The opioid crisis as a disease of despair?

The narrative that the opioid and overdose crisis is a product of despair has become very popular. The logic is that people in bad economic conditions are more likely to turn to opioids to cope with their circumstances, and that their hopeless environmental conditions make them more likely to die of an overdose. This model frames addiction and overdose as diseases of despair.

This model fits nicely with other writers who have garnered a lot of attention on the internet.

  • Johann Hari presents addiction as a product of a lack of connection to others.
  • Carl Hart frames sociological factors as causative and argues that there’s a rationality to escaping terrible circumstances via drug use and that a form of learned helplessness eventually takes root.
  • Bruce Alexander is frequently cited to support these theories. He did the “rat park” study that found rats deprived of stimulation and social interaction compulsively used drugs, while rats in enriched environments did not.

These understandings are so intuitive, but what if they are wrong?

These narratives make so much sense, and they support other beliefs and agendas many of us hold. Further, it feels like no one is going to harmed by efforts to improve economic, social, and environmental conditions, right?

Well, that’s not quite true. Bill White pointed out that how we define the problem determines who “owns” the problem, and that problem ownership has profound implications for addicts and their loved ones.

Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

The existence of a “treatment industry” and its “ownership” of the problem of addiction should not be taken for granted. Sweeping shifts in values and changes in the alignment of major social institutions might pass ownership of this problem to another group.

With so many bad actors in treatment right now, there is not a great rush to protect the treatment industry.

To be sure, we’d be better off of a significant portion of the industry disappeared. However, the disappearance of specialty addiction treatment would be tragic for addicts and alcoholics in need of help.

Further, it just so happens that there’s good reason to doubt the “diseases of despair” narrative.

New study casts doubt on “diseases of despair” narrative

A new study looked at county level data and examined the relationship between several economic hardship indicators and deaths by overdose, alcohol-related causes, and suicide.

Mother Jones describes the findings this way:

Economic conditions explained only 8 percent of the change in overdose deaths from all drugs and 7 percent of the change in deaths from opioid painkillers—and even that small effect probably goes away if you control for additional unobservable factors. It explained none of the change in deaths from heroin, fentanyl, and other illegal opioids.

They quote the researcher as observing:

Such results probably should not be surprising since drug fatalities increased substantially – including a rapid acceleration of illicit opioid deaths – after the end of the Great Recession (i.e. subsequent to 2009), when economic performance considerably improved.

If it’s not economic hardship, what is it?

Vox describes the study’s conclusions this way [emphasis mine]:

. . . the bigger driver of overdose deaths was “the broader drug environment” — meaning the expanded supply of opioid painkillers, heroin, and illicit fentanyl over the past decade and a half, which has made these drugs much more available and, therefore, easier to misuse and overdose on.

Leonid Bershidsky from Bloomberg noted the following:

The absence of an opioid epidemic in Europe indirectly confirms Ruhm’s finding. European nations have experienced the same globalization-related transition as the U.S. In some of them — Greece, Portugal, Ireland, Spain, even France — economic problems were more severe in recent years than in the U.S. Yet no explosion of overdose deaths has occurred.

. . .

There’s also a notable difference in what substances are causing overdose deaths. In the U.S., heroin accounted for 24 percent of last year’s overdose deaths. In Europe in 2018, its share of the death toll was 81 percent. That should say something about how supply affects the outcomes.

Piling on

Then, as if to drive the point home, BMJ posted a study examining the relationship between opioid exposure and misuse. They looked at post-surgical pain treatment,

Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.

The study “excluded patients with presurgical evidence of opioid or other non-specific forms of misuse in the six months before surgery.” (I would have liked more stringent exclusionary criteria, but it’s still instructive.)

Where does this leave us?

I’ll repeat (a modified version of) what I wrote in a post in response to Johann Hari’s TED talk that emphasized lack of purpose and connection as the cause of addiction and add economic factors to the mix.

  • Do economic/social/environmental factors cause addiction? No.
  • Are they important? Yes.
  • Could they influence the onset and course of addiction? Yes.
  • Is addressing those factors important in facilitating recovery for many addicts? Yes.
  • Do economic/social/environmental factors cause addiction? No.

Ok, but what about policy?

This leaves us with some uncomfortable (but obvious, to anyone paying attention to this crisis) findings to consider.

Much of the policy discussion over the last several years has been dismissive of supply as a factor in addiction. This poses very serious concerns about that stance.

I’ve never been dismissive of supply as an important consideration, but I am coming to believe that I’ve underestimated its importance.

A lot of that dismissiveness is in response to the drug war and the moral horror of mass incarceration.

The problem demands more of us than we are typically capable of. We need to figure out how to address illicit and licit supply without resorting to mass incarceration AND assure treatment of adequate quality, duration, and intensity.

12 thoughts on “The opioid crisis as a disease of despair?

      1. We know so very little about the brain. Perhaps even epigenetics are involved.. I’ve long wondered what evolutionary advantage there is in using mind altering chemicals. Or is it a fluke. A genetic dead end. I suspect in the near future scientists will have a means of testing humans as children to ascertain their susceptibility to opiate addiction. One strong indicator I believe is those that have an amphetamine response to doses of opiates that make most lethargic and tired. They could introduce small amount into a child and measure physiological response. I know for me and most I’ve talked to experienced a hyper amphetamine response with total mental clarity. Similar to what one reports taking Adderall. In fact it was this effect that most appealed to me.. This mimicry of a manic state. Identify those people early and there chart could follow them through life as well as factual info from parents and peers to be mindful of the danger.

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  1. Clarity over Agreement. Well said by yourself and Bill White. But that is the conundrum.. how to address supply without mass incarceration. Perhaps an opportunity lies within incarceration.

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    1. In one of the Nordic countries I was in can’t remember which had a zero tolerance to drunk driving. If pulled over you immediately went to jail for 6 months. No trial. Was just the way it was. You could do similar thing for heroin users…. Only immediately admitted to treatment. No questions asked. 6 months

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      1. Dr. Nora Volkow, the head of the NIDA, once said that it was her opinion that with the law, we have a tremendous opportunity to compel treatment. I’m in agreement. Must be, in my opinion, long term, affordable, and grounded in sound medical practices. Then, we may .. may have a chance.

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  2. The hows and why’s? If the human brain was so simple that we could understand it… We’d be so simple that we couldn’t… It’s a strange thing to think a human brain can be so hijacked that literally every decision made revolves around acquiring a chemical… Is there even decision at that point? Interestingly enough humans not the only victim. Papaver Somniferum the opium producing poppy has evolved over tens of thousands of years to guarantee its existence with one simple gimmick… Addict humans primarily, who then assure the plants existence… All animals living near opium fields also become addicted… From the airborne opium particles and never move far from the fields.

    So. We are combating the genius and fecundity of nature….and a few chemists. This plant exists for the sole purpose to addict.

    How to stop it? Legalize. Regulate. Does it make sense that a 15 year old can acquire heroin easier than a 6 pack.

    Also I was thinking. From a strict legal perspective. If my brain is hijacked, I am no longer capable of making rational decisions… Therfore I immediately forfeit my right to self determination. My point being, the moment someone found in possession of heroin, commit them to a treatment facility. The cops ought immediately take them. They can not leave…. They are committed by the state mandatory… 6 months. No exceptions.

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  3. Great article. Naturally, I like alot of humanists out there, fell I in love with the Hari solution because it resonated with humanity in an area so overwrought with shame .However, their is no magic recovery template but a constellation of different causes and possible solutions.

    I think Maria Salvitz’s recent book was great in suggesting that in addiction their are often a confluence of commodities such as ADHD,Bi-Polar, Autism
    and many others that are coexisting and exacerbating addiction in the framework of a chicken and egg and nature vs nurture contrasts that is mapped out on a continuum that is constantly morphing.

    Lastly, I think addiction is very much tied to codependency and the dysfunctional family dynamic. With the belief addicts are just running away from a childhood insult we need more psychoanalysis and less band-aid talk

    Finally, to deny genetics as a factor was always shamanistic. I do work with genograms to map out the pattern skip of addictions in families(which often skips a generations. Addicts like this because it shows an evolution of causation based on genes and this goes along way in eliminating individual shame.

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