Opiate of the Masses: What’s Really Driving America’s Prescription Drug Epidemic

robert-kneschke

IN THE SPRING of 2016 a physician in Buffalo, New York, was issued a 114-count indictment accusing him of “the unlawful distribution of narcotics” and “operating a criminal conspiracy.” The US Attorney General for the western district of New York said that the doctor, who had nearly 10,000 patients and had written over 100,000 prescriptions in a single year, “was acting like a drug dealer.” An FBI spokesperson added that the doctor “let his patients down, he let his employees down, and he let the community down.”

The indictment brought an immediate response from all three constituencies. In chat rooms and on Facebook pages, on radio talk shows and television network news programs, hundreds protested the indictment and the subsequent closing of the busy medical office. Patients maintained the medication was required for them to both carry out routine tasks, like driving a car, and to experience the fulfilling joys of life, such as playing with grandchildren. One said the pills allowed her to, quite simply, “have a life”; another called the man who prescribed them a “godsend.” Employees described the doctor as dedicated and caring. Their tone was one of indignation, based on a shared belief that they had been let down not by their physician, but by their government.

On the heels of this response, the Attorney General and a Drug Enforcement Administration spokesperson promptly met with reporters to “clear up some confusion” about the case; days later the clinic reopened.

More than 250 million prescriptions for painkillers are written each year in the United States. Enough were prescribed in 2010 to medicate each American adult every four hours for a month. Americans, about 5 percent of the world’s population, account for 99 percent of the world’s hydrocodone (Vicodin) consumption, 80 percent of the world’s oxycodone (Percocet and OxyContin) consumption and 65 percent of the world’s hydromorphone (Dilaudid) consumption, according to the New York Times. All the while the use of illicit drugs, including non-prescribed painkillers, continues to grow.

It’s no longer a secret that the substantial swath of Americans living under the influence of these opiates do so with at least the tacit approval of our political system. Our law enforcement agencies, after all, focus on only a small number of the poorest users (and then only the few who become addicted and engage in crime), and our taxpayer-funded healthcare programs support the epidemic by spending billions annually on these drugs. Moreover, government-sanctioned discussions of the problem typically revolve around addiction-related crime; the devastation the drug has brought to many small, rural communities; the spread of opioid use into the white middle class; or the easy transition to heroin use. Recent negotiations in Congress, touted for their bipartisan nature, are designed to make treatment and the anti-overdose drug Naloxone more available to addicts. There are also proposals to fund school-based educational programs and to limit the practice of “doctor shopping.”  Analyses of the root causes of the epidemic as well as the inordinate profits of the pharmaceutical industry are typically left to reporters and filmmakers. But very little attention has addressed a most basic problem: Why are our elected officials not confronting this widespread drug dependence with the goal of limiting it, rather than trying to make addiction treatment more available?

Consider this analogy: Constipation caused by regular opioid use is now so common that there are medications marketed for opioid-induced constipation (OIC). That drug’s consumers are numerous enough to warrant an expensive Super Bowl commercial, one that depicts long-term opioid use as a given, and its amusingly chronic side effect as an easily treatable annoyance. According to the pharmaceutical industry, it’s the unfortunate consequence of long-term use that must be addressed. A second industry commercial mentions several specific side effects of OIC medications: a tear in the stomach or intestine and opioid withdrawal, for example. Another set of drugs designed to treat these symptoms is probably in the works, creating an expanding cycle of pills made to lessen the side effects of other pills, and so on. Though profitable for drug-makers, the pattern avoids the real problem while treating one set of symptoms after another.

This “symptom-response exchange” that occurs in the pharmaceutical industry intertwines with a similar symptom-response exchange taking place in the social world, where systemic problems are ignored while symptoms are addressed: A lack of jobs is responded to with medications; resulting crime elicits prison, which weakens families; broken families are responded to with welfare benefits, which breed dependence; and so on.

Perhaps the public furor elicited by the Buffalo case provides a hint of what would occur on a much wider and more active scale if fewer Americans were chemically numbed, or if their ready access to drugs were threatened, and if they instead confronted what they experience as painful lives. In tentative and understated ways, these otherwise silent Buffalonians pushed back on a system they had found nonresponsive. Previously mute, they found a voice. They demanded to be heard, and this time they were. In the end, they were not denied access to the painkillers that allowed them to get on with life and to be happy, even if for some it meant doing so in “zombie-like” fashion.

The personal assessments of hopelessness by the chronically poor and the former working class reflect what is often an objectively harsh reality, one that includes inferior education, lost jobs, low and stagnant wages, and little prospect of upward mobility. In a sense, the world they grew up in and anticipated living in has vanished. For the hollowed-out middle class, it’s frequently a life filled with the apprehension that accompanies continual change, and the fear of falling into the void that waits below. In this context, readily available and subsidized pain relievers offer an alluring promise of a more tolerable existence. It’s a promise that’s kept more reliably than are similar pledges offered every election cycle by mainstream politicians who are no longer believed.

Certainly, the benefits of widespread opioid use are understood by our elected leaders, especially in an era when respected pundits, viewing angry mobs, speak of a possible need to “restrain democracy.” It’s quite possible that during an era of gross inequality and low-paying, no-benefits jobs, a numbed electorate may be viewed favorably as an apathetic citizenry inclined to accept the status quo, even one that is traumatic, frightening, cruel, unfair, or lonely. It’s a status quo in which former sources of meaning are crippled or dead. Data on marriage and divorce rates, as well as those on non-marital childbearing and marital satisfaction levels, show that for the poor and working class, the family has effectively collapsed; jobs that provide a sense of dignity, control, and the wherewithal to provide for oneself and others, are gone; and religion’s capacity to nurture the spirit has broken down and a vibrant group life of neighborhoods has failed to replace it.

This reality has been ignored by those who helped create it. Only now, as darkness falls on a troubling presidential campaign, is the political class, suddenly worried about its own job security, conceding the devastation their policies have inflicted on so many. Unbalanced, international trade agreements and rampant outsourcing, the voiceless are finally told, might have been mistakes.

But what if they weren’t mistakes? What if these decisions were made with the knowledge that they would benefit the few and hurt the many? What if we have constructed a society in which there cannot be meaningful jobs for all who want them; a nation incapable of making all of its citizens literate; a place in which the sources of stability in families and neighborhoods cannot be resuscitated; one in which houses of worship and voluntary associations can no longer sustain a shared set of altruistic beliefs? What if, unwilling to provide the conditions necessary for contentment, our leaders are settling for a state of indifferent acceptance, one in which, rather than a reasonable income or usable skill set, they offer the disaffected a prescription?

Karl Marx wrote, “Religion is the sigh of the oppressed creature, the heart of a heartless world, and the soul of soulless conditions. It is the opium of the people.” By encouraging compliance and promising relief and contentment after death, religion convinces the exploited and the alienated to endure a burdensome existence. But Marx also believed that religion was a form of protest against those oppressive conditions, one that could become as real as the suffering itself. In this context, opiates may be fulfilling the political function once met by religion by keeping the masses quiet; but it could also be where the “revolution” begins: with the refusal of a small group in Buffalo to allow their comfortably numb lives to be threatened. When that distorted reality is interfered with, as one day it will likely be, the collapse of institutionalized widespread chemical pain relief could prove Marx right, sort of.

Religion’s grip on the lower classes has loosened considerably and may soon lack the ability to placate an expansive and increasingly diverse category of people. Soon, the truth in the metaphor underlying Marx’s observation may be reversed, with opiates becoming the religion of the masses, tied to shared beliefs, common rituals, and sacred objects. It may be the opioid epidemic that is the sigh of the oppressed creature, a lament for what has been lost, a distorted vision of a contented life worth rebelling for, a cry for change.

Marx believed that the premise of all criticism is the criticism of religion, that a critique of religion would lead to the critical assessment of other social institutions. In the United States today, an analysis of the opioid epidemic leads to an understanding of the profit-driven pharmaceutical industry, which in turn triggers a critique of the economy, and then of the political system that facilitates it, and so on.

Many of the Buffalo doctor’s supporters, for example, denounced those politicians who threatened easy access to painkillers, saying they were only trying to make a name for themselves and get votes. Others condemned the profit-hungry pharmaceutical industry for creating such widespread dependence in the first place. One comment cut to the core of the issue by asking what one was to do when life was defined by psychological or physical suffering: “If there is no cure for what a person has, should that person just curl up and suffer? Go from doctor to doctor trying to find some kind of mental relief—even a psychiatrist and therapist for months and years? Go from doctor to doctor for months and years looking for and praying for physical relief? Or just call it quits and find someway to end their life?”

In our secularized world, suffering and praying have lost their cachet; suicide has not, with rates increasing alarmingly among the white working class. For now, those who protest their diminished lives have limited themselves to rowdy displays of support for a man who promises to resurrect what has been lost. In Buffalo, confronted with the unwelcome prospect of viewing reality soberly, a group of people formed a small and angry congregation outside a closed pain management clinic.