Exclusive – Immigration: The Hidden Driver of the Opioid Epidemic
3:54
More than 900 Americans died every week from opioid-related overdoses in 2017. Every American community, big or small, has experienced the epidemic’s merciless, corrosive advance across our cities and towns. It is human tragedy, a family tragedy, and a national crisis.
The issue is complicated by the fact that tens of thousands of Americans need prescription pain medications for legitimate medical reasons. Pharmaceutical companies have been innovative in creating potent opioid based medicines and they were, and remain, rewarded with successful sales.
Some patients, however, abuse legitimate drugs, lie to treating physicians, and illegally sell otherwise lawful drugs. But the real problem is not from frazzled doctors, bad patients or bad medicine. The overwhelming source of the problem is cheap but powerful drugs coming in from Mexico by way of China.
There is another core contributor to the problem that isn’t as widely known: the river of illegal aliens surging across our porous borders. As former LA Times reporter Sam Quinones’ award-winning book, Dreamland: The True Story of America’s Opioid Epidemic recounts, just as standards for the prescription of oxycodone and other painkillers were being tightened, a group of largely illegal Mexican immigrants from Xalisco, in the Mexican state of Nayarit, pioneered a new model of heroin distribution. It was in essence Uber for drug dealers, involving small franchises, with a nonviolent approach, carrying small amounts of drugs directly to addicts in their homes and neighborhoods, using a customer-first mentality and lots and lots of delivery drivers.
From Dreamland, “The delivery drivers did tours of six months and then left. If they were arrested they were deported, not prosecuted, because they never carried large amounts of dope.” With hundreds of new illegal aliens from the state entering the country every day, the police could arrest as many street-level dealers as they liked. As a DEA agent tells Quinones in another part of the book, “We arrest drivers all the time and they send new ones up from Mexico. They never go away.” There would always be new dealers, and the model could continue. An essential part of the process was the dealers returning home, where their ill-gotten gains provided them with status in their rural, poor homeland.
Another law enforcement officer recounts to Quinones, “Their system is a simply thing, reall, and relies on cheap, illegal Mexican labor, just the way that any fast-food joint does.” That flow of dealers is the linchpin of the Nayarit model, which has since spread nationwide. Illegal immigration is the lynchpin of the flow of dealers. Stop illegal immigration, and you stop the flow.
The biggest contributor to illegal immigration are the loopholes in our laws, and our lack of southern border infrastructure. The Center for Immigration Studies has estimated that in the last two years, because of loopholes, more than 250,000 illegal aliens have been caught at the border and released. If even one-tenth of one percent of those illegal aliens are drug dealers, the Border Patrol will have actually caught 600 traffickers and released them to wreak their havoc in our communities.
There is also, of course, the fact that a porous border allows drugs to flow across the border, but people are much easier to interdict than fentanyl. That is why we must also deliver on the president’s border wall–providing $5 billion in unrestricted funding this year, immediately. The funding bill is the last train leaving the station, to stop the flow of drugs and the illegal aliens that bring them from pouring into our communities. Nancy Pelosi will ensure when she takes over as Speaker of the House that nothing will be done.
More than 49,000 Americans died last year from heroin and opioid related overdoses. If open-borders liberal Democrats or weak-kneed establishment Republicans stop us from fixing the problem by closing the loopholes and building the wall, they will be accomplices to the next 49,000 deaths as much as the drug dealers of Xalisco.
http://mexicanoccupation.blogspot.com/2018/05/highly-graphic-la-raza-heroin-cartels.html
AMERICA: MEXICO’S WELFARE STATE
… and in exchange we get 40 million Mexican flag
wavers, homelessness, a housing crisis, heroin & opioid crisis and jobs for
legals crisis…. ALL THANKS TO THE DEMOCRAT PARTY
http://mexicanoccupation.blogspot.com/2013/08/how-cheap-is-staggering-cost-of-mexicos.html
“Thirteen
years after welfare reform, the share of immigrant-headed households (legal and
illegal) with a child (under age 18) using at least one welfare program continues
to be very high. This is partly due to the large share of immigrants with low
levels of education and their resulting low incomes — not their legal status or
an unwillingness to work. The major welfare programs examined in this report
include cash assistance, food assistance, Medicaid, and public and subsidized
housing.” Steven A. Camarota
OPIOID AMERICA:
CHINA AND MEXICO PARTNER TO ADDICT AMERICA
http://mexicanoccupation.blogspot.com/2018/08/the-opioid-war-on-america-chin
“While drug distributors have paid a total of $400 million in fines over the past 10 years, their combined revenue during this same period was over $5 trillion.”
“Opioids
have ravaged families and devastated communities across the country.
Encouraging their open use undermines the rule of law and will do nothing to
quell their continued abuse, let alone the problems underlying mass addiction.”
The Washington-imposed economic policy of
economic growth via mass-immigration floods the market with foreign labor, spikes profits and Wall Street values by cutting salaries for manual and skilled labor offered by
blue-collar and white-collar employees. It also drives up real estate prices, widens wealth-gaps, reduces high-tech investment, increases state and local tax burdens, hurts kids’ schools and college education, pushes Americans away from high-tech careers, and sidelines at least 5 million
marginalized Americans and their families, including many who are now
struggling with opioid addictions. NEIL
MUNRO
Opioid
Nation
Pain Killer: An Empire of Deceit
and the Origin of America’s Opioid Epidemic (Expanded and Updated Edition)
Dopesick: Dealers, Doctors, and the
Drug Company That Addicted America
American Overdose: The Opioid
Tragedy in Three Acts
American Fix: Inside the Opioid
Addiction Crisis—and How to End It
PELOSI’S
OPEN BORDERS FOR MORE CHEAP LABOR
The Mexican
Army made two seizures in Ensenada on August
17 (1,036 pounds of meth, heroin, and fentanyl) and August 18 (1,653 pounds of
meth, fentanyl, and marijuana).
The Mexican
Army discovered an
active drug lab on August 25 in Tecate and seized four tons of methamphetamine.
The Mexican
Federal Police seized 350 pounds of
methamphetamine in an active drug lab in Tijuana on August 26.
The Mexican
Federal Police seized 20,000 fentanyl pills
in an active lab in Mexicali on September 10.
A.G. JEFF SESSIONS DEFENDS U.S. BORDERS AGAINST
THE DEMOCRAT PARTY AND MEXICO’S INVASION.
"Some of the most violent criminals at large
today are illegal aliens. Yet in cities where the crime these aliens
commit is highest, the police cannot use the most obvious tool to
apprehend them: their immigration status. In Los Angeles, for example,
dozens of members of a ruthless Salvadoran prison gang have sneaked back
into town after having been deported for such crimes as murder, assault with a
deadly weapon, and drug trafficking." HEATHER MAC DONALD
“Heroin is not produced in the
United States. Every gram of heroin present in the United States provides
unequivocal evidence of a failure of border security because every gram of
heroin was smuggled into the United States. Indeed, this is precisely a
point that Attorney General Jeff Sessions made during his appearance before the
Senate Judiciary Committee hearing on October 18, 2017 when he again raised the
need to secure the U.S./Mexican border to protect American lives.” Michael
Cutler …..FrontPageMag.com
A.G. JEFF SESSIONS DEFENDS U.S. BORDERS AGAINST
THE DEMOCRAT PARTY AND MEXICO’S INVASION.
"Some of the most violent criminals at large
today are illegal aliens. Yet in cities where the crime these aliens
commit is highest, the police cannot use the most obvious tool to
apprehend them: their immigration status. In Los Angeles, for example,
dozens of members of a ruthless Salvadoran prison gang have sneaked back
into town after having been deported for such crimes as murder, assault with a
deadly weapon, and drug trafficking." HEATHER MAC DONALD
“Heroin is not produced in the
United States. Every gram of heroin present in the United States provides
unequivocal evidence of a failure of border security because every gram of
heroin was smuggled into the United States. Indeed, this is precisely a
point that Attorney General Jeff Sessions made during his appearance before the
Senate Judiciary Committee hearing on October 18, 2017 when he again raised the
need to secure the U.S./Mexican border to protect American lives.” Michael
Cutler …..FrontPageMag.com
CJNG is one of the most powerful cartels in
Mexico and the Department of Justice considers it to be one of the five most
dangerous transnational criminal organizations in the world — responsible for
trafficking tons of cocaine, methamphetamine, and fentanyl-laced heroin into
the United States.
BEHEADINGS LONG U.S. OPEN BORDERS WITH
NARCOMEX: The La Raza Heroin Cartels Take the Border and Leave Heads
http://mexicanoccupation.blogspot.com/2018/05/highly-graphic-la-raza-heroin-cartels.html
AMERICA: MEXICO’S WELFARE STATE
… and in exchange we get 40 million Mexican flag
wavers, homelessness, a housing crisis, heroin & opioid crisis and jobs for
legals crisis…. ALL THANKS TO THE DEMOCRAT PARTY
http://mexicanoccupation.blogspot.com/2013/08/how-cheap-is-staggering-cost-of-mexicos.html
“Thirteen
years after welfare reform, the share of immigrant-headed households (legal and
illegal) with a child (under age 18) using at least one welfare program continues
to be very high. This is partly due to the large share of immigrants with low
levels of education and their resulting low incomes — not their legal status or
an unwillingness to work. The major welfare programs examined in this report
include cash assistance, food assistance, Medicaid, and public and subsidized
housing.” Steven A. Camarota
THE LA
RAZA MEXICAN DRUG CARTELS REMIND AMERICANS (Legals) THAT THERE IS NO (REAL)
BORDER WITH NARCOMEX!
SHOCKING
IMAGES OF CARTELS ON U.S. BORDERS:
“Heroin is not produced in the United
States. Every gram of heroin present in the United States provides unequivocal
evidence of a failure of border security because every gram of heroin was
smuggled into the United States. Indeed,
this is precisely a point that Attorney General Jeff Sessions made during his
appearance before the Senate Judiciary Committee hearing on October 18, 2017
when he again raised the need to secure the U.S./Mexican border to protect
American lives.” Michael Cutler …..FrontPageMag.com
LOS ANGELES – GATEWAY FOR THE LA RAZA MEX DRUG CARTELS
NARCOMEX in LA RAZA-OCCUPIED LOS ANGELES – Western gateway for the MEXICAN
DRUG CARTELS and MEXICO’S SECOND LARGEST CITY.
Federal agents raided Q.T Fashion and numerous other businesses in the
downtown fashion district Wednesday, cracking down on a scheme that cartels are
increasingly relying on to get their profits — from drug sales, kidnappings and
other illegal activities — back to Mexico, authorities said.
Nine people were arrested in raids targeting 75 locations, and $90 million
was seized — $70 million in cash. In one condo, agents found $35 million
stuffed in banker boxes. At a mansion in Bel-Air, they discovered $10 million
in duffel bags.
"Los Angeles has become the epicenter of narco-dollar money laundering
with couriers regularly bringing duffel bags and suitcases full of cash to many
businesses," said Robert E. Dugdale, the assistant U.S. attorney in charge
of federal criminal prosecutions in Los Angeles.
LOS ANGELES: MEXICO’S SECOND LARGEST CITY AND GATEWAY FOR THE LA RAZA HEROIN
CARTELS
Every CEO in every company sees the business opportunity:
Will I earn higher profits by replacing my American staff with cheaper H-1B
workers? The answer is an obvious yes.
The Washington-imposed economic policy of
economic growth via mass-immigration shifts wealth from young people towards
older people by flooding the
market with foreign labor. That
process spikes profits
and Wall Street values by cutting
salaries for manual and skilled labor offered by
blue-collar and white-collar employees. The policy also drives up real estate
prices, widens
wealth-gaps, reduces high-tech
investment, increases state and
local tax burdens, hurts kids’
schools and college
education, pushes Americans away from
high-tech careers, and sidelines at least 5 million
marginalized Americans and
their families, including many who are now struggling with opioid
addictions.
A NATION DIES OF OPIOID
ADDICTION
AMERICAN BIG PHARMA,
RED CHINA and NARCOMEX PARTNER FOR THE BIG BUCKS
“The drug epidemic is the product of capitalism and the
policies of the capitalist parties, both Democrats and
Republicans. There is, first of all, the role of the pharmaceutical
companies, which have amassed huge profits from the
deceptive marketing of opioid pain killers, which they claimed were
not addictive. Prescriptions for opioids such as Percocet, Oxycontin
and Vicodin skyrocketed from 76 million in 1991 to nearly 259 million in
2012. What are the numbers and profits now?
OPIOID AMERICA:
CHINA AND MEXICO PARTNER TO ADDICT AMERICA
http://mexicanoccupation.blogspot.com/2018/08/the-opioid-war-on-america-chin
PRINCETON REPORT:
American middle-class is addicted,
poor, jobless and suicidal…. Thank the corrupt government for surrendering our
borders to 40 million looting Mexicans and then handing the bills to middle
America?
OPIOID MURDERS BY BIG
PHARMA
“While drug distributors have paid a total of $400 million in fines over the past 10 years, their combined revenue during this same period was over $5 trillion.”
“Opioids
have ravaged families and devastated communities across the country.
Encouraging their open use undermines the rule of law and will do nothing to
quell their continued abuse, let alone the problems underlying mass addiction.”
THE
LA RAZA INVASION:
The Washington-imposed economic policy of
economic growth via mass-immigration floods the market with foreign labor, spikes profits and Wall Street values by cutting salaries for manual and skilled labor offered by
blue-collar and white-collar employees. It also drives up real estate prices, widens wealth-gaps, reduces high-tech investment, increases state and local tax burdens, hurts kids’ schools and college education, pushes Americans away from high-tech careers, and sidelines at least 5 million
marginalized Americans and their families, including many who are now
struggling with opioid addictions. NEIL
MUNRO
Opioid
Nation
Pain Killer: An Empire of Deceit
and the Origin of America’s Opioid Epidemic (Expanded and Updated Edition)
by Barry Meier
Random House, 223 pp., $27.00
Dopesick: Dealers, Doctors, and the
Drug Company That Addicted America
by Beth Macy
Little, Brown, 376 pp., $28.00
American Overdose: The Opioid
Tragedy in Three Acts
by Chris McGreal
PublicAffairs, 316 pp., $27.00
American Fix: Inside the Opioid
Addiction Crisis—and How to End It
by Ryan Hampton, with Claire Rudy Foster
All Points, 290 pp., $27.99
A man who has just taken heroin, Philadelphia, April 2018
The
National Institute on Drug Abuse estimates that 72,000 Americans died from drug
overdoses in 2017, up from some 64,000 the previous year and 52,000 the year
before that—a staggering increase with no end in sight. Most involved opioids.
A few
definitions are in order. The term opioid is now used to
include opiates, which are derivatives of the opium poppy, and opioids, which
originally referred only to synthesized drugs that act in the same way as
opiates do. Opium, the sap from the poppy, has been used throughout the world
for thousands of years to treat pain and shortness of breath, suppress cough
and diarrhea, and, maybe most often, simply for its tranquilizing effect. The
active constituent of opium, morphine, was not identified until 1806. Soon a
variety of morphine tinctures became readily available without any social
opprobrium, used, in some accounts, to combat the travails and boredom of
Victorian women. (Thomas Jefferson was also an enthusiast of laudanum, one of
the morphine tinctures.) Heroin, a stronger opiate made from morphine, entered
the market later in the nineteenth century. It wasn’t until the twentieth
century that synthetic or partially synthetic opioids, including fentanyl,
methadone, oxycodone (Percocet), hydrocodone (Vicodin), and hydromorphone
(Dilaudid), were developed.
In 1996 a
new form of oxycodone called OxyContin came on the market, and three recent
books—Beth Macy’s Dopesick, Chris McGreal’s American
Overdose, and Barry Meier’s Pain Killer—blame the opioid
epidemic almost entirely on its maker, Purdue Pharma. OxyContin is formulated
to be released more slowly and therefore lasts longer. The company claimed that
the drug’s slow release would make it less addictive than ordinary oxycodone,
since the initial euphoria—the high—would be muted. Based on this theory and
little else, the FDA permitted OxyContin to contain twice the usual
dose of oxycodone and carry on the label this statement: “Delayed absorption,
as provided by OxyContin tablets, is believed to reduce the abuse liability of
a drug.” (The FDAofficial who oversaw OxyContin’s approval later got a
plum job at Purdue Pharma.)
The
company launched an extraordinarily aggressive and successful marketing
campaign to convince physicians that they had the holy grail of a nonaddictive
opioid. It sent hundreds of sales representatives to doctors’ offices to tout
OxyContin, and offered doctors dinners and trips to meetings at luxury resorts.
And it paid more than five thousand doctors, pharmacists, and nurses to train
as speakers to tour the country promoting OxyContin. But like all opioids,
OxyContin is addictive. And soon enough, users found that they
could crush the pills or dissolve the coating, then snort the drug like cocaine
or inject it like heroin. Each pill would then become essentially an
instantaneous double dose of oxycodone.
OxyContin almost immediately became a blockbuster—that is, a prescription
drug with annual sales of more than $1 billion. It was widely used not just by
those for whom the prescriptions were written, but by their relatives and
friends. The pills were also sold or stolen or otherwise diverted to street
use. In addition, “pill mills” sprang up, where unethical physicians wrote
innumerable prescriptions for OxyContin and refilled them automatically without
ever seeing the patient. McGreal describes “one of the most productive pill
mills in the country,” which operated in the small town of Williamson, West
Virginia—known locally as “Pilliamson.” The town, he says, “was awash in
pills,” and people came by car and bus to line up at the clinic and cooperating
drugstores. “Investigators calculated that in 2009 alone, the clinic pulled in
$4.6 million in a town with a population of little more than three thousand
people.”
It’s
impossible to know how many new prescriptions were obtained in each of these
ways, but one way or another, OxyContin addiction grew into an epidemic. The
epicenter was central Appalachia, and its victims were mainly white people in
small, economically depressed coal-mining communities in southern West Virginia
and parts of Kentucky, Tennessee, and southwestern Virginia.1
The three
books that focus on Purdue Pharma are in a sense the same book. Barry Meier
first published Pain Killer in 2003. The new edition (released
by a different publisher) is much the same, with some updating and
re-arrangements. The two new books, Dopesick and American
Overdose, cover the same story as it unfolded in the same region of the
country. Both Macy and McGreal refer to the 2003 edition of Meier’s book (but
not the new edition, probably because they could not have known of it at the
time their books were written). All three books are gripping and well written,
with detailed accounts, one after another (perhaps too many), of families
decimated by the epidemic. And they all tell the story of Art Van Zee, a
physician in southwestern Virginia, who in 2000 became aware of the growing
epidemic of OxyContin there and tried heroically to get Purdue Pharma and
the FDA to take responsibility for it.
Purdue
Pharma and the Sackler family that founded it are very hard to defend. By
aggressively marketing OxyContin, even after they knew it was being widely
abused, the family became enormously wealthy. But the FDA was also
guilty. It permitted OxyContin to be sold as a relatively nonaddictive opioid
without good evidence to support that claim, and it should have been obvious
that the pills might be crushed or dissolved to make them even more addictive.
Van Zee, along with Beth Davies, a nun who ran the local substance abuse
clinic, saw Lee County, Virginia, blanketed with OxyContin prescriptions and
watched the deaths mount, particularly among young people. They informed
Purdue, which simply stonewalled. Over the following year, Van Zee devoted
himself completely to the cause, meeting with company and FDAofficials and
testifying before a Senate committee, trying to get Purdue to reformulate the
drug or even withdraw it from the market.
In 2007
Purdue pled guilty to criminal charges of fraudulently marketing OxyContin and
settled for $600 million in fines and penalties. Three executives pled guilty
to misdemeanor charges and were sentenced to four hundred hours of community
service and lesser fines. The company’s fine was trivial in comparison with its
profits from OxyContin. In fact, almost every other major pharmaceutical
company has had to settle both civil and criminal charges of fraudulent
marketing for much more (the record settlement is now GlaxoSmithKline’s $3
billion, for a variety of violations, including falsely promoting drugs and
failing to report safety data). These kinds of fines are just the cost of doing
business. And so it was for Purdue Pharma, although the fraudulent marketing
stopped and a warning was added to the label.
The
problem with these three books, and it’s a big one, is that they treat the
Purdue story as though it were the whole story of the opioid epidemic. But
OxyContin did not give rise to opioid addiction, although it jump-started the
current epidemic. Heroin has been a common street drug ever since it was banned
in 1924. Morphine has also been widely abused.
Nor would
taking OxyContin off the market end the epidemic. The overwhelming majority of
opioid deaths are caused not by OxyContin but by combinations of fentanyl,
heroin, and cocaine, often brought in from China via Mexican cartels, and
frequently taken along with benzodiazepines (such as Valium or Xanax) and
alcohol. These drugs are cheaper and stronger, particularly fentanyl. Fentanyl
was first synthesized in 1960, and soon became widely used as an anesthetic and
powerful painkiller. It is legally manufactured and highly effective when used
appropriately, often for short medical procedures such as colonoscopies. The
illicit production and street use is relatively new, but it is now the main
cause of most opioid-related deaths (nearly 90 percent in Massachusetts).
The
steady increase in opioid deaths after OxyContin came on the market has been
supplanted by a much faster increase starting around 2013, when heroin and
fentanyl use increased dramatically. We now have two epidemics—the overuse of
prescription drugs and the much more deadly and now largely unrelated epidemic
of street drugs. By concentrating on the first, we are closing the barn door
after the horse is long gone.
Efforts to deal with the epidemic have been all over the map—literally.
Possession of illegal drugs (and legal drugs illicitly used) is still a federal
crime, and prisons are still full of people whose only crime was that. But many
states, counties, and cities have begun to regard opioid addiction as a public
health issue, not a police issue. They are opening centers in which people who
seek help are shifted to less powerful opioids like methadone and buprenorphine
(Subutex)—a method known as “medication-assisted treatment,” or MAT.
Naloxone (Narcan), the antidote for an opioid overdose, is now sold over the
counter in almost all states. If used immediately, it can prevent an otherwise
inevitable death from a drug overdose. And drug courts, which may drop criminal
charges in return for an agreement to submit to treatment and monitoring, are
becoming more common.
Nan Goldin: Withdrawal/Quicksand, Berlin/NY, February
2016, 2016
Most
controversial are facilities called “safe injection sites,” or SIFs, where
drug users can come to use drugs without fear of arrest. The staff provides
clean needles to reduce the risk of HIV and hepatitis C infections,
and is prepared to resuscitate addicts who overdose. This approach is called
“harm reduction.” The problem is that addicts must still buy drugs illegally,
and it’s almost impossible to know exactly what is in them.
In a
recent New York Times Op-Ed, the deputy attorney general, Rod
Rosenstein, came down hard on SIFs. He warned that “it is a federal felony
to maintain any location for the purpose of facilitating illicit drug use,” and
that “cities and counties should expect the Department of Justice to meet the
opening of any injection site with swift and aggressive action.” He was
referring to plans to operate SIFs in San Francisco, New York City, and
Seattle, and similar options now being considered by Colorado, Maine,
Massachusetts, and Vermont. Later in the same article, however, he softened,
saying we should “help drug users get treatment and aggressively prosecute
criminals who supply the deadly poison,” suggesting that perhaps he doesn’t
believe simple possession is so bad, after all.
But the
proposed solutions to this epidemic range from the extreme of “lock ’em up” to
“drug abuse is no less a disease than cancer or diabetes” and should therefore
be met with the same solicitude. Ryan Hampton exemplifies the latter view in
his angry book, American Fix. A former drug user himself and now an
impassioned advocate and activist, he insists that drug abuse should be
regarded like other diseases. He doesn’t acknowledge that for most users there
was a moment of choice in becoming addicted that is not the case for people
with cancer or diabetes. After receiving Dilaudid for a painful ankle, Hampton
decided to ask for more, and then more. I think one can make the argument for
sympathy with drug users and for understanding how the quest for drugs ceases
to be under their control without claiming an analogy to diseases like cancer
or diabetes.
Hampton
paints a vivid picture of the downward spiral of addiction. When he “leveled up
to IV heroin,” he explains, “it was cheaper than pills, easier to get
hold of, and a quarter the cost. More important, nobody was tracking us in a
database.”
Where
Hampton is at his best is in his exposure of the profiteering and corruption in
the burgeoning addiction industry—what he calls “the treatment industry swamp.”
In the swamp, he found
lack of
effective treatment, exorbitant costs, and ridiculous twenty-eight-day
vacations disguised as medical help, fed by patient brokers who run a
completely legal, high-end human trafficking cartel to push tens of thousands
of patients through the broken system.
He was
referring to the panoply of treatment centers, both residential and outpatient,
and detox facilities, where users are supposed to be weaned from drugs before
entering “sober living houses.” As in so much of American medicine, even
nonprofit insurers like Medicaid outsource the actual delivery of care to
for-profit companies that charge whatever the market will bear. According to
Hampton, “one of the most expensive treatment centers in America, Passages
Malibu, costs more than $60,000 per month.” Costs are settled by a crazy quilt
of payers, including state and local governments, Medicaid, other federal
programs, private insurers, and often by desperate families. Not surprisingly,
only a minority of users are ever treated.
In 2017 the Aspen Institute’s Health Strategy Group, led by two former
secretaries of health and human services, Tommy Thompson and Kathleen Sebelius,
and consisting of twenty-four members from various health-related fields (I am
among them), met for three days to examine the opioid epidemic. The
deliberations were preceded by four presentations by experts in the field. In
the final broad and comprehensive report, the group made a strong case for
decriminalizing drug addiction and instead regarding it as a public health
issue. Among the five major recommendations was a call for more research into
nearly all aspects of the epidemic. It’s startling how little we know, given
the immensity of the problem and the media attention it receives.2
We need
to know, for instance, how effective opioids are for different kinds of pain,
including long-term treatment for chronic pain. We need to know how opioids
compare in effectiveness and side effects with acetaminophen (which can cause
liver failure) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
(which can cause gastrointestinal bleeding). We need to know how the death rate
in the opioid epidemic compares with the rate of use. We know the death rate is
soaring, but does that mean the rate of use is, too, or is it simply a result
of the lethality of the drug mixtures obtained on the street? We need to know
how much diversion there is now from legitimate treatment to abuse. That
includes diversion of methadone and buprenorphine, which are also opioids and
can be sold on the street or added to the user’s illicit intake. According to
Macy, “Buprenorphine is the third-most-diverted opioid in the country, after
oxycodone and hydrocodone.”
We need
to know how many addicts want to quit, since most don’t seek
treatment. Why don’t they? And finally, we need to know the best approach to
treatment. There is concern, for example, that detox might be dangerous,
because the first dose after a relapse can be deadly if the user is no longer
tolerant to the drug’s effects. Is providing methadone or buprenorphine
indefinitely, even for life, the best treatment among bad choices? There is
plenty of speculation about all of these questions, and suggestive findings
about some of them, but little solid evidence.
We also need to remember an essential and crucial fact: opioids do have a
legitimate purpose, and it’s an enormously important one. They treat severe
pain, often when no other treatment is effective. Patients suffering from
cancer are sometimes completely dependent on opioids for relief, as are some
patients with other forms of severe pain. As the authors of the books
acknowledge, pain was systematically undertreated throughout most of the
twentieth century. After centuries of free and easy use of opioids, there was a
sudden reaction in the United States at the start of the twentieth century,
which had much to do with anti-immigrant sentiment, particularly animus toward
Chinese immigrants who were widely assumed to be opium addicts. (It also
paralleled the growing reaction against alcohol that resulted in Prohibition.)
The 1914 Harrison Narcotics Tax Act imposed strict regulations on the use of
opioids; they had to be prescribed by physicians, and then only for patients
not already taking them. Prohibition lasted for only thirteen years, but the
dread of opioid addiction stayed with us until the 1980s and caused cruel
suffering for generations of patients.
Even in
hospitals where cancer patients lay dying in agony, opioids were administered reluctantly,
in small doses, and at infrequent intervals. When I was in training in a
teaching hospital in the 1960s, there was an awful ritual to it. The drugs were
administered according to a pro re nata (prn) regimen
(ostensibly “as needed”) that required the patient to wait out a four-hour
interval, no matter how severe the pain, and then request the next dose. Those
who badly wanted the drug had to keep track of the time and have the strength
and endurance to summon a nurse if one was nearby. Patients were sometimes
inhibited in asking for the next dose by a desire to please the medical staff
and not be a nuisance, or by their own belief that taking morphine was somehow
wrong or reflected weakness. The extent to which nurses and physicians shared
the common fears of addiction influenced their readiness to respond. Desperate
patients would count the minutes toward the end of the interval, hoping they
could flag down a nurse. Many doctors and nurses interpreted the anxiety and
clock-watching as a sign of growing addiction, not inadequate pain relief.
These patients were labeled “drug-seeking” and often punished for it by being
denied the very help they needed.
During
the 1980s there was a welcome change in that attitude, partly due to the
hospice movement that had begun in the United Kingdom. The prn system
became more flexible, or was eliminated altogether. There was a realization
that because pain is entirely subjective, there is no way to measure or verify
it, and even patients with the same condition could differ in their experience
of pain. Instead of having to flag down nurses, patients were asked at shorter
intervals whether they needed pain relief, and how much. In 2001 the Joint
Commission on the Accreditation of Healthcare Organizations proclaimed pain the
fifth vital sign, to be assessed in every patient, along with heart rate,
respiratory rate, temperature, and blood pressure. Although the motivation for
this move was laudable, it presented problems, since, unlike the other four
vital signs, pain can’t be objectively quantified.
The
authors of the books under review recognize the history of inadequate treatment
of pain throughout most of the twentieth century, but they don’t give it its
due. They concentrate instead on the reaction of the 1980s, which they consider
excessive and an underlying cause of the opioid epidemic. In 1982 I wrote an
editorial in The New England Journal of Medicine, which
began, “Few things a doctor does are more important than relieving pain.” I
still believe that. I ended with these words: “Pain is soul-destroying. No
patients should have to endure intense pain unnecessarily. The quality of mercy
is essential to the practice of medicine; here, of all places, it should not be
strained.”
The opioid epidemic, while horrifying, is still outweighed by alcohol
deaths, which are also increasing, according to the Centers for Disease
Control. Hampton writes, “If my first drug of choice came with a prescription,
the second one, alcohol, was culturally embedded and used to celebrate at every
turn of events.” In 2016, when there were 64,000 deaths in the US from the drug
epidemic, there were 90,000 from alcohol (including accidents and homicides
caused by inebriated people, as well as direct effects, mainly cirrhosis of the
liver). Cigarette smoking is estimated to cause 480,000 deaths a year. I do not
intend to minimize the opioid epidemic. Far from it. What I want to underscore
is the differences in these three epidemics. Alcohol and cigarettes have no
medical or practical uses of any kind. Yet we permit their use if regulated. In
contrast, opioids do have medical uses, and they are important.
The
opioid epidemic is usually seen as a supply problem. If we can interdict the
supply of prescription opioids, the thinking goes, we can stanch the epidemic.
But that is unlikely to work for two reasons. First, as I pointed out, this is
no longer mainly an epidemic of prescription drugs but of street drugs. And
second, it creates an onerous obstacle for doctors and outpatients who require
pain treatment. More and more, they have to satisfy regulations expressly
designed to restrict access to prescription opioids. Some make sense. For
example, it’s reasonable to monitor opioid prescriptions to detect pill mills.
It’s also reasonable to flag users who “doctor-shop,” that is, see several
doctors at once to try to get multiple doses of opioids.
But other
requirements are meant simply to inconvenience both doctors and patients until
they give up. For example, in Massachusetts doctors must limit their first-time
opioid prescriptions to seven days. That can be more than an inconvenience for
ill patients in pain. Macy quotes a letter from a friend with severe back pain
from scoliosis. “‘My life is not less important than that of an addict,’ my
friend wrote,…explaining that her new practitioner requires her to submit to
pill counts, lower-dose prescriptions, and more frequent visits for refills,
which increase her out-of-pocket expense.” Even more serious is a new shortage
of opioids for injection in cancer centers.
For
physicians, who are already weighed down by innumerable bureaucratic
requirements, these restrictions present one more hoop to jump through, and
many simply won’t do it. Instead, they’ll send the patient away with some Advil
and hope it does the trick, even though they know it probably won’t. The
regulations are having their intended effect. In Massachusetts, opioid
prescribing has decreased by 30 percent. Meanwhile, the epidemic of street
drugs continues apace. McGreal raises the possibility that reducing access to
prescription opioids might feed the demand for heroin. Macy quotes an addiction
specialist who laments that “our wacky culture can’t seem to do anything in a
nuanced way.”
I believe the modern opioid epidemic is now more a demand problem than a
supply problem. Three years ago, the Princeton economists Anne Case and Angus
Deaton published an explosive paper about the surprising rise in mortality,
starting at the turn of this century, among middle-aged white non-Hispanic men
and women. The increase was greater in women than in men. They found three main
causes: drug and alcohol overdoses, suicide, and alcohol-associated liver
disease. They later called these “deaths of despair,” because they were most
common among workers in tenuous jobs, with only a high school education or
less, who were struggling to stay afloat in isolated regions of the country.
Dragged down by these deaths, in the past three years overall life expectancy
in the United States has started to drop.
It’s not
hard to see reasons for the despair. Most working-class Americans have not
benefited from our booming economy, the fruits of which have gone almost
entirely to the richest 10 percent. For the bottom half of the population,
income has scarcely budged since the 1970s, while expenses for necessities like
housing, health care, education, and child care have skyrocketed. In
Appalachia, where the opioid epidemic first took hold, many coal miners were
unemployed and would probably remain so. People expected they wouldn’t live as
well as their parents had, and had little hope for their children. It is true
that African-Americans still have higher overall mortality rates than whites,
but that gap is closing rapidly for people under the age of sixty-five,
particularly for women. By 2027, white women will have higher mortality rates
than African-American women. Mortality for African-American men is falling even
faster than for African-American women; it is projected to be equal to that of
white men by 2030. But the epidemic has extended to all parts of the country
and to all ethnic groups, so it’s unclear how the effects will be distributed
in the future.
By the
middle of this decade, the grotesque inequality in this country began to get
the attention it deserves. And the growing awareness of that inequality fed the
populist passion that, when twisted and distorted, produced the election of
Donald J. Trump. It’s probably not coincidental, then, that the opioid epidemic
got its second wind at about that time. It certainly marks the time when the
opioids of choice changed from prescription drugs to the witches’ brew of
street drugs. Did the epidemic explode because people were becoming aware that
the American Dream was no longer theirs to dream?
As long
as this country tolerates the chasm between the rich and the poor, and fails
even to pretend to provide for the most basic needs of our citizens, such as
health care, education, and child care, some people will want to use drugs to
escape. This increasingly seems to me not a legal or medical problem, nor even
a public health problem. It’s a political problem. We need a government
dedicated to policies that will narrow the gap between the rich and the poor
and ensure basic services for everyone. To end the epidemic of deaths of
despair, we need to target the sources of the despair.
No comments:
Post a Comment