By Janice Russell
-Executive Summary-
Opioid use, abuse, and overdose have always been a homeland security matter, even before the Department of Homeland Security was established. The first federal law focused on opium products was passed in 1914, and since that time a multitude of laws and policies have been introduced to control the influx of opioids into the U.S. and to control the use, abuse, addiction to, and death from opium-based products, both licit and illicit.[1]
The Department of Homeland Security is engaged in interdiction efforts and in the effort to combat individuals and groups who transport opioids and their precursors, which are used to manufacture opioid based drugs. This effort has not been successful; opioid use, addiction, and death from overdose increases in the U.S. every year. The threat of opioids to the U.S. has morphed from opium designed to be smoked, to crude opium manufactured into illicit substances such as morphine and heroin, to the driver of the current opioid crisis, synthetic fentanyl and new analogs that become undetectable as they change.
Drug policy and the war on drugs have been focused on supply reduction since their inception yet attempts to prevent drug use and overdose deaths from opioids have failed miserably.[2] Much of the reason for this failure is that U.S. drug policy does not sufficiently consider the second challenge; demand for the drug that is rooted in systemic inequality that is beyond deterrence through punishment.
Data show that between 1999 and 2016 overdose deaths from prescribed opioids and fentanyl have increased 583 percent in women, as opposed to 404 percent in men; women are also more likely to use opioids to commit suicide than men.[3] Moreover, though there has been a decrease in the number of prescriptions for opioids since 1999, opioid overdoses continue to increase due mainly to overdose from illicit fentanyl and analogs. In 2021, there was a 23% increase in opioid overdoses over 2020.[4]
The U.S. is at a crossroads. The most recent rise in opioid addiction and overdose has introduced a new threat to the nation, and without momentous action to understand and confront women’s biopsychosocial needs, not only will the war on drugs continue to be futile, but the women who are caught up in the failed war and those who depend on them will be lost.
- RESEARCH DESIGN
In this thesis, I analyzed U.S. drug policy for its efficacy in helping women who are using or addicted to opiates stop using. I used gap analysis and biopsychosocial theory (BPS) for the analysis. The gap analysis identified shortcomings in past and existing policy, while BPS framed the recommendations for policy change.
Gap analyses are often used to determine the efficacy of public and private policy.[5] Gap analysis is used to determine whether a policy as written reaches desired goals and outcomes through its implementation, and to fill the ‘gaps’ between desired outcomes and the outcomes that will be realized though the policy.[6] Though this method is a good framework to evaluate the efficacy of a policy, it does not adequately inform the researcher about how to close the gap between what is desired and what is possible through the current policy. To determine changes that must be made to the policy, further analysis of the gaps and scientific best practices must be employed.
Combined with gap analysis, the biopsychosocial theoretical framework of human behavior and wellbeing allows a thorough examination of a policy’s ability to meet the unique needs of a population through implementation.[7] The BPS informs analysis of the changes needed to fill the gaps in a policy, should there be any.
- ON DRUG POLICY AND LAW
Drug law and policy in the U.S. spans over 100-years. The intended purpose of the first laws was to control the distribution and use of opium products and remained the law of the land for over 50-years. Subsequent laws placed mandatory minimum sentences for drug manufacturers, distributers, and users of illicit opioid products. Though all laws speak to supply reduction, few include measures to confront demand for the drugs.
Drug laws in the U.S. have not always been implemented for the welfare of the people, rather they are often guided by political priorities, the need or desire to control people’s behavior, and pushed on the citizens using hyperbole, fear, and pandering to stereotypes of women drug abusers and racism. A pattern in the conception and tone of drug laws can be seen from the first Federal narcotics law of 1909, to the National Drug Control Strategy of the Biden-Harris Administration in 2022.
From the inception of drug law and drug policy, physicians have been criticized for overprescribing. Physicians are accused of being too lazy to research patients’ symptoms and diagnose the core sources of their illness. It is well documented that during opioid crises, physician overprescription has been a variable in every case.[8] It is also clear from the history of drug law and policy that the legal course is not going to cure the ills of U.S. culture that lead to drug use and abuse.
The Nixon administration was the first to incorporate a treatment arm in their drug policy. Unfortunately, that policy was short-lived and by 1980 treatment had been written out of drug policy. Only Nixon’s drug policy and to some extent Carter’s drug policy came close to addressing the core issues that underlie drug use, and those attempts were still miles short of what is needed to combat the drug problems found in the U.S.
Through over 200 years of drug policy and treatment it has become clear that as with any social issue, there is not one policy or program that can entirely address and eradicate a problem. There is a complex interaction between poverty, helplessness, despair, and hopelessness that is connected to drug use, abuse, addiction, overdose, and death. Acknowledging that the use of drugs that alter the consciousness of human beings will continue regardless of laws or policies, and then developing a system of counteracting the source of, and the most dangerous and harmful aspects of drug use, is a realistic and common-sense approach to drug policy and law.
As previous U.S. drug policy has done, the existing federal policy on opioids does little to address women’s unique needs. This policy follows the same pattern as every other U.S. policy written to address drugs. It is punitive, it does not offer any substantive action to alleviate the core issues and social ills associated with drug use and abuse, and it lacks focus on women’s experiences in the drugs arena. It risks failure because of these shortcomings.
- ON WOMEN’S EXPERIENCE WITH OPIOIDS
Rich feminist scholarship that emerged in the early 20th Century with the battle for women’s reproductive rights underpins this research.[9] Though the present research is not specific to reproductive rights, the discourse from those early disputes carries on through current women’s health issues. Since the early 20th Century, the Women’s Health Movement (WHM) has emerged, arguing for inclusion of women in medical research and consideration of women’s unique medical needs in diagnosis and treatment.[10] Despite these calls, in many instances women’s unique experiences are largely ignored. Diagnosis and treatment of opioid use and abuse, and public policy represent two of those instances.
Though many great strides have been made in women’s health care, health issues and conditions for which little progress has been made continue to persist.[11] One of these is use and abuse of opioids by women. While Sanger and her contemporaries spent decades fighting for bodily autonomy for women, women who struggled with drug abuse did not have the same advocacy.[12] Perhaps due to lack of advocacy, or perhaps due to the stigma associated with drug abuse, women’s struggle with opioid use and abuse has not been met with sufficient action to overcome the core issues related to drug abuse in this nation.
The issue is not just about women and opioids, but about the recognition of women’s experiences more broadly. Though there has recently been an increase in the examination of sex differences in many academic, medical, and sociocultural arenas, these examinations often fall short. There is more to the differences between men and women than research is generally willing to explore. Women’s experience of the world differs greatly from men on many levels that are not widely addressed. Patriarchy and Protestant morality have set the standard for where women fit in the world, and what women are expected to do and be.[13]
Benevolent patriarchy is framed such that it seems that the choices and decisions taken away from women are done for their own good.[14] In the case of women who use or are addicted to drugs, it is benevolent to save women from themselves by creating punitive measures to punish, and thereby dissuade, them from using drugs. Since the primary issue is one of control, the social and psychological influences of drug use and drug addiction are not examined since that could lead to conclusions that run counter to the concepts of benevolent patriarchy (i.e. it is harmful, not beneficial). Given this mind-set, drug policy cannot be centered around demand or curbing the demand for opiates as it brings up questions about the functioning of society as a whole.
- CONCLUSION
The research in this thesis demonstrated that drug policy must not stand alone. Rather it must be incorporated in sweeping social changes that remove the long-standing patriarchal tone toward women and rid sociocultural institutions of Protestant morality that restricts women from full participation in their own lives. These changes cannot be made instantaneously, however steps toward the goal of women’s full participation in choices and decisions that affect them must begin immediately, and that includes their experiences with drug use and abuse, as well as the life experience that may have initiated drug use.
The biopsychosocial theory posits that to successfully counter drug abuse, an individual’s unique biology, psychological wellbeing, and sociocultural experiences must be considered. For women to fully participate in their journey to avoid and recover from opioid use and abuse, many barriers must be removed. First, the biological pathway to substance addiction and abuse must be identified for women. Second, programs and policies that improve social determinants of health must be implemented alongside treatment options and recovery support and an infrastructure must be put in place to provide the resources women need to succeed. And finally, women must gain bodily autonomy and be freed from patriarchal and protestant expectations, allowing them to have full agency in the choices and decisions that affect them.
There is little known about women’s biological experiences with drugs, including opioids; past research on biological determinants and other physiological aspects of drug use have focused on men.[15] To increase knowledge and better prevent opioid use, abuse, overdose, and death in women, women centered research must be expanded within the science community. While progress has been made toward this goal, it has been slow moving, and even when women began to be included in research protocols, focus was placed on a small population of them and provided very little insight.[16] Research protocols must change so that women who are addicted to drugs can be best served.
Further, the focus of any drug policy must be on improving social determinants of health and individual wellbeing; women who become addicted to drugs must feel safe in seeking treatment without the fear of judgment. While treatment has become more readily available, women are still less likely than men to receive treatment, an indication that there are social barriers in place keeping them from seeking the treatment they need. The National Survey on Drug Use and Health indicated that while one in three people with substance use disorders were women, women only accounted for one in five people in treatment.[17] This is an indication that women do not feel safe seeking help, and for good reason. In the U.S., women are at greater risk of losing their children, becoming homeless, experiencing physical abuse, losing a job, being denied social services including financial assistance and educational grants to help pay for job training, and longer terms in prison for lesser charges than men.[18] Each of these affect women’s ability and willingness to seek help when they find themselves addicted to drugs, which leads to fewer women getting treatment and other assistance they need.
It is not surprising given the political atmosphere that there are no calls for social change. The U.S. is sliding into more conservative mindset in which women are losing ground socially, economically, and in their bodily autonomy. With the ongoing fight for income equality, more women than men living in poverty, loss of bodily autonomy for many women, and still no ratification of the Equal Rights Amendment after 100-years of negotiating and arguing, women’s lives today, and our futures, look bleaker than they did for our mothers and grandmothers. It remains to be seen how these factors will affect women and drug use. If there is a decline in quality of social determinants of health, which according to some has already begun, the chance of drug use diminishing for women is very low.
Drug policy and laws have failed women since their inception over 100 years ago. Women’s unique needs and life experiences must be considered and included in all discussion of and legislation developed concerning drug use, abuse, overdose, and death. It is becoming more urgent for substantive action on drug use as the U.S. finds itself in the midst of a crisis that is killing more people every day, a group of which women are a growing percentage.
Decades of drug supply reduction efforts have done little to keep drugs from ruining lives, as evidenced by growing prison overcrowding and soaring death rate. The time is long overdue for more efforts toward demand reduction. Inclusion of meaningful efforts to improve social determinants of health must be made. Drug use, abuse, overdose, and death are a lifespan issue that begins long before the first drug is consumed.
It’s time to end the Drug Policy Theater and institute policies that tackle the core issues behind drug use, abuse, overdose, and death head on. The federal government knows what is necessary and are willing to put money and time into helping other nations fight these issues; poverty, helplessness, violence, economic inequality, and instability, to name a few.
Unless and until the U.S. is willing to put the same efforts into improving SDOH in our nation, the drug problem, the opioid crisis, and the ongoing and meaningless war on drugs are not going to end. Women in the U.S. and the people, communities, and the nation that needs them will continue to suffer.
[1] David T. Courtwright, Dark Paradise: A History of Opiate Addiction in America (Cambridge, MA: Harvard University Press, 2001), ProQuest, 1-2.
[2] Charles F. Manski, John V. Pepper, and Carol V. Petrie, eds., Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us (Washington D.C.: The National Academies Press, 2001), https://doi.org/10.17226/10021, 141-144.
[3] Teddy G. Goetz, Jill B. Becker, and Carolyn M. Mazure, “Women, Opioid Use and Addiction,” Federation of American Societies for Experimental Biology 35, no. 2 (January 12, 2021): 1–12, https://doi.org/10.1096/fj.202002125R.
[4] Mike Stobbe. “US Overdose Deaths Hit Record 107,000 Last Year, CDC Says,” AP NEWS, May 11, 2022, https://apnews.com/article/overdose-deaths-opioids-fentanyl-8cb302a70ddbb6a435f9e8fbb19f153b.
[5] Isabell Koske and Nigel Pain, The Usefulness of Output Gaps for Policy Analysis (Paris: Organisation for Economic Co-operation and Development, 2008), https://doi.org/10.1787/18151973, 5-8.
[6] Koske and Pain, 6.
[7] Francesc Borrell-Carrió, Anthony L. Suchman, and Ronald M. Epstein, “The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry,” Annals of Family Medicine 2, no. 6 (2004): 576–82, https://doi.org/10.1370/afm.245.
[8] Micah L. Issitt, Opinions Throughout History: Drug Use & Abuse, 1st ed. (Boston: Grey House Publishing, 2018), 59-120.
[9] Kristie Yasunari, “Peace Profile: Margaret Sanger,” Peace Review 12, no. 4 (December 2000): 619–26, https://doi.org/10.1080/10402650020014735.
[10] Nancy Tuana, “The Speculum of Ignorance: The Women’s Health Movement and Epistemologies of Ignorance,” Hypatia 21, no. 3 (2006): 1–19.
[11] Institute on Medicine, Women’s Health Research: Progress, Pitfalls, and Promise (Washington, DC: The National Academies Press, 2010), https://doi.org/10.17226/12908, 143-170.
[12] Natasha Du Rose, The Governance of Female Drug Users: Women’s Experiences of Drug Policy (Chicago: Bristol University Press, 2015), https://doi.org/10.2307/j.ctt1t89h83, 68-115.
[13] Du Rose, 44-85.
[14] Melanie Tannenbaum, “The Problem When Sexism Just Sounds So Darn Friendly…,” Scientific American Blog Network (blog), April 2, 2013, https://blogs.scientificamerican.com/psysociety/benevolent-sexism/.
[15] Department of Health and Human Services: Office on Women’s Health, Final Report: Opioid Use, Misuse, and Overdose in Women. (Washington, DC: U.S. Department of Health and Human Services, 2017), https://www.rmtlc.org/wp-content/uploads/2017/08/final-report-opioid-508.pdf.
[16] Jaimie P. Meyer et al., “Research on Women with Substance Use Disorders: Reviewing Progress and Developing a Research and Implementation Roadmap,” Drug and Alcohol Dependence 197 (April 1, 2019): 158–63, https://doi.org/10.1016/j.drugalcdep.2019.01.017.
[17] Meyer et al.
[18] Elizabeth A. Wahler, “Retribution or Rehabilitation? Conflicting Goals of Us Policies Pertaining to Drug Felonies and Their Impact on Women,” Journal of Women, Politics & Policy 36, no. 1 (January 2, 2015): 95–106, https://doi.org/10.1080/1554477X.2015.985155.
