Given that this article only touches on the supply of these drugs, is there a tacit assumption that the demand for opioids is driven by unemployment? If so, what can be done about the demand for these drugs in the long term? "Bringing back jobs" to those people whose comparative advantage is no longer manufacturing by taxing robots or imposing tariffs is a temporary stall, and to the degree it does work it amounts to a fat, inefficient handout.
Fighting the "epidemic" at the supply level seems like a losing battle, as it is for the hard drugs that plague inner cities. Addressing it at the demand level has to be the answer, but I don't see any possible answers floated.
I think its more dissatisfaction with life in general, with unemployment maybe being one of many triggers.
You're probably right about addressing at the demand level. But, I see the problem being more societal - think no one really understands everything. You take away self-reliance of people (whether they realize it or not) at many levels... its cheaper to get some good-enough quality food at 13 places near my home, so why should I learn to cook. I can get any vegetable I want at the store, so I probably don't need to learn how to tend a garden. In both instances as examples I'm losing a little control of my life. And then....
TV gives me entertainment, and the internet even more so, so maybe i'll just sit back and let it entertain me. So maybe I don't need to read anymore. Its easier to have short non-contextual entertainment bits, which rewire my brain further to think differently [wrongly?]... [0]
And, now capitalism has made all margins of businesses so slim that there's no real way to enter a business and still have a safety net in case you fail. You either need to disrupt an industry, create a marketplace, find a niche, or fail hard.
I think we're just starting to see the uglier stuff here. Short of some great awakening I also don't see the correct prescription. Pun intended.
Postman's book is now 32 years old! I read it as a teenager, which dates me...
I'm not sure about the Amusing Ourselves To Death stuff or the tut-tutting about cooking and gardening, but overall, though, I think you're on the right track. I'm sure that between automation of both manufacturing and services, big-box retailers and the fact that the covering of the 'long tail' is done very well by web-based business. It's hard to picture what a lot of people are going to be able to do in this circumstance and there seems to be the real potential for a cascading unpleasantness.
If you even half-believe the 'technological unemployment' worry, the scary part is that the non-automatable jobs that involved providing goods and services to those displaced by technology will also suffer.
There may be plenty of spare time for people to have that 'great awakening', whatever that might turn out to be.
two examples of many, admittedly probably too personal. Others: technology obsolescence, and the move toward not actually OWNing anything so nothing to learn to repair.
>>If you even half-believe the 'technological unemployment' worry, the scary part is that the non-automatable jobs that involved providing goods and services to those displaced by technology will also suffer.
Yes... My context is now that as a parent, I'm seeing windows closing for the kids' future that I had. I mean programming (maybe; I hope) and robot repair will be very lucrative. So will professions like plumbing and electricians.
I feel the 'parent context' too. I have kids old enough to be thinking more seriously about what they want to do when they group up (i.e. early teens) and it's difficult to know what to tell them. I suspect that many of the hopefully lucrative paths you mentioned will be things that gets more and more 'sealed' and routinized (i.e. robot repair == "remove broken assembly, put in new assembly, send broken assembly to factory in low-cost geo for salvage/repair").
It's not all doom and gloom, of course, and I think it's important to maintain a positive outlook esp. in front of one's kids when talking about this stuff. And of course, the growing helplessness and screen addiction of many of their peers suggests that in competitive terms, finding and holding a good job might be easier and easier (which isn't very encouraging overall, but appeals to the "amoral familism" streak I occasionally get).
> And, now capitalism has made all margins of businesses so slim that there's no real way to enter a business and still have a safety net in case you fail. You either need to disrupt an industry, create a marketplace, find a niche, or fail hard.
While this is true, phrasing it like a critique of capitalism seems very, very weird. As if in a socialist or communist society starting a business is supposed to be easier and margins larger. (Disclaimer: I have founded two failed startups to date, still living on friends' couch after the second one now).
Fair enough, I think I mean distribution of wealth. Capitalism is VERY good at moving money up. But, lately, in America, there's been not enough ways to get money going back down.
You're phrasing it as if you're comparing it with something. Have you ever lived in a communist country? I have yet to see a "redistribution of wealth" system that actually distributes more wealth than it lives for itself.
> Seems like attacking the supply is great place to start.
That is what was done, transferring the demand to heroin as opposed to oxy. Also, focusing on the supply side of things is the last 30 years of US policy: it's not worked effectively, and has a concomitant effect of incentivizing black market dealers to be wealthy and power. It'd be better to sell OTC heroin than to fund violent gangs, just in the name of limiting side effects.
Pills were given out like candy, then restricted which caused demand for cheaper alternatives. Had the drug companies been regulated in the first place, we might be OK.
The pills aren't coming from mules or cartels, they are coming from US companies. The pill supply has to lowered.
However now the US made that mistake, what's the problem with continuing to give out the pills "like candy", although with tighter controls to make sure that they don't go to create new addicts?
For people with short term pain, or who are at the end of life, opioids can be a good choice.
For people with long term pain opioids can, rarely, be a good choice, if other things have been tried first, and if there's a careful package of care.
Most people with long term pain need variations of / combinations of:
1) Access to evidence based pain management specialist clinics
2) Graded strength building exercise (for musculo-skeletal, not for nerve)
3) Medication that isn't opioids
Giving opioids to people with long term pain isn't a good way of controlling their pain (they develop a tolerance) and risks severe harm (on top of addiction).
Here's a website from the English Faculty of Pain Medicine, which is part of the Royal College of Anaesthetists. They explain it far better than I can.
I'm not sure if this is inherent in your #1, but there should be an increased focus on alternative methods for dealing with pain. For instance, since starting meditation training, I haven't needed so much as a single Ibuprofen. It's not that my incidence of pain has decreased, but my way of thinking about/reacting to that pain has changed dramatically and I can now make just about any pain quickly fade into the background. It's also helped me to clarify the difference between pain and injury to know when I can push through the pain and when I need to pull back and rest.
I learned an important lesson, however. Doctors will frequently use the amount of pain someone is experiencing as a diagnostic aid when determining a patient's diagnosis. I had a ruptured eardrum that I saw a doctor for and that doctor misdiagnosed it because I wasn't showing any signs of pain and that injury is supposed to be excruciating. The doctor explained to me that if it was ruptured, I'd be near tears and screaming for pain medication.
Yes, I agree. Whenever I've mentioned cognitive behaviour therapy for pain control, or meditation for pain control, it derailed conversation into discussion about pain that was "real" or "all in the head", with some people refusing to see that in some cases there's no difference: the patient is in real pain, the pain is debilitating, and the treatment has a psychological component.
some possibly sunny news: experiments with a new fentanyl-derived opioid that acts only as a local analgesic and doesn't cross into the brain, meaning no high, non-addictive, and one can't overdose. this is very preliminary (rat experiments) but i'm hopeful:
They don't need to be given out like candy. That's the point. The supply needs to be drastically reduced to prevent new addicts and we should be looking at what other countries are doing for their existing addicts: safe injection sites etc.
> Had the drug companies been regulated in the first place, we might be OK.
What are you talking about? Everything in medicine is highly regulated. Introducing a new drug is a very expensive process, run in the US by the FDA. It takes all sorts of expensive tests and trials to be allowed to sell a new medicine in the US.
Maybe the process messed up in this case. Sure. Many things are possible. But this was regulated start to finish.
MD's are often compensated based on patient assessments. "Rate your doctor" sort of things. How do you think opioid addicts rate doctors who tell them they have had enough?
I agree with the substance of your comment - opioid over-prescription is a huge problem.
The stat though about Kermit, West Virginia example has to be due to fraud and illegal sales, though? Or include vastly more people within the area covered by its pharmacies and/or doctors, which ever the data source used?
Otherwise each person in that town is receiving (on average) 31 pills/day. Maybe I wildly misunderstand hydrocodone prescriptions, but dozens of pills per day seems to be an excess.
I agree that opioid over-prescription is an issue, but I imagine some of these numbers are being inflated by similar "pill mills" run by unscrupulous doctors.
We have the numbers because the DEA tracks it. Why they didn't look into the numbers is beyond me.
Manufacturer seems to have played a role too by sticking to dosing they knew was ineffective and then pushing for higher doses which lead to big bonuses: http://www.latimes.com/projects/oxycontin-part1/
[Apologize for the back-to-back EconTalk plugs, but I really enjoy the show!]
This EconTalk episode on Narconomics goes into a great deal of detail regarding exactly how structurally broken the supply-side attacks are; I found it quite fascinating!
The root cause was the never-allow-pain mantra of the 90s when it came to proscribing painkillers like Oxy; this was followed years later by a later tightening of prescription policy that led many to look to Heroin as an alternative.
You have to understand the context of what you call "the never-allow-pain mantra". The drug warriors had gotten us to the point where you couldn't get treatment for pain. Doctors were harassed out of prescribing opiates and would give you Tylenol for back surgery. People in hospice were allowed to spend their final days in terrible pain.
And now we're heading back in that direction. For some reason we can't seem to stop in the middle somewhere.
> For some reason we can't seem to stop in the middle somewhere.
After observing this country 20+ years I have concluded that extremes rule. Nothing ever ends up done via a measured and calculated approach, always extremes. You can see that in politics, economic distributions, rules and lack of there of (deregulation). It's not just today; I've been reading a fair amount of history and it's like in the DNA of the country.
The resulting crackdown did exactly what you said, drove people straight into the open arms of heroin.
Tightening the already tightened restrictions would only worsen the issue.
Diversion, etc cannot be stopped and you might just see a sudden uptick in pharmacy truck heists like the one that happened five or so years ago. Corrupt pharmacists unable to resist the temptation of easy money, etc.
Or worse, heroin continues to spread like wildfire. Heroin has no QC, it's being cut with fentanyl across the country and addicts are dropping like flies. Sicker addicts have been seeking out these OD stories and score from those areas looking for the fentanyl cut H. It's bad and only getting worse, as if the government overcorrected its steering and has now spun out of control. The result is going to be a grisly accident.
I just go laparoscopic surgery. I told them multiple times I didn't want to use opiates to manage pain, that I wasn't in very much pain, and they still gave me iv fentanyl, and about 150 Vicodin tablets to take home. They asked me if I had an opiate problem, like turning down opiates meant that I had some kind of drug issue. It was bizarre.
I've had Vicodin prescribed a couple of times. I never felt it did much. Certainly didn't make me high. I don't see how it's a gateway to opioid addicion unless you're eating them like candy from the get-go.
I can't believe that many more people, especially (and coincidentally?) in the inner cities, need pain meds. This seems like something bigger in my mind. But I also don't have any data to back it up.
> This doesn't help the root cause of people starting to use them in the first place.
I don't think you can stop at drug use and claim "root cause." There's a variety of motivating factors involved in using particular drugs, and ignoring those is what leads to things like Prohibition, The War on Drugs, and other related failures.
If you want to stop people from doing something, you need to look at their motivations for doing it.
A related-ish thing I remember reading about is how doctors would ask folks complaining about back pain what career they were in. The goal is that folks who complain about back pain who are unemployed due to the local mill closing would get shunted into disability, while knowledge workers wouldn't.
So there's likely a pretty big effect of society telling folks that they have to be "disabled" in order for us to support them, and one way to be "disabled" is to have debilitating pain, and so you wind up with a bunch of folks who can't work and have a pain pill prescription.
It helps to separate out several aspects of the demand side:
- Addiction: may or may not be a problem at all, heroin isn't actually very expensive so the government can just keep giving it even to large numbers of people
- Other health risks: the risk of catching Hep C or dying of an overdose.
- Acquisitive crime: largely caused by the drugs being illegal.
- Morality: drug users are "bad people" because they lack moral strength or whatever. (Personally I have no truck with this, but it seems to be very important for a lot of people)
I'm not sure anyone really knows why the demand is so huge.
Unemployment seems obvious, but it's not. New Hampshire, for example, if often cited as one of the areas hit the worst by opiate addiction. Yet, it's doing well with unemployment, in relative terms.
There was a tremendous amount of unemployment during the Great Depression - far worse than now. Sure, opioids weren't as available, so people didn't turn to them. (Alcohol, on the other hand...)
But I think a lot of what people did then was turn to each other. They had deeper relationships with people than (many) people do today. Sure, you've got two hundred Facebook friends. How many of them can you call at 3 AM because your marriage is about to fall apart, or because you're feeling suicidal? Technology has given us more relationships, but I think that in the process, we've lost much of the depth. That leaves a huge hole, because people are wired to connect to people. We crave human contact, and we get tweets. It's not enough.
So my suspicion is that we're turning to opioids to try to fill that void. But as I said, this is just my suspicion.
I don't know, I see young people taking to each other about suicidal thoughts and making support groups do each other all the time. Teenagers making Discord chats where they can talk about how their families are abusive and they want to kill themselves, Skype chats where young adults discuss obscure chronic illnesses that the rest of the world can't empathize with them for.
Fair enough. Technology allows people to connect who would not have been able to in the past. But I still claim that, for the average (or perhaps median) person, the net result has been dehumanizing - it has resulted in less depth of relationship.
American doctors follow national guidelines, because if they don't they expose themselves to malpractice suits. The guidelines currently say that if someone is in pain, give them as much painkiller as they want. Their ability to use their extensive training and judgement to make a better call is somewhat limited.
> The guidelines currently say that if someone is in pain, give them as much painkiller as they want
Can you point me to those guidelines please? I'm struggling to find them.
I can understand the advice if it's relating to short term immediate pain - for example post-operative pain. Addiction is unlikely to result from pain medication use in that example.
I went looking for you. The guidelines appear to have been updated since last I checked, and are no longer as irresponsible as I thought they were. Here's what I found:
It's actually pretty hard for legitimate patients to get opioids in many circumstances. My mother has chronic pain from a surgery and has been on a very low dose of oxycodone for years now (10mg a day, I think), and she regularly is subjected to urine and other tests to prove that she's not an addict. My grandpa just had an operation and later at home ended up in a lot of pain, but he could not get oxycodone for two days -- the first night because he went in after 7:00 PM and apparently Indiana has some law against prescribing them past that time.
Huh, I might be basing my perception on what is high vs. low from knowing some people who abused oxycodone. I believe my mom takes 5mg twice a day, and from what I'm reading that still seems pretty light. Oxycontin pills are minimum 5mg, correct?
Erowid puts that in the "light" category for users with some tolerance, FWIW:
I'll have to take your word that the guidelines say effectively to give the patient what they want, it seems a strange idea.
Here, in Norway, the doctor also tells the patient to take as much as they need but the decision on the actual type of pain relief is arrived at collaboratively between the patient and the doctor, sometimes including a short stay, two or three nights, in hospital so that multiple regimes can be quickly tried out under supervision.
In some cases they can prescribe more suitable drugs and more suitable delivery methods.
For instance the pain associated with cancer is often better controlled with a Fentanyl continuous delivery patch than an Oxy capsule. Oxy is good for relatively quick relief when you have a temporary increase in pain but the effect wears off so you get uneven pain relief.
I'm not a doctor, just speaking from personal knowledge of someone very close to me.
I've heard Drew Pinsky rail against physicians for their role in the epidemic. But he also mentions an assist from the legal community in that they've taught patients they are entitled to lengthy doses of opioids.
Despite the evidence showing only short term benefits to opioid treatment physicians fear being sued by patients for refusing to continue prescriptions. I believe the argument is "Pain is the fifth vital sign."
There has to be a some kind of change in lifestyle. Like you said, trying to cutoff supply will only criminalize the activity and make it worse. I've heard, among other solutions, recommending yoga, physical therapy etc. instead of immediately prescribing opiod painkillers. This is certainly an important problem and I'm as interested as you are in what the solutions might be.
Fighting the "epidemic" at the supply level seems like a losing battle, as it is for the hard drugs that plague inner cities. Addressing it at the demand level has to be the answer, but I don't see any possible answers floated.