Opioids

What Drug Warriors Got Wrong About the Opioid Epidemic

The original formulation of OxyContin didn’t create the opioid crisis, argues psychiatrist Sally Satel, and removing it from the market didn’t make the problem go away.

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Why did prescription opioids bring so much misery to the small towns of post-industrial America?

The standard narrative is to put the blame on OxyContin, a powerful painkiller pushed on rural America 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 regulation made toothless by anti-government zealots.

Sally Satel, a practicing psychiatrist and resident scholar at the American Enterprise Institute, has a more complicated story to tell. In 2018, she moved to Ironton, Ohio, a small, economically depressed town in Appalachia. With the help of Hillbilly Elegy author J.D. Vance, she found a job working with patients and social service providers to better understand the opioid epidemic. Satel says that the opioid crisis didn't start with OxyContin. It was a natural 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 the Purdue sales force came to small towns in Appalachia, it was pushing on open clinic doors." While there's no question that OxyContin was a particularly potent painkiller, 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 why 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, which typically characterize addiction as a disease like diabetes or Alzheimer's. That narrative denies the agency of individuals with substance abuse issues and makes it harder to treat them. Substance abuse, she says, derives from both inborn predilections and environment. Effective treatment has to deal with both factors. In a deeply ironic way, many of the people who blame the opioid epidemic on bad pills see the solution as a different set of pills such as methadone, buprenorphine, and naltrexone. 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.

Photo credits: Credits: ID 118820734© Eshmadeva| Dreamstime.com, ID 67095798© Ljupco Dreamstime.com, ID 8248015© Gemenacom Dreamstime.com, ochre7 | thenounproject.com, Purdue Pharma building; Credit: Kris Tripplaar/Sipa USA/Newscom, Oxycotin pills; Credit: Kris Tripplaar/Sipa USA/Newscom, ID 83510092 © Pureradiancephoto | Dreamstime.com, ID 74433193 © Pureradiancephoto | Dreamstime.com, ID 83505630 © Pureradiancephoto | Dreamstime.com, Oxycodone; Credit: Robin Rayne/ZUMA Press/Newscom, ID 119487794 © David Wood | Dreamstime.com, ID 92374531 © Pureradiancephoto | Dreamstime.com, ID 186618334 © Darwin Brandis | Dreamstime.com, Oxycotin tablet and bottles; Credit: JEFF SINER/KRT/Newscom, ID 177835776 © Jon Anders Wiken | Dreamstime.com, Oxycotin protest; Credit: Erik McGregor/Sipa USA/Newscom, Painkiller protesters; Credit: Erik McGregor/ZUMA Press/Newscom, Ironton, Ohio; Credit: BRIAN SNYDER/REUTERS/Newscom, ID 83220881 © Sherman Cahal | Dreamstime.com, ID 42727529 © Auntkandis | Dreamstime.com, J.D. Vance; Credit: Jeff Malet Photography/Newscom, Ironton, Ohio; Credit: ID 109543668 © Sherman Cahal | Dreamstime.com, Oxycotin, close; Credit: Kris Tripplaar/Sipa USA/Newscom, Brain scan: ID 104709884 © Ded Mityay | Dreamstime.com, ID 104708862 © Ded Mityay | Dreamstime.com, Appalachia, Credit: Everett Collection/Newscom, Pills, Credit: Stephan Jansen/dpa/picture-alliance/Newscom, ID 12683852 © Reino Jonsson | Dreamstime.com, ID 51873792 © Marsia16 | Dreamstime.com, Alcoholic: ID 42516984 © Ocusfocus | Dreamstime.com, ID 42516940 © Ocusfocus | Dreamstime.com, ID 42516922 © Ocusfocus | Dreamstime.com, Addiction patient; Credit: Norma Jean Gargasz/agefotostock/Newscom, Powder in spoon; Credit: ID 143292811 © Eag1e | Dreamstime.com, Hand with pills; Credit: Gado Images/Smith Collection/Gado/Sipa USA/Newscom, ID 165273655 © Mark Youso | Dreamstime.com, Methadone: ID 140482461 © Newgixxer | Dreamstime.com, Hydrocodone: ID 153684292 © Jessica Fischer | Dreamstime.com, ID 173159293 © Soleg1974 | Dreamstime.com

NEXT: Citizen vs. Government (Vol. 6)

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  1. An enlightening letter in today’s WSJ.
    https://www.wsj.com/articles/how-government-subsidized-the-opioid-crisis-11609690096

    How Government Subsidized the Opioid Crisis

    The share of opioid pills paid for by the government went from 17% to 60% through the initial phase of the epidemic, from 2001 to 2010, when prescriptions dominated misuse.

    The share of opioid pills paid for by the government went from 17% to 60% through the initial phase of the epidemic, from 2001 to 2010, when prescriptions dominated misuse.

    But your editorial “Scapegoating Walmart” (Dec. 30) is correct: Walmart’s pharmacies are not among them. Our government is scapegoating and suing the private sector, when the most important driver of the crisis was the federal government’s indiscriminate financing of the underlying opioid prescriptions. Government subsidies for pain management and other medical uses of opioids may be valuable, but people are dying from nonmedical uses that shouldn’t be publicly financed.

    A 2019 report by the White House’s Council of Economic Advisers shows that the share of opioid pills paid for by the government went from 17% to 60% through the initial phase of the epidemic, from 2001 to 2010, when prescriptions dominated misuse, and didn’t stop there. Out-of-pocket prices for prescription opioids declined by 81% during this period. Without government subsidies, it would have cost between $26,000 and $53,000 a year to buy the pills to maintain an opioid addiction out-of-pocket.

    The large prescription-based crisis would have been infeasible without government funding. Innovation into illegal opioids, which lowered the “price of a high” through fentanyl, was profitable only because of the large demand already generated by the prescription crisis. The government would make greater strides toward limiting the crisis by looking inward, not only outward, for its causes.

    Prof. Tomas J. Philipson
    University of Chicago

    Mr. Philipson was acting chairman of the Council of Economic Advisers (2019-2020).

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  2. “What Drug Warriors Got Wrong About the Opioid Epidemic”

    TLDR version: Everything.

  3. Someone is watching the US election…

    DUBAI, United Arab Emirates (AP) — Iran began enriching uranium Monday to levels unseen since its 2015 nuclear deal with world powers and also seized a South Korean-flagged tanker near the crucial Strait of Hormuz, a double-barreled challenge to the West that further raised Mideast tensions.

    Both decisions appeared aimed at increasing Tehran’s leverage in the waning days in office for President Donald Trump, whose unilateral withdrawal from the atomic accord in 2018 began a series of escalating incidents.

    But you noticed they waited for Biden to be declared the President Elect?

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    2. A, the Iranians are probably lying. They don’t currently have the ability to deter a first strike attack on their enrichment program. If they could produce much at 20%, they’d be pulverized.

      B, they’re desperate for a Biden bailout and he’s stupid enough to provide it. So they want to scare him into offering money to back down from their nuclear weapons ambitions.

      C, you are right. They watch and plot.

  4. As addictions go, opiates by themselves are relatively harmless. The overdoses are mostly caused by mixing with other drugs (usually suicide attempts) and fentanyl (high potency is a consequence of the war on opiates).

    The point is, let people do drugs. They will usually moderate naturally on their own, and if they don’t it’s not because of ‘addiction’ but other physical and emotional problems in their lives that addiction ‘treatment’ is likely to worsen.

    1. Well we know what happens when they don’t get treatment… so I guess we’re at a stalemate… so I’m fine with the bodies piling up as long as they stay out of my neighborhood while dying. Also not attacking people on the street while high on meth would be an added bonus.

      1. Treatment usually worsens the situation, like I said. It’s better to avoid treatment if possible. A big problem is that it is often mandated by the courts.

        Decriminalizing meth will reduce violence and crime.

        1. I simply don’t believe that. I’m not going to get on my high horse and extoll the virtues of all treatment methods, there are many. And treatments differ depending on the addiction– alcohol, heroin, cigarettes, but we can see first hand what happens when you have a large, desperately addicted population (who yes, might have other emotional issues or mental illnesses) and then let them just hum along on their own without intervention.

          1. These towns are ‘desperately addicted’ because of hopelessness and economic disruptions. The best thing you could do to help them is to stop trying to ‘help’ them. Most of the damage is caused not by ‘addiction’ but intervention.

            Perhaps you’re not a libertarian.

            1. I’m a libertarian who’s watched my entire town turn into a dangerous, addict-infested shithole with tends in every open space and human waste and needles all over the sidewalks because we have a city which “refuses to help them”.

              1. the Downtown Emergency Service Center in Seattle moved its homeless residents from crowded shelters into hotels

                Actually Seattle is a national leader in ‘treatment’. They basically subsidize drug use with free housing and other goodies.

                1. Well, if we’re going to call ‘treatment’ greasing the rails with money, free, low threshold housing where residents are free to use as they wish, needle exchanges and safe injection sites, then we may be back in agreement about treatment.

                  1. I’m all for decriminalization (e.g. safe injection sites), but giving people free housing and other goodies is just subsidizing drug use. That’s why you have the epidemic. And the more trouble the ‘addicts’ make for you, the more you demand giving them free stuff. But appeasement never works. If you were a libertarian, you’d know that.

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              2. But you’re up-linking drugs to dangerous sh*thole. While it’s undeniable the government focus should be locking up the dangerous not necessarily the practice of liberty.

                Kind of goes into the old saying the path to h*ll is loaded with good intentions. Criminalize the Crime not the expectation of crime.

          2. we can see first hand what happens when you have a large, desperately addicted population (who yes, might have other emotional issues or mental illnesses) and then let them just hum along on their own without intervention.

            Yes, but don’t worry about COPD and lung cancer anymore. Surely the Biden administration will mandate drug court treatment for everyone desperately addicted to nicotine.

        2. The entire German army was on meth from 1943 on. After the war they got over it. The biggest problem with meth is that it is illegal and can be a source of easy illicit income to some and the high cost requires crime to come up with the money to buy the stuff.
          Drugs should be legal, so if someone decides to overdose it can be seen as suicide and not an accident. There’s a guy in my county who has been taken to hospital 12 time in two years for overdose. Let him succeed in his goal.

          1. I’m a big, big fan of letting the problem burn itself out. But I don’t lie to myself about the conditions while it’s happening.

          2. Fun fact: because of the Germans giving meth to their soldiers, the allies countered this tactic by giving amphetamines to our soldiers in a multitude of instances. Seems like drugs improved performance in warfare, go figure…

      2. Switching from meth to opioids should reduce the random attacks while high at least. Junkies rob people on the streets when they aren’t high, as a rule.

        1. That’s only because the black market drives up prices. If drugs were legal, the junkies would still be high, but they’d be passive and content, instead of violent, because prices would be affordable for a junky’s salary.

          1. Do you really think there is good pay on a junky’s salary?

    2. As addictions go, opiates by themselves are relatively harmless.

      I disagree, but the Devil is hidden by the word ‘relatively’. Not to justify the subsequent regulatory stupidity or contravene every facet of your larger thesis but opiate addiction is uquestionably more harmful than caffeine, nicotine, and THC as well as several other niche addictions.

      1. You people seem to just want to quibble for the sake of it.

      2. I think the point was that the drugs themselves don’t do a lot of direct harm (absent an acute overdose). And without black market prices and unreliability, the habit itself can be manageable and not terribly destructive.

      3. but opiate addiction is uquestionably more harmful than caffeine, nicotine, and

        All those tents and broken down RVs are people hopelessly addicted to Marlboros and Starbucks.

  5. There never was an opioid crisis. Only a war on pain patients.

    But I sure wish they’d invent a pill that makes predatory lawyers go away.

    1. “Only a war on pain patients.”

      Oh man. Have you ever observed what goes on inside a pain clinic? They are treated like garbage. Presumed to be criminals even when their injuries are obvious. It’s very sad to observe how they are psychologically abused by our medical “professionals.”

  6. I would like to thank the “profiteers” of now-defunct Purdue Pharma for providing me with the oxycontin I used after incurring a serious back injury. I only needed it for a few days, but I couldn’t have done without it.

  7. Oxycontin isn’t particularly potent it’s just time release. You take one pill in the morning for chronic pain and are good all day. You take one pill crush it and snort it you’re a junkie.

    1. Right. The guy in his tent under the overpass, surrounded by garbage and human waste isn’t taking it as directed by a physician.

      1. He’s probably taking heroin too because it is way cheaper.

        1. Ground up oxy combined with black tar heroin with a meth chaser. Then finish it off with a little pot laced with angel dust.

    2. Oxycontin tablets were reformulated a few years back. Now they crush about as well as Play-Doh.

      Meanwhile, oxycodone, the active ingredient in that product, is a particularly potent opiate. At least as compared to hydrocodone, the other commonly prescribed oral opiate.

      Oxycontin is a twice a day (Q12H) dosage form.

      But otherwise, spot on!

  8. The most libertarian and humanitarian solution to help reduce the overdose risks of fentanyl laced heroin is to allow/increase legal access to the least deadly opioid alternatives (i.e. methadone and prescription pills), which will likely only be legalize via a doctor’s prescription.

    By lying about, aggressively marketing and addicting several million Americans (who didn’t need them) to opioid pills in the 1990s and 2000s, Perdue and other greedy opioid pill marketers (who falsely told the FDA and doctors the pills had very little potential for addiction) not only created and fueled the current fentanyl and heroin overdose pandemic, but made it far more difficult to resolve (as Big Pharma, Big Medicine need to be part of any Big Government political solution to resolve or at least reduce the fentanyl pandemic they all created).

  9. Satel on how doctors should treat illicit drug users: “Force is the best medicine.”

    Naturally, there is a place in Reason for a medical drug warrior.

  10. The “war” on any financial, cultural or addictive behavior is and always will be a failure. Every time they start a “war” dealing with anything other than fighting to the death and preserving natural rights always ends with the problem getting worse. The reason being is they don’t actually fight a war, they try to treat a symptom, and do it poorly at that. You cannot take out the personal responsibility aspect and try to abolish the offending subject/ throw money at it( which is what they always do) . People need to rise and fall on their own, Iing their own decisions, and when they’re ready to better themselves ask for a helping hand and then it’s given to them, but not until.

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  13. This is anecdotal, but I think Satellite has a point about opioid use. I’ve known three people Boomer generation or slightly younger who had long term pain pill prescriptions. They were low income largely due to being disabled by injuries for which they were prescribed usually several types of pill each. But they mostly didn’t actually take the pills. Instead they chose to be in pain most days of the month and sold most of the pills to the local dealer. They certainly had a “good reason” to get the prescriptions. But the poverty was even worse than the chronic pain.

    1. Satel. Good grief.

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