Our society is in the throes of a devastating opioid epidemic. Data from the Center of Disease Control reveals drug overdose deaths nearly tripled from 1999 to 2014. Of the 46,055 deaths that occurred in 2014, 28,647 (60.9%) involved a narcotic. Drug overdose deaths increased again in 2015, exceeding 52,000.
While the magnitude of these numbers is startling, the individual deaths are not mere statistics. Nearly all of us know among our family, friends, and co-workers one or more persons who have died from a narcotic overdose, and the subsequent anguish and heartbreak that death caused.
So, who is to blame for this epidemic? The accepted narrative is that careless physicians inappropriately prescribed painkillers to their patients, and that these highly addictive medications were the “gateway” to the abuse of more dangerous narcotics including heroin. This analysis of the problem has lead the government to ramp up the War on Drugs and to regulate physician treatment of pain problems. However, there is significant prescription and epidemiological data suggesting that something more deep-seated and complex is happening.
Physicians in Canada and England often give diamorphine (the chemical name for heroin) to persons after surgery or trauma, and sometimes for prolonged periods. Yet, the use of such powerful opiate has not resulted in high addiction rates in those countries.
A 2016 American study found that in a group of 640,000 patients with no prior history of narcotic use who were prescribed narcotics after surgery, the incidence of chronic opioid use over the next year ranged between 0.12% to 1.4% depending on the procedure performed. Another study of 675,000 patients undergoing urologic procedures treated post-operatively with narcotics resulted in chronic opioid use in only 1 in 1,111 persons (<0.1%).
The National Survey on Drug Use and Health – a survey of 10s of thousands of Americans found that 1 in 130 prescriptions of opiates resulted in addiction. That same survey found that less than 25% of persons misusing opioid medications started with prescriptions from doctors, while over 50% started with a pill given by a family member or friend.
All of this is not to deny that physicians at times have prescribed narcotics without adequate care, or to ignore the fact that there are persons who have a biochemical predisposition to drug or alcohol dependency; but rather to say, something more than the addictive power of opioids must underlie this deadly abuse epidemic.
Addiction and death rates vary significantly across the country with rates highest in the Rust Belt and economically depressed rural America. For instance, in 2013, Kentucky, Rhode Island, and Nevada had particularly high rates of unemployment, and also of narcotic overdose. A recent National Bureau of Economic Research study found that in a given county, a 1% increase in unemployment correlated with a 7% increase in narcotic related ER visits and with a 3.6% increase in narcotic related deaths.
As it turns out, opioid overdose deaths are part of a broader trend of increasing mortality, reversing a decades long trend of longer life expectancy. The US mortality rate had been dropping steadily at 2% annually from1970, but that progress stopped at the millennium. A startling 2015 investigation by economists Angus Deaton and Ann Case of Princeton University found the mortality rate for white Americans between the ages 45 to 54, increased by a half percent each year from 1999 to 2013. Drilling down further into the data revealed that not all in this demographic suffered increased death rates, but primarily those without college educations.
The study also found that among this population who are dying younger, there are lower rates of labor force participation and of marriage. They have higher reports of physical pain, poor health, and depression. Additional research found that half of all working-age, unemployed men in America are taking pain medication—and two-thirds of them are taking prescription painkillers. While not the primary cause of the increased death rates, opioids along with other drug overdose, suicide, and alcoholism have been the means of what the authors have called “deaths of despair”.
Another analysis has found that after the Great Recession of 2008, mortality for persons between the ages of 25 and 44 had risen an astounding 8% between 2010 and 2015. Again, drug overdose, alcohol abuse, and suicide chiefly accounted for that increased mortality.
The results of a successful Swiss addiction program reveal principles to more effectively treat opioid abuse, and further lend credence to the hypothesis that despair and disaffection underlie this crisis. Beginning in the early 2000s, narcotic-addicted Swiss were referred to clinics where they could get opiates twice a day under medical supervision. Additionally, they were given counseling, and help finding a job and housing. These individuals could stay in the program as long they desired. Ultimately though, nearly all program participants made the decision to stop using as they turned their lives around.
Finally, though obvious, it needs to be pointed out that to effectively address the opioid crisis, or any problem for that matter, a proper understanding of causation is necessary. Faulty analysis of causation can only lead to faulty solutions. Government regulating physician care of pain is likely to make the situation worse, not better. Certainly physician reexamination of how to more safely use narcotics for treating pain needs to be and is being done; however, the fundamental issue is not opioids but rather a societal collapse and despair. Opioid and other drug overdose, alcohol abuse, and suicide are the manifestations of that collapse and despair.
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