Policing the Opioid Crisis

Thesis

Presented in Partial Fulfillment of the Requirements for the Degree Master of Arts in the

Graduate School of The Ohio State University

By

Brookes Grant Hammock

Graduate Program in Geography

The Ohio State University

2019

Thesis Committee

Mat Coleman, Advisor

Kendra McSweeney

Elisabeth Root

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Copyrighted by

Brookes Grant Hammock

2019

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Abstract

Accidental drug overdose is now the leading cause of death for Americans under 50 years of age. In 2017 alone, more than 70,000 persons died in the United States due to a drug overdose. Indeed, it is estimated that the opioid epidemic has now killed more people than the U.S. wars in Vietnam and Iraq, combined. Although most analysts agree that the origins of the crisis stretch back more than a decade, and the uptick in opioid deaths is detectable as early as the turn of the century, the crisis narrative is more recent and likely stems from the persistence of overdose deaths despite pervasive media attention and policy interventions.

This thesis first argues that the opioid crisis is best understood not as one crisis but three overlapping crises or epidemics: prescription opioids (1990 – present), heroin

(2010 – present), and synthetic opioids (2013 – present). The three phases of the crisis constitute an intertwined epidemic where the phases coexist temporally and sometimes spatially. Second, the thesis presents a critical overview of the policing literature, with special attention to policing as the fabrication of social order. Third, the thesis confronts the policing literature with the example of the opioid crisis to explore how policing sometimes fails to cohere as a state project. Finally, interspersed throughout the thesis are three interludes—on deaths of despair, the politics of naloxone distribution, and J.D.

Vance’s Hillbilly Elegy—that examine dominant ways of thinking about the opioid crisis.

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Dedication

To my parents and to Eric—condiciones sine quibus non.

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Acknowledgments

I’d like to thank my advisor for seeing me through this project, my committee members for agreeing to serve, my parents for their decades of support, and my husband for reminding me that this was worth doing.

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Vita

2010...... J.D., Moritz College of Law, The Ohio State University

2006...... B.A., Comparative Cultural Studies, The Ohio State University

2002...... Miamisburg High School

Fields of Study

Major Field: Geography

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Table of Contents

Abstract ...... iii Dedication ...... iv Acknowledgments ...... v Vita ...... vi List of Figures ...... viii I. Introduction: One Opioid Crisis, Or Three? ...... 1 First Interlude: Deaths of Despair and the Dismal Science ...... 19 II. A Critical Introduction to Policing ...... 37 Second Interlude: Naloxone, Moral Hazard, and Necropolitics ...... 55 III. Policing the Opioid Crisis ...... 69 Third Interlude: Hillbilly Elegy ...... 74 Conclusion ...... 90 Bibliography ...... 96

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List of Figures

Figure 1. Prescription drug and heroin OD hospitalization estimates (left panel) and crude death rates due to prescription and heroin ODs (Unick et al. 2013) ...... 4 Figure 2. OD hospitalization estimates by race (top panel), gender (middle panel), and age (bottom panel) (Unick et al. 2013) ...... 5 Figure 3. POD rates by region (top panel) and HOD rates by region (bottom panel) (Unick and Ciccarone 2017) ...... 9 Figure 4. Age-adjusted drug overdose death rates: United States, 1999-2017 (Hedegaard, Miniño, and Warner 2018) ...... 12 Figure 5. Age adjusted drug overdose death rates, by state: United States, 2017 (Hedegaard, Miniño, and Warner 2018) ...... 13 Figure 6. Age-adjusted drug overdose death rates, by opioid category: United States, 1999-2017 (Hedegaard, Miniño, and Warner 2018) ...... 13 Figure 7. All-cause mortality by race and ethnicity for age 50-54, 1999-2015 (Case and Deaton 2017) ...... 22 Figure 8. White non-Hispanics reporting excellent or very good health, by survey year (Case and Deaton 2017) ...... 24 Figure 9. All-cause mortality and median household income per member for white non- Hispanics, 1990-2015 (Case and Deaton 2017) ...... 26 Figure 10. Year margins for all-cause mortality and median household income per member for white non-Hispanics age 30-64, 1992-2015 (Case and Deaton 2017) ...... 27 Figure 11. Percent change in wealth, 2007-2016 (Cooper and Bruenig 2016) ...... 30 Figure 12. Miamisburg, Ohio, family mourns loss of their son to an opioid overdose (Montgomery and Talbot 2017) ...... 94

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I. Introduction: One Opioid Crisis, Or Three?

Accidental drug overdose is now the leading cause of death for Americans under 50 years of age (Katz 2017; Katz and Sanger-Katz 2018). In 2017 alone, 70,237 persons died in the United States due to a drug overdose (Hedegaard, Miniño, and Warner 2018, 1), a yearly incidence that exceeds peak years for car crash deaths (1972), peak gun deaths

(1993), and peak HIV/AIDS deaths (1995) (Katz and Sanger-Katz 2018). Indeed, it is estimated that the opioid epidemic has now killed more people than the U.S. wars in

Vietnam and Iraq, combined (Sinha et al. 2018). Although most analysts agree that the origins of the crisis stretch back more than a decade, and the uptick in opioid deaths is detectable as early as the turn of the century, the crisis narrative is more recent and likely stems from the persistence of overdose deaths despite pervasive media attention and policy interventions.

Stepping back from the present emergency to take a longer view, a recent CDC

Data Brief illustrates how drug overdoses have changed remarkably over the last two decades (Hedegaard, Miniño, and Warner 2018). In 1999, the age-adjusted death rate due to drug overdoses was 6.1 per 100,000. In 2017, it was 21.7 per 100,000 (1). Nationwide numbers smooth out overdose hot spots in the Midwest and Northeast. In 2017, the highest age-adjusted overdose death rates were seen in West Virginia (57.8 per 100,000),

Ohio (46.3), and the District of Columbia (44.0) (1). Many narratives of the origins of the 1 opioid crisis trace its origins from Mexico to California to Appalachia, where it settled for a while in the mid-late 2000s before spreading to the rest of the country. We will complicate this narrative below, but it is axiomatic that the spatiality (and temporality) of the opioid crisis is key to grasping it as a totality.

The opioid crisis is not one crisis, but instead a series of three crises or epidemics.

Although related, intertwined, and in some senses causal, it is useful to keep these crises analytically separate for purposes of understanding their root causes and evaluating potential solutions. Following Dasgupta, Beletsky, and Ciccarone (2018), I will characterize the opioid epidemic as having three defined phases: prescription opioids

(1990 – present), heroin (2010 – present), and synthetic opioids (2013 – present). As

Dasgupta et al. argue, the three phases of the crisis constitute an “intertwined epidemic” where the phases coexist temporally and sometimes spatially; that is, the heroin epidemic did not “replace” the prescription opioid epidemic, nor did synthetic opioids replace heroin in turn. All three epidemics are currently unfolding in different ways and places across the U.S.

The first phase of the opioid epidemic—the one dominated by prescription opioid misuse—is typically understood to be driven by both supply- and demand-side factors.

On the demand size, analysts locate the source of demand in an epidemic of pain stretching back to the 1980s (or even earlier). The pain epidemic reflects a combination of patient characteristics, trends in the treatment of pain, and drug company strategies. On the patient population side, the Institute of Medicine identified the following factors at work:

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1. patients expect comprehensive pain relief; 2. they have more musculo-skeletal pain as they age; 3. patients are more obese; 4. they survive (and live longer) after injury and cancer; and 5. patients undergo increasingly complex surgeries

(Dasgupta, Beletsky, and Ciccarone 2018, 182). On the provider side, a revolution in pain management occurred in which pain became understood as the so-called fifth vital sign, thus requiring constant monitoring, attention, and intervention by medical providers. This revolution gave us, among other things, the ubiquitous Wong-Baker Faces Pain Scale, in which patients are asked to describe their pain on a scale from 0-10, with higher numbers representing higher levels of pain, represented by increasingly distressed faces. Around the same time, insurance companies curtailed coverage of behavioral approaches to pain, which enabled a shift to pharmaceutical approaches to pain management (182).

Pharmaceutical companies flooded the market with opioid pain relievers, like OxyContin, which Purdue Pharma introduced in 1996. These drugs were aggressively marketed to physicians and characterized as non-addictive ways to manage severe and chronic pain.

In combination, these supply and demand-side factors contributed to the rise in opioid prescriptions and use, especially in the mid- to late-1990s.

A study of hospitalizations due to opioid- and heroin-related overdoses from

1993-1999 found that prescription opioid-related overdoses and deaths rose precipitously after 1997 (Unick et al., 2013; see Fig. 1). These patterns were particularly pronounced among whites, women, and those at mid-life (Unick et al., 2013; see Fig. 2). The authors of this study remind us

that changes in the form of opiates, their availability and the stigma attached to them coincides with changes in the population at risk for abuse and overdose. The 3

recent rise in POD [prescription opioid overdose] corresponds with the rise in prescription opioid availability.” (2013, 6)

Put simply, if we want to understand the opioid crisis, it is important to distinguish between the kinds of opiates being used, because different kinds of opiates give rise to different patterns of use and abuse in different populations, which in turn produce different opportunities for intervention.

Figure 1. Prescription drug and heroin OD hospitalization estimates (left panel) and crude death rates due to prescription and heroin ODs (Unick et al. 2013)

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Figure 2. OD hospitalization estimates by race (top panel), gender (middle panel), and age (bottom panel) (Unick et al. 2013)

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The second epidemic coincides with the rise—some might say return—of heroin overdose deaths that occurred between 2010 and 2015. Again, both supply and demand play a role. In terms of user demand, it is thought that the prescription opioid crisis

“tenderized the terrain” for heroin, in that it created widespread opioid dependency and tolerance among naive users (Quinones 2016, 165). These users increasingly sought opioids from a diminishing supply, as states implemented prescription drug monitoring programs (PDMP) that effectively restricted the ability of physicians to prescribe opioids.

States also began aggressively to identify and shut down so-called pill mills, which are operations that essentially sell prescription drugs to patients-users for cash without medical justification. (Pill mills were key to the development of the first phase of the opioid crisis in some regions, especially Florida and Appalachia.) Physicians and the agencies that regulate them also cracked down on what were seen as abusive prescribing practices; this self-regulation occurred via state medical boards, the revision of prescribing guidelines, and other actions designed to shift professional norms around opioid prescribing. Around the same time, a new supply of black tar heroin emerged from

Mexico into the U.S. via California. As the street price of prescription opioids went up due to decreased supply (and other forms of regulation, like policing), problem opioid users shifted to cheaper, newly available black-tar heroin.

In the U.S., the market for heroin can fruitfully be understood in relation to three factors: (1) the structure of retail heroin markets (2) techniques used to market heroin, and (3) the difference in sources for heroin (i.e., black tar heroin from Mexico versus powder heroin from Colombia) (Mars et al. 2015, 47). In terms of market structure, the

6 primary distinction is between open-air markets and closed markets. Stereotypical open- air markets, such as Kensington in Philadelphia or Skid Row in Los Angeles, feature buyers and sellers meeting on the street to exchange drugs for money. Closed markets, such as San Francisco or parts of the Midwest, tend to be more private, with dealers meeting buyers inside buildings or cars, or even consummating transactions on the pizza delivery model discussed in Quinones (2016). Mars et al. (2015, 48) found that open-air markets can provide a deeply committed user base with plentiful, cheap heroin, while closed markets can be more difficult for users, especially in cities experiencing pressures from policing or gentrification that shrink the safe operating space for drug sellers and buyers.

Marketing techniques also play a role. Dealers often market “brands” of heroin, which are stamped on bags, to generate buzz and attract users to open-air markets. In places like Philadelphia, users (who often lack cell phones) rely on word-of-mouth information from other users to convey which brands—like “Obamacare” (yes, really)— are hot at any given moment (Mars et al. 2015, 49). In closed markets like San Francisco with a different user base that, e.g., is more likely to own a cell phone, users frequently contact personal dealers who meet them at a predetermined location or in a vehicle.

While this kind of structure is “safer” in the sense that it’s less exposed to policing, it also gives users fewer opportunities to sort good product from bad—indeed, good heroin from heroin that is killing people, although that, too, is sometimes desired by users themselves

(49).

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The physical structure of the heroin involved matters. Black tar heroin is gummy and has to be heated and then diluted before it can be used, while powder heroin can be dissolved in cold water and injected directly. Mars et al. found that users who inject black tar heroin are much more likely to report suffering vein damage and loss of access than those who use powder heroin. On the other hand, because serial dilution is often needed to get black tar heroin into a form that’s injectable, this drawn-out process may protect some users from overdose (Mars et al. 2015, 50).

While these kinds of details provide helpful background for understanding the heroin-dominated, second phase of the epidemic, it would be incorrect to assume that heroin simply replaced prescription drugs across the country in a straightforward way. In fact, as Unick and Ciccarone (2017, 116) report in a study of regional and demographic differences in hospital admissions for prescription opioid and heroin overdoses, “the simple opioid-to-heroin transition story” can be misleading. As Figure 3 below shows, while all U.S. regions show a steady increase in prescription opioid-related hospitalizations through 2010, and then a drop off thereafter, the same data for heroin show that overdose-related hospitalizations in the Northeast increased at a rate more than twice as high than other regions in 2000 and then again after 2010 (114-15).

Demographically, Unick and Ciccarone (2017, 116) found that whites showed the highest rates of prescription drug overdose-related hospitalizations in all census divisions they examined, as well as the highest heroin overdose-related hospitalizations in most divisions. Results for blacks and Hispanics were mixed. To tease apart the demographic trends and link them to testable hypotheses, the authors suggest, is a difficult task that

8 requires incorporating quantitative analysis with ethnographic accounts of the daily lives of heroin users1.

Figure 3. POD rates by region (top panel) and HOD rates by region (bottom panel) (Unick and Ciccarone 2017) The third phase of the epidemic, dating from 2013 to the present, is that of synthetic opioids like fentanyl and carfentanil. Synthetic opioids are thought to be “30-50 times more potent by weight compared with heroin” (Ciccarone, Ondoscin, and Mars

1 See Unick and Ciccarone (2017, 116, 199) for speculations alone these lines. 9

2017, 146). These drugs are often manufactured in labs in China or India and then transported through highly efficient supply chains either directly to the U.S. (via cargo containers) or by courier across the Mexican border. Because synthetic opioids are incredibly potent and often added to heroin or prescription opioids sold in illegal markets, this phase of the crisis is deadlier than the earlier two. This trend intersects with two structural changes in the heroin market that are worth noting. First, since 2008, the number of heroin users in the U.S. has doubled (Ciccarone 2017, 107). The demand-side shift has been met by a supply-side shock from Mexico: almost 80% of heroin is now sourced from Mexico (compared to 15% in the previous decade), and much of this heroin is no longer black tar but instead a “mimic” of South American powder heroin (107).

This Mexican heroin is no longer isolated to its tradition home western U.S. markets; it can now be found all over the eastern U.S., in both cities and rural areas—and at a price that fell by roughly half from 2010-2014 (108).

Second, there is a “wave of synthetic opioids contaminating or circulating within the heroin supply” (108). Ethnographic evidence from heroin markets in the Northeast suggest “an increased diversity of heroin-like products beginning around 2013,” i.e., penetration of synthetic opioids into the heroin supply (Ciccarone, Ondoscin, and Mars

2017, 152). These authors characterize the changing drug environment for users this way:

Overdose is the foremost health risk amplified by the introduction of fentanyl into the powder heroin supply due not just to its potency at the mu receptor but also vicissitudes in potency at retail. (152)

This amplified risk has resulted in a truly astounding rise in deaths attributed to fentanyl nationwide. “Between 2013 and 2016, deaths attributed to fentanyl analogs spiked by a

10 shocking 540% nationally, with pronounced regional increases” (Dasgupta, Beletsky, and

Ciccarone 2018, 183).

Although overdose rates associated with the third opioid epidemic are indeed shocking, it is important to note that the first two crises continue apace. In spite of the supply restriction measures mentioned earlier, such as PDMPs, which did in fact reduce opioid prescriptions, “Overdose deaths attributable to prescription opioids have not decreased proportionally to dispensing” (Dasgupta, Beletsky, and Ciccarone 2018, 183).

Heroin deaths have continued to increase, too. The overall picture is one in which the opioid crisis is not one crisis but actually three crises that move in temporal sequence and coexist in the present while exhibiting complex spatio-temporal patterns. The following figures show where the data stand at the end of 2017: overdose deaths remain at historic highs; overdoses are especially common in the Midwest, Florida, and much of the

Northeast; and while synthetic opioids are now driving high overdose rates, heroin and prescription opioids are still important components of drug overdose deaths.

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Figure 4. Age-adjusted drug overdose death rates: United States, 1999-2017 (Hedegaard, Miniño, and Warner 2018)

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Figure 5. Age adjusted drug overdose death rates, by state: United States, 2017 (Hedegaard, Miniño, and Warner 2018)

Figure 6. Age-adjusted drug overdose death rates, by opioid category: United States, 1999-2017 (Hedegaard, Miniño, and Warner 2018) 13

It’s also useful to put the opioid epidemic in its historical place, regardless of whether we conceive of it as one epidemic or three. Why? Because understanding the history of drug epidemics in the U.S. helps us to evaluate responses to this epidemic and to plan for the next one. As Herzberg et al. (2016, 408) argue, “Today’s ‘epidemic’ is just the most recent of three waves of mass abuse of psychoactive pharmaceuticals in

America that stretch back over a century.” According to these authors, the first wave of abuse, dating back to the end of the 19th century, was of morphine and cocaine. The second wave, from the 1920s to 1970s, primarily revolved around barbiturate and methamphetamine misuse (408). They locate the third, current wave in the crack cocaine epidemic as well as the release of new sedatives, stimulants, anti-depressants, and analgesics that pharmaceutical companies released in the late 1980s to early 1990s (409).

Herzberg et al. (2016, 409) note that state responses to these waves follow a characteristic pattern. First, there are non-coercive interventions that focus on educating physicians and the public; the goal is to “raise awareness.” Second, there are supply-side interventions designed to reduce prescribing, e.g., PDMPs and the Schedule of Controlled

Substances. Finally, and often occurring alongside supply-side measures, there are criminal justice (or policing) interventions—aimed at suppliers (doctors), sellers, and users—that try to deter drug misuse (409). The state response to the opioid crisis has followed this familiar pattern, although as I will discuss later, the criminal justice response has been tepid compared to prior epidemics. The reason why it is useful to see that the response to the opioid epidemic recapitulates responses to prior raves of drug misuse is because

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history offers little evidence that primary reliance on such strategies can genuinely reduce problematic drug use. Instead, these approaches have tended to shift problematic drug use to new substances while bringing negative consequences to those already dependent on drugs and their communities.” (409)

This path dependence can be seen in responses to the prescription opioid crisis, which, as noted above, have shifted users to new substances without providing a path away from dependency or even curbing overdose rates. The lesson Herzberg et al. draw from this historical analysis is that drug wars don’t work very well, and they certainly don’t position us to address the next wave of misuse—and that wave is inevitable. These authors advocate for “an expanded public health response” consisting of harm-reduction, expansion of treatment to both medical and non-medical misusers, and a focus on delivering health care in the community (409). In short, they argue, “we must stop making arbitrary distinctions between types of drug use, and make effective treatments and harm reduction techniques available to all drug users” (410).

In concluding this section, I would like to reflect on the concept of “crisis” and the role that the crisis narrative has played in the opioid drug epidemic over the last decade or more. In a review of the term “crisis” as a political concept, Janet Roitman

(n.d.) observes that

crisis signifies a diagnostic of the present; it implies a certain telos—that is, it is … directed toward a norm. Evoking crisis entails reference to a norm because it requires a comparative state for judgment: crisis compared to what?

In other words, one way that crisis can function is as a diagnosis in the present that invites critical reflection, indeed judgment, on the current state of affairs and how it could be otherwise. Roitman notes that “crisis is not intrinsic to a system or the result of a teleology, but is rather a distinction that produces meaning.” That is, the rhetoric of crisis 15 forecloses certain kinds of narrative while opening space for others. For that reason, it is important to attend to the different ways that the crisis is narrated. As we will see below, some commentators are stuck on just one phase of the prescription drug crisis, particularly its first phase. This fixation causes them to miss ways in which the opioid crisis as it actually unfolds fails to conform to their preferred diagnoses and remedies.

Ruth Wilson Gilmore and Craig Gilmore (2016, 188) take a different tack from

Roitman and define crisis as “organized abandonment’s condition of existence and its inherent vice. To persist, systematic abandonment depends on the agile durability of organized violence.” Here, crisis can be seen as a crisis of the state. In its drive to manage the inherent structural crises of capitalism and the zones of abandonment left behind due to capital’s inherent drive to seek higher rates of profit, the state must deploy forms of

“organized violence.” The Gilmores are talking about policing, and an important part of this perspective is to consider how crisis enables policing.

This understanding of crisis as productive of organized state violence sometimes privileges spectacular understandings of power—violence as the shooting of yet another unarmed black man on the street, as a no-knock drug raid on the home of an undocumented family, as the rough-and-tumble arrest of a trans person merely for walking on the street alone at night. While this kind of perspective illuminates some of the fundamental structures of the state in crisis and the state as police, it can also obscure other dimensions of power and violence, in particular their everydayness. To illuminate this aspect of state power, I will turn to the anthropologist Elizabeth Povinelli and her book Economies of Abandonment: Social Belonging and Endurance in Late Liberalism

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(2011). Although not a theorist of state power per se, her investigations into what she calls “late liberalism” reveal important characteristics about violence and power that can help us understand policing and crisis.

In the course of explicating a short story by Ursula Le Guin, Povinelli (2011, 3) notes that “the nature of suffering that interests Le Guin is ordinary, chronic, and cruddy rather than catastrophic, crisis-laden, and sublime.” The kinds of events that Povinelli is interested in aren’t really events at all—they’re “quasi-events” that are not part of a narrative of crisis and spectacularity (4). As she puts it:

If events are things that we can say happened such that they have a certain objective being, then quasi-events never quite achieve the status of having occurred or taken place. They neither happen nor not happen.” (13)

Povinelli is interested in the kinds of techniques we might employ in order to understand these quasi-events, this “ordinary suffering” (14). So am I. Although this thesis is an attempt to understand the causes and consequences of the opioid crisis, it tries not to dwell too long on the spectacular statistics that provide a neat, but incomplete, accounting of the actual human suffering related to opioid misuse. It’s my sense that to really come to terms with the kind of methodological shift Povinelli argues for would require an ethnographic project, which this thesis is not. Nonetheless, getting a grip on the ordinary suffering of opioid users through a site-specific, ethnographic intervention would be a fruitful avenue for future work, in which case this thesis is best understood as clearing some preliminary ground for that work.2

2 See Coleman (2016) for further reflection on what Povinelli’s methodological prescriptions might mean for studying state power and policing, especially in the form of ethnography. 17

The rest of the thesis proceeds as follows. It presents a critical overview of the policing literature, with special attention to policing as the fabrication of social order.

Next, it confronts the policing literature with the example of the opioid crisis to explore how policing sometimes fails to cohere as a state project. Finally, interspersed throughout the thesis are three interludes—on deaths of despair, the politics of naloxone distribution, and J.D. Vance’s Hillbilly Elegy—that examine dominant ways of thinking about the opioid crisis.

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First Interlude: Deaths of Despair and the Dismal Science

In a widely noted intervention entitled, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” economists Anne Case and Angus

Deaton (2015, 15078) document a disturbing trend: “a marked deterioration in the morbidity and mortality of middle-aged white non-Hispanics in the United States after

1998.”3 The authors attribute this mortality trend to three causes of death, “namely suicide, drug and alcohol poisoning (accidental and intent undetermined), and chronic liver diseases and cirrhosis” (15079). Case and Deaton also report changes in white morbidity at midlife. In particular, middle-aged whites self-report increasing rates of chronic pain, psychological distress, and difficulty performing activities of daily living

(15080). At the time of the 2015 analysis, the authors admitted that these trends are “only partly understood.”. Despite this note of caution, Case and Denton single out “[t]he increased availability of opioid prescriptions,” and associated heroin use, as important potential factors. But the authors are reluctant to make causal claims, because they believe that while there is an “epidemic of pain [that is] real enough,” it is nonetheless difficult to determine whether opioids cause the pain, or the pain the opioid use. They also note that these morbidity and mortality trends may be “tie[d]” to the financial crisis, but that macroeconomic factors like productivity slowdowns, income inequality, and wage stagnation are weak explanations, especially when one compares the U.S. with

3 Comprehensive lists of the coverage this research has received can be found at the authors’ Princeton media pages, which are available for Case at https://scholar.princeton.edu/accase/news-0 and for Deaton at https://scholar.princeton.edu/deaton/media. 19

Europe. At the end of the article, despite their concerns about the explanatory power of the opioid crisis, Case and Deaton worry that unless “the epidemic is brought under control, [. . .] those currently in midlife may be a ‘lost generation’ whose future is less bright than those who preceded them” (15081).

In 2017, Case and Deaton released a much-expanded analysis of these data entitled “Mortality and Morbidity in the 21st Century,” which marshals new evidence and crafts a narrative about “deaths of despair” to explain white decline at midlife in the U.S.

(Case and Deaton 2017, 398). While the 2015 report “simply reported a set of facts,” this paper extends the analysis to “underlying factors.” The authors admit that they “are still far from a smoking gun or a fully developed model,” but they believe that exploratory,

“descriptive work” can “suggest a differential diagnosis,” or at least directions for future inquiry (399). I will argue that while the 2015 paper does indeed report a disturbing set of facts, the 2017 analysis is akin to a set of political priors and policy prescriptions in search of facts to justify them. Case and Deaton’s differential diagnosis turns out to be a familiar set of conservative complaints about the decline of the family recycled in the language of structural disadvantage and yoked to anemic remedies for so-called deaths of despair. These familiar complaints not only lead Case and Deaton to an alliance with racist social science but also leave them with few plausible remedies for deaths of despair.

Their narrative has three parts. First, the authors document the trends in mortality and morbidity data that concern them. Second, they make an argument about the relationship between mortality and incomes, ultimately concluding that “the changes in

20 mortality and morbidity are only coincidentally correlated with changes in income”

(420). Finally, Case and Deaton offer a framework for interpreting the data that advances their own preferred explanation, i.e., “cumulative disadvantage” rooted in changing family structure, educational attainment, and labor force participation (429). I will work through each section in detail so that we can see how Case and Deaton’s argument unfolds.

Mortality and Morbidity Trends

From the period 1999 to 2015, white (or WNH = White Non-Hispanic, the authors’ preferred term) mortality at midlife is increasing, while midlife mortality for blacks

(BNHs) and Hispanics is decreasing. (See Fig. 7.) The trend line for whites without a college education (shown in red) is quite different from the other lines and shows a marked increase around 2012. Speaking about whites, Case and Denton say that they are

“losing ground,” and that a “mortality crossover” has occurred between whites and blacks

(403).4 Rising white mortality is surprising, because over the course of the 20th century, mortality rates for whites declined yearly since the late 1930s (403).5 Thus, the authors conclude, “In this historical context of almost continuous improvement, the rise in mortality in midlife is an extraordinary and unanticipated event” (403).

4 The language of “losing ground” echoes the title of the racist social scientist and commentator Charles Murray’s 1984 book Losing Ground: American Social Policy, 1950-1980. In that book, Murray argues that the rise of the American welfare state increased poverty rather than ameliorating it. Losing Ground arguably laid the groundwork for President Clinton’s 1996 welfare reform legislation. It will be shown that Case and Deaton are sympathetic to Murray’s ongoing interventions on behalf of the white working class. In the context of this paper, the “losing ground” framing prompts us to ask, “losing ground to whom”? Given the authors’ broader argument, it is clear that whites are losing ground to blacks and Hispanics. The paper’s odd race war framing does not appear to be visible to the authors. 5 As the authors note, white mortality declines paused around 1960, probably due to a lag in the negative effects of smoking, the prevalence of which rapidly increased in the 1930s and 1940s (403). 21

Figure 7. All-cause mortality by race and ethnicity for age 50-54, 1999-2015 (Case and Deaton 2017) Not only has white mortality at midlife increased in an absolute sense; it has also changed position with respect to other groups, like blacks and Hispanics. One could call the trends illustrated in figure two a convergence of mortality trends over the last two decades, or, with Case and Deaton, one could characterize them as the disappearance of a white/black mortality gap. The authors go on to perform exploratory data analysis of the mortality trends,6 but these details need not detain us here, because the overarching claim

6 For example, they compare whites at midlife in the U.S. to their European counterparts, both rich and poor; they decompose the data to show an “educational gradient” (i.e., much higher mortality rates for 22 is straightforward to summarize: there is rising mortality for whites at midlife in the U.S., and two salient features are the particularly poor performance of whites in general and whites with less than a high school education in particular.

Having documented the mortality trends, the authors turn to morbidity, where they see similarly disturbing trends for whites at midlife. Case and Deaton summarize:

Since the mid-1990s … , middle-aged whites’ reports of chronic pain and mental distress have increased, as have their reports of difficulties with activities of daily living. … Pain is a risk factor for suicide and … for those with less than a college degree there has been a marked increase between birth cohorts in reports of sciatic pain. (419)

These trends are illustrated below in Fig. 8.

those with a high school degree or less); they make a first cut at identifying geographical variation across the U.S. for deaths of despair; and they show the experience of different birth cohorts from 1940 to 1980. 23

Figure 8. White non-Hispanics reporting excellent or very good health, by survey year (Case and Deaton 2017) The Relationship Between Mortality and Income

The standard story in economics and elsewhere is that there is a causal relationship between income and health outcomes. The discipline has recently been focused on rising income inequality, and so it is straightforward to absorb the story that Case and Deaton

24 tell about increasing white mortality at midlife to a more general narrative about inequality. In other words, deaths of despair “would not have occurred if economic growth had been more equally shared” (420). Case and Deaton absolutely reject this counterfactual claim. They say that

The economic story can account for part of the increases in mortality and morbidity, but only a part, and that it leaves more unexplained than it explains. Our preliminary conclusion is that, as in previous historical episodes, the changes in mortality and morbidity are only coincidentally correlated with changes in income. (420)

In other words, the authors offer a story about spurious correlation in which income7 distribution does not drive changes in mortality and morbidity in general.

Consider the following graph:

7 It is important to note that Case and Deaton are resolutely focused on income, not, say, patterns of income distribution, wealth, or some other measure of inequality. As discussed in further detail below, this focus leads them to ignore key macroeconomic factors in their analysis. 25

Figure 9. All-cause mortality and median household income per member for white non- Hispanics, 1990-2015 (Case and Deaton 2017) What we observe in the top panel is an inverse U-shape of median household income and a corresponding U-shape of mortality, the latter of which declined until 1998, then rose

(421). The bottom panel shows that individuals in a somewhat older age cohort have done well since 1990, probably because of the cushioning effects of Social Security payments, which have helped to increase incomes for this age group. In this figure, income appears to track mortality; i.e., it appears to support the hypothesis that higher incomes are related to lower mortality (422). Call this the income-mortality hypothesis.

But then Case and Deaton ask us to consider another graph:

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Figure 10. Year margins for all-cause mortality and median household income per member for white non-Hispanics age 30-64, 1992-2015 (Case and Deaton 2017) This figure disaggregates data from the previous one by educational attainment. If the income-mortality hypothesis is valid, we would expect to see matching patterns from the left panel to the right panel. Instead, it appears that the dispersion in median household incomes by educational attainment seen in the left panel fails to match the obvious divergence in the right panel in terms of mortality by educational attainment (422). As

Case and Deaton explain:

The general widening inequality in family incomes in the United States does not show up here in any divergence between the median incomes of those with different educational qualifications, and does not match the divergence in mortality between education groups, as … seen in the right panel. (423)

Furthermore, the income-mortality story is a poor fit for the data we have on blacks and

Hispanics. Trends in black median household income closely track those for white households from 1980 to 2018 (when disaggregated by educational attainment), but as previously discussed, white mortality rates have risen, while black mortality rates have

27 continued to fall. (The trends are the same when comparing white with Hispanics, although with more noise in the data.) (423)

Trying to make sense of the income-mortality hypothesis in light of European data is equally puzzling, according to Case and Deaton. It is convenient to divide Europe into two categories: countries hard-hit by the Great Recession (Ireland, Italy, the

Netherlands, Spain, and the UK) and those that were not (Denmark, France, Germany, and Sweden). The former group saw family incomes decline or remain stagnant after the recession, while the latter group saw no slowdown in family incomes after 2007. Thus, the authors conclude,

If incomes work in Europe as they do in the United States, and if the income turnaround is responsible for the mortality turnaround in the United States, we would expect to see at least a slowing in the mortality decline in Europe, if only among the worst-affected countries, but there is none. (423)

Taken together, this analysis leads Case and Denton to conclude that “it [is] hard to sustain the income-based explanation” (424). The authors understand that this might be a difficult pill for readers to swallow. Even in their own discipline of economics, there is a robust literature on health determinants that demonstrates a link between higher incomes and lower mortality (425). But the authors also emphasize that there is conflicting evidence, e.g., from studies of business cycles on the connection between unemployment and mortality (426). There is even a body of literature suggesting that a bad economy is good for (aggregate) health (427). In light of this conflicting data, Case and Deaton offer the following evaluation:

Our own interpretation is that there is likely some genuine individual-level positive effect of income on health, but that it is swamped by other macro factors in the aggregate. Of the results here, particularly those shown in figure 14, we 28

suspect that the matching relationships are largely coincidental, as has happened in other historical periods. (427)

The authors realize that rejecting the income-mortality hypothesis leaves the reader with essentially no obvious explanation for the rise in deaths of despair. Reiterating their earlier interpretation, Case and Deaton say, “We suspect that more likely causes are various slowly moving social trends—such as the declining ratio of employment to population, or the decline in marriage rates.” That said, they are of course worried about their ability to rule out “long-run forces,” such as the different experiences or exposures of successive age cohorts (428). One anomaly they definitely do want to address is “why stagnant incomes have this effect on whites but not on blacks” (428-29). They go so far as to speculate that

Perhaps the substantial reduction in the black/white wage gap from the mid-1960s to the mid-1970s gave an enduring sense of hope to African Americans, though there has been little subsequent reason in income patterns to renew it. (429)

This hypothesis, though, is pure speculation unsupported by evidence in their text.

Furthermore, it ignores the difference between income and wealth, which allows the authors to gloss over the effect of recent macroeconomic events on African

Americans—particularly the foreclosure crisis. In an analysis of wealth destruction during the Obama years, Cooper and Bruenig (2016) found that the foreclosure crisis, mediated by Obama-era policies, essentially functioned to strip wealth from black and

Hispanic families, primarily through the devaluation of and foreclosure on their homes.

This dynamic produced unequally distributes gains and losses in wealth from 2006-2016, as can be seen in the following figure.

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Figure 11. Percent change in wealth, 2007-2016 (Cooper and Bruenig 2016) Another report on the racial wealth gap found that black families saw their inflation- adjusted household wealth drop by half between 1983 and 2016 (compared to a one-third increase for whites), and more than a third of black families today have zero or negative wealth (compared to about 16% of white households) (Collins et al. 2019, 3-4). All of this is to say that it makes little sense for Case and Deaton to talk about wage dynamics favorable to African Americans without discussing wealth trends that run in the opposite direction.

Cumulative Disadvantage

Case and Deaton (2017, 429) want to square suspicion of aggregate factors with their belief that convincing explanations (from economics and elsewhere) of the plight of the white working class emphasize “long-term process[es] of decline,” i.e., the very same aggregate factors they are suspicious of, such as income inequality. So, the authors try out another narrative, this one primarily internal to the economics literature. It goes something like this. What is happening to the white working class is part of a long 30 decline. The primary factor is that well-paying jobs for poorly educated people have been disappearing, which first began to occur for the cohort entering the workforce in the

1970s. This labor market problem unfolded alongside a number of other changes that the authors assert “made life more difficult for less educated people.” One such change was the decline of unions. Another was the waning of marriage and the rise of cohabitation

(429). Furthermore, individuals moved away from mainstream religions or left organized religion altogether (429-30). The net result, according to Case and Deaton, is that

these changes left people with less structure when they came to choose their careers, their religion, and the nature of their family lives. When such choices succeed, they are liberating; when they fail, the individual can only hold himself or herself responsible. In the worst cases of failure, this is a Durkheim-like recipe for suicide. We can see this as a failure to meet early expectations or, more fundamentally, as a loss of the structures that give life a meaning. (430)

Two things are worth noting about this assertion. First, the framing makes these shifts primarily a matter of individual choice or of shifting social norms. It could instead show that this process of individualization was a government policy and/or endogenous to neoliberalism as a form of governance, as Melinda Cooper (2017) does in her book

Family Values. Second, when Case and Deaton say “people,” they must mean white people. But we should be very careful not to conflate structure with dominance—that would be a basic interpretive mistake, but it would also cause us to miss how the period looks to people of color, especially to African Americans. In other words, “a loss of the structures that give life a meaning” looks a lot like the loss of power and structural disadvantage that flows from white domination, which was in decline over the period in question (the 1970s to the present).

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Continuing, Case and Deaton (2017) argue that the twin blows of technological change and globalization altered the labor market to the disadvantage of the poorly educated, such that their wages declined as the so-called college premium (the idea that there is a strong relationship between a college education and higher wages) increased.

Although the massive entry of women into the labor force padded households with female wage earners, some households undoubtedly suffered from the decline in real wages. Economists “estimate that only 60 percent of the cohort born in 1960 was better off in 1990 than their parents had been at age 30,” while “for those born in 1940, 90 percent were better off at 30 than their parents had been at the same age” (430). Case and

Deaton conclude: “The data do not permit an analysis, but the deterioration was likely worse for whites than blacks, and for those with no more than a high school degree”

(430). Again, it is worth understanding what the authors mean by “deterioration.” How is it possible to claim that the deterioration was worse for whites than for blacks over this period, when we know, for example, what the Great Recession did to black wealth? Are we again not conflating change in position with loss of domination?

Beyond technological change and globalization, the authors also make the case that dynamics in the marriage market have impacted the fortunes of the white working class. As wage declines produced exits from the labor force, “men [became] less marriageable” (431). Declining marriage rates coincided with an increase in the number of cohabiting adults (i.e., non-marrying adults), particularly among those with less than a bachelor’s degree. Case and Deaton flatly claim that:

unmarried, cohabiting partnerships are less stable than marriages [. . .]. The instability of cohabiting partnerships is indeed their raison d’être, especially for 32

the women, who preserve the option of trading up—so that both men and women lose the security of the stable marriages that were the standard among their parents.” (431)

The authors offer additional observations on modern family structure, but it is unclear how what can only be described as their version of the decline of the modern family relates to deaths of despair, beyond what Case and Deaton call “social upheaval” (423).

These sorts of sociological asides put the authors on the same ground as Charles Murray and J.D. Vance, who are discussed at length in the final interlude of the thesis. Suffice it to say that “social upheaval” in this context recapitulates older debates about the pathology of certain kinds of families, even while it glosses correlations between family structure and life outcomes.

Speaking of social upheaval, the authors single out black families for special attention, notably in a paragraph that contains no citations. They say:

Social upheaval may have taken different forms, on average, for African Americans. Black kin networks, though often looser, may be more extensive and more protective, as when grandmothers care for children. Black churches provide a traditional and continuing source of support. As has often been noted, blacks are no strangers to labor market deprivations, and may be more inured to the insults of the market. (432)

Leaving the issue of the black church to one side, there are two knots to be untied here.

First, the black family. The idea that the black family is loose, but protective, can be traced back to Daniel Patrick Moynihan’s (1965) “tangle of pathology” concept, as well as to the later intervention of Carol Stack in All Our Kin (1974), which provided ethnographic evidence that ran counter to Moynihan’s pathologizing account. (A longer genealogy of these ideas can be found in the final interlude of this thesis.) Case and

Deaton seem to want to have it both ways. The black family is disorganized, which 33 presumably ought to contribute to poor outcomes at midlife; on the other hand, the black family’s extended kin networks can be protective, which might mitigate this negative effect. But the authors offer no citations here. Their analysis is present as social science common sense. No need to do the kind of exploratory data analysis for the contemporary black family that the authors found necessary to do for whites at midlife.

Second, the labor market. Here, it is hard to know how to take Case and Deaton’s observation that “blacks are no strangers to labor market deprivations.” Without a doubt, this is obviously one way to signal euphemistically that the authors have digested the

“lessons” of the underclass debate of the 1980s and 1990s without having to rehearse that debate or be associated with its conclusions (although in the very next paragraph, they basically affirm the work of Charles Murray, who was central to this debate). But the authors may be signaling something about the long, sordid history of what “the labor market” has meant to blacks in the U.S., that is, the black labor tradition from the slave auction and the plantation to convict leasing and the chain gang, and on down the line.

Why this story is beyond Case and Deaton’s purview is unclear. The most obvious, if not the most charitable, interpretation is that the authors are only interested in a story of white’s comparative decline; the mechanisms at work on the other side of the comparison are not of interest.

In the very next paragraph, Case and Deaton admit that their story is consistent with “much, though not all,” of what Charles Murray (2013) says in his book Coming

Apart: The State of White America, 1960-2010 (Case and Deaton 2017, 433). In short,

Murray argues that there is a deficit of “industriousness” among white working class

34 men, who increasingly prefer leisure to work. This decline in “virtue” has been facilitated by the U.S. welfare state, especially disability payments (433). That said, Case and

Deaton are skeptical, because this kind of argument fails to explain why mortality rates among non-whites and Europeans have failed to rise in step with whites (433).

Returning to potential explanations for deaths of despair, Case and Deaton (2017,

433) recognize that pain and pain-related unemployment may have played a role, as well as physician over-prescribing, lack of FDA oversight, and Purdue Pharma’s sales tactics.

Ultimately, though, Case and Deaton choose to emphasize other factors, namely, “the labor market, globalization, and technical change as the fundamental forces.” That said, they do maintain that “there is surely general agreement on the roles played by changing beliefs and attitudes, particularly the acceptance of cohabitation, and of the rearing of children in unstable cohabiting unions” (433). Two things are remarkable here. First,

Case and Deaton go out of their way in this paper to say that income (and income as a proxy for inequality) cannot be driving deaths of despair. That is, all of the aggregate/macroeconomic/structural factors one might imagine to be driving these deaths cannot be the explanation. But then they ultimately endorse aggregate factors as their preferred explanation for the mortality and morbidity trends: the labor market, globalization, and technical change—these are the “fundamental forces.” But is it not the case that these factors are just another way to talk about income and distributional inequities? Second, the factors that Case and Deaton label “beliefs and attitudes” are also structural. They are not properties that reside in individuals, but are produced by other structures, like markets and the state, for example. In any case, the authors refuse to give

35 priority of place to these explanations, even as they clearly endorse their validity as consistent with the ideology. Ultimately, Case and Deaton come down this way:

These slow-acting social forces seem to use to be plausible candidates to explain rising morbidity and mortality, particularly suicide and the other deaths of despair, which share much with suicide. (433)

Why bother with this extended analysis of a white paper by two eminent economists? Because they are prominent liberal academics who have access to policymakers and ideologues at the Brookings Institution and elsewhere. Their ideas will shape the way that the opioid crisis is understood. Their conclusions represent a kind of liberal common sense about the causes and consequences of the opioid crisis. They blame deaths of despair on “slow-acting social forces” that undermine traditional sources of stability, like work and the family. Although at this stage, their analysis is more exploratory than hortatory, they still essentially argue for the restoration of these kinds of stabilizing structures in American life—the nuclear family, the Fordist family wage, and so on. Case and Deaton go out of their way to decouple income from well-being in order to insulate the policy space from state-led redistribution of wealth via welfare state programs. In the final analysis, they embrace milquetoast policies, such as reducing access to opioids, expanding access to non-opioid pain relievers, ensuring that more

Americans can go to college, and expanding the earned income tax credit (Case and

Deaton 2017, 465-66). Thus, although their analysis suggests that a variety of macroeconomic trends tell us the most about what’s driving the opioid crisis, they rule out a priori the possibility of state intervention in those realms.

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II. A Critical Introduction to Policing

Both mainstream and critical literatures on the police within the disciplines of history and criminology tend to reduce policing to the work of the beat cop. In The Politics of Police, for example, historian Robert Reiner (1985) provides a detailed account of the rise of police forces in Britain from the 1820s to the present day alongside keen observations on the sociological and political problems of policing, such as legitimacy, reform, and discrimination. This account is illuminating, but there is never any doubt that its focus is the police as a bureaucratic organization and on policing as the work of the beat cop: stops, searches, arrests, and the use of force. Similarly, in Sidney Harring’s (2017, 251) classic Policing a Class Society, having demonstrated that “the state and its municipal institutions, including the police, [are] instruments of the capitalist class,” one nevertheless understands that for Harring, the police are only urban police forces and beat cops. The same can be said of pioneering police theorist Egon Bittner. In his book, The

Functions of Police in Modern Society, he says:

the role of the police is best understood as a mechanism for the distribution of non-negotiably coercive force employed in accordance with the dictates of an intuitive grasp of situational exigencies. (Bittner 1970, 46)

Even this interesting definition, which emphases the functional role of police as embodiments of discretion and legitimate violence in a democratic society, ends up being instrumental to an account of police professionalization. That is, insights into the nature of policing as such take a back seat to an institutional account of what cops do and how they could do it more consistently with democratic norms.

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There are, of course, lots of interesting things to be learned from this mainstream perspective, but it unduly narrows our understanding of what policing is. On the one hand, as I discuss below, policing ought to be understood as much more than just police.

On the other hand, literally doing nothing is how much of police time is spent. This basic fact is obscured by the relentless misrepresentation of the work of beat cops. As Didier

Fassin (2013, 68-84) points out in Enforcing Order, his book on policing housing projects on the outskirts of Paris, contrary to popular representations of policing as a never-ending car chase or manhunt, most police spend their time doing very little: waiting to be called, doing paperwork, idly patrolling, and so on. He cites one study of

Canadian police officers that estimates “an average of 76 minutes per 8 hours” are spent interacting with the public. For Fassin, these facts about the reality of policing lead to the conclusion that the presence of police officers is more about the “embod[iment of] law and order” than any function we traditionally associate with the police (71).

Against this mainstream definition of policing, most critical engagements with the police rely on the work of Michel Foucault (2007), in particular, two lectures from his

Security, Territory, Population, originally delivered in 1978. In the lecture of 29 March

1978, Foucault begins to build a genealogy of police in Europe from the Middle Ages. He notes that, beginning in the 15th and 16th centuries, police were understood both as a kind of small-scale political community or public authority, on the one hand, and as a set of actions undertaken by public authorities, on the other (312-13). Another transformation takes place in the 17th century, according to Foucault, when police becomes strongly associated with “good order” (313). Here, “police will be the

38 calculation and technique that will make it possible to establish a mobile, yet stable and controllable relationship between the state’s internal order and the development of its forces” (313). Interestingly, Foucault associates this development with the rise of statistics and a “whole administrative assemblage” that allows that state to know itself and its competition, i.e., other states. For Foucault, “Police makes statistics necessary, but police also makes statistics possible” (315).

Police developed differently in different European countries—Foucault mentions

Italy, France, and Germany—but police science as a science of the state, a

Polizeiwissenschaft, reached its apogee in Germany (318). The Germans understood the object of police in their police state to be, on one hand, “‘the order of everything that one can see’ in the city” and, on the other, “‘a particular practice of modesty, charity, loyalty, industry, and domestic order’ in the people” (319). Under these broad rubrics, the police are responsible for charity, public health, and even small business development (320).

On Foucault’s reading, one of the key aspects of German police during this period is the way that they act on persons vis-à-vis the state. As he puts it, “Police is directed toward men’s activity, but insofar as this activity has a relationship to the state” (322).

The basic logic is, in order for a state to be good, the people in it also have to be good; and the role of the police is to mediate the person and the state by ensuring that the person is set to a good end—and is in good order. “What is characteristic of a police state is its interest in what men do; it is interested in their activity, their ‘occupation’” (322).

As such, Foucault has a particular view of the task of police:

As its instrument, it will have to provide itself with whatever is necessary and sufficient for effectively integrating men’s activity into the state, into its forces, 39

and into the development of these forces, and it will have to ensure that the state, in turn, can stimulate, determine, and orientate this activity in such a way that it is in fact useful to the state. (322-23)

Among these useful activities are a census, the provision of food, public health, and the circulation of goods (and thus the maintenance of bridges, routes, etc.) (324-35).

By the 18th century, the definition of police becomes even broader: “Police is basically concerned with society” (326). It covers all manner of intercourse that people have with each other in society. In Foucault’s words:

So what police thus embraces is basically an immense domain that we could say goes from living to more than just living. I mean by this that police must ensure that men live, and live in large numbers; it must ensure that they have the wherewithal to live and so do not die in excessive numbers. But at the same time it must also ensure that everything in their activity that may go beyond this pure and simple subsistence will in fact be produced, distributed, divided up, and put in circulation in such a way that the state really can draw its strength from it. (326)

In short, we are now in the realm of biopolitics. The object police is the well-being of individuals in society understood in the broadest sense: “the objective of police is everything from being to well-being, everything that may produce this well-being beyond being, and in such a way that the well-being of individuals is the state’s strength” (328).

In the lecture of 5 April 1978, Foucault expands on the reflections just rehearsed to flesh out his evolving understand of policing in 18th-century Europe. Drawing on a compendium of police ordinances prepared by the police theorist Delamare, Foucault offers a series of observations on the objects and practices of police intervention (334).

First, he reminds us that police work on urban objects. That is to say, the work of police is essentially co-extensive with urbanization in Europe and especially the concomitant public health problems associated with agglomeration of people in towns (334-35).

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Second, police work on markets. In some ways, this is a corollary to the urban transformation just mentioned. Where people concentrate, problems of circulation arise.

Food must be imported, goods must be circulated, etc. (335). In short, Foucault is reminding us that there is a tight nexus between police and urbanization: “Police, then, as a condition of existence of urban existence” (336).

Another key distinction that Foucault makes in this lecture is the relationship between police power and state power, which during this time period means royal power.

Royal power is the realm of justice. Police is something different; “Police is not justice”

(339). Instead, it is a way for the state (or the monarch) to touch the people without routing power through judges. As Foucault puts it,

Police consists therefore in the sovereign exercise of royal power over individuals who are subjects. In other words, police is the direct governmentality of the sovereign qua sovereign. Or again, let’s say that police is the permanent coup d’État. (339)

What this means for police is that they are less concerned with the lofty ideals associated with the law and with justice. Their remit is closer to the ground. Foucault characterizes it this way: “‘Police is concerned with little things, whereas the laws are concerned with important things. Police is perpetually concerned with details.’” The police articulates its power over the little things not via judgment or decree but through “regulation, the ordinance, the interdiction, the instruction.” For Foucault, “the world of the regulation

[is] the world of discipline” (340). This puts us back onto the familiar Foucaultian terrain of “workshops, schools and the army” that he analyzes in Discipline and Punish and elsewhere (Foucault 1995).

41

Where does Foucault’s intervention into the theory and history of policing leave us? First and foremost, he unsettles the tight connection between policing and crime.

Foucault demonstrates that for several centuries in Europe, policing has taken society as its object with the goal of producing good order. Second, he argues that policing is a state project. It’s not enough to understand police bureaus as mere auxiliaries of the state designed to address novel urban problems of the 18th and 19th centuries. Instead, police are central to European state power, which, for Foucault, means that police are central to biopolitics: the well-being of individual bodies and of aggregated bodies at the level of population, both of which are key components of the strength of the state.

Foucault’s perspective gives us a much wider view of police and policing than the traditional view sketched above. One limitation is that his view of policing casts too wide a net—given that the police embrace “an immense domain” which turns to be almost everything, it can be difficult in Foucault to identify which aspects of life escape police power, what other modalities of power are at work. That is, if police are everything, then that may end up telling us nothing. Another limitation of this approach, discussed in more detail below, is that it tends to make police power so abstract (the well-being of individuals and of society) that it tends to obscure the fundamental violence of police power.

The contemporary critical literature on policing stems from an engagement with the polemical work of Mark Neocleous (2000), especially the book The Fabrication of

Social Order, where he develops a novel approach to policing that makes use of

Foucault’s interventions to modulate Marxist approaches to policing that focus only on

42 class analysis. According to Neocleous, in the discipline of criminology, “policing, like the criminal law of which it is a part, is no more and no less than a set of instruments to manage something called crime” (ix). In this way, policing exists essentially in the sphere of ideology. In contrast to this approach, we have Foucault, who uses police and policing to try to understand government more broadly. For him, “police” belongs to the spheres of power, discipline, and governmentality (ix). This is a useful corrective to the disciplinary blind spots of mainstream criminology, but it is very far from the everyday world of police and policing (x). Thus, “Foucaultian texts are stripped of any sense that police has anything to do with violence and thus with state power” (x). In other words, even a Foucaultian approach tends to ignore how police interact with state power in its violent, directly repressive mode (ix-x).

In The Fabrication of Social Order, Neocleous (2000) takes a different approach.

He claims that poverty and class are at the core of policing, and that much of what police do is in service of a state project of “social security” and “social police” (xi). In this way,

Neocleous can “recover part of the original meaning of police as it emerged with the collapse of feudalism” (x). This means going back further in time than police studies often does, i.e., before the birth of modern policing in London circa 1829, when the

Metropolitan Police were founded (x). Axiomatically, for Neocleous, “police and policing should not be identified with the police, and … one must stifle the impulse to equate police with men in uniform” (xi). Instead, Neocleous points us toward “an expanded concept of police, to reflect the expansive set of institutions through which policing takes place” (xi). For him, “the core of the police project remains the question of

43 poverty and thus the condition of the class of poverty” (xi). He’s also keen to argue that

Marxism, especially insofar as it’s concerned with state power or the state-bourgeoisie nexus, must theorize the police directly (xii). The police are more than just a functional arm of the state used to crush the working class and protect private property. Instead, the police have “positive” moments in which their project is “the fabrication of social order”

(xiii). The basic argument is that as society increasingly revolved around the bourgeois mode of production, then police addressed itself to creating a social order in which wage labor was reproduced and poverty was managed (xiii). According to Neocleous, to develop these theses fully would be truly “to develop a materialist conception of police”

(xiii).

As Neocleous details, from the late 15th century in Europe, the concept of police power was much broader than we think of now. Police were about “the legislative and administrative regulation of the internal life of the community to promote general welfare and the condition of good order … , and the regimenting of social life” (1). This is the idea of the “Polizeistaat” as a “‘well-ordered police state’” (1). In Neocleous’s telling, we can locate the emergence of this expanded concept of police in the collapse of European feudalism. The disintegration of the feudal order emancipated serfs, which also coincided with their proletarianization (2). The power of labor also increased in the wake of depopulation caused by the Black Death. These political and demographic trends coincided with a trend toward town living and urbanization, which produced public health problems associated with dense living, such that urban management became a distinct activity of town authorities. In short, as “masterless men” emerged from the

44 collapse of feudalism, the absolutist state stepped into this orderless world to impose order, which was essentially the fertile ground for this particular police project (2-3).

At the time, the police project was very broad. According to Neocleous,

The police mandate extended to the minutiae of social life, including the means of comfort, public health, food and wine adulteration, expenses at christenings, weddings and funerals, the wearing of extravagant clothing, the behavior of citizens at church or during festivities, the maintenance of roads, bridges and town buildings, public security, the regulation of the provision of goods and services, the performance of trades and occupations, religion, morals and manners, and the behavior of servants towards their masters. (3)

This kind of everything-and-the-kitchen-sink approach to policing is obviously quite different than the modern ideology of the beat cop, who is imagined to prowl the streets in a car, chase down criminals, and make felony arrests. Synthesizing the prior literature on this policing project, Neocleous offers several axioms about how to understand this early modern model of policing:

1. The police didn’t focus on criminal activity; instead, they focused on commercial good order. 2. Police were a form of governance, not a form of law. 3. Police were as focused on “administrative” regulation as anything else. 4. Police and policing should be understood as an activity, not an institution, a function, not an entity or a thing. (4-5)

Put a bit differently, Neocleous shows that we can also understand the policing project as a project about mobility. “Whereas in its mobilizing activities police sought to render disorderly elements harmless, in its mobilizing activities it sought to fashion these elements into a mobile and active workforce” (17).

Another touchstone for the Foucaultian approach to policing is a series of articles written by his student and assistant, Pasquale Pasquino (1991), especially his intervention, “Theatrum Politicum: The Genealogy of Capital—Police and the State of 45

Prosperity.” If Neocleous makes the case for an approach to policing that is resolutely focused on class and the way that policing fabricates a social order conducive to capital accumulation by mobilizing the poor and working class, Pasquino directs our attention to the limits of a capital-focused account. According to him, critical theorists have begun to question a teleological, Marxist approach to history in which every story is focused on providing a more nuanced genealogy of capital. First, this kind of narrative doesn’t help us answer questions about certain institutions, e.g., the prison. Second, this narrative is politically out of touch with the political and social movements of the 1960s. Thus, according to Pasquino, capital as the explanatory category is gradually being replaced by more diffuse or polymorphous technologies of power (107).

What Pasquino is after with this intervention is to access history as such and its genealogy, not merely a narrow sliver of history as the genealogy of capital. Thus, it’s important for him to focus on political economy as emblematic of a certain bourgeois, capital-centric genealogy of history. Political economy matters because of its alleged scientificity and because as a discipline it founded capitalist history and also historical materialism (in Marx). For Pasquino, capitalist or bourgeois history is any history that takes capital and the bourgeoisie as its privileged objects of analysis. He argues that around the same time as the birth of political economy, an alternative tradition arose from

Germany regarding the conflict between society and state (107). A key aspect of this tradition is its view of the state as a repressive entity that exerts power over the social body or civil society, which is presumed to be virtuous (society, that is). According to

Pasquino, what’s going on behind the scenes of this discourse is the police. Here, as with

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Neocleous, police are key to the fabrication of social order via a science of happiness and of government (108). Therefore, what Pasquino is trying to offer is a history of the present, because the genealogy of the police will tell us more about the present than the genealogy of capital (108-9).

Like Neocleous’s fourth methodological axiom noted above, Pasquino suggests that police are best understood as an activity, and that therefore we should focus on what the police do and develop a programmatic definition of police grounded in police interventions and regulations. Thus, it is not surprising that in terms of defining the field of intervention, he directs us to the same kind of list of activities that Neocleous cited, and we find police working on everything from “commerce” and “foodstuffs” to

“building[s],” “beggars,” and “Jews” (110). Taking a step back, Pasquino defines three different fields of police intervention where we can understand police to be working:

1. The formless or vacant area left by the waning of feudalism and the resultant power vacuum, a space that “cr[ies] out for intervention” 2. Specific spaces within the territory, for example, sites of human and capital circulation, such as markets, bridges, roads, etc. 3. Situations in which there is a kind of spontaneous demand for order beyond law (111).

Regarding the third site, Pasquino says, “Not that power is installing itself here in what was previously a total void, but rather it installs itself where there was a void of power and where a demand for power can be generated” (111). Despite this enigmatic formulation, Pasquino knows that specifying the exact nature of this power is important if we want not to turn the police into another myth. His hypothesis, then, is this: police is an exercise of government or administration over a relatively new phenomenon called

“population” (112). As Pasquino shows in a detailed analysis of German texts from the 47 period he’s working with, police work concerns statistics, the enrichment of the population and the state, and the production of public happiness (113). On one hand, this work coincides with the emerging sciences of the 17th and 18th centuries, namely statistics and demography (114). On the other hand, population as an object of knowledge begins to be understood as a force of production, i.e., as an input to capital with a characteristic “health” that the state must manage; in other words, we are in the realm of

Foucaultian biopolitics. “Population is wealth, health is a value” (116).

Finally, according to Pasquino, we need to attend to the problem of the state as such. He suggests that we move away from crude Marxist understandings of the state to something else more diffuse and coextensive with society itself. For him, “the state would then signify not the site or source of power, the one great adversary to be smashed, but rather one instruments among others, and one modality of ‘government’” (117).

The research of Foucault, Neocleous, and Pasquino is focused on pre-modern and modern Europe with the aim of shedding light on the development of the police primarily within European society. It would not be wrong to call it Eurocentric. These are charges that have been levelled at Foucault for a long time, but it makes sense to move beyond these authors in terms of trying to understand what policing means in the U.S. context, because here, policing is so strongly tied to race and indeed to slavery. The American reader will not find a satisfactory discussion of race in any of the authors just reviewed, and it is necessary to turn elsewhere to develop a genealogy of policing in the U.S. that is sensitive to the founding predicament of the nation—race and slavery.

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To enter that territory, I will turn to Bryan Wagner’s (2009) book, Disturbing the

Police: Black Culture and the Police Power After Slavery. In that book, which has become a touchstone for interdisciplinary, critical work on the police, Wagner investigates police power in the U.S. through a series of cases (or primal scenes) in black culture. One stop on Wagner’s itinerary in the book is to develop what he calls “a possible history of the black tradition” in both folk culture and mass entertainment (237).

That aspect of Disturbing the Police will not be covered here. What I will try to do is extract some methodological principles for studying policing in the U.S. from Wagner’s dense investigation.

The basic setup for Wagner’s argument proceeds in three parts. First, “Blackness is an adjunct to racial slavery” (1); put differently, “there was no blackness before there was racial slavery” (3). Second, the natural place to understand slavery in the Americas is with the slave codes—the colonial documents that constructed blackness and ordered black life (3-4). Finally, the logic of the slave codes is homologous to the kind of broad police power that Neocleous and Pasquino identify. To return to the logic of the list that we’ve seen before, Wagner provides his own list of status and conduct that the slave codes governed: “clothing, trade, domicile, outlawry, miscegenation, baptism, permits to travel, custody of firearms, hiring out, false petitions to indenture, flight, literacy, inveigling, insurrection, lurking, keeping livestock, and religious observance” (4).

(Wagner later calls this the “paratactic method” (42).) And these are just more or less random examples. The codes make clear that

49

it is always possible to attach new entries to the list, and it is always conceivable that some threat may arise that is wholly unanticipated in the existing law, to which the law’s authority nonetheless immediately applies. (4)

In short, parataxis is constitutive of police power and to the logic of the threat to which it is addressed.

Wagner makes sense of slave codes by identifying them with the logic of police power. It is common in the literature to say that police power cannot be defined because its object is unknown. For how is it possible to define the field of operation of a power whose list-like quality is endless? Instead, Wagner inverts this premise to argue that police power cannot be defined, is entirely discretionary, because it refuses to know anything about its object except for its potential threat. For Wagner, it is axiomatic that

“Police is not disposed to definition, because it relates to threats whose character cannot be known in advance” (6). Like those theorists discussed above, it goes without saying that Wagner opposes the contemporary reduction of police to crime prevention or control, let alone to the state monopoly on violence. This understanding is clearly inappropriate to the American colonial context, where all kinds of state-sanctioned violence was private, where the master was authorized to work violence on his slave property (7). As Wagner argues:

Police, for purposes of this book, is not a specific institution, nor is it a category of practice. Although it is easy to imagine the relationship between policing and blackness through on-the-street practices like racial profiling, this is not the level at which their fundamental association becomes available to analysis. Police relates to blackness not as practice but simply as a power. (7-8)

Although, as Wagner notes, many of the foundational police power cases in

American jurisprudence have to do not with slaves but with places and property,

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these cases are directly relevant to blackness because they declare the self- evidence of the police power, and police comes closest to blackness at the point where it passes into self-evidence. (8)

The “founding fathers” of the republic took police power to be axiomatic, self-evident, and over a number of decades in America’s early history, jurists borrowed from the

English common law tradition to solidify “the self-evidently natural connection between police sovereignty and overruling necessity” (9). Before the civil war, police power was basically understood as an adjunct to sovereignty. When the public is at risk, the sovereign’s prerogative is to exercise police power to ensure an order protective of persons and things (10). In one case dating from 1851, Wagner notes that the Supreme

Court articulated an expansive understanding of police power as the precondition for society: “It was a ‘settled principle, growing out of the nature of well ordered civil society.’” According to Wagner, the “genius” of this kind of definition is that it installs police power as an obvious precondition for society, thus making it exceedingly difficult to draw a line around what police power is—an important first step in any project that seeks to regulate or restrict its sphere of operation (11).

Antebellum police power cases reached to Blackstone’s commentaries and even further back to locate the police power in the structure of exception, that is, situations of exigency that exempt police power from normal restrictions on state power one could expect to find in routine criminal law—restrictions like the Fourth Amendment, whose text protects persons from unreasonable searches and seizures. Reaching beyond

Blackstone and related common law sources, these police power cases also sought justification in the tradition of natural law, which argued that self-defense is the primary

51 principle from which morality derives; thus, self-defense is an exception that can always be made in the face of necessity (14). Drawing on this natural law tradition, the antebellum police power cases took “nature” to be “a heuristic method naming the logical presuppositions of the state” (15). In this way, as discussed above, police power is necessary to the state in that it protects the state in case of emergency (16). In the natural law tradition, we exit the state of nature through a social contract. When someone violates the law (natural or man-made), society “ends” the social contract with respect to that person. This annulment may result in death, which isn’t a punishment (like capital punishment) but a security measure meted out by the police (16). “Executing the criminal, the state acts, not as a state, but as a superior force of nature, which is to say that its action is guided not by the text of positive law but by the nature of police” (17).8

Another aspect of police power that Wagner effectively illustrates is the way that policing thrives on the distinction between “regulars” and “strangers” (206). Although we can see this in contemporary police studies in the foundational work of Wilson and

Kelling on broken windows theory (Kelling and Wilson 1982), Wagner shows that it’s foundational to police power. He says:

Police statutes do not address the people to whom they apply. Their audience does not include the people who will pay the price if the law is broken. Slave statutes mostly cover the actions and station of slaves, but they are addressed not to slaves but to their masters or society at large. Vagrancy codes speak not to vagrants but to citizens who believe they are citizens, in part, because they know they are not vagrants. … It is possible to have an association with the objects named in these laws … , but it should not be possible to feel addressed by these laws and at the same time to believe that you are their object. To the degree that this identification is possible, the law in question fails to qualify under the police

8 See Wagner (2009,152-53) for one example of how this was translated into the rhetoric of “warfare” postbellum. 52

power and is open to constitutional challenge. Police is for other people. It is not for regulars who already know their name before they are hailed by the law, but for those left nameless by the law. Police does not operate as a commandment (“Thou shalt not”), as it avoids at all times the direct address that would distinguish anything about its object. (206-7)

Wagner goes on to note that

it is not that whites are subject to one address and blacks to another; the law’s inconsistency is felt in every case. Rather it is that every identification confronts a point where law stops making sense, a point where identification can proceed only through racial fantasy. This is a fantasy that allows some people to make the law by passing its burden, its ever-present insecurity, to someone else. Through the operation of this fantasy, blackness becomes an object lesson whose existence makes it possible for anyone (including black people) to manifest a normal relationship to authority. (207-8)

These passages reveal that for Wagner, police power is prior to everything. In this way,

Wagner becomes the police theorist par excellence.

To recapitulate, Wagner takes us from the terrain of Eurocentric critical police studies into the American context, where there is no avoiding the centrality of race to police power and policing as a state project. Going all the way back to colonial slave codes, Wagner demonstrates that these codes are instantiations of police power that produce blackness. They operate through the logic of parataxis, the list, which renders police power mercurial and therefore difficult to regulate or constrain. Similarly, police power thrives on discretion. It refuses to know anything about the subjects-objects on which it operates other than that they are a threat to the state. Their humanity is not in question or really even of interest; it is enough for police power to recognize that they threaten sovereignty, in which case they are deemed threats to be eliminated. That it is within the state’s power to maintain sovereignty against all enemies is self-evident, and this justification bleeds into the self-evidence of police power in American life. 53

This section of the thesis has offered a partial but synthetic overview of the critical literature on policing and police power, paying particular attention to the way in which police generate social order of various kinds—class, racial, and other state projects. Following the second interlude, I will confront some of the results of this overview of the policing literature with the example of the opioid crisis to see what light, if any, they shed on each other.

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Second Interlude: Naloxone, Moral Hazard, and Necropolitics

In a paper first drafted in March 2017 and now available as a discussion paper, economists Jennifer Doleac and Anita Mukherjee (2018a) make the counterintuitive claim that states’ efforts to expand access to naloxone—a drug that can “reverse” the effects of opioid overdose and save users’ lives—may actually increase opioid abuse and opioid-related mortality.9 Although according to the authors the paper’s “findings do not necessary imply that we should stop making naloxone available to individuals suffering from opioid addiction, or those who are at risk of overdose,” that is one available interpretation of the paper, and a number of commentators were deeply offended by the apparent moral callousness of the authors.10 Others have already discussed the paper’s methodological flaws,11 and the professional politics peddling Freakonomics-style research results to the public will be left to one side here. My commentary will instead focus on what I see as an under-appreciated aspect of the paper and the debate it engendered: how the paper’s use of “moral hazard” as a lens through which to view the opioid crisis is homologous to an earlier crisis, namely, the AIDS crisis.

9 Professor Doleac’s personal research page collects much of the relevant media coverage. See http://jenniferdoleac.com/research/. 10 See Khazan (2018) for coverage of the response—both online and off—to Doleac’s release of the paper’s abstract. 11 One of the most comprehensive analyses along these lines can be found in a Twitter thread of law professor and public health advocate Leo Beletsky (2018a), available at https://twitter.com/leobeletsky/status/973063923237867520. 55

“The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime”

Doleac and Mukherjee (2018a) begin by recognizing that the opioid crisis is ravaging the nation, and policymakers have struggled to come up with solutions to address it.

Although there are no silver bullets, almost everyone agrees that naloxone is an effective tool to reduce drug overdose-related mortality. As a result, “Every U.S. state has passed a law that facilitates widespread distribution and use of naloxone” (1). These adoptions occurred at different times, which allows the authors to demarcate clear before and after states for the treatment variable in their longitudinal data set. They estimate the effects of these laws using an econometric model.12

As Doleac and Mukherjee acknowledge, the theoretical “backbone” for their model is “moral hazard,” an economic concept that describes how interventions designed to increased safety can see their safety gains offset by behavioral effects that actually increase risk. In short, moral hazard says that when an agent who is the subject of an intervention designed to reduce harm is aware of the intervention, the agent will respond to this information by engaging in even riskier behavior. The authors locate the origin of their understanding of moral hazard in a 1975 paper demonstrating that safety gains from seatbelts and other technologies that increase automobile safety were mitigated by increases in riskier driving behavior (4). They also mention recent evidence from studies of treatments for HIV that reducing the risk of contracting and transmitting HIV increases

12 Specifically, a panel fixed effects model in a differences-in-differences framework. 56 risky sexual behavior (4). This is a potted history of moral hazard to which I will return below.

The paper reports the following results:

1. Naloxone expansion laws increased “residents’ knowledge of and interest in naloxone” (18).13 2. Naloxone expansion laws “reduce[] local interest in treatment for opioid addiction” (18).14 3. Naloxone expansion laws increase crime (18-20).15 4. Naloxone expansion laws increase opioid abuse (20).16 5. There is significant regional variation. Naloxone expansion laws increased mortality due to opioids in the Midwest and the South but decreased it in the Northeast and West (21).17 6. Overall, taking rural and urban areas together, naloxone access laws increase the abuse of opioids, but do not affect opioid-related mortality rates (22). 7. “It appears that naloxone access increases opioid-related mortality in places with limited treatment and decreases it in places with more treatment” (24).18

Having reported these findings, most importantly findings three and four, the authors discuss their implication for policymakers, who are the ostensible target audience for this paper. According to Doleac and Mukherjee, everyone agrees that naloxone can save lives. But, they believe, expanding the availability of naloxone can have unintended consequences; in particular, it can increase opioid-related crime and fails to reduce opioid-related mortality (30). The authors aver that their analysis does not imply that policymakers should stop expanding access to naloxone. On the contrary:

13 The authors report a 7.2% increase in their proxy for knowledge and interest (p < 0.05). 14 The authors report a 1.4% decrease in the proxy for interest in treatment (p < 0.10). 15 The authors report a 27% monthly increase in arrests for sale of opioids (p < 0.01) and a 64% increase in fentanyl-involved opioid arrests over the baseline (p < 0.05). 16 The authors report a 15% increase in ER visits related to opioids, which they use as a proxy for opioid abuse (p < 0.05). 17 The effect in the Midwest is significant for opioid- (14%, p < 0.05) and fentanyl-related (84%, p < 0.10), but not statistically significant in any other region. 18 This finding is not statistically significant. 57

The public health community should acknowledge and prepare for the behavioral effects we find here. Our results show that broad naloxone access may be limited in its ability to reduce the epidemic’s death toll because not only does it not address the root causes of addiction, but it may exacerbate them. Looking forward, our results suggest that naloxone’s effects may depend on the availability of local drug treatment …. Increasing access to drug treatment, then, might be a necessary complement to naloxone access in curbing the opioid overdose epidemic. (31)

I think we should take Doleac and Mukherjee at their word; that is, we should believe that their paper is designed to reveal the limitations of one intervention to ameliorate the opioid crisis (expanding access to naloxone) and to suggest additional policies that might improve existing interventions (expand access to drug treatment). That said, we should also hold the authors responsible for how their major findings are presented in the paper and, therefore, how they will be perceived by policy audiences desperate for quick solutions to an intransigent problem—or still other audiences eager to discredit any programs that target stigmatized populations with assistance.

Critiques19

“The Moral Hazard of Lifesaving Innovations” was immediately met with trenchant criticism of its framing, methodology, and findings. I will not rehearse all of them here, but it is worth dwelling on some of them, if for no other reason than that the machine of academic econometrics appears poised to confront every opioid-related policy intervention with the specter of moral hazard.20 The problem with the paper’s framing is

19 The section draws significantly from Beletsky (2018a). 20 See, e.g., Packham (2019), which finds that while syringe exchange programs (SEPs) reduce new cases of HIV, they also increase mortality related to opioids: “SEPs have the potential to create large positive externalities by reducing the stock of used needles on the streets and preventing the spread of disease. However, by providing clean needles to drug users, and/or creating a safe environment for networking with other users, SEPs may also generate moral hazard” (1). 58 straightforward: the authors call persons who use drugs “abusers” whose drug abuse renders them “criminally active” a level sufficient to give policymakers pause when considering whether to expand access to an intervention—naloxone—that everyone agrees does in fact save the lives of persons who presently use opioids (1). Now, there is no question that Doleac and Mukherjee’s language is stigmatizing and offensive, but that sort of critique only skims the surface of the deeper problems with the framing. It is more important to refute one implication of their framing, namely, that it would be better simply to let opioid users die. The authors seem to recognize that this kind of thinking is already an undercurrent among police offers, who are increasingly tasked with reviving opioid users who overdose with naloxone. In a footnote, they quote a Dayton, Ohio, police officer who says, “‘We’ve Narcan’d the same guy 20 times. … [T]hat is a waste of police resources’” (2 n.2).

The authors try to head off this inference by insisting that the point of their analysis is to insist that naloxone alone is insufficient to address the opioid crisis (broader treatment options would be helpful). In a response to critics, Doleac and Mukherjee

(2018b) register their belief “that academics have a responsibility to facilitate accurate interpretations of their research.” Furthermore, according to the authors, when they have discussed their research with policymakers, they have “been gratified that they recognize that even worthwhile policies involve costs as well as benefits.” Based on these assumptions about policymakers’ rationality, the authors reject the claim that their research could be “‘weaponized’ by opponents of their preferred policy” (2018b). It is, of course, possible that policymakers will process the article as a cautionary tale against

59 naloxone expansion as a silver bullet to end the opioid crisis. They may even decide to work to expand access to drug treatment in line with the authors’ recommendation. But it seems just as likely that policymakers and others will walk away from the article believing that opioid abusers are so intransigent that every dollar spent on naloxone is wasted at best and harmful at worst, given that expanding access to naloxone, according to the authors, causes opioid abusers to commit more crimes and does little to save their lives in the long run. Despite their protests to the contrary, Doleac and Mukherjee cannot seriously believe that the moral implications of their work can so easily be shifted to policymakers.

In terms of methodology, the fundamental problem with the authors’ analysis is that their claim to measure naloxone access is misleading. Unfortunately for Doleac and

Mukherjee, there simply is no dataset that would allow them to measure naloxone access directly. The lack of data causes the authors to do two things. First, although their treatment variable is naloxone expansion laws, in the title of the paper and elsewhere when discussing results, they characterize the variable as naloxone access. This slippage obscures all the conceptual work the authors do to get from naloxone expansion laws to naloxone access in general, and therefore is misleading on its face. Second, because there are no direct data on naloxone access, the authors are forced to use a series of proxies for naloxone access, each of which carries its own limitations. The upshot of this critique is that the authors essentially measured “exposure to state laws expanding access to naloxone” rather than “exposure to more naloxone.” That kind of analysis in itself is not worthless, but it is different than what Doleac and Mukherjee say that they are doing, i.e.,

60 giving the reader access to information about the effect of making more naloxone available per se.

The moral hazard finding is also suspect. They authors essentially claim that expanding access to naloxone causes persons who use opioids to engage in riskier behavior. Doleac and Mukherjee’s paper notwithstanding, no published analysis has found that opioid users engage in risk compensation or experience disinhibition as a result of expanding access to naloxone. In fact, several studies have found exactly the opposite (Jones et al. 2017).

Moral Hazard21

The concept of moral hazard first emerged in a debate between economists about justifying social insurance in particular and the welfare state more generally. In the

1960s, the economist Kenneth Arrow published a series of papers in which he argued that health care is different from other kinds of goods and that the market for health care and health insurance were failures. As a result, he advocated massive government involvement in social insurance. Arrow’s conclusion, while innovative, actually did not run against the neoclassical consensus, which had spoken the language of externalities and market failures for decades. But there was a nascent neoliberal backlash forming at this time against the expansionary social policies of the New Deal. As Melinda Cooper

(2017) shows in her book Family Values: Between Neoliberalism and the New Social

Conservatism, against the New Deal ethos of community and welfare, “neoliberals

21 This section draws heavily from a chapter entitled “The Price of Promiscuity: The Chicago School Confronts AIDS” in Cooper (2017). 61 sought to reinsert the analytics of risk within ‘the punitive and contractual framework that characterized nineteenth century [tort] law,’ with its related notions of strict personal responsibility, retribution, and fault” (177).

Into this scene stepped economist Mark Pauly, who sought to block the expansionist conclusions of Arrow’s arguments with the shield of moral hazard. Pauly argued that the demand for health care is variable—it is in part a function of the level of insurance available. According to Pauly, in Arrow’s preferred world, where robust public health insurance is available to everyone, the state shields individuals from the true cost of their actions and, as a result, shifts costs from those who engage in riskier behavior to those who are risk-averse. Thus,

When the costs of health care are redistributed across a large risk pool, it is in the interest of each individual to consume as much medical care as possible, with the paradoxical result that healthcare premiums are raised for all subscribers. Public health insurance, Pauly concluded, generates a problem of moral hazard that fatally compromises its aims, resulting in a net welfare loss rather than a gain. (177)

Pauly thought that insurance ought to be left to the private market with very few state protections. He understood this state of affairs to flow logically from the lesson that moral hazard teaches: “When the consequences of risk-taking are insured by the state, it is in the rational interest of the consumer to engage in irresponsible behavior.” This inference revolves around a legalistic notion of “harm,” where risk translates into self- inflicted harm for which one must be held responsible unless one is able to show fraud or duress, that is to say, unless one can show breach of contract. This analysis of harm is then applied to individual health choices like smoking, poor diet, or becoming pregnant.

According to the economists, therefore, “moral hazard” has very little to do with 62 morality. “It simply represents the logical expression of ‘rational economic behavior’ in the face of perverse incentives” (179).

In the late 1980s and early 1990s, the state was coming to terms with how to address the massive social and economic costs associated with the AIDS epidemic. The homophobic responses of the Reagan and Bush administrations to the AIDS crisis have been extensively documented. Less well known is the way that a generation of neoliberal law and economics scholars leveraged the discourse of moral hazard to argue that insurance companies should be able to discriminate against people with HIV/AIDS, that the state had no particular obligation to enact social policies to ameliorate the epidemic, and that gay marriage ought to be embraced in order to internalize the costs of care for people with AIDS inside the family.

Enter Judge Richard Posner and economist Tomas Philipson. Over the course of several decades, Posner was the most influential proponent of law and economics, especially its Chicago-school variant, which seeks to apply the lessons of neoclassical economics to every domain of public and private law. Posner was key to this movement as a textbook writer, law professor, and federal judge. The question that Posner and

Philipson asked in the early 1990s was basically, is the AIDS crisis really that bad

(Cooper 2017, 169)? A committed Nietzschean, Posner’s anti-normative commitments prevented him from endorsing policy approaches that demonized homosexuality or shamed non-normative sexual behavior. And, in any case, Posner and Philipson thought that the sexual “marketplace,” like any other marketplace, functioned best when not regulated. That said, these thinkers also thought that the social costs of the AIDS crisis

63 were overblown and didn’t merit a large, coordinated (i.e., governmental) response. In their view, for example, because many AIDS victims were young and relatively poor, their deaths cost the state little in terms of economic productivity—in fact, on balance, the state might even save money due to reduced Social Security payouts. (Yes, these were thoughts thought and words said in public.) In the final tally, Posner and Philipson suggested, it might even be efficient to let the AIDS epidemic “run its course, as it were”

(170).

On the surface, this approach to the crisis sounds callous—even sociopathic. But for Posner and thinkers like him, it made sense because of the harms and social costs involved in the AIDS crisis (as viewed through the lens of neoclassical economics). To the economist, once you exclude edge cases like contaminated blood transfusions and rape, the harms and social costs associated with HIV/AIDS all arise from private transactions between consenting adults. This brings us back into the realm of the contract and of assumed risk (Cooper 2017, 171). In other words, sexually transmitted diseases like HIV are not the classic public health problem that presents externalities outside the realm of contractual relations and thus requires state intervention (such as, say, the flu).

At least since 1984, when the virus and its mode of transmission were first ascertained, we can assume that most of those who have contracted AIDS have done so as the result of a freely assumed cost-benefit calculus. The HIV-infected have no doubt calculated

“that the cost of reducing the risk of the disease to zero through a change in behavior [is] greater than the expected cost in disease, disability and death of the risk itself” (171).

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Working back to the logic of moral hazard described above, why, Posner and

Philipson ask, should we insure these people? Why should society pay for their choices?

By the economist’s logic, the state should neither intervene in the sexual markets that give rise to HIV/AIDS, nor should it insure the freely undertaken risks and choices made in these markets. “We are all of us free to assume—or shun—the risks of sexual pleasure and each of us is individually responsible for the risks we have chosen to bear” (Cooper

2017, 172).

In spite of their rejection of paternalism, Posner and Philipson nevertheless end up making a utilitarian case for monogamy. Why? According to the logic of moral hazard,

“When the state subsidizes health care for those who have voluntarily assumed the risks of infection, it ends up lowering the price of high-risk behavior and endorsing irresponsible lifestyle choices such as promiscuity or addiction” (172). In other words, it incentivizes perverse choices. This logic is one reason that Posner and Philipson were against safe-sex campaigns; they thought that such campaigns would increase all kinds of sexual activity and would therefore lead to an increase in HIV transmission through human error (like condom misuse). For them, basically all state intervention at this level is a bad idea, because “insuring irresponsible lifestyle choices begets more of the same,” as opposed to a competitive market, where individual actors would be incentivized to respond rationally to market signals (173).

Is there anything the government can do? Posner and Philipson say that there is something: it can fund interventions that promote gay marriage (173). Why? Because instituting gay marriage will internalize the cost of caring for persons with HIV/AIDS

65 within the family and subtract it from the realm of the state and social costs. The mechanism of action here is two-fold. First, Posner and Philipson think that marriage in its canonical form is monogamous marriage, which is thought to reduce high-risk sexual activity and therefore infection rates. Second, marriage replaces state-funded care work with unfunded domestic care work performed by the now-legally sanctioned same-sex spouse (174).

Ultimately, then, Posner and Philipson identify the legal institution of marriage as a substitute for social insurance and the most efficient means of minimizing the social costs of health care. In this way, the neoliberal critique of normativity ends up endorsing an alternative form of moral philosophy—one that restores the private family and its legal obligations of care to a foundational role in the free market order (174). Thus, the maxim of moral hazard is that it is always wrong to socialize the cost of purely private harms via the mechanism of state social policies.

Doleac and Mukherjee’s article on the moral hazard of life-saving interventions into the opioid crisis, I would argue, ought to be understood in light of that maxim. To repeat: it is always wrong to socialize the cost of purely private harms via the mechanism of state social policies. We might object that the opioid crisis does in fact impose massive social costs. Indeed, various analysts have estimated that the opioid crisis cost, for example, about $79 billion in 2013, roughly one quarter of which is borne by the public sector in the form of criminal justice, health care, and substance abuse treatment

(Florence et al. 2016). The President’s Council of Economic Advisors (2017) put the

66 number closer to $500 billion for the year 2015.22 Those are large, devastating numbers that attempt to quantify untold human suffering. One should note, however, that the U.S. spends approximately $3.5 trillion on health care every year (Center for Medicare &

Medicaid Services, n.d.). Furthermore, it is estimated that Purdue Pharma, the company that makes OxyContin, earned more than $35 billion since releasing the drug in 1995

(Morrell 2015). (Sales have dropped recently after OxyContin went off patent.) Their profits should count for something in our tally.

It is not entirely clear—at least to me—how to do this kind of cost accounting, especially in the first phase of the crisis, in which the sale of legal drugs predominated.

During that time, patients were being both helped and harmed by prescription opioids, and Purdue was raking in profits. Even stipulating that there is social harm to address, given Case and Deaton’s analysis presented above, is the state in a position to address it?

Would it not be better to try to reinforce family structures that support addicts in their treatment communities? Following Posner and Philipson, might we not conclude that state intervention into the market could do more harm than good? In my view, their arguments against safe sex campaigns are homologous to Doleac and Mukherjee’s analysis of naloxone expansion campaigns. If the treatment amounts to the same thing as the illness, then why bother?

It should be clear by now that I don’t agree with this framing of the issue. Moral hazard entails endorsing a vision of life and of government—in short, a fully neoliberal one—that I do not find compelling. The purpose of this interlude has been to show that

22 Similar contemporaneous cost estimates were produced for the AIDS crisis. See Oldham (1995). 67 economistic analyses that make use of moral hazard can lead us down the road to endorsing this way of seeing the world, loudly exclaiming all the while that they’re just trying to make interventions more effective. They are a kind of wolf in sheep’s clothing.

Econometric modeling has its place in public health and policy analysis, but it would be a disservice to those affected by the crisis and policymakers trying to help them if moral hazard became the dominant framework through which all future interventions were judged.

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III. Policing the Opioid Crisis

Has the opioid crisis been policed? This might seem like a strange question to ask, but in light of the basic questions raised above about what police and policing mean, I hope that it’s no so strange. To begin to answer the question, this would be the point to introduce traditional crime statistics into the analysis—data on arrests related to opioids, convictions for drug possession and trafficking, sentencing patterns for new drug offenders, and the like. Those kinds of data would, indeed, tell us something about how the opioid crisis is being policed. They would tell us a story from the beat cop’s perspective—a story of stops, arrests, and convictions. For reasons detailed above, I’m not particularly interested in that story; or, put differently, I’m more interested in the expanded field of policing sketched in the critical literature. But there is another reason that this thesis refuses to explore crime statistics in more detail.

A foundational myth of modern criminology is that crime data exist independently of police practice. Police do something over here—they stop individuals on the street, they confiscate drugs, they make arrests—and then researchers do something entirely different over there—they make use of these data to build models and test hypotheses. As Coleman and Kocher (forthcoming) argue in in the context of racial profiling, this view about the relationship between crime stats and police power is misleading (Coleman and Kocher forthcoming). In their article, they discuss a handbook published by the Police Executive Research Forum on how to document racial profiling.

The manual advances a methodology that’s accepted by a variety of participants in the

69 field, from lawyers and police groups to researchers and community activists (22). In order to prove racial bias, the manual says, researchers have to rule out other potential causes of racial disparity—causes like the differential representation of racialized groups in a particular policing zone, or variation in driving behavior across racialized groups

(22). Only after these other causes have been ruled out can one conclude that racial bias has been demonstrated. This way of approaching police practice puts critical researchers in a difficult position, because they will always be confronted with alibis from the police that explain away racial bias: we devote more resources to policing this community because there’s more crime there, and that’s why we make more arrests there; we target this neighborhood with broken windows-style policing because our police researchers tell us that it’s a hot spot of property crime, and that’s why we make more arrests there; and so on. As the authors put it:

In this way, racially discrepant police practices are rendered neutral because they follow from a policy that on the face of it is about crime hot spots and potential criminality, and not race. Never mind that what counts as criminal activity, and crucially where criminal activity is said to happen, is a deeply racialized problem—especially in the United States. (24)

The upshot of this problematic is that it’s nearly impossible to “prove” the existence of racial profiling in a way that matters to courts and public officials in a position to shape policy. The methodological approach (and the way it figures the relationship between police practice and crime data) simply won’t allow it. Thus, “Policing as such is emptied of content and defined as a nuts and bolts, seemingly neutral, series of decisions about where to allocate resources” (24).

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During the course of writing this thesis, I became increasingly convinced that, to a significant extent, available crime stats are essentially police stats that are an effect of police power. This realization made me skeptical about the value of quantitative analysis of the policing of the opioid crisis. As mentioned above, I’ve come to view this thesis as an exercise in clearing the ground for a different kind of analysis, in particular, one with an ethnographic component, which is outside the scope of this project.

Nonetheless, it is still useful to offer some preliminary comments on the policing of the opioid crisis in light of the expanded definition of police power sketched above. I noted in the introduction to this thesis that, historically, state responses to drug crises tend to display a characteristic pattern (Herzberg et al. 2016). First, non-coercive interventions that focus on raising awareness (409). Second, supply-side measures designed to reduce prescribing. And, finally increased policing to deter drug misuse (409). In response to the opioid crisis, the state has followed this familiar pattern, although with some interesting deviations.

The first stage is exemplified by efforts undertaken by state medical boards’ and professional associations’ attempts to inform medical professionals of the dangers of opioid over-prescribing and to drive down the opioid prescriptions written. Prescription

Drug Monitoring Programs (PMDPs) are typical of the second stage. These mandatory, state-run surveillance programs link insurance providers, pharmacists, medical care providers, state agencies, and law enforcement together via real-time databases that track the prescription of controlled substances. The goal of PMDPs is to identify patients at risk of being dispensed medications that could harm them and to curb inappropriate

71 prescribing practices. Medical education and PMDPs have, to some extent, been successful, in that they’ve driven down opioid prescribing, which leveled off around

2012. But these programs are not a panacea, because “addition does not simply go away when the pills do, which is why people dependent on prescription opioids have been switching to heroin in record numbers” (Beletsky 2018b, 163). And as noted at the outset, deaths from opioid overdoses have continued to climb in the face of these interventions.

From the perspective of this thesis, another problem with PMDPs is that, as a form of indirect policing and surveillance, they solidify links between law enforcement and health care, which may stigmatize patients and deter efforts to seek help for drug misuse (167-

68).

Finally, there are straightforward policing interventions to address the opioid crisis. In particular, police at all levels are key players in drug interdiction efforts, which increased after the crisis switched from legal prescription drugs to illegal heroin and synthetic opioids. Notably, police tend to understand their role in the crisis as one that reframes policing as a public health intervention. In a report on the opioid crisis by the

Police Executive Research Forum (2017, 8), the summary headline reads, “police agencies are rushing to save lives, help addicted persons, and reduce drug abuse.” The report details, among other things, how police are partnering with public health organizations to address the crisis, directly intervening to stop overdoses with naloxone, facilitating drug treatment in jails, targeting at-risk juveniles, educating the public about the risks of opioids, and much more (9-13). Time and again, the report flatly states, “We can’t arrest our way out of this problem” (24).

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What’s most striking about this report is that it demonstrates how quickly the police themselves pivoted to a public health framing of the opioid crisis. This kind of response is almost inconceivable when compared to prior waves of drug misuse in the

U.S., especially the crack cocaine epidemic of the 1980s and 1990s. Relentlessly policed, that epidemic gave us, among other things, the crack/powder sentencing disparity, with its racialized sentences for cocaine possession. It is beyond the scope of this thesis to examine the reasons for the peculiarly soft policing response to the opioid crisis, but I would suggest that race and geography play important roles. The crisis started out primarily in rural areas, where white cops were arresting and administering naloxone primarily to white drug users. In other words, police were interacting with people who looked like them; in rural areas, it’s likely drug users were even known to police. It would be surprising if these racial dynamics didn’t play a role in setting the tone for the initial police response to the opioid crisis.

Whatever the dynamics were at the beginning of the crisis, it’s no longer possible to maintain that the opioid crisis is a white crisis. Prescription drugs, heroin, and synthetic opioids have all moved into cities with large non-white populations, from

Philadelphia and Boston to D.C. and Cleveland (Shihipar 2019). African American,

Latino/a, and Native American communities are all affected by the crisis. Because of inequalities in access to health care in general and drug treatment in particular, these urban communities are suffering in different ways than rural white communities, which have been evolving treatment infrastructures to deal with the opioid crisis.

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Third Interlude: Hillbilly Elegy

In 2016, at a time when national media coverage of the opioid crisis was pervasive, J.D.

Vance (2016) published Hillbilly Elegy: A Memoir of a Family and Culture in Crisis.

Hillbilly Elegy came to my attention primarily because many representations of the opioid crisis focused on Appalachia—especially the parts of that region that touch Ohio,

Kentucky, and West Virginia, where the prescription drug phase of the opioid crisis is thought to have started in pill mills along the Ohio River. Commentators naturally wondered what it was about this part of the country that made it so vulnerable to the ravages of opioids. Was it capital flight? Aggressive marketing of OxyContin by Purdue

Pharma? Greedy local doctors making millions from pill mills? Or was it perhaps the defective local culture rooted in generations of Appalachian poverty. The possibility that it was the latter not only fit into traditional American patterns of explaining poverty

(blame individuals, not structures) but also defied these patterns, in that the group being examined was white people and their families, not black ones.

This idea—that there is something wrong with the poor white people who live in little-known parts Ohio, Kentucky, and West Virginia—needs to do some ideological heavy lifting in order to convince Americans that, in this case, despite competing explanations to the contrary, there’s something wrong with these people that’s causing them to pop pills. Enter Hillbilly Elegy, in which Vance appropriates the hillbilly stereotype, imbues it with a comprehensive, pathological culture, and then deploys that stereotype to explain a variety of things that ail this country, including drug abuse.

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I was also interested in Vance’s memoir because he and I share similar backgrounds. Born six days apart in 1984, we both grew up in southwestern Ohio with extended families from the hollers of Kentucky. Although he served in the military and I did not, we graduated from the Ohio State University and went on to law school—the first people in our immediate families to do so.23 As recounted in the book and elsewhere,

Vance graduated from Yale Law School, clerked for a federal judge and, ultimately, went to work for Pay Pal co-founder Peter Thiel’s venture capital company. In the wake of the success of Hillbilly Elegy, Vance returned to his native Ohio to start a non-profit called

Our Ohio Renewal, which, among other things, seeks to “fight[] against opiate abuse”

(Our Ohio Renewal, n.d.). In 2019, Netflix signed a $45 million deal to adapt Hillbilly

Elegy for release on its streaming platform. Ron Howard, who purchased the rights to the book in 2017, will direct and produce the film (Guerrasio 2019).

This sort of bare-bones biographical scaffolding is plain to read in the text, and I will not dwell on it any further here. It is more interesting to read the text as trying to accomplish three things: first, as an opportunity for Vance to explain himself to himself, i.e., to make sense of his current place in the world in light of humble beginnings; second, to offer up his personal narrative and hillbilly identification as a lens through which to understand the white working class in America; and finally, to make sociological

23 As Vance puts it, “The 9/11 attacks had occurred … during my junior year of high school; like any self- respecting hillbilly, I considered heading to the Middle East to kill terrorists” (156). I was a senior in high school and more worried about whether or not I was going to get into college. But then again, I didn’t identify as a hillbilly, self-respecting or otherwise. 75 commentary and political observations in a way that reads like nothing so much as a campaign book from a future hopeful for national office.24

One might as well wait for the movie to take in all the various details of Vance’s biography, but I will note a couple of highlights, because they color his worldview so thoroughly that he begins to mistake idiosyncrasy for widespread social pathology. In the book’s introduction, Vance notes that despite graduating from Yale Law School and

“hav[ing] a nice job, a happy marriage, a comfortable home, and two lively dogs” (1), he

“was [once] one of those kids with a grim future,” a “statistic” (2). This striking rise motivates Hillbilly Elegy:

I want people to know what it feels like to nearly give up on yourself and why you might do it. I want people to understand what happens in the lives of the poor and the psychological impact that spiritual and material poverty has on their children. I want people to understand the American Dream as my family and I encountered it. I want people to understand how upward mobility really feels. And I want people to understand something I learned only recently: that for those of us lucky enough to live the American Dream, the demons of the life we left behind continue to chase us. (2)

This statement of purpose, which comes right at the beginning of the book, could be anyone, anywhere. Its themes of spiritual and material poverty, the American dream, and the demons of a life left behind are staples of rags-to-riches stories in white, Christian

America. But in short order, Vance gets very specific about where he’s coming from: ethnically Scots-Irish hillbilly, geographically Appalachian.

24 Vance will be old enough to run for President in 2020, but he appears to be focusing most of his energy on Rise of the Rest, a “seed” fund that he runs with former AOL executive Steve Case and others. Rise is essentially a venture capital firm that invests in “flyover country.” See Lohr (2017). 76

I’ll address the Appalachian part first, because it’s both risible and its primary function in the book is to frame Vance as a privileged regional insider who, though he

“escaped,” can tell the rest of America about this mysterious region. First, Vance is not from Appalachia; he’s from Middletown, Ohio, a small city in the southwestern part of the state located about halfway between Dayton (where I grew up) and Cincinnati (where

Vance lived at the time Hillbilly Elegy came out). As Vance reports, Middletown is a classic “Rust Belt” city, “an Ohio steel town that has been hemorrhaging jobs and hope” for decades” (1). He defines Appalachia as the region “stretching from Alabama to

Georgia in the South to Ohio to parts of New York in the North.” Despite this vast geographical swath of the eastern part of the U.S., according to Vance, “the culture of

Greater Appalachia is remarkably cohesive” (4). (As discussed below, that remarkably cohesive culture is hillbilly culture.)

Putting aside the question of what it would mean for a cohesive regional culture to be endemic from Alabama to the Hudson Valley, Vance is right to note that many

Millennials, Gen Xers, and Boomers are one or two generations removed from actual

Appalachians. Much of the story in Hillbilly Elegy revolves around “Mamaw,” Vance’s grandmother, who was born in Jackson, Kentucky, and left in the 1940s for Middletown.

She, like many in her generation and subsequent ones, traveled on the “Hillbilly

Highway” from Appalachia to industrial centers in Ohio, Pennsylvania, Michigan, and beyond. These people left a region that offered two options—either agrarian subsistence farming or coal mines—for cities in the North where they could work in the booming auto industry (for men) or service industries (for women). Not surprisingly, my personal

77 story more or less parallels Vance’s. My “Mamaw,” whom I called “Ma’am,” was born on a tobacco farm in a Kentucky holler. She followed the Hillbilly Highway all the way to Dayton, where she raised five kids as a single mom and worked in a hospital cafeteria before retiring in the 1990s.25 Her mother, my great-grandmother, whom I called

“Granny,” lived and worked on the family tobacco farm into her 80s, when she came to live with my grandmother in Dayton. Granny lived well into her 90s spent her days at

Ma’am’s house sewing patchwork quilts and chewing tobacco. (She put her dentures in to eat meals.) When my dad and his siblings were kids, they used to visit the family farm in

Kentucky during the summer. I went there exactly once: for Granny’s funeral, so that she could be buried on the farm. Granny and Ma’am can plausibly be described as

Appalachian. My dad and I cannot, and neither can J.D. Vance. All of us grew up in the industrial and post-industrial Rust Belt Midwest. The “evidence of experience” aside,26 I wouldn’t dare to explain my grandmother’s life to her, nor would my life story have anything to offer contemporary Appalachians—at least nothing that operates at the level of cultural critique from the perspective of an insider. There is, no doubt, much to be said about the inter-generational transmission of cultural contexts to those who leave a marginal American region, but nonetheless remain in contact with it. That, however, is not the perspective Vance adopts in Hillbilly Elegy, where he, an “Appalachian

American” once or twice removed, deigns to explain a region he doesn’t belong to, to itself.

25 Compare Vance (2016, 28-29). 26 “Experience is at once always already an interpretation and something that needs to be interpreted. What counts as experience is neither self-evident nor straightforward; it is always contested, and always therefore political” (Scott 1991, 797). 78

As for ethnicity, Vance does not identify as white—at least not the kind white person he encountered at Yale, the northeastern WASP. Instead, he identifies as a

“working-class white America[n] of Scots-Irish descent” (3). For him, this bloodline stretches back to

day laborers in the Southern slave economy, sharecroppers after that, coal miners after that, and machinists and millworkers during more recent times. Americans call them hillbillies, rednecks, or white trash. I call them neighbors, friends, and family. (3)27

According to Vance, “The Scots-Irish are one of the most distinctive subgroups in

America” (3). Scots-Irish cultural distinctiveness is glossed here as “an intense sense of loyalty, a fierce dedication to family and country” as well as insularity, suspicion of outsiders, and poverty (3). The reader can be forgiven for thinking that Vance takes stereotypes often applied to the urban, black working class, whitewashes them, and parachutes them into eastern Kentucky, because that’s exactly what he appears to be doing. As historian Elizabeth Catte notes, the Scots-Irish narrative Vance draws on is a myth (Catte 2017).28 In her telling, the myth is often told this way:

Once upon a time, during some indeterminate period usually in the eighteenth century, white people who weren’t pilgrims came to the United States. Those of Irish or Scottish origins were attracted to the eastern mountains because mountains were in their blood or some other romantic nonsense. The mountains, in turn, provided powerful insulation against the forces of the modern world and allowed the Scots-Irish to retain “old world” characteristics such as a clannish or tribal family structure, peculiar forms of speech, and the general traits of an “honor” or “warrior” culture that included a propensity for violence. Over time,

27 As Vance puts it later on, “‘the disturbing aspect of hillbillies was their racialness. Ostensibly, they were part of the same racial order (whites) as those who dominated economic , political, and social power in local and national arenas. But hillbillies shared many regional characteristics with the southern blacks arriving in Detroit’” (31). 28 Catte expands on this theme and related ones in her excellent book, What You Are Getting Wrong About Appalachia (Catte 2018). 79

this shared heritage became the presumed basis for certain ethnocultural deficiencies due to over and interbreeding. (Catte 2017)

This myth, of course, is not “correct,” even though it performs important ideological work for Vance—in particular, it makes it seem like there are only white people in

Appalachia. In contrast, historical and archaeological studies of the region show that it is ethnically heterogeneous; residents can trace their ancestry not only to a corner of northern Europe but also to West African, other parts of Europe, and to various indigenous peoples of America (Catte 2017).

Given that Vance’s ethnic self-identification is a myth, one should ask what purpose this invented history serves. As previously suggested, the primary purpose it serves in Hillbilly Elegy is to construct the white working class in the areas Vance is talking about in contrast to the other poor people that are the object of social science and state intervention, i.e., urban African Americans. Vance candidly admitted that one of the aims of the book is “to complicate universal notions of white privilege” by showing that he and his family suffered from real disadvantages that are obscured by the discourse of white privilege (Catte 2017). In other words, Scots-Irish is an alibi for white domination that seeks to flip the script of white privilege by articulating a new subject of white suffering.

But Vance’s Scots-Irish identification is more than bad amateur sociology. It also brings him into contact with the theory and practice of white supremacist academic

Charles Murray, whom Vance (2016, 144) approvingly cites in Hillbilly Elegy.29 Murray,

29 In a passage discussing the impact that the work of sociologist William Julius Wilson had on him, he also cites “Charles Murray’s seminal Losing Ground, another book about black folks that could have been 80 co-author of the infamous book The Bell Curve (Herrnstein and Murray 1994), which posited a causal, biological link between race and IQ and explored the implications of

African Americans’ comparatively low IQ scores (his analysis, not mine, to be clear).

More recently, in Coming Apart: The State of White America, 1960-2010, Murray (2013) has offered explanations for the plight of the white working class and increasing economic polarization in America. This book no doubt brought Murray and Vance together; they made a joint appearance in 2016 to discuss “the decline of the white working class” in a forum at the American Enterprise Institute, a conservative think tank

(Catte 2017).30 According to Catte, the two authors—one a self-described amateur sociologist and the other a former sociologist who now does racial science full-time—

“discussed their ‘pretty clean Scots-Irish blood’ while getting to the heart of what

‘hillbilly culture’ actually is” (Catte 2017).

Were it not for the policy observations Vance offers throughout Hillbilly Elegy, it might be enough to chide him for keeping the poor company of white supremacists and move on. But that’s not enough, because Vance’s diagnoses of and prescriptions for white working class pathology echo what Murray has been advocating (especially regarding African Americans) for decades. The diagnoses, such as they are, are scattered throughout the book:

• “From low social mobility to poverty to divorce and drug addiction, my home is a hub of misery.” (4)

written about hillbillies” (144). See Slobodian and Schrader (2018) for a pithy excavation of Murray’s thought. 30 I don’t have the heart to watch it, but the full conversation can be viewed at this link: https://youtu.be/Y_Idvppb_io. 81

• “It’s about a culture that increasingly encourages social decay instead of counteracting it.” (7) • “Too many young men [are] immune to hard work.” (7) • “I have known many welfare queens; some were my neighbors, and all were white.” (8) • “An epidemic of prescription drug addiction has taken root [in Jackson, Kentucky].” (19) • “The people [in Jackson] are physically unhealthy, and without government assistance they lack treatment for the most basic problems. Most important, they’re mean about it—they will hesitate to open their lives up to others for the simple reason that they don’t wish to be judged.” (19) • “Virtuous fathers are in short supply in Jackson, but they are equally scarce in the lives of my grandparent’s grandchildren.” (22-23) • Describing one of his mother’s husbands, who adopted him, Vance says, “Half of his teeth had rotted out, and the other half were black, brown, and misshapen, the consequence of a lifetime of Mountain Dew consumption and presumably some missed dental checkups. He was a high school dropout who drove a truck for a living.” (62)31 • “Yes, my parents fought intensely, but so did everyone else’s. … We didn’t live a peaceful life in a small nuclear family. We lived a chaotic life in big groups of aunts, uncles, grandparents, and cousins.” (69) • “Of all the things that I hated about my childhood, nothing compared to the revolving door of father figures.” (88) • “This was my world: a world of truly irrational behavior. We spend our way into the poorhouse. We buy giant TVs and iPads. Our children wear nice clothes thanks to high-interest credit cards and payday loans. We purchase homes we don’t need, refinance them for more spending money, and declare bankruptcy, often leaving hem full of garbage in our wake. Thrift is inimical to our being. We spend to pretend that we’re upper-class. … We know we shouldn’t spend like this. Sometimes we beat ourselves up over it, but we do it anyway.” (146) • “Our homes are a chaotic mess. We scream and yell at each other like we’re spectators at a football game. At least one member of the family uses drugs …. At especially stressful times, we’ll hit and punch each other, all in front of the rest of the family, including young children; much of the time, the neighbors hear what’s happening.” (147-48) • “We don’t study as children, and we don’t make our kids study when we’re parents. Our kids perform poorly in school.” (147)

31 It’s anachronistic, but it nonetheless seems worth reporting that currently, the median salary for a private fleet truck driver in 2015 was $73,000, while the median salary for all truck drivers was approximately $40,000 (Gillespie 2015). The private truck driver salary is therefore somewhat higher than that of a tenure- track assistant professor at a large state university, though presumably lower than an employee of a Bay Area venture capitalist. 82

• “We choose not to work when we should be looking for jobs. Sometimes we’ll get a job, but it won’t last. We’ll get fired for tardiness, or for stealing merchandise and selling it on eBay….” (147) • “Our eating and exercise habits seem designed to send us to an early grave, and it’s working: In certain parts of Kentucky, local life expectancy is sixty-seven, a full decade and a half below what it is in nearby Virginia.” (148)

I don’t mean to belabor the point here, but Vance himself belabors it. I think it’s important to experience the devastating portrait he paints of Appalachia and hillbilly culture. As Catte (2017) points out, one problem with this portrayal is that Vance

“transforms the personal reality of his difficult childhood into a universal experience.”

That is, even if one is credulous enough to grant that Vance is a hillbilly and can speak for an entire region, it’s not even clear that his reportage does much more than elevate a truly abusive childhood into the culture of a whole region—the particular into the universal. Another, perhaps more important, problem with Vance’s depiction of hillbilly culture is that he rehearses the same tired tropes that have been hauled out for decades to demonize and pathologize black families.

These tropes can be traced to Daniel Patrick Moynihan’s (1965) infamous report,

The Negro Family, which introduced the pathological black family into mainstream consciousness. As Moynihan puts it near the beginning of the report, “the family structure of lower class Negroes is highly unstable, and in many urban centers is approaching complete breakdown” (5). The chapter of The Negro Family entitled “The

Tangle of Pathology” paints a bleak, now-familiar portrait of black families: dominated

83 by strong females, they are matriarchies32 that produce numerous children whom they are unable adequately to support; husbands are nowhere to be found or are dependent; and children, caught up in this tangle, are set on a path to alienation from the labor force and, ultimately, a life of crime (29-45). Sound familiar? This picture of the black family set the stage for debates ranging from Reagan’s welfare queens to welfare reform under

Clinton, as well as the so-called underclass debate in the social sciences in the 1980s and

1990s. But these tropes also track closely to the details from Hillbilly Elegy recounted above: strong mothers, absent fathers, instability, and violence. Only in Vance’s retelling, the characters are white and rural, not black and urban—white working class hillbillies from Greater Appalachia, not black welfare queens from the inner-city ghetto.

In some ways, it’s not all that surprising that Vance finds himself telling the same story with different characters. He admits to the reader that he “consumed books about social policy and the working poor” to try to understand what was ailing his hillbilly family (Vance 2016, 144). Among the books he cites are William Julius Wilson’s (1987)

The Truly Disadvantaged and Charles Murray’s (1984) Losing Ground, two books released in the early 1980s that shaped the debate on the black underclass and welfare policy. While Vance (2016, 144) reads Wilson’s book as an early explanation of structural disadvantage in the inner city and of folks trapped in poor communities with few prospects of making it out, his precis of Losing Ground is that it “addressed the way our government encouraged social decay through the welfare state.” This kind of

32 Matriarchies, and therefore constitutively defective: “Ours is a society which presumes male leadership in private and public affairs. … A subculture, such as that of the Negro American, in which this is not the pattern, is paced at a distinct disadvantage” (29). 84 contradiction—that on one hand, broad structural forces in the economy are grinding communities into poverty from which they can’t escape while, on the other hand, the welfare state is simultaneously disintegrating communities and encouraging pathology— is difficult to square, nor does Vance try to do so. Instead, he embraces the spirit of

Murray’s book, probably because it aligns with what he’s able to see in the communities of which he is a part. It also, no doubt, aligns with the broadly mainstream conservative ideology that Vance espouses throughout the book.

This ideology is at work throughout Hillbilly Elegy, but it gains traction toward the end, when Vance discussed the disappearance of community in contemporary

America. He notes in passing that many people in his community falsely believed that then-President Barack Obama is a Muslim with ties to Islamic terrorists. Vance finds these beliefs shocking; he locates their origin not in anti-black racism but in, on one hand, white working class fear of racial domination and, on the other, pervasive mistrust of the media. Obama, whom Vance describes as “conduct[ing] himself with a confidence that comes from knowing that the modern American meritocracy was built for him,” casts hillbillies in an unsavory light; he reveals their failings, and they hate him for it. Vance expands:

Barack Obama strikes at the heart of our deepest insecurities. He is a good father while many of us aren’t. He wears suits to his job while we wear overalls …. His wife tells us that we shouldn’t be feeding our children certain foods, and we hate her for it—not because we think she’s wrong but because we know she’s right. (191)

In other words, Vance sees his fellow hillbillies’ anti-Obama beliefs as rooted in a kind of hatred of elite domination, not in racism. He also blames right-wing media figures such

85 as Alex Jones and conservative Christian websites for feeding “misinformation” to a white working class that can’t tell the difference (192).

The lesson Vance draws from these observations is that there “is deep skepticism of the very institutions of our society,” like the presidency and the media (193). For him, this skepticism is a symptom of wider disengagement from a system that’s not working for white working class Americans, a system that fails to deliver them opportunities to work and live meaningful lives in communities of their choice (193). Thus, “If you believe that hard work pays off, then you work hard; if you think it’s hard to get ahead even when you try, then why try at all?” Vance links this attitude to “a cultural movement in the white working class to blame problems on society or the government” (194). But

Vance has no time for government solutions to social problems. Toward the end of

Hillbilly Elegy, he admits that he’s skeptical of “magical public policy solution[s] or … innovating government program[s]” (238). He goes on: “These problems of family, faith, and culture aren’t like a Rubik’s Cube, and I don’t think that solutions (as most understand the term) really exist” (238). It turns out that, at the end of the day, Vance is actually a public policy nihilist about the plight of the white working class; he doesn’t actually believe that much can be done to help them.

Which, of course, doesn’t prevent him from offering solutions. Drawing on anecdote and mainstream social science literature, Vance suggests that we support family stability (239), alter social services to deal with non-normative family structures by keeping kids out of foster care and placing them with extended family (243-44), build better schools and support first-generation college students (244), etc. Note that hillbilly

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“culture” is not on the list of problems Vance believes government can address (245).

“We do need to create a space for the J.D.s … of the world to have a chance. I don’t know what the answer is, precisely, but I know it starts when we stop blaming Obama or

Bush or faceless companies and ask ourselves what we can do to make things better”

(256). What is clear, however, is that Vance foresees no role for the state to ameliorate the social problems of the white working class. Having spent hundreds of pages detailing the social pathologies of poor whites, he ends up in the same place that Charles Murray and others did in the early 90s, having arrived there through a parallel analysis of the social pathologies of poor blacks: the state can only do harm, so in the face of widespread immiseration, it’s up to individuals and their families to pull themselves up.

I’ve said nothing about drugs in this section so far; that’s because for Vance, drugs are really just a subset of the broader hillbilly social pathology discussed above.

Drugs enter the narrative through the figure of Vance’s mother, whom he introduces as a loving but also violent alcoholic early in the narrative (69-80). Later, we learn that she became addicted to “prescription narcotics” and spent time in rehab (113, 115-16). Not a constant presence in Vance’s life, she reappears toward the end of the narrative, having become addicted to heroin (“the Kentucky Derby of drugs”) (233) and “prescription opiates” (237). At this point in the book, Vance is living with his wife in Cincinnati, and his mother is on the verge of homelessness. Vance pays for a motel to keep his mom off the streets but is reluctant to get involved in her life in a sustained way: “By the grace of

God, I no longer hide from Mom. But I can’t fix everything, either” (238).

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The website for Our Ohio Renewal (n.d.), a non-profit Vance founded to address some of problems that Hillbilly Elegy identifies, contains a section on an initiative entitled “Fighting Against Opiate Abuse.” It states, “Our Ohio Renewal will lead on solutions to opioid abuse so we can take our communities back.” The webpage then offers a way for readers to sign up to receive updates about further initiatives. No actual initiatives are in evidence on Our Ohio Renewal’s webpage, but there is extensive coverage of Vance’s op-eds, public appearances, and media interviews. In an interview with Philanthropy Magazine where he discussed the opioid crisis, Vance offers this summary of Our Ohio Renewal’s opioid work:

On the opioid-abuse front, we’re identifying the things that have been tried, from prevention programs to physician training to treatment options, and trying to understand how well they are working. This information will be useful in redirecting resources to what actually succeeds. We’ll identify a couple key strategies we can stand behind, and then try to get community buy-in. (Philanthropy Roundtable 2017)

The quotation is low on the specifics, as is the interview, but Vance misses no opportunity espouse conservative bromides: family values, personal responsibility, local community, learned helplessness vs. learned willfulness, military valor, and so on. At the end of his Hillbilly Elegy journey and now in a position to use venture capital to combat the opioid crisis, we can see that Vance isn’t very far from where he started—in fact, as noted above, he isn’t very far from, say, Daniel Patrick Moynihan or Charles Murray.

Government is the enemy, and the family must be restored. And, of course, this is just the beginning. The release of the Hillbilly Elegy movie will expose millions more people to

Vance’s take on the white working class and the opioid crisis. Time will tell whether

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Vance has new talking points for the pressers and talk shows. Or perhaps venture capital will succeed in curbing an epidemic where the state has failed?

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Conclusion

Ohio is my home state. I was born in Dayton, Ohio, in 1984 and have lived in the state my entire life. I attended Catholic grade school and public high school in a predominately white, middle- to lower-middle class suburb of Dayton. I didn’t drink or do drugs in high school, and most of my friends didn’t, either. Some kids I knew drank; even fewer smoked pot. And no one I knew took pills or even knew where to get them. I knew where to get them, though, because I worked as a pharmacy technician at the Walgreens in my town. It was a great job for a high school kid, and definitely an improvement over my first real job working at McDonald’s. Beyond the better hours and not smelling like a cheeseburger when you got home, working at the home town pharmacy was interesting because you were privy to the medications people take. You knew which of your friends was on birth control, whose mom was depressed, and whose dad just hurt his back at work, landing him a 90-day supply of OxyContin. Oxy-Contin and Purdue Pharma figure prominently in most narratives about the opioid crisis, but what I remember most about working at the pharmacy circa 2000 is how worried the pharmacists were about stocking

Oxy at all. Even in those early years, they traded stories about inner-city drug addicts driving to the suburbs to hold up drive-through pharmacies at gunpoint.

No one I knew at the pharmacy or in my social circle engaged in what we now call “drug diversion” or “prescription drug misuse,” and I didn’t really think much about prescription drugs until years later, in the summer of 2008, when I was a legal intern at the Ohio Attorney General’s office. I had unwittingly begun law school at the start of the

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Great Recession, and I was thrilled to land a summer job. At the AG, I was assigned to the Health and Human Services section, which provides in-house counsel for a number of the State’s administrative agencies, including the State Medical Board of Ohio. The primary work of the Medical Board is to grant physicians licenses to practice in the State and to suspend or revoke those licenses when physicians misbehave. Doctors are like regular people: they drink and drive, use drugs, sexually harass coworkers, lie on paperwork, and suffer from mental illness. Over the summer, most of the cases that I worked on dealt with matters like these. A doctor would transgress a boundary; the

Medical Board would suspend his license and specify the path to redemption; and the lawyers would mediate between the physicians and the Board members to make sure everything went smoothly.

One afternoon, my supervisor asked me if I wanted to attend an administrative hearing involving a physician who was suspected of some billing irregularities in a number of clinics that he operated in Springfield, Ohio, about halfway between the capitol of Columbus and my hometown of Dayton. I jumped at the chance to get out of my office, and later that week, I was sitting in a cramped room with the hearing officer, my supervisor, the physician, and his attorney. As the hearing officer began to recite the formalities of the deposition, I observed the physician across the table. What I still remember is that he was wearing a gold watch about the size of a sundial, gold cufflinks, and what I believe was a purple suit. He didn’t look like any physician I’d ever met. In fact, he looked more like a successful preacher than a doctor. But I was a just an intern

91 and hadn’t reviewed the case files before the hearing, so I set my prejudices aside and listened to the testimony.

I’ve forgotten most of the details of the case, but I do remember that one of the lawyers in the room used the phrase “pill mill.” Like “Oxy-Contin” and “Purdue

Pharma,” “pill mill” is another familiar dramatis personae of narratives of the opioid crisis. A pill mill “is typically used to describe a doctor, clinic, or pharmacy that is prescribing or dispensing controlled prescription drugs inappropriately” (Rigg, March, and Inciardi 2010, 682). Operations like these, where physicians would see as many as a hundred patients a day and dispense pain meds in exchange for cash, played a key role in the early years of the opioid crisis in Ohio and nationwide, back when the crisis was thought simply to be a prescription drug crisis.33

In the early months of 2017, as I was awaiting decisions from graduate schools I had applied to, I read with alarm the slew of The New York Times articles reporting the grim details of how the opioid crisis was unfolding across the country. One such article was entitled, “Amid Opioid Overdoses, Ohio Coroner’s Office Runs Out of Room for

Bodies” (Freytas-Tamura 2017). The Ohio coroner’s office described in the article is in

Montgomery County, where my hometown of Dayton is located. Overwhelmed by the number of the bodies requiring autopsy due to opioid-related drug overdose, the article notes that the coroner’s office simply ran out of room to store bodies and began asking local funeral homes to accept the overflow. Recent reporting from ProPublica shows that

33 Quinones (2015, 25-27, 156-60) contains many relevant details about Ohio’s experience with the prescription opioid and heroin crisis. 92 the same Dayton coroner is now using “refrigerator truck back-ups usually reserved for mass fatality events” to address the ongoing overflow bodies (MacGillis 2018).

Later in the autumn, in the midst of my first semester of graduate school at Ohio

State, I opened The New Yorker to find a photo-essay, “Faces of an Epidemic,” again set in Montgomery County, Ohio (Montgomery and Talbot 2017). The print essay contains photos accompanied by small captions explaining the events presented in pictures, such as body bags, families gathered outside houses after a loved one has overdosed, and drug users in the midst of getting dosed with naloxone. One of the captions reads as follows:

“A family mourns the death of their son, Brian Malmsbury, who overdosed on heroin in the basement of their home.” (See Figure 10 below.) A later caption elaborates: “Brian

Malmsbury’s death was an especially quiet one. He was thirty-three and had been living at home, in Miamisburg, Ohio, trying to get clean after years of addiction.”

Reading this photo-essay as a new graduate student, a shock of recognition moved through me. I moved to Columbus to attend OSU in 2002. After that, I only returned to the Dayton to visit my parents, all of whom have also lived in the area their entire lives. I became an adult in Columbus, and it was an important part of my identify that I was a person who had left, who had escaped Dayton. During my brief visits, I was aware of the city’s ongoing decline, even if it didn’t register as something that concerned me.

Especially after 2008, you could see it in the increasing number of homeless people downtown, in the hollowing out of the urban core, and in the closing of GM’s Moraine

Assembly plant—once an economic engine of the city’s white male working class. With a mix of recognition and shame I assume is typical of people who leave a place behind

93 without being able to really purge it, I saw The New Yorker essay as a ghostly image of what my life could have been like had I stayed in Dayton, and what it is like for some people who live there now. I went to high school in Miamisburg, Ohio, and I was the same age as Brian Malmsbury, the man who overdosed and whose mourning family is depicted in the pages of the essay. The people and places that appear in “Faces of an

Epidemic” look like my high school classmates, my family, and the street where I grew up.

Figure 12. Miamisburg, Ohio, family mourns loss of their son to an opioid overdose (Montgomery and Talbot 2017) These experiences and a desire to come to terms with a major social problem affecting my home state and the nation more generally form the impetus of this master’s thesis, which is simply an attempt to reach a fuller understanding of the opioid crisis and why attempts to address it have, by and large, failed. In particular, I have tried to answer 94 basic questions, such as: (1) what is the opioid crisis, and how has it changed over time?

(2) what are the competing narratives about the cause of the crisis? (3) how do these narratives shape policy responses? (4) how has the state addressed the opioid crisis, e.g., via regulation, legislation, and policing, and have the responses been successful? (5) what do these successes and failures tell us about the nature and limits of state power to address problems like the opioid crisis, especially when state power appears through the modality of policing?

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