Causes and Consequences of a Drug Epidemic
(Originally published January 2020)
All social behavior is potentially contagious. It is difficult to fully appreciate the extent to which imitation influences human behavior of all kinds, e.g., food tastes leisure activities, taste in music, art, drama, comedy, ethical standards, risk taking and just about every other facet of culture. Imitation has a powerful influence on behavior for three main reasons:
(1) humans are highly attuned to indicators of status and therefore interested in copying behaviors that will maintain or improve their social standing;
(2) both adults and children imitate behaviors that appear to be beneficial (in various ways) to others; and,
(3) all social behavior implies rules of conduct. For example, when drivers of cars frequently play fast and loose with red lights and yet are rarely ticketed for doing so, all drivers learn the implicit rule: “it’s no big deal to run a red light if you’re in the intersection when the light changes to green or when there is no other car close to the intersection.” Pedestrians beware in these communities!
Drug epidemics that involve the ingestion of large amounts of dangerous legal or illegal drugs (e.g., alcohol, opioids, stimulants) must overcome the disinclination to risk life and limb for powerful short-term benefits. This is more likely to occur when a specific population or social group has given up on having a long-term future and is motivated to use any substance that will get them through the day. Widespread hopelessness regarding the future, or the expectation of sudden death, grievous injury and/or ongoing social humiliation is a sine qua non for a drug epidemic that has “legs”, i.e., staying power. In addition, drug epidemics create drug addicts (some, but not all regular users) who are subject to powerful cravings that may come to control their behavior, eliminate job opportunities and destroy interpersonal relationships. Once a drug epidemic has gathered a head of steam (so to speak) it’s difficult to stop because, initially, friends and acquaintances of drug users witness and hear testimonials to a drug’s powerful benefits, for example, relief from chronic pain (opioids), bursts of energy and increase of pleasure (stimulants), decrease of anxiety and social inhibition (alcohol). By the time the destructive effects of a drug have become widely apparent “on the street”, there are likely to be a large number of persons who crave the drug and need it regularly to avoid severe physical and emotional pain and suffering.
There have been two major drug epidemics in the U.S. during the past forty years: (a) the crack cocaine epidemic that began in the mid-1980’s, an epidemic that eventually included methamphetamine on the West Coast and in Midwestern states and, (b) the opioid epidemic that began about 2012 and continues to this day. Both of these drug epidemics began about four years after a severe recession, that is after the federal, state and local governments had withdrawn emergency measures designed to ameliorate immediate economic effects on vulnerable populations, and after many extended families were thoroughly fed up with the emotional and economic drain of supporting destitute family members. In their initial stages, these drug epidemics were powered by the withdrawal of economic and emotional support for low income persons and/or for workers who had lost well paid employment. The drug epidemics reflected a decline in community solidarity for people whose economic supports or prospects had been devastated by cuts to social programs (1980’s) or job losses associated with dramatic declines in mining and manufacturing and in other types of well-paid physical labor (2012 to present). It is not material hardship per se that leads to a drug epidemic; it is the loss of hope following severe economic downturns when affected populations perceive that communities and extended families have cut them adrift. In other words, a drug epidemic reflects how people who have suffered severe economic losses perceive the degree of community solidarity surrounding their predicament.
Economic losses underly recent U.S. drug epidemics, but it’s harsh public attitudes regarding substance abuse and substance dependent persons that sustain and deepen these epidemics. Consider some of the reactions to Nicholas Kristof’s and Sheryl WuDunns’s book, Tightrope: Americans Reaching for Hope (2019), which features the story of the Knapp’s, a family in Yamhill Oregon, whose children grew up with Kristof. Several members of this working-class family became drug addicted and/or manufactured methamphetamine, served time in prison for various offenses, and died early from disease or accidents resulting from heavy drug use. Around the date of the release of Tightrope, Kristof wrote a column in the New York Times titled, “Who Killed My Friends, the Knapp’s?” Kristof received many scathing replies to this column. One reader asserted that drug related deaths among the Knapps was an example of “natural selection weeding out those less fit for survival.” Other readers “suggested that when people use drugs or otherwise make bad choices, there’s nothing to be done.”
Anyone who works in child welfare is familiar with the inclination to morally condemn substance abusing parents who abuse and/or neglect their children. However, treating substance abusing parents like social pariahs intensifies and strengthens a drug epidemic by deepening drug users’ sense of social isolation. Furthermore, the criterion for offering services and other assistance to substance abusers and other afflicted populations is not a question of “just deserts”. Substance abuse and widespread drug addiction has powerful effects on children, extended families and entire communities. The costs of doing nothing, or (worse) doing dumb, ineffective things (e.g., mass incarceration of street level drug dealers) are immense and widely distributed. Kristof and his co-author (wife) return repeatedly to the question of responsibility and blame for drug addiction and criminal behavior because they believe that advocacy for more effective social policies depends on increased empathy for families such as the Knapp’s. I have a different view. Social policy discussions should be based on dispassionate analysis of the aggregate effects of various policies on social conditions that affect everyone, not just drug users or, for example, homeless persons. What sensible person would choose to live in a community afflicted by a drug epidemic that has resulted in hundreds of thousands of overdose deaths, along with large increases in CPS reports and the foster care population in many states, as well as an increase in homelessness, when it’s possible to greatly reduce the scope of the epidemic and its destructive effects through changes in social policy?
Deaths from Despair
The opioid epidemic has received extensive media coverage, in part because of it’s devastating effects on the White working class, and because of the increase in deaths from drug overdoses (68,000 per year at peak). However, deaths resulting from alcohol abuse (88,000 per year) far outnumber deaths from overdoses of opioids. Some drug users die from abuse of methamphetamine or cocaine, or from other drugs. Suicide rates, including children and youth (7-19 years) have greatly increased (more than 50%) since 2007. Male adolescents and young adults have far higher suicide rates than females of the same age. Many young and middle age men (of all races/ethnicities) with poor educational credentials are having a difficult time imagining a decent life for themselves in American society.
Material hardship is just one dimension of deaths of despair that have reduced average life span in the U.S. during recent years. The loss of status in the community and social inclusion following job loss also contribute to a sense of hopelessness.
Despite an historically low unemployment rate, a surprising number of Americans, 25-54, do not have full time employment in jobs that sustain self-respect and the respect of extended family members. In Tightrope, Kristof and WuDunn call attention to William Julius Wilson’s book, When Work Disappears (1988) which described the effects of loss of reasonably well-paying manufacturing jobs on African American men in the 1970’s and 80’s. They assert that “white culture” has reacted in pretty much the same ways. … It turns out that when members of any race lose jobs and self-esteem, people are more likely to soothe themselves with narcotics, drift into crime and suffer family breakdown.” (p.185)
Effects of drug epidemics on children
The Ripple Effect: National and State Estimates of the U.S. Opioid Epidemic’s Impact on Children (2019), a report released by the United Hospital Fund, estimates that, in 2017, 2.2 million children and adolescents “had a parent with an opioid use disorder (OUD) or had OUD themselves … Approximately 2 million young people were affected primarily by parental use: they were either living with a parent with opioid use disorder, had lost a parent to an opioid-related death …., had a parent in prison or jail because of opioids, or had been removed from their home due to an opioid-related issue.” This report asserts that 28 out every 1000 children in the U.S. were affected by the opioid epidemic in 2017. States varied widely in their rates of children affected by opioid abuse. Rates per 1000 children:
West Virginia - 54
New Hampshire - 51
Vermont - 46
Kentucky - 42
Delaware - 41
Oregon - 39
Washington - 34
Utah - 24
Idaho - 25
California - 20
Children, 0-5, have been the most affected age group by far due to the diminished capacity of substance abusing parents to provide dependable nurturing care, 24/7 to young children, especially infants. The Ripple Effect estimates the health care, drug treatment and child welfare costs for children affected by the opioid epidemic in 2017 in Washington State at $10.5 billion dollars by 2030.
Effects of the opioid epidemic on child welfare
Drug epidemics have huge effects on child welfare systems by (a) increasing the number of CPS reports and (b) increasing the number of babies and other young children in foster care. The drug epidemic that began in the mid-1980’s doubled the nation’s foster care population to 568,000 in 1999. There were years in the 1990’s and early 2000’s when New York City, Illinois and/or Los Angeles County had 50,000 or more children in foster care on any one day! Currently, New York City has less than 9,000 children in foster care, and Illinois has almost 18,000 children in its foster care system.
The current opioid epidemic led to a 12% increase in foster care nationally from 2012-2017 (443,00 at peak), but the increases in both CPS reports and/or foster care vary greatly among states. Several states including Ohio, Vermont, South Carolina and West Virginia had increases of 30-45% in their foster care populations between 2012 and 2017. Two states, New Hampshire and Indiana, doubled or nearly doubled the number of children in foster care from 2012-17.
Indiana, Kentucky, West Virginia and Vermont have had increases in CPS referrals per 1000 children greater than 100% since 2014. The CPS response (investigations or assessments) rate per 1000 children in Indiana exceeded 100 per 1000 in 2018; Kentucky’s rate was 83.2 per 1000 in 2018. West Virginia’s CPS response rate was 143.6 per 1000 in 2018, which means concretely that almost 15% of the state’s children were the subject of a CPS investigation or assessment in a single year!
The most surprising feature of the opioid epidemic has been the differences among states where the epidemic has had the greatest impact on children. West Virginia and Kentucky have very different economies and social policies compared to states in New England such as Vermont, New Hampshire and Delaware. Some states in New England have been hit hard by the opioid epidemic; nevertheless, even after large increases in CPS reports, New Hampshire and Vermont had CPS response rates per 1000 children far lower than CPS response rates in Kentucky and West Virginia in 2018.
No single social phenomenon such as a drug epidemic or child poverty rate totally determines what occurs in a public child welfare system. Consider Indiana and Washington, states with similar rates of opioid affected children in 2017 (35 vs. 34 per 1000). Washington State’s CPS response rate in 2018 was 27.7 per 1000 vs. Indiana’s rate of 102.9, i.e., 3.7 times greater than Washington’s rate. CPS intake screening policies have a large effect on a state’s CPS response rate. Indiana is one of several states in which policymakers and advocates appear to believe that more CPS intervention is better than less, a false idea which ignores the negative effects of overwhelming workloads on understaffed child protection caseworkers. Practitioners, policymakers and advocates in Washington State might consider the likely consequences of increasing this state’s CPS response rate per 1000 children by a factor of 3 or 4 while increasing staffing levels by a modest amount. It is an understatement to say that child safety would not be enhanced.
The economic context in which a drug epidemic occurs, the availability and quality of drug treatment, Medicaid expansion (or lack thereof) and other supports for low income families influence the impact of a drug epidemic on families and on state and county child welfare systems. States whose response to the opioid epidemic has been to greatly increase funding for their child welfare systems while cutting family support services have dug a deeper hole to climb out of. Child protection systems and law enforcement agencies cannot, by themselves, stop a drug epidemic. Every part of a community, including law enforcement, economic services, public health departments, drug treatment and public mental health agencies, child welfare and parent advocates must come together to achieve this goal.
The next Sounding Board will discuss promising strategies for preventing and combating a drug epidemic and for reducing the rate of youth suicides.
Casey Family Programs Foster Care Database, available online at
Child Maltreatment 2018, Administration for Children and Families, U.S. Department of Health and Human Services, Washington, D.C.
Kristof N. & WuDunn, S. Tightrope: Americans Reaching for Hope, Alfred A. Knopf, New York City, 2020.
The Ripple Effect: National and State Estimates of the U.S. Opioid Epidemic’s Impact on Children, United Hospital Fund, November 2019.