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Why Is The Opioid Epidemic Overwhelmingly White? : NPR

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Why Is The Opioid Epidemic Overwhelmingly White? : NPR

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The opioid epidemic is ravaging large parts of the American population. But some races are being hit harder than others. Dr. Andrew Kolodny, a drug abuse expert, explains why that might be the case.

NOEL KING, HOST:

An opioid epidemic is ravaging parts of this country. President Trump has declared it a public health emergency. Last year, overdoses killed some 64,000 people. It's being compared to the AIDS epidemic of the 1980s and '90s. The face of the opioid epidemic has been mostly white, and that's because we have seen a massive increase in drug overdoses among young white adults, often in rural areas. But what's been happening in black and Latino communities? For answers, we called up Dr. Andrew Kolodny. He's co-director of the Opioid Policy Research Collaborative at Brandeis. Dr. Kolodny, thanks for coming on.

ANDREW KOLODNY: Thanks for having me.

KING: So by the numbers, white communities do seem to be suffering the most from this epidemic or impacted the most. How is opioid addiction affecting black and Latino communities?

KOLODNY: So our new opioid addiction epidemic is sparing African-American and Latino communities, and it's striking when you look at the data. Whether you're looking at overdose deaths or emergency room visits for opioid use problems or treatment admissions for opiate addiction, it's very clear that this epidemic is overwhelmingly white. And it begs the question, why? I can share with you a theory, and it is a theory that's based on evidence.

Something that we do know is that doctors prescribe narcotics more cautiously to their non-white patients. It would seem that if the patient is black, the doctor is more concerned about the patient becoming addicted, or maybe they're more concerned about the patient selling their pills, or maybe they are less concerned about pain in that population. But the black patient is less likely to be prescribed narcotics, and therefore less likely to wind up becoming addicted to the medication. So what I believe is happening is that racial stereotyping is having a protective effect on non-white populations.

KING: Are doctors acknowledging that they're less likely to prescribe narcotics, pain medication, to black and Latino patients?

KOLODNY: I don't think they're aware of it. I think this happens on an unconscious level.

KING: This isn't, of course, the first time that the U.S. has faced a drug epidemic. There's crack cocaine in the '80s and '90s. That was often affecting black communities. Is the response to this crisis different?

KOLODNY: Very different.

KING: Why?

KOLODNY: What we saw from policymakers, what we got from policymakers was a message that we could potentially arrest our way out of the problem. What we got was a war on drugs and a crackdown on crime. What we're seeing now is a very different response now that we've got an addiction epidemic that's disproportionately white. What we're hearing from policymakers, even conservative Republican politicians when they talk about the opioid crisis, many begin by saying, we can't arrest our way out of this. We have to see that people who are addicted can access effective treatment. We didn't hear that during the crack cocaine epidemic. It's good that we're hearing it now. It's too bad we didn't hear it then.

KING: President Trump interestingly has declared this crisis a public health emergency but not a national emergency. If it was a national emergency, that would allow federal funding, even access to FEMA funds to go toward treating it. Does this fall short? Do you think of a national emergency? What's the difference?

KOLODNY: Well, you know, I don't know that the problem is so much the type of national emergency or public health emergency that was designated. My concern is that what we haven't received from the Trump administration is a plan for addressing the problem or a request from Congress for funding.

KING: What would a solution, what would a new system look like?

KOLODNY: One of the first things that we have to do is we have to prevent more people from becoming addicted to opioids, and that's not lecturing to kids, don't do drugs. More than anything else, that's about promoting much more cautious prescribing so that we don't directly addict patients and so that people don't indirectly become addicted because we've stocked everybody's home with a highly addictive drug. But we also have to recognize, now that the genie is out of the bottle, millions of Americans are suffering from opioid addiction. We have to see that they can access the most effective treatments very easily.

If you're opioid addicted, when you wake up in the morning you're going to need to use an opioid pretty quickly or you're going to be feeling very sick. We want that individual to be able to access effective outpatient treatment more easily than they can access pain pills, heroin or fentanyl. If that person wakes up and they've got $20 in their pocket and they know where to go get heroin, that is what they're going to do. We want that person to be able to walk into a treatment center, regardless of their ability to pay for their care, and to be started on treatment - outpatient treatment, that same day.

KING: Dr. Andrew Kolodny is co-director of the Opioid Policy Research Collaborative at Brandeis. Dr. Kolodny, thank you so much for joining us.

KOLODNY: Thank you for having me.

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Why Is The Opioid Epidemic Overwhelmingly White?

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The opioid epidemic is ravaging large parts of the American population. But some races are being hit harder than others. Dr. Andrew Kolodny, a drug abuse expert, explains why that might be the case. NOEL KING, HOST: An opioid epidemic is ravaging parts of this country.

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‘Lock them up:’ My double standard in responding to the crack crisis vs. the opioid epidemic - The Washington Post

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‘Lock them up:’ My double standard in responding to the crack crisis vs. the opioid epidemic - The Washington Post

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Short Answers to Hard Questions About the Opioid Crisis - The New York Times

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Short Answers to Hard Questions About the Opioid Crisis - The New York Times

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On Thursday, President Trump said he intended to declare the opioid crisis a national emergency, as previously recommended by his opioid commission.

With the death toll from drugs rising faster than ever, you might feel that you could use a little catching up. For a quick refresher, and more on the practical effects of a formal declaration of an emergency, here are answers to 12 critical questions.

It's the deadliest drug crisis in American history.

Drug overdoses are the leading cause of death for Americans under 50, and deaths are rising faster than ever, primarily because of opioids.

Overdoses killed more people last year than guns or car accidents, and are doing so at a pace faster than the H.I.V. epidemic at its peak. In 2015, roughly 2 percent of deaths - one in 50 - in the United States were drug-related.

Percentage of deaths classified as drug-related

Something that acts on opioid receptors in the nervous system.

That's not really a helpful answer.

The first such drug, and the one from which the opioid receptors get their name, was opium. Opium, a narcotic obtained from a kind of poppy, has been used in human societies for thousands of years. From opium people derived a whole host of other drugs with similar properties: first morphine, then heroin, then prescription painkillers like Vicodin, Percocet and OxyContin. Opium along with all of these derivatives are collectively known as opiates.

Then there are a handful of compounds that act just like opiates but aren't made from the plant. Opiates along with these synthetic drugs - chiefly methadone and fentanyl - are grouped together into the category of substances called opioids.

Opioid receptors regulate pain and the reward system in the human body. That makes opioids powerful painkillers, but also debilitatingly addictive.

Drug overdose deaths involving ...

While heroin and fentanyl are the primary killers now, experts agree that the epidemic will not stop without halting the flow of prescription opioids that got people hooked in the first place.

The latest iteration of the opioid epidemic has been especially deadly among adults in their 20s and early 30s.

Distribution of drug deaths by age

In 2000, the most common age for drug deaths, including those not involving opioids, was around 40. This was the generation that first grew addicted to prescription opioids in large numbers - white people especially so. Now there's evidence that the opioid epidemic is dividing into two waves, with a new group of younger drug users growing addicted to, and dying from, heroin or fentanyl rather than prescription pills.

The Midwest, Appalachia and New England. For now.

There's a lot of geographic variation in the rate of drug deaths, with the highest overdose rates clustered in Appalachia, the Rust Belt and New England.

Teasing out the reasons for the geographical differences is not easy. In certain places, the ways in which people use drugs could be more dangerous (you're more likely to die from injecting heroin than you are from smoking it, for example).

But it's clear that a significant portion of the variation in deaths, if not necessarily in use, is being driven by the appearance of fentanyl in the drug supply. Fentanyl, a highly potent opioid, affects heroin users and pill users both, the latter often falling victim to counterfeit pills that look like prescription painkillers.

Decades of opioid overprescription, an influx of cheap heroin and the emergence of fentanyl.

Pill mills began popping up around the country as communities were flooded with prescription opioids. Over the next decade, a growing number of people grew addicted to the drugs, whether from prescriptions or from taking them recreationally. For many, what started with pills evolved into a heroin addiction.

At the same time, the heroin market was changing. The price plummeted. Newly decentralized drug distribution networks pushed heroin and counterfeit pharmaceuticals into suburban and rural areas where they had never been. Everywhere the suppliers went, they found a ready and willing customer base, primed for addiction by decades of prescription opiate use.

Then in 2014, fentanyl began entering the drug supply in large amounts.

Drug seizures containing fentanyl

It's a synthetic opioid 50 times more potent than heroin.

Heroin is derived from opium, a plant. That means its growers need fields and labor to harvest the crop. They are tied to land, weather and time.

Fentanyl is purely synthetic. Think chemistry, not agriculture. It's commonly used for surgical anesthesia and is prescribed to treat pain, but almost all of the fentanyl on the streets is illicitly manufactured. According to the Drug Enforcement Administration, the majority of illicit fentanyl in the United States is manufactured either in China or in Mexico using precursors bought from China. And at least some portion of it comes to the United States in the mail, ordered from dark web sources like the recently shuttered AlphaBay. But we don't know how much.

Fentanyl is a fine-grained powder, meaning that it's easy to mix into other drugs. This is how most people are exposed to illicit fentanyl: It will be mixed into, or made to look like, powdered heroin or it will be used to produce counterfeit prescription pills.

Many aren't intending to.

From a dealer's perspective, fentanyl is easier to get and more profitable to sell. Some law enforcement officials argue that drug users will seek out batches of drugs that contain fentanyl or that are known to have killed people, as that demonstrates the drugs' potency.

For long-time drug users, their continued use underlines the grip of addiction and the agony of withdrawal: They know it could kill them but do it anyway. Casual drug users are also at risk of fentanyl poisoning, particularly with increased reports of fentanyl-adulterated cocaine.

Opioids are a vital component of modern medicine that have measurably improved the quality of life for millions of people, particularly cancer patients and those with acute pain. But their efficacy in treating chronic pain is less clear, especially when weighed against the risks of overdose and addiction.

Average days of opioid use per resident per year

At the same time, some chronic pain patients now struggle to fill their prescriptions. Solving the opioid problem requires controlling prescription opioid distribution while maintaining access for patients with legitimate medical needs. Suddenly removing access to opioids from those who are dependent on them to function could easily push people to illicit opioid sources, like heroin or counterfeit pills.

There's no silver bullet.

Experts agree fixing the opioid epidemic will take a combination of solutions. But it's a question of priorities: Which approaches will be most effective and most efficient? What is the best use of resources?

In the meantime, widespread distribution of naloxone - an overdose antidote - will save lives in acute cases.

Maybe, but only if they're adopted.

The commission laid out a series of recommendations in its interim report, with a final report expected in October.

Of course, these are only recommendations. It's up to the president and the various executive agencies to implement them. Experts know how to attack the problem. It's just a matter of having the will to put those policies into practice.

It unlocks money and gives the H.H.S. secretary more power.

During a public health emergency, this law gives the secretary of health and human service broad authority to make grants, conduct investigations and waive or amend a variety of health regulations.

For example, the opioid commission argued that the H.H.S. secretary would be able to waive the I.M.D. exclusion, an obscure rule that bars Medicaid reimbursement for patients in mental health facilities with more than 16 beds. Since Medicaid pays for a significant portion of inpatient drug addiction treatment, the exclusion is a major obstacle.

Many states have been granted waivers from this regulation, but the onus is on each state to prove that it qualifies for one. The commission asserted that an emergency declaration would give the H.H.S. secretary the power to grant a waiver to any state that requests one, but it's not clear that this is the case.

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Short Answers to Hard Questions About the Opioid Crisis (Published 2017)

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On Thursday, President Trump said he intended to declare the opioid crisis a national emergency, as previously recommended by his opioid commission. With the death toll from drugs rising faster than ever, you might feel that you could use a little catching up.

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How Bad is the Opioid Epidemic? | Chasing Heroin | FRONTLINE | PBS | Official Site

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How Bad is the Opioid Epidemic? | Chasing Heroin | FRONTLINE | PBS | Official Site

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The opioid epidemic has been called the worst drug crisis in American history. Death rates now rival those of AIDS during the 1990s, and with overdoses from heroin and other opioids now killing more than 27,000 people a year, the crisis has led to urgent calls for action.

The epidemic didn't happen overnight. Over the course of more than a decade, it has grown into a problem destroying lives across the nation, regardless of age, race, wealth or location. Here's a look at how it happened and who is most affected.

Drugs now kill more Americans than cars

In 1999, there were more than twice as many motor vehicle deaths as fatal drug overdoses. By 2014, those numbers had flipped, with almost 40 percent more deaths from overdoses than car crashes. In all, 29,230 people died in car accidents in 2014, while 47,055 died from a drug overdose.

Cocaine used to be the leading killer. Not anymore.

The majority of overdoses now stem from prescription opioids and heroin, according to data from the Centers for Disease Control and Prevention. That wasn't always the case. In 1999, cocaine killed about twice as many people as heroin - 3,822 and 1,960 deaths, respectively - while opioids killed 4,030.

By 2014, opioid deaths were up 369 percent, while deaths from heroin jumped 439 percent, according to CDC data. That same year, cocaine deaths dropped below those caused by benzodiazepines, a class of drugs often used in sleeping pills or to combat anxiety.

Opioid prescriptions tripled over 20 years

One factor behind the surge in heroin and opioid use was the dramatic spike in the use of prescription painkillers.

In 1991, doctors wrote 76 million prescriptions. By 2011, that number had nearly tripled, to 219 million, according to a report from the National Institute on Drug Abuse. This rise was made all the more dangerous when drug cartels began flooding the United States with heroin, which was cheaper, more potent, and often easier to acquire than prescription pain meds. As the National Institute on Drug Abuse noted:

Mexican heroin production increased from an estimated 8 metric tons in 2005 to 50 metric tons in 2009 - more than a six-fold increase in just four years. Domination of the U.S. market by Mexican and Colombian heroin sources, along with technology transfer between these suppliers, has increased the availability of easily injectable, white powder heroin. In a recent survey of patients receiving treatment for opioid abuse, accessibility was one of the main factors identified in the decision to start using heroin.

As both heroin and prescription opioids became more common, so too did overdoses.

The epidemic has hit nearly everyone, regardless of race

Every racial demographic has seen more overdoses since 1999, with heroin spiking especially after 2010. Whites and Native Americans have experienced the largest rise in death rates, particularly when it comes to opioid-related fatalities. By 2014, whites and Native Americans were dying at double or triple the rates of African-Americans and Latinos, according to the CDC.

The New York Times found that "racial stereotypes" might be one explanation for the gap:

There is a reason that blacks appear to have been spared the worst of the narcotic epidemic, said Dr. Andrew Kolodny, a drug abuse expert. Studies have found that doctors are much more reluctant to prescribe painkillers to minority patients, worrying that they might sell them or become addicted.

But that doesn't mean communities of color have escaped the epidemic. While media attention has often focused on the uptick of deaths among white, middle-class users, among African-Americans the death rate from heroin overdoses has gone up more than 200 percent since 2010. Among Latinos, it has climbed nearly 140 percent.

Heroin deaths skew younger. Opioid deaths come later.

Likewise, nearly every age group has been touched by the opioid epidemic. Heroin deaths skew younger, according to CDC data, while fatal opioid overdoses are more likely to happen in middle age.

Twelve states have more opioid prescriptions than people

Not every state has seen an equal rise in opioid use. In Hawaii, doctors wrote 52 opioid prescriptions for every 100 people in 2012, the least of any state according to a 2014 CDC study. In Alabama, it was almost 143 prescriptions per 100 people, more than anywhere else.

In all, 12 states had more opioid prescriptions than people 2012:

The CDC study found no obvious geographic pattern to high levels of opioid prescriptions. If anything, researchers suspect that the variation shows a lack of consensus among doctors about how much pain medication to prescribe. Further, research shows that higher rates of prescription drug use don't necessarily lead to better health outcomes or patient satisfaction.

"In fact, "the report says, "high rates of use might produce worse outcomes."

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The opioid epidemic has been called the worst drug crisis in American history. Death rates now rival those of AIDS during the 1990s, and with overdoses from heroin and other opioids now killing more than 27,000 people a year, the crisis has led to urgent calls for action.

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The deadliness of the opioid epidemic has roots in America’s failed response to crack - Vox

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The deadliness of the opioid epidemic has roots in America’s failed response to crack - Vox

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The death toll from the opioid epidemic ravaging the US has been climbing by the thousands for years:In 2015, opioid overdose deaths killed more people in the US - 52,000 - than guns, car crashes, and even HIV/AIDS at its peak, and overdoses since the epidemic began in the late '90s had killed more people than the entire population of Atlanta.Based on preliminary data, 2016 will be worse. And 2017 could be even worse than that, as the deadly synthetic opioid fentanyl continues to spread across the US.

Public health officials at every level of government have been unable to reverse or even stabilize the rising death toll from the crisis, which was sparked by the widespread misuse of highly addictive prescription painkillers. This stark inability to manage the crisis shows just how unprepared America is to deal with such a massive epidemic of addiction.

But that's not because America has never dealt with a drug crisis in the past. Since the 1980s, for instance, devastating and prolonged crack cocaine and methamphetamine epidemics have destroyed and destabilized communities across the country. Rather, the opioid crisis has gotten so far out of control because of the spiraling effects of America's flawed response to those previous crises. And that has a lot to do with who the victims of those crises were, and how that informed the way Americans viewed their struggle.

Consider a hypothetical scenario, raised to me by Atlantic writer Ta-Nehisi Coates: Back in the 1980s and early '90s, America was ravaged by the crack cocaine epidemic, with thousands of overdoses a year and thousands more murders associated with the drug trade at the time. If the US had responded to this crisis by investing in drug addiction treatment, there would be an infrastructure for dealing with such a crisis that could have endured to this day. This may have prevented one of the biggest challenges in the current opioid crisis - that only about 10 percent of people with a drug use disorder get specialty treatment, according to a 2016 report from the surgeon general.

But crack largely afflicted black communities, and the response at the time was not public health-oriented. Instead, it focused almost entirely on criminalizing addiction, passing laws to lock up people who use drugs and drug dealers through exorbitant prison sentences, such as mandatory minimums - an approach that many policymakers, including some Republicans, now consider a mistake and are looking to undo. As a result, the US never got the treatment system it needs to deal with these crises.

Today, white Americans are the ones disproportionately suffering in the opioid crisis. The largely empathetic rhetorical response to their addiction, compared with the way black people addicted to crack were treated decades ago, has been noted many times over. But you can draw a direct line between the fact that the people suffering in this crisis can't get the help that they need and society's failure, 30 years ago, to view black people as worthy of the same help.

"There weren't signs on the billboards and the subways that said save people at all costs," Heather McGhee, president of the left-leaning public policy group Demos, told me. "White Republican politicians weren't saying that this is a national crisis, and 'there but for the grace of God go I,' as Chris Christie has said. There is a difference. There absolutely is a difference." She added, "Racial bias distorts our response and ... made it so we did not create the infrastructure and the policy understanding during the earlier drug epidemics."

This is just one of the many ways that systemic racism ultimately hurts not just those who are the targets of bigotry, but society as a whole. Time and time again, politicians have deployed explicit racism and dog whistles to justify policies to white constituents who harbor racial resentment. But these policies can lead to outcomes that ultimately hurt the white constituents who are activated by racial calls. The opioid epidemic, as the country's deadliest drug overdose crisis in history, is a concrete example of this trend.

"In our interconnected society, racism - both interpersonal and institutional - is the flaw in the machine that often stymies our democracy and our economy," McGhee, who's working on a book on this topic, said. "Racism and bias against full portions of the population color the policy responses of elected officials."

The US was totally unprepared to handle the opioid epidemic

The opioid epidemic is not America's first drug overdose crisis, although it is so far the deadliest. In 2016, preliminary data suggests that 59,000 to 65,000 people died of drug overdoses - the highest death toll from overdoses ever recorded in the US. In the next 10 years, as many as 650,000 people could die from opioid overdoses alone - a death toll that totals more than the entire population of Baltimore.

Policymakers and the public are widely in agreement that people addicted to opioids need treatment. But there is little existing addiction treatment infrastructure in the US, and systems like that cannot be built overnight.

It's common to hear stories across the US, particularly in places hit especially hard by the crisis (such as West Virginia and New Hampshire), about weeks- or months-long waiting periods to get into treatment - if patients can get into care at all.

Take Dean Lemire of New Hampshire: In 2012, as reported by NPR, Lemire was finally fed up with his heroin addiction. He tried to sign up for a state-funded treatment center but was put on a waiting list. He called multiple times a day for three weeks, but after repeated denials, he gave up. He drank some whiskey, got into his car to find heroin, and got into three car crashes before waking up in a jail cell. Only then could the treatment center let him in, apparently deeming his case serious enough.

And Lemire is one of the lucky ones - he survived and ultimately got into care.

States that want to treat a growing wave of newly addicted people just don't have the resources in place to act quickly. That's because they're largely starting from scratch. And starting from scratch is expensive - New Hampshire, which is second in overdose deaths after West Virginia, still doesn't have treatment centers in swaths of the state, especially in rural areas.

Drug policy experts have told me that the US as a whole will likely need to spend tens of billions a year to seriously boost addiction treatment. That may lead to financial savings in the long term, given that studies show addiction treatment prevents all sorts of negative, costly outcomes. But it's a big upfront investment, and it will take years to implement and build on.

Meanwhile, people will continue to die - and so states may be tempted to use their existing criminal justice systems to deal with their overdose crises. Some states have, for example, begun asking prosecutors to bring more drug-induced homicide charges against people who supply opioids to someone who overdoses and dies.

Criminal justice experts widely agree this is not only costly but ineffective. A 2014 review of the research by Peter Reuter at the University of Maryland and Harold Pollack at the University of Chicago, for example, found that while simply prohibiting drugs to some extent does raise their prices, there's no good evidence that tougher punishments or harsher supply-elimination efforts do a better job of driving down access to drugs and substance misuse than lighter penalties. So increasing the severity of the punishment doesn't do much, if anything, to slow the flow of drugs.

As ineffective as that may be, states already have the means to carry out this kind of response. They have enough prisons to make the US the world's leader in incarceration. They have old laws in place that allow prosecutors to pursue stiffer penalties. And they have an incentive to use these systems, because it makes them look like they're doing something about an epidemic that kills tens of thousands of people a year.

America "built up this massive incarceral state, which is a hungry critter," Keith Humphreys, a Stanford drug policy expert, told me.

Put another way, the table is set so that America responds in the same way it has before to drug crises: not much on the public health side, but a lot more on the criminal justice side. And people will suffer and die as a result.

It didn't have to be this way. In the 1980s, America had a chance to implement the sort of public health infrastructure for addiction that states are scrambling to put in place today. Under pressure from the public to do something about the crack epidemic, policymakers could have invested in a serious drug addiction treatment system that could have been scaled or retooled for other drugs, from meth to opioid painkillers and heroin.

Humphreys gave a concrete example of how this could have worked: "Something we could have done then, which is what we've done now, is we could have mainstreamed addiction treatment benefits into the Medicaid system." That, he said, would have let patients more easily afford treatment today - and since health care providers would know those customers are around and now able to pay, they would have been more likely to scale up treatment to match demand even before the opioid epidemic got so bad.

Of course, that didn't happen in the '80s and '90s.

The differences between the response of today and that of the 1980s and '90s

In the 1980s, crack cocaine came to America. Taken up disproportionately by black and poor neighborhoods (while the original powdered version of cocaine remained popular in wealthier, whiter areas), crack quickly became the center of the illicit drug trade - contributing to thousands of overdose deaths as well as a spike in murders and violent crime in the '80s and '90s. As crack addiction strangled black communities in particular, policymakers didn't reach to more treatment to deal with the problem; instead, the response to the crack epidemic was built almost entirely around the criminal justice system.

The media reflected this. There was not a day that the nightly news didn't tell a new, horrifying story of a gang shooting related to crack. The New York Times ran headlines like "New Violence Seen in Users of Cocaine." Stories of "crack babies" dominated much of the news, warning that crack use by single black mothers in particular would lead to a new wave of addicted, stunted, violent youth later called "superpredators" - warnings that later research found to be severely exaggerated.

"The media portrayals during the crack epidemic were exceedingly hostile," Rachel Godsil, co-founder and director of research at the Perception Institute, previously told me. "When they talked about mothers who were crack-addicted, there wasn't, 'What kind of treatment can we provide for them?' but, 'What kind of criminalization can we impose upon them?'"

The prejudiced ties between race and drug use had a long history in America. In 1914, for example, the New York Times ran an article headlined "Negro cocaine 'fiends' are a new southern menace," in which an actual physician claimed that cocaine made black men uniquely violent and even impervious to bullets. Many Americans can now look back at this kind of claim with scorn at its obvious absurdity, but it shows the sort of attitudes that have dominated American views on drugs for decades.

Policymakers responded in kind. Across the country, states passed tougher prison sentences for drugs. The federal government enacted with its own "tough on crime" laws, such as the Anti-Drug Abuse Acts of 1986 and 1988. Republicans backed these measures, but Democrats played a big role too - with former Vice President Joe Biden even helping write some of the "tough on crime" laws of the '80s and '90s while he was a senator. It was a time when it was bipartisan to treat drugs as a moral failure and a criminal justice issue.

Take former President George H.W. Bush, who used his first televised national address in the Oval Office to warn of what he called "the greatest domestic threat facing our nation today": drugs. He held up a bag of crack cocaine - purportedly bought near the White House, though later the story was found to be a bit more complicated - and vowed to escalate the war on drugs.

"Drugs are sapping our strength as a nation," Bush said. "Who's responsible? Let me tell you straight out: everyone who uses drugs, everyone who sells drugs, and everyone who looks the other way." He was as brutal in describing the consequences, arguing that crack is "turning our cities into battle zones" and "murdering our children."

There were also some treatment-focused programs in response to crack, such as the creation of drug courts. But the great majority of the response was punitive.

The opioid epidemic has inspired a different response. Media coverage of the epidemic is much more sympathetic of people struggling with drug addiction, with the New York Times now running headlines such as "In Heroin Crisis, White Families Seek Gentler War on Drugs."

In a rarity in today's politics, the compassion is even bipartisan. Michael Botticelli, President Barack Obama's former drug czar, repeatedly stated that "we can't arrest and incarcerate addiction out of people." New Jersey Gov. Chris Christie, who's leading President Donald Trump's opioid commission, in 2015 gave a passionate speech urging Americans to treat addiction as a medical issue, drawing from a friend's story to argue that "we need to start treating people in this country, not jailing them. We need to give them the tools they need to recover, because every life is precious."

And the one major piece of legislation that Congress has passed related to the opioid epidemic, the 21st Century Cures Act, put $1 billion toward addiction treatment over two years - far from what experts say is necessary, but remarkable in that it approached the crisis exclusively as a public health problem.

Some states have passed laws toughening prison sentences related to opioids, and more have encouraged police and prosecutors to use old "tough on crime" laws to crack down on drug addiction. But these kinds of actions have not reached the all-consuming fervor, at least yet and at least not rhetorically, that engulfed the nation during the crack epidemic in the 1980s and '90s.

Of course, a change in the public perception of addiction - a disease we still don't fully understand but understood even less in the 1980s - has something to do with this disparity. But racism does too.

A key explanation in all of this is race

Consider this chart, which shows that until the early 2000s, black Americans tended to suffer more drug overdose deaths when controlling for population - and now white Americans have taken the lead by far, due to the opioid epidemic:

The trend is central to understanding why America's drug addiction treatment system remains woefully inadequate - to the point that as many as 90 percent of people with drug use disorders won't access it.

Drug addiction was widely seen in the past as a problem that afflicted mostly racial minorities, especially black Americans. So a lot of Americans felt more comfortable treating it not as a medical problem but more as a criminal justice issue, with surveys of the era showing greater support for arresting drug dealers and, to a lesser degree, people who use drugs than later surveys have found.

As an example of how this can work, consider a 2007 study that examined the aftermath of Hurricane Katrina in 2005. In that study, researchers found that people tended to believe that victims in racial groups they don't belong to suffered fewer "uniquely human" emotions like anguish, mourning, and remorse than victims in racial groups they did belong to. And in the aftermath of a natural disaster, that perception of fewer "uniquely human" emotions led participants to be less willing to help victims of a different race.

A 2009 study similarly found that when participants looked at images of people in pain, the parts of their brains that respond to pain tended to show more activity if the person in the image was of the same race as the participant. Those researchers concluded that their findings "support the view that shared common membership enhances a perceiver's empathic concerns for others." Other studies reached similar conclusions.

Really, it seems like common sense: Once someone can relate to the person who's suffering, it becomes much easier to empathize. And when it comes to federal and state legislators - the majority of whom are white - empathy can then translate to more sympathetic policy preferences and outcomes.

So it's not hard to understand why America didn't have much in the way of serious discussions about scaling up drug addiction treatment in the 1980s and '90s but is suddenly discussing the value of treatment in response to the opioid epidemic.

Ithaca, New York, Mayor Svante Myrick, who's black, previously told me the disparity in how crack was approached in previous decades and how opioids are now viewed has led to resentment in much of the black community in his predominantly white town.

"It's very real," he acknowledged. The typical response from his black constituents, he said, goes something like this: "Oh, when it was happening in my neighborhood it was, 'Lock 'em up.' Now that it's happening in the [largely white, wealthy] Heights, the answer is to use my tax dollars to fund treatment centers. Well, my son could have used a treatment center in 1989, and he didn't get one."

Still, Myrick added, "I'm as angry about this as anybody. But just because these are now white kids dying doesn't mean we shouldn't care, because these are still kids dying."

Now, race isn't the only reason these systems turned out as they are today. For one, the crack epidemic was associated with more street violence - there were more shootings and murders during the crack epidemic, as the homicide statistics show, than there have been during the opioid epidemic. To some degree, that justified a criminal justice response at the time. (Although the greater levels of violence in minority communities can also be blamed on institutional racism.)

Class likely plays a role too. The recent meth epidemic was predominantly linked to white Americans, yet it also invited a punitive "tough on crime" response. That may be because it was also linked to poor white Americans, while the opioid crisis is associated more with middle-class white Americans.

And society's understanding of addiction was simply much worse in the 1980s. As Humphreys has noted, activists in the addiction treatment and recovery fields have done a lot to boost the view of addiction as a medical problem in recent years. This kind of awareness simply wasn't around in the '80s, especially as racism colored how Americans viewed addiction.

The result, however, is that America is better suited to deal with drug addiction as a criminal justice, not public health, problem as it faces an extremely deadly overdose crisis.

Racism affects policy outcomes for everyone in all sorts of ways

The response to drug epidemics exemplifies just one way in which race can shape so much of American politics and policy.

A prominent example is President Donald Trump. Several studies suggest that racial resentment was a big predictor of support for his candidacy, which was launched with an infamous speech explicitly attacking Mexican immigrants. Yet his legislative policy agenda so far has focused on efforts to repeal Obamacare, a budget that slashes social services to the poor, and a tax reform package that will mainly benefit the wealthy. As Dylan Matthews explained for Vox, the cuts hit programs that help millions of white Americans and keep millions out of poverty - yet through racial resentment, Trump managed to get people to support this agenda.

"People's level of racial resentment ... was the single best indicator of whether they were against the ACA, or Obamacare, in the outset," Godsil told me. "It is clear that the right used racial resentment and racism and this idea of who's benefiting from certain kinds of government programs to undermine support for [Obamacare]."

There's a lot of social science research behind this idea. As researchers Sean McElwee and Jason McDaniel explained for Vox, racial attitudes are a very strong predictor for beliefs about government spending. "For decades, social scientists have found that attitudes about race, particularly toward African Americans, persistently impact political attitudes and opinions toward government services, spending, and welfare," they wrote.

McElwee and McDaniel measured racial resentment, economic peril, and support for more government spending. They found that higher measured racial resentment correlated with a preference for decreased government spending and services, while more economic insecurity appeared to correlate - but not at a statistically significant level - with more support for increased government spending.

A recent study is particularly illustrative in this regard. In a survey, white respondents were asked about their beliefs on housing assistance. (The researchers only used data from white respondents because support among minority groups for Trump was too low to be statistically reliable.) With the question, survey takers were primed with a subtle image of either a black or white man.

The results were striking: Greater favorability toward Trump highly correlated with more opposition to a federal mortgage aid program, higher levels of anger that some people receive government assistance, and a greater likelihood to say that individuals who receive assistance are to blame for their situation. In contrast, favorability toward Hillary Clinton, Trump's 2016 opponent, did not have a statistically significant effect.

The researchers concluded, "These findings indicate that responses to the racial cue varied as a function of feelings about Donald Trump - but not feelings about Hillary Clinton - during the 2016 presidential election." Trump was clearly attracting people with high levels of racial resentment.

Much of this is driven by the perception of who gets these benefits. If critics can paint a policy as benefiting black people, that makes white people more likely to oppose it. This is why coded rhetoric about "welfare queens" and other recipients of government benefits can be so effective: It suggests the government is taking money from white taxpayers and redistributing that money to people of color who are, McGhee argued, seen as "lazy at best and criminal at worst." Never mind that, as just one example, the plurality of food stamp recipients are white.

This has been a trend for decades, going back to Richard Nixon's "Southern strategy," Ronald Reagan's original use of the term "welfare queen," and now Trump's own coded rhetoric. It's what some experts call the identity politics of the right, and perhaps the big reason, McGhee argued, that a majority of white voters have rejected Democrats in presidential elections after 1964, when the Civil Rights Act passed.

We see this consistently throughout American politics: Race plays a tremendous role in how people respond to certain policy issues and how people vote. That lets politicians like Trump leverage race to get white voters in particular to go along with an agenda that could actually hurt them - whether the issue is housing, welfare, Obamacare, or drug addiction treatment.

"It scapegoats and vilifies people of color," McGhee explained. "It sets up a response among many white people that sees policies that benefit people of color as suspect, regardless of the fact that those policies would also benefit similarly situated white people."

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The deadliness of the opioid epidemic has roots in America's failed response to crack

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The death toll from the opioid epidemic ravaging the US has been climbing by the thousands for years:In 2015, opioid overdose deaths killed more people in the US - 52,000 - than guns, car crashes, and even HIV/AIDS at its peak, and overdoses since the epidemic began in the late '90s had killed more people than the entire population of Atlanta.Based on preliminary data, 2016 will be worse.

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Opioid epidemic shares chilling similarities with the past - CBS News

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Opioid epidemic shares chilling similarities with the past - CBS News

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NEW YORK - While declaring the opioid crisis a national public health emergency Thursday, President Donald Trump said: "Nobody has seen anything like what's going on now."

He was right, and he was wrong.

Yes, this is the most widespread and deadly drug crisis in the nation's history. But there has been a long string of other such epidemics, each sharing chilling similarities with today's unfolding tragedy.

There was an outbreak after the Civil War when soldiers and others became addicted to a new pharmaceutical called morphine, one of the first of many man-made opioids. There was another in the early 1900s after a different drug was developed to help "cure" morphine addiction. It was called .

Cocaine was also developed by drugmakers and sold to help morphine addiction. It cleared nasal passages, too, and became the official remedy of the Hay Fever Association. In 1910, President William H. Taft told Congress that cocaine was the most serious drug problem the nation had ever faced.

An early Bayer aspirin advertisement.

Over the next century, abuse outbreaks of cocaine, heroin, and other drugs like methamphetamine, marketed as a diet drug, would emerge and then fall back.

"There are one or two or three wolves ahead of the pack that seem to be the most pressing threat, their jaws closest to you," said David Courtwright, a University of North Florida historian who has written books on U.S. drug epidemics. "But there's always a pack. The history is that the lead wolves keep shifting."

Trump vowed in his recent remarks "we will free our nation from the terrible affliction of drug abuse." But the grim reality is that these drugs never disappear completely once they've emerged.

The good news, though, is that drug epidemics do fade considerably - usually because reduced supply and demand eventually diminish the number of new addictions, experts say. And that history offers some hope for the future.

The 1800s: Better - and more dangerous - medicines

Most U.S. drug epidemics over the past two centuries were sparked by pharmaceutical companies and physicians pushing products that gradually proved to be addictive and dangerous. In the 1800s the drug was often opium, usually sold as a liquid in products like laudanum, and given to patients for pain or trouble sleeping. Mary Todd Lincoln, President Lincoln's wife, took it for headaches and became addicted.

The drug was also used to get high. "Opium fiends" smoked it in opium dens like those in San Francisco's Chinatown. Rev. Frederick Masters, a 19th century Methodist missionary, described opium dens in that city as dark, fumy basements "sepulcher-like in their silence save for the sputtering of opium pipes or the heavy breathing of their sleeping victims."

The young nation's drug problem grew because of morphine, a painkiller derived from opium through a chemical process that was perfected by E. Merck & Company of Germany. It made battlefield injuries more bearable for Civil War soldiers, but so many veterans got hooked that morphine addiction was sometimes called "the army disease."

It would get worse. Cocaine and heroin were soon developed - in part to help morphine addiction.

Merck introduced cocaine, which became a prime ingredient in a variety of over-the-counter tonics for sinus problems and other ailments. Because of its energizing effects, beverage makers put it in their wines and sodas and laborers in the South sniffed it to get through grueling work shifts.

Bayer, another German pharmaceutical company, began marketing heroin in the 1890s. It often came in pill form, without prescription, and was used to treat the flu and respiratory ailments. But it came to be sniffed - and later injected - by those looking for a more intense high or a substitute for other drugs, whether it was morphine in 1905 or opioid pain pills like Vicodin in 2015.

The early 1900s: From cure to curse

In the early 1900s cocaine shifted from a consumer fad into reviled epidemic, as physicians began documenting addiction problems and police chiefs linked recreational cocaine use to prostitution and violent crime. It led to the first national effort to contain a drug epidemic: In 1914, Congress passed the Harrison Act, which said cocaine and heroin could be sold only as a prescription medicine, not in over-the-counter remedies or in consumer products.

Historians believe a growing stigma attached to cocaine use was the main reason the epidemic declined, but they say enforcement of the Harrison Act - and its impact on prices - also was important. Cocaine and heroin got much more expensive when they were driven underground.

Drugs were still abused in the later years in pockets of society - cocaine use was rampant in Hollywood in the 1920s, for example. But economics and politics helped prevent large-scale epidemics for a time. The Great Depression meant few had the disposable income for an illicit drug habit, and World War II decimated the supply of drugs from overseas.

"There's no customs patrol more efficient than a U-boat," said Courtwright, the University of North Florida historian.

Mid-20th century: The first war on drugs

Alcohol and cigarettes were - and remain - the nation's primary addictions. Both kill far more people than drugs. But since the middle of the century, there's been wave after wave of other drug abuse outbreaks.

Amphetamines, developed in the 1930s, took off in the 1950s. Marketed by drug companies and promoted by doctors, they were used for weight loss, anxiety and depression. Methamphetamine, developed by the Burroughs Wellcome drug company, was often prescribed as a diet pill and abused by those attracted by the surge of energy it produced. Users who injected it were known as "speed freaks."

"The speed freak is, in many ways, an outcast in a society of outcasts. He is regarded as a fool by heroin addicts, as insane and violent by those using psychedelics and marijuana, and a 'bust' by non-drug using hustlers," wrote Dr. Roger Smith, a criminologist who studied drug use in San Francisco in the late 1960s.

Greater regulation of the drugs in 1970, along with the stigma attached to speed freaks, caused the drugs to recede as others became more widely used.

In the 1960s and 1970s, heroin use surged, prompted in part by Vietnam War soldiers who were exposed to it while fighting overseas. Unlike the doctor-driven previous drug epidemics, this one victimized poor inner-city neighborhoods most.

In 1970 and 1971, in New York City, more adolescents, many of them black and Puerto Rican, died of heroin-related incidents than any other cause. There was little compassion then for heroin addicts, recalled John de Miranda, a longtime addiction professional who worked with homeless men in Boston's South End in the early 1970s. "We basically cared for the men nobody else wanted to deal with," he said.

President Richard Nixon's 1971 "war on drugs" declaration kicked off a long period of attacking the drug problem with beefed up law enforcement and tougher sentences for users and dealers. The approach did cut down foreign shipments of heroin and marijuana, but those successes were temporary and many historians argue Nixon's war ultimately was a losing effort.

Late 20th century: Cocaine on high

Heroin use faded in the late '70s, but cocaine was on its way back, first in powder form and then becoming an epidemic of crack in the 1980s when a supply glut prompted dealers to sell hardened cocaine rocks that sold for $5 to $10 on the street.

Many young thrill-seekers, wary of heroin and needles, thought crack was less dangerous because it was smoked like marijuana.

Like the heroin surge before it, crack was seen as tied to urban blight and violent crime. This triggered a new drug war, including the "this is your brain on drugs" TV spots that showed frying eggs, and harsh jail sentences for the sale and possession of crack that were far more severe than the penalties for regular cocaine.

The crack epidemic died out in the 1990s, tailing off at roughly the same time both in cities that aggressively arrested people and cities that didn't. Experts said the police crackdown contributed, but more important was society's growing repulsion to the drugs. Families and communities were shattered by crack-related murders and arrests. The drug's users came to be regarded as disgraceful "crackheads." Even risk-taking kids, looking for new highs, started to avoid crack.

Today's opioid epidemic

In 1900, when cocaine and heroin were legal and popular, there were 250,000 Americans with a drug addiction, according to one historical estimate. That was about 1 in 300 Americans. The estimate today is 1 in 133, and the drugs are deadlier than ever.

"In all my years I've worked in the substance abuse field, I've never had so many patients die," said Joan Hartman, vice president of behavioral health services for Illinois-based Chestnut Health Systems, who has been working in treatment for three decades.

There were fewer than 3,000 overdose deaths in 1970, when a heroin epidemic was raging in U.S. cities. There were fewer than 5,000 recorded in 1988, around the height of the crack epidemic.

More than 64,000 Americans died from drug overdoses last year, according to the U.S. Centers for Disease Control and Prevention.

This epidemic started around 1995, kicked off by a drug called , which like heroin and morphine before it, was meant to be a safer and more effective opioid. OxyContin and competitor drugs were designed to release the medication slowly over long periods of time, making them and supposedly safe and effective enough to use for months to treat chronic pain. But patients found themselves hooked and wanting more, and drug abusers found they could crush the tablets and snort or inject them, delivering the drug to the bloodstream much more quickly.

Aggressive marketing and distribution pushed hundreds of millions of pills into communities. Then more and more addicts turned to cheaper alternatives, bought illegally, like heroin and fentanyl, an opioid medication developed to treat intense, end-of-life pain in cancer patients that is 50 to 100 times more powerful than morphine.

OxyContin tablets at a pharmacy in Montpelier, Vt.

"It's a very complex epidemic" that is nowhere close to being over, said Dr. Anne Schuchat, the CDC's principal deputy director, in an interview earlier this year.

Lessons of the past

What has worked for previous epidemics?

The supply is often reduced by a combination of regulations, law enforcement and economics. And historians say that demand slows when drug users became so outcast that even those looking for a risky thrill or a way to escape began to stay away.

Past epidemics have also shown what doesn't work. Many experts, including some in law enforcement, say that arresting users and dealers does not seem to slow epidemics. "We cannot arrest our way out of the heroin and opioid addiction crisis," said Brian Moran, Virginia's secretary of public safety and homeland security, speaking at a federal hearing in July.

But while health experts want to urge people to shun drugs to reduce the number of new addictions, they say ostracizing the people already suffering from addiction does little to help them. It may even impede attempts to get people into treatment, Hartman said.

Health officials are fighting the current epidemic on three fronts: Preventing overdose deaths, helping people recover from addiction, and preventing new addictions.

There appears to be some success on the first front. The number of new addictions may be receding.

A recent federal report noted a downward trend in "opioid misuse" in adults younger than 50. Prescription rates are falling, though they remain far higher than years ago. And according to a closely watched University of Michigan study of adolescents, use of the opioids OxyContin and Vicodin has been low and falling for several years. In 2016, heroin use was the lowest in the survey's 41-year history.

"I suspect we may be past the peak (of the epidemic), at least in terms of initiation," said Jonathan Caulkins, a drug policy scholar at Carnegie Mellon University.

The other two fronts - preventing deaths and treating addiction - are not so promising, despite more attention and money flowing to programs. Deaths are still rising, and University of Pittsburgh researchers estimate as many as 300,000 will die from overdoses over the next five years.

"Honestly, we're at a point where the horses are out of the barn after the gate has closed," said Dan Werb, an expert at the University of California, San Diego. "I'm not optimistic about the capacity of our classic approaches to rein this in."

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Opioid epidemic shares chilling similarities with the past

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NEW YORK - While declaring the opioid crisis a national public health emergency Thursday, President Donald Trump said: "Nobody has seen anything like what's going on now." He was right, and he was wrong. Yes, this is the most widespread and deadly drug crisis in the nation's history.

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Opioid crisis weighs on New Hampshire’s chief medical examiner - The Boston Globe

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Opioid crisis weighs on New Hampshire’s chief medical examiner - The Boston Globe

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CONCORD, N.H. - On some days, Dr. Jennie Duval calls as many as six families after fatal overdoses - some of the families stunned and heartbroken, some of them resigned to a death they saw coming.

This, Duval said, is the most difficult part of her job as the only full-time medical examiner in New Hampshire, which leads the nation in per-capita deaths caused by fentanyl and other synthetic opioids.

"It's not like I can rush the call," said Duval, the state's chief medical examiner, as she described a heart-wrenching notification. "It takes a lot of time. But sometimes I feel like a broken record."

The crush of fatal overdoses has forced the office to abandon its practice of conducting an autopsy on each suspected overdose victim. Still, Duval has no alternative but to work a grueling schedule of 10- to 12-hour days that drains her physically and emotionally.

"If this epidemic is cresting, I'm not feeling it," Duval said in a conference room at Concord Hospital, the strain of another long day visible on her face. "There are many more autopsies that I'm not doing."

A Chelsea physician writes of the importance - and rewards - of treating opioid addiction in primary care.

Duval's only assistance comes from two contractors who each work five days a month. Among them, they conducted 548 autopsies last year - about one-third for overdoses in a state where 476 people are confirmed or suspected to have died from drugs in 2017. Duval conducted nearly 300 autopsies, far above the profession's suggested limit of 250.

The state Legislature has approved funding for two physicians to join the office. But in the ultra-competitive field of forensic pathology - a limited pool of doctors to fill many openings in the country, coupled with the challenge of recruiting in a rural state with long winters - Duval is crossing her fingers that help arrives soon.

"It takes a certain kind of person to do this job," she said. "It's not pleasant. You're dealing with death every day."

The state's former chief medical examiner, Dr. Thomas Andrew, said the opioid epidemic was part of the reason he retired last year to pursue a calling for the ministry.

The office's overall caseload has more than doubled since 1997, the year Andrew became chief medical examiner, and reached 1,820 in 2017. Twenty years ago, opioids were linked to less than 10 percent of deaths referred to the office, Andrew estimated.

"It was simply a slowly unfolding catastrophe that, even in seeing it coming, we didn't have the surge capacity to account for it," Andrew said. "The casework was getting done, don't get me wrong, but the numbers became so overwhelming."

The medical examiner's office investigates fewer than 20 percent of the approximately 12,000 people who die in New Hampshire each year. They include victims of suicide, accidents, and sudden, unexpected deaths of people under 60.

The number of cases that include an autopsy makes up about one-third of all referrals, although they are mandatory for some cases, such as homicides.

Choosing which overdose victims to autopsy "is a gamble," Duval said.

Some cases seem obvious - a syringe in the arm, opioids near the body, and a documented history of drug abuse, she said. But even cases that appear straightforward can involve factors that are discovered only through an autopsy, Duval said. Perhaps a pulmonary embolism will be found. Perhaps other damage might have caused or contributed to the death.

And as the opioid crisis continues, autopsies can yield valuable information about the effects of synthetic drugs such as fentanyl.

"It's the right thing to do," Duval said. "You want to have every piece of the puzzle."

New Hampshire is not alone in its staffing struggles.

Dr. Kim Collins, a South Carolina physician who is president of the National Association of Medical Examiners, said the profession is finding it hard to fill vacancies as fewer students choose the field and more forensic pathologists are retiring.

Each year, only about 30 to 40 young doctors in the United States become certified in forensic pathology, Collins said. Medical schools are devoting less attention to the subject - "some medical students will never even see an autopsy,'' Collins said - and the field pays far less than many other specialities.

Massachusetts, for example, is working to add three or four more doctors to a staff that already has hired two others since the beginning of the fiscal year, said Daniel Bennett, the state secretary of public safety, who oversees the medical examiner's office.

The state's nine full-time medical examiners average more than 300 autopsies a year, Bennett said. Massachusetts also has three part-time forensic pathologists, nine contracted examiners, and three young physicians who work for the office on a fellowship program.

Still, Massachusetts must improve to be fully accredited by the national association that Collins leads. Bennett said the opioid epidemic, mirroring its impact elsewhere, has created a backlog in completed autopsy reports that the office hopes to shrink to industry guidelines this year.

The national association requires that 90 percent of autopsy reports be completed in 90 days. In Massachusetts, 58.3 percent of autopsy reports met that standard between October 2015 and September 2017.

To help address the lag, Governor Charlie Baker wants to boost funding for the office by $1.7 million in fiscal 2019, to a total of $11.9 million.

In Maine, two full-time forensic pathologists handle nearly all the autopsies. Two others work on a per-diem basis and handle about 10 percent of the cases.

"We did have trouble with turnover in this office, and it was difficult. Once you get an employee trained, they leave, usually for more money," said Mark Belserene, administrator of the state's medical examiner's office.

"We were successful in reclassifying positions to better reflect the actual tasks and also to bring the salaries up to a more competitive level," Belserene said.

Despite the physical and mental stress, Duval plans to stay put as New Hampshire's chief medical examiner.

"I'm not going anywhere," she said with a small smile.

Although the caseload continues to climb, the addition of two doctors should make the work more manageable. Still, Duval said she does not expect the yearly number of autopsies to fall below 250 for any examiner.

The opioid crisis should ensure that.

Brian MacQuarrie can be reached at brian.macquarrie@globe.com.

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Opioid crisis weighs on New Hampshire's chief medical examiner - The Boston Globe

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CONCORD, N.H. - On some days, Dr. Jennie Duval calls as many as six families after fatal overdoses - some of the families stunned and heartbroken, some of them resigned to a death they saw coming.