Invitation or Invasion? America’s Opioid Epidemic, Politics, and, Poverty

During the tumultuous 2016 election season in the United States, the opioid abuse epidemic sweeping the nation became a political talking point. Politicians, journalists, and activists alike have tried to capture the sense of helplessness and hopelessness that opioid addiction has brought to the nation’s heartland.

        Then-presidential candidates Donald Trump and Hillary Clinton laid out plans for combating addiction to heroin and other opioids across the Midwest. Meanwhile, journalists pondered whether opioid addiction may have swung the election in President Trump’s favor. Activists expressed concern over the difficulties addicts face in accessing rehabilitation and treatment. Author J.D. Vance, best known for capturing life in America’s Rust Belt in his memoir Hillbilly Elegy, described heroin as an invader that crept into his small Ohio town “not by invasion but by invitation” of his town’s hunger for the drug’s pain numbing effects.

Opioids are a class of drug that includes heroin as well as painkillers such as fentanyl, codeine, morphine, and oxycontin. Opioid painkillers are often prescribed to patients suffering from burns and other injuries and those recovering from surgery. They are also used to ease suffering in patients with terminal diseases like cancer. These substances provide pain relief coupled with a sense of euphoria, and that’s one of the factors that make them so addictive.

The World Health Organization lists lower socioeconomic status (SES) as a risk factor for prescription opioid overdose.  While low SES individuals are by no means the only users of opioids, they are more likely than higher SES individuals to face negative health outcomes because of their drug use. As Galea and Vlahow explain, poorer injecting drug users are less likely to receive medical help for their addiction, less likely to receive information on risk reduction, and more likely to engage in higher risk drug use. It is unsurprising, then, that the epicenter of opioid addiction and overdose in the United States coincides largely with areas of the nation which have been devastated by decades economic decline, decreasing job opportunities, and deindustrialization. These areas hardest hit by an influx of opioid addiction include West Virginia, Ohio, Kentucky, Indiana, as well parts of New Hampshire.

It is important for the United States to pay attention to rising rates of opioid addiction and overdose deaths. According to the CDC, prescription opioids were involved in 22,000 deaths in 2015, working out to 62 deaths per day. Importantly, that number does not include deaths from heroin overdoses. Opioid-related deaths are straining healthcare systems and emergency services across the nation. According to an article on opioid addiction from the National Institute on Drug Abuse (NIDA), it is estimated that healthcare expenses associated with opioid pain relievers taken non-medically cost the insurance industry average $72.5 billion every year. Dependence on prescription opioids has also been tied to heroin dependence. Half of injecting heroin users surveyed by NIDA had used prescription opioids first, some even switching to heroin because it was cheaper. As the opioid epidemic continues to spread, these negative impacts are growing as well.

        But opioid abuse does not just ruin lives and livelihoods in downtrodden communities in the United States. Although the opioid abuse epidemic in the United States is a localized issue, the effects of the drug’s trafficking and production spills over into the international realm. Globally, opioid abuse in the United States encourages the production of illicit opioids such as heroin, degrades environmental systems in production areas by way of deforestation and soil depletion, disrupts life in poorer communities, and renders treatment inaccessible to those who most need opioid pain relievers. In order to effectively combat the opioid abuse crisis, the international community must recognize and grapple with both the local and international costs of opium addiction.

        One way that opioids negatively affect the environment is through deforestation. In order to cultivate opium poppies, large swathes of suitable land must be cleared.  The United Nations Office on Drugs and Crime estimates that 281,800 hectares of land worldwide were being used to cultivate opioids in 2015.  Deforestation has also been linked to areas of drug trafficking. In the case of drug trafficking, deforestation can occur during the development of infrastructure for illicit crop cultivation. This includes the creation of landing strips and roads to transport drugs such as opium more quickly.

        The production of illicit opiates has impacted the global environment in other ways as well. Opium production in the rainforests of Thailand and Burma has been found to cause soil depletion. Soil depletion creates obvious problems for rainforest ecosystems, which may struggle to recover following opium cultivation. But depleted soil also affects the ability of poorer communities, such as small landowners and subsistence farmers, to live off of these lands. The relationship between soil depletion and opioid production is also the case in Afghanistan, where failing opium crops leave poor farmers with no alternative livelihoods.

        Illegal opium cultivation and opioid production does not just damage ecosystems in the developing world; it can damage community structures as well. In Afghanistan, the world’s largest opium producer, the connection between opium production and the nation’s violent insurgencies has been well documented. In war-ravaged Afghanistan, the success of opium crops is tied to the need for better development policy. Opium is a cash crop, allowing struggling farmers to generate the income they need to support their families. In the absence of other means of supporting themselves in a destabilized nation, farmers will continue to grow opium. Opium cultivation has, in short, helped fund an armed insurgency that destabilizes the nation and makes it difficult for farmers to produce other crops.

        It is important to note that there is a difference between the environmental and social impacts of legally and illegally produced opium crops. Legal opium crops are grown under strict government supervision in places like India, Spain, and Australia. In places where opium is being legally cultivated for production into opioid painkillers, the impacts of deforestation and soil depletion on ecosystems are regulated by the government. Legally produced opium also does not bring violence into these international communities, as access to the crop is often tightly controlled. Legal opium crops are only sold to companies that produce legal painkillers, as opposed to armed groups that traffic in illegal opium. It is the illegal production of opium for illegal drugs including heroin and counterfeit painkillers that presents problems for ecosystems and communities.

While the United States suffers from the harmful effects of over-prescribing potentially addictive opioid painkillers, people in many other parts of the world are unable to access opioid pain medications. In a 2011 study published in the Journal of Pain & Palliative Care Pharmacotherapy, researchers found that 83% of the world’s population lives in a nation with little to no access to opioid pain medications. In fact, the researchers discovered that only 7% of the world’s population had adequate access to opioid pain medications. In places where these painkillers are not easily accessible, individuals, even those suffering from excruciating pain, must go without.   

Why are so many people around the world unable to access opioid painkillers? Research suggests that American addiction may play a role in this disparity as well. Americans alone consume some 80% of the world’s opioids. Those who become addicted to painkillers and heroin are willing to spend vast sums of money on legal and illegal opioid products. The RAND Corporation estimates that American users spent 27 billion dollars on heroin alone between 2002 and 2010. Opioid addiction in the developed world can inflate the price of opioids and impact on the ability of individuals in the rest of the world to afford opioid medications. In the United States, just 50 milliliters of morphine can cost 38 dollars. Other painkillers, such as fentanyl, are even more expensive. Take into account that long-term patients suffering from diseases such as cancer can require much more than 50 milliliters of morphine and it is easy to see how that price may burden already cash-strapped healthcare systems in the developing world.

        While the environmental and social problems stemming from illegal opioid production may make banning or reducing opioid production altogether seem like a promising solution to America’s opioid epidemic, this is not the case. The majority of the world’s population still lacks access to life-saving opioid painkillers, meaning that policies focusing only on the supply-side are not the solution the global poor need. Solutions to the myriad problems caused by America’s addiction to opioids must come instead from reductions in the nation’s demand for opioids.

        When J.D. Vance remarked that heroin had been invited into his community, he was recognizing the role that America’s demand for opioids plays in exacerbating the crisis domestically. In order to reduce the nation’s dependence on opioids, America must come to terms with the factors that led doctors across the nation to overprescribe opioids. This includes encouraging the prescription of non-opioid painkillers, better communication between doctors, pharmacies, and law enforcement organizations, and working to make rehabilitation programs more accessible for users. Unless demand-side policies are utilized to reduce America’s addiction to opioids, the global poor will continue to suffer.

Angela Pupino

About Angela Pupino

Angela Pupino is a Junior in the School of International Service pursuing a BA in international studies with a concentration in global inequality and development and a minor in public health. Angela has interned at the Center for Community Change and studied health policy while abroad in London, England. She is a staff writer for the International Development, Sustainability, and Public Health column.