Ten years ago, the American thinking about the drug crisis was focused on meth. Rural communities have been devastated by its use, production, and consumption, while all levels of government have struggled to respond in any effective way. Today, thanks in large part to the campaign of Donald Trump, our focus has shifted to the opioid crisis. To that end, Ryan Hampton’s recent book American Fix: Inside the Opioid Addiction Crisis–and How to End it is timely, if not the book we need.

In American Fix, we read Hampton’s story of addiction and recovery, and the proposals he has to help opioid addicts all across the nation. These proposals include (in no particular order):

  1. Reining in over-prescription by doctors and drug company false advertising/pressure on doctors to prescribe.
  2. Changing the culture so that addicts are treated with the respect they are due as human beings with a disease, rather than with the shame and guilt of criminals. This is actually a central point; Hampton wants us to treat drug users as sick people, rather than as moral agents who have committed a crime. (More on this below.)
  3. Putting together a nationally coordinated response to the addiction crisis involving available treatment for all who need it. If we want to think of this for ‘Obamacare for addicts,’ we’re probably not far off.
Image: Macmillan

As far as the practical suggestions of this book, I don’t necessarily disagree with most of what Hampton has to say. For example, Hampton claims that AA-style programs and existing rehab centers aren’t actually useful at treating addiction. Instead, he argues for a more flexible approach that treats the whole person, involves their communities/families, and is adaptable to each individual’s needs. We could talk about the relative merits of each of his proposals, but frankly that’s not really my area of expertise.* I’m happy to leave that question to the policy wonks.

Instead, I think his attempt to redefine our cultural view of addiction merits further reflection. Hampton is deeply concerned that we stop thinking about addicts as criminals and start thinking of them as sick people. The goal is to humanize them and elicit our sympathy rather than our outrage, and encourage us as a society to get addicts treatment rather than simply chuck them into prison. Over and over he emphasizes the normal humanity of addicts, and tries to draw a parallel between their place in society and the Civil Rights/LGBTQ rights movements:

“I can’t tell you how many times I’ve introduced myself to someone new, and the first words out of their mouth are ‘you’re a heroin addict? But you look so normal!’
Uhh, yeah. I am normal. I mean, I’m awesome, but I’m also a totally ordinary person. I’m a son, a brother, and a neighbor. A friend. A worker. A voter. There are millions of people just like me–living with substance use disorder–in America today. We may not all look the same, but we all deserve to be treated with respect, equality, and dignity. Not excluded from an uncaring society that would rather let us die on the streets than make policy changes that acknowledge us.” (177)

I of course don’t disagree with any of that. I would simply point out that this kind of language doesn’t actually accomplish what Hampton wants it to. Everything he has said here is true not only of people “living in recovery” (to use his phrase, since he doesn’t like the word “addict”), but also of any criminal you would care to name. The thief, murderer, jaywalker, rapist, embezzler, etc are all sons, brothers, neighbors, friends, workers, and (at least until their felony convictions) voters. They too are human beings and deserve to be treated with dignity, even if we believe that punishment is merited. So far, Hampton hasn’t actually made the case that someone with a drug problem only needs a diagnosis rather than also deserving a conviction.

This is because merely humanizing those living in recovery doesn’t necessarily absolve anyone of responsibility. If anything, emphasizing our common humanity should make us more responsible for our actions, and more responsible when we give in to the worse parts of our nature. (See Aristotle for more on that.) Hampton, by contrast, wants nothing to do with personal responsibility. Consider this list of who he thinks is responsible for the “public health crisis” we’re currently facing: “irresponsible prescribers, ignorant lawmakers, and ineffective treatment centers.” (2)

Notice that missing from Hampton’s list is “users.” Over and over he insists that drug addiction isn’t a choice, and so there should be no guilt or shame attached to the ‘disease.’ By including drug users on the list of those responsible for the current drug crisis, Hampton would say that we are engaging in victim-blaming. After all, would we blame someone who has AIDS, Ebola, or the flu? Are they morally responsible for their condition?

The answer of course is a nuanced “sometimes.” Of courses there are times when people just get sick with no blame falling on them at all. All reasonable precautions can be taken, and a cold, the flu, or various forms of cancer can still strike. On the other hand, there are many ways that diseases can be prevented. The odds of a heterosexual who does not use drugs or engage in risky sexual behavior contracting HIV is significantly lower than, well, functionally anyone else (the risk of such an individual is basically limited to accidents during blood transfusions, at least according to the CDC). Likewise, is someone ‘responsible’ for catching the flu if they have a compromised immune system and yet choose to continue to spend time working with small children or the elderly? What if I’m a smoker who contracts emphysema? For that matter, if I have a history of alcoholism in my family, and I know that I have a low tolerance for alcohol, am I not morally culpable every time I pick up a beer? Can’t we even say that if I know I have a family history of alcoholism and pick up the beer anyway, I am more responsible for my actions?

All that said, there are obviously levels of accountability that need to be acknowledged. When it comes to opioids, many who are currently addicted got their start on the advice of a doctor who assured them that it was non-habit forming. They will have a different (but not necessarily non-existent) level of responsibility for their addiction. Hampton is right that we need to remember this when thinking about a public response, but he is wrong to say that in treating people living in recovery as human beings we should not be treating them as moral agents.

The flaws in Hampton’s book at this point are especially clear when we see that he is giving us only a very, very narrow picture of the life of drug usage. Over and over we’re told about people who are trying (whether succeeding or failing) to break the chains of addiction. They ask for help, go to treatment centers, check themselves into rehab, and attend AA meetings. They are truly trying to “live in recovery,” and this image is important to keep in mind. What we’re not given, however, is the full picture of addiction. We’re not told about people stealing from family, friends, and strangers to feed their habit. We’re not told about the violence and the self-harm, the collapse into greater and greater depths of vice in service to their need. In fact, we’re specifically told to reject such stories when they show up in popular culture as “hurtful” (pg 181), and to realize that when such things happen in real life they are merely “symptoms.”

“To the outside observer, a relapse looks ungrateful, careless, reckless, and insane. But its no more insane than the erratic behavior people exhibit when they’re in diabetic shock or suffering from a concussion.” (pg 88)

Notice that Hampton is discussing someone who has had a ‘relapse,’ which again suggests someone who is trying to recover. We’re not told about the lives of those who have simply given in to the habit, or who have not yet started attempting recovery, or who refuse to admit that what they’re doing is wrong and destructive in the first place. Again, all of this has to be taken into account when we’re thinking about the drug crisis. The issue isn’t just how to help the people who want to stop using drugs, it’s how to help the people who don’t.

Hampton also fumbles a bit with the question of identity. Over and over he talks about being a person in recovery as part of who he is and his consequent need for proper inclusion in society (hence all of his talk about this being a “civil rights” issue). The problem is, that doesn’t quite line up with his preferred language of sickness and disease. I suppose I might be missing something here, but it seems to me that in the civil rights/identity politics world, your identity isn’t something that you catch and then have to fight against. (I certainly can’t imagine any mainstream LGBTQ folks making that claim…) At least at this point Hampton wants to have his cake and eat it too, and doesn’t seem to realize how contradictory those two claims are. Either this is a civil rights issue, or its a health issue. It can’t be both, and society can’t respond in the same way if it’s one rather than the other.

Of course, in phrasing the issue as somehow balanced between those poles, we should notice that what has fallen out of the discussion is the idea that the drug issue is a criminal justice one. I know that’s what Hampton wants to see happen (re: all the discussion of responsibility and accountability above), but I’m not so sure we should just let that go. Given how personally and socially destructive drugs are, even accounting for all successful stories of recovery, there is still a solid argument for both keeping drugs illegal and for an active punishment for those who break the law. Again, that’s not to say there’s no room for reform (our criminal justice system is in serious need of reform), it is just to say that the need for reform does not mean we should overlook the massive social evils drugs and drug users create.

At the end of the day, it is undeniable that the opioid crisis needs immediate and thorough attention. It is also undeniable that this attention should be thoughtful, careful, and take into account all factors and nuances of both the situation and the people involved. Again, I’m not agreeing or disagreeing with Hampton’s specific proposals for treatment. I’m just saying that despite being well-written and clearly passionate, American Fix doesn’t give us a solid foundation from which to engage this crisis.

* Which isn’t to say I’ve got no personal investment in the issue–I certainly have family members who have been addicted to illicit substances and gone through treatment plans, and addiction of various types runs in my family so I know that I’ve got a vested interest in keeping an eye on myself and avoiding temptations as much as possible.

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