Saturday, February 25, 2012

Is the medicalization of addiction benign?

      I've been revisiting my dissertation for a book project.  Here are some of my conclusions based on my analysis of buprenorphine, a pharmaceutical treatment for opioid dependence.
Elizabeth Pisani (2008) in The Wisdom of Whores argues that a substantial portion of the funding devoted to HIV/AIDS is wasted on ineffective programming because science and good public health policy are trumped by politics, ideology, and "morality."  The same is true for current U.S. drug policies.  As my analysis of the social construction of bup has illustrated, the current classification of drugs as legal or illicit is at best irrational and at worst driven by racism (Mosher & Yanagaisako 1991).  In a culture that is increasingly medicalized and pharmaceuticalized, problematizing all “non-medical” use of substances will further exacerbate our already unjust and ineffective policy responses to drug use. 
            The use of illicit drugs is spread throughout society fairly evenly, but the harm that results from them and our responses to them are not.  Legal drugs, in fact, cause far more social and health problems than illicit ones (Mosher & Yanagaisako 1991), and our response to illicit drugs (arrest and incarceration) causes profound harm to individuals, families and communities (Global Commission on Drug Policy 2011).  One the face of it, medical approaches to drug use seem kinder and more benevolent than criminal justice approaches.  But, as I have argued, one does not preclude the other; both have and will continue to co-exist.  It seems increasingly likely that some drug users will be treated medically, and others will be locked up, escalating rather then diminishing the racial disparities that characterize U.S. drug policy.  Moreover, I have also argued that medicalized approaches do not necessarily reduce individual blame or stigma but rather merely cloak moralistic arguments in the language of science.  More perniciously, medicalized approaches, especially neuroscientific ones, radically individualize the problem of drugs and erase the effects of social factors, like racism and poverty.
            We need a drug policy that recognizes the role that racism, poverty and the lack of opportunity play in fostering drug use and our responses to it and works to resolve them.  Medicalization mutes racism and inequality and then blames individuals for not being able to overcome them.  Instead of isolating and blaming those who use drugs, we need to restore communitarian responses that will help all people lead lives of dignity.
            In addition to working towards building strong, vibrant communities where everyone has the opportunity to thrive, we need a drug policy that rationalizes our approach to substances, not arbitrarily judging them legal or illicit, but helping individuals understand the real risks and benefits each poses. To the extent that we want to control and limit the use of some substances, we should focus on the real harm they cause, not our irrational and/or racist fears about particular substances.  Imagine a drug policy where there are not arbitrary lines between bup, Oxycontin, methadone and heroin --  making some demon drugs that lead to incarceration and some cures to that same addiction.  Imagine a drug policy that does not draw a distinction between “medical” marijuana and “illicit” marijuana but simply explains the benefits and risk of marijuana use and trusts that people can make informed decisions about their own embodied experiences and health.  We believe that most people can moderately consume alcohol, Oxycontin, and Prozac without the threat of arrest.  Why not some opioids?  Imagine instead of stigma, fear, ambiguity and confusion, we offered information and support for whichever substance (or no substance at all) helps people.
            The features of buprenorphine that helped people in my study the most were its legality and availability, the autonomy it gave it them over their own drug use and treatment, and its relative freedom from stigma.  These qualities can and should guide or drug policies.  But our drug policies must also include a commitment to understanding and dismantling systemic forms of oppression, racism, and inequality and to challenging neoliberal efforts to undermine communitarian responses to social problems.
Image source: Students for Sensible Drug Policy (

Thursday, February 9, 2012

Daily Show's Asaf Mandi Reveals Drug Testing Hypocrisy

In case you thought we were done using drugs to stigmatize poor people, check out this great video from the Daily Show illustrating the hypocrisy of proposals, like the one in Florida, to require a urine tox screen to get public assistance.

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Sunday, February 5, 2012

Mass Incarceration

I recently worked on a literature looking at some of the great work being done trying assess the impact of our policies of locking up millions of Americans.  I thought I would share it here.

The Scope of the Problem
The scale of incarceration in the U.S. is without historical precedent. More than 1 in every 100 adults (2.3 million people) in the U.S is behind bars. The proportion of Americans incarcerated has increased by 300% since 1980, and the U.S. now has the highest incarceration rate in the world (Pew Charitable Trusts, 2010).  In New York under the Rockefeller Drug Laws, the incarceration rate quintupled from 73 prisoners per 100,000 resident in 1973 to 386 per 100,000 in 2007 (Drucker, 2011).  In 2010 alone, more than 437,000 New Yorkers were arrested.  The vast majority of these arrests were for “quality of life” offenses.  For instance, in the South Bronx, only 3% of convictions were for felonies (Drucker, 2011).  Nonetheless, even brief encounters with the criminal justice system can have profound consequences, such as the loss of jobs and housing, disruptions in school and health care, deportation, and losing custody of children.  While the toll on individuals is profound, what is often lost in discussions about incarceration and reentry is the cumulative effect and burden mass incarceration places on entire communities.
The impact of mass incarceration is concentrated in communities of color.  If whites were incarcerated at the same rates as blacks, more than six million men -- 5% of the male working age-population -- would be in prison (Wakefield, 2010).  One in three young Black men (ages 20-34 years) without a high school diploma is incarcerated (Pew Charitable Trusts, 2010).  An analysis by the Justice Mapping Center demonstrated that the vast majority of men sent prison come from a relatively few neighborhoods in New York City; fourteen community districts account for more than 50% of the men sent to prison from NYC, though they account for only 17% of the total adult male population (Justice Mapping Center, undated).  In some neighborhoods, like East Harlem, one in every 20 adult men is in prison (Moore, 2007).  These high rates of incarceration affect the same communities already dealing with soaring rates of unemployment, poverty and health disparities (Health disparities in New York City, 2004; Travis, McBride, & Solomon, 2005).
Some have suggested that these high rates of arrest and imprisonment in urban communities, amount to mass forced migration with concomitant population destabilization representing losses on the scale of epidemics or terrorist attacks (Drucker, 2011; Drucker, 2002; Thomas & Torrone, 2008).  Virtually all the people we incarcerate will be released and return to our communities.  In addition to the stigma of a criminal record and the damage to social networks that occurs during incarceration, many people reentering the community from prison face significant legal barriers to accessing health care, public housing and employment opportunities (Willmott & van Olphen, 2005; Iguchi, M.Y., 2005; Golembeski & Fullilove, 2008; Moore & Elkavich, 2008).  Rather than helping them fulfill their responsibilities to their families, contribute to their communities and the economy, and make restitution to their victims, our current system almost insures that they will fail at each of these.  In doing so, we weaken the health and economic vitality of some of our most fragile communities.  While the specific mechanisms by which incarceration and reentry from prison affect communities are poorly understood, there is increasing evidence that incarceration, especially when concentrated in particular communities, hurts the economy, destabilizes families and social networks, contributes to poor health, and decreases public safety.
Mass incarceration diminishes earning power and the labor force, exacerbates social inequality and poverty, and diverts resources from communities that need them most.
Before the recession, studies suggested that the unemployment rate for formerly incarcerated people one year post-release was as high as 60% (Drucker, 2011).  According to a report by the Pew Charitable Trusts, serving time reduces hourly wages for men by 11%; by age 48, the typical former inmate will have earned $179,000 less than if he had never been incarcerated (Pew Charitable Trusts, 2010).  Unfortunately, these ill effects extend to the 2.7 million children who have a parent behind bars.  Sixty-eight percent of incarcerated fathers were the primary source of income for their families (Travis & Waul, 2004).  Family income averaged over the years a father is incarcerated is 22% lower than the year before the incarceration, and family income remains 25% lower than it was even in the year after the father is released (Pew Charitable Trusts, 2010).  Moreover, parental income is a strong predictor of a child’s future economic mobility, suggesting that the economic impact of incarceration is multi-generational.  
Because incarceration is concentrated among men of color from particular neighborhoods, the economic impact in some communities is profound.  A labor force analysis that takes incarceration into account found that younger, less educated Black men are more likely to be incarcerated then employed (Pew Charitable Trusts, 2010).  Nationally, “the lost earnings associated with incarceration are equal to 6 percent of the total expected Hispanic male earnings and 9 percent of the total expected black male earnings (Pew Charitable Trusts, 2010: 12).”  Overall, increases in incarceration since 1980 have reduce the activity of young black men in the labor force by 3-5% according to one estimate (Clear, 2009). 
Based on analysis of national social science databases, Western and Pettit (2010) found that incarceration has become the core dynamic sustaining socio-economic inequality between whites and blacks because of the way it disproportionately disadvantages black men in terms of employability and lifelong earnings, while increasing single-parent households in communities of color (Clear, 2009).  Another economic analysis found that mass incarceration may help explain why poverty increased during the period of economic growth between 1980 and 2004; the authors concluded “had mass incarceration not occurred, poverty would have been decreased by more than 20%... this translates into several million fewer people in poverty had mass incarceration not occurred  (DeFina and Hannon, 2009).”
Finally, mass incarceration impacts the economy through the diversion of resources.  An estimated $70 billion is spent annually on corrections.  Researchers have identified several “million dollar blocks” in Brooklyn in which more than a million in taxpayer dollars is spent annually to incarcerate residents from each block (Spatial Information Design Lab, undated).  The reinvestment of these resources into these same neighborhoods could go a long way towards reducing crime, preventing incarceration, and rebuilding community.
Mass incarceration impacts the health of individuals and communities
Mass incarceration affects the health of communities in two primary ways.  First, research suggests that our current drug interdiction and deterrent strategies – which are concentrated in communities of color -- have serious consequences that adversely affect the health of communities, including increased violence (Mosher, J.F. and K.L. Yanagisako, 1991; Haden, 2004) and higher rates of HIV and other blood borne disease (Haden, 2004).  Although illegal drug use is spread throughout society, the harm from drug use and the war on drugs is not evenly distributed; drug-related overdose and homicide, traumatic injury, HIV/AIDS --  are all higher in communities of color and where income inequality is greatest (Mosher, J.F. and K.L. Yanagisako, 1991; Galea, S. and D. Vlahov, 2002).  Moreover, the criminalization of non-violent offenders contributes to the stigmatization of drug use, which in turn, discourages drug users from seeking needed services and negatively impacts their physical and mental health (Ahern, J., J. Stuber, and S. Galea, 2007; Young, M., et al, 2005).  Once convicted, those reentering the community from prison or jail do so facing a set of barriers that puts their health in extreme peril --  including leaving prison without Medicaid or other health coverage, the inability to secure housing or employment, and often returning to communities already challenged by poverty, poor health, and a lack of resources.
Second, as suggested above, incarceration contributes to existing social and economic inequalities, which are key determinants of health (Hathaway, 2001).  Incarceration disrupts social networks, undermines sources of social and financial support, impedes education, and contributes to homelessness and poverty --  all factors associated with poor health outcomes (London and Myers, 2006). 
Mass incarceration diminishes family and community stability and cohesion
Incarceration has profound collateral consequences for families and communities.  Nationally, 10% of all minor children have a parent in prison or jail or on probation or parole (Travis et al., 2005).  Studies suggest that parents try to stay in touch with their children but have difficulty because of distance, visiting rules, and restrictions on phone calls (Travis et al., 2005).  While the negative impact of incarceration on children can be mitigated by a number of factors, reviews of the literature suggest that the incarceration of a parent is associated with low self-esteem, depression, emotional withdrawal, disruptive behavior at home and school, poor school performance, higher rates of delinquency and arrest, illegal drug use, underemployment, and increased risk of abuse and neglect (Clear, 2009; Travis & Waul, 2004; Travis et al., 2005).  Most children are cared for by the remaining parent or placed with other family members when a parent is incarcerated, but 10% of children whose mothers are incarcerated and 2% of children whose father are incarcerated end up in foster care (Travis & Waul, 2004). 
This kind of disruption to families and social networks, when concentrated in particular communities, begins to undermine the social and family support structures that are especially vital in low-income communities (Drucker, 2011).  Increasingly, research shows that incarceration weakens ties to community, family, work and civic engagement (Willmott & van Olphen, 2005).  Todd Clear and colleagues (Clear, Rose, & Ryder, 2001) have done interesting analyses of how the spatial concentration of incarceration destabilizes informal networks of social control.  Their analysis suggests that stigma, the financial impact of incarceration, the identity of neighborhoods as ‘problem places,’ and the disruption of social networks are the main mechanisms by which incarceration impacts families and neighborhoods for years.   In a study looking at the spatial concentration of incarceration in particular New York City neighborhoods noted that the ability of communities to address the social and economic factors that contribute to incarceration diminishes as the size of the ex-inmate population grows (Fagan et al, 2004).  Golembeski and Fullilove note: “[I]t is difficult to estimate how and to what degree residential instability leads to decreased community stability… each distinct neighborhood faces a unique set of challenges that depend on the population count, demographic distributions, and health needs of residents who have been incarcerated (2008: S189).” 
Mass incarceration may be threatening public safety in some communities
The relationship between incarceration and crime is complex.  But recent scholarship suggests that we may have reached a tipping point where the negative effects of large-scale imprisonment are outweighing any reduction in crime because the large numbers of people cycling in and out of prison is destabilizing neighborhoods (Clear, 2007; Drucker, 2011; Mauer, 2005; Western and Pettit, 2010). Scholars argue that possibility of improved public safety through incarceration has been exhausted (Western and Pettit, 2010) and that we have now entered an era where mass incarceration is self perpetuating (Drucker, 2011).  The cycle of incarceration is thought to affect community safety through several pathways:  1) removal of residents changes the capacity of social networks to resolve problems and enforce community norms, and it weakens neighborhood ties; 2) removal of family members creates disruptions in home life that may lead to delinquency; 3) the imprisonment of huge numbers of young men concentrated in particular communities has grown to become a ‘bedrock experience’ that shapes families, businesses, institutions, and social groups in profound ways; and 4) the reentry from jail and prison of large numbers of individuals who have high needs but few resources strains already overburdened neighborhoods (Clear, 2007).  Moreover, the impact of policing in communities of color may be reducing confidence and trust in the justice system among Blacks, impeding the effectiveness of law enforcement (Mauer, 2005).
Finally, public safety more broadly conceived recognizes that crime is not the only threat to safety.  Family instability, poor health, substandard housing, and unemployment all threaten the health, welfare, and stability of communities.  As Western and Pettit explain: “Public safety is built as much on the everyday routines of work and family as it is on police and prisons (2010: 18).”

Ahern, J., J. Stuber, and S. Galea.  (2007). Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend, 88(2-3): 188-96.

Clear, T. (2007).   Imprisoning Communities: How Mass Incarceration Makes Disadvantaged Neighborhoods Worse. New York: Oxford University Press.

Clear, T. (2009). The collateral consequences of mass incarceration. Paper presented to the School of Criminology and Criminal Justice, Arizona State University, April 3, 2009. 
Clear, T., Rose, D., & Ryder, J. (2001). Incarceration and the community: The problem of removing and returning prisoners. Crime & Delinquency, 47(3), 335-351.
Defina, R. and L. Hannon.  (2009). The Impact of Mass Incarceration on Poverty.  Crime and Delinquency, February 12, 2009. Available at SSRN: 
Drucker, E. (2011). A Plague of Prisons: The Epidemiology of Mass Incarceration in America.  New York: The New Press.
Drucker, E. (2002). Population impact of mass incarceration under New York’s Rockefeller Drug Laws: An analysis of years of life lost. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 79(3), 434-435.
Fagan, F., West, V. and J. Holland.  (2004). Neighborhood, Crime, and Incarceration in New York City. 36 Colum. Hum. Rts. L. Rev. 71 (2004-2005).
Galea, S. and D. Vlahov. (2002). Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Rep, 117 Suppl 1: S135-45.
Golembeski, C., & Fullilove, R. (2008). Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health, 98(9 Suppl), S185-90.
Haden, M. (2004). Regulation of illegal drugs: an exploration of public health tools. Int J Drug Policy, 15: 225-230.
Hathaway, A.D. (2001). Shortcomings of harm reduction: toward a morally invested drug reform strategy. Int J Drug Policy, 12(2): 125-137.
Iguchi, Y.M et al. (2005). How criminal system racial disparities may translate into health disparities. Journal of Health Care for Poor and Underserved, 16(4)Suppl B: 48-56.
Health Disparities in New York City. (2004). New York: New York City Department of Health & Mental Hygiene.
Justice Mapping Center. (undated). Available at Retrieved December 2, 2011.
London, A. and N. Myers. (2006). Race, incarceration, and health: a life-course approach. Research on Aging, 28(3): 409-422.
Mauer, M. (2005). Thinking about prison and its impact in the 21st century. Ohio State Journal of Criminal Law, 2:607-618.
Moore, L. D., & Elkavich, A. (2008). Who's using and who's doing time: Incarceration, the war on drugs, and public health. American Journal of Public Health, 98(9 Suppl), S176-80.
Mosher, J.F. and K.L. Yanagisako (1991). Public health, not social warfare: a public health approach to illegal drug policy. J Public Health Policy, 12(3): 278-323.
Pew Charitable Trusts.  (2010). Collateral Costs: Incarceration’s Effect on Economic Mobility. Washington D.C.: The Pew Charitable Trusts.
Spatial Information Design Lab. (undated). Million dollar blocks. Available at  Retrieved December 2, 2012.
Thomas, J. C., & Torrone, E. (2008). Incarceration as forced migration: Effects on selected community health outcomes. American Journal of Public Health, 98(9 Suppl), S181-4.
Travis, J., McBride, E. C., & Solomon, A. L. (2005). Families left behind: The hidden costs of incarceration and reentry. Washington, D.C.: Urban Institute.
Travis, J., & Waul, M. (Eds.). (2004). Prisoners once removed: The impact of incarceration and reentry on children, families, and communities. Washington, D.C.: Urban Institute Press.
Wakefield, S. (2010).  Invisible inequality, million dollar blocks, and extra legal punishment: a review of recent contributions to mass incarceration scholarship. Punishment and Society, 12(2):209-215.
Western B. and B. Pettit.  (2010). Incarceration and social inequality.  Daedulus: Summer Issue.
Willmott, D., & van Olphen, J. (2005). Challenging the health impacts of incarceration: The role for community health workers. Californian Journal of Health Promotion, 3(2): 38-48.
Young, M., et al. (2005). Interpersonal discrimination and the health of illicit drug users. Am J Drug Alcohol Abuse, 31(3): 371-91.

Saturday, February 4, 2012

Musings about Methadone

I know plenty of folks who have been helped by methadone, but it also has a lot of critics.  Among the criticisms is the 'bureaucratic jungle' of regulations that surround methadone dispensing.  A lot these regulations are aimed at preventing the diversion of the medication.  In the piece below --  based on data from my dissertation -- I look at how some of the regulations surrounding methadone impacted the lives of people trying to adhere to those regulations.  I haven't had time to do an analysis of this data yet, so what's below is purely descriptive at this point.

If you're looking for a little more analysis and critique, tons a great stuff has been written about methadone.  I'm a big fan of Fraser and Valentine's book, Substance and Substitution.  Also check out Melissa Bull's work, like Governing the Heroin Trade.  Other scholars, like Bourgois and Bergschmidt, have done some nice Foucauldian analyses of methadone as a system of control, and Gomart has a couple of pieces on the productive capacities of methadone. For a recent on-the-ground look at New York City's opioid treatment system, check out a report published last Fall by Voices Of Community Advocates & Leaders (VOCAL), one of my favorite advocacy groups.

The Methadone Rat Race
Methadone treatment programs vary across the country but most share a requirement of daily attendance, directly observed dosing, and interventions or sanctions for failure to show up, having a “dirty” urine (a sign that someone has used drugs other than methadone), or refusing to participate in different aspects of the program, like counseling. Participants in the BHIVES study described that, because the way in which it is regulated and dispensed, complying with the requirements of methadone treatment was often difficult.  Rather than fostering a sense of being in a medical treatment that restores one’s “normal” functioning, they reported that the rules governing methadone disrupted their daily life in significant ways and in, some cases, contributed to relapse.  

For example, Jane[1] describes in detail how the restrictive methadone clinic hours and regulations, which require daily attendance at a specific time, combined with the fear of methadone withdrawal, can lead to relapse:

It would be the worst feeling in the world to get up and know I had to come to this fucking clinic and drink that methadone. … So you're coming this way, and you keep looking at your watch and it, it's getting close to that time and you got 30 minutes … and then when you get off the bus you got five minutes.  You're running up the stairs, you waiting for the elevator, it doesn't come, so you run up the stairs, you're breathing and you step up to the window and they closed.  They won't give it to you. … They say, ‘well, I'll bet you'll be on time tomorrow morning.’  You know, and then you have to wait until seven o'clock the next morning and ... so you either ran out of methadone, and you're actually sick.  So you go do something and you get you some money to get you some dope and especially if you don't have any money you gonna go and do something to get you some money to buy some heroin.  Then you have to go into that rat race.

Dana also found it difficult to get to the methadone clinic everyday, and when she missed her appointment, she used heroin to avoid withdrawal.  This only compounded her problems at the clinic because at her clinic, “if you have dirty urine, you either start rapid detox, or you go up 15 milligrams.”  She described how every time she “slipped up,” her methadone dose was increased to the point where she was terrified of ever being able to get off it.[2]  These kinds of struggles led Dana to conclude that she wanted to get out of methadone treatment and try buprenorphine because she was tired of “lying and trying to beat urines.”  

Even those who were able to comply with the requirements of their methadone treatment, talked about the ways in which daily attendance at the clinic disrupted their lives and made it difficult for them to work or travel.  Carl was one among many who noted that the methadone regulations, especially the requirement of daily attendance, prevent people from “having a life.”  He says:

With the methadone program, you have to go down there each and every day and that could be a hassle if you are trying to have a life.  You know, if you got a job or something, you have to work your schedule around going to pick up your methadone.

Similarly, Jesse explained that ,methadone helped him control his drug use, but having to go to the clinic interfered with his work as carpenter. 

Other people talked about how methadone prevented them from traveling or visiting family out of town.  These kinds of experiences are consistent with Bull’s study of methadone clinics in which she concluded that the regulations governing methadone impede clients “from making certain types of decisions about their daily lives, even when such decisions are considered to be of positive therapeutic value – such as working or visiting family” (2008: 163).

While several participants had successfully used methadone to stop or control their opioid addictions at least for a time, only one felt that mandated daily attendance and the highly structured environment of the methadone clinic were helpful.  This individual talked about how the structure of daily attendance was important to helping him avoid boredom and maintain sobriety.

[1] Pseudonyms are used throughout to protect the identity of participants.
[2] Some clinics increase doses when someone relapses on the theory that the individual must not be receiving enough methadone to effectively block the craving for heroin (see for example, Caplehorn et al. 1993).