By Garrison Clark
Part 1 appeared in the December issue of Piedmont Left Review.
The Opioid Crisis
After the opioid crisis broke into the consciousness of mainstream America in 2014 and 2015, it quickly became folded into the narrative of the 2016 presidential election and the decline of the “white working class.” The quickly metastasizing epidemic was framed in Trumpian terms- that these “deaths of despair” were the result of economic warfare inflicted by China and Mexico upon the United States. Yet this story conveniently left out the role that the capitalist class and neoliberal policies had in creating, sustaining, and ultimately ignoring the opioid crisis. So how did we get to the point that 3 North Carolinians die every day from opioid overdoses?
Two fundamental trends emerged in the 1990s that helped to create the worst crisis of drug overdose deaths in US history: the flooding of the drug market by opioids and the late 90s deindustrialization of large swaths of the US. These two trends occurred in the long shadow of the US drug war which brought a vicious carceral approach to dealing with drug addiction. Pharmaceutical companies began pushing opioids heavily in the 1990s as a solution to physical pain through marketing campaigns to the public and directly to doctors. The increasingly commodified healthcare system responded accordingly. Doctors, concerned about dealing with pain in “customers” and with producing quick, effective solutions, found opioid pain medications to be a fantastic method to avoid the lengthy, intensive, and costly options (to the patient) of physical rehab, etc. Pharmaceutical companies saw their markets expanding at an explosive rate and doused on the ads to tell the public that their pain had a quick and easy solution. The companies tended to avoid the underlying evidence that these drugs were highly addictive and not at all an easy solution for every patient.
Deaths from drug addiction were long a crisis in the most economically exploited communities in the United States: indigenous communities in the Southwest, Appalachia, and poor inner-city communities. As the late 90s wave of deindustrialization hit the Rust-Belt, the South, and wide areas of the US, manufacturing workers soon found themselves out of work. As explored in Part 1 of this series, the social ills arising from the late 90s decline in manufacturing jobs cannot be simply attributed to NAFTA and free-trade policy. The lack of a meaningful social safety net or jobs program, combined with an economic system that places profit first, left the working class out to dry. As manufacturing jobs began to decline and workers moved to lower paying service sector jobs, they found themselves without healthcare coverage or lower quality insurance plans. Manufacturing work takes a huge toll on the bodies of workers who often find themselves with chronic pain due to years of physical labor. Due to the loss of health insurance or lower quality insurance plans, comprehensive pain management that went beyond opioid pain medication was generally not available or affordable. It was simply easier for doctors to prescribe a large batch of opioids to a patient. Given the highly addictive qualities of these medications, it is not difficult to see how these strands began to intertwine into the crisis we know today.
The neoliberal paradigm of healthcare-as-commodity helped to shape both the beginnings of the crisis and the systemic failing to provide meaningful options for those struggling with addiction. Healthcare is not a right, simply a service provided to consumers under this view- as such care is commodified. The sort of intensive and expensive pain management options like physical rehabilitation are shunned in favor of more profitable and “quick” options as a prescription. There is little room in the working day for workers to take the time for caring for their bodies and the ever more downwardly mobile working class couldn’t risk the loss of pay. As the crisis began growing, the US healthcare system was woefully inadequate in providing care. Much like how comprehensive pain management was out of reach for those with no or low quality health insurance plans, rehabilitation for addiction was not an option due to its lack of coverage and cost. And if you could manage the cost of treatment, you still had to deal with time off of work. Compounding costs and a healthcare system unable to provide options meant that the US turned to its favorite tool for dealing with social ills: the carceral state.
As it became clear that opioids carried a much greater risk of addiction than previously thought, doctors pulled back the size of prescriptions and were less willing to prescribe opioids to patients dealing with chronic pain. This led to those struggling with opioid addiction to seek out options in the illegal drug market, whether it be simply illicit opioid medications or other substitutes like heroin. This “switchover” represents a clear carceral demarcation- what is legal for a pharmaceutical company to sell through the healthcare market is not legal for others to sell. And the individual who was simply following a drug regimen under doctor’s orders now enters the category of the transgressive, the addict, the criminal. The carceral system in the United States has long been used to deal with drug addiction, whether it be during the rise of heroin use in the 1970s or the 1980 crack cocaine “epidemic.” And in these instances, by marking drug use as transgressive and worthy of punishment, the system only serves to further suffering and harm. Individuals are not provided meaningful options for addiction treatment during incarceration and then after release are marked with another transgressive label, felon. This leads to worse job prospects, worse health care options, and a higher likelihood of relapse and recidivism.
So how did this process play out in North Carolina? We have looked at the broad view of the crisis as it unfolded nationally, but there were critical components at the state level that exacerbated the underlying issues. It cannot be overstated how rapid the manufacturing contraction of 1997-2002 was and the effects that contraction had on health insurance availability and quality for the working class of NC. While this laid a foundation for the crisis, critical decisions made by politicians in the state served to deepen and further the crisis. Throughout the 2000s the NC Department of Health and Human Services, the state’s agency that oversees Medicaid, found itself at the heart of scandals over fraud and waste. While fraud did occur in many instances, these were often the result of companies billing the state for services they never provided. The draconian measures employed by the state in the late 2000s to deal with fraud led to residents being forced to wait a month or more for care under Medicaid. WRAL and Disability Rights NC reported that many patients died waiting for care. This occurred in a period where the state had all three branches of government under Democratic Party control. Medicaid covers limited sections of the state population- mostly children and mothers in poverty and disabled state residents. But critically, many drug rehabilitation programs are covered in the state by Medicaid. By making these services difficult to obtain and setting up hoops for recipients to jump through, it only made it more likely for individuals suffering from opioid addiction to seek out illicit opioids. When the GOP won back control over the state senate and house in 2010, DHHS found itself under assault. The state Democratic Party had done much of the groundwork for this attack by invoking the right wing canard of “fraud and waste” in the years before and tightening services as a result. In the first budget created under GOP control, the legislature mandated a $356 million cut to DHHS. Such a deep cut would threaten the state’s ability to pay for a wide variety of adult health services, such as drug rehabilitation. This began an annual attack by Republicans on the state’s health services, which continues to this day. The most egregious of these cuts have been resisted by the public, largely due to the fact that thousands of state residents would be literally kicked out of hospitals, long term care facilities, and treatment centers. But the DHHS found itself constantly pushed to reduce costs and abuse, leading to longer backlogs, longer delays in services, and greater difficulty in securing care. This only served to make seeking treatment for opioid addiction that much harder. And without expanding Medicaid under the ACA, low income residents continue to struggle to find affordable options for healthcare if they do not qualify for the program.
In 2017, a report from Castlight Health found that North Carolina had 4 of the top 20 cities for opioid abuse in the country, including the number one spot occupied by Wilmington. These four cities (Jacksonville, Fayetteville, Hickory, and Wilmington) all saw decreases in real median household income between 2000 and 2016. Hickory, with the 5th highest rate of opioid abuse in the country, saw its real median household income shrink by nearly 1/5th or 19.6%. Fayetteville saw a 14.2% decrease. All four cities saw increases in poverty levels for residents, with Hickory seeing its poverty increase from 9.1% to 15.9%. Wilmington’s reached 17.7%, Fayetteville 17.6%, and Jacksonville 13.9%. Nearly a quarter of Hickory residents lack health insurance of any kind and the other 3 cities have uninsured rates of over 10%. These statistics are presented here to show one thing: that material conditions sustained this crisis. In the media discourse, drug addiction is spoken of as the cause of social ills, not the symptom of a broader failing of neoliberal capitalism to provide for society. Drug addiction is presented as a personal failing, simply bad behavior to be punished. This individualization of social crises is a product of neoliberal thinking that posits the free market as fully capable of providing for all needs- if you stumble it is because of you and not any sort of flaw in the system. Yet the broader story of the opioid crisis shows very clearly that the system left behind many North Carolinians in the wake of deindustrialization. There were options on the table for the state and the federal government. A jobs guarantee, universal healthcare, investment in rural healthcare, better addiction treatment facilities. Hell, even a robust jobs retraining program would have provided something for our communities. But our leaders didn’t pursue those options then and they won’t now. Capitalism provides no incentive to do so. Their choice only came at the cost of the lives of the 12,000 North Carolinians who have died from opioid overdoses since 1999.
Part 3 of North Carolina and the Cost of Neoliberalism will focus on the carceral state and will appear in Issue #3 of PLR.
Garrison Clark is an organizer in Greensboro and a member of DSA.