This past week, Governor John Kasich of Ohio issued an executive order limiting the amount of opioids doctors and dentists can prescribe to no more than a 7 day supply. Failure to comply could result in disciplinary action, including loss of license. Exceptions exist only for patients with cancer or those enrolled in hospice programs. For all the rest, it represents a hard full stop. No longer will the chronic pain sufferer, the woman status post lumbar back fusion x 3, be able to get a prescription for a month's supply of oxycodone with 3 refills.
On the surface this appears to be a reasonable initiative. We are undoubtedly in the midst of a true crisis in terms of opiate/opioid abuse in this country. It is a crisis that disproportionately affects the poor, the downtrodden, across large swaths of flyover rural America. Something must be done, any reasonable elected official would say. Over 50,000 Americans died last year as a result of an overdose. Overall life expectancy declined last year for the first time in nearly 30 years, a decline mainly attributable to middle aged males and females from lower economic and educational attainment strata dying sooner. Suicide and overdose have been targeted as culprits in this real "American carnage".
But what I am uncomfortable with is the evolving narrative that the entire crisis was fomented by evil "pill mill" doctors lining their pockets with cash as their patients spiraled into despair and degradation . Certainly, bad apples are out there. But anecdotal stories about physician malfeasance fail to adequately explain the opioid epidemic. Why does it exist? Why are so many Americans turning to escapist options to dull their pain? What is this constant throbbing ache, this intermittent sharp twinge, that afflicts so many? Why are so many from very specific geographic areas, from very specific socioeconomic stations seeking relief from a great contagion of pain?
It's easy to say: those damn doctors. Bad doctors can be fixed. They can be demonized as scourges upon society. All stories flow easier with an identifiable villain. But it's much harder to say: the structural/cultural/economic foundations of our country have been slowly eroding over the past 35 years and as the ramparts come tumbling down, those left exposed, vulnerable to the ravages of life's uncertainties will then turn to something, anything to assuage pain, numb anxiety. A life lived in a state of constant uncertainty and despair breeds hopelessness. And for many, escape becomes the only reasonable solution.
Since we embarked upon a path of free market globalization, our nation has seen a rise in income inequality that puts the Gilded Age to shame. As the following graphs show:
And how did this occur? How is it that, in the richest, most wealthy nation in recorded history, so much of the fruits have gone to so few of its citizens? The answers of course, reside outside of what this blog post can elucidate, but the common theme revolves around wealth concentration and restricted distribution. We have all driven by the shuttered factories in the heartland. Those jobs shipped off to third world countries in the 80's and 90's will never return. No longer can a male of mediocre intellectual talents just sign up for a job out of high school at the local Ford plant or the rubber tire factory and plan to settle in for 25-30 years of solid pay with good benefits and be able to raise a family, send his kids to college, retire at 65 with a 7 figure pension. Those days experienced by the baby boomer generation, are almost mythically unattainable by the bulk of Americans in the heartland today.
And so what happens? What happens when a man or a woman cannot honorably earn a living? When the costs of higher education go up 400% over 25 years? When health care expenses skyrocket beyond affordability and, in the absence of employer based insurance, become the driving etiology of bankruptcy and financial catastrophe? What happens? Is it simply of case of legions of evil doctors descending upon these wracked plains of a nation and unleashing their addictive and destructive medicines? Is that the narrative we ought to go with, in the face of so much contrary evidence of systematic instability?
Governor Kasich and Senator Portman in my home state, have made the opioid epidemic a priority in terms of legislation and executive orders. I am not so cynical as to doubt their motivations. They see the pain and suffering in so many of their constituents and want to alleviate it, to the extent they are able. But these measures are akin to the crackdown during the War of Drugs. We ended up incarcerating millions of Americans (mostly minorities, mind you) without having any impact on drug use, especially in the areas where the crackdown was most targeted, i.e. the inner cities. Prohibitionary measures simply don't work. The evidence from the 1920's and then from the 1970-2015 War on Drugs era is irrefutable. You cannot simply criminalize or police your way to complete abstinence. The black market will always step in to fill the gaps in supply. And the greater you restrict access, the more the black market will place its foot upon the throats of those clamoring for a fix. The vicious cycle will continue. The drugs will be less regulated, stronger, more dangerous. More will die. More will go to jail and be forever stained with a felony tag. It would be a tragedy to repeat the same mistakes we've made in the past for this new scourge.
The real issue, the potentially fixable issue, is one of demand. Why are all these Americans turning to the escapism offered in the form of heroin or prescription opioids? And how can that demand be addressed?
We know that 20% of Vietnam veterans were addicted to heroin during the war. But only a small percentage continued to use heroin once they returned home to America, back to jobs and wives and existential stability. We know that in Portugal and Switzerland, opiate addicts can go to "clinics" for heroin injections early in the morning on their way to work. That many of them eventually simply stop using the drugs as they become more and more integrated back into stable and meaningful life routines. In America opt to do things differently. Marijuana is categorized as a Schedule I substance (no accepted medical use). Addicts are treated as derelicts, scum of the earth. We continue to incarcerate more people for drug related offenses than the rest of the world combined. And nothing has changed, nothing has improved, despite the trillions of dollars spent on this ill-advised "war" over the past 35 years.
A nation writhes in pain. No one can avert their eyes from it. Our ER's fill up nightly with overdoses. The young and middle aged are dying in unprecedented numbers. A plague is upon us. You can regulate doctors a little more, I guess. You can repudiate the idea that "pain is the fifth vital sign", as the American Medical Association has done. But you can not simply tell people that they are not hurting. You cannot erase the pain of dislocation, uncertainty, economic catastrophe. You cannot tell a man with three kids, a drug habit, trapped in rural middle America, that the pain he feels every morning in his back, his joints, his heart and soul is somehow not real. That he ought to feel shame. That it is somehow all his fault.
You can threaten doctors. You can cut off the legal flow of a few bottles of prescriptions drugs. But it won't stop the pain of the millions with no prospects and no hope. Kasich's order is a band-aid applied to a gaping hemorrhaging wound. It's something, I guess. But it isn't nearly enough.