Addiction as a criminal-justice problem versus a public-health problem

Addiction as a criminal-justice problem versus a public-health problem is a central conflict in the book’s account of the opioid epidemic: people struggling with addiction may be punished as offenders even when effective treatment is difficult to obtain. The divide is not merely a dispute over language. It shapes who receives medication, who is arrested, whether families speak openly, and whether a person asking for help can make it through the door of a treatment program.

From hidden drug use to a public-health crisis

The book first shows how narrow the public understanding of heroin use in Roanoke had been. In the 1980s and 1990s, Don Wolthuis recalled, only a few dozen people in the city used heroin. It was widely regarded as an inner-city drug, and its users were imagined as isolated and largely unseen. By the time the epidemic reached suburban families, that older picture no longer explained who was affected, but it continued to influence how the crisis was understood and addressed.

The author began reporting on the suburban epidemic in 2012, after two decades covering marginalized families for the Roanoke Times. At first, many families were too ashamed to speak publicly. Five years later, most were willing to have their names used. That change in disclosure reflects the gradual emergence of addiction as a community health concern, but the secrecy surrounding families also reveals how readily the public treated it as a private failure rather than a problem requiring shared care.

A chance meeting between two mothers at a Families Anonymous meeting makes the institutional divide concrete. Their sons’ experiences crossed the worlds of suburban life, drug use, and family crisis, while their parents confronted gaps between the health-care and criminal-justice systems. The book describes people with addiction trying to survive and avoid withdrawal while family members and volunteers tried to keep them alive. Shame helped conceal these gaps; meanwhile, the account observes that some actors, including drug dealers and pharmaceutical companies, profited from them.

Unequal exposure to care and punishment

The contrast between medical treatment and criminal enforcement is also racialized. The book notes that in Roanoke, heroin had long been associated with Black residents, while a later wave of opioid addiction affected many white users. It recounts 2014 Centers for Disease Control and Prevention data indicating that doctors prescribed painkillers to people of color at substantially lower rates than to white patients, amid medical distrust that they would misuse opioids. The narrative presents this disparity as a consequential feature of access to medication, not as an inherent difference in how racial groups experience addiction.

The book then places that prescribing disparity beside the racial distribution of drug punishment. It reports that three-quarters of federal drug offenders were Black or Hispanic and that people of color made up 57 percent of those imprisoned for drug offenses in state prisons. Calls to avoid arresting one’s way out of the opioid crisis, the author observes, appeared most readily to apply to mostly white opioid users who dealt drugs or committed property crimes to stave off withdrawal. They did not extend as readily to Ronnie Jones, imprisoned for armed heroin distribution, or to many other people of color arrested for selling drugs. The juxtaposition exposes a system in which some people are more likely to be treated as patients and others as criminals, even as drug use, dealing, and addiction do not fit neatly into those categories.

The book connects this divide to a broader political history. Bryan Stevenson explains that in the 1970s the United States chose to address drug addiction and dependence as a crime problem rather than a health problem, a choice sustained by fear and the criminalization of politically vulnerable communities. Once the image of the addict as criminal became embedded in public thinking, the book argues, support weakened for alternatives that might have lowered barriers to treatment.

Stigma inside families and care settings

Criminalization is reinforced by social stigma. In 2012, parents affected by addiction lacked the online groups that might have connected them across Virginia to exchange rehabilitation information, coping strategies, or practical support. Robin Roth felt branded as a failed parent and carried her grief in silence and anger. In another account, Janine Underwood spoke to school-board members and county officials about what was happening in her community and received no questions. The school board declined to support the prevention program she sought to advance, while the county provided its usual $2,000.

Stigma also shaped access to treatment after a person had reached a recovery setting. Tess Henry had attended twelve-step meetings before, but felt judged for taking buprenorphine. Although Narcotics Anonymous officially accepted Medication-assisted treatment, longtime members asked to sponsor or mentor her declined. Her experience illustrates how formal acceptance can coexist with a local culture that treats medication as incompatible with being in recovery. The consequence was not simply hurt feelings: the rejection narrowed the support available to someone trying to remain connected to treatment.

The divide also appeared between health services and criminal justice in the ordinary mechanics of referral. Psychologist Cheri Hartman and Kuehl sought to create a smoother transition from emergency care to outpatient Medication-assisted treatment and counseling, drawing on a hospital model in Ontario. They faced legal, financial, and bureaucratic obstacles, a shortage of providers, and too few detoxification and treatment beds. Hospital social workers began referring some revived overdose patients to the Hope Initiative, but the broader system for training peer recovery specialists would not be operational for months. The result was a patchwork of urgent responses without a dependable path from overdose to continuing care.

Alternatives, implementation, and limits

The Hope Initiative represented an attempt to make police contact a route into treatment rather than an automatic route to arrest. Developed in Roanoke with reference to the Police Assisted Addiction and Recovery Initiative, it proposed a public-private partnership in which trained volunteers, called angels, would help people enter treatment and mentor them through a difficult recovery process. The plan placed the program at the Bradley Free Clinic, where it could draw on community resources including housing, mental-health services, and employment assistance.

The early figures show how far an appealing design could remain from effective access. Twenty-two people came to the Hope Initiative in its first month. Some continued to call or text and repeatedly expressed interest in getting help, but none entered residential treatment; only a handful obtained outpatient Medication-assisted treatment. Underwood became so exhausted that colleagues called emergency medical services after she passed out at work from stress-related vertigo. The program’s volunteer effort could encourage and guide people, but it could not itself create treatment beds or remove barriers built into the wider system.

Stevenson describes a more comprehensive alternative: diverting low-level drug and prostitution offenders with addiction from prosecution before booking, while helping them find housing, case management, and employment. The Equal Justice Initiative sent clients to cities such as Seattle, where harm-reduction services and employment opportunities were more plentiful. This approach linked treatment to the practical conditions that can make a return to ordinary life possible; it also addressed the loss of legitimate work that can leave former dealers with few alternatives. Stevenson argued that reducing the prison population by a quarter could save $20 billion, half of which could be invested in treatment.

The book points to Portugal as another policy contrast. After decriminalizing all drugs, including cocaine and heroin, in 2001, the country added housing, food, and job assistance and redirected resources from prosecution and imprisonment toward treatment. It is presented as evidence of a different policy direction, not as a claim that one model resolves every individual experience of addiction. The book stresses that not every patient wants or needs maintenance medication, while insisting that people who could benefit from treatment should be able to obtain it rather than be denied care as a consequence of being treated as criminals.

The enduring policy conflict

The criminal-justice model persisted in courts and treatment rules. The book notes that many drug courts continued to reject Medication-assisted treatment even though significant scientific studies supported its use, and that courts often sent people with addiction to prison when reliable treatment was hard to secure. It argues for preserving effective options and providing the practical means to get off drugs, rather than making medical care conditional on a judgment of moral deservingness.

The divide also crossed party lines. The book describes federal responses as slow or restrained under both the Obama and Trump administrations. At a 2014 National Institute on Drug Abuse meeting, historian and harm-reduction activist Caroline Jean Acker was criticized for advocating needle exchange and naloxone distribution after a speaker separated supposedly good, medically dependent patients from bad, illicit users. That distinction, the episode suggests, obscured the fluidity between medical exposure and illicit use, while fear of appearing soft on drugs constrained discussion of harm reduction.

Taken together, these examples show that the choice between punishment and public health is made repeatedly: in prescribing decisions, arrest practices, court rules, peer-support meetings, funding, and the handoff from emergency care. The book’s account does not reduce those failures to individual prejudice or to a single failed program. It shows how stigma and institutional design can turn a public-health crisis into a maze in which a person may be revived, referred, or willing to seek help and still be unable to reach sustained care.