In Washington, DC, people who use opioids confront the epidemic and intervene to stop death.
In the last few years, we have paid unprecedented national attention to opioid addiction, as overdose deaths in the United States skyrocketed. Provisional data released by the Centers for Disease Control and Prevention estimates that approximately 64,000 people died from drug overdoses in the US in 2016 (Vital Statistics Rapid Release, November 13, 2017). Washington, DC, was a jurisdiction with a large percentage increase in fatal overdoses over the previous 12-month period, with a 114.3 percent upsurge in lives lost. On October 29, 2017, President Trump declared the overdose epidemic a national public health emergency. He spoke of the human toll of the epidemic and lamented “a generation of lost potential,” while simultaneously promising more tactical enforcement in the ongoing War on Drugs and making appeals to further militarize the US–Mexico border.
Our understanding of the overdose epidemic in the US is currently dominated by several frames: (1) the frame of war residual from decades of drug war policies and the criminalization of people who use drugs, (2) a hyper-focus on prevention in order to save future perceived innocent victims from addiction, and (3) the medicalization of addiction as a disease worthy of treatment. Yet, in my research with people who use opioids in Washington, DC, I find that certain communities continue to face widespread criminalization, while finding themselves actively excluded from the frames of prevention and disease, along the axes of race and class. Further, there is a marked disjuncture between the messaging of “an emergency” on the national stage and the extent to which overdose death is treated as an emergency in local contexts and given resources to combat it. Marginalized people who use opioids here—who are on the front lines of overdose response and who intervene and administer naloxone to stop death—are rendered largely invisible in our national discourse about overdose deaths. Even in the anthropological literature, people who use drugs are often conceived of as occupying what Joel Robbins (2013) termed the “suffering slot”—too mired in the daily violences of their socio-structural positions to effectively organize. What new insights we might gain if we were to reject perspectives that render people who use drugs invisible and instead utilize a lens that frames the overdose epidemic as being about the enactment of resistance? In my ethnographic fieldwork, I find that within the local community of people who use opioids and organize around overdose, resistance is everywhere.
On August 31, International Overdose Awareness Day, a drug-user-led organizing group The Chosen Few, erected approximately 550 temporary gravestones in a park in the northeast quadrant of the city to honor the people who died of overdoses in the District of Columbia since 2014. I watched members meticulously plan the memorial, construct the cardboard gravestones, and amass them in large piles at a local drop-in center. Rather than hold their memorial at the National Mall, mere steps from the US Capitol and the White House, where its dramatic representation might have drawn larger media coverage, the group picked a park that they had targeted for syringe cleanups and overdose prevention education, in a neighborhood highly impacted by overdose and the emergence of fentanyl in the local drug scene—the synthetic opioid that is 50–100 times more powerful than morphine. Data from the DC Office of the Chief Medical Examiner shows a sharp uptick in overdose deaths with the arrival of fentanyl: a 160 percent increase in fatal overdoses due to opioid use from 2014 to 2016 (Opioid-related Fatal Overdoses: January 1, 2014 to February 28, 2017. April 19, 2017). The memorial became immediately participatory as local community members, passersby, and volunteers helped to put the gravestones in the ground and, powerfully, as people slowly paced through the rows and wrote the names of their deceased loved ones on the cardboard tablets in a moment of public, material memorialization.
Narcan is the brand name for naloxone, the opioid antagonist administered to reverse the effects of an overdose. Research shows that providing naloxone to lay people is an effective way to counter the effects of overdose (Wheeler 2015), and the CDC supports the expansion of access to naloxone and its use. Yet over the course of my research I documented multiple barriers such as a lack of educational campaigns about naloxone and access to it in sufficient quantities. Community-based naloxone distribution was also conspicuously absent from Trump’s declaration, an omission highly symbolic to those for whom overdose death is a daily reality. Though many of the people I worked with acknowledge that prevention and access to treatment are critical components of an effectual response to the epidemic, many reiterated a common sentiment: “No one can succeed in drug treatment if you’re already dead.” People like members of the Chosen Few confront these barriers head on by resisting the criminalization of drug use and prioritizing life through overdose prevention education.
One study participant, Benjamin, described himself as the “Narcan doctor” of his massive apartment building, home to many people who use drugs. Word quickly traveled about his overdose response training and his apartment door is often the first stop during an overdose in the building. Benjamin reversed over a dozen overdoses in the year we met, but had also encountered lapses in his crucial supply of naloxone. As he said, “I’ve seen people die so many times. I’m so sick of people dying in my building. But I have no more Narcan.” Occasionally the naloxone supplied to community organizations by the Health Department would run out, leaving Benjamin unable to refill the doses he kept for the building.
The morning after Trump’s declaration, I met Mickey, a 58-year-old DC native who has been using heroin since his early twenties and had recently experienced an overdose that was reversed with naloxone. Mickey told me that he started using heroin after he “moved from heaven to hell”—the result of a large displacement of African American families from a stable waterfront neighborhood into a neighborhood with an active drug economy. Mickey had watched Trump’s address with bated breath, but the speech frustrated and angered him. Overdose has long been an issue in DC, he said, especially among black men, but for politicians “when it was just affecting the blacks, it was like ‘Oh I can lay back. I don’t have to do too much work.’” This ongoing political commentary among study participants is emblematic of how communities have long strategized about how to fill the void resulting from a lack of political urgency for doing overdose prevention. Again, they do so by resisting invisibility and doing the daily work to save lives on the streets and in the homes of marginalized neighborhoods, among opioid users and their loved ones.
Samuel, a 56-year-old DC native, and his partner Melinda are living proof that when given the right resources, people are able to prevent death and enact self-care. Both have used naloxone to reverse an overdose in the other and both have lost friends to overdose when naloxone was not available. Samuel has been using heroin since 1979 to help alleviate chronic knee pain, and at the time we met he was homeless, living on the streets and awaiting two scheduled knee replacements. With winter quickly approaching, he felt anxious about sweeps of homeless encampments by city workers and the prospect of losing his tent and possessions. Samuel had learned to be hyper-vigilant in his efforts to reduce his risk for overdose: by doing a test shot, by examining the drugs for signs of the presence of fentanyl, and having a supply of naloxone on hand.
Judith Butler (2016) explores the concept of a “frame” to consider how the boundaries of what counts as reality are produced and enforced. For Butler, the frame is not only constitutive of how we understand reality, but is also “always throwing something away, always keeping something out, always de-realizing and de-legitimizing alternative versions of reality.” Our current national conversations about opioid overdose are dominated by frames which exclude the nuanced experiences of those at the front lines of the overdose epidemic, those who are quite literally engaged in daily battles to keep themselves, their friends, and their families alive. At neither the national nor local level are policymakers sufficiently rallying the decades of overdose prevention expertise that exists in the spaces of these struggles. On the contrary, people experience persistent roadblocks to even acquire naloxone and remain subject to intense criminalization for their drug use. It is precisely in this context of exclusion that I take up Laurence Ralph’s (2014) call to highlight “alternate frames” for understanding the violence that takes place in communities that are historically denied access to resources to address the most pressing social issues. So, to the frames of criminalization, prevention, and medicalization, I argue for the alternate frame of resistance.
In recent years, many anthropologists, myself included, have engaged with Robbins’s (2013) argument that anthropology is obsessed with the “suffering subject.” However, his suggestion that we cultivate an anthropology of the good is unrealistic in an ethnographic context where some policies and inaction result in the actual disallowing of life for people who use drugs. Each day people who use opioids intervene to stop death. They stop death in the face of historic marginalization from health and social services. They stop death in the face of structural constraints, such as chronically insufficient access to naloxone. They stop death even when they fear punitive consequences from dialing 911. They do so while honoring the dead and building sustainable on-the-ground networks and community capacity for local overdose response. These narratives of survival do challenge the anthropological compulsion to rely on suffering as a guiding framework for understanding the lives of people who use drugs. What I see ethnographically are historically situated, politically driven, and strategically cultivated survival tactics in the face of decades of structural policies that act to usher in death. Undoubtedly, suffering and loss do sit front and center of the opioid overdose epidemic. But, as people fight to stay alive, resistance takes a seat right next to them.
Note: All names used in this article are pseudonyms.
Andrea M. Lopez is a medical anthropologist and assistant professor at the University of Maryland, College Park. She is currently engaged in a qualitative study in Washington, DC, titled “Structural Context and Community-Based Response to Opioid Overdose.”
Maurice Abbey-Bey is the president and Tamika Spellman is the vice president of The Chosen Few. The group organizes to advocate for communities and individuals impacted by the War on Drugs to combat criminalization, stigma, and oppression and promote health, rights, and dignity of people who use drugs in Washington, DC.
Cite as: Lopez, Andrea M. 2018. “Resisting Overdose.” Anthropology News website, January 24, 2018. DOI: 10.1111/AN.742