main post: "The reasons for the difference in care between a tobacco addict and an opiate addict is stigma and money. Petty reasons to lose a life." I applaud the work of the PD in question in their care for addicts. I do not disagree that stigma can be harmful , but it can also be helpful and can save lives. There is a great deal of class-based stigma against smoking, and for those of a certain class it probably saves lives as well. There is a different stigma against illegal drug use, both because of its current illegality as well as the nature of the drug use. The main post is wrong because it claims that there are no valid distinctions between any kinds of substance use, and the difference between how they are treated is prejudiced and irrational. That is what I am trying to refute. I am not advocating for our current drug policy or that stigma that prevents people from accessing care is good, just that some stigma is justified. Some stigma is justified for multiple reasons, including both adverse consequences that cannot be treated away after the fact, and equally important questions about what a meaningful life should be. Laws and policy needs to reflect those questions as well as the question of access to healthcare, if only because that's how people actually operate and live in communities.
posted by fraxil at 8:32 AM on May 6, 2015 [1 favorite]

And we're saying that any of your comments about "what a meaningful life" should be is irrelevant to a discussion of public policy.
posted by Lemurrhea at 8:43 AM on May 6, 2015 [3 favorites]

Comparing tobacco and opiates is like comparing a candy bar and a punch in the face.

Yes, there is stigma around mental illness and drugs. But it doesn't come from nowhere. Drug addicts will steal (a crime) from their mothers and sell their houses and desert their families for drugs. That should be stigmatized, somewhat.

And yes, there aren't enough treatment centers and dollars to help all the addicts that need help. But like other mental illnesses, as long as treatment remains mostly voluntary there's going to be a limit to what we can do. Mental illness, by definition, does not want to be cured, and will do anything to protect itself.

And is prison the answer? Absolutely not. I am almost crying with happiness over this decision made by the Gloucester police department. Bravo, encore.
posted by Melismata at 9:00 AM on May 6, 2015

Portugal has 14 years of experience with decriminalized drugs. It seems to be working in many respects, and has not made things worse.
posted by Kirth Gerson at 9:15 AM on May 6, 2015 [1 favorite]

People who are treated with compassion and love begin to believe they are worthy of compassion and love. They begin to believe they deserve a better life than the one they have. They begin to want to change their behavior.
posted by rtha at 9:15 AM on May 6, 2015 [6 favorites]

Last month, the thin, 45-year-old woman learned the unforgiving consequences. She tested positive for H.I.V., one of nearly 150 cases in this socially conservative, largely rural region just north of the Kentucky border. Now a life long hobbled by addiction is, like so many others here, consumed by fear.

She is afraid to start antiretroviral therapy because she does not want to be spotted entering the clinic on Main Street, she says, and afraid to learn her prognosis after hearing a rumor — false, it turns out — that someone else with the virus was given six months to live. Other drug users have refused to be tested at all.

This is what a "little" stigma can do.
posted by rtha at 9:17 AM on May 6, 2015 [2 favorites]

fraxil, you're making valid points. I would just stray away from talk of "authentic human flourishing" and "what a meaningful life should be".

Humanity is a highly variable species, and we thrive because of that. When you present a couple of funnels, as you have, you're essentially threatening (or at the very least tackling) what allows us to thrive on the planet. Variation is "authentic human flourishing" in essence, supporting many meaningful lives, some drastically different from others.

Otherwise, you're doing incredibly good work and I thank you for your service. Keep it up.
posted by JoeXIII007 at 9:33 AM on May 6, 2015 [2 favorites]

Drug addicts will steal (a crime) from their mothers and sell their houses and desert their families for drugs.

Not if they have drugs tho!
posted by atoxyl at 9:41 AM on May 6, 2015 [1 favorite]

obviously it's more complex than I'm making it out to be either. There's a certain criminal subculture that intersects with drug culture for sure and some people throw themselves right into it. And I'm talking about crime beyond selling drugs, which a very large proportion of drug addicts I've known have done at some point and which I clearly don't have a problem with. Anyway on balance I know more families who left their drug addicts than the other way around.
posted by atoxyl at 9:48 AM on May 6, 2015

Thanks Joe. I think people are assuming I am talking about things that are both partisan and trivial when I say "human flourishing." I am not talking about attending sunday school. I am trying to get at things that are more universal like being able to contribute toward meaningful pursuits like making art, building relationships, doing good in the community, and generally being available as a person to others. People who oppose gay marriage could be said to oppose the kind of human flourishing that comes from both having a long-term committed relationship as well as the social benefits of the institution of marriage.
posted by fraxil at 10:18 AM on May 6, 2015

Yeah, fraxil, you do have some valid points in there, but I can assure you that every time you refuse to acknowledge the suffering shame causes, five valid points get lost. For example, I know that most gay men and women of my generation aren't going to listen to anything else you say once you start talking about the social utility of shame — they've just had too much of that already.
posted by benito.strauss at 10:49 AM on May 6, 2015 [6 favorites]

And yes, there aren't enough treatment centers and dollars to help all the addicts that need help. But like other mental illnesses, as long as treatment remains mostly voluntary there's going to be a limit to what we can do. Mental illness, by definition, does not want to be cured, and will do anything to protect itself.

You know that "need" in your first sentence can be equally accurately replaced with "want", and then the rest of that paragraph looks kinda ugly, right?
posted by PMdixon at 10:53 AM on May 6, 2015

Stigma isn't the factor constraining people from addiction. Pain leads them to it. Often deep pain - trauma and addiction are strongly correlated. The limiting things are absence of pain, foremost; strong relationships; feeling a sense of community and a place within it; a sense of confidence; a sense of purpose; having access to the same work and leisure opportunities available to the others you can see.
posted by cotton dress sock at 10:55 AM on May 6, 2015 [1 favorite]

every time you refuse to acknowledge the suffering shame causes, five valid points get lost


I think you are misreading me. I admit that excessive stigma without access to care causes suffering and even death. I don't think you strengthen your case however by saying that you basically turn off your thinking cap when you hear something you don't like (particularly if it wasn't said in the fist place).
posted by fraxil at 11:16 AM on May 6, 2015

(Sorry - meant to say that it's not like every one of us would be pounding back the pills or whatever if not for stigma. Some people are more vulnerable (systematically), and it's often the people for whom "flourishing" was already unimaginable. Punishing people for their pain and alienation, and for their ways of getting by, is just... altogether the wrong way around.)
posted by cotton dress sock at 11:17 AM on May 6, 2015 [3 favorites]

Thanks Joe. I think people are assuming I am talking about things that are both partisan and trivial when I say "human flourishing." I am not talking about attending sunday school. I am trying to get at things that are more universal like being able to contribute toward meaningful pursuits like making art, building relationships, doing good in the community, and generally being available as a person to others.

No I know exactly what you are saying, and in the particular case of opioid addiction you are wrong.
posted by atoxyl at 11:17 AM on May 6, 2015 [2 favorites]

> I am trying to get at things that are more universal like being able to contribute toward meaningful pursuits like making art, building relationships, doing good in the community, and generally being available as a person to others.

People who are so caught in their addiction and its associated issues (including, but not limited to: poverty; housing instability; domestic violence; lack of access to health care; lack of education and employment opportunities) are not helped by stigma - stigmatization didn't prevent them getting to where they are.

Many, many people use drugs recreationally and "are able to contribute toward meaningful pursuits like making art, building relationships, doing good in the community, and generally being available as a person to others" - very often, the thing that interrupts or prevents their contributing to meaningful pursuits is being locked up or fired for their otherwise non-problematic use.
posted by rtha at 11:44 AM on May 6, 2015

I think that is a good point rtha and decriminalization will help a lot with that. We are also seeing increased access to opioid treatments in rural areas thanks to the increasing availability of suboxone. Just today I talked to a colleague who was taking care of a kid who has two parents on suboxone. I have no doubt they would have a lot more difficulty being effective parents if they were scoring pills or heroin instead of having a safe prescription to use. However I think whoever is working with them needs to have a game plan of getting them off opioids eventually, one they are more stable, because frankly I think it is better for the child and for them. In the meantime though, I think having safe access to effective opioid maintenance is helping them engage in more meaningful pursuits, particularly taking care of their child, that they could not do when they were not in treatment.
posted by fraxil at 12:09 PM on May 6, 2015 [2 favorites]

being able to contribute toward meaningful pursuits like making art,

Artists and other creative types, especially, are known for prolific drug and alcohol (ab)use. Van Gogh (alcohol, digitalis), Beatles (Cocaine), Charles Dickens (Opium), Jack Nicholson (LSD).

It isn't just creatives though, people in all walks of life use drugs. Sigmund Freud (Cocaine), Steve Jobs (LSD), Bill Gates (LSD), Erdös (Amphetamines), Carl Sagan (Marijuana), George W Bush (Cocaine), Francis Crick (LSD), Richard Feynman (LSD, ketamine)

Some are able to leverage their enjoyment of drugs for the benefit of society. Some abuse drugs to the detriment of themselves and everyone around them, which no one disagrees is a problem.

Shame is a powerful weapon against repulsive behavior, but it does't actually deal with this problem.

So what's the plan? We shame everyone who's ever taken drugs, fire them from their jobs, kick them out of their homes, and... what, just hope they starve to death? You might feel vindicated, but all you're doing is persisting the existence of a growing criminal underclass, when in reality many could be fine, upstanding, contributing members of society. For what? Because you don't like what they do, on their own time, in their own space, and causing no harm to anyone else? Because you don't like their escapist thinking?

Absolutely criminalize stealing, criminalize assault, criminalize the bad things that junkies do to feed their habit. But don't conflate the effects of making drugs illegal to the effects of the drugs themselves. You break your leg, you get some painkillers, you hurt less. Fine. It turns out that hurting less is actually quite pleasant, so you tell your doctor a little white lie, and get more, even though your legs is healed. Still fine. You're not hurting anybody, and it's enjoyable. You lose your job because you're high all the time and cannot function and really really want more painkillers.

If there are treatment programs and no stigma against seeking help, you can go there. Still fine. But say there are no treatment programs or you are too ashamed to ask for help. You still really want more painkillers but lost your job and have no money, how are you going to get it? Rob the convenience store for money to buy drugs. Very bad, completely avoidable, and not the drugs fault, but the illegailty of drugs, and a good dose of shame.

This situation has played itself out countless times over the past 40 years of the War on Drugs, and it's time to admit the hard-lined approach just isn't working. Moreover, society has changed since 1971. What you do in your own home, on your own time, as long as you're not hurting someone else, is not my business. This was exemplified in 2003 when the supreme court struck ruled sodomy laws unconstitutional. What people put in their butt isn't the government's business and what I choose to put in the other end isn't either.
posted by fragmede at 12:25 PM on May 6, 2015 [12 favorites]

However I think whoever is working with them needs to have a game plan of getting them off opioids eventually, one they are more stable, because frankly I think it is better for the child and for them

Well can you articulate a specific reason you think that? Cognitive and motor impairment on buprenorphine maintenance is very minor once settled into a dose and right away a step up from impairment from full opioid agonists- which is itself not tremendous and quite manageable for many people. And there's an under-acknowledged positive potential of the drug - there is evidence of its potential as an antidepressant and it's almost certainly an effective anxiolytic as well though I think there are fewer formal studies investigating it in that light. A lot of clinicians would say it is safer for them to remain on maintenance longer than "necessary" to minimize the chance that they revert to illegal activity - I have mixed feelings the prevalence of such claims coming from people who make their living prescribing buprenorphine but in the case of parents of a young child I'd absolutely say they can take their sweet time changing anything about their treatment.
posted by atoxyl at 1:11 PM on May 6, 2015

I think having safe access to effective opioid maintenance is helping them engage in more meaningful pursuits, particularly taking care of their child, that they could not do when they were not in treatment.

You are right that being an opioid addict can detract from "meaningful pursuits" but by far the biggest contributors to that in the long run are hours and dollars spent avoiding getting sick, time spent being sick, and the potential to disappear into the criminal "justice" system or die suddenly or of transmissible disease- every one of which is an argument for increased safe availability.
posted by atoxyl at 1:21 PM on May 6, 2015 [1 favorite]

Suboxone is a big improvement but I think we are going to have to wait a lot longer to really know what the risks and benefits are, both medical and other. I will happily eat my words if it turns out to be effective in the long term and relatively benign.
posted by fraxil at 1:28 PM on May 6, 2015

How "long term" are you talking about? Buprenorphine has been in use in the UK since the early 80s (it's even mentioned in Trainspotting) and in the US for over a decade.
posted by zombieflanders at 1:38 PM on May 6, 2015 [1 favorite]

It has been around but due to prescribing restrictions and epidemiological trends relating to both pain management and opioid dependence there are a whole lot more people using it now than there have been in the past.
posted by fraxil at 4:12 PM on May 6, 2015

There's a much longer history of people taking full-on opioid agonists for years though - both methadone maintenance and pain management scenarios. I'd argue known long-term effects are not too bad at all. Maybe the nastiest common one to me is disruption of the endocrine system - supression of testosterone the best understood effect. Methadone seems to raise the risk of cardiac sudden death by altering electrical activity, but not all opioids do. I saw a few studies recently that link opioid receptors to growth of some tumors, but it's not clear at all yet what this means yet even for people who have cancer let alone people who don't. Cognitive and motor impairments are found on certain tasks but not on others and they are small for subjects on a stable dose. Methadone patients are not considered a major risk as drivers though they are required to undergo more regular license testing in some places.

Studies on buprenorphine thus far find it is better than methadone in every one of those respects plus impossible for a regular user to get high on, reducing the issue of "well what if they aren't on a stable dose?" Anyway, my quarrel isn't really about whether opioids could have unknown but insidious health effects in the very long run or increase your risk of crashing a car it's about whether there's any actual reason to think they prevent a person from

being able to contribute toward meaningful pursuits like making art, building relationships, doing good in the community, and generally being available as a person to others
posted by atoxyl at 6:42 PM on May 6, 2015 [2 favorites]

But stigma can also be a very helpful tool for helping the person in recovery change their behavior. It can be a powerful motivating tool.

Says someone who has obviously never been on the receiving end of stigma. I'm a fag. You think the stigma around being gay has been a helpful or motivating tool? Well hell yes it has--a tool that motivates me and helps me to want to punch in the face every mealymouthed asshole who tells me I should be ashamed of who I am.

I'm also mentally ill. You think the stigma around being mentally ill has been helpful or motivating? See above.

Stigma around most things--substance use included--prevents people from seeking help. I've seen more people than I can count go down in flames because the stigma around drug use meant they couldn't even admit to themselves that they had a problem, let alone seek help for it.

Mental illness, by definition, does not want to be cured, and will do anything to protect itself.

Is this a joke? Most mentally ill people, myself included, would give up organs in a back alley to someone with a steak knife if it would mean I wouldn't feel this way anymore.

Someone mentioned Portugal upthread. fraxil, here's the bottom line: complete decrim of drugs in Portugal has led to lower incidence of (ab)use across the board, unless I have totally misread. That is, the stigma about criminality and badness has been removed at a policy level, and fewer people are using.
posted by feckless fecal fear mongering at 7:11 PM on May 6, 2015 [6 favorites]

Douthat has a good column that I think is informative in teasing out the distinction between positive/protective stigma and negative/damaging stigma:

LINK
posted by fraxil at 2:27 PM on May 8, 2015

Leaving aside how much Douthat and the sociologist he quotes (Charles Stokes) make my eyebrows go up, I don't see how arguing that the (perhaps) existence of a very particular kind of "positive" stigma has to do with treating the ongoing public health problems created by criminalizing syringe possession and making pariahs out of those who use drugs.

Are you wanting to suggest that if more people were God-believing church-goers, we'd have fewer addicts? I mean, maybe? But how does that become policy? And then what does that mean for the people who become addicts anyway? We've got legislatures full of people who claim to believe in god and go to church regularly and they're the ones trying to score moral points in a public health crisis, which doesn't actually do anything to lessen the health crisis.
posted by rtha at 4:58 PM on May 8, 2015 [3 favorites]

fraxil, are you paying any attention to what we're saying? Religion is ridiculous, many of us aren't believers, so hitching your horse to that cart isn't likely to get you very far here.

The things you are advocating for have been shown time and time and time again not to work. Again I ask: are you familiar with Portugal and how they are treating drugs?
posted by feckless fecal fear mongering at 2:04 PM on May 11, 2015