Sally Satel: The Secret History of the Opioid Epidemic

The story of why pain relievers took root in Appalachia begins decades before the introduction of OxyContin.


Why did prescription opioids bring so much misery, addiction, and death to the small towns of post-industrial America? The media's standard narrative focuses on the role played by OxyContin, a powerful painkiller supposedly foisted on helpless rubes and naive doctors by cynical profiteers at Purdue Pharma, whose executives have already pleaded guilty to a number of crimes. In this telling, the opioid epidemic is a morality tale of capitalism run amok, regulation made toothless by anti-government zealots, and uneducated populations left behind by the knowledge economy.

Sally Satel has a vastly different, more complicated, and more accurate story to tell. She's a practicing psychiatrist who specializes in substance abuse, the author of a series of books on health care issues, and a resident scholar at the American Enterprise Institute in Washington, D.C. In 2018, she moved to Ironton, Ohio, a small, economically depressed town in Appalachian Ohio, and worked with patients and social service providers to better understand how opioids, heroin, and fentanyl became drugs of choice for people in a part of the country that have been using all manner of substances—from moonshine to marijuana to earlier versions of opioids—to escape both brutally demanding physical labor and the absence of jobs for decades if not centuries.

"The story of why pain relievers took root in Appalachia actually begins decades before the introduction of OxyContin," says Satel, and simply clamping down on prescriptions for painkillers will not only fail to solve the problem in places like Ironton, it will consign thousands of chronic-pain sufferers to excruciating discomfort.

In a conversation with Nick Gillespie, Satel explains what the standard narrative of the opioid epidemic gets wrong and discusses her heterodox theories of addiction that are laid out in her article "Dark Genies, Dark Horizons: The Riddle of Addiction," which appears in the new issue of Liberties: A Journal of Politics and Culture. "Despite popular rhetoric," she says, "addiction is not a 'disease like any other'" but a deeply human condition.

Audio production by Ian Keyser.