Anyone who has done a fair amount of training or public speaking has likely had the experience of presenting information and ideas to audiences that are not heard or assimilated, and/or having one’s comments misquoted, distorted or exaggerated in various ways. Audiences may not be prepared to grapple with unfamiliar information or ideas, not because they are too complex or controversial but because the material does not easily fit with existing preconceptions. This is famously the case in spiritual discussions; but is also true in presentations regarding more mundane matters. When teaching MSW courses, I found students had difficulty assimilating the idea that the quality of social relationships has as much impact on health and mortality as diet and exercise. It’s not that most students disagreed with this idea; rather, information regarding the social determinants of health did not resonate or connect with their assumptions regarding the underlying causes of health and disease. A common response to the assertion that joining a club has about the same positive effect on physical health as stopping smoking was a blank stare, not skeptical questions regarding research findings for may have sounded like a dubious claim.
Similarly, professional audiences concerned with stopping and/or preventing a drug epidemic are likely to be predisposed to believe in solutions that involve implementation of evidenced based programs, and to ignore more nebulous ideas that require (a) major socioeconomic changes such as poverty reduction or changes in the use of arrest and incarceration of drug dealers and users of illegal drugs or (b) lack clear operational meaning, e.g., a change in the social ethos regarding marginal or outcast groups such as the homeless or drug addicts. For these reasons, community interventions in the initial stages of a drug epidemic tend to be delayed until evidence-based programs and practices are developed and tested, and superficial in failing to address social attitudes that provide fallow ground for future drug epidemics.
Strengthening Collective Efficacy
According to the Center for Disease Control and Prevention (CDC), the nation’s opioid epidemic has unfolded in stages: widespread misuse of prescription opioids in the early 2000’s evolved into increased use of heroin as state and local governments took action to curb questionable prescription practices, which has been supplemented in recent years by powerful synthetic opioids such as fentanyl. A 2018 CDC report asserts that there were 700,000 opioid overdose deaths in the U.S. from 1999-2017; there were 6 times more opioid overdose deaths in 2017 than in 1999. Many communities hard hit by an increase in opioid overdose deaths, and by an increase in foster care, have developed collaborations among multiple state and local community agencies, including law enforcement, child welfare, public health, first responders and state Medicaid staff to develop and make good use of epidemiological surveillance data, to improve case finding and therapeutic outreach to high risk persons and groups and to equip first responders, including law enforcement officers, with naloxone to reduce overdose deaths among opioid abusers. Law enforcement officials are generally enthusiastic participants in these community collaborations; and are often the first to say that law enforcement agencies cannot stop the community’s drug epidemic with arrests and mass incarceration. Law enforcement officers play a major role in case finding in some communities, as well as temporarily interdicting supplies of illegal drugs.
Because the opioid epidemic began with greatly increased use of prescription drugs, early prevention initiatives emphasized prescription drug monitoring programs (PDMP) to identify and stop misuse and overuse of prescriptions drugs. PDMP’s have utilized statewide Medicaid data bases to improve surveillance of prescription drug use and abuse; some states (e.g., Florida) have also passed legislation to restrict the capacity of physicians to prescribe opioids for relief of acute pain to a few days or weeks. There is recent evidence that Florida’s law (HB 21) which limits opioid prescriptions to 3 days (with a possible 7-day extension) has led to a large reduction in new prescriptions of opioids.
Community collaborations with a strong public health orientation have an important role in disseminating information from research studies regarding effective practices in preventing overdose deaths. For example, a recent study published in JAMA found that Medication for Opioid Disorder (MOUD) treatment that utilizes either buprenorphine or methadone is much more effective in reducing serious opioid related acute care than no treatment, detoxification, intensive behavioral health interventions or naltrexone at 3 months and 12 months, though, surprisingly, non-intensive behavioral health interventions were also associated with reduced serious acute care episodes at 12 months. Disseminating information of this type quickly and efficiently to physicians and substance abuse treatment providers can save lives. Vigorous community collaborations organized around the opioid epidemic make this a much easier task.
Expanding the scope of community collaborations
Existing public health models are essential in reducing the harmful effects of a drug epidemic, but public health frameworks do not address underlying causes of a drug epidemic; or slow down the transmission of the social “pathogen” in a community. Public health departments, in cooperation with other community agencies, seek to isolate and quarantine persons who carry an infectious virus. This is not possible in a drug epidemic despite frequent attempts to lock up drug dealers and heavy users. The use of dangerous drugs spreads rapidly when information regarding the immediate positive effects of a drug, e.g., pain relief, is widely communicated by family members, friends and acquaintances to persons who feel hopeless about their future, especially their economic prospects.
Community collaborations focused narrowly on reducing overdose episodes or deaths, and perhaps foster care placements, will never be enough to stop a drug epidemic or prevent future ones. Once a drug epidemic gathers initial momentum, it is likely to continue for at least a decade until word on the street accepts the assertion of professionals and news stories that the drug in question is indeed dangerous and possibly lethal. By the time this occurs, there are large numbers of substance dependent individuals desperate to maintain a steady supply of the drug regardless of the danger. News stories about drug overdoses and foster care increases have a gradual effect on word of mouth communication in high risk groups; but the picture of substance abuse presented in TV shows, movies, plays and even novels may have a larger impact in the long run. The representation of a 40-year old methamphetamine addict who looks old and emaciated, and who has lost her/his teeth and hair creates an indelible impression that has far more impact than PR announcements developed by governmental agencies. One way of stopping a social epidemic of any type is to deglamorize the behavior in question. Ads that show young attractive people drinking beer and having fun at dinner parties, bars or on the beach do the opposite. It’s next to impossible to reduce alcohol related deaths (88,000 per year according to some accounts) when the social benefit of drinking alcohol is openly promoted in the media.
Deglamorizing drug use is a necessary element of slowing down and eventually stopping a drug epidemic, but this is a slow process that only works with individuals who still care about social approval. Arguably, methamphetamine abuse has made a comeback in homeless populations because many, perhaps most, homeless people perceive themselves to be a despised group. Homeless people may believe that the community of non-homeless adults will view them as an economic drain, and a plague on the community, regardless of whether they abuse drugs. The same is true of prisoners, ex-convicts, and those who have lost good jobs and become economically dependent on family members or public assistance.
Punitive attitudes and openly expressed contempt for marginalized and outcast groups strengthens drug epidemics. The powerful historical legacy which supports these attitudes includes slavery, the Jim Crow era and structural racism as applied to African Americans, dispossession of Native American lands and consignment to of Native Americans to reservations, and (crucially for the opioid epidemic) viewing “dirt poor” Whites as “trash”. Nancy Isenberg has the following to say in her great book, White Trash: The 400-Year Untold History of Class in America (2016):
First known as “waste people” and later “white trash”, marginalized Americans were stigmatized for their inability to be productive, to own property or to produce healthy and upwardly mobile children … The American solution to poverty and social backwardness was not what we might expect. Well into the twentieth century, expulsion and even sterilization sounded rational to those who wanted to reduce the burden of “loser” people on the larger economy. … The words “waste” and “trash” are crucial to any understanding of this powerful and enduring vocabulary.
….“it’s not just a question of labelling the bottom at any given time. Rationalizing economic inequality has been an unconscious part of the national credo. … The poor were not only described as waste, but as inferior animal stocks too.”
This material is painful to read, much less to live with after school failure, aging out of foster care without family support, release from prison, loss of employment without prospects for finding a decent job, lack of housing and then substance abuse and (ultimately) drug addiction. If anyone believes the social attitudes discussed by Isenberg have altered for the better, please read Nicholas Kristof’s and Shirley WuDunn’s recently published book, Tightrope, which tells the story of a poor White family Kristof grew up with in rural Oregon. Several of the children in this family used and/or manufactured methamphetamine, spent years in prison, were unemployed for long periods of time, and died early due to illness, accidents or possibly suicide. Just prior to publication of Tightrope, Kristof wrote a column in the New York Times titled “Who Killed My Friends, the Knapps?” This column was met with furious pushback from many readers who viewed what happened to the Knapps as “just desserts”, i.e., the product of their own actions and possibly a good thing for the community’s gene pool!
Investing in marginalized and outcast populations
Preventing drug epidemics requires investments in the economic potential of marginalized and outcast groups such as ex-convicts, the homeless, youth aging out of foster care, adolescents who do not graduate from high school, and the long term unemployed, especially individuals who once held well paying jobs. Concretely, job skills training programs and programs that develop prosocial talents in athletics, music, art, drama, computers, animal care, or any other talent that leads to positive social recognition are essential. In addition, social inclusion of various types is of the utmost importance. One of the most inspiring stories I’ve seen recently regarding working with homeless people featured a weekly homeless persons’ choir in Dallas, Texas. Activities that embody an experience of shared humanity between marginalized groups and advantaged persons in the community is a tonic for the sense of shame that is widespread in afflicted populations. In past decades, economically marginalized persons might have found acceptance and support in churches; and this is still true to some extent. However, in recent decades, church attendance (and presumably religious belief) has declined among low income White Americans (see Coming Apart: The State of White America, 1960-2010 by Charles Murray). There is no obvious prosocial substitute for the loss of communities of faith among economically marginalized groups, but one needs to be found or developed.
As necessary as investments in programs that focus on the economic potential – and shared humanity – of persons who have lost hope in their economic futures are, it is difficult to implement and sustain these programs when their values conflict with a community’s social ethos. When large numbers of ordinary citizens and influential policymakers categorize adults, and possibly adolescents, as winners or losers, the deserving poor or human “trash”, programs are undermined by widespread hostility directed at stigmatized groups. Community leaders must take the lead in modeling humane social attitudes; if they don’t, or actively encourage hate speech and negative stereotypes directed at afflicted groups, programs cannot succeed.
Using empowerment to combat hopeless/ helpless responses to hardship
Hopeless/helpless attitudes underly both drug addiction and suicide. Substance abusers are often amazingly resourceful at obtaining a regular supply of drugs; but feel helpless to do anything about their substance dependence, or any other of their many serious problems. More than a hundred years ago, the French sociologist, Emile Durkheim, argued that suicide rates decrease in response to a community’s or nation’s widely shared adversity, e.g., war, due to the increase in community solidarity during these crises. More recently, some scholars have described the preventive effects on youth suicide of empowerment practices in Native American or Canadian Aboriginal tribes (see The Return of the Sun: Suicide and Reclamation Among Intuit of Arctic Canada, 2019). Youth suicide can be a contagious phenomenon. Engaging youth who have experienced the suicide of peers and friends in collective activities that have the potential to improve their school, neighborhood or community is an antidote to despair, possibly the best antidote.
Three Approaches to Stopping and Preventing Social Epidemics
- Deglamorize the behavior and consequences of the behavior in question, e.g., gun violence, drug and alcohol abuse, suicide. It is impossible to stop any social epidemic in which socially toxic behavior is widely depicted by journalists, writers, TV series and movies in glamorous ways, even when the behavior is morally condemned. Every police show or crime drama that ends in a shoot out between police and criminals adds to the risk of gun violence.
- Invest in the economic potential of economically marginal populations; and create experiences of shared humanity within outcast groups and among these groups and more advantaged community members.
- Adopt empowerment practices through which adolescents and adults at high risk for developing hopeless/ helpless attitudes regarding their future are engaged in meaningful collective initiatives on behalf of schools, neighborhoods and communities.
- Carroll, J., Green, T. & Noonan, R., Evidence Based Strategies for Preventing Opioid Overdose; What’s Working in the United States (2018), Center for Disease Control and Prevention, Atlanta, Ga.
- Durkheim, E., Suicide: A Study in Sociology (1897), Routledge Classics, London and New York.
- Hincapie-Castillo, J., Goodin, A. & Possinger, M., “Changes in Opioid Use after Florida’s Restriction Law for Acute Pain Prescriptions,” (2020), JAMA Netw Open, 3 (2).
- Isenberg, N., White Trash: The 400-Year Untold History of Class in America (2016), Viking, New York, NY.
- Kral, M.J., The Return of the Sun: Suicide and Reclamation Among Inuit of Arctic Canada (2019), Oxford University Press, New York, NY.
- Kristof, N. & WuDunn, S., Tightrope: Americans Reaching for Hope (2020), Alfred A. Knopf, New York, NY.
- Murray, C., Coming Apart: The State of White America, 1960-2010 (2012), Crown Publishing, New York, NY.
- Wakeman, S., Larouche, M., & Ameli, O., “Comparing Effects of Different Treatment Pathways for Opioid Use Disorder,” (2020), JAMA Netw Open, 3 (2).