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The tragic, fentanyl-related death of music legend Prince has opened eyes and added new urgency to the nation’s attempts to deal with the opioid epidemic, which now kills 78 Americans daily. So perhaps it wasn’t surprising to see a tough-on-fentanyl amendment tacked on to a defense bill in early June.
Sponsored by U.S. Sen. Kelly Ayotte of New Hampshire, the amendment included language that called for a 5-year mandatory prison term for anyone found with 0.5 grams of a substance containing the synthetic opioid fentanyl. That’s a 20-fold reduction from the current guideline of 10 grams.
While the amendment was no doubt intended as a way to rein in the growing reach of a highly dangerous drug by a senator whose state has been reeling from opioid-related deaths, what it would have meant in practical terms if passed is that more low-level users would find themselves behind bars rather than getting the help they need to return to health and productivity.
And that’s exactly the wrong direction for our nation to take, guaranteeing only that precious resources would continue to be diverted to punishment rather than to the evidence-based addiction care we know can work.
Agreeing were more than 100 civil rights, criminal justice, public health and faith groups, which denounced the Ayotte amendment in a letter to Senate leadership, noting what was at stake:
“Our country has begun to change course on its criminal justice policy, recognizing that mandatory minimum sentencing requirements have done little to protect the health of American citizens or promote the safety of our communities. Instead, mandatory minimum sentences have resulted in persons convicted of nonviolent drug offenses receiving disproportionate prison sentences, including life sentences. We believe the Ayotte Amendments represent a step backward toward ineffective policy that fails to direct resources wisely, and their passage must be prevented.”
Action to combat our opioid epidemic must be taken, the letter continued, “however, in order to truly save lives and promote public safety, this response must be rooted in evidence-based [addiction treatment] practices.”
On June 14, common sense and compassion won. The defense bill passed without the Ayotte amendment even coming up for a vote.
I’d like to think this means we finally get it — that we understand we can’t end the epidemic of opioid abuse by continuing to lob shells in the war on drugs. But the reality is that we are still far from a true commitment to treat addiction as the illness that it is rather than turning to punishment to deal with our fearful new reality.
Fentanyl’s Potent Pull
There’s certainly no doubt that the painkiller fentanyl is a frightening drug — 50 times stronger than heroin and 100 times more potent than morphine. And because it can be easily manufactured, fentanyl has been embraced by drug traffickers as a cheap way to boost the strength of lower-grade heroin, sometimes without the buyer’s knowledge.
It’s also incredibly addictive. Kristin Waite-Labott, who became hooked on fentanyl while an ER nurse and wrote a memoir about her experiences, talked in an interview about how powerless she felt the first time she took the drug. “There’s getting high and there’s getting lost, and I just feel like I got lost once I took that,” she said.
But what’s also not in doubt is that treating those addicted to substances rather than putting them behind bars is not only the compassionate response, it’s the smart one. A 2012 study by Temple University and RTI International found, for example, that diverting just 10% of drug offenders to community based addiction treatment rather than sending them to prison would not only reduce future crime, it would save the criminal justice system $4.8 billion. If 40% were diverted to treatment, the figure would be $12.9 billion.
Addiction treatment, then, makes sense on every level, and that’s a concept that’s being increasingly recognized by social and government leaders.
The Obama administration, for example, has put its weight behind a “Smart on Crime” initiative that has led to changes in mandatory minimum sentences for certain low-level drug offenses. The administration has also called for an additional $1.1 billion in funding earmarked to help those with opioid addictions. Access to medication such as buprenorphine, which can help in the treatment of opioid use disorder, has also been increased.
And throughout society, we see signs of change. A police chief in Gloucester, Massachusetts, for example, started a highly lauded and now-growing program that promises any addicted person who walks into the police station ready to quit will be helped into treatment rather than arrested.
On the whole, however, access to care continues to fall far short of what’s needed. According to the National Center on Addiction and Substance Abuse, federal, state and local governments spend close to a combined $500 billion each year on addiction and substance abuse, but only 2 cents of each of those dollars goes to prevention and treatment.
There was also high hope for the Affordable Care Act (ACA), which was expected to dramatically boost access to care by requiring addiction treatment to be an essential benefit of its health insurance policies. A recent analysis by The National Center on Addiction and Substance Abuse, however, paints a disheartening picture.
Although the ACA mandated the coverage, it left the details about exactly what that coverage would look like to the states. None of the states’ so-called “benchmark” plans, which outline the minimum benefits its ACA plans must offer, had adequate addiction treatment benefits when all was said and done, the Center study determined. More than two-thirds had obvious violations of ACA requirements, many had harmful treatment limitations (such as incomplete coverage of medications approved to treat opioid addiction and no coverage for inpatient rehab), 18% failed to meet the required parity with other medical coverage, and the wording in 88% of the plans was so vague as to make a complete evaluation of the coverage impossible. And since that wording is the same wording that the policyholder sees, figuring out what is covered and what isn’t can be an exercise in frustration for the patient.
Plagued by Stigma
Beyond prison terms and incomplete benefits, another issue continues to play a role in keeping people from the help they need: stigma. Despite a growing body of research that helps us understand addiction as a complex, chronic brain disease, it continues to be viewed by many as a moral failing or a shameful weakness.
Prince, who is believed to have begun using opioids as a way to deal with the painful rigors of his performances, undoubtedly understood that stigma all too well. Did it keep him from reaching out for help when his substance use first began to be a problem? And the big question: If he had reached out earlier, might he be with us today? We can only wonder.
One thing is certain: His death opened the eyes of many who suddenly understood how easily substances can overtake a life — even for those with talent, resources, wealth and a devoted circle of friends, family and admirers. And we also know that if the Ayotte amendment had been in effect when Prince was alive, he might have been one of those facing half a decade behind bars.
Prince didn’t live to see compassion for the addict become the norm in our society. But if our nation remains vigilant when lawmakers attempt to return us to the punitive policies of the past and if we finally commit to provide real help for those who are struggling with substances, perhaps it will become part of his legacy.
David Sack, MD, is board certified in psychiatry, addiction psychiatry and addiction medicine. As CMO of Elements Behavioral Health, he oversees a number of opiate rehab centers including Park Bench drug rehab in New Jersey and Clarity Way luxury rehab in Pennsylvania.
