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Democracy’s Drawbacks
There have always been a few drug addicts around, but this is different. The opioid epidemic has gone from a theoretical issue to a national crisis seemingly overnight, and it continues to grow like wildfire. Like most social problems, it can be difficult to find a solution, so it’s easier to just try to find someone to blame. Unfortunately, punishing the perpetrator is tricky when the victim and the perpetrator are the same person. One problem with liberty and self-responsibility is that it becomes more difficult to find someone to blame for your troubles. But every story needs a bad guy. And in politically correct American media, that bad guy can’t be a poor person, and it can’t be government. It has to be either a conservative or a corporation. You would think that simply following the playbook to a forgone conclusion would simplify investigative reporting, but in fact it can make it much more complex. What if that forgone conclusion is either questionable or outright ridiculous? That leads to some very creatively written news stories.
So I get my latest issue of JAMA (Journal of the American Medical Association), and front and center in this issue is an article called, “Lessons Learned from the Opioid Epidemic.” The first sentence of this article reads thusly (emphasis mine): “Oklahoma’s recent settlements with Purdue Pharma and Teva Pharmaceuticals, and the trial in the state’s lawsuit against Johnson & Johnson, signal that the opioid epidemic is entering a new era of accountability.” So to the authors of this article, their idea of accountability is to blame those who made the drugs. NOT those who took the drugs, and certainly not those who bought the drugs (very often, government – many of these people receive various forms of government benefits).
One wonders if these insightful physicians will attempt to cure obesity by suing corporations which make spoons.
To be clear, the pharmaceutical companies are accused not just of producing opioid drugs, but also of stating that their drugs were safer and more effective than they really were. But first of all, every company that produces anything is likely to see their own products in a positive way.
But that’s not the point. As a physician, I just don’t understand this lawsuit. We all know how addictive and dangerous these drugs are. We rarely used them until everybody from 60 Minutes to the CDC started screaming that people were suffering needlessly because heartless physicians were ignoring their pain, while withholding treatments that would reduce their suffering immediately. Then we had pain, the fifth vital sign. Rate your pain from 1 to 10. We were told that we were not treating pain aggressively enough, and you can understand that point of view. And presto, over-prescribing became a problem.
But it’s a relatively small part of the problem, in my view. Some people get prescriptions from physicians, but many people get their opioids via other means.
Lots and lots and lots of people really want these drugs all of a sudden. Something has changed, beyond the prescribing habits of some physicians. I don’t know what it is.
People now expect to be pain free? People are less willing to accept the difficulties of life and want a pill to make it go away? People are not as tough as they once were? People are unhappy or stressed out and like drugs that dull their anxiety etc? The 60’s taught people that there are better drugs available than booze? People have lost hope for the future and just want to feel good today? Marijuana distribution networks make it easier to get opioids into typical communities? I could guess and guess and guess – I really don’t know what has changed. But something has changed. Something really, really big.
And what strikes me as remarkable is that Americans in general, and this article in particular, seem to have little interest in what that big thing is.
In the remainder of the article, they blame doctors, pharmaceutical companies again, lack of education, and pharmaceutical companies yet again. But they never mention those who took the drugs or those who bought the drugs.
Comparing drug addiction to alcoholism is a dangerous business, but just think about it on a small scale. First of all, a drunk probably buys his own booze. He is likely to be encouraged to quit by those who love him the most. So his wife will tell him, “Stop buying booze.” This may or may not help, but she views that as a big part of the problem. If his friend is buying booze for him, she will ask the friend to stop buying booze for her husband.
Again, she’s trying to help, and will likely focus on the problem of her husband buying too much alcohol and drinking too much alcohol.
She is unlikely to blame Jim Beam. And if she does, she will never be able to help her husband. And her husband will be unable to help himself, as long as he insists on blaming others for his problems.
So what do we do in this “new era of accountability in the opioid epidemic?” We blame pharmaceutical corporations. Swell.
I hesitate to even post this, because I don’t want to hear about how Oxycontin 40mg QID really helps your fibromyalgia. And I’m uninterested in the inevitable scathing comments which will suggest that pharmaceutical companies have an interest in profits. Ok, fine. But that’s not at all what I’m writing about.
I just think that intentionally ignoring the root causes of a problem – any problem – will tend to prevent us from solving it. Ever. We have to develop, at the very least, an interest in why something is happening. We should try to find the cause, even if we don’t want to hear it. It’s ok to look for a bad guy, as long as you’re willing to accept that the bad guy may be you. Or worse yet, someone that you care about.
I think that one reason that so many social problems go unsolved is not that we can’t find the solution. It’s that we don’t want to find the solution. It may be uncomfortable. It may challenge our beliefs or sympathies. It may be right, but we don’t want to hear it. Understandably. Who wants to deal with uncomfortable realities? Surely there’s another way, right?
But by averting our gaze, we discretely abandon all hope of reducing the suffering of millions, while we publicly sympathize with their plight.
These problems are difficult. The solution is likely to be very difficult.
Blaming whoever is currently unpopular may get fools elected to public office, but it can only make it even more difficult to solve problems. Such blame shifting is not merely unhelpful. It’s poison.
Democracy has many advantages. But there are disadvantages as well.
Published in General
Slight quibble. I think it’s a reflection of having lost our way; it’s just not unique.
I posit that humans don’t just like expectations and life scripts*; we need them. When you find a culture or subculture with severe addiction problems, that culture also is undergoing changes in how its people work, socialize, and form families. Hence London’s Gin Alleys during the early 19th century, where village ties broke as people left the land in search of factory jobs on one side and in response to the Enclosure movement on the other. The narrative for how to be a working class person broke down, and mass addiction to gin resulted. You see it in the alcohol problems of early 20th Century America that prompted the Prohibition, where mass immigration from European farms to American factories and cities left those workers without a life script. You see it in the urban black community where mass black immigration from southern farms to urban cities, combined with government incentives to not form strong families and social networks, left them without a life script. And now we’re seeing it in Rust Belt America. Heck, you can go back to the “Bread and Circuses” of Rome to see how economic disruptions and lack of employment opportunities
In the absence of subsidies to continue dysfunctional living, the culture either drafts a new life script that makes for a stable culture, or it dies out (generally by conquest by a culture that does have a working script).
*How to earn food and shelter, how to find a mate, how to raise children, how to interact with other people — both in the tribe and outside it.
Another possibility: People are living longer so they need to stay in the workforce longer, in many cases after the statutory “retirement age”, and that requires pain management if they hope to compete with younger workers?
Evening Dr. Bastiat,
You note that we have always had addicts. In the bell curve of humans, there are those with addictive personalities, or those whose genes leave them more likely to become addicted, and those whose lack of insight and risk taking personalities also leave them vulnerable to drug abuse. Then you note that humans seek someone (other than themselves) to blame, and that law suits against monied entities are coming. I see nothing unusual in any of this. We have had times when there are increases in drug abuse, in my lifetime the Vietnam servicemen whose addiction rate was so worrisome to the govt that servicemen had to pass a drug test before coming home. In an earlier time when opiates were legally put in common elixirs a large percentage of the population became addicted. So now we have had an increase in drug abuse and the question is how did we get here and how do we reduce this abuse. You suggest that we have had a change in pt expectations, folks now think that all their problems can be addressed with a pill. I do not exactly see this. In the world of “mother’s little helper”, we have had Marilyn Monroe, Dorothy Kilgallen, Elvis. I do not think that folks now are much more whiny than previous generations. Maybe the drugs are more potent, I am not sure about that. I also do not know if docs are scripting opioid drugs more than in the past. I also do not know if Fentanyl is especially addictive. I do know that Fentanyl patches are much cheaper than beuprenorphrine patches, although they are stronger and leave the patient less able to maintain a life engaged with other people. I assume this cost differential reflects a benefit to the drug company or the pharmacy drug manager.
I am into evolutionary psychology. Everything that you are saying makes sense but it needs proof. Has there been anyone researching this stuff?
I think that the basic legal theory of the lawsuits is that the opioid manufacturers misrepresented or concealed the addictive dangers of their products, particularly oxycontin (which seems to be the major target of the current lawsuits). As a result, doctors — at least some doctors — may have been less vigilant about the dangers of addiction, and some patients may have been misled into thinking that the danger of addiction was significantly lower than it could have been.
I don’t know whether this is true, but it is a viable legal theory.
I think that part of the objection is the idea that a problem must have a single cause. It can simultaneously be the case that the manufacturer, doctor, and patient all share fault for an opioid addiction. Perhaps the manufacturer promoted its product through misleading ads; the doctor gave an unnecessarily risky prescription at the patient’s request; and the patient wanted the opioid for reasons other than genuine pain relief.
One thing that I’ve learned, after over 20 years practicing law, is that a bad outcome is often the result of several wrongs.
Very good point. Mistakes tend to compound themselves.
I should add something else about the opioid cases, at least some of which appear to be brought by states on a damages theory that I find quite dubious. It was previously used in the tobacco cases, I believe. The idea is that the companies that sold tobacco or opioids cause damage to the state, in the form of increased health care costs.
I haven’t thought through the issue sufficiently to form a final opinion, but I doubt that I would allow the “proximate cause” element of a tort claim to extend this far. The law generally requires a closer connection than some third-party who paid for the injured person’s health care costs.
Here are a few examples. If I’m the one injured by a misleading ad, then I can claim damages. If I’m killed, then my family can claim damages for wrongful death. But my employer, as an example, is simply out of luck, even though my employer may have been harmed. The harm is too remote.
There are some exceptions to this for government-provided medical care, both at the federal level and in my state of Arizona (and probably other states). If someone is injured in a car accident, and their injury is covered by medicare, medicaid, or worker’s comp, the law allows the government to recover those costs from the tortfeasor.
Depending on how the statutes are worded, this may provide a statutory basis for the damages theory that I found dubious. The “proximate cause” requirement is a common law concept that can be varied by statute.
I’ve been interested by some of the folks in the evolutionary psychology area, like Jonathan Haidt and Gad Saad, but I think that their field is largely nonsense.
Most evolutionary explanations for human characteristics are pure speculation that are never tested, and probably cannot be tested.
If people are addicted to oxycontin or similar drugs, what would be the deleterious effect of just letting them have it? I remember hearing a long time ago that heroin itself was not really that damaging to the human body, but the substances it was cut with caused tremendous problems. I’m truly a babe in the woods about this issue and am asking sincerely; do people that are given these drugs demand more and more or can there be a maintenance dose? What would be the cost of prescribing these drugs as opposed to providing a spa treatment in Malibu paid for by ObamaCare every few months?
I was on a maintenance dose of opioids and functioned well. When the laws changed, I was forced off of them. Although, I went off voluntarily, knowing what was happening. I had no side effects. Now I take two different pills that are half as effective. I’m getting better, but it’s been slow and I have to plan ahead. Pain is strange. You don’t know what your limits are until you have passed them.
Testing them is insanely hard. But even if something is very hard to test doesn’t make it true. It may make in ridiculously hard to prove but it doesn’t make untrue.
I think it’s simple. This stuff is so restricted and controlled it becomes very expensive and thus creates powerful incentives to sell illegally and since it’s cheap, the profits are huge. The problem is the illegality. Back when I was following this subject (many decades ago, but nothing important has changed) cocaine paste cost 200 bucks a Kilo to get from Bolivian leaves to Colombia powder. The powder was sold for $2000 a kilo in Colombia and the little packages on the street in the US for $20,000 a kilo. That’s powerful incentives that enable lots of promotion by free stuff. There is no way to stop it. None. Zero. Get it through our heads it can’t be stopped. We could make it illegal to promote it, advertise it, give it away, but we have powerful interests including law enforcement that win from the battle. Some things are so simple we can’t stop them. The numbers of people killing themselves with it probably wouldn’t change much, but there would be no incentive to promote it among our kids.
This does not answer the larger question about the reason for the epidemic, but regarding your point about the bewildering rush to pick a bad guy to blame, rather than trying to find the real cause in order to find a solution: This sounds like the types of cognitive biases discussed by Daniel Kahneman in “Thinking, Fast and Slow”. Substitution bias ( subconsciously replacing a difficult problem with an easier one. ) and the coherence effect (accepting a simple coherent story rather than analyzing a complex multi-factor explanation) leap to mind. If you have not read it yet, this book is a fascinating read for the layman.
( https://www.amazon.com/Thinking-Fast-Slow-Daniel-Kahneman/dp/0374533555 )
Positions I find to be in opposition to one another. Either you let go and let God, or you make your own decisions, and live with the consequences.
Avoiding responsibility is one of the hallmarks of addicts, who spend a great deal of time, money, and effort on avoiding things, through a substance. The God part and personal responsibilities are the reasons why I find the AA model to be inherently inconsistent, while also acknowledging that it works, especially for those who are newly sober.
I’m all for what works. In the long run, though, you have to live your own life. No one can live it for you. That means you’ll always be responsible for your choices, good or bad. Forever. So you might as well get on with that responsibility right now, today, because it’s never going away.
I agree, Chris. Those positions would seem to be in conflict, as would some other points in the AA 12-step program. Logically, it seems to make little sense.
But as you pointed out, it seems to help, at least some. So there you go.
But I can’t argue with your point…
The legalization of marijuana could have catastrophic consequences. Addiction to marijuana is common. And now it’s just too easy to grow. The mentality that went into making this video is beyond the pale, even if I am a dinosaur.