Our bro­ken so­ci­ety is driv­ing over­doses

Never mind the ‘war on drugs’ or putting all the blame on phar­mas. An epi­demic of ad­dic­tion ex­ists be­cause peo­ple live with­out hope

The Guardian Weekly - - Comment & Debate - Marc Lewis

The No 1 killer of Amer­i­cans un­der the age of 50 isn’t can­cer, or heart at­tack or road traf­fic ac­ci­dents. It’s opi­ate over­doses. They have quadru­pled since 1999. More than 52,000 Amer­i­cans died from drug over­doses last year. Even in the UK, where il­le­gal drug use is on the de­cline, over­dose deaths are peak­ing, hav­ing grown by 10% from 2015 to 2016 alone. The “war on drugs” con­tin­ues – but it’s a war we’re los­ing.

Most drug-re­lated deaths re­sult from the use of opi­oids, the mol­e­cules that are mar­keted as painkillers by phar­ma­ceu­ti­cal com­pa­nies and heroin by drug lords. Opi­oids bond with re­cep­tors all over our bod­ies. These evolved to pro­tect us from panic, anx­i­ety and pain – a con­sid­er­ate move by the oft-cal­lous forces of evo­lu­tion. But the gen­tle im­pact of nat­u­ral opi­oids, pro­duced by our own bod­ies, re­sem­bles a sum­mer breeze com­pared to the hur­ri­cane of phys­i­o­log­i­cal dis­rup­tion caused by drugs de­signed to mimic their func­tion.

Most street opi­ates (in­clud­ing heroin) are laced or re­placed with fen­tanyl – the drug that killed the singer Prince – and its ana­logues, far more pow­er­ful than heroin and so cheap that drug-deal­ing prof­its are sky­rock­et­ing at about the same rate as over­dose deaths. The UK’s Na­tional Crime Agency said that traces of fen­tanyl have been found in 46 peo­ple who died this year. Users don’t know what they’re get­ting and they take too much. Fen­tanyl is a pri­mary driver of the over­dose epi­demic.

So­ci­ety’s re­sponse has been un­der­stand­ably des­per­ate but gen­er­ally wrong­headed. We start by blam­ing ad­dicts. Then we blame the phar­ma­ceu­ti­cal com­pa­nies for de­vel­op­ing and mar­ket­ing painkillers. We blame doc­tors, for over­pre­scrib­ing opi­ates, which pres­sures them to un­der­pre­scribe, which drives pa­tients to street drugs – cheaper, with home de­liv­ery avail­able via the in­ter­net, and zero qual­ity con­trol. We say we’re go­ing to reignite the war on drugs, recog­nised by ex­perts as a colos­sal fail­ure from the 1930s on­ward. We also con­tinue to view ad­dic­tion as a chronic brain dis­ease, so the ben­e­fits of ed­u­ca­tion, so­cial sup­port and psy­cho­log­i­cal in­ter­ven­tion re­ceive far too lit­tle at­ten­tion. Yes, ad­dic­tion in­volves brain change, but con­tin­ual med­i­cal­i­sa­tion does lit­tle to beat it.

There has been some progress: there are pock­ets of ac­tiv­ity where pre­scribed opi­ates – like methadone – are made more eas­ily avail­able to ad­dicts. That’s a good thing, be­cause in­creas­ingly des­per­ate ad­dicts are of­ten driven to the street, where they’re most likely to die. The avail­abil­ity of nalox­one, which works as an an­ti­dote, is slowly wend­ing its way through the drug pol­icy jun­gle. But in most seg­ments of most com­mu­ni­ties in the US and else­where, it is still too dif­fi­cult to at­tain.

There are smarter an­swers at hand – but also smarter ques­tions. This epi­demic com­pels us to stop blam­ing the play­ers and start look­ing at the source of the prob­lem. What does it feel like to be a youngish hu­man grow­ing up in the early 21st cen­tury? Why are we so stressed out that our in­ter­nal sup­ply of opi­oids isn’t enough?

Opi­oids are unique. The opi­oid sys­tem evolved to al­low us to func­tion, not panic or shut down, when we are un­der threat or in pain. That’s why opi­ates work so well as painkillers. Sup­port from other hu­mans also helps us cope with stress, but that sup­port is un­der­pinned by opi­oids too. Our at­tach­ment to oth­ers, whether in friend­ship, fam­ily or ro­mance, re­quires opi­oid me­tab­o­lism so that we can feel the love. Opi­oids grant us a sense of safety when we con­nect with each other.

You get opi­oids from your own brain stem when you get a hug. Mother’s milk is rich with opi­oids, which says a lot about the chem­i­cal foun­da­tion of mother-child at­tach­ment. When rats get an ex­tra dose of opi­oids, they in­crease their play with each other, even tickle each other. And when ro­dents are al­lowed to so­cialise freely they vol­un­tar­ily avoid the opi­ate-laden bot­tle hang­ing from the bars of their cage. They’ve al­ready got enough.

In short, mam­mals need opi­oids to feel safe and to trust each other. So what does it say about our life­style if our nat­u­ral sup­ply isn’t suf­fi­cient and so we risk our lives to get more? It says we are stressed, iso­lated and un­trust­ing. That’s a prob­lem we need to re­solve. Many have pro­posed tar­geted ed­u­ca­tion, com­mu­nity sup­port and in­ter­per­sonal bond­ing through group ac­tiv­i­ties. Jo­hann Hari’s pow­er­ful book, Chas­ing the Scream, re­views how such ini­tia­tives have worked in di­verse so­ci­eties. An in­trigu­ing ex­am­ple is the com­pas­sion­ate, blame-free di­a­logue that has evolved among high school stu­dents in Por­tu­gal, high­light­ing the dan­gers of hard drugs and urg­ing the most vul­ner­a­ble to ab­stain – not be­cause they’re go­ing to get in trou­ble, but be­cause ad­dic­tion is dan­ger­ous. This di­a­logue has par­al­leled the de­crim­i­nal­i­sa­tion of drug use.

Por­tu­gal had an as­tound­ingly high heroin ad­dic­tion rate 16 years ago. It now boasts the sec­ond-low­est over­dose rate on the con­ti­nent. So­cial in­clu­sion ac­tu­ally works against ad­dic­tion while pun­ish­ment only fu­els it.

But the pe­cu­liar ap­peal of opi­oids tells us more about our­selves as a so­ci­ety than the tu­mul­tuous ups and downs of ad­dic­tion sta­tis­tics. To­day’s young peo­ple carve out their adult lives in an en­vi­ron­ment of as­tro­nom­i­cal un­cer­tainty. Cor­po­ra­tions that used to pride them­selves on gen­eros­ity to their em­ploy­ees now strive only for profit. Mas­sive lay­offs ra­tio­nalised by glob­al­i­sa­tion make long-term con­tracts pre­his­toric relics. I ask the guys who come to the house to de­liver pack­ages how they like their jobs. They can’t say. They get up to three six-month con­tracts in a row and then get laid off so the com­pany won’t have to pay them ben­e­fits.

The op­por­tu­nity to set­tle into a vi­able niche in one’s fam­ily and one’s so­ci­ety is be­ing blown away by the winds of un­reg­u­lated cap­i­tal­ism. As for the in­ti­macy and trust we hu­mans have al­ways sought in each other, the bonds are shaky. Ur­ban life re­quires jug­gling high­stress re­la­tion­ships past the point of ex­haus­tion.

We can build so­cial struc­tures that en­cour­age sta­bil­ity, hope and trust in our day-to-day lives. Like the schoolkids in Por­tu­gal, we can of­fer com­pas­sion and in­clu­sion as an im­prove­ment over heroin. If we fail to do that, we may as well hook our­selves up to an opi­oid pump. Just to en­dure.

Marc Lewis is a neu­ro­sci­en­tist and au­thor of The Bi­ol­ogy of De­sire: Why Ad­dic­tion Is Not a Dis­ease

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