Traveling from Sympathy to Empathy on Addiction
Traveling from Sympathy to Empathy on Addiction
This is part of an occasional series on exploring ways we can unlock decades of healthy lifespan.
Read for: Why I can’t stop talking to strangers about meth, a general roadmap for moving from sympathy to empathy on any issue
One thing I’ve enjoyed recently is the freedom to explore threads of interest that don't necessarily make sense. Somewhat randomly, I consulted for a digital health company serving people with substance use disorder. After the project wrapped, it was finally time to read the opioid crisis book that had lingered on my list for years, my MPH-er guilt nagging at me.
I became mildly obsessed with the story of how opioid pills — then heroin, then fentanyl and meth — rapidly infiltrated their way into American life, devastating many, unnoticed by a few. The revolution in the business model of these substances — from manufacturing to distribution to retention — has led to astonishing reach into new markets and users. This information is newly terrifying as a parent.
This post traces my own evolution in how I saw addiction a year ago versus today. It’s also a general roadmap for traveling from sympathy to empathy on any issue or group of people you don't understand.
Step 1: That’s a sad life —> That could be me
For most of my life, I saw substance use as a black hole of worsening addiction, theft from family members, and grief. My mindset was about personally staying as far away from the addiction event horizon as possible while perhaps sparing a moment of sadness for those that didn’t.
Fiction changed my perspective most:
A Place for Us by Fatima Farheen Mirza told a story of how opioids wove their way into the lives of a suburban immigrant family. It reflects a broader trend of opioid and stimulant use expanding beyond stereotypical demographics in the last 20-30 years: 30% of suburban adults now say they or a family member have been addicted to opioids (KFF, 2023).
In Transcendent Kingdom by Yaa Gyasi, one character explained why he continued to take pills:
“It feels amazing, like everything inside my head just empties out and then there’s nothing left — in a good way.”
It’s the exact same reason I do yoga, meditate, gaze at a sunset, run, have a picnic with friends, watch easy TV. That could be me.
Step 2: Those villains are shockingly evil —> Could I have contributed to this situation?
The story of Purdue Pharma and the Sackler family is shocking in its scope and duration, especially in hindsight. They claimed Oxycontin’s pain relief would last 12 hours, a key selling point; in the very first study of 90 women in Puerto Rico in 1989, about half required more medication before the 12-hour mark. As more doctors prescribed an 8-hour dosing regimen in response to patients’ complaints (and withdrawal symptoms), Purdue pushed them to prescribe higher doses (which happened to be more profitable for them). The company’s portfolio was irresponsibly concentrated, with Oxycontin representing 80% of its revenue in 2001. Even then, it was clear that addiction was quickly becoming a national problem, but the Sackler-dominated board seemed more interested in driving up sales and cashing out billions than diversifying the business.
Beyond the villains
The book Dreamland by Sam Quinones explores the story beyond these villains, implicating many other actors in accelerating the opioid flywheel. Mission-driven believers who wanted to free the world from pain. Advocates pushing to add pain as a fifth vital sign, collapsing a complex biopsychosocial phenomenon into a legible number to track progress at a national scale. People who did quick literature reviews to claim opioids are not addictive, citing academic studies (which turned out to be based on a 1-paragraph letter). I found these behaviors (mission-driven zeal, operational legibility, surface-level lit reviews) disturbingly familiar from my own experience.
Sins of omission
Dreamland and Quinones’ follow-up book, The Least of Us, explain how the opioid pill crisis has shapeshifted into a heroin, fentanyl, and meth crisis that continues to grow. One theme that emerges from his reporting is the rapid pace of drug supplier innovation over the last few decades in:
Supply: Vertical integration (combining poppy farms and the transformation into black tar heroin) and in-house manufacturing (fentanyl, meth) dramatically drive down supply costs — leading to stronger, more potent drugs at cheaper prices
Distribution: Opening up new heroin markets (suburban kids) through retailization — offering small quantities in convenient locations
Consumer-centricity: Attracting and retaining customers through kind customer service, discounts, convenient and discreet delivery with 24/7 availability
I found it frustrating to see trends we’ve talked about in healthcare — increasing access, consumer-centric convenience, “retail front door” — be executed to perfection by illicit drug suppliers. It is, of course, much easier to sell a highly addictive product while operating illegally without any regulatory oversight. However, I felt unsettled by the thought of the lumbering health industry being outpaced and blindsided by rapid drug supplier innovation.
Step 3: There’s nothing I can do to make an impact —> Here’s a tiny thing I can do to make a better home for someone.
It can be overwhelming to read the stats and hear the stories. Poisoning and suicide are now the two leading causes of death for people under age 44. (Through most of the 1980s and 1990s, the two leading causes were motor vehicle accidents and malignant cancer, with HIV bouncing in and out).
Deaths from meth overdose have more than doubled since 2015. Quinones believes that new manufacturing methods for meth have contributed to more aggressive brain damage, psychotic symptoms, and the rise of homelessness nationwide. (This view has been criticized for lack of hard evidence and the risk of stereotyping users; he argues that this is based on robust frontline reporting). Unlike opioid use disorder, there is no evidence-based medication-assisted treatment for meth.
When a problem seems overwhelming, it helps to think about Swiss cheese. The Swiss cheese model explains that catastrophic accidents happen when multiple layers of barriers have failed — when the holes in the cheese line up perfectly. Some slices of cheese may feel like they’re in a different dimension, with no way to fix those gaping holes over there. But there may be a small hole nearby you can patch up.
Quinones harps on the role of strengthening community in finding our way back from the opioid crisis: one person caring for orphans, another teaching herself to remove former drug users’ tattoos, another cleaning up a decrepit community center, another creating a program for teens to stay engaged. Michelle Obama talks about “adding just a drop of social glue to a world that desperately needs it,” through small talk with strangers and neighbors.
Dreamland was published in 2015. In it, Quinones describes several rural towns in conservative states that had been softening their punitive stance toward drug users. As more people lost friends and family members to addiction, more and more small towns explored ways to rehabilitate instead of imprison them.
As a reader in 2023, I saw a tragic missed connection. These were the same years that the Black Lives Matter movement brought attention to violence and murder in policing and incarceration — and launched a tipping point in reimagining public safety. I kept thinking about what it would have looked like to connect to each other’s pain and build together toward a more compassionate approach to rehabilitation.
Public health problems don’t care about our borders, geographical or social. Black tar heroin use exploded in first-time white suburban users. Black users of meth were once rare, now growing exponentially (10x in the last five years). Every group is seeing increases in drug overdose deaths.
It’s why I have more appreciation for hyperlocal teen and kid’s programs that create a sense of community. And it’s why I can’t stop talking about meth with strangers.
Read with:
📕 A Place for Us by Fatima Farheen Mirza
📕 Transcendental Kingdom by Yaa Gyasi
📚 Dreamland and The Least of Us by Sam Quinones
📃 Oaklandside’s outstanding local journalism covering the growing meth crisis
📃 The Family That Built an Empire of Pain, a 2017 New Yorker article
📕 Dopamine Nation: Finding Balance in the Age of Indulgence by Dr. Anna Lembke — an addiction medicine doctor explains the link between pain and pleasure-seeking behaviors, which are ubiquitous in modern life (a non-fiction approach to step 1: “that could be me”). A podcast episode, if you prefer.
🎧 Podcast interview with Dr. Nzinga Harrison — an addiction medicine doctor explains whether an “addictive personality” exists