During an Oval Office ceremony on Wednesday for new legislation to give Border Patrol agents better equipment for intercepting illegal drug shipments, President Donald Trump said he thinks he has an answer to the epidemic of opioid abuse in America, but that the country might not be ready for the solution he has in mind.
“We’re going to sign this. And it’s a step. And it feels like a very giant step, but unfortunately it’s not going to be a giant step, because no matter what you do, this is something that keeps pouring in,” the president said.
“We’re going to find the answer,” Trump promised. “There is an answer. I think I actually know the answer, but I’m not sure the country’s ready for it yet. Does anybody know what I mean? I think so.”
Trump offered few clues to the solution he has in mind, other than implying it would be much more aggressive than current policies, including the new bill he was about to sign into law.
2017 was the year rising mortality rates for middle-aged whites in America came onto the public and government policy radar screen, two years after a landmark study from Princeton economists Angus Deaton and Anne Case first detected the statistical spike. The causes of the White Death are complex, but it seems clear that one of the important factors is the rise of drug addiction, particularly opioids — from prescription painkillers to heroin.
President Donald Trump established a commission to study the opioid epidemic in March, describing it as a “crippling problem throughout the United States.”
“This is an epidemic that knows no boundaries and shows no mercy, and we will show great compassion and resolve as we work together on this important issue,” the president said.
The President’s Commission on Combating Drug Addiction and the Opioid Crisis released a comprehensive report on the crisis in November, along with a list of recommendations for combating it.
“You’ve met hundreds of parents who have buried their children, so these numbers are no longer simply statistics,” commission chairman Gov. Chris Christie reminded President Trump in his introduction to the final report. “Instead, they represent the injured student athlete who becomes addicted after first prescription, ending her academic and athletic career; the newborn infant who is red and screaming from withdrawal pain; the grandparents using their retirement savings to raise young kids when the parents can’t; the mom who just buried her only son; and the addict who cycles in and out of jail, simply because without access to treatment he is unable to stay sober and meet the terms of his parole.”
The commission’s report acknowledged that opioids are an effective and inexpensive form of pain management, but criticized “a disturbing trend in federal health care reimbursement policies that incentivizes the widespread prescribing of opioids and limits access to other non-addictive treatments for pain, as well as addiction treatment and medication-assisted treatment.” One of the primary corrective recommendations was to reverse this trend by incentivizing the development and use of alternatives to opioids.
The commission was also disturbed by increased marijuana use, including the prescription of pot as an alternative to opioids, citing National Institute of Health research that found “marijuana use led to a 2.5 times greater chance that the marijuana user would become an opioid user and abuser.”
From this perspective, the prospect of marijuana legalization looms as a factor that could make the opioid epidemic even worse, rather than alleviating the problem. The epidemic is a downward spiral that often begins with prescription drugs or alcohol abuse and slides toward heroin.
Of course, the true beginning of that downward spiral is the environment that leads so many people to drink or take drugs in the first place. Case and Deaton called the phenomenon “death by despair,” a societal collapse occurring in tandem with increased reliance on pain medication for complaints that might have been deemed minor in earlier times. It could be argued that this, too, is an aspect of death by despair.
The level of physical pain reported by Americans to their doctors continues to increase, and the treatments prescribed for those ailments tend to be more dramatic than in other countries. Americans now report the highest levels of pain in the world, followed by the similar societies of Australia and the United Kingdom. Researchers cited the high level of obesity in the United States as one reason, which might lead to an uncomfortable sociological debate about having a lot of poor, unemployed, and underemployed people who are also fat.
More pertinently, another factor suggested for the high level of reported pain in America is the general sense of unhappiness, especially among people with low education levels — the very same cohort experiencing the White Death.
It’s not just about people telling doctors they’re in pain to get drugs so they can make themselves happy, or dull their sense of unhappiness; it’s that depression leads to physiological changes that change how the body senses and reacts to pain. The sense of stress that comes from being unemployed and helpless is very different biochemically from the stress of being overworked or dealing with a large number of commitments. Once again, we see evidence that despair is the great enemy.
A Wall Street Journal analysis published in the summer of 2017 found that rural American communities are experiencing the same social pathologies that plagued inner cities a generation ago, in part because the rural jobs base has disintegrated:
For more than a century, rural towns sustained themselves, and often thrived, through a mix of agriculture and light manufacturing. Until recently, programs funded by counties and townships, combined with the charitable efforts of churches and community groups, provided a viable social safety net in lean times.
Starting in the 1980s, the nation’s basket cases were its urban areas — where a toxic stew of crime, drugs and suburban flight conspired to make large cities the slowest-growing and most troubled places.
Today, however, a Wall Street Journal analysis shows that by many key measures of socioeconomic well-being, those charts have flipped. In terms of poverty, college attainment, teenage births, divorce, death rates from heart disease and cancer, reliance on federal disability insurance and male labor-force participation, rural counties now rank the worst among the four major U.S. population groupings (the others are big cities, suburbs and medium or small metro areas).
In fact, the total rural population — accounting for births, deaths and migration — has declined for five straight years.
It’s not just about the loss of heavy manufacturing industries developed early in the previous century, either. The Wall Street Journal piece included the story of an Amazon.com distribution center that brought hundreds of jobs to small-town Coffeyville, Kansas, in 1999, only to close down in 2015 because the rural customer base wasn’t buying enough Amazon products to sustain it. In Utah, a plan to move high-tech call centers to rural America fizzled when companies decided it was cheaper to move them to foreign countries instead. The social shock waves of economic realignment are reaching much further than the experts of the 1990s and early 2000s predicted.
On the other hand, a study published by Dr. Christopher J. Ruhm at the Frank Batten School of Leadership and Public Policy argued that the spread of “death by despair” due to poor economic conditions has been overrated as a cause of the opioid epidemic. The widespread availability of drugs and the high rate of prescriptions written to the middle-aged white demographic loomed larger in Ruhm’s analysis.
In fact, Ruhm proposed that the Deaton-Case “death by despair” analysis might have cause and effect reversed — the high rate of opioid use and abuse might be causing the labor market to decay, rather than unemployment prompting higher rates of drug abuse.
Ruhm also observed that while prescription drugs and heroin are linked in many other examinations of the White Death, they actually affect different demographics. Painkillers are primarily affecting middle-aged white people, while heroin use is rising sharply among young males, including nonwhites.
From this perspective, a longstanding and much-lamented social issue might be one of the strongest factors in the opioid epidemic: absent fathers and the disintegration of the traditional family. Young men from female-headed households seem to be more susceptible to opioid abuse, and today’s middle-aged whites grew up as children of the divorce surge in the Seventies. Conversely, Ruhm touches on the idea that “drug consumption and abuse might influence the percentage of households in the country that are headed by females.” As with other aspects of the opioid crisis, it can be tricky to establish which factors are causes and which are effects. In this case, both might be true — family breakdown creates poverty and drug abuse, which causes more family breakdown that results in even worse poverty and drug abuse.
Accurate diagnosis and effective remedies are urgently needed. In June 2017, the New York Times reported that drug overdose deaths in 2016 saw “the largest annual jump ever recorded in the United States,” making overdoses the leading cause of death for Americans under the age of 50.
“All evidence suggests the problem has continued to worsen in 2017,” the Times noted ominously. Studies cited in the article agreed with Ruhm’s observation that high unemployment rates are not sufficient to explain the epidemic, as some of the hardest-hit areas on the East Coast have unemployment rates in line with the national average.
The rise of fentanyl and its offshoots, pushed by drug dealers as a cheaply-made substitute for painkillers, heroin, and even as an ingredient in cocaine cocktails, was cited as a strong factor in the surge of overdose deaths. One of the fentanyl drugs, carfentanil, is an elephant tranquilizer so powerful that a dose the size of a pinch of salt can kill a human being.
The East Coast drug market pushes more fentanyl than the West Coast does, which might help to explain the surge of overdose deaths in the eastern United States. The new legislation President Trump discussed in his Oval Office ceremony on Wednesday funds devices for Customs and Border Patrol agents that are especially good at detecting fentanyl.
The War on Drugs has taught us that attacking both supply and demand is necessary to reduce drug abuse. Interdicting supply is a relatively straightforward law-enforcement objective, but it’s extremely difficult to accomplish if demand remains high. Every barrier becomes porous if enough money washes up against it. Attributing too much emphasis to any single factor in rising demand would be a mistake. We need to address all of them, from despair and joblessness to medical over-prescription and drug smuggling.
Americans are in pain because they’re unhappy. They’re unhappy because they lack the sense of purpose jobs and family provide. They feel desperate because their cultural environment is heavy with cynicism, nihilism, hedonism, and hopelessness. No single “kill switch” triggered rising mortality rates and drug abuse, so no single switch can be flipped to reverse these terrible trends.
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