We’re an opioid nation. It is killing us.

Summary: America is having a severe crisis, which gets too little attention because we have no idea how to deal with it. These books give information and insights that can help us find solutions. Or rather, find patches. The opioid crisis is part of a larger crash in public health, symptom of deeper problems in American society.

Man-Taking-Drugs-dreamstime_102578306
ID 102578306 © Srdjan Randjelovic | Dreamstime.

Here is grim news about America from the Centers for Disease Control in “United States Health 2017“. From the press release for the

  • “Life expectancy at birth decreased for the first time since 1993 by 0.2 years between 2014 and 2015, and then decreased another 0.1 years between 2015 and 2016.
  • The age-adjusted death rate for drug overdose in the U.S. increased 72% between 2006 and 2016 to 19.8 deaths per 100,000 population in 2016.
  • Between 2006 and 2016, the age-adjusted suicide death rate increased 23%, from 11.0 to 13.5 deaths per 100,000 resident population. {The global suicide rate is falling.}
  • Among men ages 25–34, death rates for chronic liver disease and cirrhosis increased by an average of 7.9% per year during 2006–2016. Among women in the same age group, this increase averaged 11.4% per year.”

See the sad news. These are casualties like those in a war.

Drug overdoses over time - CDC 2017

Drug Overdoses by State - CDC 2017

Before we panic and adopt the solutions of snake-oil-selling politicians, let’s learn about the problem. Fortunately, experts have published some timely books about this crisis.

Opioid Nation” by Marcia Angell.

New York Review of Books, 6 December 2018.
Posted with their generous permission.

Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic by Barry Meier.

Dopesick: Dealers, Doctors, and the Drug Company that Addicted America by Beth Macy.

American Overdose: The Opioid Tragedy in Three Acts by Chris McGreal.

American Fix: Inside the Opioid Addiction Crisis – and How to End It by Ryan Hampton.

The National Institute on Drug Abuse estimates that 72,000 Americans died from drug overdoses in 2017, up from some 64,000 the previous year and 52,000 the year before that – a staggering increase with no end in sight. Most involved opioids.

A few definitions are in order. The term opioid is now used to include opiates, which are derivatives of the opium poppy, and opioids, which originally referred only to synthesized drugs that act in the same way as opiates do. Opium, the sap from the poppy, has been used throughout the world for thousands of years to treat pain and shortness of breath, suppress cough and diarrhea, and, maybe most often, simply for its tranquilizing effect. The active constituent of opium, morphine, was not identified until 1806. Soon a variety of morphine tinctures became readily available without any social opprobrium, used, in some accounts, to combat the travails and boredom of Victorian women. (Thomas Jefferson was also an enthusiast of laudanum, one of the morphine tinctures.)

Heroin, a stronger opiate made from morphine, entered the market later in the nineteenth century. It wasn’t until the twentieth century that synthetic or partially synthetic opioids, including fentanyl, methadone, oxycodone (Percocet), hydrocodone (Vicodin), and hydromorphone (Dilaudid), were developed.

Pain Killer: An Empire of Deceit and the Origin of America's Opioid Epidemic
Available at Amazon.

In 1996 a new form of oxycodone called OxyContin came on the market, and three recent books – Beth Macy’s Dopesick, Chris McGreal’s American Overdose, and Barry Meier’s Pain Killer – blame the opioid epidemic almost entirely on its maker, Purdue Pharma. OxyContin is formulated to be released more slowly and therefore lasts longer. The company claimed that the drug’s slow release would make it less addictive than ordinary oxycodone, since the initial euphoria – the high – would be muted. Based on this theory and little else, the FDA permitted OxyContin to contain twice the usual dose of oxycodone and carry on the label this statement: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” (The FDA official who oversaw OxyContin’s approval later got a plum job at Purdue Pharma.)

The company launched an extraordinarily aggressive and successful marketing campaign to convince physicians that they had the holy grail of a nonaddictive opioid. It sent hundreds of sales representatives to doctors’ offices to tout OxyContin, and offered doctors dinners and trips to meetings at luxury resorts. And it paid more than five thousand doctors, pharmacists, and nurses to train as speakers to tour the country promoting OxyContin. But like all opioids, OxyContin is addictive. And soon enough, users found that they could crush the pills or dissolve the coating, then snort the drug like cocaine or inject it like heroin. Each pill would then become essentially an instantaneous double dose of oxycodone.

OxyContin almost immediately became a blockbuster – that is, a prescription drug with annual sales of more than $1 billion. It was widely used not just by those for whom the prescriptions were written, but by their relatives and friends. The pills were also sold or stolen or otherwise diverted to street use. In addition, “pill mills” sprang up, where unethical physicians wrote innumerable prescriptions for OxyContin and refilled them automatically without ever seeing the patient. McGreal describes “one of the most productive pill mills in the country,” which operated in the small town of Williamson, West Virginia – known locally as “Pilliamson.” The town, he says, “was awash in pills,” and people came by car and bus to line up at the clinic and cooperating drugstores. “Investigators calculated that in 2009 alone, the clinic pulled in $4.6 million in a town with a population of little more than three thousand people.”

It’s impossible to know how many new prescriptions were obtained in each of these ways, but one way or another, OxyContin addiction grew into an epidemic. The epicenter was central Appalachia, and its victims were mainly white people in small, economically depressed coal-mining communities in southern West Virginia and parts of Kentucky, Tennessee, and southwestern Virginia.

*** The books by Macy and McGreal provide full accounts of the development and promotion of OxyContin, the onset of the epidemic in Appalachia, the failure of Purdue to respond, and the company’s eventual admission to fraudulent marketing.

The three books that focus on Purdue Pharma are in a sense the same book. Barry Meier first published Pain Killer in 2003. The new edition (released by a different publisher) is much the same, with some updating and re-arrangements. The two new books, Dopesick and American Overdose, cover the same story as it unfolded in the same region of the country. Both Macy and McGreal refer to the 2003 edition of Meier’s book (but not the new edition, probably because they could not have known of it at the time their books were written). All three books are gripping and well written, with detailed accounts, one after another (perhaps too many), of families decimated by the epidemic. And they all tell the story of Art Van Zee, a physician in southwestern Virginia, who in 2000 became aware of the growing epidemic of OxyContin there and tried heroically to get Purdue Pharma and the FDA to take responsibility for it.

"Dopesick: Dealers, Doctors, and the Drug Company that Addicted America
Available at Amazon.

Purdue Pharma and the Sackler family that founded it are very hard to defend. By aggressively marketing OxyContin, even after they knew it was being widely abused, the family became enormously wealthy. But the FDA was also guilty. It permitted OxyContin to be sold as a relatively nonaddictive opioid without good evidence to support that claim, and it should have been obvious that the pills might be crushed or dissolved to make them even more addictive.

Van Zee, along with Beth Davies, a nun who ran the local substance abuse clinic, saw Lee County, Virginia, blanketed with OxyContin prescriptions and watched the deaths mount, particularly among young people. They informed Purdue, which simply stonewalled. Over the following year, Van Zee devoted himself completely to the cause, meeting with company and FDAofficials and testifying before a Senate committee, trying to get Purdue to reformulate the drug or even withdraw it from the market.

In 2007 Purdue pled guilty to criminal charges of fraudulently marketing OxyContin and settled for $600 million in fines and penalties. Three executives pled guilty to misdemeanor charges and were sentenced to four hundred hours of community service and lesser fines. The company’s fine was trivial in comparison with its profits from OxyContin. In fact, almost every other major pharmaceutical company has had to settle both civil and criminal charges of fraudulent marketing for much more (the record settlement is now GlaxoSmithKline’s $3 billion, for a variety of violations, including falsely promoting drugs and failing to report safety data). These kinds of fines are just the cost of doing business. And so it was for Purdue Pharma, although the fraudulent marketing stopped and a warning was added to the label.

The problem with these three books, and it’s a big one, is that they treat the Purdue story as though it were the whole story of the opioid epidemic. But OxyContin did not give rise to opioid addiction, although it jump-started the current epidemic. Heroin has been a common street drug ever since it was banned in 1924. Morphine has also been widely abused.

Nor would taking OxyContin off the market end the epidemic. The overwhelming majority of opioid deaths are caused not by OxyContin but by combinations of fentanyl, heroin, and cocaine, often brought in from China via Mexican cartels, and frequently taken along with benzodiazepines (such as Valium or Xanax) and alcohol. These drugs are cheaper and stronger, particularly fentanyl. Fentanyl was first synthesized in 1960, and soon became widely used as an anesthetic and powerful painkiller. It is legally manufactured and highly effective when used appropriately, often for short medical procedures such as colonoscopies. The illicit production and street use is relatively new, but it is now the main cause of most opioid-related deaths (nearly 90 percent in Massachusetts).

The steady increase in opioid deaths after OxyContin came on the market has been supplanted by a much faster increase starting around 2013, when heroin and fentanyl use increased dramatically. We now have two epidemics – the overuse of prescription drugs and the much more deadly and now largely unrelated epidemic of street drugs. By concentrating on the first, we are closing the barn door after the horse is long gone.

Efforts to deal with the epidemic have been all over the map – literally. Possession of illegal drugs (and legal drugs illicitly used) is still a federal crime, and prisons are still full of people whose only crime was that. But many states, counties, and cities have begun to regard opioid addiction as a public health issue, not a police issue. They are opening centers in which people who seek help are shifted to less powerful opioids like methadone and buprenorphine (Subutex) – a method known as “medication-assisted treatment,” or MAT. Naloxone (Narcan), the antidote for an opioid overdose, is now sold over the counter in almost all states. If used immediately, it can prevent an otherwise inevitable death from a drug overdose. And drug courts, which may drop criminal charges in return for an agreement to submit to treatment and monitoring, are becoming more common.

Most controversial are facilities called “safe injection sites,” or SIFs, where drug users can come to use drugs without fear of arrest. The staff provides clean needles to reduce the risk of HIV and hepatitis C infections, and is prepared to resuscitate addicts who overdose. This approach is called “harm reduction.” The problem is that addicts must still buy drugs illegally, and it’s almost impossible to know exactly what is in them.

In a recent New York Times Op-Ed, the deputy attorney general, Rod Rosenstein, came down hard on SIFs. He warned that “it is a federal felony to maintain any location for the purpose of facilitating illicit drug use,” and that “cities and counties should expect the Department of Justice to meet the opening of any injection site with swift and aggressive action.” He was referring to plans to operate SIFs in San Francisco, New York City, and Seattle, and similar options now being considered by Colorado, Maine, Massachusetts, and Vermont. Later in the same article, however, he softened, saying we should “help drug users get treatment and aggressively prosecute criminals who supply the deadly poison,” suggesting that perhaps he doesn’t believe simple possession is so bad, after all.

American Overdose: The Opioid Tragedy in Three Acts
Available at Amazon.

But the proposed solutions to this epidemic range from the extreme of “lock ’em up” to “drug abuse is no less a disease than cancer or diabetes” and should therefore be met with the same solicitude. Ryan Hampton exemplifies the latter view in his angry book, American Fix. A former drug user himself and now an impassioned advocate and activist, he insists that drug abuse should be regarded like other diseases. He doesn’t acknowledge that for most users there was a moment of choice in becoming addicted that is not the case for people with cancer or diabetes. After receiving Dilaudid for a painful ankle, Hampton decided to ask for more, and then more. I think one can make the argument for sympathy with drug users and for understanding how the quest for drugs ceases to be under their control without claiming an analogy to diseases like cancer or diabetes.

Hampton paints a vivid picture of the downward spiral of addiction. When he “leveled up to IV heroin,” he explains, “it was cheaper than pills, easier to get hold of, and a quarter the cost. More important, nobody was tracking us in a database.”

Where Hampton is at his best is in his exposure of the profiteering and corruption in the burgeoning addiction industry – what he calls “the treatment industry swamp.” In the swamp, he found …

“lack of effective treatment, exorbitant costs, and ridiculous twenty-eight-day vacations disguised as medical help, fed by patient brokers who run a completely legal, high-end human trafficking cartel to push tens of thousands of patients through the broken system.”

He was referring to the panoply of treatment centers, both residential and outpatient, and detox facilities, where users are supposed to be weaned from drugs before entering “sober living houses.” As in so much of American medicine, even nonprofit insurers like Medicaid outsource the actual delivery of care to for-profit companies that charge whatever the market will bear. According to Hampton, “one of the most expensive treatment centers in America, Passages Malibu, costs more than $60,000 per month.” Costs are settled by a crazy quilt of payers, including state and local governments, Medicaid, other federal programs, private insurers, and often by desperate families. Not surprisingly, only a minority of users are ever treated.

In 2017 the Aspen Institute’s Health Strategy Group, led by two former secretaries of health and human services, Tommy Thompson and Kathleen Sebelius, and consisting of twenty-four members from various health-related fields (I am among them), met for three days to examine the opioid epidemic. The deliberations were preceded by four presentations by experts in the field. In the final broad and comprehensive report, the group made a strong case for decriminalizing drug addiction and instead regarding it as a public health issue. Among the five major recommendations was a call for more research into nearly all aspects of the epidemic. It’s startling how little we know, given the immensity of the problem and the media attention it receives.

*** See “Confronting Our Nation’s Opioid Crisis” by The Aspen Institute.

We need to know, for instance, how effective opioids are for different kinds of pain, including long-term treatment for chronic pain. We need to know how opioids compare in effectiveness and side effects with acetaminophen (which can cause liver failure) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (which can cause gastrointestinal bleeding). We need to know how the death rate in the opioid epidemic compares with the rate of use. We know the death rate is soaring, but does that mean the rate of use is, too, or is it simply a result of the lethality of the drug mixtures obtained on the street? We need to know how much diversion there is now from legitimate treatment to abuse. That includes diversion of methadone and buprenorphine, which are also opioids and can be sold on the street or added to the user’s illicit intake. According to Macy, “Buprenorphine is the third-most-diverted opioid in the country, after oxycodone and hydrocodone.”

We need to know how many addicts want to quit, since most don’t seek treatment. Why don’t they? And finally, we need to know the best approach to treatment. There is concern, for example, that detox might be dangerous, because the first dose after a relapse can be deadly if the user is no longer tolerant to the drug’s effects. Is providing methadone or buprenorphine indefinitely, even for life, the best treatment among bad choices? There is plenty of speculation about all of these questions, and suggestive findings about some of them, but little solid evidence.

We also need to remember an essential and crucial fact: opioids do have a legitimate purpose, and it’s an enormously important one. They treat severe pain, often when no other treatment is effective. Patients suffering from cancer are sometimes completely dependent on opioids for relief, as are some patients with other forms of severe pain. As the authors of the books acknowledge, pain was systematically undertreated throughout most of the twentieth century. After centuries of free and easy use of opioids, there was a sudden reaction in the United States at the start of the twentieth century, which had much to do with anti-immigrant sentiment, particularly animus toward Chinese immigrants who were widely assumed to be opium addicts. (It also paralleled the growing reaction against alcohol that resulted in Prohibition.) The 1914 Harrison Narcotics Tax Act imposed strict regulations on the use of opioids; they had to be prescribed by physicians, and then only for patients not already taking them. Prohibition lasted for only thirteen years, but the dread of opioid addiction stayed with us until the 1980s and caused cruel suffering for generations of patients.

American Fix: Inside the Opioid Addiction Crisis - and How to End It
Available at Amazon.

Even in hospitals where cancer patients lay dying in agony, opioids were administered reluctantly, in small doses, and at infrequent intervals. When I was in training in a teaching hospital in the 1960s, there was an awful ritual to it. The drugs were administered according to a pro re nata (prn) regimen (ostensibly “as needed”) that required the patient to wait out a four-hour interval, no matter how severe the pain, and then request the next dose. Those who badly wanted the drug had to keep track of the time and have the strength and endurance to summon a nurse if one was nearby. Patients were sometimes inhibited in asking for the next dose by a desire to please the medical staff and not be a nuisance, or by their own belief that taking morphine was somehow wrong or reflected weakness.

The extent to which nurses and physicians shared the common fears of addiction influenced their readiness to respond. Desperate patients would count the minutes toward the end of the interval, hoping they could flag down a nurse. Many doctors and nurses interpreted the anxiety and clock-watching as a sign of growing addiction, not inadequate pain relief. These patients were labeled “drug-seeking” and often punished for it by being denied the very help they needed.

During the 1980s there was a welcome change in that attitude, partly due to the hospice movement that had begun in the United Kingdom. The prn system became more flexible, or was eliminated altogether. There was a realization that because pain is entirely subjective, there is no way to measure or verify it, and even patients with the same condition could differ in their experience of pain. Instead of having to flag down nurses, patients were asked at shorter intervals whether they needed pain relief, and how much. In 2001 the Joint Commission on the Accreditation of Healthcare Organizations proclaimed pain the fifth vital sign, to be assessed in every patient, along with heart rate, respiratory rate, temperature, and blood pressure. Although the motivation for this move was laudable, it presented problems, since, unlike the other four vital signs, pain can’t be objectively quantified.

The authors of the books under review recognize the history of inadequate treatment of pain throughout most of the twentieth century, but they don’t give it its due. They concentrate instead on the reaction of the 1980s, which they consider excessive and an underlying cause of the opioid epidemic. In 1982 I wrote an editorial in The New England Journal of Medicine, which began, “Few things a doctor does are more important than relieving pain.” I still believe that. I ended with these words: “Pain is soul-destroying. No patients should have to endure intense pain unnecessarily. The quality of mercy is essential to the practice of medicine; here, of all places, it should not be strained.”

The opioid epidemic, while horrifying, is still outweighed by alcohol deaths, which are also increasing, according to the Centers for Disease Control. Hampton writes, “If my first drug of choice came with a prescription, the second one, alcohol, was culturally embedded and used to celebrate at every turn of events.” In 2016, when there were 64,000 deaths in the US from the drug epidemic, there were 90,000 from alcohol (including accidents and homicides caused by inebriated people, as well as direct effects, mainly cirrhosis of the liver). Cigarette smoking is estimated to cause 480,000 deaths a year. I do not intend to minimize the opioid epidemic. Far from it. What I want to underscore is the differences in these three epidemics. Alcohol and cigarettes have no medical or practical uses of any kind. Yet we permit their use if regulated. In contrast, opioids do have medical uses, and they are important.

The opioid epidemic is usually seen as a supply problem. If we can interdict the supply of prescription opioids, the thinking goes, we can stanch the epidemic. But that is unlikely to work for two reasons. First, as I pointed out, this is no longer mainly an epidemic of prescription drugs but of street drugs. And second, it creates an onerous obstacle for doctors and outpatients who require pain treatment. More and more, they have to satisfy regulations expressly designed to restrict access to prescription opioids. Some make sense. For example, it’s reasonable to monitor opioid prescriptions to detect pill mills. It’s also reasonable to flag users who “doctor-shop,” that is, see several doctors at once to try to get multiple doses of opioids.

But other requirements are meant simply to inconvenience both doctors and patients until they give up. For example, in Massachusetts doctors must limit their first-time opioid prescriptions to seven days. That can be more than an inconvenience for ill patients in pain. Macy quotes a letter from a friend with severe back pain from scoliosis. “‘My life is not less important than that of an addict,’ my friend wrote,…explaining that her new practitioner requires her to submit to pill counts, lower-dose prescriptions, and more frequent visits for refills, which increase her out-of-pocket expense.” Even more serious is a new shortage of opioids for injection in cancer centers.

For physicians, who are already weighed down by innumerable bureaucratic requirements, these restrictions present one more hoop to jump through, and many simply won’t do it. Instead, they’ll send the patient away with some Advil and hope it does the trick, even though they know it probably won’t. The regulations are having their intended effect. In Massachusetts, opioid prescribing has decreased by 30 percent. Meanwhile, the epidemic of street drugs continues apace. McGreal raises the possibility that reducing access to prescription opioids might feed the demand for heroin. Macy quotes an addiction specialist who laments that “our wacky culture can’t seem to do anything in a nuanced way.”

I believe the modern opioid epidemic is now more a demand problem than a supply problem. Three years ago, the Princeton economists Anne Case and Angus Deaton published an explosive paper about the surprising rise in mortality, starting at the turn of this century, among middle-aged white non-Hispanic men and women. The increase was greater in women than in men. They found three main causes: drug and alcohol overdoses, suicide, and alcohol-associated liver disease. They later called these “deaths of despair,” because they were most common among workers in tenuous jobs, with only a high school education or less, who were struggling to stay afloat in isolated regions of the country. Dragged down by these deaths, in the past three years overall life expectancy in the United States has started to drop.

It’s not hard to see reasons for the despair. Most working-class Americans have not benefited from our booming economy, the fruits of which have gone almost entirely to the richest 10%. For the bottom half of the population, income has scarcely budged since the 1970s, while expenses for necessities like housing, health care, education, and child care have skyrocketed. In Appalachia, where the opioid epidemic first took hold, many coal miners were unemployed and would probably remain so. People expected they wouldn’t live as well as their parents had, and had little hope for their children.

It is true that African-Americans still have higher overall mortality rates than whites, but that gap is closing rapidly for people under the age of sixty-five, particularly for women. By 2027, white women will have higher mortality rates than African-American women. Mortality for African-American men is falling even faster than for African-American women; it is projected to be equal to that of white men by 2030. But the epidemic has extended to all parts of the country and to all ethnic groups, so it’s unclear how the effects will be distributed in the future.

By the middle of this decade, the grotesque inequality in this country began to get the attention it deserves. And the growing awareness of that inequality fed the populist passion that, when twisted and distorted, produced the election of Donald J. Trump. It’s probably not coincidental, then, that the opioid epidemic got its second wind at about that time. It certainly marks the time when the opioids of choice changed from prescription drugs to the witches’ brew of street drugs. Did the epidemic explode because people were becoming aware that the American Dream was no longer theirs to dream?

As long as this country tolerates the chasm between the rich and the poor, and fails even to pretend to provide for the most basic needs of our citizens, such as health care, education, and child care, some people will want to use drugs to escape. This increasingly seems to me not a legal or medical problem, nor even a public health problem. It’s a political problem. We need a government dedicated to policies that will narrow the gap between the rich and the poor and ensure basic services for everyone. To end the epidemic of deaths of despair, we need to target the sources of the despair.

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———————————

Marcia Angell

About the author

Marcia Angell is a member of the faculty of Global Health and Social Medicine at Harvard Medical School and a former Editor in Chief of The New England Journal of Medicine. She is the author of The Truth About the Drug Companies: How They Deceive Us and What to Do About It. See her bio at Wikipedia.

For More Information

See “The Family That Built an Empire of Pain” by Patrick Radden Keefe in The New Yorker – “The Sackler dynasty’s ruthless marketing of painkillers has generated billions of dollars—and millions of addicts.”

Ideas! For some shopping ideas, see my recommended books and films at Amazon.

If you liked this post, like us on Facebook and follow us on Twitter. See all posts about the war on drugs, and especially these …

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35 thoughts on “We’re an opioid nation. It is killing us.

  1. The problem is any doctor can Rx those. More than a few days worth should be limited to specialists or pain doctors who a better trained.

    1. Sven,

      I don’t understand how this works. I’ve read about the DEA’s jihad against doctors who heavily prescribe pain relievers – such as those treating the very elderly and terminally ill (e.g., at hospices). How do the pill mills get away with it?

      It’s all so odd.

    2. I’ve been a chronic pain sufferer for over a decade. Modern pain science claims that taking (exogenous) opioids increases pain over time. Most pain doctors try to wean their patients off of them. Your own brain actually produces (endogenous) opioids. THe endogenous system can be utilized through various behaviors like exercise, having fun, hugging a relative, petting a pet, etc. We’ve learned more about treating pain naturally in the past 10 years than in the previous 1000 years according to pain researchers Butler and Moseley. Ironically, the opioid crisis worsens. I suspect it has much more to do with despair – a spiritual condition – than pain care. Despair also makes pain worse. Much worse.

    3. PRCD,

      “Despair also makes pain worse.”

      That matches my experience – long ago – as a social worker. Many people using drugs and booze are often self-medicating for psychological conditions – which are often spiritual states (which we pathologize as medical issues because …reasons). Treating the addiction without the underlying causes is imo the major reason treatment programs usually fail.

      Thank you for sharing your experience from the front lines of people using drugs.

  2. An effect of capitalism without morals. Profiting (pharma and prisons) off under producing proles. Parallels to the AIDS crisis, undesirables dying and it isn’t till the body count piles up and you can make a buck off headlines like “U.S. life expectancy declines again!”. What’s different this time is the huge profits that have been made with this public health crisis. A disgusting aspect of our culture of putting profit over people.

    1. MTJ,

      “An effect of capitalism without morals”

      How is this different than the alcohol and AIDS crisis in the Soviet Union? No capitalism there. Corruption is part of human nation, for which we have not yet found a systemic remedy.

  3. This is just a personal theory, but I think it’s due to a rise in drug culture, and the authority/blanket trust enjoyed by doctors. There is this idea that if anyone with a credential tells you something, it must be true and beneficial. So if someone feels like crap and I tell them to medicate their pain away, that was bad advice 10-20 years ago but now doctors say it all the time, so I guess it’s okay? After all, if “feeling sad” is a disease that can be “cured” by taking prozac or zoloft, how hard is it to jump to opiods?

    There is a strong sense that magic pills can cure all your ills; when you point out the lack of clinical trials or effectiveness of placebos, not to mention all the money the drug companies pump into the system, no one wants to listen to you.

    1. Javier,

      I know little about the drug culture, but — are most opioid addicts supplied by doctors? Or even started on opioids by doctors? That seems unlikely to me.

  4. This is a fascinating article, but I wonder if it puts too much emphasis on issues of economics and inequality. Those are surely factors, but people used to socialize more and they used to drink while they socialized.Alcohol was very much a social drug. People went out to bars and drank and talked. Most of the bars I’ve been in lately were as quiet as a chapel with people wrapped up in their phones. And modern drunk driving laws being what they are, you’re impaired if you so much as smell a cocktail.

    It just strikes me that opioids are the drug of the socially isolated. You can drink alone, but alcohol seems to have a lot more potential to be a social drug. Maybe I’m thinking this way because I recently got hold of a book of cocktail recipes from the novels and stories of Ernest Hemingway. (The is called To Have And Have Another). The photographs were basically of a different world.

    A good friend of mine had an opioid problem. I don’t think that’s what killed him because he had other health problems too, and he moved away before he died. I’m not sure exactly where he ended up or what he died of. But I have no idea where or how he got his drugs. The stuff was just there.

  5. The poor are struggling and see no way out, they are drinking more and a percentage are asking for drugs to cut the pain of despair.

    I have family in a small industrial town in the UK, it used to make lawn mowers, the factory employed 40% of the town until the 1980’s, most of my family worked there, the results of the closure are sad to see. Some family did well, they went to University became Social Workers, Teachers and one is an Accountant. The rest drifted into casual jobs, there is a company making treated pine fence posts and palings, it is hard, dangerous to your health and lower paid than the old factory. It is also casual work, seven days a week in spring and summer, when demand is high, then it starts to drop off in Autumn and is dead in winter, 2/3 days a week at best. All my older relative there would talk about was the old factory and how they now struggle to pay for food or house repairs. Their children, if they have not moved away, work in the new factory and rent. There are the skilled jobs, but these are mainly done by the children of the better educated of 60% who did them before.

    What has the town got now, casual treated pine factory, bar work (open all day now), a telemarketing place(very low pay), and unemployment of 20%. Of my family there 70% are casual at the treated pine factory, the rest well a Bar Manger, 2 Teachers (one moved away), a Social Worker (Specialised in Substance Abuse) and several work in Aged Care as the majority of the old people have no family living in the town anymore. That side of the family have been in that village since the 1600’s. There is a feeling of just hanging on, even the Accountant says he charges, so little to the poor, after the rent on the office he earns half what he would in London, he and his wife just don’t want to cut their roots to the town. He does the Local Church’s accounts for free where they run a Thrift Shop, provide free meals and a soup van in the evenings for the homeless. His wife is a Nurse at the old People Home and says many of the old have nothing.

    I can see why middle aged people and the young are turning to drugs and alcohol, in the rural and de-industrialised areas, and why they voted for Trump, Britex and the Right in Italy. Just I can see what we sensibly do about these issues.

    1. Just a guy,

      I understand what you’re saying. I’ve seen similar thing in Appalachia, where I was briefly a social worker in the late 1970s. But the story has to be more complex. Poverty – harder, more brutal – is omnipresent in history. Yet today’s high levels of self-destructive behavior is rare.

      Perhaps because before modern times the poor had to work so hard to survive that they had no energy for self-destructive entertainment?

  6. Looking back on this issue from the future it is certain that the hype involved will be much easier to delineate. Addicted to hysteria is much more like it.

    1. Angel,

      What “hype”? What “hysteria”? Please be more specific.

      There are news articles, but low levels of public interest and little action.

      What level of attention do you believe warranted by this trend? At what rate of increase do believe these mild articles are warranted? At what levels?

  7. No kind of war on drugs would ever produce any positive results. See examples from UK and Switzerland and perhaps others, where drugs are not legal, but (locally in the UK) distributed under strict control. That can break down the original distributorship (namely the illegal trade and the associated violence) and, in turn, help the addicts to come to realize the fight is up to them by then.
    The idiocy of the past administrations (in the US) fighting the drug war at the source and the distribution chain provided the best examples of how that war “shall not be fought!”

    As for the prescription nightmare — there are “regulations” and “strict directives” for the medical practitioners; however, the doctors, in general, are not interested following these as these become a burden to their “conveyor belt” practices. And, believe this: Creating some sort of “not for profit” medicine system (from the family doctor to the insurance companies to the pharma-giants) would not work at this stage, as it would take huge effort and way too long time to bear any fruits.
    I’m not aware of any simple solution to all of this, short of very drastic measures, no contemporary politician would dare to consider…
    BTW
    The Chinese are exporting (guess where to) massive amounts of super-potent synthetic opioids for “pennies a pound” and, it seems to me, that this is not a coincidence — it is just another “front” of the fifth generation warfare.

    1. Sad but true on all points. That is a nice summary of the posts listed in the For More Info section.

      “I’m not aware of any simple solution to all of this”

      The search for “simple solutions” is a big barrier to fixing problems. There are seldom simple solutions to serious problems.

      “as it would take huge effort and way too long time”

      That’s a good example of why we can’t have nice things. Life isn’t like a TV sitcom.

    2. Further to this obvious: that no “simple solutions” to this do exist, at this moment; there’s no evident effort to find more complex ones either — all the P2B are looking after are their interests. And, as not many of the proverbial 1% are burdened by this phenomenon, the scare of homeless is joined by the scare of addiction — behave, you “liddle middle class,” as you could easily become them…
      When the vulnerable become expendable, there are NO solutions available.

      In regards of the above and the “huge efforts” — there is a “simple solution” to all of these and many other present problems readily available — fascism; I wouldn’t discount that as that’s a sheople’s way…

    3. Jako,

      “here’s no evident effort to find more complex ones either”

      That’s grossly false. There is a lot of effort put into addiction studies. Not as much as should be. With too little public pressure behind it.

      “many other present problems readily available — fascism”

      Rising rates of drug addiction and related problems — alcoholism, suicide — will go away under a fascist state? That’s a romantic delusion. Most of the 1930s fascist states were quite inefficient. When Mussolini claimed to “have made the trains run on time” in Italy, he was lying.

    4. My “effort” was meant as “action” — one can study, theorize and plan for ever and accomplish nothing (just check the last three posts on: https://fredoneverything.org/ — a worth-while-reading in any respect — my point is exemplified in the contrasting success of China’s high-speed train system); that was why I mentioned the UK and Swiss efforts as success story rather than just experimentation (also see Portugal and perhaps Norway etc.) — the point here is: First step = Treat drug use as a disease and not as a crime!

      My life originated in one of the countries over-run by fascism in mid 20thC — I had ample supply of experiences from the life under that and so from red prole’s through white intelle’s to blue bourgeois, all first hand experiences. It seems that not many people here realize how close we are to fascism right now! Just look at the rate of in incarceration, militarization of the police, intensity of surveillance, the “political correctness,” the “Balkanization” of the possible opposition and, most of all, the pretense of “democracy and justice.” I trust that the American Revolutionaries had not consider the “advancements” the ruling classes would make in their effort to fully enslave the ‘We The People’ and yet being seen as benefactors and protectors…

      I just glanced the FM next post and I may elaborate some more after reading it.

  8. Editor.

    I know this is hard, but 19.8 out of 100,000 is 0.0198%, so overdosing is still a minority of people, 50 in 100,000 is 0.05% overdosed.

    If 20 per 100,000 overdosed in 2017 and 25 per 10,000 in 2018, the increase is 20%, but the percentages are 0.02% rising to 0.025%. As a parent I can imagine the pain of the number being your son or daughter, but the numbers are small.

    The poor identify with the poverty as their lot, they “soldier on”, they work 7 days a week in summer and 3 in winter, they watch TV rapped in a blanket as they have little money and it saves putting the heating on. That is the other 99%.

    I reckon that 10 – 50 per 100,000, drank themselves to death, ran off from the farm never to be seen again or shot themselves before, too many but with the distance of history it is seen as the exception. At this point I will say again 1 is too many, I have a friend who lost a child to drugs, but it is a small percentage.

    As a college teacher I would try to help those in pain (organise counselling services to see them), but the dealers were always there hanging round the colleges looking for the vulnerable, hooking the boys on drugs to get them into crime to pay them or being in the gangs and the girls to get them hooked for prostitution. I know this if the drug sellers were hanging around colleges or school in 1850 rather than 2018, the parents would have shot them, that would have cut the problem down 75% at least. In that era no one would have seen the shooting once they know what they were selling. I am not advocating shooting them, but they are outside every school and college in the UK, US or Europe.

    Society was getting richer and developing, before now we seem to be going backwards or the poor do at least, life is getting worse, more people means more GDP, but less GDP per capita, that takes away optimism and there was a religious belief in a better after life and the need to live well to avoid hell.

    1. Just a guy,

      Your comment has no obvious meaning.

      “overdosing is still a minority of people”

      Quite the revelation of the blindingly obvious, isn’t it? Also quite true of every disease of children, the young, and the middle aged. What’s your point? Should we discontinue research into all of them?

      Esp diseases of kids, which affect really small “minorities”!

    1. info,

      IMO the loss of faith – broadly speaking – might play a large role. It certainly warrants research to find out.

  9. “As a college teacher I would try to help those in pain (organise counselling services to see them), but the dealers were always there hanging round the colleges looking for the vulnerable, hooking the boys on drugs to get them into crime to pay them or being in the gangs and the girls to get them hooked for prostitution. I know this if the drug sellers were hanging around colleges or school in 1850 rather than 2018, the parents would have shot them, that would have cut the problem down 75% at least. In that era no one would have seen the shooting once they know what they were selling. I am not advocating shooting them, but they are outside every school and college in the UK, US or Europe”.

    There is the problem, the isolated, the depressed, the children dealing with divorce there are the main customers, plus those that see their life with no future.

    War on drugs doesn’t work.

    Education doesn’t work.

    I would love to stop it, I have seen children in classes I have taught turn in addicts not many, but a few over thirty years.

    Jobs, a future, reduced crime and social deprivation, better regulation of the drugs industry…… I would pay more tax dollars to any thought out solution.

    1. Stu,

      ” I would pay more tax dollars to any thought out solution.”

      I agree. But unless we get lucky, we can’t cure what we don’t understand. Lots more research needed to understand what’s happening.

  10. Unemployment leads to despair. People who despair do drugs. The coal miners in Appalachia are turning to drugs possibly because they don’t want to leave the area and find work elsewhere. In California, logging, mining, and fishing were industries that employed blue collar men in rural counties. Manufacturing used to employ many men in Southern California. Regulations and offshoring have drastically reduced employment in these industries. Meth and pot (growing/cooking/using) are huge problems in many of these counties.

    Still, illegal immigrants from Latin America and Asia come here and find work, so there’s more to our despair, which Sir John Glubb identified as one of the conditions of a collapsing civilization. The West was Christian for 1500 years. In the past 100 years, Christianity has collapse. Despair is also a spiritual condition. This book has many remedies. It’s interesting that Dr. Lloyd-Jones wrote it under similar circumstances in Britain as we now face in America: rapidly-increasing apostasy and unbelief.

    This is just a personal theory, but I think it’s due to a rise in drug culture, and the authority/blanket trust enjoyed by doctors. There is this idea that if anyone with a credential tells you something, it must be true and beneficial. So if someone feels like crap and I tell them to medicate their pain away, that was bad advice 10-20 years ago but now doctors say it all the time, so I guess it’s okay? After all, if “feeling sad” is a disease that can be “cured” by taking prozac or zoloft, how hard is it to jump to opiods?

    There is a strong sense that magic pills can cure all your ills; when you point out the lack of clinical trials or effectiveness of placebos, not to mention all the money the drug companies pump into the system, no one wants to listen to you.

    Pain doctors say patients want a pill, not a cure. Cures require personal responsibility and work on the part of the patient. Opioids do not work to treat pain except in cases where a patient needs to be made comfortable before he dies (hospice care) or after surgery (acute care). They’re harmful for chronic cases. But patients want a pill.

    Anti-depressants don’t work beyond a placebo effect. Thoughts cause depression, not chemical imbalances. Changing your thoughts requires introspection and hard work. Patients want pills.

    For example, let’s say you’re unemployed and depressed. You have thoughts of worthlessness. You need a job to stop feeling worthless. The best thing for your depression is to get almost any job rather than spend every day at home jobless. This requires you to take at least some responsibility for your condition and make some effort. It’s easier as a patient to believe a pill will make you feel better.

    1. PRCD,

      “Unemployment leads to despair. People who despair do drugs”

      The current drug crisis coincides with a multi-generation low in unemployment. People are voluntarily dropping out of the labor force, but that’s not unemployment in any usual sense.

  11. The current drug crisis coincides with a multi-generation low in unemployment. People are voluntarily dropping out of the labor force, but that’s not unemployment in any usual sense.

    Right. I think the government has stopped counting many unemployed workers, particularly unemployed youth. Talking to Baby-Boomer parents and observing their children, I think youth unemployment might be quite high. The full-time now jobs available to blue-collar people typically pay less than mining, lumber, manufacturing, and fishing. The BLS data shows that wages for the bottom 3/5s of workers hasn’t risen in 20 years.

    Still, many people, especially youth, don’t respond to the jobs that are available. Mike Rowe makes a career demonstrating this. Trade foremen complain that they can’t find reliable people that will pass a drug test. Many kids go to college then rule-out higher-paying trade jobs even when they failed to get a technical degree. I once organized a tour of our machine shop and advertised it to a group of 200 young men. The machine shop needed apprentices and said they were having trouble finding them. Only 2 young men showed up. Another young man I know dropped out of college, worked his way up to management at Pete’s coffee. He realized he wouldn’t be able to support a family on this salary, so he’s going back to college for philosophy or something else that won’t pay the bills. “I pay my plumber a fortune and he has more work than he can handle. Why don’t you become a plumber?” I asked him. He scorned this idea. Another guy at work said his friend is desperate to find young men who are willing to learn plumbing and other trades. I told a Baby Boomer father about this opportunity. His youngest son is 20 and not figuring out the workforce. This Baby Boomer said with contempt, “I don’t want my son becoming a plumber.” Now his son is bringing in shopping carts at Costco (and selling and using hard drugs, according to his brother).

    There seems to be a contempt for trade work combined with a lack of work ethic and a lack of available work in industries that have been regulated-away or offshored.

    I compete with a lot of foreign labor in my field. I was the only one of my graduating class that wanted to do what I do. It’s good to know that when the next CEO takes over and starts replacing Americans with Hindus, I’ll be able to find work in the trades.

    1. PRCD,

      “Right. I think the government has stopped counting many unemployed workers, particularly unemployed youth.”

      First, that is a totally bonkers claims. Economic stats are an integrated description of the economy. One part cannot be changed without being inconsistent with the whole. Also, much of the govt data is duplicated by private sources (e.g., ADP payroll data, MIT’s billion price index) — and could not be tinkered with without detection.

      Second, unless it has radically improved in the past five years, Shadowstats is a grossly unreliable source of info. See this about their claim to fame: “real” inflation stats.

  12. It’s a tall order to address and correct the breakdown of the family unit of any race. Fatherless boys whose mothers work, who were never taught right from wrong and who could care less. Unsupervised adolescents mad at the world.
    On the opioids crisis. Certainly, pharmaceutical companies know the number of pills they produce and sell each day and who they distribute them to. How can that many drugs make it to the street? Maybe there are too many Doctors out there prescribing this sh!t (Synthetic heroin) for every ailment that comes along.

    1. Ron,

      “How can that many drugs make it to the street?”

      Because the manufacture allows it. That’s why the FDA fined them. Although, as usual in our grifter state, the fine was a tiny fraction of the profits illegally generated.

      “It’s a tall order to address and correct the breakdown of the family unit of any race.”

      All serious problems are “tall orders.” Every generation faces such challenges. America is a great nation because past generations met their challenges, no matter what the price (and the price was often quite high). But America is a chain, a jewel passed from generation to generation. Only one generation need drop it – and the chain is broken.

  13. Larry,

    “Because the manufacture allows it. That’s why the FDA fined them. Although, as usual in our grifter state, the fine was a tiny fraction of the profits illegally generated.”

    Ok, fix it at the federal level with the AMA and the FBI…And do it soon.

    “All serious problems are “tall orders.” Every generation faces such challenges. America is a great nation because past generations met their challenges, no matter what the price (and the price was often quite high). But America is a chain, a jewel passed from generation to generation. Only one generation need drop it – and the chain is broken.”

    Well, I hope you’re wrong but you may be right. Many problems ahead for us.

    1. Ron,

      “Well, I hope you’re wrong but you may be right.”

      It was a statement about history, not a prediction!

      “Many problems ahead for us.”

      Every generation says that. Ours are smaller than some of the greatest challenges America has faced, such as the civil war, the long depression (1873-1879), the great depression, and WWII.

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