Denaturalizing Excess Overdose Deaths

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Photo by Adobe Stock/Antonio Rodriguez.

When beginning this research, I never anticipated that overdose death rates would continue to spiral upward throughout, never seeming to peak, plateau, or decline. The most recent figures suggest that 70,237 people in the United States died from overdose in 2017, more than two-thirds from opioids; between 2000 and 2017 close to 300,000 have died, according to the Centers for Disease Control and Prevention (CDC).

Despite less ignorance, more prevention, more naloxone, and more integration between recovery, treatment, and harm reduction, “excess” death has become naturalized. The very notion of “excess” death implies that these deaths are preventable or premature. But they are far from evenly distributed, and their patterns reveal much about what a society values or devalues. As David Sudnow showed in Passing On, “social death” is reflected in the rationing of resuscitative care according to accountings of social value and moral worth.

Some such deaths are discounted—those in lower-income brackets, those who lived in darker skin, those who used drugs. A common, if morally repugnant, interpretation is that those who die “excess deaths” were already leading “excess” lives.

Cultural anthropologies of excess death suggest that people who do not feel needed die early. For instance, Michelle A. Parsons’s work on premature mortality, titled Dying Unneeded, concluded that in post-Glasnost Russia, men perceived themselves as useless whereas women experienced themselves as having something to offer others. “Being unneeded is a distal driver of the mortality crisis. Being unneeded translates social collapse to bodily death from cardiovascular-and alcohol-related causes. Being unneeded is related to the death of the body, but it is also related to the life of the soul.”

“Addicts” are often treated as “excess” people who are “wasting” their lives, having already passed into states of “social death.”  Parents or partners may value the lives thereby lost, but it is not unusual to come across a cruder moral calculus in which drug users are spoken of as “deserving” their deaths.

Prompted by parallels between Dying Unneeded and “American overdose,” I wonder what social, political, or economic orders are coming undone that so many are dying unneeded? An aptly titled study, “Bowling Alone, Dying Together,” has argued that higher levels of social capital and community resilience protect against overdose deaths. This article joins other signs that there may be a shift away from an emphasis on individuals carrying naloxone to communities showing care by collectively reducing harm in a public manner. What might it take to rebuild capacities for resilience under such conditions—for individuals, kin, communities?

This new emphasis on community was on display in the New York City campaign (see figure 12.2). Billy recounts a neighbor’s boyfriend knocking on his door one night, gesturing toward the role of chance or fate in his having been home and having naloxone on hand. There is something interesting here as the campaign directs the viewer away from close kin, and toward a neighbor whose racial, ethnic, social class, or other markers of individuality remain unclear.

Figure 12.2: “I Saved My Neighbor’s Life.” Billy, Manhattan. Used with permission of the New York City Department of Health.

In saving a life, these characteristics seem not to matter, as the important thing is the community capacity for saving lives. And there is an ethical remodeling of the “bystander” into a “neighbor”—someone who is involved enough with his neighbors that the boyfriend realizes that Billy would have naloxone. This story, of course, could only unfold in densely populated urban environments.

But the uneven topography of excess death has meant that those who live in rural areas more commonly suffer such deaths.  The US opioid overdose death rate is 45 percent higher in rural areas than in urban or suburban areas. Thanks to changes in the business end of illicit drugs, people living in rural areas—and the United States is 80 percent rural at the county level—have access to licit and illicit opioids to a much greater extent than was historically the case. Drug sellers shifted toward largely white small cities and towns in the Midwest and rural Northeast, running operations resembling pizza delivery.

Heroin markets sprang up where pharmaceutical opioids like OxyContin, Vicodin, Percocet, and generics had made inroads. When access to prescription opioids was tightened and OxyContin was reformulated, this had the apparently unanticipated consequence of pushing rural and suburban opioid users toward heroin, which was easier to get. Whereas adulterants had usually been inert in the past, adding synthetic fentanyl changed the calculus and multiplied the dangers of illicit markets, particularly in rural areas that lacked access to harm reduction infrastructures such as needle exchanges and naloxone.

Until recently rural paramedics were unfamiliar with naloxone. Studies show that more than 40 percent of people who die from overdose did not receive naloxone.  Some died alone, but some died because responders’ decisions to “break out the Narcan” depend upon social characteristics of patients and settings.

A Rhode Island study of all opioid overdoses in which EMS responders did not administer naloxone (n = 124) found women much less likely to have received naloxone. A wicked intersection between gender and age showed that older women were four times less likely to get naloxone that would probably have saved their lives. Surprisingly, naloxone administration in Rhode Island did not differ significantly by race/ethnicity or social location, but such factors surely help determine whether emergency response reaches an overdose victim in time.

Judgments about people, places, and things shape who takes naloxone home and keeps it ready to hand. Being prescribed an opioid is itself is a risk factor for opioid abuse and overdose; arguably, therefore, prescribers should “break out the Narcan” to ensure that patients’ friends and families have the antidote on hand regardless of the source of the opioids in use.

Excerpted from OD: Naloxone and the Politics of Overdoseby Nancy Campbell. Reprinted with Permission from The MIT PRESS. Copyright 2020.

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