Overdose Deaths: Not an Epidemic or a Crisis, and Not by Accident

By Bayla Ostrach MA PhD, Virgil Hayes MSW 10/23/19

Overdoses are not mysterious, they result from predictable causes like criminalizing drug use, ineffective policies, poverty, lack of stable housing, and persistent racism.

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Prison with cells on either side of a walkway.
An increase in overdose deaths is not the result of society’s inability to get tough on crime. ID 88791339 © Kristin Baalman | Dreamstime.com

Opioid-related overdoses are not a crisis or an epidemic, and should not be described as either. Both words stigmatize the victims of a phenomenon that is not happening by accident. Such overdoses have been steadily increasing throughout the United States and are especially high in Appalachia (where we both work). Yet overdoses are not a natural or mysterious phenomenon. They result primarily not from individual, but from larger structural factors — criminalization of drug use, ineffective social policies, poverty, lack of stable housing, historical and persistent racism, and other forms of systemic oppression — which are all the result of deliberate policy decisions.

We are told by the media, CDC, and state governments that the region where we live and work is ground zero for a drug "crisis." Yet those same entities contribute to the problem through policies, funding allocations, and covering-up of underlying systemic causes. We must shift our language to reflect this. Substance use and overdose happen in predictable contexts and disproportionately affect marginalized communities.

Terms Like "Epidemic" and "Crisis" Cause Alarm and Hysteria, Stigmatizing People Who Deserve Compassion

More than 67,000 people in the United States died from opioid-related overdose in 2018. Alarmist headlines, even well-intended reports, do not justify an inaccurate framing. We advocate instead for the use of the term impact, or other language that indicates the underlying roots of suffering, instead of epidemic or crisis.

Epidemic is most accurately used to describe infectious or viral spread of a disease within a population over a short period of time. Substance use, even for the relatively low 18% of people who use "chaotically," does not meet this criteria. People who overdose or suffer negative consequences of substance use may be more socially or genetically vulnerable to a substance use disorder but in basic epidemiological principles, that does not an epidemic make. Calling structural violence that leads to specific overdose patterns an epidemic or a crisis feeds into a hysteria that marginalizes drug users and their loved ones. Both words take the focus away from the underlying causes of suffering; naturalizing it and leaving the conversation at a surface level without motivating real change. 

We both work in and study harm reduction and overdose prevention in North Carolina: a microcosm of opioid-related deaths and specific patterns of suffering repeated elsewhere in Appalachia and throughout the country. Daily, we observe the dynamics of economic policies, limited healthcare access, and stigmatization that impact people already at greater risk for substance use and overdose. Later in this essay we discuss how it plays out in North Carolinians’ overdose risks — making it more likely they and their loved ones will be blamed if they do.

How Misguided Drug Policies Blame the Victims While Ignoring the Causes

Like the thousands of lives lost to fentanyl poisoning in the context of increased drug use criminalization today, there was nothing natural about the thousands of lives lost to alcohol poisoning during prohibition a century ago; or the increase in deaths and drug-related arrests that ravaged inner-cities during the government-manufactured "crack era" of the 80s and 90s. Consequences of drug use, like mass incarceration, have never been a natural disaster. Instead, policy responses to drug use tend to create systemic storms that rage in vulnerable communities. This is a classic example of blaming the victims of problems while ignoring the causes.

If a "crisis" is happening to those around you, you may feel bad for them, you may vote for a politician who promises to address it — but you probably won’t ask how the same politicians or political system contributed to creating it, or how arresting and jailing poor and Black and Brown people will fail to fix it. Overdose deaths in the U.S. have always been both a symptom and outcome of discriminatory policies

Suffering is further exacerbated by punitive policies such as drug-induced homicide laws that increase overdose deaths, weaken Good Samaritan legislation intended to reduce overdose, and criminalize drug users and their loved ones. For example, opioid de-prescribing mandates in 19 states appear to result in an increase in heroin overdose deaths. And, healthcare policy is an oft-overlooked aspect of overdose prevention -- states that did not expand Medicaid (which increases coverage of treatment) are disproportionately states with higher overdose and substance use.

Mainstream media portrays sympathetic stories of the middle-class sons and daughters of urban politicians dying of overdose, while the stigmatized partners and friends of poor Appalachians who disproportionately die of overdose from drugs often laced with fentanyl fear being arrested under ‘drug-induced homicide’ and ‘death by distribution’ laws if they call 911. The ways that drug users are talked about serve political agendas that further contribute to patterns of suffering.

We must acknowledge and address what is missing, obscured, and ignored when we promote an inaccurate framing of drug use as a "crisis" or "epidemic," rather than something caused by policy decisions. Who is disproportionately blamed? Who is left out of the conversation? 

When we fail to address how a combination of economic, political, biological, behavioral, genetic, and social factors intersect within the lives of drug users and their wider communities, we legitimize the use of simplistic and punitive approaches to complex issues. Where we live and work, North Carolina policy makers used the 2016-2017 increase in drug overdose deaths to justify an argument for harsher punishments despite a wealth of research that shows that such approaches increase the very health consequences they claim to reduce. Further, these approaches do nothing to address economic disparities in North Carolina, which continues to experience greater rates of every form of poverty than most of the nation, despite the so-called recovery. They do nothing to address the lack of Medicaid expansion or limited employment and economic growth — all upstream drivers of overdose and suffering.

Simply put, an increase in overdose deaths is not the result of society’s inability to get tough on crime, or even the need for more biomedical treatment. Rather, overdose deaths persist due to an unwillingness to acknowledge that treatment expansion and more or harsher punishment fail to address gaping social wounds

Communication: Start Using Language That Reveals the Roots of Unequal Suffering

As long as policymakers, politicians, and journalists continue to use inaccurate terms like “opioid crisis/epidemic,” opportunities are missed to discuss and address the causes and effects of substance use and overdose. We advocate for talking instead about “opioid impact” or “overdose impact.” A more neutral term like impact is less stigmatizing and hyperbolic, and thus less marginalizing for those directly affected. Impact is also more flexible — not all drug use is harmful, nor leads to substance use disorder, illness, or overdose. Impact is a more accurate and flexible term to allow for discussion of people’s lived experiences with substances.

Even so, it may not go far enough. As a parallel example, public pressure and justice-oriented advocacy shifted public conversation and journalistic style from talking about human beings as “illegal” to “undocumented.” But referring to these same folks as “economic refugees” would be even more accurate and less stigmatizing. Similarly, impact is a more useful term than "crisis" or "epidemic" when referring to patterns of opioid-related overdose and substance use-related illness. And, terminology that clearly unmasks the deeper roots of unequal suffering would be even better.

A person using drugs is not a disease vector nor the precipitator of a crisis. What we witness in communities like Philadelphia, Austin, and Asheville are not drug-related epidemics or naturally occurring crises. The harms impacting these communities are symptoms of destructive social policies that ensure the most vulnerable populations remain vulnerable, shamed, and disproportionately suffering from the very problems for which they are blamed. 

So where do we go from here? We can start by answering this with another question: How might our conversations, and thus policy and response efforts change, if we use language that reveals the structural roots of suffering instead of further contributing to stigma and hysteria that shames the people who are most directly affected?

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Bayla Ostrach, MA, PhD is a harm reduction and substance use researcher in Western North Carolina, including as a Community Research Liaison for the Steady Collective. Bayla is appointed faculty in Family Medicine and Medical Anthropology at Boston University School of Medicine. 

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Virgil Hayes, MSW is a harm reductionist newly hired as the Manager of Drug User Health for NASTAD. Until recently Virgil worked as the Advocacy Coordinator for the North Carolina Harm Reduction Coalition.

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