"Junkie Whore"—What It's Really Like for Sex Workers on Heroin
February 10, 2016 8:03 AM Subscribe
She’s the dead hooker in the trunk. A universal cautionary tale, the drug-using sex worker is too wretched to be relatable, too scorned for even countercultural cred. She is repulsive, unclean and immoral. She is pitiable at best, inhuman at worst—dismissed by police lingo about murders whose victims are drug-using street workers: “No Human Involved.” If she’s white, she’s lucky enough to be merely an abject victim. If not, she’s a deranged criminal. She’s a scarred, blotchy mugshot in your local paper’s coverage of prostitution stings—recycled without regard for privacy by anti-drug PSAs to let kids know that that’s what they’ll look like after years of doing dope. She’s the woman I’ve heard my escorting clients joke about not wanting to fuck with someone else’s dick—not realizing that they are talking to a sex worker who uses heroin, as I force myself to laugh along with them.
> But by contrast, if she is a non-hooker but a girl hooked on heroin what is she?
She still gets to be pitiable at best, inhuman at worst, the lucky girl!
I encountered this strong bias against drug use within the sex worker activist community when I began writing a column called “Ask Ms Harm Reduction,” answering questions like, “My heroin-using friend is pregnant—how do I help her?”, “How can I stay safe while taking E at the club?” and “How can I manage risks when doing drugs with clients?”
I mostly got a positive reaction, but was also berated soundly by a few sex worker activists. One New England escort/organizer commented, “why [do] you insist on portraying sex workers as addicts? …no doubt these types of articles will be used at trafficking conferences to demand that we stay criminalized.”
Oh respectability politics, is there any movement you can't fracture?
posted by rtha at 8:25 AM on February 10, 2016 [18 favorites]
She still gets to be pitiable at best, inhuman at worst, the lucky girl!
I encountered this strong bias against drug use within the sex worker activist community when I began writing a column called “Ask Ms Harm Reduction,” answering questions like, “My heroin-using friend is pregnant—how do I help her?”, “How can I stay safe while taking E at the club?” and “How can I manage risks when doing drugs with clients?”
I mostly got a positive reaction, but was also berated soundly by a few sex worker activists. One New England escort/organizer commented, “why [do] you insist on portraying sex workers as addicts? …no doubt these types of articles will be used at trafficking conferences to demand that we stay criminalized.”
Oh respectability politics, is there any movement you can't fracture?
posted by rtha at 8:25 AM on February 10, 2016 [18 favorites]
But by contrast, if she is a non-hooker but a girl hooked on heroin what is she?
Usually, she's probably still stigmatized as a whore or soon-to-be a whore.
posted by Sophie1 at 8:26 AM on February 10, 2016 [3 favorites]
Usually, she's probably still stigmatized as a whore or soon-to-be a whore.
posted by Sophie1 at 8:26 AM on February 10, 2016 [3 favorites]
Interesting article, thanks for it even though it's largely alien from my frame of reference. The idea of drug use being yet another form of intersectionality hadn't really occurred to me but it does make alot of sense.
What's interesting is that is definitely argues that any social movement cannot succeed if it reduces people to two-dimensional stereotypes. There are a lot of reasons why people turn to drugs, there are a lot of reasons why people turn to sex work, there are a lot of reasons why marginalized groups are structural excluded from "polite" society and it's only about understanding people's personal stories and the choices that they made along the way that we can hope to come to better policy decisions.
I'm definitely of mixed opinions about the drug trade and the sex trade as both tend to be inherently set up for bad power dynamics to occur. Legalization (or at least decriminalization) seems like it might reduce some of the negative externalities but might generate new ones.
posted by vuron at 8:34 AM on February 10, 2016 [2 favorites]
What's interesting is that is definitely argues that any social movement cannot succeed if it reduces people to two-dimensional stereotypes. There are a lot of reasons why people turn to drugs, there are a lot of reasons why people turn to sex work, there are a lot of reasons why marginalized groups are structural excluded from "polite" society and it's only about understanding people's personal stories and the choices that they made along the way that we can hope to come to better policy decisions.
I'm definitely of mixed opinions about the drug trade and the sex trade as both tend to be inherently set up for bad power dynamics to occur. Legalization (or at least decriminalization) seems like it might reduce some of the negative externalities but might generate new ones.
posted by vuron at 8:34 AM on February 10, 2016 [2 favorites]
Oh respectability politics, is there any movement you can't fracture?
No. People always will find something to offend them, using it as leverage to pretend to prove they are more sensitive and superior to you. That pesky hero's narrative is the true addiction, not the crack, cocaine, or the abstinence. Never underestimate the allure of getting to morally mastrubate in public for fun and profit.
That is the reason nothing ever changes or gets done because people will nag and nitpick as a misdirection and do everything else but the one thing they actually need to do improve and solve a problem.
Once upon a time, these were just the religious zealots using those carny tricks, but now everyone had gotten in on the gig, dividing the tiniest of enclaves in the name of keeping some fantasy alive. Reality would be so much more pleasant if we could just stop trying to create some sort of pecking order and rig it so we come out on top.
posted by Alexandra Kitty at 8:37 AM on February 10, 2016 [8 favorites]
No. People always will find something to offend them, using it as leverage to pretend to prove they are more sensitive and superior to you. That pesky hero's narrative is the true addiction, not the crack, cocaine, or the abstinence. Never underestimate the allure of getting to morally mastrubate in public for fun and profit.
That is the reason nothing ever changes or gets done because people will nag and nitpick as a misdirection and do everything else but the one thing they actually need to do improve and solve a problem.
Once upon a time, these were just the religious zealots using those carny tricks, but now everyone had gotten in on the gig, dividing the tiniest of enclaves in the name of keeping some fantasy alive. Reality would be so much more pleasant if we could just stop trying to create some sort of pecking order and rig it so we come out on top.
posted by Alexandra Kitty at 8:37 AM on February 10, 2016 [8 favorites]
Interesting article, thanks for it even though it's largely alien from my frame of reference. The idea of drug use being yet another form of intersectionality hadn't really occurred to me but it does make alot of sense.
If heroin addicts have ever been a part of your frame of reference, listening to users say "i don't have a problem", "i have things under control" "the problem isn't me, it's the cops" etc., like in this article, is really painful.
posted by ennui.bz at 9:54 AM on February 10, 2016 [13 favorites]
If heroin addicts have ever been a part of your frame of reference, listening to users say "i don't have a problem", "i have things under control" "the problem isn't me, it's the cops" etc., like in this article, is really painful.
posted by ennui.bz at 9:54 AM on February 10, 2016 [13 favorites]
i support some form of decriminalization for drugs precisely because of my interactions with addicts. when you combine the stigma/danger of both being a drug user and a sex worker, it's incredibly easy to see how our current approaches to either of those things are seriously lacking.
posted by nadawi at 10:04 AM on February 10, 2016 [6 favorites]
posted by nadawi at 10:04 AM on February 10, 2016 [6 favorites]
I didn't see much about having it all under control. I saw "you can be a heroin addict and otherwise be a fully-formed human being." Which I assure you is true even though being a heroin addict is fucking exhausting.
posted by atoxyl at 10:17 AM on February 10, 2016 [5 favorites]
posted by atoxyl at 10:17 AM on February 10, 2016 [5 favorites]
you don't have to think it's ok - but you should think that sex workers who are also addicts are people and deserve a baseline of respect and the ability to join in on advocacy with their own voice.
posted by nadawi at 10:19 AM on February 10, 2016 [16 favorites]
posted by nadawi at 10:19 AM on February 10, 2016 [16 favorites]
I really appreciated this article; thank you for sharing it.
(Former needle exchange volunteer worker here. Injection drug users are part of my frame of reference, some sex workers and some not, and I absolutely want to hear their voices as part of harm reduction advocacy among other types of advocacy.)
posted by Stacey at 10:27 AM on February 10, 2016 [7 favorites]
(Former needle exchange volunteer worker here. Injection drug users are part of my frame of reference, some sex workers and some not, and I absolutely want to hear their voices as part of harm reduction advocacy among other types of advocacy.)
posted by Stacey at 10:27 AM on February 10, 2016 [7 favorites]
Isn't it possible to respect and care for people while calling out their delusions and lies? This is their point of view, now ask the families, and others in their social environment.
Personally, I am strongly for decriminalization, and I'm strongly for providing the best possible help to all addicts. And part of that help must be maintain that the drug-free perception of reality is the one that works best.
Think about the person with a child, claiming she is a good mother: a mother who spends a considerable part of every day passed out? Who spends hundreds of dollars on her addiction? Who risks jail, or worse: death?
posted by mumimor at 10:49 AM on February 10, 2016 [5 favorites]
Personally, I am strongly for decriminalization, and I'm strongly for providing the best possible help to all addicts. And part of that help must be maintain that the drug-free perception of reality is the one that works best.
Think about the person with a child, claiming she is a good mother: a mother who spends a considerable part of every day passed out? Who spends hundreds of dollars on her addiction? Who risks jail, or worse: death?
posted by mumimor at 10:49 AM on February 10, 2016 [5 favorites]
who spends a considerable part of every day passed out?
Good luck even getting that high in the later stages of an opiate habit. I mean YMMV if you are seeking oblivion but this one is definitely not a universally applicable stereotype of heroin users.
Who risks jail
"cops are the problem, not me"
Who spends hundreds of dollars on her addiction?
Okay this is the one that gets nearly everyone in the end. I would add also time and energy spent acquiring drugs - functioning as a heroin user is kind of like having a second job except you pay them. Are these really unavoidable problems of being a heroin user in a perfect world? I'd say not entirely but it's complicated. I feel similarly about the risk of death - it really should not be that hard to avoid a lethal dose taking opioids of known purity. Yet people do manage to kill themselves with pills pretty often, so you know.
Anyway I merely suggest that while drug addiction can impinge on your ability to navigate life's responsibilities it should not be taken in itself as proof that you aren't navigating them.
posted by atoxyl at 12:04 PM on February 10, 2016 [4 favorites]
Good luck even getting that high in the later stages of an opiate habit. I mean YMMV if you are seeking oblivion but this one is definitely not a universally applicable stereotype of heroin users.
Who risks jail
"cops are the problem, not me"
Who spends hundreds of dollars on her addiction?
Okay this is the one that gets nearly everyone in the end. I would add also time and energy spent acquiring drugs - functioning as a heroin user is kind of like having a second job except you pay them. Are these really unavoidable problems of being a heroin user in a perfect world? I'd say not entirely but it's complicated. I feel similarly about the risk of death - it really should not be that hard to avoid a lethal dose taking opioids of known purity. Yet people do manage to kill themselves with pills pretty often, so you know.
Anyway I merely suggest that while drug addiction can impinge on your ability to navigate life's responsibilities it should not be taken in itself as proof that you aren't navigating them.
posted by atoxyl at 12:04 PM on February 10, 2016 [4 favorites]
drug-free perception of reality is the one that works best.
And this is just not true for everybody - we're talking about some of the most effective antidepressants known (which is one reason I am hopeful about expanded availability of buprenorphine).
posted by atoxyl at 12:07 PM on February 10, 2016 [5 favorites]
And this is just not true for everybody - we're talking about some of the most effective antidepressants known (which is one reason I am hopeful about expanded availability of buprenorphine).
posted by atoxyl at 12:07 PM on February 10, 2016 [5 favorites]
And part of that help must be maintain that the drug-free perception of reality is the one that works best.
which drugs? and best for who? if i went drug free i'd probably be dead in pretty short order from allergy induced asthma attacks. i certainly wouldn't be living a reality that works best. what about drugs for mental health? those seem to shift the users' reality in a pretty beneficial way a lot of times. what about people who use marijuana for pain management to get off of prescription opioids? in our current climate most laws say that you should pick the opioids.
to act like this is an open and shut thing, to act like everyone who uses heroin is passed out all day and spending all their money on it - that isn't really instructive or based in reality.
posted by nadawi at 12:18 PM on February 10, 2016 [11 favorites]
which drugs? and best for who? if i went drug free i'd probably be dead in pretty short order from allergy induced asthma attacks. i certainly wouldn't be living a reality that works best. what about drugs for mental health? those seem to shift the users' reality in a pretty beneficial way a lot of times. what about people who use marijuana for pain management to get off of prescription opioids? in our current climate most laws say that you should pick the opioids.
to act like this is an open and shut thing, to act like everyone who uses heroin is passed out all day and spending all their money on it - that isn't really instructive or based in reality.
posted by nadawi at 12:18 PM on February 10, 2016 [11 favorites]
Over 1000 heroin related deaths in Massachusetts in 2014 and in 2015 and over 900 in 2013--way more than vehicle deaths. Pretty hard to justify allowing people the freedom to pursue this recreational drug when the cost is this high.
posted by haiku warrior at 12:37 PM on February 10, 2016 [1 favorite]
posted by haiku warrior at 12:37 PM on February 10, 2016 [1 favorite]
well the current method of macro level tough love, criminalization, and stigma don't seem to be getting the job done. maybe we should try a different approach...
i also don't see this essay arguing for the freedom to pursue their recreational drug of choice, but rather to be mindful of how stereotypes, tropes, and respectability politics is putting people in danger and keeping people out of advocacy who should really be a part of it.
posted by nadawi at 12:45 PM on February 10, 2016 [12 favorites]
i also don't see this essay arguing for the freedom to pursue their recreational drug of choice, but rather to be mindful of how stereotypes, tropes, and respectability politics is putting people in danger and keeping people out of advocacy who should really be a part of it.
posted by nadawi at 12:45 PM on February 10, 2016 [12 favorites]
Over 1000 heroin related deaths in Massachusetts in 2014 and in 2015 and over 900 in 2013--way more than vehicle deaths. Pretty hard to justify allowing people the freedom to pursue this recreational drug when the cost is this high.
well the current method of macro level tough love, criminalization, and stigma don't seem to be getting the job done. maybe we should try a different approach...
As I said, this part of the issue is complicated. One would expect legal drugs of known potency to be much safer. But people do die from medical grade painkillers all the time - I suspect mixing drugs that you aren't supposed to mix accounts for a lot of it but it's hard to say. Opioid overdose has a very effective antidote, naloxone. But that doesn't work when you don't have somebody to administer it. And so on - logically and medically deaths from heroin should be quite preventable but still you can't completely stop people from fucking up. I think it's pretty clear what kind of perspective I'm coming from in this thread and I think harm reduction is the best answer overall - by far really when you consider HIV and Hep C and endocarditis and so on - but it is a problem that takes a lot of work.
posted by atoxyl at 12:58 PM on February 10, 2016 [2 favorites]
well the current method of macro level tough love, criminalization, and stigma don't seem to be getting the job done. maybe we should try a different approach...
As I said, this part of the issue is complicated. One would expect legal drugs of known potency to be much safer. But people do die from medical grade painkillers all the time - I suspect mixing drugs that you aren't supposed to mix accounts for a lot of it but it's hard to say. Opioid overdose has a very effective antidote, naloxone. But that doesn't work when you don't have somebody to administer it. And so on - logically and medically deaths from heroin should be quite preventable but still you can't completely stop people from fucking up. I think it's pretty clear what kind of perspective I'm coming from in this thread and I think harm reduction is the best answer overall - by far really when you consider HIV and Hep C and endocarditis and so on - but it is a problem that takes a lot of work.
posted by atoxyl at 12:58 PM on February 10, 2016 [2 favorites]
This is a challenging read in a lot of respects. I do believe strongly in legalization of both drugs and prostitution with appropriate support designated to assist those who want to remove themselves from their addiction, or get regular medical checkups to ensure mental/physical healthcare is provided would need to happen, too.
But as noted above it is hard for me to believe that someone can be addicted to heroin/opioids or other very addictive substances and also provide great parenting to their child. I'm not disputing that they still have the desire to do so, but I seriously doubt the capacity.
posted by glaucon at 2:15 PM on February 10, 2016 [4 favorites]
But as noted above it is hard for me to believe that someone can be addicted to heroin/opioids or other very addictive substances and also provide great parenting to their child. I'm not disputing that they still have the desire to do so, but I seriously doubt the capacity.
posted by glaucon at 2:15 PM on February 10, 2016 [4 favorites]
Heroin is fucking heroin. Addicts are addicts. I would not try to make it easier for an alcoholic to continue with their addiction, so why should I think a heroin addiction is ok?
Please forgive if this comment has been discussed - I scrolled and it just jumped out to me - but when you say "heroin is fucking heroin" and "addicts are addicts," what exactly does this mean?
To me, a substance use counselor in a relatively progressive US city , heroin is a seriously painful drug that, though it initially addresses some sort of pain (physical or emotional), often results in a hellish hamster-wheel existence of hustling and other harmful behaviors to stave off the horrors of withdrawal and dealing with the aftermath of the lives damaged in the process. The people affected are broken.
But that's just one perspective of someone who sees people nearing the end of their rope .
To a social worker or medical worker in a country that provides free pharmaceutical grade heroin in a safe, medically monitored setting that provides easy, low-barrier access to counseling, vein care, needles and other services, I would imagine heroin to them is much more along the lines of an unfortunate disease that can be managed in a way that reduces harm to the individual, their families and the larger society. The people affected suffer from a chronic disease, but are treated and are not broken.
Each person, each context and the differences in the drug itself define what a drug is and what an "addict" is. So no, heroin isn't just fucking heroin and "addicts" aren't just addicts. This simplistic view of the situation is exactly what exacerbates the pain that both users and their loved ones (and society) experience. If simplistic solutions worked, then why do we still have a problem?
posted by the lake is above, the water below at 2:16 PM on February 10, 2016 [16 favorites]
Please forgive if this comment has been discussed - I scrolled and it just jumped out to me - but when you say "heroin is fucking heroin" and "addicts are addicts," what exactly does this mean?
To me, a substance use counselor in a relatively progressive US city , heroin is a seriously painful drug that, though it initially addresses some sort of pain (physical or emotional), often results in a hellish hamster-wheel existence of hustling and other harmful behaviors to stave off the horrors of withdrawal and dealing with the aftermath of the lives damaged in the process. The people affected are broken.
But that's just one perspective of someone who sees people nearing the end of their rope .
To a social worker or medical worker in a country that provides free pharmaceutical grade heroin in a safe, medically monitored setting that provides easy, low-barrier access to counseling, vein care, needles and other services, I would imagine heroin to them is much more along the lines of an unfortunate disease that can be managed in a way that reduces harm to the individual, their families and the larger society. The people affected suffer from a chronic disease, but are treated and are not broken.
Each person, each context and the differences in the drug itself define what a drug is and what an "addict" is. So no, heroin isn't just fucking heroin and "addicts" aren't just addicts. This simplistic view of the situation is exactly what exacerbates the pain that both users and their loved ones (and society) experience. If simplistic solutions worked, then why do we still have a problem?
posted by the lake is above, the water below at 2:16 PM on February 10, 2016 [16 favorites]
WTF people? Have you never heard of harm reduction? Ie, "meet people where they're at" and don't try to stigmatize or judge or dismiss them into what you think recovery from addiction should look like...
The data shows that programs that "enable" people with addiction— AKA needle exchange programs, overdose reversal programs that provide naloxone, maintenance programs with methadone and Suboxone— actually *do* enable them to stay alive, in the case of maintenance, twice as effectively as abstinence programs.
Also, if someone takes a steady, regular dose of any opioid at the same time every day— methadone, heroin, suboxone, whatever— they will develop a complete tolerance and therefore be as able as someone on Prozac or someone on nothing to parent, love, drive, etc.
posted by Maias at 2:28 PM on February 10, 2016 [20 favorites]
The data shows that programs that "enable" people with addiction— AKA needle exchange programs, overdose reversal programs that provide naloxone, maintenance programs with methadone and Suboxone— actually *do* enable them to stay alive, in the case of maintenance, twice as effectively as abstinence programs.
Also, if someone takes a steady, regular dose of any opioid at the same time every day— methadone, heroin, suboxone, whatever— they will develop a complete tolerance and therefore be as able as someone on Prozac or someone on nothing to parent, love, drive, etc.
posted by Maias at 2:28 PM on February 10, 2016 [20 favorites]
But as noted above it is hard for me to believe that someone can be addicted to heroin/opioids or other very addictive substances and also provide great parenting to their child. I'm not disputing that they still have the desire to do so, but I seriously doubt the capacity.
In what ways are you thinking they will inevitably fall short? If you are thinking there are going to be challenges regarding money, time, and safety? Yeah, absolutely. Arguably a kinder drug policy could mitigate many of these but again I'm not pretending they are easy or simple problems. That's why they say harm reduction. If you are thinking heroin addicts inevitably lie around all day/are severely functionally and cognitively impaired/don't give a fuck about anything else - that just ain't true, which is my central point in this thread.
posted by atoxyl at 2:47 PM on February 10, 2016 [1 favorite]
In what ways are you thinking they will inevitably fall short? If you are thinking there are going to be challenges regarding money, time, and safety? Yeah, absolutely. Arguably a kinder drug policy could mitigate many of these but again I'm not pretending they are easy or simple problems. That's why they say harm reduction. If you are thinking heroin addicts inevitably lie around all day/are severely functionally and cognitively impaired/don't give a fuck about anything else - that just ain't true, which is my central point in this thread.
posted by atoxyl at 2:47 PM on February 10, 2016 [1 favorite]
"which drugs? and best for who? if i went drug free i'd probably be dead in pretty short order from allergy induced asthma attacks. i certainly wouldn't be living a reality that works best. what about drugs for mental health? those seem to shift the users' reality in a pretty beneficial way a lot of times. what about people who use marijuana for pain management to get off of prescription opioids? in our current climate most laws say that you should pick the opioids. "
I do think this highlights something that was disingenuous about the article, the comparisons to Paxil and Xanax. There are obviously edge cases, but in general that drug you take to control asthma attacks is taken through the medical authority of a licensed doctor, who knows your health, prescribes an effective dose, and informs you about the incidence of side effects. And mental health drugs generally aren't recreational.
Likewise, the odd lack of self-awareness on the part of some of the subjects in the article — like the woman complaining that once you decide you'd rather not take drugs anymore, there are all these barriers to re-entering the mainstream economy. How was this news to her?
And, like a lot of advocacy pieces, this article does fall into the same failing that it accuses others of: Oversimplification, in this case treating heroin-addicted sex workers as if the majority of them are pleased with their current life, and who are functional grad students and parents. Countering stigma is important, but countering with a cherry-picked set of high functioning addicts as a basis for public policy does little to reduce the harms to those who aren't high functioning.
I tend to prefer policies that treat addiction as a medical problem, not a criminal one, and sex work as an economic problem, not a criminal (or moral) one, but in both cases, insisting that they're not actually a problem at all (or that the problems only come from criminalization) because some people have perfectly fulfilled lives as heroin addicted sex workers comes across as blinkered.
posted by klangklangston at 3:43 PM on February 10, 2016 [9 favorites]
I do think this highlights something that was disingenuous about the article, the comparisons to Paxil and Xanax. There are obviously edge cases, but in general that drug you take to control asthma attacks is taken through the medical authority of a licensed doctor, who knows your health, prescribes an effective dose, and informs you about the incidence of side effects. And mental health drugs generally aren't recreational.
Likewise, the odd lack of self-awareness on the part of some of the subjects in the article — like the woman complaining that once you decide you'd rather not take drugs anymore, there are all these barriers to re-entering the mainstream economy. How was this news to her?
And, like a lot of advocacy pieces, this article does fall into the same failing that it accuses others of: Oversimplification, in this case treating heroin-addicted sex workers as if the majority of them are pleased with their current life, and who are functional grad students and parents. Countering stigma is important, but countering with a cherry-picked set of high functioning addicts as a basis for public policy does little to reduce the harms to those who aren't high functioning.
I tend to prefer policies that treat addiction as a medical problem, not a criminal one, and sex work as an economic problem, not a criminal (or moral) one, but in both cases, insisting that they're not actually a problem at all (or that the problems only come from criminalization) because some people have perfectly fulfilled lives as heroin addicted sex workers comes across as blinkered.
posted by klangklangston at 3:43 PM on February 10, 2016 [9 favorites]
Dr. Gabor Maté is chief physician of Vancouver British Columbia's legal supervised safe injection facility and detox, Insite/Onsite. He has stated that all of his female patients addicted to narcotics and involved in street prostitution were sexually abused as children.
This casts a grim light upon those who would use harsh and dehumanizing language towards such women.
posted by little eiffel at 4:03 PM on February 10, 2016 [4 favorites]
This casts a grim light upon those who would use harsh and dehumanizing language towards such women.
posted by little eiffel at 4:03 PM on February 10, 2016 [4 favorites]
You want hatred for users? Check Ask Metafilter.
posted by telstar at 5:39 PM on February 10, 2016 [1 favorite]
posted by telstar at 5:39 PM on February 10, 2016 [1 favorite]
I think some people have been through abuse and atrocities that is hell on earth and there is really no drug, save one that turns reality off, that can make them ok.
The safety of people AROUND the person when they are numb is perfectly worth considering, but presuming forcing people to be more aware and present in their lives, and that lengthening their life is the ultimate ideal for everyone is missing the number of people who really live grotesque horrors and would rather live as long as they can, with as much enjoyment as they can while blocking the pain out as much as possible.
It's an understandable trade off for some people for whatever their reasons are. I know some people who went through so much physical and sexual violence from parents and grandparents and everyone around them and I don't know that they would have wanted to be sober for it. I have my own hopes for them everything can be better, but I know plenty of people that being forced into mental health "care" is hellish and doesn't help and they go to what works.
I can agree with concerns about safety of those around the addict- say children involved. Being drunk or high is not legal to drive a car, I really don't think it should be ok to be in charge of children in this condition either- but I also think coming up with harm reduction solutions and ways to help addicted families-- say with live in sites that offer supervision and enrichment for the kids onsite and managed drug use- with assistance to work off the drugs over a period of time while working through trauma and the physical issues of addiction would help. I'm not sure it should be legal to be a sole provider of children and be addicted to heavy duty drugs (even legal pain medicine, if you're on heavy doses of morphine you should probably not be the sole provider of a child without having in home care for the child).
My friends and family have done a lot of this and the kids of addicts in my family have definitely been harmed. The children of those family members who got sober were definitely better off. But some of my family members who got off still struggle on measures of basic functioning at work and homelife and they had a LOT of support getting through it without drugs. I think people don't realize that plenty of addicts are not able to work a regular job even when NOT on the drugs, the drugs help numb the pain of everyone thinking bad of you even when you ARE trying. Some people can't be functional like everyone else, not without a whole lot of accommodation and support that extend so far beyond what is offered as lifelong care to people. If we want people to get off we need to get realistic about how extensive the supports might need to be to take the place of that--- like as in housing and food and necessity budget for those who can't do traditional work without designing jobs specifically for them and their needs (totally flex arrival time, part time options, allowing for days weeks off at a time to deal with mental of physical health issues, ability to avoid doing things with numbers or counting, ability to avoid doing things standing in one place...) so many people just can't handle the work force and the "easy" jobs often require a lot more physical health and quick thinking memory and accuracy (cashier/waiting tables) than many people can muster.
Plenty of disabilities in parents are hard for kids- I do think we should offer extensive measures for parents with disabilities to ensure their children's needs are met while in the care of their family when a parent is ill or struggling. Something we too off use either CPS or nothing to address. The more punitive and forceful and horrific the solutions are (and removing the children leads to addiction getting worse and pretending this will help the parent get better is a lie. "Large numbers of children who are placed in child protective custody have parents with a substance use disorder. This placement occurs despite evidence that the trauma of removal is associated with poor long-term child outcomes."
Also child removal is likely to worsen addictive behavior and coping mechanisms increasing trauma in the mothers and worsening their ability to ever get better and parent well. "Trauma was identified as a key impact of separation, further exacerbated by women's cumulative trauma histories and ongoing mother-child apartness. Women described this trauma as unbearable and reported persistent symptoms of post-traumatic stress disorder and other mental health conditions. Practices of dissociation through increased use of drugs and alcohol were central in tending to the pain of separation, and were often synergistically reinforced by heightened structural vulnerability observed in increased exposure to housing instability, intimate partner violence, and initiation of injection drug use and sex work. Findings highlight needs for strategies addressing women's health and structural vulnerability following custody loss and also direct attention to altering institutional processes to support community-based alternatives to parent-child separation."
Harm reduction done right does NOT say there is no harm, it's called harm reduction because it's saying there's a problem, potentially a serious one, but it's about being realistic about the best way to mitigate the harms. I don't think it should mean no regulation or laws around these things, and in some cases being realistic about the harms may actually call for making something illegal (like I don't support harm reduction for rape crimes so I don't assume everything should be handled with harm reduction or that everything should be totally legal).
My cousins son was not raised by her, his dad OD'd, his uncles OD'd, now he's been using and he's in his 20's even though she didn't raise him. Refusing to handle this with compassion just means he can fall through the cracks like his parents and other family have. He's already been in prison, don't think that's helped.
posted by xarnop at 6:18 PM on February 10, 2016 [5 favorites]
The safety of people AROUND the person when they are numb is perfectly worth considering, but presuming forcing people to be more aware and present in their lives, and that lengthening their life is the ultimate ideal for everyone is missing the number of people who really live grotesque horrors and would rather live as long as they can, with as much enjoyment as they can while blocking the pain out as much as possible.
It's an understandable trade off for some people for whatever their reasons are. I know some people who went through so much physical and sexual violence from parents and grandparents and everyone around them and I don't know that they would have wanted to be sober for it. I have my own hopes for them everything can be better, but I know plenty of people that being forced into mental health "care" is hellish and doesn't help and they go to what works.
I can agree with concerns about safety of those around the addict- say children involved. Being drunk or high is not legal to drive a car, I really don't think it should be ok to be in charge of children in this condition either- but I also think coming up with harm reduction solutions and ways to help addicted families-- say with live in sites that offer supervision and enrichment for the kids onsite and managed drug use- with assistance to work off the drugs over a period of time while working through trauma and the physical issues of addiction would help. I'm not sure it should be legal to be a sole provider of children and be addicted to heavy duty drugs (even legal pain medicine, if you're on heavy doses of morphine you should probably not be the sole provider of a child without having in home care for the child).
My friends and family have done a lot of this and the kids of addicts in my family have definitely been harmed. The children of those family members who got sober were definitely better off. But some of my family members who got off still struggle on measures of basic functioning at work and homelife and they had a LOT of support getting through it without drugs. I think people don't realize that plenty of addicts are not able to work a regular job even when NOT on the drugs, the drugs help numb the pain of everyone thinking bad of you even when you ARE trying. Some people can't be functional like everyone else, not without a whole lot of accommodation and support that extend so far beyond what is offered as lifelong care to people. If we want people to get off we need to get realistic about how extensive the supports might need to be to take the place of that--- like as in housing and food and necessity budget for those who can't do traditional work without designing jobs specifically for them and their needs (totally flex arrival time, part time options, allowing for days weeks off at a time to deal with mental of physical health issues, ability to avoid doing things with numbers or counting, ability to avoid doing things standing in one place...) so many people just can't handle the work force and the "easy" jobs often require a lot more physical health and quick thinking memory and accuracy (cashier/waiting tables) than many people can muster.
Plenty of disabilities in parents are hard for kids- I do think we should offer extensive measures for parents with disabilities to ensure their children's needs are met while in the care of their family when a parent is ill or struggling. Something we too off use either CPS or nothing to address. The more punitive and forceful and horrific the solutions are (and removing the children leads to addiction getting worse and pretending this will help the parent get better is a lie. "Large numbers of children who are placed in child protective custody have parents with a substance use disorder. This placement occurs despite evidence that the trauma of removal is associated with poor long-term child outcomes."
Also child removal is likely to worsen addictive behavior and coping mechanisms increasing trauma in the mothers and worsening their ability to ever get better and parent well. "Trauma was identified as a key impact of separation, further exacerbated by women's cumulative trauma histories and ongoing mother-child apartness. Women described this trauma as unbearable and reported persistent symptoms of post-traumatic stress disorder and other mental health conditions. Practices of dissociation through increased use of drugs and alcohol were central in tending to the pain of separation, and were often synergistically reinforced by heightened structural vulnerability observed in increased exposure to housing instability, intimate partner violence, and initiation of injection drug use and sex work. Findings highlight needs for strategies addressing women's health and structural vulnerability following custody loss and also direct attention to altering institutional processes to support community-based alternatives to parent-child separation."
Harm reduction done right does NOT say there is no harm, it's called harm reduction because it's saying there's a problem, potentially a serious one, but it's about being realistic about the best way to mitigate the harms. I don't think it should mean no regulation or laws around these things, and in some cases being realistic about the harms may actually call for making something illegal (like I don't support harm reduction for rape crimes so I don't assume everything should be handled with harm reduction or that everything should be totally legal).
My cousins son was not raised by her, his dad OD'd, his uncles OD'd, now he's been using and he's in his 20's even though she didn't raise him. Refusing to handle this with compassion just means he can fall through the cracks like his parents and other family have. He's already been in prison, don't think that's helped.
posted by xarnop at 6:18 PM on February 10, 2016 [5 favorites]
Dr. Gabor Maté is chief physician of Vancouver British Columbia's legal supervised safe injection facility and detox, Insite/Onsite.
His book In the Realm of Hungry Ghosts may oversimplify things a bit, but it's genuinely moving.
Insite/Onsite has fought attempts to shut it down since its inception. I wonder how many lives it's saved. Probably thousands. It's heartbreaking that no other city in North America has been willing to adopt its model.
This article seems to conflate two separate points in a way that seems to be provoking more dissension than if it made one of them alone: "sex workers with addictions are human beings, who deserve respect and dignity and to have a voice in their own destinies" and "heroin addiction isn't really that much of a problem for the addict and the people who depend on her." Like, the reason a certain set of sex worker advocates make a point of disclaiming addiction is partially respectability politics, but also partially that addiction is a coercive experience, especially in current society, and it's a lot harder to make the argument that a sex worker is in the profession by choice when her options are limited by her need to feed an expensive habit. The argument that addiction is not likely to be deleterious to one's parenting is...not compelling. Even if you decriminalize and provide a cheap supply (thereby eliminating or minimizing many of the costs), you still have a person regularly getting high, significantly impairing their judgment and their ability to get things done. This problem is not exclusive to heroin or to illegal drugs, but it still exists. Still, you don't need to accept the second point to believe in harm-reduction approaches and the basic dignity of the human being, regardless of her health or occupation.
posted by praemunire at 6:23 PM on February 10, 2016 [6 favorites]
His book In the Realm of Hungry Ghosts may oversimplify things a bit, but it's genuinely moving.
Insite/Onsite has fought attempts to shut it down since its inception. I wonder how many lives it's saved. Probably thousands. It's heartbreaking that no other city in North America has been willing to adopt its model.
This article seems to conflate two separate points in a way that seems to be provoking more dissension than if it made one of them alone: "sex workers with addictions are human beings, who deserve respect and dignity and to have a voice in their own destinies" and "heroin addiction isn't really that much of a problem for the addict and the people who depend on her." Like, the reason a certain set of sex worker advocates make a point of disclaiming addiction is partially respectability politics, but also partially that addiction is a coercive experience, especially in current society, and it's a lot harder to make the argument that a sex worker is in the profession by choice when her options are limited by her need to feed an expensive habit. The argument that addiction is not likely to be deleterious to one's parenting is...not compelling. Even if you decriminalize and provide a cheap supply (thereby eliminating or minimizing many of the costs), you still have a person regularly getting high, significantly impairing their judgment and their ability to get things done. This problem is not exclusive to heroin or to illegal drugs, but it still exists. Still, you don't need to accept the second point to believe in harm-reduction approaches and the basic dignity of the human being, regardless of her health or occupation.
posted by praemunire at 6:23 PM on February 10, 2016 [6 favorites]
You are using IV drugs.
Later on, you are having sex with clients.
It would be fucking great if the needles were ALWAYS sterile, and you knew exactly what was going in your body
A person injecting anything is always putting themselves at a greater risk of infection with something than a person who isn't injecting anything, but if we're talking blood-borne/sexually-transmittable infection that comes from paraphernalia that has been in contact with other people's blood. Which is to say avoiding this route of exposure is entirely plausible if you have access to clean needles (and cookers etc.). You seem to be aware of the existence and purpose of needle exchanges so I'm really not quite sure what you're getting at. The author advocates this solution herself, because it's a pretty good one, but that's "dropping the ball" somehow?
(I gotta do some stuff and I don't feel like addressing the other part of the comment right now. Maybe later)
posted by atoxyl at 7:33 PM on February 10, 2016 [1 favorite]
I mean it's true that people don't always take advantage of the resources available to them but insinuating that the specific people profiled here are spreading disease is more than unfair.
posted by atoxyl at 7:53 PM on February 10, 2016 [1 favorite]
posted by atoxyl at 7:53 PM on February 10, 2016 [1 favorite]
You want hatred for users? Check Ask Metafilter.
You know, I really don't see that. What I often see is respondents saying that you can't fix someone else's addiction. If you're giving advice to someone who's life is turned upside down by a partner or parent's addiction ending contact is a reasonable course of action. It's not about hating the addict, but about isolating the damage.
I'm sure there are examples to the contrary but mostly ask.me functions to serve the asker and not others.
posted by 26.2 at 8:00 PM on February 10, 2016 [1 favorite]
You know, I really don't see that. What I often see is respondents saying that you can't fix someone else's addiction. If you're giving advice to someone who's life is turned upside down by a partner or parent's addiction ending contact is a reasonable course of action. It's not about hating the addict, but about isolating the damage.
I'm sure there are examples to the contrary but mostly ask.me functions to serve the asker and not others.
posted by 26.2 at 8:00 PM on February 10, 2016 [1 favorite]
I guarantee you that every one of you know someone who is physically dependent on an opiate or benzodiazapene but have no idea that they are in that position because they appear to have a perfectly normal life. Usually those are the folks who have a prescription, but sometimes people just don't get in that deep.
It isn't like every opiate user is sitting around nodded off for hours every day. Grandma took an oxycodone for her joint pain and made you an apple pie. Your coworker smoked one and drove his kid to school completely unimpaired then showed up to work on time. Your sister took a Xanax when she got to the restaurant to eat dinner with you. You're taking Bupropion every night before bed to ward off the depression. All of those people would be in shitsville if their doctor suddenly cut them off, but since they haven't been labeled an abuser or drug seeker, they can afford to live their lives just like you do.
If/when any of you are suddenly forced to go cold turkey, they'll be stuck in bed or the hospital for days to weeks until their bodies adjust to not having the drugs, no matter how much they'd like things to be different. That's why criminalization is so ridiculous. The irregularity of the supply and/or the risk of jail is mostly what ruins people's lives. Yeah, maybe they shouldn't have started in the first place (never mind that people take these drugs because they are effective at treating what ails them!), but it seems a rather disproportionate punishment to me.
posted by wierdo at 9:27 PM on February 10, 2016 [7 favorites]
It isn't like every opiate user is sitting around nodded off for hours every day. Grandma took an oxycodone for her joint pain and made you an apple pie. Your coworker smoked one and drove his kid to school completely unimpaired then showed up to work on time. Your sister took a Xanax when she got to the restaurant to eat dinner with you. You're taking Bupropion every night before bed to ward off the depression. All of those people would be in shitsville if their doctor suddenly cut them off, but since they haven't been labeled an abuser or drug seeker, they can afford to live their lives just like you do.
If/when any of you are suddenly forced to go cold turkey, they'll be stuck in bed or the hospital for days to weeks until their bodies adjust to not having the drugs, no matter how much they'd like things to be different. That's why criminalization is so ridiculous. The irregularity of the supply and/or the risk of jail is mostly what ruins people's lives. Yeah, maybe they shouldn't have started in the first place (never mind that people take these drugs because they are effective at treating what ails them!), but it seems a rather disproportionate punishment to me.
posted by wierdo at 9:27 PM on February 10, 2016 [7 favorites]
someone who is physically dependent on an opiate or benzodiazapene but have no idea that they are in that position because they appear to have a perfectly normal life
Physical dependency and addiction are two different things, though. (Also, the ability to hide how impaired you are doesn't mean you're not impaired.)
I don't think you get very far with the argument that an addict is not seeking a high when he uses (as well as, eventually, trying to stave off withdrawal). When habituation develops, that's a bug, not a feature, for the addict; that's why he increases the dosage. I don't even fully understand the argument that seeking a high in and of itself is blameworthy (if I could enjoy the sensation of the time I got Dilaudid in the ER at will, without any of the risks or costs, I would probably spend a Sunday evening or two a month doing so), but opiates are popular drugs precisely because they have powerful physical and mental effects. That's why, after all, Grandma is taking the oxy, and your sister the Xanax: to get an effect. Not just not to go into withdrawal. There may be some people on maintenance treatment who are habituated to the dose they're taking, don't crave or seek the original effects, and are basically taking the methadone or bupe to avoid physical detox, but I'd say those are people who are well along in their recovery, precisely because they are no longer seeking to be intoxicated.
posted by praemunire at 10:05 PM on February 10, 2016 [3 favorites]
Physical dependency and addiction are two different things, though. (Also, the ability to hide how impaired you are doesn't mean you're not impaired.)
I don't think you get very far with the argument that an addict is not seeking a high when he uses (as well as, eventually, trying to stave off withdrawal). When habituation develops, that's a bug, not a feature, for the addict; that's why he increases the dosage. I don't even fully understand the argument that seeking a high in and of itself is blameworthy (if I could enjoy the sensation of the time I got Dilaudid in the ER at will, without any of the risks or costs, I would probably spend a Sunday evening or two a month doing so), but opiates are popular drugs precisely because they have powerful physical and mental effects. That's why, after all, Grandma is taking the oxy, and your sister the Xanax: to get an effect. Not just not to go into withdrawal. There may be some people on maintenance treatment who are habituated to the dose they're taking, don't crave or seek the original effects, and are basically taking the methadone or bupe to avoid physical detox, but I'd say those are people who are well along in their recovery, precisely because they are no longer seeking to be intoxicated.
posted by praemunire at 10:05 PM on February 10, 2016 [3 favorites]
When our cost of living is higher than anyone else’s, and when every moment of our daily business, from earning that living to getting well, is fraught with fear and danger, the wonder is not what desperate creatures drug-using sex workers are. The wonder is how we so often manage to transcend that desperation, living fuller lives than anyone imagines.
I agree. At the same time, one of the worst aspects of my experience as a stripper is having my club friends die at a substantially higher rate than my friends at college or at my other workplaces. Overdose, suicide, gruesome murder. I have complex feelings about it.
For instance, I clicked on an article about a horrific murder, and staring at me from the screen was a photo of the victim—a girl I had worked with. The article didn't say that she stripped at my club or that she was a heroin addict.
I was friendly to her when she started, as I am to all the girls, because people were friendly to me when I started. Her locker was nearby mine.
I've been trying to remember what she did that pissed everyone off, and for the life of me, I can't recall. Everybody was ticked at her and I remember thinking that I understood why they were pissed but it wasn't the end of the world so I still tried to be nice to her. Partially because nobody else had the patience for her anymore.
After reading that she had died a horrific death with her body left in a horrific manner, I talked to my friends and learned that she had been a heroin addict, with suspicions that she had been dealing as well. It didn't surprise me.
Unfortunately, at the club where I work, there is no help available to addicts. If a girl starts exhibiting signs of drug use after she is a known and well-liked quantity, she can get a second chance, maybe a third, occasionally a fourth. (These are "chances," as in, not getting fired, rather than "help.")
But a new girl who comes in and exhibits signs of drug use gets no sympathy. It's not "we should help her, she's clearly on drugs," it's "oh my GOD, she's clearly on drugs, someone get her off the stage right fucking now." There is an instinct to distance yourself from Girls Like That—the "Junkie Whore"—because she, in her drug-induced haze, reminds you of the stigma. She reminds you of how you're nervous to tell your parents, professors, friends, significant other's parents, about your profession. Because maybe they'll think you're her.
As a society, we tend to reduce drug users to their drug use, and sex workers to their jobs. Sex workers who also use drugs experience stigma exponentially worse than either one alone. And the stigma isn't helpful to dealing with the problem.
And ultimately, I do think that drug addiction is a problem. (A health problem that should be treated with harm reduction, not a crime.) It is a physical dependency on a mind-altering substance, which changes your priorities. It's not that you can't be a good mother and also a drug addict. It's that you are likely to be a different mother, make different financial choices, and have a higher likelihood of death.
Selfishly speaking as a bystander, I'm just fucking tired of my friends dying. I miss them.
As such, I am having trouble pinning down the overall sentiment of Caty Simon's article, and deciding whether or not I agree with it. (I do retain a ton of respect for her as an a person, writer, and activist, though.)
I have friends whom I deeply care about who use "hard" drugs across the entire spectrum, from high-functioning "you'd never guess" types to low-functioning "you'd totally guess" types, as well as a substantial number of friends in recovery, from a couple weeks to a couple decades.
I love them. I cannot put into words how much I love these girls.
Sex workers who use drugs are people. For better or worse—and I think better—they're my people. Is it hard to be close to them sometimes? Yes. But I haven't walked away, at least, not yet. Most of them do live full lives, which I am lucky to be a part of. And they sure as hell make my life fuller.
posted by Peppermint Snowflake at 11:01 PM on February 10, 2016 [19 favorites]
I agree. At the same time, one of the worst aspects of my experience as a stripper is having my club friends die at a substantially higher rate than my friends at college or at my other workplaces. Overdose, suicide, gruesome murder. I have complex feelings about it.
For instance, I clicked on an article about a horrific murder, and staring at me from the screen was a photo of the victim—a girl I had worked with. The article didn't say that she stripped at my club or that she was a heroin addict.
I was friendly to her when she started, as I am to all the girls, because people were friendly to me when I started. Her locker was nearby mine.
I've been trying to remember what she did that pissed everyone off, and for the life of me, I can't recall. Everybody was ticked at her and I remember thinking that I understood why they were pissed but it wasn't the end of the world so I still tried to be nice to her. Partially because nobody else had the patience for her anymore.
After reading that she had died a horrific death with her body left in a horrific manner, I talked to my friends and learned that she had been a heroin addict, with suspicions that she had been dealing as well. It didn't surprise me.
Unfortunately, at the club where I work, there is no help available to addicts. If a girl starts exhibiting signs of drug use after she is a known and well-liked quantity, she can get a second chance, maybe a third, occasionally a fourth. (These are "chances," as in, not getting fired, rather than "help.")
But a new girl who comes in and exhibits signs of drug use gets no sympathy. It's not "we should help her, she's clearly on drugs," it's "oh my GOD, she's clearly on drugs, someone get her off the stage right fucking now." There is an instinct to distance yourself from Girls Like That—the "Junkie Whore"—because she, in her drug-induced haze, reminds you of the stigma. She reminds you of how you're nervous to tell your parents, professors, friends, significant other's parents, about your profession. Because maybe they'll think you're her.
As a society, we tend to reduce drug users to their drug use, and sex workers to their jobs. Sex workers who also use drugs experience stigma exponentially worse than either one alone. And the stigma isn't helpful to dealing with the problem.
And ultimately, I do think that drug addiction is a problem. (A health problem that should be treated with harm reduction, not a crime.) It is a physical dependency on a mind-altering substance, which changes your priorities. It's not that you can't be a good mother and also a drug addict. It's that you are likely to be a different mother, make different financial choices, and have a higher likelihood of death.
Selfishly speaking as a bystander, I'm just fucking tired of my friends dying. I miss them.
As such, I am having trouble pinning down the overall sentiment of Caty Simon's article, and deciding whether or not I agree with it. (I do retain a ton of respect for her as an a person, writer, and activist, though.)
I have friends whom I deeply care about who use "hard" drugs across the entire spectrum, from high-functioning "you'd never guess" types to low-functioning "you'd totally guess" types, as well as a substantial number of friends in recovery, from a couple weeks to a couple decades.
I love them. I cannot put into words how much I love these girls.
Sex workers who use drugs are people. For better or worse—and I think better—they're my people. Is it hard to be close to them sometimes? Yes. But I haven't walked away, at least, not yet. Most of them do live full lives, which I am lucky to be a part of. And they sure as hell make my life fuller.
posted by Peppermint Snowflake at 11:01 PM on February 10, 2016 [19 favorites]
"You know, I really don't see that."
Heh. I read that as a hatred of MeFi users, not opioid users.
"You're taking Bupropion every night before bed to ward off the depression."
I take it in the morning, thanks.
But again, I have to go and see a doctor every other month because of it, and that doctor requires me to go through a moderately involved rubric to continue taking it, and prior to this doctor, when I didn't have insurance, it was functionally unavailable to me. Likewise, if I stop taking it cold turkey, I won't get withdrawal pains, I'll run a risk of having uncontrollable seizures (despite not taking it to control seizures).
I've also had long-term runs of prescription opioids, due to a nasty injury, and have moderate experience with recreational opioids. I know more than a few people who have prescriptions for benzos, as well as more than a few people who have had serious, rehab-worthy runs with opioids, as well as a ton of alcoholics and amphetamine users.
The problem with this comparison is that the differences between substance use (even recreational) and substance abuse are based on much more than just the binary of whether or not you're taking drugs — it's like responding to a discussion of chronic depression that everyone gets depressed sometimes. The problem is largely defined by ancillary effects, whether or not someone's use is causing them real, negative effects in their life — substance use isn't a problem unless it's a problem, so dismissing the real, negative effects that can come with substance abuse because other people use substances and don't have a problem is either naive or disingenuous.
Compounding that is the fact that the drugs the article is talking about have a profound, well documented ability to subjectively mask the problems that users are having. Users generally are not good at judging whether or not they are actually having problems, and have a strong incentive to lie to both themselves and others about their use. Which means, as other people have noted, people that do have a problem with substance abuse will say exactly the same things that people who do not have a problem say.
Too often that gets generalized into the "never trust a junkie" assumption that everyone who says those things is lying and has a problem, but reversing that to take people who are the definition of unreliable narrators at their word is a mistake too.
When I worked with sex workers, substance abuse was rife, and (as some other folks mentioned upthread) often used as a way to disassociate with doing fairly fucked up, degrading things. But one of the stronger points I think the article implies is that while sex work is portrayed as if it's unique in that regard, it really isn't, at least in my experience — I probably worked with more junkies in food service than I did in porn. I think the need to dissociate from doing fairly fucked up, degrading things is similar there, though the lack of social support for sex workers due to stigma means that the power structure of sex work gives workers less autonomy and inflicts a greater level of institutional misogyny. "Junkie dishwasher" or "junkie delivery driver" has less fraught connotations than "junkie whore" or "junkie porn star."
I do wonder if some of the extra internecine venom from fellow sex workers comes from a sense of self-preservation — junkies tend to be less careful about risks, and are often more willing to rope other people into schemes, like misrepresenting sketchy outcall work, something that in sex work tends to place them and their coworkers in more personally dangerous situations, compared to schemes from my junkie food service coworkers, which tended more toward burglaries and robberies, which seemed less likely to put the people around them into vulnerable situations. (I could totally be wrong there, since most of the more harrowing stories about coworkers in porn came from people who had gotten clean, and involved violence done to them, as opposed to junkie food service coworkers, who I tended to know more contemporarily with their fuck-up-ery, and who seemed to mostly just botch property crimes.)
posted by klangklangston at 1:12 PM on February 11, 2016 [1 favorite]
Heh. I read that as a hatred of MeFi users, not opioid users.
"You're taking Bupropion every night before bed to ward off the depression."
I take it in the morning, thanks.
But again, I have to go and see a doctor every other month because of it, and that doctor requires me to go through a moderately involved rubric to continue taking it, and prior to this doctor, when I didn't have insurance, it was functionally unavailable to me. Likewise, if I stop taking it cold turkey, I won't get withdrawal pains, I'll run a risk of having uncontrollable seizures (despite not taking it to control seizures).
I've also had long-term runs of prescription opioids, due to a nasty injury, and have moderate experience with recreational opioids. I know more than a few people who have prescriptions for benzos, as well as more than a few people who have had serious, rehab-worthy runs with opioids, as well as a ton of alcoholics and amphetamine users.
The problem with this comparison is that the differences between substance use (even recreational) and substance abuse are based on much more than just the binary of whether or not you're taking drugs — it's like responding to a discussion of chronic depression that everyone gets depressed sometimes. The problem is largely defined by ancillary effects, whether or not someone's use is causing them real, negative effects in their life — substance use isn't a problem unless it's a problem, so dismissing the real, negative effects that can come with substance abuse because other people use substances and don't have a problem is either naive or disingenuous.
Compounding that is the fact that the drugs the article is talking about have a profound, well documented ability to subjectively mask the problems that users are having. Users generally are not good at judging whether or not they are actually having problems, and have a strong incentive to lie to both themselves and others about their use. Which means, as other people have noted, people that do have a problem with substance abuse will say exactly the same things that people who do not have a problem say.
Too often that gets generalized into the "never trust a junkie" assumption that everyone who says those things is lying and has a problem, but reversing that to take people who are the definition of unreliable narrators at their word is a mistake too.
When I worked with sex workers, substance abuse was rife, and (as some other folks mentioned upthread) often used as a way to disassociate with doing fairly fucked up, degrading things. But one of the stronger points I think the article implies is that while sex work is portrayed as if it's unique in that regard, it really isn't, at least in my experience — I probably worked with more junkies in food service than I did in porn. I think the need to dissociate from doing fairly fucked up, degrading things is similar there, though the lack of social support for sex workers due to stigma means that the power structure of sex work gives workers less autonomy and inflicts a greater level of institutional misogyny. "Junkie dishwasher" or "junkie delivery driver" has less fraught connotations than "junkie whore" or "junkie porn star."
I do wonder if some of the extra internecine venom from fellow sex workers comes from a sense of self-preservation — junkies tend to be less careful about risks, and are often more willing to rope other people into schemes, like misrepresenting sketchy outcall work, something that in sex work tends to place them and their coworkers in more personally dangerous situations, compared to schemes from my junkie food service coworkers, which tended more toward burglaries and robberies, which seemed less likely to put the people around them into vulnerable situations. (I could totally be wrong there, since most of the more harrowing stories about coworkers in porn came from people who had gotten clean, and involved violence done to them, as opposed to junkie food service coworkers, who I tended to know more contemporarily with their fuck-up-ery, and who seemed to mostly just botch property crimes.)
posted by klangklangston at 1:12 PM on February 11, 2016 [1 favorite]
I'm sure I can find all sorts of coked up Phd students, lawyers, athletes, and they will talk about how they have agency to live their life and make great decisions. But undercutting those smooth words is the fact that the rest of us need air, food, water, shelter, while they also need their fix.
I can't speak to Heroin because I've never knowingly known a user. But this is an inaccurate perception of Cocaine, at least.
Yup, lots of people develop an addiction.
But despite media portrayals, those people are a minority. Many more use it occasionally.
I know people in both categories. It's possible that my sample is bad, but its size is not all that small, and the ratio of "people who have had a problem":"people who will have some sometimes" is very low.
Drug use is more complicated than DARE and after school specials and movies have led people to believe.
posted by flaterik at 2:15 PM on February 11, 2016 [2 favorites]
I can't speak to Heroin because I've never knowingly known a user. But this is an inaccurate perception of Cocaine, at least.
Yup, lots of people develop an addiction.
But despite media portrayals, those people are a minority. Many more use it occasionally.
I know people in both categories. It's possible that my sample is bad, but its size is not all that small, and the ratio of "people who have had a problem":"people who will have some sometimes" is very low.
Drug use is more complicated than DARE and after school specials and movies have led people to believe.
posted by flaterik at 2:15 PM on February 11, 2016 [2 favorites]
And one of the symptoms is "there is no problem here",
The ideal that denial is a universal part of addiction is actually incorrect: basically, denial exists in addiction as part of a relationship. If there is a trusting relationship and the person doesn't believe he will be punished for admitting the truth or be forced into doing something like getting treatment or lifelong abstinence, it typically disappears or is dramatically reduced.
The same person who will "deny" being an "alcoholic or addict" will admit reasonably accurately on an anonymous survey how much drink or drugs they use and how often. And will be completely open with needle exchange workers about their concerns about the consequences of continued use— while hiding those concerns from say, their mother or their partner. That's because they know the needle exchange people aren't going to judge them or try to coerce them.
The reason "denial" exists is because people with addiction believe that if they don't deny and hide what's going on, they will be treated disrespectfully or forced to make a change that seems to them unbearably painful. Make the change seem bearable or even desirable and a matter of choice, not force— suddenly, boom, denial is gone.
Denial exists overwhelmingly as a response to stigma and fear— remove those and you remove denial, which is why it is silly to see denial as a reason to not treat people with addiction with dignity, respect and compassion or as a reason to disregard accounts like the one in this article.
posted by Maias at 4:43 PM on February 11, 2016 [21 favorites]
The ideal that denial is a universal part of addiction is actually incorrect: basically, denial exists in addiction as part of a relationship. If there is a trusting relationship and the person doesn't believe he will be punished for admitting the truth or be forced into doing something like getting treatment or lifelong abstinence, it typically disappears or is dramatically reduced.
The same person who will "deny" being an "alcoholic or addict" will admit reasonably accurately on an anonymous survey how much drink or drugs they use and how often. And will be completely open with needle exchange workers about their concerns about the consequences of continued use— while hiding those concerns from say, their mother or their partner. That's because they know the needle exchange people aren't going to judge them or try to coerce them.
The reason "denial" exists is because people with addiction believe that if they don't deny and hide what's going on, they will be treated disrespectfully or forced to make a change that seems to them unbearably painful. Make the change seem bearable or even desirable and a matter of choice, not force— suddenly, boom, denial is gone.
Denial exists overwhelmingly as a response to stigma and fear— remove those and you remove denial, which is why it is silly to see denial as a reason to not treat people with addiction with dignity, respect and compassion or as a reason to disregard accounts like the one in this article.
posted by Maias at 4:43 PM on February 11, 2016 [21 favorites]
addicts are people and deserve a baseline of respect
I think approach fails to understand the social function of "respect" and conversely "stigmatization". I mean are not respect and stigmatization the very means by which the "community", the social group, marks certain activities as good or bad?
If you respect drug users, you are advocating for drugs, or at least undermining attempts to say "drugs are bad". If a certain activity is considered bad for the community, and something that needs to be limited and discouraged, then it seems counter-productive to respect those that engage in it. Stigmatization is one of the few effective discouragements communities have against what is considered "anti-social" behaviour. If you take that away you are effectively disempowering the community.
I think this notion that "respect" is due purely to biological human nature is a perverse libertarianism.
posted by mary8nne at 12:56 AM on February 12, 2016
I think approach fails to understand the social function of "respect" and conversely "stigmatization". I mean are not respect and stigmatization the very means by which the "community", the social group, marks certain activities as good or bad?
If you respect drug users, you are advocating for drugs, or at least undermining attempts to say "drugs are bad". If a certain activity is considered bad for the community, and something that needs to be limited and discouraged, then it seems counter-productive to respect those that engage in it. Stigmatization is one of the few effective discouragements communities have against what is considered "anti-social" behaviour. If you take that away you are effectively disempowering the community.
I think this notion that "respect" is due purely to biological human nature is a perverse libertarianism.
posted by mary8nne at 12:56 AM on February 12, 2016
Stigmatization is one of the few effective discouragements communities have against what is considered "anti-social" behaviour.
How's that working out so far?
posted by shakespeherian at 6:10 AM on February 12, 2016 [11 favorites]
How's that working out so far?
posted by shakespeherian at 6:10 AM on February 12, 2016 [11 favorites]
The reason "denial" exists is because people with addiction believe that if they don't deny and hide what's going on, they will be treated disrespectfully or forced to make a change that seems to them unbearably painful. Make the change seem bearable or even desirable and a matter of choice, not force— suddenly, boom, denial is gone.
In my experience, this is wishful thinking - yes addicts are open with needle exchange workers, but needle exchange workers provide a service to the users and users are not obligated beyond the rules of the house.
Even the most understanding and accepting among family and friends of addicts I've known have experienced ruthless manipulation and betrayal. It is an addiction, not recreational use. And addiction means in practice that the addiction comes first.
When more than one person in my closest family have been or still are in denial, it doesn't mean so much that they deny their use, they don't/didn't - it means that they deny the harmful effects of it on their friends and family - and themselves.
which is why it is silly to see denial as a reason to not treat people with addiction with dignity, respect and compassion
Nah, it is always silly to treat people with less than dignity, respect and compassion. Doing so makes you, not the victim of your contempt, seem less human.
posted by mumimor at 6:27 AM on February 12, 2016 [1 favorite]
In my experience, this is wishful thinking - yes addicts are open with needle exchange workers, but needle exchange workers provide a service to the users and users are not obligated beyond the rules of the house.
Even the most understanding and accepting among family and friends of addicts I've known have experienced ruthless manipulation and betrayal. It is an addiction, not recreational use. And addiction means in practice that the addiction comes first.
When more than one person in my closest family have been or still are in denial, it doesn't mean so much that they deny their use, they don't/didn't - it means that they deny the harmful effects of it on their friends and family - and themselves.
which is why it is silly to see denial as a reason to not treat people with addiction with dignity, respect and compassion
Nah, it is always silly to treat people with less than dignity, respect and compassion. Doing so makes you, not the victim of your contempt, seem less human.
posted by mumimor at 6:27 AM on February 12, 2016 [1 favorite]
If you respect drug users, you are advocating for drugs, or at least undermining attempts to say "drugs are bad". If a certain activity is considered bad for the community, and something that needs to be limited and discouraged, then it seems counter-productive to respect those that engage in it. Stigmatization is one of the few effective discouragements communities have against what is considered "anti-social" behaviour. If you take that away you are effectively disempowering the community.
Most of the scientific communities dedicated to drug addiction believe the complete opposite, actually. Here's some selections from the Substance Abuse and Mental Health Services Administration (SAMHSA), the US federal organization tasked with addressing substance abuse:
Briefing on Substance Use Treatment and Recovery in the United States (PDF)
Most of the scientific communities dedicated to drug addiction believe the complete opposite, actually. Here's some selections from the Substance Abuse and Mental Health Services Administration (SAMHSA), the US federal organization tasked with addressing substance abuse:
Briefing on Substance Use Treatment and Recovery in the United States (PDF)
Stigma remains a barrier to recovery. Individuals who have substance use disorders are negatively impacted by discrimination in areas of health care, education, financial assistance, and employment.posted by zombieflanders at 6:37 AM on February 12, 2016 [16 favorites]Substance Use Disorders: A Guide to the Use of Language (PDF)
- Insurance coverage for treatment is often denied or restricted, and employers turn away recovering individuals that report their drug histories 75 percent of the time (Marks, 2002).
- Individuals with substance use disorders who need treatment may not seek it because of stigma associated with this health care service. Individuals report several concerns related to accessing treatment, such as the possible negative effects on their job (13.3%), concern that neighbors and the community will have a negative opinion of them (11.0%), and lack of health care coverage (36.3%) (NSDUH, 2007).
Those involved in preventing, treating, and supporting recovery for substance use disorders employ a variety of competing terms to describe the illness and the people it affects. This lack of a common language fosters fragmentation within the workforce, causes confusion in public discourse, and allows for the perpetuation of stigma. In discussing substance use disorders, words can be powerful when used to inform, clarify, encourage, support, enlighten, and unify. On the other hand, stigmatizing words often discourage, isolate, misinform, shame, and embarrass. Recognizing the power of words, this guide is designed to raise awareness around language and offer alternatives to stigmatizing terminology associated with substance use disorders. It is offered primarily as a resource to those who work within the field of prevention, treatment, and recovery support.And here's more from the American Society of Addiction Medicine, one of the major organizations for addiction treatment:
[...]
While this guide aims to promote nonstigmatizing language for the prevention/treatment/recovery workforce, it is not for the workforce to define how those who have substance use disorders or those in recovery choose to identify themselves. To attempt to do so would negate the autonomy and selfdefinition of the very individuals the workforce seeks to serve.
Finally, attention to language is a critical step toward the reduction of stigma, but it is only one step. Reducing stigma involves not only changes in language, but also a significant transformation in people’s underlying perceptions and attitudes, and in society’s discriminatory policies. These developments are essential to creating a society that fully supports prevention, treatment, and recovery for substance use disorders.
Patients with Addiction Need Treatment - Not StigmaScientific progress has helped us understand that addiction – also referred to as substance use disorder – is a chronic disease of the brain. It is a disease that can be treated – and treated successfully. No one chooses to develop this disease. Instead, a combination of genetic predisposition and environmental stimulus – analogous to other chronic diseases like diabetes and hypertension – can result in physical changes to the brain’s circuitry, which lead to tolerance, cravings, and the characteristic compulsive and destructive behaviors of addiction that are such a large public health burden for our nation.I think this notion that "respect" is due purely to biological human nature is a perverse libertarianism.
[...]
[W]e must change the conversation about what it means to have addiction, and we also must increase access to evidence-based treatments. This means putting an end to stigma, increasing access to medication that can treat opioid use disorder, and supporting the expanded use of naloxone – a life-saving medication that can reverse the effects of an opioid-related overdose. People with addiction deserve to be treated like any other patient with a medical disease, and physicians are helping the nation understand how to do this. That is one reason the Task Force encourages increased education and training for MAT.
[...]
As clinicians, we see the harsh reality faced by our patients with a substance use disorder. Stigmatizing patients helps no one. Our goal is to treat our patients and help them live as fully functional members of society. There are people in recovery at every level of government, the private sector and throughout our towns and communities. That is because treatment works.
The scientific community dealing with addiction sees your notion as a perverse authoritarianism, and as far as I can tell, is as acceptable to them as denial of climate change is to climate scientists.
Most of the scientific communities dedicated to drug addiction believe the complete opposite, actually.
but you cited issues related to recovery and I wasn't saying that stigmatisation was good for recovery. I think stigmatisation is more of a pre-emptive measure to discourage open drug use. If drug addiction was respectable and acceptable then there would be little desire to avoid it in the first place.
And I think you are wrong in claiming that stigmatisation is authoritarian. Given that the article is aimed at the "everyday person", to try and change typical behaviour, then attempts to de-stigmatise drug addiction are acting against public opinion, are they not?
posted by mary8nne at 10:10 AM on February 12, 2016
but you cited issues related to recovery and I wasn't saying that stigmatisation was good for recovery. I think stigmatisation is more of a pre-emptive measure to discourage open drug use. If drug addiction was respectable and acceptable then there would be little desire to avoid it in the first place.
And I think you are wrong in claiming that stigmatisation is authoritarian. Given that the article is aimed at the "everyday person", to try and change typical behaviour, then attempts to de-stigmatise drug addiction are acting against public opinion, are they not?
posted by mary8nne at 10:10 AM on February 12, 2016
Actually, stigma *worsens* addiction— and there's no evidence that it deters people from using drugs who are at risk of addiction. The people it does deter are at low risk and the people it doesn't deter are harmed. So, not very helpful.
Also, our stereotypes of people with addiction are based on racist stereotypes: lying, manipulative, deceitful, violent, criminal, lazy.
But they are not actually based in the actions of most people with addiction: it's true that 18% of people with addiction have antisocial personality disorder (which *does* make people lie and manipulate) and also that that rate is about 4x higher than for the general population. However, that means 82% of us *don't* fit that stereotype.
What stigma does is increase shame and what shame does is drive relapse. See this LTE I recently published in the New York Times.
Regarding denial and needle exchange, the fact is that programs that ignore denial are far more effective than those that try to confront it. As noted in my letter, the research on confrontational and shaming treatments over 40 years has not shown a single instance where it is superior to empathetic and respectful care.
posted by Maias at 10:49 AM on February 12, 2016 [8 favorites]
If social stigma deterred people from starting to use substances, there would be no smokers. Positively portraying drugs and those who use them does encourage people to try them, but stigmatizing doesn't have the opposite effect. If anything, it creates a perverse incentive, arousing curiosity and a sense of bravado and rebellion in would-be and new users.
The only things that work are eradicating positive marketing, disincentive taxation, and treatment. Finding a way to address despair, powerlessness, and social isolation might help, but it's an ambitious plan that nobody has tried yet.
posted by gingerest at 2:05 PM on February 12, 2016 [5 favorites]
The only things that work are eradicating positive marketing, disincentive taxation, and treatment. Finding a way to address despair, powerlessness, and social isolation might help, but it's an ambitious plan that nobody has tried yet.
posted by gingerest at 2:05 PM on February 12, 2016 [5 favorites]
"but you cited issues related to recovery and I wasn't saying that stigmatisation was good for recovery. I think stigmatisation is more of a pre-emptive measure to discourage open drug use. If drug addiction was respectable and acceptable then there would be little desire to avoid it in the first place. "
There are a whole bunch of complicated assumptions piled into this, so I'm gonna try to be brief in dealing with some of them:
First off, distinguishing drug use from addiction is worthwhile — the NIH estimates that only about 23% of longterm heroin users become addicted. The public perception of addiction and abuse is often based on pretty dubious definitions — the definition of prescription opioid abuse is taking opioids longer than they're prescribed, which while implying in increased likelihood of dependence doesn't actually equate with being dependent.
So, and this is something that I think the FPP muddies as well, not all people using opioids (prescription or street) are what I'd call junkies, and treating them as if they all are in order to apply a stigma to the minority that develop dependence seems to undercut the credibility of an anti-addiction effect.
The second thing is that stigma, and shame, in general are bad public policy tools. That's because, in general, the shame and stigma applied, cf. John Braithwaite, are what would be termed "disintegrative" stigmas and shames, rather than "reintegrative" stigmas and shames. The desire to avoid being viewed shamefully by other members of the community is a strong one, but most stigmas (including those around poverty, criminality, etc.) are imposed in a way that 1) blames the persistent character of the individual, and 2) encourages withdrawal from social situations in which stigma or shame is likely to be applied — they diminish or inhibit the integration of an individual with the community. Reintegrative stigmas and shames can be really powerful in a positive direction — that's a lot of what the idea of "restorative justice" is based on, the idea that the community can impose an action of restitution that will absolve the shame or stigma of a bad act and reintegrate the offender with society. Developing a stigma about junkies doesn't do this.
The third thing is that public education campaigns based on stigma and shame have really mixed results, at best. The most prevalent campaigns that I know of are cigarettes, drunk driving and seat belt use. For cigarettes, the broad public campaign of stigma has helped decrease people using cigarettes in public, but has had disproportionately negative effects on people who are poor, people who are minorities, and people with other attributes marked by stigma (mental health, obesity, etc.). They also tend to have negative effects on the longterm cessation rates for smokers, especially when combined with the cigarette advertising that portrays smoking as a freedom and an individual choice — people who have trouble quitting smoking end up with the message that their failure to stop smoking is because of them as a person, and are less likely to have broader resources available to help them quit smoking from places perceived to be hostile, e.g. doctors.
As for drunk driving, despite the prevalence of MADD anti-drunk driving stigma-based campaigns, they've been shown to have basically zero effect on preventing drunk driving. People who drive drunk just decide that they're not really DRUNK drunk, or just don't care, and keep driving. The only effective thing, according to longterm studies from the Department of Transportation, has been the publicity around random checkpoints.
(In one of those weird public psychology quirks, the actual checkpoints do very little to curb drunk driving, but publicizing them cuts drunk driving by 10 to 20% — the checkpoints are only necessary insofar as they keep the messaging of checkpoints credible. But in places where, due to quirks of whether or whatever, checkpoints have been publicized but not actually realized, the incidence of DUIs falls about the same as the places where they have them, while the rate of DUI decline correlates much more with the areas and relative media reach of the publicity — just having the checkpoints and doing mild publicity barely helps.)
Similarly, in terms of seat belt use, public education campaigns that focused on the stigma of not wearing seat belts or the risk in safety haven't been nearly as effective as campaigns based on the risk of getting caught — i.e. Click It or Ticket.
Shame and stigma is worth something — economic games based on quantifying how much money people will give up to avoid being seen as untrustworthy in public (basically, whether or not the second party's choice to collaborate or screw the first party will be reported to the first party) routinely show that people are motivated by it, but that the effects of shame and stigma aren't straightforward, and the overall most likely response is withdrawal and concealment, not avoidance.
Finally, it's worth noting that with both legal and illegal addictive substances (notably tobacco and heroin), a sizable plurality of users tend to seek to quit on their own — between 40 and 80% self report attempting to quit, depending on the study, and that seems to be true more based on their own perception of their substance use rather than interactions with outside parties. Obviously, you can't isolate out the broader stigmas of society, but the argument that addicts without stigma wouldn't try to quit doesn't seem supported, and given that one of the larger problems is that people who try to quit on their own often take longer and have more relapses, getting people effective help without stigma ends up with a better public health outcome.
I will say that, like many things, I do think there can be a conflation in conversations between the responsibilities of public health professionals and regular members of the public — I think that the public has much less obligation to be non-judgmental about this stuff, and I think that one of MeFi's quirks is that the relatively high number of people involved in these fields who do have an obligation who are also participating here means that often that obligation is implied to exist more broadly than it does. Way back when I was still mostly doing food service jobs, I remember how happy I was to finally get a boss who wasn't a coke head, because while I can recognize that many coke users wouldn't habitually try to fuck me with wage theft, enough of them did that I didn't want to be around 'em. Similarly, while not every heroin user I've known has been a thieving, unreliable shit, in general the coworkers and neighbors I've had who were obvious heroin users were just that. The obligations for nuance in public policy are different than they are in interpersonal relationships, just as interpersonal relationships widely vary in the amount of compassion owed to another person for their foibles.
posted by klangklangston at 2:18 PM on February 12, 2016 [4 favorites]
There are a whole bunch of complicated assumptions piled into this, so I'm gonna try to be brief in dealing with some of them:
First off, distinguishing drug use from addiction is worthwhile — the NIH estimates that only about 23% of longterm heroin users become addicted. The public perception of addiction and abuse is often based on pretty dubious definitions — the definition of prescription opioid abuse is taking opioids longer than they're prescribed, which while implying in increased likelihood of dependence doesn't actually equate with being dependent.
So, and this is something that I think the FPP muddies as well, not all people using opioids (prescription or street) are what I'd call junkies, and treating them as if they all are in order to apply a stigma to the minority that develop dependence seems to undercut the credibility of an anti-addiction effect.
The second thing is that stigma, and shame, in general are bad public policy tools. That's because, in general, the shame and stigma applied, cf. John Braithwaite, are what would be termed "disintegrative" stigmas and shames, rather than "reintegrative" stigmas and shames. The desire to avoid being viewed shamefully by other members of the community is a strong one, but most stigmas (including those around poverty, criminality, etc.) are imposed in a way that 1) blames the persistent character of the individual, and 2) encourages withdrawal from social situations in which stigma or shame is likely to be applied — they diminish or inhibit the integration of an individual with the community. Reintegrative stigmas and shames can be really powerful in a positive direction — that's a lot of what the idea of "restorative justice" is based on, the idea that the community can impose an action of restitution that will absolve the shame or stigma of a bad act and reintegrate the offender with society. Developing a stigma about junkies doesn't do this.
The third thing is that public education campaigns based on stigma and shame have really mixed results, at best. The most prevalent campaigns that I know of are cigarettes, drunk driving and seat belt use. For cigarettes, the broad public campaign of stigma has helped decrease people using cigarettes in public, but has had disproportionately negative effects on people who are poor, people who are minorities, and people with other attributes marked by stigma (mental health, obesity, etc.). They also tend to have negative effects on the longterm cessation rates for smokers, especially when combined with the cigarette advertising that portrays smoking as a freedom and an individual choice — people who have trouble quitting smoking end up with the message that their failure to stop smoking is because of them as a person, and are less likely to have broader resources available to help them quit smoking from places perceived to be hostile, e.g. doctors.
As for drunk driving, despite the prevalence of MADD anti-drunk driving stigma-based campaigns, they've been shown to have basically zero effect on preventing drunk driving. People who drive drunk just decide that they're not really DRUNK drunk, or just don't care, and keep driving. The only effective thing, according to longterm studies from the Department of Transportation, has been the publicity around random checkpoints.
(In one of those weird public psychology quirks, the actual checkpoints do very little to curb drunk driving, but publicizing them cuts drunk driving by 10 to 20% — the checkpoints are only necessary insofar as they keep the messaging of checkpoints credible. But in places where, due to quirks of whether or whatever, checkpoints have been publicized but not actually realized, the incidence of DUIs falls about the same as the places where they have them, while the rate of DUI decline correlates much more with the areas and relative media reach of the publicity — just having the checkpoints and doing mild publicity barely helps.)
Similarly, in terms of seat belt use, public education campaigns that focused on the stigma of not wearing seat belts or the risk in safety haven't been nearly as effective as campaigns based on the risk of getting caught — i.e. Click It or Ticket.
Shame and stigma is worth something — economic games based on quantifying how much money people will give up to avoid being seen as untrustworthy in public (basically, whether or not the second party's choice to collaborate or screw the first party will be reported to the first party) routinely show that people are motivated by it, but that the effects of shame and stigma aren't straightforward, and the overall most likely response is withdrawal and concealment, not avoidance.
Finally, it's worth noting that with both legal and illegal addictive substances (notably tobacco and heroin), a sizable plurality of users tend to seek to quit on their own — between 40 and 80% self report attempting to quit, depending on the study, and that seems to be true more based on their own perception of their substance use rather than interactions with outside parties. Obviously, you can't isolate out the broader stigmas of society, but the argument that addicts without stigma wouldn't try to quit doesn't seem supported, and given that one of the larger problems is that people who try to quit on their own often take longer and have more relapses, getting people effective help without stigma ends up with a better public health outcome.
I will say that, like many things, I do think there can be a conflation in conversations between the responsibilities of public health professionals and regular members of the public — I think that the public has much less obligation to be non-judgmental about this stuff, and I think that one of MeFi's quirks is that the relatively high number of people involved in these fields who do have an obligation who are also participating here means that often that obligation is implied to exist more broadly than it does. Way back when I was still mostly doing food service jobs, I remember how happy I was to finally get a boss who wasn't a coke head, because while I can recognize that many coke users wouldn't habitually try to fuck me with wage theft, enough of them did that I didn't want to be around 'em. Similarly, while not every heroin user I've known has been a thieving, unreliable shit, in general the coworkers and neighbors I've had who were obvious heroin users were just that. The obligations for nuance in public policy are different than they are in interpersonal relationships, just as interpersonal relationships widely vary in the amount of compassion owed to another person for their foibles.
posted by klangklangston at 2:18 PM on February 12, 2016 [4 favorites]
Ah, confirmation bias. Is there anything you can't make worse? Of course it looks like all drug addicts are thieving, unreliable shits. You can't identify the addicts who aren't because you don't know that they have an addiction if they don't tell you.
posted by wierdo at 9:28 AM on February 13, 2016 [1 favorite]
posted by wierdo at 9:28 AM on February 13, 2016 [1 favorite]
Sure, but the counterpoint is that if someone is obviously exhibiting the signs of addiction, it's a reasonable Bayesian prior for assuming that they're not someone you should have in your house unattended. Acting like there's no connection between junkies and anti-social behavior like theft is taking a non-judgmental attitude that's good for clinical work to an idiotic extreme for members of the general public.
posted by klangklangston at 4:02 PM on February 13, 2016 [1 favorite]
posted by klangklangston at 4:02 PM on February 13, 2016 [1 favorite]
I don't disagree with that. What I'm saying is that many to most people addicted to or dependent on psychoactive substances don't fit that profile. Most of them are otherwise perfectly normal, right up until they lose their insurance or their doctor gets in the shit for prescribing too many controlled substances and they get cut off.
posted by wierdo at 4:14 PM on February 13, 2016 [1 favorite]
posted by wierdo at 4:14 PM on February 13, 2016 [1 favorite]
You can't identify the addicts who aren't because you don't know that they have an addiction if they don't tell you.
It's been mentioned several times before, but it is just not universally true. Maybe some people, even many people, cannot recognize a well-functioning addict. But others can. And the reasons they don't say anything can be many and diverse and change over time even in one person. But one strong reason is that they don't care and they don't want to get involved.
posted by mumimor at 10:22 PM on February 13, 2016
It's been mentioned several times before, but it is just not universally true. Maybe some people, even many people, cannot recognize a well-functioning addict. But others can. And the reasons they don't say anything can be many and diverse and change over time even in one person. But one strong reason is that they don't care and they don't want to get involved.
posted by mumimor at 10:22 PM on February 13, 2016
Just like gaydar is hardly infallible, so is "addict-dar." You really can't tell, even those who think you always can. Certainly, it's obvious in some cases— but sometimes that "obvious" addict is actually undergoing chemo or anorexic or suffering from some other disease that can make you look physically run-down and shaky.
And sometimes that "obvious" addict who is clearly the one who is lying, cheating and stealing is doing nothing of the sort— for one, rich addicts often do not need to hide what they are doing, nor do they lack for money, so they simply don't engage in the behavior that is seen as "typical."
Also, actually the drunk driving campaigns involving stigmatizing drunk drivers were one of the biggest public health successes ever— drunk driving has dropped by more than half since they were introduced. The secret is shaming the *drunk driving* not the drinking and creating roles like "designated driver" that give people a legit reason not to drink while allowing their friends a safe way to get home.
I don't know where you got the idea that they didn't work— but the data on drunk driving is pretty overwhelming and straightforward in terms of its decline since it went from being something that people laughed at but did anyway till it become seen as immoral.
posted by Maias at 1:44 PM on February 15, 2016 [1 favorite]
And sometimes that "obvious" addict who is clearly the one who is lying, cheating and stealing is doing nothing of the sort— for one, rich addicts often do not need to hide what they are doing, nor do they lack for money, so they simply don't engage in the behavior that is seen as "typical."
Also, actually the drunk driving campaigns involving stigmatizing drunk drivers were one of the biggest public health successes ever— drunk driving has dropped by more than half since they were introduced. The secret is shaming the *drunk driving* not the drinking and creating roles like "designated driver" that give people a legit reason not to drink while allowing their friends a safe way to get home.
I don't know where you got the idea that they didn't work— but the data on drunk driving is pretty overwhelming and straightforward in terms of its decline since it went from being something that people laughed at but did anyway till it become seen as immoral.
posted by Maias at 1:44 PM on February 15, 2016 [1 favorite]
"Just like gaydar is hardly infallible, so is "addict-dar." You really can't tell, even those who think you always can. Certainly, it's obvious in some cases— but sometimes that "obvious" addict is actually undergoing chemo or anorexic or suffering from some other disease that can make you look physically run-down and shaky."
Just like gaydar, I'm going to go with my junkie-dar being reliable more often than not. Signs include: Repeatedly coming to work too fucked up to work, leaving a photo shoot for four hours to cop, having more than one ambulance-level OD, nodding off in the bathroom with a needle in their arm… (Likewise, if you try to sell me your mother's toilet, and when I decline, ask me if you can just have some money for crack — true story — I'm going to assume that it's now fair to call you a crackhead.)
I mean, point taken about the wide variety of other things that can be going on when someone looks like they may be substance-dependent and anti-social — I used to manage a group of magazine distributors who I know my friends thought were likely all drunks and junkies, and most of them weren't and were unfairly judged. And it was the most respectable looking one of them who stole the company van and went on a three-week crack bender.
I know that you've got reams more experience working with addicts than I do, but, again, I've had enough experience that I feel pretty OK setting some pretty firm boundaries.
"Also, actually the drunk driving campaigns involving stigmatizing drunk drivers were one of the biggest public health successes ever— drunk driving has dropped by more than half since they were introduced. The secret is shaming the *drunk driving* not the drinking and creating roles like "designated driver" that give people a legit reason not to drink while allowing their friends a safe way to get home."
Sorry, that's post hoc ergo propter hoc. The evidence just isn't there for the PSAs, and the statistics cited by the Ad Council et al. are misleading at best. Drunk driving has declined — how much did stigmatization campaigns contribute compared to other factors? Not very much.
Effectiveness of Mass Media Campaigns forReducing Drinking and Driving and Alcohol-InvolvedCrashes: A Systematic Review. (Elder, American Journal of Preventative Medicine, 2004) found that while the contribution was economically justified, the median supportable contribution to alcohol-involved driving collision reduction was 13%, with campaigns that focused on fear of enforcement being more effective than social appeals.
A 2015 review in BMC Public Health A systematic review: effectiveness of mass media campaigns for reducing alcohol-impaired driving and alcohol-related crashes (Yadav, BMC Public Health, 2015 concluded that current literature did not show reductions in alcohol-related fatalities. Worth noting is that the less rigorous the methodology, in general, the bigger the impact claimed bigger results.
The best support for the argument that shame and stigma-based campaigns work is "Reduction in Drunk Driving as a Response to Increased Threats of Shame, Embarrassment and Legal Sanction" by Harold Grasmick, Robert Bursik and Bruce Arneklev (Criminology, v. 31, 1, 1993), which finds a significant impact of private moral beliefs (shame — compared to public morals, or embarrasment, and legal sanction) on the self-reported incidence of drunk driving and the future likelihood of driving drunk. But while Grasmick et al. linked those self-reported beliefs to a decrease in Oklahoma City drunk driving fatalities, further study has undermined the link between self-reported behavioral preferences and fatality outcomes ("Drink-Driving and DUI Recidivists’Attitudes and Beliefs: A Longitudinal Analysis," Greenberg, J. Stud. Alcohol 66: 640-647, 2005), which found that while they are a factor in preventing recidivism, DUI offenders rated the probability of friends disapproving as less a concern than their own perception of the morality of DUI, and a higher score in social desirability (meaning, they cared more what their peers thought of them) made them more likely to reoffend, not less.
The Gramsick studies were all prior ti 1990, when the Ad Council started running the "Friends don't let friends" ad campaigns, and while alcohol-involved fatal collisions were decreasing, they had a more dramatic drop afterwards. Maybe that's evidence?
"Evaluating the Effectiveness of Policies Related to Drunk Driving" (Eisenberg, Journal of Policy Analysis and Management, Vol. 22, No. 2, 249–274 [2003]) finds that almost all of the change came from shifts in per se BAC laws, first to .10, then .08, with the National Highway Safety Administration's Statistical Analysis of Alcohol-Related Driving Trends, 1982-2005 putting most of the rest of the decrease down to shifting demographic trends — the US was older, drivers were less male, and the economic situation had dramatically worsened during the largest drop (which does correspond with decreases in alcohol-related fatalities, as more people drink at home and fewer are getting drinks after work).
And even if we're continuing with self-reported attitudes on drinking and driving, the NHTSA's 2008 "National Survey of Drinking and Driving Attitudes and Behaviors" found that the largest deterrent wasn't direct perception of social stigma, but rather a fear of crashing (similarly, a study in Spain found that fear of crashes was the number one contributor to a decision to not drink and drive). That supports the earlier "Drunk-Driving Research and Innovation: A Factorial Survey of the Study of Decisions to Drink and Drive," (Thurman, Social Science Research 22, 245-264, 1993), which found that while the general population reported being undeterred by legal consequences and more motivated by community response, the subsample of people who have admitted to drinking and driving previously, whether or not they were caught, were much more concerned about things like checkpoints and relatively unconcerned with peer reaction.
So, basically, the Ad Council's arguments, and arguments that the shaming and stigmatization campaigns have been some of the "biggest public health successes ever" are incredibly weak, at best. The studies that claim that they have the most effect are the weakest, with significant methodological flaws and very little correlation with underlying empirical data. Meta-analysis can only show that public health media campaigns — of all types stigma, fear, etc. — likely influenced public perception, and that public perception shifting has influenced the underlying behavior to a mild extent. What the meta-analysis makes much more likely is that the campaigns influenced decision makers — particularly state and federal lawmakers — and that those interactions had a much more dramatic effect on actually decreasing the incidence of drunk driving — there's a much better fit with the data based on shifts in BAC (which went state by state) than the Ad Council campaign, which was national.
Contrasting this with the efforts like the NHTSA’s High-Visibility Enforcement Impaired Driving Campaign in 2003, or 2006 National Labor Day Impaired Driving Enforcement Crackdown, which (along with similar, more local studies on roadblocks and media markets) can show a direct correlation with decreases in fatalities related to the public awareness of checkpoints, and the case for efficacy of stigma campaigns is incredibly thin.
That doesn't mean that public health campaigns are worthless, or that they aren't part of a broader intervention strategy — especially since the evidence strongly suggests that the utility of enforcement and legislative interventions is powerful but relatively short-lived and relatively costly. In theory, public health campaigns that shift attitudes can be much more durable and cheap per interaction.
"I don't know where you got the idea that they didn't work— but the data on drunk driving is pretty overwhelming and straightforward in terms of its decline since it went from being something that people laughed at but did anyway till it become seen as immoral."
The evidence that drunk driving has declined is pretty overwhelming, but the argument that this is caused by a stigmatization, or that stigmatization campaigns have been more effective than media campaigns that highlight risks (legal, financial, physical) is anything but.
Maybe I've missed some papers or something that supports this contention, but all of the research that I've seen that claims to support the notion of these campaigns has done so with either pretty transparently bunk Ad Council exposure numbers (recognition does not mean changing behavior), or with dubious college student self-reporting unconnected with any empirical data. It wouldn't be that hard to design a study to check message salience and behavioral effect (harder to fund, obvs.), but it seems like nobody's actually done so — or, as several meta-analyses point out, the publication bias implies that null or negative results are unlikely to get published.
Again, maybe you've got some great research that I've missed — it's not like I did a full lit review on this. But it would be odd if none of the people behind these campaigns (Ad Council, MADD, RID, etc.) and none of the meta-analyses dealing with this well-researched issue would mention them.
posted by klangklangston at 6:19 PM on February 19, 2016
Just like gaydar, I'm going to go with my junkie-dar being reliable more often than not. Signs include: Repeatedly coming to work too fucked up to work, leaving a photo shoot for four hours to cop, having more than one ambulance-level OD, nodding off in the bathroom with a needle in their arm… (Likewise, if you try to sell me your mother's toilet, and when I decline, ask me if you can just have some money for crack — true story — I'm going to assume that it's now fair to call you a crackhead.)
I mean, point taken about the wide variety of other things that can be going on when someone looks like they may be substance-dependent and anti-social — I used to manage a group of magazine distributors who I know my friends thought were likely all drunks and junkies, and most of them weren't and were unfairly judged. And it was the most respectable looking one of them who stole the company van and went on a three-week crack bender.
I know that you've got reams more experience working with addicts than I do, but, again, I've had enough experience that I feel pretty OK setting some pretty firm boundaries.
"Also, actually the drunk driving campaigns involving stigmatizing drunk drivers were one of the biggest public health successes ever— drunk driving has dropped by more than half since they were introduced. The secret is shaming the *drunk driving* not the drinking and creating roles like "designated driver" that give people a legit reason not to drink while allowing their friends a safe way to get home."
Sorry, that's post hoc ergo propter hoc. The evidence just isn't there for the PSAs, and the statistics cited by the Ad Council et al. are misleading at best. Drunk driving has declined — how much did stigmatization campaigns contribute compared to other factors? Not very much.
Effectiveness of Mass Media Campaigns forReducing Drinking and Driving and Alcohol-InvolvedCrashes: A Systematic Review. (Elder, American Journal of Preventative Medicine, 2004) found that while the contribution was economically justified, the median supportable contribution to alcohol-involved driving collision reduction was 13%, with campaigns that focused on fear of enforcement being more effective than social appeals.
A 2015 review in BMC Public Health A systematic review: effectiveness of mass media campaigns for reducing alcohol-impaired driving and alcohol-related crashes (Yadav, BMC Public Health, 2015 concluded that current literature did not show reductions in alcohol-related fatalities. Worth noting is that the less rigorous the methodology, in general, the bigger the impact claimed bigger results.
The best support for the argument that shame and stigma-based campaigns work is "Reduction in Drunk Driving as a Response to Increased Threats of Shame, Embarrassment and Legal Sanction" by Harold Grasmick, Robert Bursik and Bruce Arneklev (Criminology, v. 31, 1, 1993), which finds a significant impact of private moral beliefs (shame — compared to public morals, or embarrasment, and legal sanction) on the self-reported incidence of drunk driving and the future likelihood of driving drunk. But while Grasmick et al. linked those self-reported beliefs to a decrease in Oklahoma City drunk driving fatalities, further study has undermined the link between self-reported behavioral preferences and fatality outcomes ("Drink-Driving and DUI Recidivists’Attitudes and Beliefs: A Longitudinal Analysis," Greenberg, J. Stud. Alcohol 66: 640-647, 2005), which found that while they are a factor in preventing recidivism, DUI offenders rated the probability of friends disapproving as less a concern than their own perception of the morality of DUI, and a higher score in social desirability (meaning, they cared more what their peers thought of them) made them more likely to reoffend, not less.
The Gramsick studies were all prior ti 1990, when the Ad Council started running the "Friends don't let friends" ad campaigns, and while alcohol-involved fatal collisions were decreasing, they had a more dramatic drop afterwards. Maybe that's evidence?
"Evaluating the Effectiveness of Policies Related to Drunk Driving" (Eisenberg, Journal of Policy Analysis and Management, Vol. 22, No. 2, 249–274 [2003]) finds that almost all of the change came from shifts in per se BAC laws, first to .10, then .08, with the National Highway Safety Administration's Statistical Analysis of Alcohol-Related Driving Trends, 1982-2005 putting most of the rest of the decrease down to shifting demographic trends — the US was older, drivers were less male, and the economic situation had dramatically worsened during the largest drop (which does correspond with decreases in alcohol-related fatalities, as more people drink at home and fewer are getting drinks after work).
And even if we're continuing with self-reported attitudes on drinking and driving, the NHTSA's 2008 "National Survey of Drinking and Driving Attitudes and Behaviors" found that the largest deterrent wasn't direct perception of social stigma, but rather a fear of crashing (similarly, a study in Spain found that fear of crashes was the number one contributor to a decision to not drink and drive). That supports the earlier "Drunk-Driving Research and Innovation: A Factorial Survey of the Study of Decisions to Drink and Drive," (Thurman, Social Science Research 22, 245-264, 1993), which found that while the general population reported being undeterred by legal consequences and more motivated by community response, the subsample of people who have admitted to drinking and driving previously, whether or not they were caught, were much more concerned about things like checkpoints and relatively unconcerned with peer reaction.
So, basically, the Ad Council's arguments, and arguments that the shaming and stigmatization campaigns have been some of the "biggest public health successes ever" are incredibly weak, at best. The studies that claim that they have the most effect are the weakest, with significant methodological flaws and very little correlation with underlying empirical data. Meta-analysis can only show that public health media campaigns — of all types stigma, fear, etc. — likely influenced public perception, and that public perception shifting has influenced the underlying behavior to a mild extent. What the meta-analysis makes much more likely is that the campaigns influenced decision makers — particularly state and federal lawmakers — and that those interactions had a much more dramatic effect on actually decreasing the incidence of drunk driving — there's a much better fit with the data based on shifts in BAC (which went state by state) than the Ad Council campaign, which was national.
Contrasting this with the efforts like the NHTSA’s High-Visibility Enforcement Impaired Driving Campaign in 2003, or 2006 National Labor Day Impaired Driving Enforcement Crackdown, which (along with similar, more local studies on roadblocks and media markets) can show a direct correlation with decreases in fatalities related to the public awareness of checkpoints, and the case for efficacy of stigma campaigns is incredibly thin.
That doesn't mean that public health campaigns are worthless, or that they aren't part of a broader intervention strategy — especially since the evidence strongly suggests that the utility of enforcement and legislative interventions is powerful but relatively short-lived and relatively costly. In theory, public health campaigns that shift attitudes can be much more durable and cheap per interaction.
"I don't know where you got the idea that they didn't work— but the data on drunk driving is pretty overwhelming and straightforward in terms of its decline since it went from being something that people laughed at but did anyway till it become seen as immoral."
The evidence that drunk driving has declined is pretty overwhelming, but the argument that this is caused by a stigmatization, or that stigmatization campaigns have been more effective than media campaigns that highlight risks (legal, financial, physical) is anything but.
Maybe I've missed some papers or something that supports this contention, but all of the research that I've seen that claims to support the notion of these campaigns has done so with either pretty transparently bunk Ad Council exposure numbers (recognition does not mean changing behavior), or with dubious college student self-reporting unconnected with any empirical data. It wouldn't be that hard to design a study to check message salience and behavioral effect (harder to fund, obvs.), but it seems like nobody's actually done so — or, as several meta-analyses point out, the publication bias implies that null or negative results are unlikely to get published.
Again, maybe you've got some great research that I've missed — it's not like I did a full lit review on this. But it would be odd if none of the people behind these campaigns (Ad Council, MADD, RID, etc.) and none of the meta-analyses dealing with this well-researched issue would mention them.
posted by klangklangston at 6:19 PM on February 19, 2016
Whether or not stigma works to control driving behaviour at a population level is orthogonal to the original point, which was that stigma is ineffective in changing decisions to begin, maintain, decrease, or stop substance use. Australia has some campaigns that seek to discourage substance misuse by talking about secondary negative behaviours - the one that comes to mind is the "Don't Turn a Night Out into a Nightmare" anti-binge-drinking campaign, which (tries to) motivate people to drink less by raising awareness of associations between binge drinking and increased risk of accidental injury, violence, unsafe sex, and social embarrassment - but all the evidence suggests that it works better to go at it the other way around, and to try to mitigate those secondary behaviours instead of using them to scare or shame people into avoiding substance use and misuse. (Note that there is minimal information about any plans to evaluate effectiveness of this bit of the National Binge Drinking Strategy.)
posted by gingerest at 7:12 PM on February 19, 2016 [2 favorites]
posted by gingerest at 7:12 PM on February 19, 2016 [2 favorites]
I'm not saying that the stigmatizing of drunk ***driving*** (not drinking!!!!) was the *only* factor in the massive drop in drunk driving deaths over the last few decades. But there was a huge increase in awareness that it was harmful, not funny— accompanied by increased enforcement, increased criminal penalties and lots of other stigmatizing stuff that makes me believe that stigma worked in this case BECAUSE IT WAS STIGMATIZING HARMFUL BEHAVIOR, NOT DRUG USE.
The vast majority of people with addiction DO NOT HAVE ANTISOCIAL PERSONALITY DISORDER (about 80% DO NOT) and they do not want to harm anyone. When you simultaneously tell them that drunk driving is harmful and that they can still drink and not do harm— they act accordingly.
Again, this is why your "addict-dar" is going to miss most people with addiction— you think you know what we look like, but you don't.
posted by Maias at 3:13 PM on February 20, 2016 [1 favorite]
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