Opioids of the Masses: America’s Silent Killer.

“Keep ’em coming! Flying out of there. It’s like people are addicted to these things or something. Oh, wait, they are…”

— Steve Cochrane, sales executive at KeySource Medical.

Every day, over 130 Americans die from overdosing on opioids, according to figures from the US Department of Health and Human Services. In one of the most devastating public health crises ever seen, large pharmaceutical companies have incessantly promoted the sale of harmful, addictive drugs to ordinary people, lobbying on Capitol Hill and even influencing scientific journals to portray such drugs in a positive light. The result is an unmitigated catastrophe: in 2017 alone, 47,000 Americans died as a result of opioid overdose, and 1.7 million suffered from substance abuse disorders. Purdue Pharmaceuticals, Johnson and Johnson and other major companies have profited immensely from the suffering and fatalities caused by the substance abuse disorders developed by the victims of this epidemic. This piece will examine the roots of the epidemic and the nefarious actions of major drug companies, analysing how the obstinacy of the current Republican Party and their inability to see past their vision of deregulation and profiteering has alienated some of their core voting demographics. It will also analyse how the racialised notions of ‘licit’ drug use, treated as a public health issue and ‘illicit’ drug use as an issue to be criminalised enabled the deregulation of Big Pharma and proliferation of addictive opioids into rural American communities. Lastly, it will argue that the reintegration of discourses of race and class, and of legality and illegality, is essential if the Left is to prevent the far — right from taking advantage of the opioid crisis by blaming Mexicans and “foreign drug cartels”.

For decades, the Republican Party has relied on a blend of economic liberalism and social conservatism to draw together a coalition of rural white workers in de-industrialised Midwestern areas such as Utah, Applachia and Ohio, alongside big business and financial plutocrats. This coalition is rapidly becoming fractured, as the consequences of the privatisation and deregulation of the healthcare system become increasingly apparent. The maximisation of short — term profits, the premise of production under a capitalist economy, has facilitated the creation of the ‘pill mills’ of America, culminating in 3 of the biggest pharmaceutical providers shipping 9 million hydrocone pills to a single pharmacy in a town in West Virginia, with a population of just 392. Between 1999 and 2017, 400,000 people died due to overdosing on opioids, and in 2016 alone, more Americans died from opioid overdosing than had died in the Vietnam War, with opioids claiming more lives than car accidents, gun violence and deaths from HIV at the height of the AIDS epidemic. The worst effects of prescription opioid addiction can be identified in those same Midwestern heartlands on which the Republicans depend for votes. For the Republican Party to act meaningfully to counteract the extent of this epidemic would require diverting funds away from the pockets of rich shareholders.

Although President Trump has declared the opioid crisis a public health emergency, the alleviation of its worst effects would require departing from the Party’s deregulatory ideology. Some of the most senior figures within both parties have explicitly taken the side of Big Pharma, which has poured an estimated $2.5 BN into buying out politicians over the past decade, but this is particularly endemic within the Republican Party. That Trump’s pick for Secretary of Health and Human Services was Alex Azar II, previously the President of major Pharmaceuticals company Eli Lilly + Co, indicates that the problem runs deeper than he would like to admit.

It is not only collusion between politicians and Big Pharma that has allowed the opioid crisis to run rampant, but a warped conception of justice that views the unabated exploitation of millions of Americans as part of normal business ethics, as opposed to the ‘illegal’ drug trade, framed as an issue warranting punitive punishment. President Trump’s nomination for drug Czar, Tom Marino, was recently forced to resign over attempting to craft a bill which would prevent the DEA (Drug Enforcement Agency) from preventing the large scale shipment of opioids into some of the worst affected areas in the United States. The justification given by Marino for preventing the DEA from taking action was that pharmaceutical companies were being treated like illegal narcotics dealers. In distinguishing between the profiteering actions of Big Pharma, framed as honest business and the dishonest, immoral actions of illegal narcotics dealers, Marino unwittingly revealed the underlying prejudice at the heart of the opioid crisis: the conception of justice. One of the main reasons why Big Pharma has been allowed to proliferate as far into American public life as it has, to buy out politicians and to spend millions of dollars on advertising directly to consumers is that it is not viewed as a criminal or immoral enterprise. The demographics that Big Pharma appeals to: (ie. rural, white, midwestern) preclude it from encountering the sort of stringent regulations or punishments that other drug dealers encounter.

This warped conception of justice is bifurcated along racial lines. To examine the roots of this problem, it is imperative to analyse how the opioid crisis emerged out of the ‘War on Drugs’ in the 1980s and 1990s, and the connections and contradictions between the commercialised, legal, ‘white’ opioid trade and the heavily criminalised use of illegal drugs by Blacks and Hispanics. This dialectic of justice; whereby those who advocate for the deregulation and expansion of Big Pharma also support the criminalisation of drug use they deem ‘illicit’, has crushed working class Americans of all races under the yoke of Capitalism and the State. The Presidency of Ronald Reagan saw the expansion of federal efforts to (quite literally) ‘crack’ down on illicit drug usage, primarily amongst black users. The 1988 Omnibus Act, for instance, promulgated that 5 grams of crack cocaine would carry a 5 year prison sentence. Mass incarceration became the de facto policy, as public housing was denied to anyone who even had a family member convicted of a drug crime, and the list of crimes warranting the death penalty was expanded. As a result, 1 in 9 black children in the United States now has an incarcerated parent. The corresponding figure for white children is just 1 in 57.

The relationship between the conception of drug taking as a criminal activity rather than a health issue coincided with the deregulation of Big Pharma, as the other side of the dialectic of justice allowed major Pharmaceutical companies such as Purdue to market directly to consumers in rural, white areas. In 1996, Purdue introduced Oxycontin, backed by a fleet of sales representatives and marketed to primary care physicians for a multitude of minor ailments. Consequently, the revenue gained by Purdue rose from $48 Mn upon its inception to $1.1 Bn by 2000. This was an issue of bipartisan legislation, in which Democrats such as Joe Biden and Rudy Giuliani were just as complicit as any Republican. Giuliani, for instance, was Mayor of New York between 1994 and 2001, during which time he oversaw around 40,000 marijuana — related arrests per year, but provided legal defence for Purdue Pharma against federal charges regarding the marketing of Oxycontin. Providing Purdue with access to Washington politicians who could be bought and paid for, in addition to giving them protection against future attempts to prosecute them, Giuliani epitomised the hypocrisy at the heart of the way the drug issue was approached, and the reason why it has had such dire repercussions to this day. The combination of criminalisation for black drug users and absolution for white drug users prevented addicts from seeking help, while at the same time prescribing opioids as the solution for the problems of the overworked and underpaid.

Moreover, the success of Big Pharma in marketing drugs in rural and Midwestern areas has coincided with an uptick in heroin and synthetic opioid usage among urban American populations. This is partially due to the presuppositions that doctors have of nonwhite patients, but also due to the aforementioned notions of legality and illegality. That the opioid crisis has recently come to involve more urban areas, concentrated particularly in the Eastern Third of the United States, indicates that this is not merely a rural problem limited to deaths from prescription pills, but is part of a country — wide problem. Citylab notes that an additional, ‘syndemic’ crisis, comprising deaths from a mixture of prescription opioids and heroin, has recently broken out in metropolitan areas. 10% of metropolitan areas with over 1 million people are experiencing a syndemic opioid crisis. That illegal drugs are contributing to this epidemic to the degree that they are shows how prevalent, and yet ineffective, the criminalisation strategies have become, as ‘overdose prevention sites’ remain against federal law. These are sites where addicts can avoid overdosing by consuming drugs under medical supervision and find treatment, but were made illegal under the old 1986 Anti — Drug Abuse Act.

The extent of the corruption and collusion between Big Pharma and members of the House and Senate indicates that the Republican Party is ill — equipped to adequately deal with the opioid crisis. The aversion to harm — reduction on the basis of upholding ‘law and order’, coupled with their aversion to the necessary public expenditure and public investment required to alleviate the crisis’ worst ramifications has led to Trump and other senior Republican figures blaming Mexico and China for dumping Fentanyl on American markets. Trump, therefore, in deflecting criticism away from Big Pharma by implying that ‘sanctuary cities’ are responsible for drug smuggling and the proliferation of opioid addiction, is attempting to roll back the frontiers of the State in one form only to reimpose the State’s coercive power in a different form. The power of the State to deal with unaccountable corporations is significantly circumscribed, yet the power to offload the blame by targeting those who are suitably ‘other’ is accentuated. Keith Humphreys, a Stanford Psychologist, repudiated this logic in 2018, stating that:

“West Virginia is emblematic of where this epidemic is at its most destructive: rural areas that don’t have sanctuary cities and indeed generally don’t have cities at all. Recent immigrants are rare, yet opioid addiction is rampant. That’s because the opioid epidemic was made in America, not in Mexico, China, or any other foreign country.”

This demonstrates the necessity for the Left to take action on the Opioid epidemic: those rural communities who have been hardest hit may continue to blame foreign forces and other racial demographics and, as a consequence, may fall into the arms of the far right. These deindustrialised communities, which have become atomised due to the repercussions of neoliberal policy and ideology, contain many broken, isolated people. A study by Justin Pierce and Peter Schott has shown that the liberalisation of trade and rise in automation replacing low — skilled jobs has correlated significantly with increased mortality not just from opioids, but from suicide. Therefore a danger exists that, no longer able to organise around an economic or occupational identity, these communities will begin to organise around an ethnic identity instead. The left can either take their concerns seriously and hold Big Pharma to account, or can continue to alienate them further by referring to them as the ‘Basket of Deplorables’.

But it is not only the economic side of neoliberal atomisation that the Left should emphasise and oppose. The loss of family and community among these Midwestern areas is part of the reason why they are vulnerable to the far right. The far right can offer a sense of identity and belonging to disenfranchised rural whites, as we have already seen them offer to other disenfranchised whites via internet forums. The necessity for the Left to reengage with communitarian thinking and an in depth analysis of the contradictions of capitalism is particularly essential in an era in which the nativist, racist far right seeks to hijack causes that were once left wing. Hostility towards Globalisation, for example, which was dominated by anarchists, communists and anti — World Bank/IMF campaigners during the G20 protests in London and protests in Berlin in 1988, Paris in 1989 and Washington in 2000, has now morphed into an opportunity for the far right to peddle antisemitic conspiracy theories about George Soros as the central figure in an international banking conspiracy.

To prevent the opioid crisis from being remoulded by nefarious right wing interests as an issue for which Mexicans and other racial groups can be blamed, the Left must take on a bold plan to hold Big Pharma to account not only economically, but criminally. Bernie Sanders has proposed the imposition of a civil fine or salary confiscation for any manufacturer or distributor who illegally markets an addictive opioid product, and to revoke market exclusivity for such products. Elizabeth Warren’s plan, cosponsored by Sanders, would commit $100 Bn over 10 years to harm-reduction programmes. These are potentially transformative measures, which must be combined with a recognition of the destructive notion that addiction is a crime. In conjunction with a bold, socially democratic agenda that recognises the realities of how precarious and low waged work can lead to workers taking opioids as a way of managing physical pain, such a programme could provide a starting point for the transformative economic and social plan that the American left requires to take on this crisis.

The Opioid epidemic has torn apart vast swathes of the United States, from the urban areas in which heroin has been used in lieu of prescription pills, to the rural areas in which pills manufactured by exploitative multinational corporations have caused overdose death tolls that rival major wars. This crisis has not developed out of nowhere, but has emerged out of a conception of justice within America’s governments for decades. Both Republican and Democratic administrations have posited a difference between ‘illegal’ drug taking by Blacks and Hispanics, judged as a criminal offence to be prosecuted and ‘legal’ drug taking by Whites, precipitating the deregulation of Big Pharma and the marketing of addictive opioids to these Midwestern communities. Therefore, race has played a key role in allowing Big Pharma to become so unaccountable. That the epidemic has fatally split the Republican Party between its donors and plutocratic supporters (among whom are many Big Pharma executives), and the Midwestern rural populations in key swing states who are most afflicted by this crisis, has led to them offloading the blame onto racial ‘others’ such as Mexicans and foreigners, placating Big Pharma. The priority for the Left, therefore, must be to combine an unapologetic assault on Big Pharma with a communitarian engagement with the communities that have been afflicted. A thorough reintegration of the discourses of race and class, and an acknowledgement of how the working class of all races has been harmed, can explain not only the origins of this crisis, but its solutions.