Just say no

I just finished reading Dopesick, by Beth Macy. You don't need to take my word that it's worth your while, the book was a huge bestseller.  However, it does have a fairly narrow focus. It tells the story of the opioid epidemic largely within the confines of a region of rural Virginia, but this is a disaster of national scope that manifests somewhat differently in different places. Here's the really sad news:

 

 source: U.S. Department of Health and Human Services 

I know it's a little small but you can see it full size if you click the link. The short version of the story is that deaths from opioid overdoses were mostly from prescription drugs in 1999, and became a growing problem, claiming more than 15,000 lives in 2011. But then deaths from prescription opioids more or less leveled off and in 2014, while deaths from synthetic illicit opioids started to shoot up almost vertically, reaching more than 70,000 by 2021. 

The one thing that's a bit disappointing about Macy's book is that it focuses on the specific social setting which is the main reason why people started to pay attention to this in the first place. The U.S. has had a heroin problem for as long as I've been alive. While it's a myth that it was largely confined to non-white people (viz. William S. Buroughs and  Drug Store Cowboy, and I've known plenty of white junkies) it was a mostly urban problem. What people suddenly noticed was that opioid addiction was afflicting "real America," the mostly white, less densely populated areas away from the major metropolises. Then, all of a sudden, it mattered.

The first driver of this tragedy was aggressive marketing of prescription opioids, most notably by Purdue Pharmaceuticals, a privately owned corporation controlled by the Sackler family. The marketing campaign focused mostly on physicians -- prescribers -- claiming that Purdue's product Oxycontin was safe, posed almost no potential for addiction, and that pain was grossly undertreated and that Oxycontin was the cure. Doctors started writing 30 day prescriptions for every sprained ankle and extracted wisdom tooth and it turned out that yep, you can get hooked on that. Not everybody -- I never liked the effects of opioids and when I had surgery, the first thing I wanted was to get off of them. But I'm just lucky that way.

 

The reason those yellow and purple lines crossed in 2016 is that the FDA and the DEA finally realized what was happening and cracked down on overprescribing and diversion. But by that time criminal organizations had discovered the synthetic opioid fentanyl, mostly made in China and either imported directly, or via Mexico.* The market was there, prescription drugs could no longer satisfy it, so people turned to illicit products. Unfortunately, fentanyl and related chemicals are far more potent than heroin or prescription opioids, so they are more likely to kill people. And that's where we are.

Next, I'll discuss what to do about it.

 

*No, it isn't brought into the country by illegal immigrants. That's a completely unrelated issue. It comes concealed in cargo through legal border crossings. Or in the U.S. mail, believe it or not. They just can't inspect most packages.

This caused a huge epidemic of addiction, which at first people could satisfy by getting more prescriptions, going to multiple doctors and emergency rooms with complaints of pain and usually finding it easy to get a scrip. Some physicians went into the business of writing prescriptions for opioids indiscriminately. Some areas with small populations had literally millions of pills dispensed in a year. People would fill the prescriptions and re-sell some of them, keeping the rest to meet their own needs and the money to pay for them, and to support themselves. The latter is an important factor in all this because at the same time, jobs were disappearing from rural America as the coal industry declined, manufacturing moved overseas, and automation drew what was left to metropolises with more educated workforces.