Sunday, July 30, 2017

Trying to Make Sense of The Opioid "Epidemic"

A couple of days ago, I sat down to collect my thoughts on the so-called "Opioid Epidemic" in the US.  I found it a lot harder to make sense of it than I would have thought. 

Let me backup for a minute and tell you where I'm starting from.  Borepatch had a great article on the big picture; as has Bayou Renaissance Man.  One of the aspects frequently talked about is how high the addiction and death numbers are in places like Ohio and West Virginia.  The Charleston (WV) Gazette-Mail wrote (last December) writes:
In six years, drug wholesalers showered the state with 780 million hydrocodone and oxycodone pills, while 1,728 West Virginians fatally overdosed on those two painkillers, a Sunday Gazette-Mail investigation found.

The unfettered shipments amount to 433 pain pills for every man, woman and child in West Virginia.
This doesn't begin to tally up the damages, not to mention the lives of the addicts that OD.  What about the crime committed trying to steal drugs?  What about armed robbery of medical clinics, drugstores, veterinarians and even robbery of people followed home from those places?  Exactly who the villains are depends on who's telling the story.  To the writers at the Charleston Gazette-Mail, it appears to be that the drug companies are the villain.  Liberal media sure hates them some big business!  To the determined libertarians, it's the government and the War on Drugs - and there's tons of collateral damage there.  To the CDC and some doctors I've read online, it's the doctors and especially "pill mills" writing the prescriptions.

That summary started to bother me.  When the Gazette-Mail said the drug companies shipped in "433 pain pills for every man, woman and child", it sure sounds like too many, but when you think about it, well, what does that mean?  That number was obtained by dividing the number of pills sent into the state by the number of residents over six years.  Looked at as pills/person in 2191 days (six years), that's less than 0.2 pills/person per day.  Now nobody takes 1/5 of a pill per day, so you're talking 1 person in 5 is taking one pill a day.  Only opioids aren't typically one pill once a day.  If those are prescription pills, the person is probably going to get four or five a day for a week or two.  That also cuts the number of people.  Now you have one person in 20 or 25 taking pills every day.  You're talking that statewide, 5% of the people may be recovering from an injury or surgery or something.  Some of the people are getting those strong pain pills daily, and they skew the numbers even more.  Maybe it's 4% or less of the population getting those pills.

I think "less than 4% of the population being treated for an injury or recovering from surgery" on any given day sounds pretty normal.  It sounds rather different than "433 pain pills for every man, woman and child", doesn't it?

What's a normal rate for the prescription of these drugs?  There have been heroin overdoses and deaths for as long as I can remember - and centuries before that, too.  So what's new here?  How do I know if something is really going on and it's not just the media being pushed by the people who hate "big pharma" or it's not just a push to get this covered by what certainly seems like the coming single-payer, socialized medicine fuster cluck we're heading for?  Are we really seeing something different? 

I can't answer what's normal, but if you can trust the Centers for Disease Control, they present data that appears to show that after a long period of low, but steady number of overdose deaths, starting in 2013 or '14, the rate began to really climb.  (looking at the blue numbers in this graph, 2012 is up less over 2011 than 2013 is over 2012).  This plot goes back to 1999, but I saw an extension to 1990 and it didn't look very different than the first few years of this plot. 
So if there's really a problem, and it really seems to be bad in West Virginia and Ohio, what's really going on?  

I got a new perspective from a seemingly unrelated article I read last week.  I get the weekly newsletter/ad, and they linked to this long but haunting piece on the Bitter Southerner.  I'm absolutely a Southerner, but bitter isn't in my makeup.  Still, the phrase that hooked me into reading was something like, "how do you have a dialog with people who automatically add the word 'trash' whenever they hear the word 'trailer'?"  While I've never lived in a trailer, I've visited many, had family that lived in one, and partied in a few more.  The expression they refer to, though, seems to be a stereotypical elitist phrase - a disparaging term the "northern and coastal elites" use against the southerners in flyover country.

After describing a world more like the one I grew up in than not, author David Joy threw in this paragraph.   
I get the same kind of questions about addiction. People don’t understand what would push someone to drugs like methamphetamine or heroin. They don’t understand what would make a man drink like my grandfather. The reason they can’t understand it is because they’ve never been that low. When all you’ve got is a twenty-dollar bill, twenty dollars doesn’t ward off eviction notices. Twenty dollars doesn’t get you health insurance. Twenty dollars doesn’t make a car payment. Twenty dollars doesn’t even keep the lights on. But twenty dollars can take you right out of this world for just a little while. Just a minute. Just long enough to breathe. That’s what every single addict I’ve ever known really wanted: just a second to breathe.
I have never reached that level of desperation in life, and for that I'm incredibly thankful.  And it is true that some of the worst death rates in West Virginia come from coal mining counties where EPA policies caused shutdowns of various mines.  The thing is, I don't think that sort of reaction to desperation - doing meth or heroin - is or could be widespread in a population. 
Red Kool-Aid in an old pickle jar (note to coastal elites: the jar is recycled!) - pure southern.  From Bitter Southerner.

The problem with this explanation is that the "epidemic" isn't just among the trailer population in the rural south.  The death rate is the same ballpark in New Hampshire, Massachusetts, Rhode Island and nine other states as it is in Ohio and West Virginia.  The epidemic affects bored kids from "good backgrounds" with not enough to keep them occupied and all sorts of "good kids", not just unemployed rural southerners with no economic future.   Yes, some people get prescribed narcotics for chronic pain and get addicted, too.

On the other hand, I believe there's evidence that there are such things as addictive personalities and some people are more inclined to those behaviors than the majority.  Not everyone can go the route that Bitter Southerner describes.  I know that's not a "politically correct" view, but I often wonder if our modern, "everyone can get addicted to something" mindset is just a way to get addiction treatment added to the "universal health care roster" that everyone pays for - just like getting retired widowers to pay for maternity coverage they'd never buy. 
(source: HHS Opioid Factsheet - pdf warning)

Ultimately, though, the soul-searching and navel-gazing does nothing about the problem.  The War on Drugs is no solution.  First off, if it was doing anything worthwhile the price of those drugs would be too high for the desperate people who only have $20.  Condemning the pharmaceutical companies doesn't do any good, either.  The couple of groups in the few companies that sold their pain pills as not being addictive when they're really very addictive should be investigated for fraud or improper practices and charged where appropriate (whatever the charges should be).  Locking up doctors for prescribing pain medication for patients doesn't help doctors and it doesn't help patients.  Shutting down pill mills dispensing "narcotics by the bag" has been blamed for forcing users to heroin (these guys make my head hurt).  Living in pain is bad for your health, too.  All of medicine is a compromise, just like all of engineering. 

Although it's painful to say it and I'm sure there will be objections, the people responsible for the opioid addicts are the opioid addicts.  If the libertarian creed is "don't hurt people and don't take their stuff", the opioid addicts are the ones violating that.  They're the ones raiding our wallets.  With the WoD, we pay in money and loss of freedoms.  In the case of doing a Portugal and going full legalization, we pay in money.  In both cases, we pay any other social costs. Without the WoD, perhaps we recoup some of the billions poured into that bottomless pit. 

Wait.  If we go full legalization it still costs us?  Who do you think pays for those detox programs we hear about working in Portugal?  Likewise, I really doubt that there are no health care costs at all for drug addicts even if it is legal.  Will it be cheaper than the WoD?  More than likely.  Even if we do the most heartless stuff you can read online and either just let the addicts die or do like the did during prohibition and actively try to kill them, it's still going to cost us.  If nothing else, someone has to pay to bury or otherwise handle the bodies.   

I don't see any way to handle the opioid problem that's a Good Solution.  The best we seem to be able to find is coming up with the least awful option: minimizing bad, not maximizing good.  More freedom is always better, but there's still a Shop Vac attached to your wallet even if there is no WoD. 

The desire to get high seems to be a fundamental human drive.  Judging by the cats' reactions to catnip, it's not limited to humans.  There will always be some percentage that become addicts.  Given that, it seems like the least awful solution is full legalization.  I don't have an estimate for what all the other costs of that will really be. I am, however, opposed to the "legalize it and tax it" mantra.  Ask Eric Garner how that "just tax it" thing worked out on cigarettes, which have been legalized but taxed forever. 

And none of this is going to happen.  If we have a senate that can't get rid of clearly unconstitutional meddling by the hydra taking over 1/5 of the economy, the entrenched deep state will never allow legalization.  The law enforcement industry, the civil asset forfeiture industry and all the other pieces of gravy train that keeps them sucking on our wallets is simply incapable of thinking they should give it up.

The title of this piece, "Trying to Make Sense of the Opioid Epidemic" is what this is all about.  I don't pretend to have any answers.  I'm just simply trying to make sense of it.


  1. The saying "lies, damn lies and statistics" definitely applies to the misinformation about the volume of pills shipped you referred to in the opening paragraphs.

    People are addictive by nature. It's hardwired into us chemically. We do something that releases dopamine in our brains we feel good...and we want to repeat that experience. It's part of being a mammal. But SOME people are rational. They understand that deferring or delaying gratification now leads to better results later. This is why we see people eating ramen, beans and rice in college so they can afford lobster later. But many people cannot or will not exercise this type of rational thought and self control. All people could be addicts. Most choose not to. And that is the fundamental issue. Addiction is a physiologic reality but the CHOICE to use addictive substances is NOT. It is a choice. People should be free to make this choice as long as they don't harm anyone else. This is why the gov "war on drugs" is a failure at it's stated purpose. But of course the "war on drugs" like all the other "wars" is actually .govs WAR ON FREEDOM.

    We need to disband the DEA. Decriminalize drugs and allow people to live or die by their own choice. For MILLENIA this has been the way of humanity. It's only been in the past century or so that politicians felt the need to control addictive behavior and choices. And as always they aren't doing it for 'good'. They are doing it because of THEIR CONTROL.

  2. What is killing people IS NOT prescription drugs. It is bad Heroin being imported into the US to fund the "black war". This is NOT about drugs. It IS about control. --Ray

  3. I believe I heard that there are an estimated 3.5 mil addicts and govt proposes $4.5 b to "solve" the problem. That's about $12.5k/addict. Somehow, I'm more inclined to think "black" budgets.

  4. Most people who use illegal drugs do it because of sex. That is the girls put out when high and you have to be a user yourself to be accepted by other druggies. They don't smoke pot or shoot heroin because it makes them smarter they do it for the free sex. Most people who do drugs are on welfare. If we ended all forms of welfare tomorrow 95% of the drug dealers would go bankrupt.

    One other point. I have had some operations and some oxycodone and and 90% of it gets dumped in the toilet after I am back up to par. So a lot of the drug produced does not necessarily get used.

    Also if you take the drug as prescribed there is no high. It slowly reduces the pain and that is all. No good feeling, no bad feeling just somewhat less pain. Those who abuse the drug have to take intentional steps to get high, it isn't accidental.

    Why W Va.? Unemployment and welfare create hours/days/weeks of free time and money comes in over the transom to buy the drugs. Simple as that.

  5. I stopped working for the VA in 2008, but at that time there was a big push on (had been for a few years) to make sure every vet's pain was addressed. Unfortunately, that meant all a veteran had to do was claim to have pain, and the doctors would write them a prescription for morphine or oxycodone (oxycontin is the long-acting form of oxycodone) or even fentanyl (a very potent synthetic narcotic commonly used in anesthesia and for cancer patients).

    I had vets who would get their meds in the morning at the counter who would grin as they chewed their oxycontin, because it would make that long-acting form "instant release" by chewing it, giving them a high along with whatever pain relief they might - or might not - have had. Usually these were guys who had no demonstrable reason for having the pain they claimed to have.

    By the same token, I had vets who were in considerable pain but who would refuse narcotics, because they didn't want to get grouped with the ones abusing their narcotics.

    As a former police officer, I was trained and expected to make drug arrests, but even as a rookie I could see that the War On Drugs™ was about money (for the DEA, for the various Narcotics Task Forces, for the police departments and federal agencies (asset forfeiture and high employment stats). If it was set up to protect kids, who have little impulse control and a poor understanding of consequences, reducing as much as possible their access to drugs, I also agree that legalization is the way to go. Yes, I understand that kids get drugs just as they get alcohol, so even if legalization makes it easier for them, we'll just have to deal with that. At least fewer of them would be hurt or killed by poorly made drugs, drugs made with, or diluted with, toxic substances, fights over drug territories, drive-by shootings, or similar issues.

    The billions of dollars involved in illegal drugs costs us billions in fighting against, arresting, convicting, and jailing/imprisoning for, along with all of the agencies which focus on drugs. I haven't done a cost-analysis on the issue, but I think the savings realized in legalizing drugs would exceed whatever costs were incurred in providing them, safe places to use them, and even treating addicts who wish to recover. Most overdoses occur in populations who can't pay for their ER visits, so that shouldn't be any more expensive than it already is.

    When you understand that our state and federal prisons are full of people who are non-violent prisoners convicted of growing and selling marijuana, legalizing it - and releasing all of those inmates would be a big savings right there. We should at least have the states which have legalized marijuana release their state inmates who are serving time for non-violent convictions of selling or using it. I know the feds won't go along with that, unless we force them to accept legalization of it, too.

  6. Epidemics are where infectious disease agents infect people who don't want that disease. Addictive drugs don't leap out of sneeze droplets and jump on people, they can not create epidemics.

    What's a normal rate for the prescription of these drugs? There have been heroin overdoses and deaths for as long as I can remember - and centuries before that, too. So what's new here? How do I know if something is really going on and it's not just the media being pushed by the people who hate "big pharma" or it's not just a push to get this covered by what certainly seems like the coming single-payer, socialized medicine fuster cluck we're heading for? Are we really seeing something different?

    Here's a nice comic book describing the addiction environment before opium etc. was outlawed in America, and voters hadn't robbed people of the inexpensive addictive drugs they used to have, which were cheap enough they did not inspire robbery of pharmacies:

    the people responsible for the opioid addicts are the opioid addicts.


    If the libertarian creed is "don't hurt people and don't take their stuff", the opioid addicts are the ones violating that. They're the ones raiding our wallets. With the WoD, we pay in money and loss of freedoms. In the case of doing a Portugal and going full legalization, we pay in money. In both cases, we pay any other social costs.

    Nope. The ones raiding our wallets are the voters who favor the WoD; I assume opioid addicts don't vote for that. In the case of full legalization, you restore the situation before criminalization described in Drug War Carol, where addicts had functional middle class lives because they weren't being driven broke by drug price controls or sent to prison.

    Wait. If we go full legalization it still costs us? Who do you think pays for those detox programs we hear about working in Portugal?

    Maybe they are funded from literature sales and donations like Alcoholics Anonymous does?

    If nothing else, someone has to pay to bury or otherwise handle the bodies.

    Make the WoD jackboots do it, that's cost neutral.

    but there's still a Shop Vac attached to your wallet even if there is no WoD.


    1. Let me show you a paragraph I removed during editing this post - and I think I spent five hours on this. I thought it was too self-evident to take up column space with.

      It was after the part about the numbers not "smelling right" and I was bothered by the newspaper.

      That's not all that bothers me. I really hate the word "epidemic" being applied here. It seems to be an effort to make it a medical issue when maybe it really isn't. "The E-word" has traditionally only been applied to communicable diseases, but in the last few years it has started to be applied to non-infectious diseases, too: the obesity epidemic, the diabetes epidemic and so forth. I'm a bit old school here: if not communicable, then not epidemic, and before you ask, I don't think obesity, diabetes or the other non-communicable diseases are epidemics, either. Opioid addictions are not communicable. You could live with an addict and not catch it. I'm not 100% sure, but I believe you could safely swap bodily fluids with one. Maybe if you got a transfusion of their blood, while they had lots of drugs in their bloodstream, you could get addicted. If it didn't kill you. People can learn behaviors from each other, but that doesn't make behaviors infectious diseases.

    2. A very good point I hadn't thought about - but as I do, I'm not surprised. Liberals have been intentionally mixing up nature and choices for years now - with both AIDS and Homosexuality they have presented lifestyle choices as pre-ordained by nature, so this is the logical next step.
      As Reg T mentions above, this is a change from just a few years ago when doctors were encouraged to 'over prescribe' pain killers - one way of looking at it is that that was overkill and the change now is the pendulum swinging too far the other way. Of course, the hype and discussion is assisted by those who stand to make a profit off of it, just like with AIDS - though in this case, the only profiteers I can think of are police/ law enforcement suppliers and the departments/ agencies themselves getting bigger budgets and a slice of 'forfeitures'.

  7. 1) Dopamine isn't the problem. Opioids are thousands of times more potent than the body's own opioids. "Endorphin" is simply a contraction for endongenous(self produced) morphine. That's where "runner's high" and similar phenomena come from. You have built in endorphin receptors, because we all make our own morphine. But not enough for when you break a leg or whatnot. Enter pharmacopeia. Your body is built to like the stuff. Some people (like with most things) just can't or won't say "enough".
    2) The ODs you're reading about aren't from pills.
    They're almost entirely from heroin that's been laced with a acetyl fentanyl, a variation of regular fentanyl which is thousands of times more potent.
    E.G.: You OD on heroin, we can reverse it with a blast of Narcan (naloxone). Pisses you off, burns up your high, wastes your drug buy money, but you start breathing again. A standard 1-amp dose (0.4) is good enough to bring you back, until it wears off, and you get another. Initial dosage may be up to 2 mgs, or 5 amps, and repeated as necessary, because they might wear off before all the opiate is processed out of your system, and respiratory depression begins again until it's all gone.
    But it works so well, with such minimal complications, that some municipalities not only have their firefighter/paramedics give it, they've given auto-injectors to cops (with, literally, 5 minutes of training) to use on suspected junkie ODs because they find them before the FD gets there. And until recently, save them.
    Enter acetyl fentanyl.
    3) Acetyl fentanyl is a designer-drug version of fentanyl (a regularly used short-acting pain reliever). And it's fifteen or more times more potent than heroin. Put the acetyl fentanyl into a batch of heroin, and it's possibly hundreds of times stronger, because with drugs, 1+1=37.
    Long-time junkies searching for a higher high, because of opioid tolerance, try the new junk, and one hit of Narcan doesn't come close to reversing things. In fact, the new smack with acetyl fentanyl is so potent, they go into instant respiratory arrest, and are found with the needles still in their arms, and quite cold and dead.
    It's been estimated by medical/clinical professionals in lectures and papers I've seen/heard you'd have to start an IV bag of Narcan - or even have one running before the person shot up - to have any hope at all of getting them back alive.
    Ain't no cop gonna start IV bags, ever.

    That's how you get a spike in OD fatalities, and it has jack and $#!^ to do with pills, or Big Pharma.
    This is street chemists cooking up batches of $#!^ that are lethal.
    Nota bene that street drugs have no FDA-approved labeling.
    Caveat emptor, or A.M.F.

    Hope that clears up what's going on.

    1. Aesop: Is there anything you don't know more about than everyone else? Your god like intellect is just stunning. With your expert knowledge on every subject Your life really is wasted watching porn in your mothers basement. You should rule the world, or at least get a job that doesn't involve French fry's. We should all bow to your genius, your intellect, your eternal rightness, and your mastery of the fry cook arts. I humbly debase myself at your awesome magnificence, and shall build shrines tour your magnificent , eternal rightness. All hail the god of the basement keyboard! See? All that and G-rated. Not a single word children couldn't read. I must be stupid, and like everyone else,I always wrong in your holy presence. Please continue to correct us every time we have an opinion. It is the only way we can know that you are the one true internet god.

    2. Verrrry interesting. Thanks for the download. This is, to me, much ado about nothing. I think it is a red herring and everyone, at the media's behest, and the WH, is distracting people from other things that are going on.

      I was quite surprised actually, when seemingly out-of-the-blue, this "opiod" thing came up. I scratched my head wondering if I had been asleep or missed something. It just popped up out of nowhere.

      I'm kinda like SiG, doesn't make sense to me. But neither does beating up on Jeff Sessions different days on the playground. If Trump is really unhappy with his performance, we know he would "normally" just fire the person. So what is going on is the real question. And with the "opiod" thing, same question: "What is going on?" Doesn't make sense.

    3. Dear Anonymous troll:
      Sorry to spoil your pompous jackassical response, but I'm the business in question, well-acquainted with the phenomenon, and working with the detritus in question. For going on a piddling 25 years or so. And you're...what, exactly, besides butthurt?

      I didn't post personal opinions, I posted facts. As Casey Stengel commended, "You could look it up."
      Lacking the ability to respond to same nor process actual information, go back to your usual domain, and wallow in stupidity.
      SG's site is usually remarkable for both his own intelligence, and the lack of mouth-breathing replies, but there's always an exception.
      Thanks for earning your "That Guy" tab, and cowering in fear behind your Anonymous troll-post ID.
      Get back under your bridge.

    4. All hail the all knowing. All seeing. God of the internet. He who is never wrong and can never be questioned. Hail your godlike mind and obscenely worded comeback. He who must defend his sacred rightness, his holy word. Because he must think himself a god. Otherwise he would just be another internet bully. A petty ,vile little worm , who must always be right and always have the last word. A person like that would suffer from a profound mental disorder. And you sir obviously couldn't be a childish batshit crazy, troll across half a dozen websights. After all you think you are a god.

    5. Boy must have gotten close that time Aesop; Or you wouldn't be howling so loud----Ray

    6. That wasn't any such howl, Ray, that was swatting a fly.
      And he thinks by doubling down on his troll, he's proving anything but his lack of mental ability.

      When you've got nothing, you just talk smack.
      Feel free, Anonymass, to try refuting anything factually. Otherwise, you're just wasting bandwidth.

  8. After finishing this piece last night and getting away from the computer, Mrs. Graybeard found a trail that gave some very good insight into what's going on.

    None of you bring it up.

    More later.

  9. There is another factor. Most "normal" people do not choose to do drugs. While it is true young people, teens and young adults, will do foolish things and make mistakes, most drug users have a mental disability. Most are bi-polar and this illness constantly causes them to make bad choices and anti-social actions. The reason this is significant is because you cannot "cure" bi-polar illness. If you put them in jail or spend thousands to send them to rehab they still are bi-polar when they come out and still make the same stupid mistakes/choices. Bi-polar is not one single thing it varies among people both in the degree and the effects. Some bi-polar are effectively incapable of taking care of themselves while others have developed coping mechanisms that allow them to function and even appear normal. Often the worst behavior of someone who is bi-polar occurs after they experience some kind of personal problem and otherwise they might appear to be more or less normal. There is medication that will suppress some of the worst symptoms but the side effects are uncomfortable and thus the bi-polar person prefers to not take the medication. This is exacerbated by the simple fact that regardless of their mood or action to a bi-polar person THEIR action seems "normal" while your action/reaction seems "crazy" so they don't see their own illness at all. My best advice to anyone with a harmful bi-polar person in their life is to get away from them. You can't fix them and they will ruin your life.

    1. Another point about bi-polar individuals - the reason so many stop taking their medication is because the "high" of the manic phase is enjoyable. Their flatter affect - calmer but somewhat duller emotional responses - was no fun at all. So they would stop taking the med(s) because they don't know how to derive enjoyment from living without that "high".

      This is one of the main reasons I hated psychiatry back when I was working in it - the preponderance of doctors preferred to treat the symptoms of psych disorders with medication, and disdained therapy, claiming most behaviors are imbalances in brain chemistry. The patients were seldom introduced to any therapies that could help them make healthier choices in lifestyle, understand their own motivators, or see any light in the tunnel of possible improvement in their conditions, of recovering some enjoyment of living.

      The only good program we had (at our VA medical center, at least) was an excellent PTSD program that was 90% therapy, with a program manager that was a wizard at helping vets (mostly Vietnam vets at that time, but a few Korean and a few Desert Storm vets as well) reconnect socially with friends and family, and begin to function within the world once more.

  10. Alcohol and tobacco kill 100 times as many people as opioids and they are (a) legal and (b) taxed.

    There is a model here where the users pay taxes that can fund a system of detox centers, but that would remove tens of billions of dollars a year from the WoD.

  11. Detox only works if the addict chooses to kick his habit and then typically only after they hit bottom. You can't simply send them to detox and expect them to be OK.

    There are things to dislike about the war on drugs but anyone/everyone with children and grandchildren do not want drugs legalized or accepted. We don't have a war on drugs because there is money in it for the police; we have a war on drugs because the parents and voters want it that way. About the only people who do not want to keep these bad drugs illegal are the users and a few so-called libetarians.