NYT Takes on NH Opioid Problem
Jan. 21st, 2018 11:07 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
walkitoutGather Round, Dear Readers, because Walkitout is in the mood to tell a few stories.
When Walkitout was young, she grew up in what is now Shoreline, Washington, a "city" immediately north of the Seattle city limits. At the time, it was unincorporated King County, addressed as Seattle, and its zip code to this day begins 981, just like all the zip codes in Seattle. Her parents had moved there between offspring #2 and offspring #3, as part of White Flight in response to mandatory busing of children attending Seattle Public Schools. So when Walkitout says she grew up on racist imagination about Drug Infested Cities to the south and so forth, she isn't messing around.
Fortunately, Walkitout _did_ (eventually) grow up (it was a gradual and somewhat chaotic process), moved south into the Drug Infested City, and kept moving closer to the center of the Drug Infested City, and greatly enjoyed its walkability, mature trees, vibrant restaurants and bars. She was less happy about having to commute across the bridge to the Good Jobs in suburban office parks, but persisted in looking for Seattle employment and was mostly successful in finding it.
Upon retirement (and recovery from overwork), Walkitout was then presented with a conundrum: who was she if she no longer worked? Walkitout, um, walked. And then hiked, and then traveled around to other places to walk and hike and reconnect with friends. Eventually, Walkitout moved to New Hampshire and got married.
But before Offspring #1 arrived, Walkitout retained the problem of identity post-retirement (once there were kids on scene, identity questions took a back seat to more immediate and relentless demands on her time). In addition to walking and hiking, Walkitout took to volunteering at the local library in Mayberry, NH (<-- not its real name). Residents of Mayberry were adamant about not wanting things like sidewalks, because it would detract from the rural character of the town. They also often refused to travel to the state directly south of the town line, Massachusetts, because it was a den of Drug Dealers. Walkitout found this racist imagination to be quite hysterical, and to counter the not very realistic and at times unhinged bigotry (not always racial -- often ethnic, or rural vs urban) of her neighbors and friends, she loved to tell stories about fatal car accidents involving meth that occurred in the Granite State, particularly when they occurred in Mayberry or NH towns adjacent to Mayberry. Even better was the woman who accused a man of rape, but then it turned out to be a dispute arising from (illegal) services associated with her in-home "massage" business. Walkitout also got a real kick out of retelling the story of the dead guy found on the floor of a house in town (OD, obviously). (Walkitout tells people she doesn't have a sense of humor, because she correctly realized long ago that her sense of humor was deeply cruel and inappropriate. If we're being honest here, that's probably true of most humor).
Anyway, moved back to Seattle, then back to Mayberry, then down to the Drug Infested State to the South, to a town that not only has sidewalks, but a plan to add more, and has created a dial-a-ride/website reservation paratransit system that everyone can use, and is in the process of creating cross-town agreements with neighboring towns so that there is something resembling town-to-town public transit, along with the commuter rail station which was a compelling feature of her new home town. Walkitout still goes to book group in Mayberry, and dearly loves many of her friends in Mayberry, even tho they sometimes still say things like No One Would Pay $1 million for a condo in Brooklyn, NYC, that's a joke, right? Right?!? It's a Drug Infested City!?! Etc.
To be fair to Mayberry, early on in her time volunteering at the library, a lovely woman told Walkitout that the local high school had a significant problem with opioids. Walkitout insensitively laughed. She had grown up in the White Flight zone of unincorporated king county (if you don't have a city, you can't have city problems, right?), and remembered that there were always people talking about how drugs had infested her high school. And it is true. Drugs were present. But people really probably worried a lot more about those drugs and drug users than was really justified -- they probably should have worried more about the smoking, honestly. And the alcohol that killed several kids a year, usually near the end of their senior year. Including Walkitout's best friend's younger brother (he wasn't drinking, but someone else was and hit and killed him).
But Walkitout's friend in Mayberry wasn't wrong. Mayberry _did_ have a significant opioid problem, before it really even became trendy to have a significant opioid problem (overnight sensations usually take some time to really develop). And now, Mayberry, or at least NH's significant opioid problem has finally attracted the attention of the NYT.
I saw this go by first (I probably should warn you, if you haven't worked it out already, that this might be emotionally wrenching, if not outright triggering, to read):
https://www.nytimes.com/2018/01/21/us/opioid-addiction-treatment-families.html
Unsurprisingly, but conveniently noted in the article, the person with the cartoonish habit of OD'ing does in fact have borderline personality disorder. It is unfortunate that while individual members of the family have gone to Al Anon and learned some useful things there, that the family as a whole has not accessed / received / wtf the kind of therapeutic support and education which families whose member(s) has / have borderline personality disorder really need. Typical, but unfortunate.
I was really struck in this article by something that I have found to be more generally true. For all that this family has gone through -- much of the pain proximately caused by the son Patrick -- at least the article's author is committed to the idea that the family members still fear that Patrick might die / take his own life. Anyone wandering around thinking that Patrick actually dying would be a relief to his family is probably a little delusional. And I think this is more true than not, with this kind of mixture of substance abuse / personality disorder / etc. (So, Governor LePage, nuts to you! Along with everyone like LePage who thinks that the people who love and live with drug addicts would, as a group, be relieved by their abrupt passing. Really the exception rather than the rule.)
But NYT also published this:
https://www.nytimes.com/2018/01/21/us/new-hampshire-opioids-epidemic.html
"One big reason, they say, is the proximity to an abundant drug supply in neighboring Massachusetts, the center of drug distribution networks that traffic opioids throughout New England."
For some reason, this really made me chuckle. Because there is some place in this world that is NOT part of a drug distribution network? Somehow, I doubt that.
"Another, they say, is New Hampshire’s low per capita spending on services to help drug users break free from addiction. Nationally, the state, which has no income or sales tax, ranks at the bottom in availability of treatment programs. The fire departments’ safe stations are one effort to fill that void.
The researchers also noted that the state has pockets of “economic degradation,” especially in rural areas where jobs are few, and that may contribute to the problem.
Beyond that, the researchers say, doctors here have long prescribed “significantly higher rates” of opioid pain relievers, almost twice the national average. When the government cracked down on legal painkillers, New Hampshire residents were primed to seek out illegal street drugs."
This is a much more compelling explanation to me. But I still think they are missing a key feature of New Hampshire. New Hampshire has functionally two settlement patterns. One settlement pattern is fairly old: the last hangers on of extractive industry, and all the problems that come with the death of extractive industries. The other settlement pattern is the line of people along the southern border, who moved there because the taxes were lower and the houses were cheaper. Everyone (<-- hyperbole) in New Hampshire is politically opposed to government and taxation (the state was viewed by libertarians as a potential state to take over, at least at one point), and their perspective in terms of respecting laws of their neighbors is that of land pirates. They sell cigarettes and alcohol in Costco (sorry, Costco, but Sam's Club doesn't have the same ring to it) sized barns at rest stops where interstates run through the state, to help people in Connect the Dots, Taxachusetts and NY avoid their home states' high taxes on those items. While New Hampshire is refreshingly open minded in some ways, encouraging a really broad range of people to perceive themselves as part of the local norm, they are also appallingly unwilling to provide any kind of services to anyone at all who might need them. (Very, very late to game of Kindergarten, for example.) It's pretty normal to go to a bbq in NH and wind up listening to someone say we should get rid of social security and all welfare programs administered at the state and federal level, and just handle it at the family level. Everyone who actually needs services, say, when they are old or ill, goes somewhere else. If they have kids, they go to Massachusetts (that would be Walkitout, right here). If they are old, they retire to Maine.
This isn't a political and social environment that has any capacity to absorb any of the lessons of the therapeutic frame we have been developing over the last few decades. This is a will power, tough it out, personal responsibility, handle it locally, Don't Tell Us How to Do It kind of place.
I'm sorry for all the people who are suffering from the opioid epidemic. I'm _really_ sorry for all the people who have undiagnosed and/or un or under treated personality disorders. The first step for all of these problems is recognition that the problem is large, and a group problem, not an individual failing. The next step is to recognize that some approaches to this problem work better than others. The approaches that work better are ones that involve _sustained_ _outpatient_ treatment and support, and which provide education, therapy, respite, etc. to the family system, as well as to the "patient" (addict, victim, felon, wtf).
It's pretty unfair to blame this all on New Hampshire (Ohio, West Virginia, etc.). The rest of the country has benefited from extractive industries and then abandoned the places that we no longer need to extract from. And the people who can't afford to leave those places or who don't want to. People having difficulty in places that _do_ offer services often feel compelled to leave those places in search of a place that is cheaper, which makes places with fewer services more attractive -- and more of a trap.
I have no simple solution (duh). I'm a big believer in harm mitigation -- I worked at a place across the street from a needle exchange, and as weird and occasionally terrifying as that was, I still believe in harm mitigation. In addition to the therapeutic network which will help someone to enjoy life unmedicated enough to reduce the temptation to OD, we're going to need to do a lot more harm mitigation around fentanyl.
https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0153-2
My walking partner heard coverage of this approach on Fresh Air:
https://www.npr.org/2018/01/08/576457029/could-prescription-heroin-and-safe-injection-sites-slow-the-opioid-crisis
Obviously, universal health insurance or any step in that direction, with mandated inclusion of mental health and substance abuse services, is an important part of the solution. There is also a useful role to be played by the free market (if someone can make money with outpatient rehab, that'd be awesome -- but only if it really works) and by faith communities and services like Al-Anon. Law enforcement will also play a role in disrupting networks of distribution, but it will probably do its job better with more legalization / decriminalization so we can quit spreading these problems through incarceration. And we really, really, really are not going to make outpatient and diversion programs work without meaningful surveillance.
When Walkitout was young, she grew up in what is now Shoreline, Washington, a "city" immediately north of the Seattle city limits. At the time, it was unincorporated King County, addressed as Seattle, and its zip code to this day begins 981, just like all the zip codes in Seattle. Her parents had moved there between offspring #2 and offspring #3, as part of White Flight in response to mandatory busing of children attending Seattle Public Schools. So when Walkitout says she grew up on racist imagination about Drug Infested Cities to the south and so forth, she isn't messing around.
Fortunately, Walkitout _did_ (eventually) grow up (it was a gradual and somewhat chaotic process), moved south into the Drug Infested City, and kept moving closer to the center of the Drug Infested City, and greatly enjoyed its walkability, mature trees, vibrant restaurants and bars. She was less happy about having to commute across the bridge to the Good Jobs in suburban office parks, but persisted in looking for Seattle employment and was mostly successful in finding it.
Upon retirement (and recovery from overwork), Walkitout was then presented with a conundrum: who was she if she no longer worked? Walkitout, um, walked. And then hiked, and then traveled around to other places to walk and hike and reconnect with friends. Eventually, Walkitout moved to New Hampshire and got married.
But before Offspring #1 arrived, Walkitout retained the problem of identity post-retirement (once there were kids on scene, identity questions took a back seat to more immediate and relentless demands on her time). In addition to walking and hiking, Walkitout took to volunteering at the local library in Mayberry, NH (<-- not its real name). Residents of Mayberry were adamant about not wanting things like sidewalks, because it would detract from the rural character of the town. They also often refused to travel to the state directly south of the town line, Massachusetts, because it was a den of Drug Dealers. Walkitout found this racist imagination to be quite hysterical, and to counter the not very realistic and at times unhinged bigotry (not always racial -- often ethnic, or rural vs urban) of her neighbors and friends, she loved to tell stories about fatal car accidents involving meth that occurred in the Granite State, particularly when they occurred in Mayberry or NH towns adjacent to Mayberry. Even better was the woman who accused a man of rape, but then it turned out to be a dispute arising from (illegal) services associated with her in-home "massage" business. Walkitout also got a real kick out of retelling the story of the dead guy found on the floor of a house in town (OD, obviously). (Walkitout tells people she doesn't have a sense of humor, because she correctly realized long ago that her sense of humor was deeply cruel and inappropriate. If we're being honest here, that's probably true of most humor).
Anyway, moved back to Seattle, then back to Mayberry, then down to the Drug Infested State to the South, to a town that not only has sidewalks, but a plan to add more, and has created a dial-a-ride/website reservation paratransit system that everyone can use, and is in the process of creating cross-town agreements with neighboring towns so that there is something resembling town-to-town public transit, along with the commuter rail station which was a compelling feature of her new home town. Walkitout still goes to book group in Mayberry, and dearly loves many of her friends in Mayberry, even tho they sometimes still say things like No One Would Pay $1 million for a condo in Brooklyn, NYC, that's a joke, right? Right?!? It's a Drug Infested City!?! Etc.
To be fair to Mayberry, early on in her time volunteering at the library, a lovely woman told Walkitout that the local high school had a significant problem with opioids. Walkitout insensitively laughed. She had grown up in the White Flight zone of unincorporated king county (if you don't have a city, you can't have city problems, right?), and remembered that there were always people talking about how drugs had infested her high school. And it is true. Drugs were present. But people really probably worried a lot more about those drugs and drug users than was really justified -- they probably should have worried more about the smoking, honestly. And the alcohol that killed several kids a year, usually near the end of their senior year. Including Walkitout's best friend's younger brother (he wasn't drinking, but someone else was and hit and killed him).
But Walkitout's friend in Mayberry wasn't wrong. Mayberry _did_ have a significant opioid problem, before it really even became trendy to have a significant opioid problem (overnight sensations usually take some time to really develop). And now, Mayberry, or at least NH's significant opioid problem has finally attracted the attention of the NYT.
I saw this go by first (I probably should warn you, if you haven't worked it out already, that this might be emotionally wrenching, if not outright triggering, to read):
https://www.nytimes.com/2018/01/21/us/opioid-addiction-treatment-families.html
Unsurprisingly, but conveniently noted in the article, the person with the cartoonish habit of OD'ing does in fact have borderline personality disorder. It is unfortunate that while individual members of the family have gone to Al Anon and learned some useful things there, that the family as a whole has not accessed / received / wtf the kind of therapeutic support and education which families whose member(s) has / have borderline personality disorder really need. Typical, but unfortunate.
I was really struck in this article by something that I have found to be more generally true. For all that this family has gone through -- much of the pain proximately caused by the son Patrick -- at least the article's author is committed to the idea that the family members still fear that Patrick might die / take his own life. Anyone wandering around thinking that Patrick actually dying would be a relief to his family is probably a little delusional. And I think this is more true than not, with this kind of mixture of substance abuse / personality disorder / etc. (So, Governor LePage, nuts to you! Along with everyone like LePage who thinks that the people who love and live with drug addicts would, as a group, be relieved by their abrupt passing. Really the exception rather than the rule.)
But NYT also published this:
https://www.nytimes.com/2018/01/21/us/new-hampshire-opioids-epidemic.html
"One big reason, they say, is the proximity to an abundant drug supply in neighboring Massachusetts, the center of drug distribution networks that traffic opioids throughout New England."
For some reason, this really made me chuckle. Because there is some place in this world that is NOT part of a drug distribution network? Somehow, I doubt that.
"Another, they say, is New Hampshire’s low per capita spending on services to help drug users break free from addiction. Nationally, the state, which has no income or sales tax, ranks at the bottom in availability of treatment programs. The fire departments’ safe stations are one effort to fill that void.
The researchers also noted that the state has pockets of “economic degradation,” especially in rural areas where jobs are few, and that may contribute to the problem.
Beyond that, the researchers say, doctors here have long prescribed “significantly higher rates” of opioid pain relievers, almost twice the national average. When the government cracked down on legal painkillers, New Hampshire residents were primed to seek out illegal street drugs."
This is a much more compelling explanation to me. But I still think they are missing a key feature of New Hampshire. New Hampshire has functionally two settlement patterns. One settlement pattern is fairly old: the last hangers on of extractive industry, and all the problems that come with the death of extractive industries. The other settlement pattern is the line of people along the southern border, who moved there because the taxes were lower and the houses were cheaper. Everyone (<-- hyperbole) in New Hampshire is politically opposed to government and taxation (the state was viewed by libertarians as a potential state to take over, at least at one point), and their perspective in terms of respecting laws of their neighbors is that of land pirates. They sell cigarettes and alcohol in Costco (sorry, Costco, but Sam's Club doesn't have the same ring to it) sized barns at rest stops where interstates run through the state, to help people in Connect the Dots, Taxachusetts and NY avoid their home states' high taxes on those items. While New Hampshire is refreshingly open minded in some ways, encouraging a really broad range of people to perceive themselves as part of the local norm, they are also appallingly unwilling to provide any kind of services to anyone at all who might need them. (Very, very late to game of Kindergarten, for example.) It's pretty normal to go to a bbq in NH and wind up listening to someone say we should get rid of social security and all welfare programs administered at the state and federal level, and just handle it at the family level. Everyone who actually needs services, say, when they are old or ill, goes somewhere else. If they have kids, they go to Massachusetts (that would be Walkitout, right here). If they are old, they retire to Maine.
This isn't a political and social environment that has any capacity to absorb any of the lessons of the therapeutic frame we have been developing over the last few decades. This is a will power, tough it out, personal responsibility, handle it locally, Don't Tell Us How to Do It kind of place.
I'm sorry for all the people who are suffering from the opioid epidemic. I'm _really_ sorry for all the people who have undiagnosed and/or un or under treated personality disorders. The first step for all of these problems is recognition that the problem is large, and a group problem, not an individual failing. The next step is to recognize that some approaches to this problem work better than others. The approaches that work better are ones that involve _sustained_ _outpatient_ treatment and support, and which provide education, therapy, respite, etc. to the family system, as well as to the "patient" (addict, victim, felon, wtf).
It's pretty unfair to blame this all on New Hampshire (Ohio, West Virginia, etc.). The rest of the country has benefited from extractive industries and then abandoned the places that we no longer need to extract from. And the people who can't afford to leave those places or who don't want to. People having difficulty in places that _do_ offer services often feel compelled to leave those places in search of a place that is cheaper, which makes places with fewer services more attractive -- and more of a trap.
I have no simple solution (duh). I'm a big believer in harm mitigation -- I worked at a place across the street from a needle exchange, and as weird and occasionally terrifying as that was, I still believe in harm mitigation. In addition to the therapeutic network which will help someone to enjoy life unmedicated enough to reduce the temptation to OD, we're going to need to do a lot more harm mitigation around fentanyl.
https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0153-2
My walking partner heard coverage of this approach on Fresh Air:
https://www.npr.org/2018/01/08/576457029/could-prescription-heroin-and-safe-injection-sites-slow-the-opioid-crisis
Obviously, universal health insurance or any step in that direction, with mandated inclusion of mental health and substance abuse services, is an important part of the solution. There is also a useful role to be played by the free market (if someone can make money with outpatient rehab, that'd be awesome -- but only if it really works) and by faith communities and services like Al-Anon. Law enforcement will also play a role in disrupting networks of distribution, but it will probably do its job better with more legalization / decriminalization so we can quit spreading these problems through incarceration. And we really, really, really are not going to make outpatient and diversion programs work without meaningful surveillance.