The opioid crisis has hit hard in Macomb County, Mich. Composed of 27 Detroit suburbs, the county has the state's second-highest opioid-overdose death rate, more than double the national average.
District Court Judge Linda Davis has been on the bench 17 years. She sees the consequences pretty much every day.
"When I look at the docket I handle, I'd say 70 percent is addiction-related," she says, not counting low-level traffic offenses like driving with a suspended license. "We've definitely seen a rise in thefts with this opioid surge."
Although opioid addiction often starts out legally, recent years have seen a shift toward illegal opioids. It's an all-too-familiar story: People get hooked on prescription painkillers, often moving on to heroin, which can be cheaper on the street. Since 2011, as prescription opioid overdose deaths leveled off, heroin overdoses started rising. Starting in 2014, illicit fentanyl deaths began spiking upward.
Whatever the substance, the cost mounts up fast. So many users resort to theft. They'll steal from family, friends, acquaintances or strangers. They'll shoplift, commit fraud, rob pharmacies, break into homes or cars. Even commit armed robbery.
And whether or not they're committing those crimes themselves, their desperate dependency can feed some even worse ones.
In 2015, the nation's homicide rate rose sharply (11 percent) after decades of decline. The uptrend continued in 2016, climbing another 8 percent. Some observers looked for racial reasons for it.
There could be one, says Richard Rosenfeld, an emeritus professor of criminology and criminal justice at the University of Missouri-St. Louis. But he thinks there's more to the story.
When Rosenfeld looked into the data, he quickly saw homicides had jumped among several ethnicities—and it was very pronounced among whites.
"The increase is quite abrupt, quite recent and quite large, at levels we hadn't seen since the early 1990s outside of 9/11," Rosenfeld says. "The 'Ferguson effect' doesn't explain that."
What might? The opioid epidemic, for one thing—which crosses racial lines, but is most concentrated among whites. Drug-related homicides rose more than 21 percent in 2015, a rate far higher than other common categories of homicide, which rose between 3 and 5 percent.
It stands to reason that there'd be a connection between the spikes in opioid use and lethal violence, Rosenfeld says.
"It's not opioid use per se that sparks violence, but the markets," he says. "When disputes arise between sellers or buyers, they can't be settled by police or courts or the Better Business Bureau.
"As the number of buyers expands, so does the number of sellers. As you get more players in the market, the number of disputes that turn deadly will also go up."
Just how big a role do opioids play in driving the rise in homicides? That calls for more research, Rosenfeld says. But he sees ample evidence to sound the warning, and to call for addressing the root causes.
"Policymakers and law enforcement are framing this as a public-health crisis more than as a criminal-justice crisis, and I'm very much in favor of that," he says. "The bottom line is: If we reduce demand, we reduce crime."
'We Don't Want Those People Here'
Reducing demand for opioids would likely reduce other social pathologies too. Like homelessness.
"For those of us who've been providing health care to people who are homeless, this is not a new problem," says Barbara DiPietro, senior policy director for the National Health Care for the Homeless Council. "We've been seeing opioid addiction and overdoses for decades.
"When people are in a spiral and aren't getting the help they need, oftentimes they lose their jobs and their ability to pay rent. Before you know it, you cycle through family and friends, and you're in a shelter or on the street."
Not all people who are homeless have addiction issues, but those that do have a harder time getting into treatment once the stability of housing is gone.
"Living on the street could easily drive anyone to substance abuse," DiPietro says. "Maybe you started with alcohol, but once you were on the street, you found other things. It's very hard to get well when you're homeless."
Federally qualified health centers provide care to 1.2 million people a year, and the Council provides technical assistance to help improve quality and access. DiPietro says homeless service providers often see clients who never expected to be in this situation.
"We see a lot of clients who come from construction work or other hard-physical-labor jobs, who got hurt and got prescriptions for legitimate reasons," she says. "We see a lot of people who've experienced trauma in their lives—child abuse, domestic violence, sexual assault. So they self-medicate to deal with the pain."
And on the street, their problems are much more visible than those of people who engage in their addictive behavior behind closed doors.
"They're living their private lives in a public space," DiPietro says. "They're subject to public scrutiny, arrest and incarceration at a much higher rate. And once you have an incarceration history, it's hard to get housing assistance or a job again."
While more medical facilities and first responders are being equipped with opioid-overdose medications like naloxone, that's just an emergency measure, not a solution. DiPietro says what people struggling with addiction and homelessness need most is stable housing where they can get effective treatment.
The health care providers the Council works with can provide some of that—but not enough to meet the scale of the problem.
"Right now, communities don't have the capacity desperately needed to get people into treatment," she says.
Another big obstacle is the attitude known as NIMBY—Not in My Back Yard.
"Everyone believes treatment is important, but no one wants the services near them," DiPietro says. "When that's proposed, they rise up in community meetings and say, 'We don't want those people here.'
"We've got to get beyond that attitude."