Contributor Post Created with Sketch. Is the Opioid Crisis Mainly a Story of ‘Late Capitalism’ or Something More Complicated?

 

For capitalism’s critics, the opioid crisis is a powerful witness for the prosecution. They charge that inequality, stagnant wages, immobility, job loss — the four horsemen of the neoliberalism endgame — have generated a massive surge in “deaths of despair,” especially from overdoses of opioid drugs. Case closed.

But a new NBER working paper “Origins of the Opioid Crisis and Its Enduring Impacts” suggests a different theory of the case, one that focuses on a supply rather than demand explanation.

From the paper (bold by me):

Overdose deaths involving opioids have increased dramatically since the mid-1990s, leading to the worst drug overdose epidemic in U.S. history, but there is limited empirical evidence on the initial causes. In this paper, we examine the role of the 1996 introduction and marketing of OxyContin as a potential leading cause of the opioid crisis. We leverage cross-state variation in exposure to OxyContin’s introduction due to a state policy that substantially limited OxyContin’s early entry and marketing in select states. Recently-unsealed court documents involving Purdue Pharma show that state-based triplicate prescription programs posed a major obstacle to sales of OxyContin and suggest that less marketing was targeted to states with these programs. We find that OxyContin distribution was about 50 percent lower in “triplicate states” in the years after the launch. While triplicate states had higher rates of overdose deaths prior to 1996, this relationship flipped shortly after the launch and triplicate states saw substantially slower growth in overdose deaths, continuing even twenty years after OxyContin’s introduction. Our results show that the introduction and marketing of OxyContin explain a substantial share of overdose deaths over the last two decades.

So how big an impact did state-based prescription policy make? The paper’s findings suggest that “if non-triplicate states had the same initial level of exposure to OxyContin as triplicate states, they would have had 36 percent fewer drug overdose deaths and 44 percent fewer opioid overdose deaths on average in each year from 1996-2017.” Moreover, a rough calculation 65 percent of the dramatic growth in drug overdose deaths can be accounted for by the introduction and marketing of OxyContin.

Now, these findings don’t rule out the “deaths from despair” thesis, but the researchers add that the effects of the supply-side shock studied in this paper “persist” even when they account for demand-side factors. From the paper’s conclusion: “Overall, we find strong evidence that the marketing practices of OxyContin interacted with state-level policy conditions led to dramatically reduced overdose death rates in triplicate states. By deterring OxyContin’s widespread introduction in 1996, triplicate programs appear to have protected some states against the long-term fatal overdose trends experienced by most other states.”

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  1. Henry Castaigne Member

    Why didn’t something like the opiod crisis devastate people during the Great Depression? 

    • #1
    • December 4, 2019, at 12:28 PM PST
    • 1 like
  2. Bill Nelson Member

    James Pethokoukis: that inequality, stagnant wages, immobility, job loss — the four horsemen of the neoliberalism endgame

    So in 1931, in the depths of the depression, what was the suicide rate?

    I don’t think that it is an external cause but internal. Life today seems to have far less value for some. Easier to take and easier to throw away.

     

    • #2
    • December 4, 2019, at 12:34 PM PST
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  3. Henry Castaigne Member

    Bill Nelson (View Comment):

    James Pethokoukis: that inequality, stagnant wages, immobility, job loss — the four horsemen of the neoliberalism endgame

    So in 1931, in the depths of the depression, what was the suicide rate?

    I don’t think that it is an external cause but internal. Life today seems to have far less value for some. Easier to take and easier to throw away.

     

    Jinx.

    • #3
    • December 4, 2019, at 12:36 PM PST
    • Like
  4. DonG (skeptic) Coolidge

    The story is more complicated. Villagers in Mexico started growing heroin and wanted to distribute it to the US. Cities were too dangerous, since the crack and meth gangs would kill any competition. So, the villagers went to rural America and started pushing heroin. It is the classic story of someone spotting and unserved market and then building a business to fill that market. Read and listen to the story here.

    • #4
    • December 4, 2019, at 1:30 PM PST
    • 1 like
  5. MarciN Member

    I have a theory about the addiction side-effect based on my own experience with OxyContin. I think the pharmaceutical companies misread the addiction potential honestly and/or they may not have even known about it. They thought they had found a drug less addictive than the previous generations of painkillers. The people potentially addicted to it were so small in number that they didn’t realize it was a problem.

    I say this because when I’ve taken it, it has worked exactly as it was supposed to: it dulled the pain so I could sleep or move around, but it did not alter my state of mind in any way. There was no antianxiety or sedative effect from it at all. Once the pain stopped, I easily switched to something milder, which I did simply because of the other unpleasant side-effects from OxyContin on my digestive system. The extremely painful side-effects in the colon from prolonged use of OxyContin I would think would be sufficient in and of itself to keep people from taking it for longer than they absolutely needed it. The doctors and pharmaceutical companies were forthright and diligent in warning patients against prolonged use of OxyContin for that reason.

    I’m guessing that the doctors who prescribed it to me, who told me it was a good new painkiller that did not have the addictive side-effects of the earlier prescription painkillers, were mostly right. It is only a small percentage of OxyContin users who are achieving some sort of altered mental state by using it. I can’t blame the pharmaceutical companies for not realizing that. It really was a great drug for the people who took it–much better than the other painkillers on the market. In fact, what I liked about it was that I could work while taking it. It did not affect my cognitive abilities at all.

    We need a much better understanding of the psychiatric issues this epidemic has revealed. And I’m not at all sure the drug companies are to blame. I’m sure they never meant to cause addiction problems for people. In fact, they were trying to do the exact opposite–find a drug less addictive than existing opiate drugs.

    • #5
    • December 4, 2019, at 1:38 PM PST
    • 3 likes
  6. David Foster Member
    David Foster Joined in the first year of Ricochet Ricochet Charter Member

    Even if opioid abuse *is* a disease of despair…and I think that’s a big part of it…it’s a mighty big leap to conclude that it’s “a story of late capitalism.” A disease of despair…in the form of alcoholism…was quite prevalent in the Soviet Union, which was hardly a capitalist country.

    The American despair that exists in America today has more to do with bad trade policy, regulatory policy, and tax policy than it has with capitalism per se. And economic despair is greatly magnified by social despair caused in substantial part by the sustained “you are terrible people with a terrible history” memes directed at Americans in general.

    • #6
    • December 4, 2019, at 3:40 PM PST
    • 3 likes
  7. Quietpi Member

    There are several elements of this “opioid crisis” that keep me wondering. For a start, as it happens the first case I dealt with involving substances other than alcohol, involved Vicodin. That would have been about 1975. The subject didn’t have a prescription for it. I don’t remember anything else about the case, except that even then doctors knew full well about the addictive nature of opioids, and were already taking steps to prevent over-prescribing, doctor shopping, etc. The idea that doctors weren’t aware of the addictive properties of opioids, or that it was somehow hidden from them, is silly. The idea that opioid abuse is a new issue is just as silly.

    Second, I keep looking for a breakdown of deaths by prescribed users and users / abusers who are obtaining it by illicit means. Without that information, it is impossible to know the true nature of the problem.

    • #7
    • December 4, 2019, at 4:29 PM PST
    • 2 likes
  8. DonG (skeptic) Coolidge

    MarciN (View Comment):
    They thought they had found a drug less addictive than the previous generations of painkillers. The people potentially addicted to it were so small in number that they didn’t realize it was a problem.

    Purdue Pharma was selling about as many prescriptions per year as there are adults in this country. They knew there was abuse.

    • #8
    • December 4, 2019, at 10:06 PM PST
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  9. DonG (skeptic) Coolidge

    I heard today that 400,000 Americans have died from opioids since 2001. That is almost exactly the same number of Americans killed in WWII. At the current pace we’ll pass up the number for the Civil War by 2023. By 2029, deaths from opioids will equal the total of all combat deaths in all wars the USA has ever fought.

    • #9
    • December 4, 2019, at 10:14 PM PST
    • 1 like
  10. Fake John/Jane Galt Coolidge

    Quietpi (View Comment):
    Second, I keep looking for a breakdown of deaths by prescribed users and users / abusers who are obtaining it by illicit means. Without that information, it is impossible to know the true nature of the problem.

    There is a reason that info is not easily available. I suspect that deaths by legal prescriptions is low but death by people getting illegal drugs from illegal sources is high. But that can’t be published because it would interfere with the government self funding via lawsuits binge that is about to happen. Our various governments like to cause problems and sue others for financing. Just like they did with tobacco, the are in the middle of with these drugs, will do to gun companies, followed by the energy sectors.

    • #10
    • December 4, 2019, at 10:33 PM PST
    • 1 like
  11. Fake John/Jane Galt Coolidge

    DonG (skeptic) (View Comment):

    I heard today that 400,000 Americans have died from opioids since 2001. That is almost exactly the same number of Americans killed in WWII. At the current pace we’ll pass up the number for the Civil War by 2023. By 2029, deaths from opioids will equal the total of all combat deaths in all wars the USA has ever fought.

    I suspect it will depend on how it is defined and reported. Opioids effect you for around 6 hours but can be identified in the body 3 to 30 days depending on testing. If you take a pill today and wreck your car in a week that would be an opioid related death by some testing standards.

    • #11
    • December 4, 2019, at 10:36 PM PST
    • 2 likes
  12. Kozak Member
    Kozak Joined in the first year of Ricochet Ricochet Charter Member

    This crisis took lots of people making lots of mistakes to get us here.

    As a physician in the 80’s the accepted wisdom that opiates were highly addictive was dismissed as being incorrect. A lot of this was based on one letter to the editor in the new England Journal of Medicine, that stated that patients taking opiates for pain control rarely became addicted.

    Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

    This was seized upon by the drug industry, which was about to roll out new narcotic meds with a long acting formulation, oxycontin and oxymorphine. The letter was cited over and over again in the literature, and began to morph in it’s interpretation. Along with some other studies that followed.

    One researcher, writing in 1990 in Scientific American, called Porter and Jick an “extensive study.” A paper for the Institute for Clinical Systems Improvement called Porter and Jick “a landmark report.” Then the final anointing: Timemagazine in 2001 story titled “Less Pain, More Gain,” called Porter and Jick a “landmark study” showing that the “exaggerated fear that patients would become addicted” to opiates was “basically unwarranted.”

    So a new drug was being marketed, and the drug companies were bringing “experts” on pain control , lecturing us on how we were undertreating pain and making patients suffer unnecessarily.

    In addition JCAHO, the hospital accreditation mafia, got in the act in the 90’s and instituted pain as “The Fifth Vital Sign” . Every patient was supposed to be asked about their pain and rated on a pain scale, usually from 1 to 10. So surprise, tons of patients rate their pain at a 9 or 10. Sitting there, looking comfortable, not sweaty, not tachycardic, but still “it’s a 10 doc”. And if they had their mind made up that then needed some opiates, nothing else was going to budge that number.

    Continued

     

    • #12
    • December 5, 2019, at 7:54 AM PST
    • 2 likes
  13. Kozak Member
    Kozak Joined in the first year of Ricochet Ricochet Charter Member

    And woe to the physician who didn’t show improvement in that number. JCAHO was tracking it. In addition hospitals started to use all kinds of patient satisfaction surveys in the 90’s like Press Ganey, and your job or reimbursement was tied to those patient satisfaction numbers. State med boards would act on patient complaints about physicians who were not adequately addressing pain. The only time I ever had a complaint in 30+ years go to the medical board it was from a group of 3 patients all drug seeking together. They knew exactly what button to push to try and get me in trouble.

    So, new drug being marketed hard, people being told addiction wasn’t a problem, industry and even government leaning on physicians to prescribe, and a patient population that is not willing in many cases to accept any discomfort or pain. You had the perfect storm to create this monster.

    When it finally became evident we had a huge problem we had created, there was a sudden crackdown and the candy store was closed. And thats where the drug cartels were ready to step in with first cheap heroin, and then fentanyl. Lots of us warned that this was going to happen but we were ignored.

    • #13
    • December 5, 2019, at 7:55 AM PST
    • 2 likes
  14. Kozak Member
    Kozak Joined in the first year of Ricochet Ricochet Charter Member

    DonG (skeptic) (View Comment):

    I heard today that 400,000 Americans have died from opioids since 2001. That is almost exactly the same number of Americans killed in WWII. At the current pace we’ll pass up the number for the Civil War by 2023. By 2029, deaths from opioids will equal the total of all combat deaths in all wars the USA has ever fought.

    What Mexico and China in particular are doing with the heroin and fentanyl should be considered an act of war.

    China has sent shipments of fentanyl and carfentanyl sufficient to OD everyone in the US multiple times. That’s not happening without the government being at least aware of whats happening.

    I suspect it’s China’s long memory and payback for the Opium Wars.

    • #14
    • December 5, 2019, at 8:23 AM PST
    • 2 likes
  15. MarciN Member

    Kozak (View Comment):
    I suspect it’s China’s long memory and payback for the Opium Wars.

    That has crossed my mind too. 

    • #15
    • December 5, 2019, at 8:33 AM PST
    • Like
  16. Kozak Member
    Kozak Joined in the first year of Ricochet Ricochet Charter Member

    MarciN (View Comment):

    Kozak (View Comment):
    I suspect it’s China’s long memory and payback for the Opium Wars.

    That has crossed my mind too.

    China wasn’t able to eradicate their opium addiction problem until the Communists took over almost a century after the first Opium War and starting shooting all the drug suppliers and the users.

    A supply and demand side solution so to speak.

    • #16
    • December 5, 2019, at 8:49 AM PST
    • 1 like