Ann Case & Angus Deaton. Deaths of Despair and the Future of Capitalism. Princeton UP, 2021.
In his book Imperial Twilight, the historian Stephen Platt tells the story of the origins of the Opium War between Britain and China. Like the American South after the Civil War, and like working-class America today, the Chinese empire was in distress. The British East India Company was struggling to be profitable, and its most profitable line of business in the 1830s was opium, produced in India and sold to China. The physician William Jardine, born in Edinburgh, was one of the most important merchants in the business. His partner was fellow Scot James Matheson, and together they founded Jardine, Matheson & Company in 1832. Known today as Jardine Matheson Holdings, it has more than four hundred thousand employees and is in the top three hundred companies in the world. As Platt notes, Jardine, Matheson, and other drug dealers, “far from being stigmatized by their line of business, back home … would count among the most admired members of their respective societies.”
The Chinese authorities were not so impressed. They sought to exclude the British from all of the Chinese coast except for Canton (today’s Guangzhou) and to suppress the opium trade. Yet enforcement was erratic and intermittent. The emperor had many troubles on his hands, trying to hold together a disintegrating empire and suppress rebellion, and the opium trade was not always his first priority. But in 1839, Lin Zexu was sent to Canton by the Daoguang Emperor with full authority to suppress the trade. Lin believed not only in interdiction but also in what today is called medication-assisted treatment for addiction. A statue of him now stands in Chinatown in Manhattan with the inscription “Pioneer in the war against drugs”; in China, he is regarded as a national hero.
When in June 1839, under direct instructions from the emperor, Lin destroyed more than a thousand tons of British opium, a year’s supply, the traders lobbied the British government for compensation, which was not feasible politically. But sending in the gunboats to make the Chinese pay was another matter, as was seizing the opportunity to open up the rest of the Chinese coast, not only to opium but also to other British trade. The opium trade was not legal; it is as if the Mexican government were asked to compensate Mexican drug dealers for a shipment seized by the US Drug Enforcement Agency (DEA) and the Mexican government, while declining to pay out of its own resources, invaded Texas to make Americans pay. Yet the British Parliament narrowly approved the war, in spite of serious criticism; slavery had not long been abolished in Britain, and many believed that the opium trade was Britain’s other great crime. It was not as if the members of Parliament did not understand the ethics of what they were doing, but profit won out over principle, and Prime Minister Melbourne sent the navy to the East.
There is another part to the story that is less well known. The East India Company did not control the western part of India, where the opium poppy also flourished, and the company faced severe competition from drug dealers in Bombay, the best known of whom was a Parsi merchant called Jamsetjee Jejeebhoy. It was his supply that helped drive down the price of opium in China, enabling the drug to move from a luxury for the rich to a much wider population. Jejeebhoy used his drug profits for good works, a playbook that is still familiar today. He was knighted by the Queen of England for his philanthropy, the first Indian ever to be so honored. In 1858, he was elevated to become a lord, becoming Baronet Jejeebhoy of Bombay. The title was a hereditary one and was inherited by his son.
What of Jardine and Matheson? Jardine became a member of Parliament and was succeeded by Matheson on his death in 1843. Matheson became a fellow of the Royal Society and governor of the Bank of England, and he was one of the richest men and largest landholders in Britain. He purchased the Isle of Lewis in the Outer Hebrides in 1844, and in 1851 he became Sir James Matheson, first Baronet of Lewis. The Highland potato famine reached Lewis not long after his purchase, and he was a generous landowner, who spent large sums on relief and on improvements; he also financed the (more or less voluntary) emigration of 2,337 islanders, about 13 percent of the population, to Quebec and Ontario, and paid for their clergymen to travel with them. He too earned his baronetcy by his philanthropy.
In the words of economic historian Tom Devine, writers have often seen the Highland Clearances as “the brazen subordination of human need to human profit.” Unlike some of his fellow landowners of the time, Matheson seems not to have deserved this condemnation, but the same can hardly be said of his earlier activities, nor of the government-supported drug dealers of our own time, whom we shall meet in this chapter.
Opioids
Accidental drug overdoses are the largest and fastest growing of the three midlife deaths of despair, though suicide and alcohol-related mortality together accounted for more deaths in 2017. In chapter 8, we explored suicide and alcohol-related deaths, and how they were linked to the social and economic turmoil among white working-class Americans. We now turn to the story of opioids and the deaths that they have wrought.
Opioids are either the natural derivatives of the opium poppy, such as opium itself and morphine, which have been used for thousands of years and are technically referred to as opiates, or synthetic or partially synthetic compounds that have some or all of the same properties, technically known as opioids. The term opioid is now routinely used for both. Opioids are implicated in 70 percent of drug deaths, either alone or in combination with other drugs. Heroin is an opioid; it was synthesized in 1874 and cannot be legally used in the US, though it is used in medicine in several other countries.
The strength of an opioid is measured by comparing it with morphine. A milligram of heroin is equivalent to three milligrams of morphine (or opium), so its morphine milligram equivalent (MME) is 3. One of the most important opioids in the current epidemic is oxycodone (MME 1.5), which is sold in an extended-release form as OxyContin, manufactured by Purdue Pharmaceutical. OxyContin, known on the street by many names, including “hillbilly heroin,” was approved by the Food and Drug Administration (FDA) in 1995. Another is hydrocodone (MME 1), which is in Vicodin. Yet another currently important opioid is fentanyl (MME 100), which was approved by the FDA in 1968. Unlike heroin (illegal only) or OxyContin (legally manufactured, but often sold illegally), fentanyl is available both legally and illegally; today, the illegal version is imported into the US from China via Mexico.
Opioids relieve pain. But they are more than painkillers and can produce a euphoria that people find enjoyable and want to repeat. We say “can” because not everyone gets the high or the pain relief. The body can build up tolerance to opioids, so that ever-higher doses may be required to keep pain under control, or to get to the same high. Users can find it difficult to stop using them, because they have become physically dependent and face fierce withdrawal symptoms when they try to stop. These can include vomiting, diarrhea, sweating, insomnia, cramps, and the experience known technically as delusional parasitosis or formication (alas, the m is not a typo), a feeling that ants or other insects are crawling underneath the skin.
Opioids can also lead to addiction, and to the destruction of self and of family that addiction brings. Even dependence can compromise lives; people become focused on maintaining their consumption of the drug, which can make it difficult to work, socialize, or tend to family.
The progression from prescription to tolerance to dependence to addiction is far from automatic. Heroin has been demonized in movies so often that many people think one injection is enough to destroy your life. That is not true in general, but opioids are dangerous, and long-term pain relief through opioids comes with terrible risks, and with questionable effectiveness. The secret, if there is one, is to get the relief without the horrors, to get rid of the pain without the formication.
In the late 1990s, thinking about pain management changed. As we have seen, there was (and still is) a great deal of pain in the US. Pain-relief advocates argued that the US was undertreating pain, and enormous quantities of very powerful opioids were unleashed on the American population. By 2012, enough opioid prescriptions were written for each American adult to have a month’s supply. People began to die from prescription overdoses, small numbers at the start, but rising over time to 17,087 deaths from prescription opioids in 2016, then falling to 17,029 in 2017, perhaps the beginning of a downward trend. The people who die are sometimes the people who were given the prescription, but these drugs are often diverted to others, through black-market sales or through theft.
Opioids prescribed by physicians accounted for fully a third of all opioid deaths in 2017, and a quarter of the 70,237 drug overdose deaths that year. This overall number is greater than the peak annual number of deaths from HIV, from guns, or from automobile crashes. It is greater than the total number of Americans who died in Vietnam. The cumulative total from 2000 to 2017 is greater than the total number of Americans who died in the two world wars. The overuse of prescription opioids triggered the secondary epidemic of illegal drugs when Purdue introduced an abuse-resistant form of OxyContin and as physicians became more aware of the dangers and held back, or at least reduced the growth of the legal supply.
Most people who use opioids do not die. And some of those who die may have intended to kill themselves; the distinction between an accidental overdose and a suicide is not always clear, even to the victim. For every death, there are more than thirty visits to emergency rooms for misuse or abuse, ten of which lead to a hospital admission. Each death corresponds to more than a hundred people abusing the drugs; these numbers have been increasing in parallel with the numbers of deaths. In 2016, nearly 29 million Americans ages twelve and over self-reported using illicit drugs in the last month (including misused prescription drugs) and 948,000 reported using heroin in the preceding twelve months.7 Given that these are self-reports, from people participating in the National Survey on Drug Use and Health, the number is likely to be an underestimate. More than a third of all adults, 98 million people, were prescribed opioids in 2015. Many employers will not hire new workers without a drug test, so it seems likely that drug use is keeping people out of the labor force, in addition to those who are unable to participate because of their dependence on drugs.
Opioid deaths, like other deaths of despair, are not equal opportunity. Overdose deaths involving legal and illegal opioids are predominantly of Americans who do not have a bachelor’s degree. For whites, since the early 1990s, the percentage of accidental drug overdose deaths accounted for by those with a bachelor’s degree has held constant at 9 percent. Two-thirds of victims have no more than a high school education. Blacks and Hispanics were largely exempt until the arrival of illegal fentanyl in 2013, after which they, too, have seen a large increase in overdose deaths. With a few exceptions, mostly English-speaking countries—Canada, the UK (especially Scotland), Australia, Ireland—and Sweden, there are no similar epidemics elsewhere, and apart from Scotland, the numbers dying are very small compared with the US. Yet opioids are used in other rich countries too, usually in hospitals for cancer or for postsurgical pain. But they are much less commonly used by doctors or dentists working in the community, or for the long-term treatment of chronic pain.
Producers made huge sums of money from legal opioids. According to various reports, including investigative work by the Los Angeles Times, Purdue Pharmaceutical, which is privately owned by the Sackler family, has sold somewhere between $30 and $50 billion worth of OxyContin. Recently released court documents show that the family itself received $12 billion or $13 billion. Illegal drug dealers, many from Mexico, have also prospered, but legal producers have the advantage of not having arrest or violence as a routine business risk.
Physicians are also implicated in the epidemic and, at the least, have been guilty of careless overprescribing, especially in the early days of the epidemic. A substantial fraction of opioid deaths was caused by the American healthcare system; the standard term for such deaths is iatrogenic, meaning “brought forth by the healer.” It is one of the ironies of the epidemic that the US healthcare system, by far the most expensive in the world, not only is failing to prevent the decline in life expectancy but is actually contributing to its fall. And as we shall see in chapter 13 , this is not only a result of its mishandling of opioids.
How Did It Happen?
Throughout history, people have used the products of the opium poppy to relieve pain and to get high. The suppliers of those products have often been motivated to help others, and often to enrich themselves, aims that are not necessarily contradictory. The genius of free markets is that people can prosper by helping others. But free markets do not work well for healthcare in general or, in particular, for addictive drugs, whose users often do things that are manifestly against their own interests. Suppliers have an interest in addicting consumers, and mutual gain is likely to be replaced by conflict. At the beginning of this chapter, we saw how this was resolved in favor of British drug dealers in China.
In the American Civil War, upwards of ten million opium pills and nearly three million ounces of opium in tinctures and powders were given to Union soldiers, according to historian David Courtwright, who has written extensively on the history of drugs. The then recently invented hypodermic needle (initially thought to reduce the chances of addiction by bypassing the digestive system) was widely used after the war to bring opium-based pain relief to veterans. Courtwright notes that “for the first time in the entire history of medicine, near-instantaneous, symptomatic relief for a wide range of diseases was possible. A syringe of morphine was, in a very real sense, a magic wand.” Around one hundred thousand veterans eventually became addicted. By the late nineteenth century, morphine and opium were widely available in the US and were widely used, including by children. Addiction was especially prevalent among white Southerners, whose postwar world was in disarray. By the end of the century, heroin had been synthesized and marketed by Bayer as, once again, a nonaddictive substitute for morphine. Many more Americans became addicted. And heroin helped many a difficult child go to sleep.
Eventually, the medical profession pushed back, working to restrict the use of opioids both by the public and by physicians, and the Harrison Narcotics Act of 1914 marked the end of the first great American opioid epidemic. The act severely restricted the use and sale of opioids, and heroin was entirely banned ten years later. The sale and possession of opioids became criminal activities, and their use vanished from the vast majority of the population. Respectable people no longer used opium or heroin for minor aches and pains, nor did they feed them to babies with colic.
How, then, could a new epidemic spring up less than a century later? People forget the past, and even those who remember it may think that circumstances have changed, that this time is different, and that the risks of the past are safely locked up in the past. That drugs can be so enormously profitable will always bring a supply of people who say the risks have been exaggerated. Pain certainly had not been abolished and, as we have already seen, chronic pain was rising, and treating (or not treating) it posed an enormous challenge to physicians. Ronald Melzack, whose gate-control theory of pain had revolutionized the understanding of pain twenty-five years earlier, wrote a paper in 1990 entitled “The Tragedy of Needless Pain,” which eloquently documented the horrors of pain and argued that “the fact is that when patients take morphine to combat pain, it is rare to see addiction.” For terminal cancer patients, the risk of addiction is irrelevant. But many cancer patients survive, many more patients face acute postsurgical pain, and beyond that, there is an ocean of patients with chronic pain. By 2017, 54.4 million American adults had been diagnosed with arthritis, and arthritis is only one of many painful conditions that become more prevalent as the population ages.
Starting around 1990, pain experts increasingly called for pain to be better recognized, and for physicians to ask their patients about their pain level. In his 1995 Presidential Address to the American Pain Society, physician James Campbell argued that “we should consider pain the fifth vital sign” (italics in the original), meaning that physicians should assess pain routinely, just as they assess respiration, blood pressure, pulse, and body temperature. Campbell also called into question the usefulness of the distinction between cancer and noncancer pain and between acute and chronic pain. The American Pain Society was shuttered in June 2019, a casualty of the twenty-first-century Opioid Wars, bankrupted by legal fees in its defense against charges (that it denies) that it had acted as a pawn of the pharmaceutical companies.
Debate continues to this day on whether, as Melzack argued, those who take opioids for pain relief need not fear addiction. The Mayo Clinic’s website, often a reliable source, offers contradictory advice. In its discussion of hydrocodone, it states that “when hydrocodone is used for a long time, it may become habit-forming, causing mental or physical dependence. However, people who have continuing pain should not let the fear of dependence keep them from using narcotics to relieve their pain. Mental dependence (addiction) is not likely to occur when narcotics are used for this purpose.” But in a different area of the Mayo Clinic’s website, more caution is offered: “Anyone who takes opioids is at risk of developing addiction … The odds you’ll still be on opioids a year after starting a short course increase after only five days on opioids.” Doctors want to help patients and are reluctant to give up their magic wand.
In this changed atmosphere, doctors and dentists increasingly prescribed opioids for all kinds of pain, especially after the introduction of OxyContin in 1996. Its twelve-hour slow-release mechanism, it was claimed, allowed pain sufferers to sleep through the night. Unfortunately, in a large share of users, pain returned and opioid withdrawal began well short of the twelve-hour mark, and many physicians responded by shortening the interval to eight hours or increasing dosages. The cycle of relief followed by pain and withdrawal increased the risks of abuse and addiction.
The introduction of OxyContin was met by a seemingly unlimited demand by patients in pain. Most doctors practiced under extreme time and financial constraints that made the prescription of a pill attractive compared with approaches that were expensive and time consuming. The interdisciplinary treatment of pain, which was the earlier standard, used some combination of medication—for example, the much less dangerous nonsteroidal anti-inflammatory drugs (NSAIDs), like (nonprescription) aspirin, acetaminophen (Tylenol), ibuprofen (Advil), or naproxen (Aleve) or (prescription) celecoxib (Celebrex)—together with counseling, exercise, yoga, acupuncture, and meditation, all of which are difficult to fit into a standard doctor’s appointment. Patient satisfaction surveys also became common, and opioids did well on such metrics. Satisfaction was doubtless also high a century before among colicky babies and their heroin-dispensing parents. Arthritis patients were prescribed opioids by primary care doctors, people were sent home from their dentists with many days’ supply, and all manner of injuries treated in emergency departments were sent home with opioids.
It is arguably possible for a doctor to assess which patients are at risk for addiction, but not in a few minutes, nor in a system in which many people do not have regular doctors and there are no unified medical records. Doctors may not even know that their patients have died from drugs that they have prescribed; when they are sent a letter informing them, many reduce their prescribing of opioids.
A century after the last epidemic, the conditions were once again in place for another iatrogenic wave of opioid abuse, addiction, and death. David Courtwright told the journalist and author Beth Macy, “What surprised me in my lifetime were things like the internet, or seeing tattoos on respectable women. But I’ve got to add this to the list of real shockers. I’m sixty-four years old, and I have to admit, I didn’t think I would ever see another massive wave of iatrogenic opiate addiction in my lifetime.”
As religion faltered, opioids became the opium of the masses.
Overdose deaths began to rise in the early 1990s, gathering real momentum after 2000, a year in which more than fourteen thousand people died of accidental overdoses. Assigning overdoses to the drug responsible is complicated. In a large minority of overdose deaths, more than one drug is present. Benzodiazepines taken alone are unlikely to kill you, but mixed with opioids or alcohol, they can become deadly. In addition, details on the drugs responsible are often not written on death certificates and are instead recorded as “unspecified.” In 2000, between a third and a half of all accidental overdoses involved (mostly prescription) opioids, with the exact count dependent on how we attribute deaths from “unspecified” narcotics. Heroin, a long-standing scourge, was recorded as present in 1,999 deaths that year. Before 2011, the increases in deaths were powered by prescription opioids, particularly those based on hydrocodone (Vicodin) and oxycodone (Percocet, OxyContin). In 2011, Purdue Pharmaceutical reformulated OxyContin to make it resistant to abuse. The original formulation had warnings against taking it other than as directed, but those warnings, by telling you exactly what not to do, were easily reversed to give accurate instructions for how to convert the extended-release pill into one giving an immediate high, or to prepare it for injection. Deaths from prescription opioids stopped rising in 2011, almost certainly in response to the reformulation, though the increasing awareness of physicians of their part in the epidemic was by then playing a role in limiting unmindful prescription. It is possible that the reformulation actually cost lives, if users switched to relatively unsafe street drugs. At the same time, the reformulation allowed Purdue’s about-to-expire patent to be renewed, which was possibly of more concern to the company than saving lives.
In any case, by 2011 it was too late to put the genie back in the bottle. Illegal heroin, an almost perfect substitute for oxycodone, quickly picked up the slack; deaths from prescription drugs were replaced by deaths from heroin, and the total of overdose deaths continued its climb. Drug dealers waited outside pain clinics for patients whose doctors had denied them refills. Some bought (diverted) OxyContin on the street until discovering that heroin was both cheaper and more potent. It was also more dangerous, because the quality of street drugs is never guaranteed. At the same time, there was an explosion of high-quality black-tar heroin from new suppliers in Mexico, so for many, the switch was an easy one. Misappropriated OxyContin prescriptions could be sold for morphine-equivalent doses of heroin, maintaining a habit and producing a profit on the deal.
Heroin deaths continued to increase but were soon overtaken by deaths from fentanyl, which rose to 28,400 in 2017. The rise of fentanyl reflects its potency, the ease of its importation given that it is effective in much smaller quantities than heroin, and the fact that it can be mixed with heroin, cocaine (“speedballs”), and methamphetamine (“goofballs”) to deliver a more effective high. Heroin and illegal fentanyl became widely available in part to meet the demand of those addicted to prescription opioids who were finding it harder to feed their habits. But their presence appears to have led to an epidemic of its own, in which users start out not on prescription opioids but rather on these illegal substitutes. Cutting cocaine and heroin with fentanyl has been one of the causes of rising overdose mortality among African Americans; death certificates listing fentanyl can account for three-quarters of the increase in midlife African American mortality after 2012.
The fire had jumped its boundaries.
One might think that overdose deaths would drive customers away from dealers whose customers die, but anecdotal evidence suggests that the opposite is true. Those addicted to opioids are so desperate to be numb that they see a death as an indicator that the source of supply is desirable, the “real thing.” Indeed, this is not the only hint of suicide in these deaths. The drug naloxone (Narcan) has the almost magical property of bringing back to life people who are about to die from an overdose. Yet there are multiple reports from police and fire departments of their administering naloxone to the same person on multiple occasions, sometimes within a single day. Either people want to die, or they do not care about anything other than feeding their addiction, even if it kills them. The addiction is in control.
The Epidemic and Deaths of Despair
The term epidemic invites comparison with an epidemic of smallpox or the influenza epidemic that killed millions in the US and around the world in 1918-19. In the opioid epidemic, the agents were not viruses or bacteria but rather the pharmaceutical companies that manufactured the drugs and aggressively pushed their sales; the members of Congress who prevented the DEA from prosecuting mindful overprescription; the DEA, which acceded to lobbyists’ requests not to close the legal loophole that was allowing importation of raw material from poppy farms in Tasmania that had been planted to feed the epidemic; the FDA, which approved the drugs without considering the broad social consequences of doing so and which acceded to producer requests to approve label changes that greatly widened use and profits; the medical professionals who carelessly overprescribed them; and the drug dealers from Mexico and China who took over when the medical profession began to pull back. This is a story of supply, where immense profits were made by addicting and killing people, and where political power protected the perpetrators. Once you have started using opioids, it is as if you have caught the virus, and while you will probably survive, there is some chance that you will die. No one should doubt the importance of supply in the epidemic—which is why we have told the story as we have—but it does not offer anything like a complete account.
Why is it that the epidemic is so much worse in America and almost absent in most other rich countries? Even in America, some opioids, such as Vicodin and even fentanyl, have long been available. Other countries use opioids for postsurgical and cancer-related pain, and some, including Britain, have long used heroin, even when it was banned in the US. What is it that has prevented those drugs leaking out from intended uses into the population at large?
Why, too, is it that Americans with a bachelor’s degree rarely die of overdoses, and why are 90 percent of the deaths among those without a four-year degree? Certainly, those with less education are more likely to be injured at work, or to work at jobs that bring a high risk of acute or chronic pain, and so to be prescribed opioids, but this cannot be the whole story. Arthritis, which is one of the leading conditions for opioid prescriptions, is largely a consequence of age, and if access to opioids is more common among the elderly, it is not killing them. In chapter 7, we saw that about half of sixty-year-old whites with a bachelor’s degree reported back, neck, or joint pain, as opposed to 60 percent of those without the degree. This is not nearly enough of a difference to explain the sevenfold-higher overdose mortality rate if it is those with pain who get opioids, if a constant fraction of those prescribed become addicted, and if a constant fraction of those people die. It is possible that the pain of the less educated is more suitable for opioid treatment, but we see no evidence of it. Something else is going on.
Here is our own account and interpretation of what happened.
While there was plenty of misbehavior and greed by all of the players in the drama, we think it is a mistake to think of doctors as little better than drug dealers. Certainly, there were some doctors who took the opportunity to operate “pill mills,” selling prescriptions for cash (or for sex) without examining or even interviewing the “patient.” Many of those doctors are now (or have been) in jail. But few physicians are corrupt and, given the state of medical knowledge in the mid-1990s, they had good reason to prescribe opioids to patients in pain, and little reason not to. Our guess is that it is true that the appropriate dose of opioids for acute pain relief is not, in and of itself, very likely to lead to addiction. Nor will it do so for those who are terminally ill. The appropriateness of the drugs for the long-term treatment of chronic pain is another matter. Clearly, there are exceptions where appropriate short-term prescription led to addiction. One was the case of Travis Rieder, a philosopher and bioethicist at Johns Hopkins in Baltimore, whose left foot was crushed in a motorcycle accident, who was prescribed ever-increasing doses to control his pain after multiple surgeries, and who escaped his addiction only with terrible difficulty and with no help at all from the doctors who had prescribed the painkillers. His story is worth keeping in mind as a cautionary tale of what can happen. Addiction is extraordinarily hard to overcome under even the best of circumstances.
However, it is simply false that a single injection of heroin will immediately and inevitably addict anyone and everyone. It is estimated that around a million people in America today use heroin daily or near daily; most of them not only do not die but in fact live functional lives. Many “mature out” of their addiction, and many others quit by themselves, with medical treatment or with social support.
During the Nixon administration, there were reports from Congressmen Robert Steele and Morgan Murphy, who on an official visit to Vietnam in 1971 found that servicemen were using heroin. Nixon immediately declared that heroin addiction was the nation’s number one public health problem. Servicemen could be compelled to take urine tests, and the results—in line with the soldiers’ own reports—showed that 34 percent had tried heroin and as many as 20 percent were addicted. Much to the surprise of the investigators, 38 percent were using opium. (More than 90 percent used alcohol, and three-quarters used marijuana.) Those who tested positive were detoxed and urine-tested before being allowed to go home, a powerful incentive to get clean. The program became known as Operation Golden Flow, and its veterans were followed up once they got home. Only 12 percent returned to opioid addiction in the US within three years; in most of those cases, the readdiction was brief. Perhaps the detox was successful; it was not expected to be, so if it was, it was much more successful than detox usually is. Perhaps it was because, under the stress of combat, opium and heroin offered some relief. But most servicemen who used opioids started very soon after arriving in Vietnam, and those who had seen more combat were no more likely to use.
The most plausible story, and that of Lee Robins, one of the investigators, on whose description of events this account is based, is that these men used opioids because “they said it was enjoyable and made life in the service bearable.” They used opioids not to make combat risks tolerable—and they knew very well the risks of being high in combat—but because they were bored out of their minds. When they returned home and were no longer in the army, there were other means of enjoyment, and life made sense and was bearable without drugs. The environment matters. The drugs were also extraordinarily cheap in Vietnam. The daily triggers for use in Vietnam were absent at home, and because the men were detoxed in Vietnam rather than at home, the detox-readdiction cycle was broken by geography. Robins argues that the widespread perception of heroin addiction comes from the fact that so many studies have been done on special populations that are more likely to be addicted in the first place, and not on more general populations such as those who served in Vietnam.
It is something in people’s lives that drives them to seek euphoria or numbness through drugs, not some inherent property of the drugs themselves that will addict anyone who touches them. It is impossible to understand drug use without understanding the environments in which users live, and how those environments are treating them and have treated them in the past. As one physician put it to us, biographies matter. We give our own account of the disintegration of working-class lives in chapters 11 and 12.
Few doctors were or are directly addicting their patients. But they were perhaps too ready to believe the claims that opioids provided more successful long-term relief than the earlier, interdisciplinary approaches. Indeed, there has been little such evidence, and we note again that national levels of pain have been rising, not falling, though the latter would be expected if these drugs were usually effective, given the enormous amounts being prescribed. Physicians are rightly responsive to the pain of their patients and may not consider the wider social costs of prescriptions. They were also exposed to great pressure by the manufacturers, through direct marketing and well-funded “educational” campaigns, and through advocacy organizations for pain sufferers, some of which accepted large donations from pharma. (These fake or infiltrated grassroots associations are sometimes referred to as “Astroturf” groups.) Physicians prescribed strong opioids in numbers beyond those needed, at times to patients who did not need them at all, leaving unused pills that could find their way onto the black market, itself evidence against inevitable addiction. They also prescribed to patients who intended to resell the drugs rather than use them, and who shopped for doctors until they found one who would write a prescription. Doctors try not to prescribe to such people, but it is unclear how they are supposed to know, particularly given the time pressure that they face, and even people who are at risk and have a previous history of abuse can be in real pain. Doctors were being asked to police and prevent abuse in a way that was beyond their ability under the circumstances in which they work.
Some commentators have argued that the rollout of Obamacare was in part responsible for the epidemic, that the expansion of Medicaid made opioids more widely available. But the timing on this is wrong, because the epidemic was in full swing before any Medicaid expansion. By contrast, Medicaid has played an important role in making available affordable treatment for people with opioid abuse disorder, with levels of therapy much higher in states that expanded Medicaid after 2014.
The producers, directly and through prescription benefit managers, did everything possible to increase sales and profits, even when it was clear that the drugs were being abused. In one two-year period, nine million pills were shipped to a pharmacy in Kermit, West Virginia, population 406. Between 2007 and 2012, according to a report by the Energy and Commerce Committee, “drug distributors shipped more than 780 million hydrocodone and oxycodone pills to West Virginia.” According to an investigation by the CBS program 60 Minutes and the Washington Post, when the DEA, which is charged with stopping such abuse, tried to do so, Congress passed the 2016 Ensuring Patient Access and Effective Drug Enforcement Act, whose language effectively prevented the DEA from stopping the flood. President Donald Trump then nominated one of the moving forces for the bill, Representative Tom Marino of Pennsylvania, to be his drug czar. Marino withdrew in the face of public outrage after the exposés on 60 Minutes and in the Washington Post revealed his multiyear effort to pass such a bill on behalf of the industry. The investigative journalism also revealed the role of an important “revolver,” D. Linden Barber, previously a senior lawyer in the DEA, who switched sides to advise the industry and help write the bill.
Johnson & Johnson, one of the best-known American pharmaceutical companies, supplied most of the raw material for opioid painkillers in the US from a subsidiary, Tasmanian Alkaloids, which grew poppies on farms in Tasmania. According to journalist Peter Audrey Smith, the DEA was aware of what was going on but backed off from closing the legal loophole at the request of pharmaceutical lobbyists. At a time when the American military was bombing the opium supply in Helmand province in Afghanistan, Johnson & Johnson was legally growing the raw material for the nation’s opioid supply in Tasmania. In August 2019, Johnson & Johnson was ordered to pay $572 million to the State of Oklahoma for its role in fueling the epidemic. The company is expected to appeal, but other suits are pending.
We tell these stories because they illustrate the failure of democratic politics to address the opioid epidemic. Marino’s district was heavily affected by opioids, as was that of one of the bill’s sponsors in the House, Representative Marsha Blackburn of Tennessee. Yet they fought against effective regulation, not for it; money and pro-business ideology subordinated the voices of those who had been addicted or were dying. The scandal did not prevent Marino being reelected to Congress in 2018, but he resigned in January 2019 in the face of ill health. Blackburn was also reelected and is now the junior senator for Tennessee. Senator Orrin Hatch, a lifelong friend to a pharmaceutical industry that long supported him, smoothed the bill’s way with the DEA. For forty-two years, Hatch represented Utah—a state whose drug-induced mortality rate increased sevenfold between 1999 and the signing of the bill into law in 2016.
The epidemic would not have happened without the carelessness of doctors, without a flawed approval process at the FDA, or without the pursuit of profits by the industry at whatever human cost. The story of that industry, unrestrained and running amok, is being told in American courtrooms today as pharmaceutical executives are being pursued for accountability and compensation by nearly two thousand municipalities. One case, settled in May 2019, saw the conviction on federal racketeering charges of five top executives of Insys Therapeutics, whose salespeople bribed doctors to prescribe fentanyl to patients who did not need it.
Our story is that the misbehavior poured fuel on the fire, making the epidemic worse, rather than creating the conditions under which such an epidemic could take place in the first place. The people who used the opioids, the many millions who became opioid abusers or became addicted, who became zombies walking the streets of once-prosperous towns, were those whose lives had already come apart, whose economic and social lives were no longer supporting them. The supply side of the epidemic was important—the pharma companies and their enablers in Congress, the doctors who were imprudent with their prescriptions—but so was the demand side—the white working class, less educated people, whose already distressed lives were fertile ground for corporate greed, a dysfunctional regulatory system, and a flawed medical system. The opioid epidemic did not happen in other countries both because they had not destroyed their working class and because their pharmaceutical companies are better controlled and their governments are less easily influenced by corporations seeking profits.
Corporate Power and Individual Wellbeing
One of the themes of this book, which we address at length in later chapters, is how the American economy has shifted away from serving ordinary people and toward serving businesses, their managers, and their owners. Government and the law have been complicit. This chapter, on opioids, provides a dramatic example of this general process. Later, we focus largely on the mechanisms that redistribute money upward, away from working people, and toward firms and their shareholders. The American healthcare industry is the prime example, even beyond the opioid manufacturers and distributors. Their behavior, for which, as we write, they are being called to account in the courts, is not typical, but the use of market power to bring about upward redistribution, from a large number of people with little, to a smaller number with a great deal, is symptomatic of the industry and, more arguably, of American capitalism more generally. The beneficiaries are not only the rich people who are large shareholders but also the many members of the educated elite who hold stock indirectly in their retirement funds, and who benefit from anything that increases corporate profits, including lower wages. We shall argue that this process, run out over half a century, has slowly eaten away at the foundations of working-class life, high wages and good jobs, and has been central in causing deaths of despair. The opioid story fits with this more general theme but is much more flagrant, because it is rare that corporations can so directly benefit from death.
We do not believe that the FDA has been captured by the industry. Even so, much went wrong with its approval of opioids, especially Oxy-Contin. The FDA (and the general public) greatly reveres the randomized controlled trials that are required to demonstrate that drugs work, but even here there were problems with opioids. Those who were in the control group for OxyContin—the randomly selected group that did not receive the drug—had previously been taking OxyContin in an earlier phase of the trial, called the open-label phase; this is done to exclude from the trial those who cannot tolerate the drug. In this type of trial there is a “washout” period between the two phases, in which the drug is supposed to wash out of the patients’ systems. The danger in the case of OxyContin (or any addictive drug) is that if the washout period is not long enough, some of those in the control group, no longer receiving the drug, may suffer withdrawal symptoms, which would make them look bad relative to those who go into the treatment group and receive it again. Moreover, the exclusion of those who, in the earlier, open-label phase, could not tolerate the drug means that the trial understates the rate of problems in the wider population for which the drug will be prescribed. Manufacturers are allowed to discuss these and other aspects of trial design with the FDA before the trials are run.
More generally, and as has been correctly argued by a panel of the National Academies of Sciences, Engineering, and Medicine, a testing and approval process that looks only at what these drugs do for individuals ignores the broader effects of releasing a powerful and highly addictive drug into society. It is a lot to ask the FDA to anticipate everything that happened after its approval of OxyContin, but the failure of a system that does not consider the public health consequences of approving the drug is surely inexcusable. After all, the FDA was essentially putting a government stamp of approval on legalized heroin.
The opioid story shows the power of money to prevent politics from protecting ordinary citizens, even against death. Until 2019, at least, when rising public outrage eventually changed perceptions, those who got rich were neither ostracized nor condemned but rather recognized and lauded as successful businesspeople and philanthropists. Purdue Pharmaceutical is the leading example. The Sackler family name appears on museums, universities, and institutions, not only in the US but also in Britain and in France. Arthur M. Sackler, who died before OxyContin was developed, was the donor to many of the institutions, including the Metropolitan Museum in New York (the Temple of Dendur), Princeton University, the Smithsonian, and the National Academy of Sciences. Sackler’s fortune came from developing the system of pharmaceutical advertising and sales that is in place in the US today. In the words of one commentator, “Most of the questionable practices that propelled the pharmaceutical industry into the scourge it is today can be attributed to Arthur Sackler.”
Arthur Sackler’s brothers Raymond and Mortimer, together with Raymond’s son Richard, controlled the company during the launch and marketing of OxyContin. Both Raymond and Mortimer were knighted by Queen Elizabeth in 1995, an uncanny echo of Jamsetjee Jejeebhoy a century and a half before. Like an eighteenth-century wig, the perfume disguises, but does not eliminate, the stench of moral decay.
The Queen would be unlikely to convey these honors today. Most of the organizations just listed have stopped using the Sackler name—sometimes after resisting the step for years—and others have said that they will accept no more money.
The pharmaceutical companies, having made so much money from creating the crisis, now stand ready to profit from its treatment. There are no easy or surefire cures for addiction, but the best available—albeit on relatively weak evidence—is known as medication-assisted treatment (MAT), whereby those with addictions use different opioids (methadone or buprenorphine) to control their craving while quitting. While we suspect that MAT is likely being oversold, because the demonstrations of effectiveness come only from patients who admit to their addiction and seek treatment—which many do not—and because a substantial fraction drop out along the way, it has an advantage over abstinence-only treatment because relapsing from the latter is often how overdose deaths happen. Those who have been clean for a while will lose their tolerance to the drug and can die after relapse from the same dose that they used when they first quit. Even so, it takes a strong stomach to watch pharma and their allies push MAT so that they can profit both by causing the epidemic and by curing it. Indeed, in the summer of 2018, Purdue Pharmaceutical was granted a patent for a variant of MAT, setting itself up to repeat its earlier success with OxyContin. It is as if the poisoner of the water supply, having killed and sickened tens of thousands, were to demand a huge ransom for the antidote to save the survivors.
What of the lawsuits against the pharmaceutical companies that are raging as we write? These will permanently reduce the supply of prescription opioids, a reduction that is already under way. They will do little to reduce the use of illegal drugs, and may even increase it, as demand switches from legal to illegal sources. The settlements will probably bankrupt some companies, including Purdue, though others have easily paid large fines in the past out of their even larger resources, or by raising the prices of their drugs. Purdue is trying to retain control over its European subsidiary, Mundipharma, in order to continue the business elsewhere in the world, just as the tobacco companies have done. Whether the states and localities that receive the payments will use them well is not clear. A not reassuring parallel is the Master Tobacco Settlement of 1998 between states and tobacco companies. Since then, the states have received hundreds of billions of dollars from the companies—paid for by the predominantly poorer and less educated Americans who smoke—but have used nearly all of it for general revenue and thus to reduce property and income taxes. In the case of opioids, the surviving companies have the ability to raise prices, making healthcare even more expensive, so that, once again, it is ordinary people, those who pay for healthcare or health insurance, who will be paying for the transfers to the states who win the verdicts. Nor will the payments do much to incentivize the companies to change their behavior. Only admissions of wrongdoing and criminal verdicts against executives are likely to do that, and such verdicts, although not unknown, are rare.
The benefits of free-market capitalism are often rightly noted, including its ability to give people what they want, its incentives for innovation, and its ability to promote economic growth. We agree. But the American medical system, including the pharmaceutical industry, is nothing like a free market. The existence of moneymaking corporations does not imply competitive free markets. Instead, these highly regulated corporations are largely concerned with seeking protective regulations from government and government agencies to protect their profits and limit competition in a way that would be impossible in a free market. We are certainly not arguing for a free-market solution to the American healthcare system, only that what we have now cannot be defended as a free-market system. It is outrageous when an industry that makes so much from corrupting free-market competition should be able to dismiss its critics as opponents of free markets. There is nothing antimarket about condemning theft. Other countries have a range of other ways of organizing healthcare, all have their strengths and weaknesses, but none are killing people. None are supporting “the brazen subordination of human need to human profit.”
It would be a tragedy if the profits of the drug trade were allowed to corrupt America and were later seen, as was the case in China a century and a half ago, as the beginning of a hundred years of humiliation and decline.