A review of Ryan Hampton, American Fix: Inside the Addiction Crisis and How to End It (All Points Books, 2018)
A necessary and moving call to action. But we need more nuance in our discussion of anonymity and more critical reflection about the intersection of addiction and racism.
How can we convey the magnitude of the opioid epidemic? In American Fix, Ryan Hampton calls it a “genocide.” If you find this word too strong, he would respond that you have not registered the scale of the crisis. People with a medical illness—addiction—have been deliberately targeted by corporations for profit, denied treatment or mistreated on a large scale, criminalized for their symptoms, socially stigmatized, and abandoned to die. “Imagine,” he writes, “that every three weeks, 9/11 happens again. That’s how many people are dying due to opioids in this country. Or imagine that a full jetliner crashes every three days: every man, woman, and child on board is erased.” Since the beginning of the epidemic, over 800,000 people have lost their lives. 500,000 more are projected to die in the next decade. Drug overdoses are now the leading cause of deaths of Americans under the age of 50. Two million opiate users meet the criteria of substance use disorder. “Genocide” might not be a great fit, but we don’t have many words to describe a catastrophe of these dimensions. “This is,” Hampton warns, “our Black Plague.” More personally: “It’s a tsunami of loss.”
American Fix is nothing less than a manifesto. A former White House staffer and Democratic Party fundraiser, Hampton is in long-term recovery from ten years of active opioid use. His addiction began with a prescription of Diluadid for a sore ankle. Before he found sobriety, he ended up scoring oxycontin at pill mills, shooting heroin, burning his career to the ground, alienating his friends, losing his apartment and sleeping on couches, begging for change to eat at a homeless shelter, attending multiple rehabs, and watching scores of people like himself die. He believes that America needs to see the individuals masked by the statistics and stigma: “I was a person when I injected heroin, and I’m a person now. I’m also an advocate, a brother, a son, a friend, and a writer. I love my dog. I sing in my car. I’m a person. I also happen to have a life-threatening, terribly misunderstood chronic brain disease commonly known as addiction.” However, he doesn’t think that his book alone, or a dozen others like it, will accomplish this task. His most significant message is directed at others living with addiction. Hampton believes that we have remained silent for far too long while politicians, the medical profession, and the treatment industry have shaped the discussion and crafted policies with devastating consequences. “We need our own Pride event,” Hampton declares. “We need to fill public parks and streets, just as the Occupy movement did….We need people from our community in office, crafting policy that benefits people with substance abuse disorder.” He envisions a mass movement for addiction and recovery rights that would transform government, medicine, and the legal system in far-reaching ways.
To visualize the scope of the necessary changes, we have to understand the power of the industries that profit. Hampton describes an entire model of capitalism based on monetizing addiction. It begins with the pharmaceutical companies. Hampton doesn’t mince words: “They’re evil.” At this point, there is no doubt that they deceptively market addictive and potentially lethal products as part of their business models. Hampton lays it out: “Pharmaceutical companies planted and watered the seeds of the drug epidemic all in the name of profit. They created a medically sanctioned golden goose: protected by the government, aided by medical professionals, and commercially distributed by the pharmacists.” Then there are America’s doctors, who are lavishly courted by pharmaceutical reps and incentivized for prescriptions. Most physicians receive a one-hour lecture on addiction in medical school. In other words, the people responsible for monitoring legal drug use are frequently uninformed regarding basic addiction science and medicine. The list goes on. There is the vast industry of public and private prisons, policing, and repressive technologies that exploded during the decades-long and racist “war on drugs.” Imprisoning rather than treating people with substance use disorder, especially Black and poor people, is still big business. And in the cracks of the system, there are the scavengers: the hundreds of “pill mill” clinics that mushroomed to capitalize on the opioid epidemic; the strip-mall pharmacies that appeared to fill these prescriptions; the fake recovery houses that scam people seeking help….
Some of the most infuriating and heartrending pages of American Fix are aimed at the for-profit treatment industry. Recognizing that many rehabs have the best of intentions, Hampton argues that the twenty-eight day inpatient treatment model—the industry standard—is profoundly flawed. Developed in the 1950s for alcoholics, this framework has not evolved with the current understanding of how to treat opioid addiction. Rather than a calibrated approach designed for individuals, most facilities follow a standardized format: inpatient care of highly variable quality (there are no industry norms and little regulation), suggested outpatient follow up, and no aftercare. Treatment is not integrated with primary medicine, long-term patient support, or quality mental health care—let alone vocational training and other resources designed to help people with addiction transform their lives. Many facilities don’t prescribe Medication-Assisted Treatment (such as buprenorphine), despite its proven effectiveness in reducing relapse. In short, treatment centers offer acute intervention mislabeled as a solution for a chronic illness. After inflated promises, rehabs release patients back into their former situations. Families are then devastated when their recently “cured” sons or daughters use again. And relapses following inpatient treatment—given the reduction in tolerance after a month of abstinence—are especially lethal. What is necessary, Hampton argues, is a five year plan, including integrated aftercare and safe, sober living facilities.
The above scenario, however, is much better than what often happens. As the scale of the epidemic became clear, there was an overnight explosion of hastily assembled treatment centres, some of which offered zero programming beyond driving people to local AA or NA meetings. “Lack of strict oversight,” Hampton explains, “combined with a mathematically unlimited market created a gold rush.” Designed to appear identical with legit facilities, these rehabs are little better than scams targeting desperate families and insurance companies. American Fix describes predatory “brokers” scouring the streets to recruit people with addiction with medicaid for fly-by-night programs, facilities holding people against their will while they continue to bill their insurance, daily 25 dollar urine tests billed at fifteen hundred bucks a pop, and rapid turnover in poorly trained staff. (Hampton doesn’t mention sexual assault in treatment centers. When the histories are eventually written, abuse in rehabs, the exploitation of sex workers, and predation against women while using will fill many, dark pages.) Such exploitation is made possible by the systemic failure of the health care system.While millions pass through facilities each year, only a tenth of those living with substance use disorder receive treatment of any kind.
Stigma makes this all possible. Despite increasing recognition that addiction is a disease, substance use disorder continues to encounter fear, miscomprehension, and revulsion. “Go kill yourself.” “You don’t deserve to live.” “You did this to yourself.” “Junkie.” This is a sample of the messages that Hampton receives daily. Even when they know better, many people respond to addiction as if it were a moral failing or weakness of the will. This attitude, Hampton argues, even seeps into the recovery community. His best example is the way that we talk about relapse. Hampton doesn’t deny that we can do a great deal to manage our disease and limit the likelihood of resumption. But anyone—no matter how many years of sobriety they have—can relapse. They are common in early recovery. In short, relapse is a symptom of addiction. “It doesn’t mean they were not ‘working their program’ or didn’t want to stay healthy,” Hampton explains. “It simply means their symptoms flared up.” The sensible response is to adjust the treatment plan—as one would respond to the aggravation of any other chronic illness. Instead, treatment centres threaten to expel patients who relapse in order to free up beds for “people who really want to get better.” In twelve step programs, people who “slip” are sometimes shamed for not working hard enough to stay sober (although, in my experience, this attitude varies between groups and many people also welcome relapsers back warmly). People lose their jobs for relapsing. They can go to jail. Addiction is a difficult illness to control in the best of circumstances (stable employment, housing, adequate medical and mental health care, a supportive family and social network); and the circumstances of most people with substance use disorders are far from ideal. Given how inadequate treatment often is, these responses to relapse are nothing less than cruel.
As a manifesto, American Fix sounds a call to arms. It is not a nuanced, multi-causal analysis of the epidemic nor is it meant to be. The first pages promise to take the reader inside the crisis and show (as the subtitle says) “how to end it.” The broad-strokes picture it offers is generally compelling. But we are no longer at the beginning of the response to the epidemic. In the last three years, there has been a large mobilization of national, state, and local resources; the allocation of billions of dollars; and an outpouring of media coverage. State legislatures are currently a battle ground between proponents of competing agendas, all of which claim to be “humane solutions,” but which have starkly different implications for treatment, patient rights, and criminalization. I have heard frontline care providers express frustration that so much money is being earmarked to tackle opioids that it is limiting their capacity to respond to other addiction crises they are seeing, namely alcohol and crystal meth. And still, none of these measures has stopped the deaths, although provisional evidence suggests that their rate of increase is slowing in some states. Along with untangling the politics behind the competing responses, we need fine-grained analysis of what is working and what is not in different contexts (some research suggests what is driving the crisis varies between urban and rural geographies). American Fix champions general principles—harm reduction, health care rather than criminalization, fighting stigma, reforming medical eduction, transforming the treatment industry—rather than a detailed blue print.
Hampton is most compelling when he connects opioids to the larger addiction crisis. The number of opioid overdoses is both horrifying and enraging. It is also true that a greater number of people die every day from alcohol-related causes, a reality that has been all-but normalized. In 2014 20.2 million adults aged 18 or older (8.4 percent of the total population of adults) reported a substance use disorder. 46 percent of adults report that a family member or close friend has been addicted to drugs. Eliminating the stigma around the disease of addiction will require transforming society’s deeply engrained denial regarding its ubiquity. In short, American Fix is calling for a cultural revolution. Moreover, phenomenon such as the opioid epidemic and alcoholism are not fully distinct. As has been widely reported, the confluence of drug overdoses, alcohol-related liver disease, and suicide has driven an unprecedented growth in midlife mortality for white Americans without college degrees, especially women. These “diseases of despair” reflect the cumulative impact of de-industrialization, wage decreases, hollowed-out neighborhoods, collapsing families, and diminishing life opportunities. And these processes of neoliberal capitalism—it should be underscored—have assailed Black and Latino communities with even greater intensity. As journalist Zachary Siegel argues, a one-sided emphasis on the crimes of big Pharma risks obscuring the epidemic’s social drivers. Along with Hampton’s cultural transformation, we need a confrontation with the interweaving structures of class and racial power.
In the recovery community writ large, the most controversial aspect of Hampton’s book will almost certainly be its rejection of anonymity. The traditions of Twelve Step Programs such as Alcoholics Anonymous state: “Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.” (There is no central enforcement mechanism for the traditions: each local AA group is fully autonomous and no one can be disciplined or expelled for breaking a tradition.) Acknowledging that this stance made sense when AA emerged in the 1930s and alcoholics faced severe discrimination, Hampton argues that the public silence of people in recovery is deadly in the context of the epidemic. Although the situation has started to change, people in recovery were initially invisible in debates over the nature of the crisis and the correct response. They were not widely represented in the press. They were frequently not incorporated in task forces and leadership groups. They had few, if any, national political organizations of their own to mobilize, demonstrate, and advocate in their interests. The “addict” remained faceless, feared, stereotyped, marginal, and despised. Your “normal” coworker, friend, or child was not a “junky”—nor were you as long as your use remained confined to just what the doctor ordered. Hampton quotes ACT UP’s slogan from the height of the AIDS crisis: “silence=death.” The only way to transform the ignorance and stigma surrounding addiction, he concludes, is to come out.
Anonymity is a complex and charged issue. It provokes heated reactions because it concerns both the organizations that many people rely on for their continued sobriety and the possible revelation of the most sensitive aspects of their lives. As Bob White (the deeply wise historian of U.S. recovery movements) once remarked, the discussion about anonymity should not take the form of a war between two camps. Hampton convinced me of his main argument: we urgently need to find ways to intervene in public and policy discussions around addiction while offering visible models of long-term recovery. We have to become agents in transforming the entrenched denial around addiction and the social, legal, and medical discrimination against people with our disease. In his more cautious moments, Hampton recognizes that not every person in recovery needs to go public: an energetic minority can have a transformative impact, especially if they are supported by the vast number of people who either suffer from addiction or whose families have been touched by the illness. Hampton is probably right in arguing that a common interpretation of anonymity in twelve step programs—although it is not the only one on offer—has served as an obstacle to building this movement.
That being said (and it’s a big that), I wish that his discussion was more nuanced. For starters, we should show compassion for what motivates each other’s choices. To be blunt, it’s not our place to take other people’s inventories on this question. The people in recovery speaking publicly are doing essential work. We need to support them. But not everyone is in a position to act so openly. They may be prevented by their immigration status, their employment, or the potential impact on their partners and children. Of course, sometimes it’s not a choice at all. Some people’s history of overdoses or arrests are online, seriously complicating their ability to find work and housing. Hampton concedes that anonymity made sense in the climate of the 1930s, but this argument sits uneasily with his central thesis: people with the disease of addiction face wide-spread and systemic discrimination. Most importantly, we should understand that people need to make the best decision for their own recovery. Some of us are genuinely able to balance well-being with being out in our communities. For others, however, the stress of this scrutiny is too much in the context of the difficult, uncertain, and often precarious process of living sober day-to-day. One could reply that the choice not to live openly is a privilege enjoyed by people in recovery that is denied to most other marginalized groups. But it’s not so simple. For people struggling with addiction, their sobriety is a life-or-death question—as well as a matter of the well-being and safety of their families and others around them. They can’t afford the gamble.
In the flush of polemic, Hampton slides into treating anonymity as an all or nothing proposition. At times, he writes as if there were two choices on the table: either we broadcast our identities over the airwaves or we hide under the pews in the proverbial church basement. But there are ways that we can be more visible while shielding ourselves from the kinds of discrimination that online exposure (for example) might produce. Depending on our situation, we can begin speaking about our recovery in our churches, university classes, unions, political organizations, and with our coworkers or larger circles of friends. Transforming the media landscape is crucial work, but so is the frontline labor of changing people’s preconceptions face-to-face. There are also ways that we can engage politically without disclosing our illness. We can raise issues related to addiction in different contexts without self-identifying. We can volunteer our time and money to local recovery advocacy organizations. We can write in professional magazines or church bulletins under our initials. Posing the question of anonymity in yes-or-no terms, Hampton risks obscuring the ways that we can become active while still protecting ourselves in the fashion demanded by our situations.
Finally, Hampton equivocates on a crucial issue. Is he arguing that AA and other twelve step programs should drop the principle of anonymity or that we need other types of organizations that we can use for political mobilization? It’s not clear. The tradition of anonymity does not discourage anyone from publicly identifying as a person in recovery (although some may interpret it in this way). It asks people not to present themselves in the media as members—and therefore as representatives—of AA or NA. Beyond the question of discrimination, there are sound reasons for this norm. Predecessor organizations of AA were damaged when their (sometimes self-appointed) spokespeople relapsed or became entangled in scandal. They were also fractured by political debates. Public anonymity may seem restrictive, but it helps guard against controversy, factionalism, and prestige battles so that it remains focussed on its primary purpose: helping alcoholics achieve sobriety. Hampton’s forceful call for people in recovery to organize resonates with me. But the logical conclusion is not that we transform organizations that developed for one purpose into something else. In my opinion, the debate over anonymity and twelve step programs is misdirected and needlessly divisive. The better question is “what new political platforms do we need in order to generate change?”
“The American drug epidemic,” Hampton observes, “has further exposed the deep inequality of race, class, and gender in our country. Who gets help for their substance use problems, when, and how are all reliant on how white and well off they are.” America Fix is not a book of color-blind liberalism. Hampton devotes an entire chapter to the “War on Drugs” which emphasizes its systemic racism and devastating consequences for Black communities. Importantly, Hampton challenges the whiteness and general middle class nature of the current recovery movement leadership. In these respects, his book marks a significant step beyond the film The Anonymous People. While making a genuine effort to depict the diversity of the recovery community, the film only briefly mentions the media’s obsession with inner city black men during the crack epidemic and never once uses the word racism. It also neglects the history of organizing in Black communities around the problems of drugs and addiction, for example the ground breaking programs of the Black Panther Party.
However, Hampton struggles to balance two realities: depicting addiction as a disease that affects every American and recognizing the structuring role that racism plays in society’s response. Ultimately, the first emphasis wins out. This tension is evident in his discussion of the “War on Drugs.” Hampton depicts the integrated system of racialized policing, mass incarceration, and targeted political repression as an irrational drug policy that was implemented in a racist fashion. The work of scholar activists such as Michelle Alexander, Keeanga-Yamahtta Taylor, and Ruth Wilson Gilmore has demonstrated that this narrative is inadequate. Originating in white reaction to the Black freedom struggle, the “war on drugs” created an infrastructure designed to police racialized surplus populations produced by the neoliberal reorganization of the economy while reversing the limited forms of integration propelled by the Civil Rights movement. In Alexander’s phrase, it created a “New Jim Crow.” Neglecting this political dimension, Hampton understates the extent to which structural racism is a key obstacle—neck-and-neck with stigma and profit-driven medicine—to rational drug and addiction policies. As a result, he advocates a lowest-common-denominator politics in pursuit of the (ever elusive) all-American, bipartisan coalition. In his final chapter on strategy, Hampton proposes an “addiction pledge” as a tool to determine which candidates the recovery movement should endorse. I embrace much of what he suggests: humanizing addiction, expanding early intervention, mainstreaming addiction services, and promoting multiple pathways to recovery. However, Hampton fails to include planks that explicitly address the racism targeting Black people and other people of color, for example massive investment in African American communities or reparations for people whose lives have been destroyed by the “War on Drugs.” Avoiding the call for decriminalization (although, earlier, he states it’s his own preference), he incorporates the demand for “criminal justice reform,” language which falls rather short of challenging the systemic racism of the carceral state. This reticence is compounded by moments of tone deafness. In particular, Hampton repeatedly lays claim to the heritage of the Civil Rights movement—a form of appropriation widely critiqued by Black activists—without seeking to support or build alliances with contemporary African American political movements, for example the Movement for Black Lives.
In posing this critique, I am not trying to score points for being “radical” or rehash the perennial debate over single versus multi-issue coalitions. There is nothing “single issue” about addiction. The failure to address this public health crisis connects every institution in our society: the health care system, the legal and criminal “justice” system, education, and the economy. In a concrete manner, it relates to how we understand human well-being; who we include in our communities; what it means to heal, make restitution, and forgive; how we respond to trauma and pain; the missing spiritual core of consumerist society; and the place of compassion within our culture. A true solution will require including people—and values—that fall on the “left” and “right” of America’s highly artificial political divide. Here, I agree with Hampton and I am truly grateful for his work. Nevertheless, every mass movement for change since the late nineteenth century has had to confront the central role of anti-Black racism in maintaining the status quo. When movements have downplayed this question (for example, by addressing it “indirectly” in economic terms), they have either fragmented on racial lines or sacrificed the needs of African Americans in order to gain advances for whites. No doubt, making anti-racism more central to the recovery movement will alienate some sections of “main stream” America. But in confronting this question, we face a test even more important than political unity or legislative effectiveness: are we ready to tell the full story of addiction?