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I- Why Don’t Other Western, Developed Countries Have the Same Problem?
I generally don’t like breaking posts up into parts, though I’m frequently glad when I do because it often produces the best comments. If I’m in the middle of saying something then it’s more productive to interject a point or a question because it’s easier to incorporate it into what I’m already working on than it is for me to reopen a subject.
The most interesting comment was left by Zach who pointed me at a tweet, from Max Roser, the founder of Our World in Data, which claimed that the dramatic increase in overdose deaths I talked about in the last post is strictly a US phenomenon. I confess to being embarrassed that I didn’t come across this assertion before starting my examination of the drug crisis. In particular I’m surprised that it was not mentioned in any of the books I read. I think it’s pretty easy to fall into a US centric view of events and issues, which is probably what happened to the authors of the books I read, and it’s definitely what happened to me. Regardless, now that it’s been brought to my attention it deserves a deeper discussion.
I went to the Our World in Data page the tweet was referencing, and I can’t seem to find the exact chart Roser was using, the one that allows you to compare total overdose deaths by country. If someone else can, let me know. But I can pull a breakdown of the type of overdose deaths (opioids, meth, cocaine, other) by country, and I think the situation is a little bit more complicated than Roser claims. First off when I compare Canada and the US on this website, the percentage increase is pretty similar. Taking the period from 1999 to 2019 (the last year on the site) Canada’s opioid overdoses increased three-fold as compared to a five-fold increase in the US. The US is still worse but it appears more a matter of degree than of kind.
Roser does include Australia on his chart, which is something, since Australia, unlike the other countries he included for comparison, had a bulge around the turn of the century, but then overdose deaths went down till around 2010 when they started to climb again. But once you look at the breakdown of deaths, Australia appears to have its own unique story to tell, because it’s the only country (as far as I can see) where overdose deaths from “other” drugs are higher than deaths from opioids. I’m not sure what the unique story is behind this phenomenon, but in five minutes of searching it looks like they might have a particularly bad problem with benzodiazepine and antidepressant overdose deaths.
There are other countries which have seen the same steady upward trend as the US and Australia, but which do not appear on Roser’s chart, these include Finland, Sweden, and the United Kingdom. Also all the Latin American countries I looked at had a steady upward trend of overdose deaths. I don’t want to accuse him of cherry picking countries, but I think he has definitely left out some elements which complicate his narrative. This is of course the whole problem with Twitter. But, despite all of this, his central point stands, some countries are doing much better than other countries. Though I would say that the US is not quite as unique as he claims.
The next step in this process is to determine why some countries are doing better than others and why all countries are doing better than the US. Roser offers up a Vox article which claims that the reason the US is uniquely bad is that drug programs in the US eschew medications like methadone, buprenorphine and naltrexone in favor of the 12 step program and other non-pharmaceutical interventions. I’m sure this is part of it, but does this same aversion also exist in Canada and the other countries I mentioned? I don’t have the time to research the various drug treatment regimens in all the different countries, but I’d be surprised if all these countries with their different cultures and medical setups just happened to all have the same aversion to these drugs. That Sweden and Finland have a policy similar to the US, but that Norway, sitting between them, does not.
One answer a lot of people would give is that it has to do with the US healthcare system, which makes drugs uniquely profitable. While presumably Perdue Pharma could sell Oxycontin everywhere, the incentive to set up pill mills only existed in the United States. But then you still have to explain Canada, which has a single payer system. Certainly proximity to the US was a factor, but part of my point in the last post is that technology and progress have made every every location proximate.
This brings up the possibility that the US is on the leading edge of this trend, Canada is close behind and other countries will soon follow. While we just talked about distribution, “marketing” (for lack of a better term) is also a big factor in this upward trend. We can see it play out within the US, where for a very long time opioids were primarily a problem of white America. But recently black Americans have overtaken white Americans in opioid death rates. With the “white” opioid market effectively being saturated, it was predictable that dealers and distributors would turn to marketing to black Americans. Something similar may be coming for those countries that have thus far escaped the drug epidemic.
Pulling all of this together, my theory at this point would be that once you’ve lost control of opioids it’s difficult to regain that control. That this is what happened in the US, and in other countries where deaths are rising. Perhaps a related thing happened in Australia, they lost control of benzos and that’s how more people are dying from benzo overdoses than from opioid overdoses. (Of course it could also be an artifact of how they collect statistics.)
I’d like to end this section by talking about China. There are actually two things worth mentioning. The first is their role in the US’s fentanyl problem, which, despite the increase in deaths from all the other drugs, is clearly the drug causing the single biggest problem. And according to the DEA, who’s the primary provider of that drug? China, at least as of January of 2020. This is obviously important for a lot of reasons, but while I was in Vegas hanging out with a friend of mine, he brought up one that I had inexplicably missed. It’s hard to overstate the role the Century of Humiliation plays in Chinese thinking, and of course one of the biggest humiliations during that period was the Opium Wars, when the UK forced China to import opium. For a country that is trying to shake off those humiliations, a reversal of that flow, pushing opioids into the US, is too perfect to resist. I am not claiming that this was a grand conspiracy, more that it was a fortuitous opportunity which was too lucrative to pass up, and is now too symbolic to do anything substantial to stop. And, as we’re seeing, China has significant power to stop things. Which takes us to the next point.
In looking through the charts it does appear that China had their own significant problem with opioid overdose deaths in the late 90’s. Deaths started falling precipitously in 2000 and leveled out at about one-fourth their peak. To get the US death total back to where it was before the epidemic we’d have to decrease the total by an even greater percentage. Do you think the Chinese did it through the use of methadone, buprenorphine and naltrexone If not, which seems likely, do you think the methods they did use would work here? I suspect just like Chinese COVID mitigation policies, that we would also be unable to duplicate their opioid mitigation policies.
Speaking of COVID…
II- The Pandemic Made Things Way Worse
Even if the problem is mostly just a US problem it’s still a problem which needs to be solved, and we’ll get to that, but first I want to look at what happened to the problem during the pandemic, because I think it gives us clues to what kind of problem it is.
If you look at graphs of overdose deaths it’s possible to make the case that by 2017 things were plateauing. Roser’s charts conveniently end in 2017, since those were the most recent numbers available to him when he tweeted in December of 2019, which was also conveniently right before the pandemic. As I mentioned in the last post, 2018 was the first year since 1990 when deaths were down from the previous year. And if you adjust for population, 2019 also had a slightly lower death rate than 2017.
Of course, even if deaths were plateauing in 2018 and 2019, it was still a very high plateau, but even a high plateau would be better than having it continue to go up, year after year, which is what it had been doing. And of course one hopes that after it plateaus that it starts gradually coming down. But then 2020 comes along and deaths jump 30%, presumably because of the pandemic. This is the highest increase on record other than the 71%(!) jump from 1998 to 1999. And preliminary numbers for 2021 indicate that it kept going up, though the rate of increase appears to have dropped all the way to 28.5%… I made this point in a previous post, but at growth rates like that everyone in the country will be dead of a drug overdose by 2057, or 35 years from now. Obviously this rate of increase can’t continue for long, and it’s amazing that it continued for two years.
I bring all of this up for several reasons. First, to give you a sense of the scale of the problem. Obviously it’s bad, but it’s the rate at which it’s getting worse that’s truly alarming. Second, though this is tangential to my primary subject, it’s an interesting but also stark reminder that pandemic precautions were not cost free. I was in favor of most of the precautions that were taken, particularly at the beginning when uncertainty was at its highest, but no one should be under the impression that there are no trade-offs, and some of those tradeoffs consist of people dying, many from drug overdoses, but not all. Third, and most importantly, studying the manner and timing of overdose deaths, particularly when they’re increasing, might help us isolate the cause of those deaths and give us better tools for mitigation.
Furthermore, as long as we’re talking about the current state of the crisis, I came across one other point that was worth mentioning. A recent paper suggested that up to a quarter of the drop in labor force participation might be due to “increased substance abuse”. So the great resignation might be 25% due to people being addicted to drugs. I don’t have the time to go down that rabbit hole, but it seems like a very big deal.
I pointed out a lot of reasons in the last section for believing that the problem was not one that was unique to the US, but this is my biggest reason for being cautious. All the numbers I quoted above were from charts that ended in 2019. As I already pointed out all of Roser’s numbers were from charts that ended in 2017. I don’t think we’ll know the true scale of the problem either here or abroad until we have a full accounting of what happened over the last two years. And probably what happened this year as well. Do the pandemic overdose numbers represent a new plateau? Or are they a temporary peak, and we’ll fall back to the numbers of the late 20-teens. Or is it just going to keep getting worse as it has basically every year since 1990? I’d love to be optimistic, but so far the arc of the epidemic has always been worse than I predicted.
Of course the pandemic was awful, but why did it make overdose deaths so much worse? As in the worst year over year increase since the epidemic started. I assume that there are various possible theories, but I prefer the simple explanation: it was the loneliness. If one could associate any emotion with the pandemic, more than fear, more than frustration, more than anger at the idiots on the other side, the dominant emotion was loneliness. I’ve seen people call these overdoses “deaths of despair”. I’ve also seen people mock this idea, but when deaths go up by 30% one year, and then almost 30% the next year, and those years happen to coincide with a pandemic, I think calling them deaths of despair is probably pretty accurate. I would also accept deaths of loneliness, but I will not accept any explanation which doesn’t include some connection to the pandemic, and I haven’t seen any better ones on offer.
Pinpointing loneliness as the cause of the increase in deaths gives us our starting point for talking about how best to reduce those deaths.
III- The Best Way to Deal With the Problem
As I said, all of the information I collected in preparation for this post is from a US perspective. So to the extent that this is or isn’t a problem elsewhere, it isn’t going to enter much into the discussion, though I’m sure there will be some amount of overlap even so. But even should the problem be completely unique to the United States it would still merit serious discussion. Far more than it’s getting now.
To begin with we should talk about what doesn’t work. And it’s clear that top down governmental action is one of those things. Perhaps there was a time when it might have worked, but at this point I think it’s too late. The problem is too big and the addicts are too numerous. In the course of reading several books on the subject it became clear that the federal government, and specifically the FDA, is just too far easy to hack, and beyond that, because the US is the richest country in the world, not to mention the 3rd most populous, the rewards for doing so are enormous. This is similar to the situation that existed in the early days of the internet when there were numerous viruses for Windows machines, but very few for Macs. It wasn’t that Apple machines were significantly more secure, they weren’t. It was the fact that Windows machines were far more numerous.
Perhaps here we have stumbled on US uniqueness, not that we are uniquely bad at treating addiction, but that we were just the juiciest target for the three factors mentioned in the last post. Pharmaceutical companies were presented with a unique opportunity when the ideology of pain management changed, but where should they pursue this opportunity? Clearly if you were going to start making something like Oxycontin and begin marketing it, the only logical place was the US, and once you had a bunch of addicts, it was also the obvious target for Mexican heroin smugglers (in addition to being next door) and later for distributors of Chinese fentanyl. To reuse our analogy, the change in the terrain of pain management was the internet, and the US is Windows, the biggest attack surface. And as late as 2018 there were still more threats per Windows machine than there were for an individual Mac, but by 2019 that had flipped and there were twice as many threats for each Mac as opposed to each PC. Perhaps eventually something similar will happen, but for now, the US is still the best market for opioids the world has ever known.
The futility of expecting the federal government and FDA to do anything was brought home most starkly by the story of Insys, told in the book The Hard Sell. As I mentioned in my review, this was a company that started marketing a fentanyl spray in 2012, and did it for five years in the most egregious fashion imaginable before they were finally stopped. If the FDA wasn’t going to pay special attention to fentanyl in 2012, then it kind of feels like they are never going to be the solution to the crisis, nor do other arms of the federal government seem to be doing much better. I’m largely with people who believe that the War on Drugs has been a pretty massive failure. Of course most of these people conclude from this that we should legalize all drugs.
I had initially planned to spend a fair amount of time talking about legalization, but that time got taken up by dealing with the subject of differential death rates between the US and other western democracies, and given that this post is already late, I don’t have any additional time I can draw on. I will say that when I was young I was a really big fan of legalization. I remember a particular Bloom County comic strip (for those old enough to remember that strip) where drugs were legalized and all the associated drug violence stopped. The punch line was that a drug dealer was out on the lawn wondering what had happened to government price fixing, or something like that (I was unable to find the actual comic).
I am no longer so idealistic. The problem is how do we keep bad actors from abusing the system in the fashion of Insys and Perdue? One of the arguments has always been that with a legal market at least the drugs won’t be mislabeled or cut with some other, more dangerous drug, but Insys and Perdue produced completely pure product, and that didn’t prevent it from being a gigantic problem. Also the experience we’ve had with marijuana legalization is not encouraging. To take one example California legalized weed in 2016, but five years later 80-90 percent of the market is still underground. The same thing happened in the transition from Oxycontin to heroin, people were addicted to oxy which was available and legal, but expensive, so as a result they turned to heroin which was illegal, but cheap. I would love to hear a credible framework for legalization, even if it were politically infeasible, but I haven’t come across one. Now of course decriminalization is another matter, and I do think that has some real possibilities, which I’ll touch on in just a second.
Okay I’ve talked about all the things that don’t work, it’s finally time to talk about things which might work. Let’s start at the beginning.
While in Vietnam a significant percentage of soldiers ended up addicted to heroin, and there was widespread belief that upon their return that society would have to grapple with a massive addiction problem, but as it turned out once the soldiers were home the vast majority transitioned back to civilian life and their normal jobs without much fuss. While this was surprising, on a certain level it makes sense. You could imagine that, when faced by the horrors of war, someone might have no other option than to seek to dull things with an opioid, but that once they were home and away from those horrors that they would no longer be dependent on that stuff.
Despite this, and it’s not clear from the numbers how much of the problem was returning soldiers and how much of the problem was other things, from 1968 to 1969 overdose deaths went up by 19%, and from 1969 to 1970 they went up by 18%. 1971 is when Nixon started the War on Drugs and whether because of this or because of the ongoing drawdown of troops from Vietnam, or because something else, the number of overdose deaths stabilized and even dropped a little bit for the rest of the decade, until 1979 when deaths suddenly more than halved and stayed at that level for several years. (The per capita death rate didn’t surpass the 1978 level until 1993. I have no idea why this happened, and perhaps it’s an artifact of the reporting methodology being changed, but it is interesting to note that when Nancy Reagen was unveiling her “Just Say No” campaign that drug overdose deaths were about as low as they’ve ever been.
The foregoing history of overdose deaths in the 70’s and 80’s was mostly included because it seemed interesting. I’m not sure there are any morals to be drawn, particularly for the sudden drop in 1979, since I have no idea why it happened. Though one might draw the weak conclusion that the initial War on Drugs was not quite the abject failure people claim. No, what I’m mostly interested in, is the lesson of the soldiers returning from Vietnam and the vast increase in deaths during the pandemic, because both phenomena, though directionally opposite, touch on the only thing that seems to be working: being part of an involved community. Soldiers who were addicts in Vietnam were able to shake that addiction when they returned home (clearly not all, but the vast majority did). When people were deprived of community during the pandemic, overdose deaths which were already stratospheric went up even more.
This is a point Sam Quinones returns to again and again in The Least of Us, that what seems to work is when a town, or occasionally something larger decides to really engage with treating the problem rather than locking people up. When they establish special drug courts, de facto decriminalization through suspending sentencing while the defendant seeks treatment, of helping them with jobs, and giving them places to sleep. It’s when an individual addict can draw on the help of several engaged individuals. When, for lack of a better term they have a tribe to draw on. It was when these things were happening that Quinones saw people successfully recovering from their addictions. As he says in the final paragraph of his introduction:
That is what fueled this book—two stories that I set out to tell here. One is the story of an ominous die-off amid a global economy producing catastrophic supplies of dope cheaper and more potent than ever. The other is of Americans’ quiet attempts to recover community through simple acts, guided by the belief—the message of our addiction crisis to those who would notice—that the least of us lies within us all.”
Now I’m not saying this is easy, or straightforward. In particular, I don’t think I can boil it down to something easily digestible in the closing paragraphs of this post. If you’re curious you should probably read the book. Nor am I saying that this is the only possible way to do it. I’d be very interested in trying methadone, buprenorphine and naltrexone as part of a treatment plan. But if you have a bunch of different communities experimenting with stuff then presumably some community will try these drugs and if they work as well as has been claimed then they’ll keep using them and more communities will follow.
IV- Miscellaneous Points I Wanted to Cover but Didn’t Have Time For
This discussion of the failures at the lowest and highest levels, i.e. the failure of the federal government and numerous individuals reminded me of the central assertion of Why Liberalism Failed by Patrick Deneen: that we have hollowed out the middle of society. Certainly one could make the argument that that’s exactly what has happened with drugs. The federal government midwifed the problem into existence, individuals operating mostly alone acquire the problem and can’t shake it, and only communities acting in the middle can resolve the problems created by both ends. Problems that would not be nearly so bad if communities had maintained their historic strength.
They screwed up so badly with Oxycontin that, perhaps understandably, the entire medical establishment is now overreacting in the other direction—underprescribing opioids. While I do think that our primary focus needs to be on the harms of these substances, particularly while those harms still appear to be increasing, it’s important not to entirely lose sight of the benefits of opioids. One of my readers pointed me at a presentation made by a libertarian city councilor pointing out how difficult it is even for terminal patients in extreme pain to get Oxycontin and similar drugs now. That now everyone is assumed to be an addict. He also reminded me of Scott Alexander’s piece Against Against Pseudoaddiction which makes some related and very valid points. But, to go back to my argument, you could imagine that this also might be something that a strong middle is better at. It’s much easier to prescribe Oxycontin to someone that has the support of a whole community, a community you might very well belong to, that to prescribe them to someone you just met.
A big part of this whole discussion is the idea of hedonic calculus. You can imagine that people feel much happier when they are pain free, but if that comes at the cost of dying early from an overdose how are we to balance those two things? This is why the question of giving opioids to those who are dying is easy “yes”, and the question of whether we should have given opioids to people who ended up dying prematurely an easy “no”. But what about all the space in between? To illustrate I’ll end with a story.
One of my college friends, actually my roommate, had pretty bad back problems and was put on Lortab, which is hydrocodone and acetaminophen. I don’t know if he was overprescribed Lortab, or if he had problems getting it, but he ended up taking a lot of it. Even today doctor’s are less worried about prescribing it because the acetaminophen is supposed to make it difficult to abuse. Because it will destroy your liver. Well that’s what happened to my friend, he died of what the doctor’s said was alcoholic hepatitis, and while I’m sure alcohol contributed, I think it was mostly the acetaminophen. And as a result he died when he was 40. If he had been taking heroin he might have actually lived longer, and one wonders if, in the final analysis, whether it would have been a better life.
I still think about him, a lot.
That ended on a sad note, and of course the whole subject is sad. But sometimes being sad is good; it spurs you to reflection or even action. I kind of doubt that action will be donating to this blog, but on the off chance that is precisely the action it inspires, here’s a link.