Why did prescription opioids bring so much misery to the small towns of postindustrial America?
The standard narrative puts the blame on OxyContin, a powerful painkiller supposedly pushed on rural Americans by the profiteers at Purdue Pharma, which ended up filing for bankruptcy and settling criminal charges with the federal government for $8.3 billion. In this telling, the opioid epidemic is a morality tale of capitalism run amok and regulations made toothless by anti-government zealots.
Sally Satel, a practicing psychiatrist who works at a methadone clinic in Washington, D.C., has a more complicated story to tell. In 2018, she moved to Ironton, Ohio, an economically depressed town in Appalachia, where she worked with patients and social service providers. Satel doesn’t stint on criticism of drug makers, but she says that the opioid crisis is an outgrowth of a century-old tradition of medicating pain as a way of tending to the broken bodies of the region’s laborers.
She stresses that when Purdue’s sales force came to small towns in Appalachia, it was “pushing on an open door.” While there’s no question that OxyContin was a particularly potent painkiller whose potential for abuse was criminally downplayed by its makers, it was merely the latest in a long line of legal and illegal substances used by people in the region to ease physical and psychological suffering. That’s one of the reasons that, even after OxyContin was reformulated to reduce abuse and opioid prescriptions declined, overdoses and dysfunction are still commonplace.
Satel also challenges conventional theories of addiction that characterize it as a disease like diabetes or Alzheimer’s. Substance abuse, she says, derives from both inborn predilections and a person’s environment, or what she calls “dark genies” and “dark horizons.” Satel stresses that the best way forward is to give individuals tools to make better use decisions while improving their chances to live lives with open-ended futures.
Satel is a resident scholar at the American Enterprise Institute and co-author of the 2013 book Brainwashed: The Seductive Appeal of Mindless Neuroscience, among other works. She spoke with Reason’s Nick Gillespie via Zoom in late December.
Reason: What drew you to rural Ohio, and how long did you stay?
Satel: I was there for a year. I became the only psychiatrist in Lawrence County in southern Ohio. I worked in a clinic, and I ran a group with a wonderful seasoned social worker. I saw patients and found, not to my surprise, that addiction is addiction.
In the inner city, the drug that was available was heroin and, increasingly, fentanyl. By the time I got to Appalachia, heroin had already moved in, but pills still had a presence. There has always been a pill problem in rural America and especially in central Appalachia, where coal mining was huge.
Many people, when they talk about the opioid epidemic in Appalachia, start the clock in 1996, which is when OxyContin was introduced. OxyContin is a long-acting form of oxycodone, which is the actual opioid. But a lot predates that. There had been trafficking of prescription pills for a long time, mainly Percocet, Lortab, Vicodin—all of those are preparations of oxycodone and hydrocodone. They’ve been very, very popular, and doctors had a fairly low threshold for prescribing them.
OxyContin is extremely potent because it’s long-acting. The pill has a lot of oxycodone in it. For example, your average Percocet is 5 to 10 milligrams of oxycodone, but an OxyContin pill can have up to 80 milligrams. The immediate-release pills—the Vicodins and Percocets—are designed to last between three and six hours. If you’re dealing with acute pain, that’s usually fine. Most people never needed the 30-day [supply] they were given for their tooth extraction or whatever. The appeal of OxyContin is that it was long-acting, so that if you had severe or moderate chronic pain, you had a more steady blood level. You wouldn’t have almost mini withdrawals in between doses. That is a pharmacologically legitimate strategy.
When you chop it up and either snort it or mix it with water and inject it, you’re getting an enormous rush. It’s pharmaceutical grade, so it’s safe in terms of no impurities. But of course, if you don’t have tolerance, it’s not safe, and you can overdose on that.
What were people being prescribed pain pills for?
Any blue-collar area is going to have a lot of hard-labor jobs. Coal mining is just brutal. Of course, that’s not a dominant industry there any longer, but coal mining was unbearably brutal and dangerous. In the 1920s and ’30s, many men lived in coal camps, which were owned by the mining companies. The coal camp doctor, who was employed by the company, had to get them into the mines. They medicated them so that they could work. This culture of prescribing for non-cancer chronic pain was endemic to the region even after coal mining disappeared.
What’s it like now?
You had communities that were economically imperiled, because there had been a deindustrialization due to globalization or automation. In Ironton, there were jobs; they were just low-paying jobs. There was a great out-migration of what would have been the middle and upper classes, so you’re left with a hollowed-out community. The social service layer was huge. Hospitals are often the major employer in these areas. There’s a whole layer of people who are struggling, a whole miasma of hopelessness. The drug companies did target Appalachia, and also northern Maine in the Northeast, because they’d been selling there for so long. The drug reps were pushing on an open door.
Most people who are prescribed these drugs use them uneventfully, and that’s the end of it. They don’t even finish their prescriptions. But there’s a problem that they then put the extra in the medicine cabinet, and those end up getting in the wrong hands.
One of the most pernicious myths of the opioid epidemic is that of the accidental addict. The idea that you go to the doctor and he gives you an opioid—not necessarily OxyContin. Only 4 percent of all prescriptions for pain were written for OxyContin, although they were always preferred by people who abused pills.
Overwhelmingly, studies will show that fewer than 1 percent [of users with prescriptions become addicted] is a common finding. You find some that are about 8 percent. The meta-analyses that separated out studies that exclude patients with a history of addiction, or a concurrent problem with depression or anxiety, found these rates of under 1 percent. Patients who are vulnerable are those with a history of addiction, history of alcoholism, or a concurrent problem with either a psychiatric diagnosis or a severe existential problem. You can imagine getting in an accident, having a completely otherwise normal psychiatric history, but the accident is devastating. You’ve lost your job. You’ve lost function. It’s a deeply depressing and demoralizing and terrifying state, and these drugs are not only good for physical pain, they’re excellent for psychic pain. Those are the folks who are vulnerable. Those are the folks we have to watch.
You’ve found that the bigger problem is with people who were never prescribed these drugs.
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