By Mãdãlina Alamã
Death due to opiate overdose is a growing concern in the U.S. Together with mental health, wellbeing, and employment, opiate addiction is one of the topics often described as contributing to a national crisis (Mega 2020). However, in public discourse the concept of crisis is wielded to depict situations that seem without solutions.
Historically, U.S. public discourse about addiction to opiates has been framed in several terms, ranging from illness to be treated medically to moral failure and implicitly individual responsibility (Bourne 2008). Particularly starting in the 1980s, during Ronald Reagan’s presidency, the U.S. government decreased social welfare programs and replaced them with mass incarceration, thus directly and effectively eliminating possibilities of care for vulnerable communities (Masco 2017).
President Reagan’s (in)famous approach to addressing addiction to opiates was rooted in two beliefs: that the addict was not an ill person but a morally flawed one, and that reducing societal harm caused by addiction to opiates should not be a governmental responsibility (Bourne 2008). His approach was consistent with promoting a no-care policy across the board towards social issues and consisted in outlawing opiate addiction and dismantling previous systems of care (Masco 2017). Thus, in the U.S. opiate-addiction context during and post-Reagan, the question of “what went wrong” has been shaped by a political and legal focus on the presumed moral flaws that supposedly lead to opiate users’ poor decision- making. Reagan took President Nixon’s 1971 statement that America had a new enemy in narcotics and Nixon’s call for a ‘war on drugs’ and expanded them into a real, actual, still ongoing war on opiate users (Zigon 2019).
For the Reagan and the Bush administrations, incarceration rates of opiate users became the measure of success in addressing the opiate addiction issue in the U.S. (Bourne 2008). Reagan’s approach greatly shaped decades of federal policy that took legal aim at punishing people experiencing opiate addiction, and the War on Drugs has been growing continuously from its incipient stages, becoming a complex and powerful entity in today’s world, one creating new forms of government-generated abuse such as domestic and international surveillance, aggressive policing, military interventions, all supported by increasingly punitive legislation, and enormous budgets (Zigon 2019).
Under these circumstances, for the past decades, people experiencing opiate addiction have become targeted as criminals and addiction treatment facilities have been underfunded (Bowles J. , 2016), all contributing to the steep increase in the number of opioid overdose deaths in the U.S. leaving families to grieve the loss of their young ones (Uzwiak 2021). During the first year of the COVID-19 pandemic, the opioid overdose deaths increased by over 30% from pre-pandemic years (State Health Access Data Assistance Center 2023). Given this situation, it is no surprise that many sectors refer to this pattern of ever-increasing opiate use and opiate-related deaths across the nation as an opiate epidemic, a crisis with no end in sight (ABC News 2022). At the same time, in contrast with the ongoing reporting of opioid-related deaths, there seems to be a conspicuous silence in the media about people living with opiate addiction and about the people recovering from it. A singular focus on the death toll alone seems to purposefully obfuscate any possibility of life for addicts and imply that the only possible outcome of opioid addiction is death by overdose. Thus, despite its ineffectiveness at diminishing opiate addiction, the War on Drugs has been purposefully carried out as a war on the people who struggled with opiate addiction. On top of this war, we have been witnessing a mediatized war against the hope that opiate addiction is a human problem that has solutions.
"Ethnographic observation at an outpatient organization where opiate addicts seek help voluntarily underscores how, in a context of care, hopes of recovering addicts move beyond narratives of addiction as an epidemic or crisis, and focus on forms of astute support that transcend crisis-imposed boundaries."
Anthropologist Joseph Masco (2017) tackles the concept of crisis and exposes the deep and enduring ideological mechanisms that actively drive the production of cultural narratives of life as a multitude of interspersed crises. He puts forth that repetitive usage of the term ‘crisis,’ together with a lack of well-articulated solutions, rob people of their individual and collective ability to imagine and carry out constructive ways of engaging with problems (2017: S65).
Janet Roitman traces the origin of the word “crisis” to the Greek ‘Krinô’ that meant a turning point, or irrevocable decision (2013: 15). She also explains that naming a situation, a difficulty, a problem ‘crisis’ is not a logical, existential evaluation, but a politically motivated statement, one that allows for specifically tailored answers to the “what went wrong” question. Successive administrations have directed state violence towards the most vulnerable people, framing addiction as nothing but death and removing from the realm of possibility any non-punitive way of addressing addiction. This several decades-long approach has thus effectively created a crisis.
Ethnographic observation at an outpatient organization where opiate addicts seek help voluntarily underscores how, in a context of care, hopes of recovering addicts move beyond narratives of addiction as an epidemic or crisis, and focus on forms of astute support that transcend crisis-imposed boundaries. By drawing on the fieldwork I conducted in a medication-assisted treatment (MAT) non-governmental organization that treats opiate addiction in the American West, I point to a setting in which life beyond crisis is made possible. Here, care seekers and care providers successfully challenge the seeming intractability of ‘crisis’ that Masco and Roitman describe. I show that on a small scale, in this context of opiate addiction care, life as crisis is indeed a turning point for addicts, a point from which help-seekers can turn their lives around. To do so I distinguish between what care is, as an institutionalized, processual activity based on Reagan-era policies, and how care is performed based on values care takers hold dear. I refer to the former, as facts and contrast them with the latter, what I have learned caretakers consider the truths of life.
During my 2018-2020 fieldwork in an addiction-care context in Nevada, I documented the daily work that adults working on their recovery from opiate addiction, together with the specialized assistance of caregivers, put into creating possible and desirable futures. I observed how, in a cultural milieu permeated by a heightened awareness of the dangers and destruction entailed by opiate use, care was designed to move patients away from crisis, by uncovering and enhancing each recoveree’s own ability to slowly work on not needing opiates and building healthy, purposeful lives.
At the time of my fieldwork the organization did not advertise, actively seek potential patients, or ask for private sponsorship. The management felt strongly that recovery from opiate addiction was possible if the person experiencing addiction wanted to recover and sought the help themselves. They also believed that treatment for addiction is a fundamental right for anyone seeking help. Thus, patients seeking help obtained onsite assistance to register with Medicaid/Medicare for their treatment bills. Treatment consisted of individual and group therapy, medication, and family support activities. Every caregiver I met believed wholeheartedly that while opiate addiction was a serious, often life-threatening condition, and that anyone could suffer from addiction, recovery from this condition was possible and every addict was entitled to support in creating a liveable life for themselves.
"The entire framework of assessment procedures and treatment plans was rooted into the Reagan-era belief that the addict is fully responsible for their willingness and ability to follow societal rules of abstinence."
Most people who sought help at the organization did so voluntarily, out of what many described to me as a last resort in a losing battle with opiates. Upon entering treatment their goal was survival and their emotional, physiological, and social vulnerabilities were extremely high. Even the most motivated patients had lost dear ones to opiate addiction, burned bridges with significant others due to repeated behaviors associated with deepening addiction, and constantly heard news about overdose deaths, leaving them cautiously optimistic at best about their ability to become opiate-free. Before coming to this specific MAT center, many of my interlocutors had repeatedly experienced several rehabilitation and detoxification facilities, each employing a variety of approaches to rapid opiate abstinence. Most of my interlocutors reported ambivalence about previous treatments, relaying an acute sense of frustration at not being able to follow what many perceived to be carefully tailored yet highly artificial, unrealistic recovery programs rooted in the Reagan legacy of addiction as a moral flaw. Thus, the newcomers often expressed feelings of worry, disappointment, even despair at what they came away with from previous treatments. Life for them seemed like a continuous crisis shaped by the following inescapable facts: that opiate addiction is engulfing the nation, that a police record and the occasional stints in detox clinics are the standard treatment, and that there is no foreseeable way for them to move forward from these facts due to all the harm they have already done to themselves and others and their inability to successfully tackle their addictions.
Due to all these concerns as well as timetables and schedule conflicts it was difficult but not impossible to connect closely with people who were just starting their recovery at this MAT center, I joined them at every opportunity in their various structured sessions and conducted informal interviews afterwards. It became apparent to me that if I wanted to understand why people signed up, stayed, and thrived in this MAT center, I had to look at how care was performed rather than what care consisted of. Specifically, starting with enrolment and continuing throughout the treatment period, care was structured by multiple layers of rules, policies, and procedures that the MAT center had to follow closely to be in good legal standing. As part of their ratification process, counsellors underwent a thorough examination consisting of showing ability to design a convincingly successful treatment plan that required an abstinent patient. The entire framework of assessment procedures and treatment plans was rooted into the Reagan-era belief that the addict is fully responsible for their willingness and ability to follow societal rules of abstinence. However, given that specialized care providers understood recovery from opiate addiction as a highly individualized process with its constant interplay of challenges and affordances specific to each patient, discussions that centered around the processual nature of recovery permeated therapy sessions despite the ‘golden rule’ of treatment stipulating that upon treatment inception, abstinence of any opiates and alcohol was the only way forward, and that drinking even a small amount of alcohol or coming into contact with any non-prescribed opiates could spiral one’s life into a hopeless crisis.
Thus, despite requirements for treatment plans to be premised on complete abstinence of any substances other than the methadone prescribed by the organization’s medical professionals, all specialists in opiate addiction in the organization worked relentlessly towards achieving acceptance of what they considered some of the fundamental truths of life with addiction. One enduring truth was that relapse is part of the recovery and that as such the journey towards an opiate-free life should be taken in full honesty with oneself, and one day at a time. Another one is that the past cannot be changed, but one can learn to influence the present and immediate future and to do so one must let go of fears, set boundaries with people who are negative influences, and allow the self to find joy in life. And finally, recovery from opiate addiction means different things to different people and that the recoveree has support in crafting their own journey: setting their goals and learning to be patient and astute with themselves, despite the ongoing narratives of addiction as crisis and the number of deaths by overdose being constantly on the rise across the nation.
In a national landscape ideologically and institutionally shaped by Reaganism and its legacy on how care institutions can define and treat addiction, the what of care still seemed to consist heavily of laws, rules, regulations, policies, and procedures. These are rooted in concerns about getting people abstinent, rather than able to reflect on their lives in ways that are sobering, empowering and generative of possible futures beyond crisis. The how of care, however, was what, according to people in treatment, made recovery from opiate addiction successful: care as unapologetically positive, daily interactions with staff and other recoverees that allowed them to develop an interest and hope in the possibility of inhabiting the world without needing opiates.
Mãdãlina Alamã
Mãdãlina Alamã is a PhD candidate in cultural anthropology at the University of Nevada Reno (UNR).
Bio
She conducted fieldwork in northern Nevada, focusing on the intersection between women’s happiness/well-being and addiction to opiates in the American West. She explores Northern Nevadan women’s efforts to create good lives, their relationships with their addiction, and the process of receiving care for opioid addiction from a non-governmental organization in the region.
References Cited
ABC News
2022 Opioid Crisis is ‘Gripping the Nation,’ ABC News, November 28. https://abcnews.go.com/ThisWeek/video/opioid-crisis-gripping-nation-hartung-81432980.
Bourne, P.G.
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Bowles, Jennifer
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Masco, Joseph
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Mega, Rodriguez, Emiliano
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Roitman, Janet
2013 Anti-Crisis. Durham: Duke.
State Health Access Data Assistance Center
2023 The Opiod Epidemic in the United States. https://www.shadac.org/opioid-epidemic-united-states.
Uzwiak, Beth A.
2021 “Quit Ditching the Love”: Kinship and Death from Opioid Overdose in Philadelphia. Journal for the Anthropology of North America.
Zigon, J.
2019 A war on People. Drug User Politics and a New Ethics of Community. Oakland, California: University of California Press.
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