Opioids

What It's Like To Treat Opioid Addiction in Appalachia

Psychiatrist Sally Satel on her eye-opening year at a clinic in Ironton, Ohio

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Why did prescription opioids bring so much misery to the small towns of postindustrial America?

The standard narrative puts the blame on OxyContin, a powerful painkiller supposedly pushed on rural Americans by the profiteers at Purdue Pharma, which ended up filing for bankruptcy and settling criminal charges with the federal government for $8.3 billion. In this telling, the opioid epidemic is a morality tale of capitalism run amok and regulations made toothless by anti-government zealots.

Sally Satel, a practicing psychiatrist who works at a methadone clinic in Washington, D.C., has a more complicated story to tell. In 2018, she moved to Ironton, Ohio, an economically depressed town in Appalachia, where she worked with patients and social service providers. Satel doesn't stint on criticism of drug makers, but she says that the opioid crisis is an outgrowth of a century-old tradition of medicating pain as a way of tending to the broken bodies of the region's laborers.

She stresses that when Purdue's sales force came to small towns in Appalachia, it was "pushing on an open door." While there's no question that OxyContin was a particularly potent painkiller whose potential for abuse was criminally downplayed by its makers, it was merely the latest in a long line of legal and illegal substances used by people in the region to ease physical and psychological suffering. That's one of the reasons that, even after OxyContin was reformulated to reduce abuse and opioid prescriptions declined, overdoses and dysfunction are still commonplace.

Satel also challenges conventional theories of addiction that characterize it as a disease like diabetes or Alzheimer's. Substance abuse, she says, derives from both inborn predilections and a person's environment, or what she calls "dark genies" and "dark horizons." Satel stresses that the best way forward is to give individuals tools to make better use decisions while improving their chances to live lives with open-ended futures.

Satel is a resident scholar at the American Enterprise Institute and co-author of the 2013 book Brainwashed: The Seductive Appeal of Mindless Neuroscience, among other works. She spoke with Reason's Nick Gillespie via Zoom in late December.

Reason: What drew you to rural Ohio, and how long did you stay?

Satel: I was there for a year. I became the only psychiatrist in Lawrence County in southern Ohio. I worked in a clinic, and I ran a group with a wonderful seasoned social worker. I saw patients and found, not to my surprise, that addiction is addiction.

In the inner city, the drug that was available was heroin and, increasingly, fentanyl. By the time I got to Appalachia, heroin had already moved in, but pills still had a presence. There has always been a pill problem in rural America and especially in central Appalachia, where coal mining was huge.

Many people, when they talk about the opioid epidemic in Appalachia, start the clock in 1996, which is when OxyContin was introduced. OxyContin is a long-acting form of oxycodone, which is the actual opioid. But a lot predates that. There had been trafficking of prescription pills for a long time, mainly Percocet, Lortab, Vicodin—all of those are preparations of oxycodone and hydrocodone. They've been very, very popular, and doctors had a fairly low threshold for prescribing them.

OxyContin is extremely potent because it's long-acting. The pill has a lot of oxycodone in it. For example, your average Percocet is 5 to 10 milligrams of oxycodone, but an OxyContin pill can have up to 80 milligrams. The immediate-release pills—the Vicodins and Percocets—are designed to last between three and six hours. If you're dealing with acute pain, that's usually fine. Most people never needed the 30-day [supply] they were given for their tooth extraction or whatever. The appeal of OxyContin is that it was long-acting, so that if you had severe or moderate chronic pain, you had a more steady blood level. You wouldn't have almost mini-withdrawals in between doses. That is a pharmacologically legitimate strategy.

When you chop it up and either snort it or mix it with water and inject it, you're getting an enormous rush. It's pharmaceutical grade, so it's safe in terms of no impurities. But of course, if you don't have tolerance, it's not safe, and you can overdose on that.

What were people being prescribed pain pills for?

Any blue-collar area is going to have a lot of hard-labor jobs. Coal mining is just brutal. Of course, that's not a dominant industry there any longer, but coal mining was unbearably brutal and dangerous. In the 1920s and '30s, many men lived in coal camps, which were owned by the mining companies. The coal camp doctor, who was employed by the company, had to get them into the mines. They medicated them so that they could work. This culture of prescribing for non-cancer chronic pain was endemic to the region even after coal mining disappeared.

What's it like now?

You had communities that were economically imperiled, because there had been a deindustrialization due to globalization or automation. In Ironton, there were jobs; they were just low-paying jobs. There was a great out-migration of what would have been the middle and upper classes, so you're left with a hollowed-out community. The social service layer was huge. Hospitals are often the major employer in these areas. There's a whole layer of people who are struggling, a whole miasma of hopelessness. The drug companies did target Appalachia, and also northern Maine in the Northeast, because they'd been selling there for so long. The drug reps were pushing on an open door.

Most people who are prescribed these drugs use them uneventfully, and that's the end of it. They don't even finish their prescriptions. But there's a problem that they then put the extra in the medicine cabinet, and those end up getting in the wrong hands.

One of the most pernicious myths of the opioid epidemic is that of the accidental addict. The idea that you go to the doctor and he gives you an opioid—not necessarily OxyContin. Only 4 percent of all prescriptions for pain were written for OxyContin, although they were always preferred by people who abused pills.

Overwhelmingly, studies will show that fewer than 1 percent [of users with prescriptions become addicted] is a common finding. You find some that are about 8 percent. The meta-analyses that separated out studies that exclude patients with a history of addiction, or a concurrent problem with depression or anxiety, found these rates of under 1 percent. Patients who are vulnerable are those with a history of addiction, history of alcoholism, or a concurrent problem with either a psychiatric diagnosis or a severe existential problem. You can imagine getting in an accident, having a completely otherwise normal psychiatric history, but the accident is devastating. You've lost your job. You've lost function. It's a deeply depressing and demoralizing and terrifying state, and these drugs are not only good for physical pain, they're excellent for psychic pain. Those are the folks who are vulnerable. Those are the folks we have to watch.

You've found that the bigger problem is with people who were never prescribed these drugs.

Much more often, they're abused by people who were never prescribed them at all. There is a nice graphic from a government agency showing that only 22 percent who misused prescription painkillers got them from a doctor. The average person who abuses these medications knows what they're doing. I ran a group with this wonderful social worker named John, a real Santa Claus of a guy and very seasoned. We'd sit in the group, and sometimes the patients would say, "Well, I wouldn't have gotten in trouble with OxyContin if my doctor didn't prescribe it for me." John would lay back in his seat and say, "I get it. You mean the doctor wrote a prescription that said, 'OxyContin, 40 milligrams, twice a day, chop and snort.' Is that what he wrote?" The folks in the room would laugh. What you really find is that most people who abused prescription medications had abused other drugs before that, and they abused other drugs with their medication.

When you look at toxicology screens of people who have overdosed and died, you rarely find one drug in there. You find alcohol, or Valium-type drugs, benzodiazepines, cocaine, other depressants, which are together more dangerous than either alone.

The truth about addiction is that people seek whatever it is they seek. When your life eventually strikes you as unlivable, these drugs become what I call obliviants. I mean, we call cocaine stimulants and alcohol depressants, but opioids are obliviants. They can numb you. They can make all kinds of distress bearable.

You found there were strong, informal folkways about what drugs were around and how to use them.

Drug information often passes from person to person. It's very grassroots. Before OxyContin, people in Appalachia would chop up Tylox, which is Tylenol and oxycodone. Before that, it was Vicodin. It was other pills—Valiums and Xanaxes. They would be traded for goods or services. But OxyContin became an extremely potent kind of currency.

There had always been doctors that were very free with prescriptions. By no means were all of them lazy Dr. Feelgoods who just wanted cash. I spoke to about 16 physicians who were all in their 60s and 70s, so they really saw the evolution of this problem. They knew that some of their patients would be selling the drugs to make rent or because their husband had just lost his job. They didn't like doing it, but they felt sympathy for these folks. They also knew that there was no pain program to send them to.

How did Medicare and Medicaid help fuel the problem?

OxyContin is quite expensive. It's not generic, and neither were other long-term opioids. They're still on patent and they're quite expensive, but because Medicare paid for it, there was really little motivation for doctors to think twice about [the cost to the patient]. The copayment was almost nothing. Then when you turn around and you can make a dollar a milligram, you can make an enormous amount of money on this.

OxyContin and other prescription pills were vilified to the point where prescriptions for them declined. How did heroin and fentanyl come in to fill the void?

Pill prescribing peaked around 2010–2011. OxyContin was reformulated so it couldn't be chopped up. Pill mills were really clamped down on, and prescription monitoring programs became more stringent. Doctors were getting much wiser to the fact that we were over-prescribing.

As pills became less available to people who abused them, heroin was there. You start to see the rise of heroin in 2010. It was always waiting in the wings. People will use what's available and what's inexpensive, and that was heroin. Around 2014, you can see just a sweep up into the stratosphere of deaths that are attributable to fentanyl, which is about 100 times as powerful as morphine. If you have a surgery, when you wake up with a drip in your arm that you get to actually control through a button, it's likely going to be fentanyl—it's excellent. And fentanyl patches are extremely effective. It's long-acting, so people would cut them out [of the bandage]. If you're interested in abuse, you don't want something long-acting. You want something short-acting. You could slice open the fentanyl and suck it out.

That's a sign of desperation. People would dive into dumpsters outside of nursing homes, and there was that whole culture of if your loved one died of cancer, don't mention that in the obituary because that'll put a red flag on your house that you've got a lot of pills there.

What are the specific numbers involved for regular users?

About 2 million people are estimated to use, abuse, or misuse pills. It is so hard to get a measure of heroin. It'll be maybe half a million or less when you look at government statistics. I don't think there has been an increase in people using opioids for the past few years; it's more of an overdose phenomenon, because the drug used now, fentanyl, is just so powerful.

Is there actually more despair in various parts of the country than there was 50 or 100 years ago? Or are deaths increasing because we have access to more powerful drugs that might kill us?

That's too difficult to answer. Suicides are going up. A death is a death, and coroners could still make mistakes about identifying suicides, but it's a little more clear than arguing over whether there's more depression or not, because now people are culturally more comfortable with coming forward.

More people are dying at their own hands. It might be that the mode of self-medication is more dangerous, but it also does seem that more people are looking to escape.

Some of my patients were young people who were fourth-generation [substance abusers], where the grandfather or the great-grandfather lost the job at the factory in the '60s. He always drank too much and maybe was a little rough with the wife. When he lost it, he started drinking more, and domestic violence really became an issue. By the fourth generation, there's too much dysfunction handed down for too long, and you've got people who are not well-educated and don't see much promise.

You have families that don't work. That kind of discipline is not internalized of having to be somewhere, of being responsible. How to delay gratification, how to control impulses, how to develop trust, how to have relationships—that kind of development really gets derailed. You have people with a triple whammy: They live in environments where the boredom is crushing, their future doesn't look very bright, and they don't have these inner strengths. It's easy to understand why these substances have appeal.

You've written that you are "hesitant to call addiction a disease," especially a "disease of the brain." Yet addiction, or at least serious substance abuse, seems to be at or near the center of the opioid epidemic.

I prefer calling addiction a symptom rather than a disease. I'm not going to argue with someone, especially someone in recovery, who conceptualizes their problem as a disease. Whatever works for them. But from a conceptual standpoint, I do have a significant problem with the disease model, especially with the formulation of brain disease.

This is something that the National Institutes of Health has been pushing since 1995. I understand why that has appeal, because the more you medicalize something, the theory goes, the more you take it out of the realm of the criminal justice arena, the less you think in terms of punitive responses, and the more you think about therapy and funding for treatment and funding for research. It's an anti-stigma kind of strategy. I appreciate that and I like those ends. I just don't feel that they're accomplished well by reducing one of the most complex behaviors to a slice of brain tissue. I'm not going to deny any of the neurobiological facts or the very dramatic and eye-catching brain scans that they use—of course the brain has changed in addiction. So that's all true. But the point is the brain isn't changed to the point where a person can no longer make decisions.

If my choices are saying addiction is a disease vs. it's a sin or it's a crime or it's evidence of moral failing, well, damn, I'm going to pick disease. But it's a condition, a behavioral phenomenon that responds to contingencies, that responds to consequences, and that people engage in for -reasons.

In Ironton and D.C., there's not one patient who walked into a clinic and didn't say that they were there because their wife was going to leave them, their boss is going to fire them, their probation officer is going to punish them, or their kid's going to hate them. The point is they're responding to something in their environment. If I had Alzheimer's disease, which is to me a classic brain pathology, it wouldn't matter what was going on in the environment or in my cognition or in my view of myself.

If you talk to someone who drinks too much or uses drugs too much—and I emphasize the too much, because that's the problem—I'd say to them, "Why are you doing that? What's going on?" That question makes sense. That question can be answered in existential terms. If I said to a person with Alzheimer's disease, "Why do you have Alzheimer's disease?" maybe they'll talk to me about [brain] plaques and tangles and neural pathology. The answer doesn't come in the form of existential language. That's very important, because that goes to why people use and how we get them out of it.

The vast majority of pill abusers were not prescribed the medication by their physicians. Instead, they were mostly individuals who were already involved with drugs or alcohol. OxyContin, fentanyl, and heroin are all powerful drugs, but their use is building on an existing problem. How does that insight influence treatment?

Most people stop on their own, which is another thing that is not well known. Start with a hundred people who just try heroin or cocaine for the first time. Half of them are going to just go, "What's the big deal?" A smaller fraction of the other half is going to say, "Wow, this is really good." What is it about one person's brain that finds this drug more rewarding than the other person?

Let's focus on the group that found it rewarding, intensely pleasurable. They say, "That was really good. Give me more." Some of them are going to go home and the spouse is going to say, "Where the hell were you? What's happening to the money? Why didn't you come to Timmy's baseball game?" They're going to say, "Oh, wait a minute, wait a minute. What am I doing?" They stop, and that's the end of it.

You get a smaller and smaller population of people who think, "You know, this is costing me, but I'm so unhappy that this kind of relief, which was great at the beginning and has now cost me a lot, is still worth it." You have a person who has basically two layers of anguish. First, they have that genie that made drugs attractive to them in the first place, so that was always a baseline misery. Now they have a second layer that they've accrued: Maybe they've gotten hepatitis, maybe they've lost their job, maybe their wife is going to divorce them, maybe they just hate themselves because of all the people they've disappointed, and that makes the drugs even more appealing.

It's a very, very hard cycle to stop, but there's the example of the woman I met in Ironton and I wrote about. She ran out of pills, really wanted them, went to her friend's house because she thought her friend would give her some. The friend wasn't there, but her gross boyfriend was. He said, "I'll give you those pills." The young woman was already starting to develop withdrawal symptoms. If you want to talk about brain scans, her brain was probably on fire at that moment, and the guy said, "Here are the pills, but I'm going to expect something from you." And that was an unsavory act.

The woman got help the next day. Some people don't even get help. They just stop the next day, and you can't really predict who's going to respond to what.

I've seen people who come in and you think, "My God, haven't you hit bottom enough?" Yet it's that next time that does it. The problem with fentanyl is it's very dangerous to keep waiting for that next time. That's where harm reduction comes in, with Narcan [a drug that reverses opioid overdoses], where you can at least keep people alive until they make a decision or until they're arrested. I have to say that coerced [court-ordered] treatment can work. The addicts ultimately have to internalize the values of the treatment system, because it's not like pneumonia, where you can be in a coma and I can give you a penicillin IV and you'll wake up cured. You have to be motivated, but that motivation can actually come to people even when they're in a coerced setting.

You're an M.D. and a psychiatrist. Over the past 30 or 40 years, do you think we've made progress in understanding and treating addiction?

The more we medicalize this problem, the more we're going to be misled, the more we're going to put emphasis on medications—the methadones, the buprenorphines, the naltrexones. I'm all in favor of those medications, because they help people stand still. If you're craving, you're never going to make the first step toward stopping. I'm all for the medications, but to think that could possibly be enough strikes me as incredibly naive. The National Institute on Drug Abuse, ironically and to its credit, funds lots of [treatment] research, but they don't talk about that. Instead, they show brain scans and talk about addiction as "a disease like any other," which of course it's not. When you go to a place like Ironton, you can see how medicine and even public health are necessary but not at all sufficient. What do you do when you finally do get somebody sober but they're in an environment that doesn't appear to offer much?

There are lots of different crosscurrents here. Maybe because the pill problem is mainly a white problem, it has been treated with more understanding and compassion and seen in a broader light as a response to circumstances. That's a positive thing, but it goes beyond medicine. People drop out of treatment at enormous rates. Fewer than 60 percent will still be in a treatment program at the end of the year. I can tell you that very few people came into our methadone clinic and were able to be just fine with their first or second or third dose of methadone. If your problem was simply withdrawal, if it was simply physiological instability, then we should have been able to fix you with a medication. Of course, we didn't, but we helped you stand still, and if you were motivated, we could really help you.

Talk a bit more about the perils of medicalizing behaviors.

I have two thoughts: The first is that it can be problematic even in the clinic, let alone in society more broadly. I worked in an urgent care clinic in D.C. It was connected with the criminal justice system, and I would see people who were awaiting trial. The judge would say, "Well, we sent him to you because he cried" or "We sent him to you because he was once on a medication in jail." So many were not happy people—they had a lot of problems with making good decisions and with controlling their impulses—but they weren't mentally ill in a classic way, and they weren't people who were going to be responsive to medication. They needed help, but not in the domain of psychiatry.

The second thing is that we don't medicalize some problems enough. We've underserved and ignored people with schizophrenia, and that is a huge blight on our society. Rikers Island and L.A. County Jail and Cook County Jail are the biggest psychiatric facilities in the country. We criminalize severely mentally ill people. On the one hand, we over-medicalize, and on the other, we have people with real brain diseases and we don't pay enough attention to them.

Do you think we've become more psychologically sophisticated or astute as a society over the past half-century?

I think in terms of people who have the wherewithal or the financial means to do creative things with psychedelics, that's a very interesting development. I don't mean they should run off and experiment on their own at all, but research into that is so important. But there's also a lot of unhelpful pop psychology, which is the whole field of trauma. I don't want to diminish the life-altering impact of child abuse and devastating things that happen to people, but people are looking for explanatory systems and exoneration. The trauma field, which consists of the most brilliant psychiatrists and psychologists I know and the most two-bit counselors, is often reduced to a system of: This happened to you, it's horrible, and it's ruined your life. You can't do anything about it, and you should forever stew in the resentment of what was done to you.

Have we become too dependent on pills?

I'm not blaming pharmaceutical companies, God bless them. They make wonderful, life-saving medications for many people. But a lot of the time the message looks like, "If I just had this pill, everything would be fine." Sometimes, a pill does make a massive difference, but usually so much other work needs to be done as well that the fantasy of a magic bullet doesn't help.

This interview has been edited for clarity and style. To listen to the full version, subscribe to The Reason Interview With Nick Gillespie.

NEXT: Brickbat: Fiery Talk

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  1. But being black is supposedly the worst possible thing in America.

    1. I would argue that being a Jew in America is worse because we experience anti-Semitism from white supremacists and black supremacists. Unfortunately, the mainstream media does a terrible job of covering the endemic anti-Semitism in the black community. Shvartze goyim will happily blame all of their misfortunes on the Jewish people because they are fed lies by anti-Semitic losers, like members of the Nation of Islam.

      1. Is it because The media is run by self hating jews?

        1. I’m tired of the common anti-Semitic trope that Jews somehow control society at large. We’re just hardworking people and we know what is best for you Goyim. Take as an example Michael Bloomberg. Can your average Goy really know what size soda is most appropriate for his blood sugar levels and BMI? No and I have no problem with the government making that decision for him.

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    3. Actually, the Native Americans (or American Indians), are at the very bottom of the list here in the United States. They’re far worse off than even the Blacks and Hispanics here in this country.

  2. Interviewer questions not italicized or anything. It’s literally killing me.

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  3. How long has the human population had such a large portion of dysfunctional people?

    Do wild chimps have large numbers of depressed monkeys? Did many early humans sit around and try to avoid life? Is wide-spread chronic depression a modern phenomenon?

    1. Who cares? If some Goyim are too dumb to work in the tech fields, we can import new engineers from China and India with the H1B visa system. And if the American Goyim are too drugged up on opioids, we can replace them with cheap laborers from Latin America. Who cares about the American people when you can just import more Americans. The most important thing in our society is driving growth in the economy and we drive that growth by increasing demand with an unlimited and unrestricted immigration policy.

      1. If you could no longer find a plumber, have a house built, get your AC repaired or your vehicle serviced you would learn the difference between essential and non-essential. If there was no space exploration or automation or the other achievements by hi-tech people would not even miss it. If your toilet stops up and you can’t get it flowing, your AC breaks and it is 100 degrees or you can’t find a house to live in you would miss it badly. Maybe your value system is a bit skewed.

        1. None of those things you mentioned are “essential “. We lived without AC and toilets for thousands of years, and we will do so again. Probably soon.

          1. Actually, no we didn’t live without air conditioning or toilets. It’s just that no one had the knowledge or sense to know from heat-stroke and from e coli-bourne disease.

          2. Oh, come on now! If the above-mentioned things aren’t essential, then I don’t know what they are. It’s important to be able to find a plumber, get your A/C repaired or replaced if necessary,

        2. Actually, what you’re using right now is high-tech and partially dependent on space technology, as is the smartphone used to Call Roto-Rooter and Mister Sparky. Also, all of those fields you mentioned are vastly improved with electronics. Think laser-levels, electronic thermostats, pipe snakes with mini-cams, etc. as well as online learning to grasp it.

      2. And I guess you think it’s all Heaven-sent? I guess Yeshiva is proof that you don’t need opioids to nod off your noggin.

      3. You’re getting a little out of line there, RabbiHarveyWeinstein. Your attitude is not helping the situation at all. I don’t think that constantly having undocumented or illegal immigrants cross over into the United States is the answer, but the trouble is that the United States has made a lot of these countries uninhabitable for these people by supporting really repressive governments. We should also help regular Americans find work, and get an education, as well.

    2. This study from Canada did not find a difference from 1952, 1970 and 1992.

      https://jamanetwork.com/journals/jamapsychiatry/fullarticle/481578

      However others say that it is on the increase.

      1. How about compared to 100, 200, or even 500 years ago (or between different modern cultures)?

        I just wonder if our modern societies have induced higher rates of depression and other psychological problems, and how. Maybe even dramatic modern decreases in mortality?

        1. I bet there was a lot of depression and anxiety among the Carthaginians after Carthage fell.
          And the survivors were dragged off in chains as slaves.
          Might have been some anxiety after the Romans took a lot of Carthaginian children as hostages the year before.
          Probably a lot of anxiety and depression among the Goths when the Huns pushed them across the Rhine and the Romans took their children as slaves in exchange for dog meat to eat.
          Probably a lot of anxiety among the citizens of Byzantium when the Arabs showed with cannon.
          And that whole Black Death probably caused more than a little anxiety among the population.
          Maybe some depression, too.
          Every single cut or even a thorn caused anxiety before antibiotics.
          And worrying about pirates, brigands and wild animals caused anxiety among travelers.
          So, lots of anxiety and depression in the ancient world

          1. As Paul Harvey always observed: “The ‘Good Old Days’…weren’t…Always…Good!”

        2. Perhaps. It certainly has been around since ancient times.

          Psalm 40:1-2
          I waited patiently for the LORD to help me, and he turned to me and heard my cry. He lifted me out of the pit of despair, out of the mud and the mire. He set my feet on solid ground and steadied me as I walked along.

          1. I always think G-d already has plenty enough to do & you should endeavor to help yourself

            1. I say God does not exist and one should still endeavor to help one’s self. *Tips fedora!*

        3. There’s no accurate data, obviously, but they used to call it “melancholia” and blamed it on an imbalance of humors. So it’s been around enough to be a recognized social category for a long, long time.

          1. blamed it on an imbalance of humors

            Now, of course, we’re Enlightened and we know that it’s an imbalance of hormones.

            1. No, it’s an imbalance of outcomes.

    3. I’ve asked myself this a lot. Up until relatively recently in human history people who were too stupid or weak to live pretty much didn’t.

      Now modern technology and medicine and the welfare state not only keeps these individuals alive, they have the most children .

      I’ve accepted in the past few years that there is no more likely outcome for society then for it to collapse under its own crushing weight…I suppose there’s victory in that

    4. Eh, for a lot of human history, people were drunk most of the time. It was usually safer than drinking water

    5. Being offended by everything is no doubt a widespread modern phenomenon and seems to lead to chronic depression that can only be relieved by protesting and rioting.

    6. I dunno. Ask the people of Salem who were stoned on molded, spoiled rye bread, or people in Europe who had mass manias wher they danced and danced for days at a time until they died in countless different ways, or any number of peoples who were blitzed on psylosybin. At least now, we can identify such things and react better.

  4. I bet the docs can get paid in some awsome moonshine

  5. “How did Medicare and Medicaid help fuel the problem?

    —-Nick Gillespie

    We should be talking about the expansion of Medicaid under ObamaCare specifically.

    Premise One: The overwhelming majority of addicts sourced their opioids from a legal prescription–either their own or someone else’s.

    Premise Two: Those who were poor enough to qualify for Medicaid were far more likely to become opioid addicts than the average person with an average income.

    Conclusion: Suddenly making millions of poor people eligible for a free supply of opioids and a free doctor’s appointment to get a prescription was sure to create an opioid crisis in these Appalachian coal mining communities.

    You can find studies that show Medicaid funding for opioid treatment will help ease some of the damage from the fire, but we really should account for how the Obamacare Medicaid expansion spread the wildfire in the first place. If and when we see the Biden administration push through something like Medicare for All, we should expect to see another big wave of opioid addiction for the same reasons.

    1. Opioids would be cheap and affordable if they were legal and users would be free to quit or continue using as they see fit.

      1. They were both legal and easily available. That’s the point of Ken’s post:

        Suddenly making millions of poor people eligible for a free supply of opioids and a free doctor’s appointment to get a prescription

      2. I can understand the view that adults should be allowed to take any chemical they wish. But from a societal point of view, they are destroying their own lives and those of their families. Then they are passing those costs to the rest of us.
        We are not capable as a society of allowing people to fully face the consequences of their actions. I’m not sure that will ever happen.
        So, how much do we intervene in their lives? A tough question without easy answers.

        1. There are thousands of people that have chronic pain that were taking pain pills everyday which they needed to work and function. They were not doing it for the high but to take enough of the edge off of the pain they could deal with it. When the government stepped in doctors became worried about prescribing and left these people to fend for themselves. Many went to pain management doctors that wanted to give them shots of different steroids or other drugs that would cause worse damage over time if they wanted to get a prescription. If they went to a few different doctors looking to get a prescription to allow them to live normally they were called doctor shopping and cut off.
          Any time the government gets involved it makes it worse.
          Most people have worked with or around people like that and never knew the difference.

        2. That’s because we live in a society that encourages people not to take responsibility for their actions and behaviors. Shouldn’t a person who mugs, rob, seriously injures or possibly kills a person in order to get money for a fix be forced to suffer the consequences?

  6. First of all, italics notwithstanding, this is a great interview.

    [B]ecause the more you medicalize something…the more you think about therapy and funding for treatment and funding for research. It’s an anti-stigma kind of strategy.

    It’s a racket. From top to bottom. From the drug war to the prison industrial complex to the welfare state it is a system that needs fuel, and inner city blacks and hillbilly whites are cheap and disposable.

    There is no malum in se in consuming intoxicants. Not for any reason, from pain relief to coping to gratification. And until we recognize that the government has neither the moral nor the constitutional authority to try to prevent individuals from doing so, nothing will change.

    1. I’m with you here too. And genetically modify drug plants so they kill pain without killing people.

      Oh, and the more they automate coal mining, the fewer deaths from brown lung, black lung, asthma, emphysema, lung cancer, and mine cave-ins. Let miners play with Radio-Controlled borers then come home and play with model rockets with their own Homer Hickam sons and daughters.

  7. While there’s no question that OxyContin was a particularly potent painkiller whose potential for abuse was criminally downplayed by its makers

    I would like to thank the Perdue Pharma criminal syndicate for providing me with the oxycontin that got me through the first few days of my back injury.

  8. Purdue Pharma, which ended up filing for bankruptcy and settling criminal charges with the federal government for $8.3 billion.

    So Corporations are people.

  9. “of course the brain has changed in addiction. So that’s all true. But the point is the brain isn’t changed to the point where a person can no longer make decisions.”

    And this is the biggest problem that I have seen. Whether tobacco, heroin or nachos – the problem is the same. People need help, but they must decide to get it and have the discipline to receive it and live it. That can be a tall order for many people.

    1. I’ll go for the nachos. Nobody ever bit off a cashier’s head or sold themselves or robbed people for them.

  10. You’ve written that you are “hesitant to call addiction a disease,” especially a “disease of the brain.” Yet addiction, or at least serious substance abuse, seems to be at or near the center of the opioid epidemic.

    You aren’t sure whether to classify tomatoes as fruits. Yet they’re very popular to eat.

    Can you at least try to make the questions seem to make sense? Even when they’re not actually questions?

    1. Yet they’re very popular to eat.

  11. Most people stop on their own, which is another thing that is not well known.

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