Opioids

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.

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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.

NEXT: Government by 'Harrison Bergeron'

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  3. WTF would liberaltarians care I mean more people are taking drugs and also lots of manufacturing moved away so companies could profit a few pennies per share. That’s like billions to a few very rich people.

    That is the dream or has all your writing been for nought.

    1. That’s like billions to a few very rich people.

      Or to tens of millions of people who invest in these companies through their 401k, pension or investment portfolios.

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  4. I’m sure that the opioid epidemic had deeper roots than ObamaCare, but the most proximate cause of the opioid epidemic was the expansion of Medicaid under ObamaCare.

    I’ll break the argument down point by point.

    Premise 1)

    More than 75% of opioid addicts, during the explosion of the epidemic, obtained their drugs either from a prescription themselves or–for free–from a family member or friend who had a prescription.

    Only about 4% of opioid addicts bought their drugs from a dealer.

    —-Department of Health and Human Services

    http://tinyurl.com/ybhy8d94

    Premise 2)

    People who made less than $20,000 a year were 3.4 times more likely to become addicted to opioids than people who earned $50,000 per year or more.

    —-Center for Disease Control (Link to follow).

    Conclusion):

    The people of Appalachia were disproportionately represented among those who made less than $20,000 a year at the time, and, thus, were disproportionately represented among those who were both eligible for the the Medicaid expansion under ObamaCare and were 3.5 times more likely to become addicted to opioids. The fact that 75% of opioid addicts at the time were obtaining their drugs through a prescription further underscores the point that making these people eligible for Medicaid was building a superhighway to addiction.

    We should keep this in mind when we hear Democrats tout further Medicaid expansion (or Medicare for All) as part of the solution to problems like opioid addiction. Repealing the ObamaCare Medicaid expansion won’t do anything for those who are already addicted, but it will cut down the rate of new addicts. Meanwhile, flooding a low income community with free access to opioids by expanding Medicaid further (or Medicare for All) is just throwing kerosene on the fire.

    Only progressive “intellectuals”, like the ones in the Obama administration, could flood a low income region of the country with an entitlement program for free opioids and wonder why there was an explosion in opioid addiction.

      1. To me, that CDC info graphic, to the extent it says anything at all about the “opioid” crisis, says that the problem isn’t prescription opioids.

        1. Care to elaborate?

          To the extent that people without private insurance or Medicaid end up addicted to heroin, specifically, that’s to be expected, especially if they don’t have access to free prescription opioids through Medicaid. Addicts often turn to the black market when they lose their coverage.

          Meanwhile, note (from the CDC stats) that people on prescription opioids were 40 times more likely to be heroin addicts. Pair that with the observation from the DHS stats that say 75% of opioid addicts obtained their drugs through a legal prescription–either their own or through friends and family who had a prescription–and it isn’t hard to see why the stats went up for people with lower incomes, even those who didn’t have their own Medicaid coverage, too.

          In other words, as millions of people became eligible for Medicaid financed opioids across Appalachia, it wasn’t just the people on the program who became addicts. You flood the region with free opioids, and people who aren’t on the program will become addicted, too. It isn’t being on the program that makes people opioid addicts. It’s taking the opioids. When you flood the region with free opioids, people become addicts when they take them regardless of whether it’s them or their friends and family who are on Medicaid.

          1. This issue is very complex

            Opioid prescriptions and doses rose significantly in the US from 1990 to 2010 (due to aggressive marketing by pain pill manufacturers, including Perdue).

            But in 2010, FDA changed regs on opioid pills to make them ineffective for opioid maintenance, which prompted hundreds of thousands (perhaps millions) of opioid addicts to switch to street heroin (much of which is laced with deadly fentanyl), which caused heroin overdoses to skyrocket.

            The best libertarian, human rights, and harm reduction solutions (to the heroin/fentanyl overdose epidemic) include:
            – allow and increase methadone access for all opioid addicts,
            – FDA should allow/approve other prescription opioids for long term use for documented addicts (to prevent them from using herion), and subsequently
            – decriminalize opioids and opioid use

            1. “Opioid prescriptions and doses rose significantly in the US from 1990 to 2010 (due to aggressive marketing by pain pill manufacturers, including Perdue).”

              The reason pharmaceutical companies market to consumers is because it works. When consumers ask their doctors about a prescription by name, their doctors are more likely to prescribe them that medication.

              However, I do not believe opioids were marketed directly to consumers, and patients weren’t about to ask doctors they couldn’t afford to go see for prescriptions they couldn’t afford to buy. The primary driver of this and every market is price signals.

              People were signing up for free doctor’s visits and free opioids because they were free–courtesy of the taxpayer by way of Medicaid anyway. Flooding the market with free opioids from free doctors’ visits would have resulted in higher addiction rates regardless of other factors.

              I agree that the solutions to existing addicts has little or nothing to do with law enforcement. I maintain that if the Biden administration expands Medicaid again or introduces Medicare for All, we should expect to see the rate of addiction increase dramatically again.

          2. P.S. If they had flooded the region with free beer through an entitlement program for people with low incomes, the origin of the resulting uptick in beer consumption would also not have been mysterious.

            There are other factors at play–low income people are more susceptible to addiction and alcoholism for all sorts of reasons, and Appalachia has all sorts of economic, historical, and other factors playing into that poverty. Regardless, there’s this thing called moral hazard, and it eats good intentions for breakfast. We really shouldn’t ignore that.

            Here’s a story about how Medicaid expansion apparently lowers the mortality rate associated with overdoses.

            https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2758476

            Doesn’t say a goddamn thing about the increase in addiction rates associated with giving low income people free access to prescription opioids. I suspect it’s just not a fashionable topic for polite conversation. Ever read “Heart of Darkness” in college? I bet that isn’t a fashionable book in survey of literature classes anymore either. Maybe you saw Apocalypse Now? Anyway, turns out that the good intentions of progressives can be an enormous source of pain and agony in the world. Appalachia almost certainly would have been better off without them.

            Pushers and pimps notoriously will give people their first shot of heroin for free. Their intentions aren’t as good as the progressives were when they wanted to expand Medicaid, but if the end result is the same, what difference does it make? The country is still full of more addicts than there were before anyway.

            Couple those “good” intentions, in the abstract, with the contempt even average progressives have for the real people of Appalachia, their manners, and their culture, and there’s a good case to make that progressives really are America’s most horrible people. I think the smugness is just a defense mechanism to help them sleep at night.

            1. I live in Pittsburgh, and have been advocating methadone clinics for three decades, as that lets chronic addicts get a safe daily dosage while otherwise living a normal life.

              But anti drug groups and NIMBY residents who “don’t want drug dealers and addicts in our neighborhood” have opposed opening methadone clinics (while abstinence only drug treatment centers oppose methadone because they oppose harm reduction).

              During the past decade, very few politicians or public health officials (who denounced the opioid epidemic) have advocated (or proposed expanding) methadone clinics (or other harm reduction alternatives for chronic addicts).

              Meanwhile, we continue reading daily obituaries for people under 50 who died “suddenly” or “unexpectedly”, although some of those are suicides.

              1. Back in 1999, I met with and urged an Assistant PA Attorney General to sue Perdue Pharma (for causing many opioid addictions via fraudulent marketing). But it took more than another decade before current PA AG Shapiro sued Perdue, and they are in the process of settling the multi state litigation.

            2. low income people are more susceptible to addiction and alcoholism for all sorts of reasons

              No, just one reason: Drugs will get you thru times of no money better than money will get you thru times of no drugs.

            3. “Maybe you saw Apocalypse Now? Anyway, turns out that the good intentions of progressives can be an enormous source of pain and agony in the world. Appalachia almost certainly would have been better off without them.”

              Problem is, people in Appalachia actually support progressive policies. Anything that FDR/LBJ did- i.e. socialism- is very popular in that region, especially in West Virginia. Only thing stopping most of them from voting Dem is their social conservatism; if the Dems went all socon all of a sudden that would change right quick.

              Same goes for ACA/Obamacare. They’re fine with the actual ACA and its contents, they just don’t like Obama or like calling it Obamacare. 😉

              1. People becoming dependent on government programs that are harming them in various ways is a common feature of a lot of government programs. The solution to that problem may not depend on the popularity of those programs with the people who are “benefiting” from them but, rather, may depend on the killing the support of the people who are funding these programs.

                In “Heart of Darkness”, the bleeding heart abolitionists of London were funding the excursions into Africa to end the slave trade at its source. The problem with that “solution” was, it turned out, that ending the slave trade at its source necessitated extreme brutality that the well-meaning liberals of London could hardly imagine. The cure not only didn’t work but also was in some ways worse than the disease. When this was translated into the Vietnam War for Apocalypse Now, it was the same thing. Turning the jungle tribes of Cambodia on to American style democracy required the imposition of terror, brutality, and slaughter far beyond what the well-meaning supporters of the war of liberation back home (and in the command structure) were willing to accept. In fact, we wouldn’t have been there inflicting that brutality on the people at all if it weren’t for the “good” intentions of the liberals back home and their war of liberation.

                It was the same thing with the Drug War back when Daryl Gates was using military tactics in the Drug War, instituting the first SWAT teams and even using a tank to destroy crack houses while “serving a warrant”. The Drug War has finally become unpopular among progressives now, but liberals at the time genuinely supported saving the African-American community with an army of police to liberate them from drugs and gangs, back then, with the best of intentions. That pro-Drug War narrative survived the Rodney King riots by a long shot. Until recently, the left was still far more likely to blame police brutality on bad apples in the department rather than on the Drug War itself. How could progressives be so wrong when their intentions were so good?!

                Same thing with Medicaid expansion and the opioid crisis in Appalachia. It isn’t the local support among the poor for the programs they depend on that’s the ultimate cause of the problem. The ultimate cause of the problem is the “good” intentions of the people who finance the program–like the progressives of suburban America who support these programs with their taxes with the understanding that they’re helping people who are worse off than themselves. The road to hell is paved with good intentions.

                The victims of imperialism in Africa might have been better off without the brutal efforts of well-intended abolitionists. The people of Cambodia might have been better off without the well-meaning efforts of a U.S. war of liberation. The African-American community of southcentral Los Angeles might have been better off without a police state perpetrating the Drug War and fighting against gangs. I remember when we bombed, invaded, and occupied Iraq for the good of the Iraqis, but I still don’t know that the people of Iraq are or should be grateful for our efforts. And, yeah, the good intentions of progressives may be ultimately to blame for expanding Medicaid and setting off an opioid crisis in Appalachia. It is often the case that trying to solve other people’s problems for them is the proximate cause of so much misery, and the solution appears to have something to do with taxpayers caring more about their own money than solving other people’s problems for them.

                Or maybe it’s about using the government to try to solve these problems as a substitute for personal involvement. The world isn’t a worse place because people who care volunteer and raise money from willing donors to address people’s problems. But government programs mostly just make us feel like we’re doing something important through forced sacrifice. That religious kind of forced sacrifice makes certain people, especially progressives, feel good about what they’re doing–even if what they’re doing is hurting people. In fact, the more dramatic the effect of their actions, the more they feel like they’re doing something important. The world would be a better place if those frenzied progressives were more selfish and less concerned about others.

                1. Ken, you should write for Reason. Good post.

                  1. He does, he just doesn’t get paid for it. We all do, and don’t.

                  2. Ken don’t do narrative. So, while he is free to contribute, he will never get paid.

            4. GET YOUR GOVERNMENT HANDS OFF MY MEDICARE LEFTIES

    1. She did talk about Medicaid as contributory to the problem, but didn’t finger that particular expansion.

      1. Blaming people for their good intentions never plays well until long after the fact–when the negative consequences of their good intentions become abundantly clear. Why wait for that when people’s lives are being ruined?

        The people who supported Chavez nationalizing grocery stores and food distribution did so with the best of intentions. It just seemed like their intentions were evil to those of us who knew that would result in food shortages. But when we called them out as evil at the time, they thought we were being mean, outrageous, and extremely rude. They knew they weren’t evil. They knew they had the best of intentions.

        The Trump administration called the Green New Deal an insane plot to destroy the American economy. So rude! Doesn’t he know its supporters have the best of intentions?

        That doesn’t play well in polite society.

        The freedom to be offensive is really important. There’s a Cassandra effect to offending people’s good intentions, but I don’t know that you can criticize their good intentions without having that effect. Not everyone has the stomach for it, but when people’s good intentions are the proximate source of misery, they really do need to be excoriated for it–and the sooner they get it, the better.

        1. I’ve offered to solve particular problems for people who didn’t realize what they had was a problem, and they just tend to get defensive about it. It’s a paradox: To motivate them to make change, they have to be shown that what they’ve created is flawed; but showing them that what they’ve created is flawed disinclines them to take the critic’s advice on fixing it, because it’s an insult. I have a friend who’s seen that happen in his business too; what he told a potential client was wrong did come to pass exactly as he’d foretold, costing them enormously, but they’d turned away his offer to fix it when they could have.

  5. I’m wondering when personal responsibility comes into play when it comes to your health or the health of a loved one that you may be responsible for and the ability to ask questions, if you really care about your well-being, to protect yourself from money hungry doctors?

  6. The problem started when we disconnected productivity from wages due to Nixon’s moronic monetary decision to detach from gold. Deficit spending demanded a way to offshore the inflation and have someone buy the new debt..viola..China…of course that meant the destruction of our manufacturing base and devastation of small towns/cities (drive around western and central NY and see abandoned factories by the thousands)….replaced by dollar stores…and you wonder why these folks drugged themselves. DC/Coastal Woke Elites did this and should be held responsible. Solutions are possible but that would need the overthrow of the elites..

  7. SleepyJoe will use his giant brain to solve this problem.

    1. Go fuck yourself lefty Sleepy Creepy Joe Biden’s brain will NEVER be as big as Trump’s!!!

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  9. Been living, and working in healthcare, in Appalachia for over a dozen years now. It is indeed a pill popping culture in comparison to many other places I’ve lived. While Mamaw now knows that Oxy is the Devil sent to destroy she says the ‘nerve pill’ she’s been taking for the last three decades is nothing to worry about.

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