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Friday, September 13, 2019

Review: Dopesick

Dopesick is a book exploring the opoid epidemic in the USA, specifically in Virginia. Scarlet pointed me at the book, and it's very much worth reading for an overview of what some economists call "The diseases of despair." I learned a ton in this book.

For instance, I didn't know that selling addictive drugs has long been part of the history of the big pharmaceutical companies:
By 1899, Bayer was cranking out a ton of heroin a year and selling it in twenty-three countries. In the United States, cough drops and even baby-soothing syrups were laced with heroin, ballyhooed at a time when typical opioid consumers were by now not only war veterans but also middle-aged barbers and teachers, shopkeepers and housewives. Many were mostly functioning, doctor-approved users, able to hide their habits—as long as their supply remained steady, and as long as they didn’t overdo. (pg 24)
Even more importantly, I didn't realize that the subjective pain management scale and the relatively recent emphasis on pain management was propaganda foisted onto the medical profession by the pharmaceutical companies. It's astounding to me that the FDA allowed opoid-based pain medication out along without guidance on the possibilities of addiction to powerful drugs. Many of the drug addicts became addicted not because they were partying, but because they were prescribed a drug for too long (and it's not clear to me how studies are done about potential addiction to a pain-killer --- I remember a nurse injecting morphine into me after I'd gotten hit by a car, telling me: "don't worry, you won't get addicted to it." Mercifully, right after that injection I lost consciousness, and needless to say she was right --- I had no craving for morphine after that).
New patients were given OxyContin “starter coupons” for free prescriptions—redeemable for a thirty-day supply—and Purdue conducted more than forty national pain management and speaker-training conferences, luring doctors to resorts from Boca Raton, Florida, to Scottsdale, Arizona. The trips were free, including beach hats with the royal-blue OxyContin logo. More than five thousand doctors, nurses, and pharmacists attended the conferences during the drug’s first five years—all expenses paid. (pg 47)
Again, this is only something that happens in the USA. Other countries with government provided healthcare wouldn't have marketing driven prescriptions. Again and again, the politics of the situation rears its head. For instance, Virginia was one of the states that fought Obamacare by not expanding medicaid coverage.  That creates a cycle of drug use, since many of the addicts were too poor to afford rehab (not that they would have wanted rehab --- many of the victims had families that paid for and pushed them into rehab). After a US district attorney successfully sued Purdue Pharmaceuticals and got them to cough up a relatively small settlement, he was almost fired:
Eight days after it accepted the deal, Brownlee was stunned to see his name on a firing list, along with four other U.S. attorneys. Though he wasn’t ultimately fired, the incident provided fresh criticism of then–attorney general Alberto Gonzales, accused of trying to sway the work of U.S. attorneys’ offices. And it only underscored the long reach of Purdue: Udell’s defense lawyer Mary Jo White, a former Manhattan U.S. attorney, had been the one to press for more time in a call to a Department of Justice official. (Brownlee would break down how Purdue’s attempted influence peddling worked—or didn’t—in a later Senate hearing about the case.) (pg. 82)
I'm always amazed by how Americans seem to fear the government, which is subject to elections and public oversight, while heaping social approval on corporations, who are effectively legally required to be psychopaths in pursuit of maximum profits regardless of the social consequences, can't go to jail, and have so much money that even multi-million dollar fines have no incentive effect on their  behavior.

More importantly, the book provides case studies of the drug addicts. This not just puts a face on the victims, but also points out that many of these drug addicts do not fit your stereotype of one: these were successful men and women from good families who were doing well in school. Drug addiction really does change your brain, and turns you into a desperate junkie in search of the next fix no matter your economic class or social status. (There's even a person who was a doctor on probation due to addiction) If you're a parent you will probably come away from this book fearful for your kids.

Ironically, these diseases of despair only hit white people. The black population was spared this because:
Why had blacks failed to become ensnared in opioid addiction? That question was addressed in 2014 data issued by the Centers for Disease Control and Prevention: Doctors didn’t trust people of color not to abuse opioids, so they prescribed them painkillers at far lower rates than they did whites. “It’s a case where racial stereotyping actually seems to be having a protective effect,” marveled researcher Dr. Andrew Kolodny of Brandeis University. Put another way: By 2014, while young whites were dying of overdose at a rate three times higher than they did in 2002, the death rate for people of color was relatively unchanged. (pg. 253)
There's lots more in this book, such as the political fight over effective rehab (the scientifically proven to work stuff isn't used because the religious people and the AA types are ideologically opposed to it), and of course the individual case studies.
—he believes the five-year treatment model, common for addicted doctors and airline pilots, is ideal. It’s why they tend to have opioid-recovery rates as high as 70 to 90 percent. “There’s nothing scientific at all about twenty-eight days of [residential] treatment,” Loyd said of the kind heralded in movies and on reality TV. “It takes the frontal lobe, the insight and judgment part that’s been shut down by continued drug use, at least ninety days just to start to come back online and sometimes two years to be fully functioning.” (pg. 294)
There's a poignant section of the book where the author attends a "free healthcare" camp and compares it to 3rd world countries like Haiti:
In rural America, where overdose rates are still 50 percent higher than in urban areas, the Third World disaster imagery is apt, although the state of health of RAM patients was actually far worse. “In Central America, they’re eating beans and rice and walking everywhere,” a volunteer doctor told the New York Times reporter sent to cover the event. “They’re not drinking Mountain Dew and eating candy. They’re not having an epidemic of obesity and diabetes and lung cancer.” (pg. 274)
There are comparisons with other countries that have decriminalized drugs and reduced the cost of addicts to society by providing working rehab programs. Again, ideology (mostly from the non-evidence based crowd) trumps effective operation of society in the USA in a way that's uniquely dysfunctional.

While the author works hard to draw your sympathy, by the end of the book I was starting to get irritated that the voters of Virginia continue to vote for politicians that propound ineffective solutions that kill their children and loved ones while criminalizing them and blaming them for being victims of big pharma. Unfortunately, this book does not have a happy ending, and of course, it's not clear that the country as a whole will have a happy ending if voters keep operating as though the opoid epidemic is a crime issue rather than a medical issue.

The book does have weaknesses: I would have wanted to see a more involved examination of the various rehab approaches and the studies involved. I would rather have seen more statistics about drug movement and distribution rather than a lone interview with a drug dealer (who, like the executives at Purdue Pharmaceuticals, demonstrated no remorse about the lives he ruined). But overall, that does not detract from the point that the book's very much worth your time reading. Recommended.


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