Why Drug Epidemics End

Despite rising overdose deaths, there’s some important good news regarding opioid misuse. Rates of nonmedical use by high school seniors have fallen by nearly 83 percent since 2002, when 14 percent reported having ever tried using prescription pain pills to get high. By 2021, that proportion was down to just 2 percent. Heroin use also shows a precipitous drop, with only 0.4 percent of 12th graders reporting trying it as of 2021.

This is especially welcome news because teen use is an excellent predictor of the course of drug epidemics: The vast majority of addictions start in late adolescence or early adulthood. Since the deadliest opioids like fentanyl are most often sold in the guise of prescription pain pills or heroin, this bodes well for reductions in overdose deaths.

But to translate this positive change into lasting reductions in addiction and overdoses, it’s important to understand how drug use patterns change over time and not view them solely as isolated crises related to specific substances.

The story of crack cocaine shows what can happen when the underlying causes of a drug crisis are ignored. In 1986 it felt impossible to avoid news about this drug. According to the authors of “Crack in America,” Craig Reinarman and Harry Levine, in July of that year alone, the three major TV networks’ evening news shows aired 74 segments on drugs, about half of which were about crack, warning that it was a crisis and a plague.

But crack use rates among high school seniors began dropping as soon as data on it began to be collected — and before fear about it drove billions of dollars in spending on policing and mass incarceration. It didn’t spread widely to middle-class neighborhoods, and at its peak, only 5 percent of 12th graders had ever tried it. By the mid-1990s, journalists and politicians had moved on to concern about heroin chic, and the decline in crack’s popularity wasn’t thoroughly explored.

Philippe Bourgois, now a professor of anthropology at the University of California, Los Angeles, followed the changes in the onset of crack use in East Harlem for his 1996 book “In Search of Respect.” He closely observed the lives of a group of Puerto Rican and Black youths who sold and used the drug. Most of the sellers he studied previously worked factory jobs that were disappearing rapidly in those years at the height of deindustrialization; the drug offered these young people a new source of money and a way to escape the distress of unemployment and diminished opportunities — similar to what has happened with prescription opioids in Appalachia.

But, Dr. Bourgois told me, not long after crack became common on the street, little children began saying “you’re on crack” as an insult. The damage the drug produced was “very, very, very” visible, he said, describing how people lost weight, lost teeth and began acting in ways that repelled their families and friends. “It was a terrifying thing to see,” he said.

Anybody who used crack “on any kind of regular basis became an object lesson for everybody around them — ‘You don’t want to go here,’” said Dr. Reinarman, a professor emeritus of sociology at the University of California, Santa Cruz.

In response, said Dr. Bourgois, many young men who sold the drug vowed to stay away from using it, with some describing their mothers’ addictions as their reason for avoiding it. “They wouldn’t take anything they considered a hard drug,” he said. “Because they’ve seen their mother get destroyed.” This didn’t, however, mean that they said no to all drugs; many consumed large amounts of cannabis. And it didn’t mean the economic stressors that drove people to crack in the first place were well addressed.

Today, with youth opioid use falling, America may be at another inflection point. “Quite often, drug epidemics follow a classic curve,” said Samuel K. Roberts, an associate professor of history and of sociomedical sciences at Columbia University, describing how they seem to start slowly, spike and then fall.

One reason for this pattern may be the rising visibility of harm associated with use, both in the media and, probably more important, among family and friends. “What makes it subside is usually a number of things,” said Dr. Roberts, “but one of them is often that the negative perception of a particular drug will take off.”

That seems to be happening with opioids now, given the extraordinarily high death rate. There is no fentanyl chic; the drug is publicly associated with sudden death, homelessness and skin infections, not fun.

“Most younger people, they’re very much concerned,” said Jeremy Sharp, the operations director for Students for Sensible Drug Policy, which organizes youth to fight for more compassionate approaches to drugs. “I think a lot of them have witnessed what happened to folks that are my age or younger, and I think it is a huge turnoff.” Mr. Sharp, who is 35, said he lost seven friends to overdose deaths in the past two years.

Just like youths in the crack era, however, this doesn’t mean young people aren’t doing other drugs. There’s a phenomenon known as generational forgetting, originally identified by Lloyd Johnston, who led the largest national survey on drug use among youths for the past 43 years. The idea is that young people often avoid the drug that is currently the most feared. But since they have little experience with those that were popular earlier, they are less aware of their potential dangers.

This results in a broadly defined cycle in which, roughly every 10 to 15 years, a different drug epidemic appears. Heroin, for example, was the demon drug of the 1970s, crack in the 1980s, heroin again in the 1990s, methamphetamine in the 2000s, prescription opioids in the 2010s and now fentanyl and other opioids that are being sold as heroin. By seeing and covering each crisis as being caused by a particular substance — without understanding why addiction persists — we miss the opportunity to use policy to reduce related harm.

A study published in the journal Sciencein 2018 found that rather than starting with the marketing of OxyContin in the late 1990s and early 2000s, the exponential rise in American overdose deaths actually began in 1979. Not coincidentally, economic inequality began to skyrocket at the same time. But in part because of racism and because the deaths involved different drugs and, for the most part, affected different groups of people in different regions — crack in cities and prescription opioids in rural areas — the rising trend was obscured. And politically, blaming drugs is easier than countering economic stresses.

People use drugs for reasons. Typically, those who become addicted struggle with hopelessness, trauma or mental illness — often all three. This economic and social pain is the commonality across drug crises. Until policymakers prioritize healing the distress that makes particular people and communities facing economic loss and trauma especially vulnerable to addiction, this vicious cycle will only continue.

Maia Szalavitz is a contributing Opinion writer and the author, most recently, of “Undoing Drugs: How Harm Reduction Is Changing the Future of Addiction.”

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