How the Epidemic of Drug Overdose Deaths Ripples Across America | Hacker News Reader

How the Epidemic of Drug Overdose Deaths Ripples Across America

nytimes.com

111 pointstysone135 comments

We share a lot in common with our neighbours to the south and it seems that the drug overdose epidemic has been happening in Canada as well. With some very alarming rates of increase due to Fentanyl overdoses. In the province of Alberta, Fentanyl detected deaths have risen from six in 2011 to 120 in 2014.[1] Other provinces are showing double and higher rates of increases.

If you were to look at Alberta alone there is a correlation to the collapse in oil prices, since it's an oil and gas producing economy, and increased overdoses. But Fentanyl is just this monster of a drug 80 times as powerful as morphine that is being laced into so many other drugs and sold to unsuspecting customers as OxyContin or laced into it. As a response to the epidemic the government is fast tracking Naloxone to become a non prescription drug since it reverses the effects of an opioid overdose within minutes.[2] I don't remember where I read that first responders (Paramedics, EMS) will be carrying Naloxone to administer it during responses.

1.http://www.theglobeandmail.com/news/british-columbia/fentany... 2.http://www.theglobeandmail.com/news/national/government-to-f...

My cousin died of a Fentanyl overdose last year. This is the worst part of the criminalization of drugs, IMO. If heroine weren't criminalized, I'm sure my cousin would have gotten actual heroine instead of fentanyl -- which you have to be an anesthesiologist to administer properly, not a dumb red-neck.

Of course, if oxy were legal (and I know that oxy is kinda legal but only while they're getting you hooked. Once you're an addict it becomes criminal) he would have stuck with that instead of moving up to the cheaper and easier to get heroine.

The therapeutic index of opiates narrows continuously as addiction proceeds. Users have to skate closer and closer to dangerous levels to reach the same level of intoxication.

While dosage, purity, etc may possibly make the drug more predictable, fundamentally it doesn't matter which drug your cousin was taking. The longer he remained addicted to opiates, as a class, the greater his risk of death by overdose.

You have to be an anesthesiologist to administer fentanyl not because handling it safely is so difficult, but because managing high opiate tolerance is extremely dangerous.

you're not characterizing overdose correctly. it's often people coming from pharmaceuticals and not knowing what they're doing, or not knowing the potency or contents of their drugs.

The majority of overdose deaths occur after a period of abstinence (getting clean, running out, etc.) followed by using the same amount (or more in the case of withdrawal) of the drug before the cessation. It can take as little as 48 hours for your tolerance to drop by a meaningful margin.

My ex-girlfriend died in September of this year from a heroin overdose. She was in the process of getting clean and then relapsed.

http://www.businessinsider.com.au/philip-seymour-hoffman-ove...

https://www.thefix.com/content/high-risk-relapse-how-going-b...

Another reason for a large amount of overdoses is drug mixing - people taking oxy and then xanax and then they're dead. But I think your comment and the guy above you both refute hapless's claim that most people who die from an OD are simply misjudging their own doses. In truth, I believe very few people misjudge their own doses. Drug addicts are notoriously good at knowing the exact amount to get them high. Why? Because too much is a waste (they try to extend their supply as long as possible) and too little won't have the desired effect.

In addition to your reason for ODing (use after a period of abstinence), the recent rash of ODs in my state are because dealers & suppliers are cutting their dope with fetanyl and other stuff that the drug user isn't/can't account for.

> taking oxy and then xanax

One of the more common "mixes" that also happens to be particularly dangerous is drinking EtOH while taking an opiate (or other depressants). Unfortunately, as beer or liquor holds a different cultural status, it isn't always listed with other drugs.

If there is any opiate involved, it will invariably be written up as a "oxy/heroin overdose" even if the main problem was the 10oz of liquor consumed the same evening.

this too -- i wasn't sure i wanted to mention it because i didn't have any links to back it up

My brother died from fentanyl in 2014. It is so strong that it is harder to dose correctly and to manufacture into even batches. Things sold as something else are getting laced with it. Even when people do know what they are getting, small uneveness in the mixing of a large batch can cause multiple deaths.

It isn't just due to the normal generic tolerance increases over time, and it isn't just about all opiods being complete substitutes for one another; they aren't. Half-lifes matter, some research shows some affect repiratory pathways faster than others relative to their other effects, etc.

My brother would have likely died from heroin even if fentanyl didn't exist, but there is something more to the wave of fentanyl overdoses than you are making it sound.

I don't necessarily agree with the parent post about legalization, legal sources boomed in the 90s through doctors and brought about a lot of the current epidemic. Would complete legalization be a net positive? I don't know. It would have upsides and downsides.

You are missing an important point. Fentanyl is loved by traffickers because you can order it from China and its extreme potency means it's easy to sneak across borders. Moving an amount the size of a brick across borders and then selling it as oxy or cutting it into heroin could make tens of millions of dollars on the street. This extreme potency, however, means that it must be mixed/pressed perfectly or you end up with "hot spots" - a chunk of fentanyl in a pressed "OxyContin" pill that's fatal.

The therapeutic index of opiates narrows continuously as addiction proceeds.

Whoa there. That's not correct. As you develop tolerance to the "high" you also develop tolerance to the side-effects, namely respiratory depression (what usually kills you during an overdose).[1]

"Tolerance to the analgesic effect of opioids can begin after a few weeks of around-the-clock dosing, as does tolerance to the respiratory depression effect of opioids (and other side effects except constipation)."

The paper I reference has a great example of just how much morphine you can give to someone in pain:

"The final dose escalation was to 1,100 mg/hour of morphine IV plus 100 mg IV every 10 minutes as needed. MK lived 3 days on this morphine dose. He was somnolent his last day, but he could be aroused to take fluids with gentle verbal stimulation."[1]

Just to provide some context, if you were to break your leg and go to the hospital, they'd probably give you 10 mg of morphine IV every 4-6 hours. This guy was on 1,100 mg every hour around the clock.

[1]http://www.promotingexcellence.org/downloads/jacs_0203.pdf

The therapeutic index is the ratio between the necessary dose to achieve desired effects, and the dose that incurs dangerous side effects. Both doses rise with tolerance, but the ratio between them narrows.

That opiate-tolerant fellow on 1,100mg/hr of morphine required around-the-clock monitoring by experts.

> As a response to the epidemic the government is fast tracking Naloxone to become a non prescription drug since it reverses the effects of an opioid overdose within minutes.[2] I don't remember where I read that first responders (Paramedics, EMS) will be carrying Naloxone to administer it during responses.

Naloxone should be handed out at needle exchanges no questions asked, it has no side-effects if you are not using.

IMO whoever supported requiring prescriptions for Naloxone and syringes should be tried for crimes against humanity.

This really hits home to me as one of my best friends and one of the most brilliant people I have ever met died 6 months ago from a fentanyl overdose alone in a motel room. I met him in the #django channel on irc about 10 years ago when I was learning python an django and we ultimately later became great friends and he came to live with me in California for a time and did consulting work. He was always way ahead of the curve with technology - he knew about technologies, platforms, and architectures before anyone else I ever knew would know about them. He also suffered from the disease of addiction and ultimately his life ended all by himself in a motel room in Texas after taking a bad batch of fentanyl. It was a complete and total waste and if pisses me off more than words can describe. He could have been working at Google but instead all he got was a short obituary in some small town in Texas. His death has motivated me in many ways in my personal life and in my professional life and I really hope that we as a society can figure out a way to prevent other people like him from losing their life at such a young age and having such a horrific ripple effect through their friends and family that is a total preventable waste. It sucks :/

Society knows how. We've figured it out. Unfortunately, government is a giant roadblock to getting it done at the moment.

Has anyone come across coverage of the heroin epidemic as it relates to the growth of heroin production in Afghanistan since the arrival of US forces? Seems like no one is connecting these dots and I'm curious why? Not to imply there is a conspiracy theory at all, it may just be that I'm more "fascinated" by that relationship than the average reader?

From my recollection, just before the invasion, meth and one other drug that I've forgotten the name where real popular, not the H.

So you may be on to something, but I'll need to see real data before I subscribe.

Do you have data to support this. Also is Afghanistan the lone producer of heroin? You have to be careful in making inferences like this without considering the multitude of other factors such as how easy has the process to create heroin become over the last decade, was there a drop in other drugs and why.

To your point however, I wonder if the war has enabled Big Phrama to get easier access to make there own opioids. To me it seems like the growth of Opioids for pain lead people to seek heroin and other drugs when there prescription runs out.

data to support what? I didn't make any claims. It is widely reported that the Taliban banned growing poppy (it was un-islamic) in Afghanistan and since US forces put them on the run the local war lords, who help US forces with intel, etc., have overseen the massive rebirth of the industry.

It is also widely reported that there is a heroin epidemic in the United States. To me they must be somewhat related.

Considering that most of the US drugs are either made in the US, or come up from Mexico, I think blaming countries that are on the other side of the world separated by the largest oceans is a bit ridiculous.

http://opiophilia.blogspot.com/2013/05/heroin-in-united-stat...

US Heroin comes from South America and Mexico.

'Serving All Your Heroin Needs' | Apr 17, 2015 http://www.nytimes.com/2015/04/19/opinion/sunday/serving-all...

> Most of our heroin now comes not from Asia, but from Latin America, particularly Mexico, where poppies grow well in the mountains along the Pacific Coast. Mexican traffickers have focused on a rudimentary, less-processed form of heroin that can be smoked or injected. It is called black tar, which accurately describes its appearance. Cheaper to produce and ship than the stuff of decades past from Asia, heroin has fallen in price, and so more people have become addicted.

'How El Chapo Was Finally Captured, Again' | Jan 16, 2016 http://www.nytimes.com/2016/01/17/world/americas/mexico-el-c...

> [El Chapo] was, after all, a creator of the border tunnel, underground passages equipped with lighting, ventilation and mechanical carts to smuggle drugs into the United States without having to bother with the headache of evading customs agents. In total, Mr. Guzmán’s organization is estimated to have burrowed more than 90 such passages between Mexico and the United States.

'El Chapo Faces Array of Drug Charges in United States' | Jan 16, 2016 http://www.nytimes.com/2016/01/11/world/americas/extradition...

> Their joint indictment charged Mr. Guzmán and another suspected leader of the Sinaloa Cartel, Ismael Zambada García, with distributing more than 500 tons of cocaine in the United States since the late 1980s. It also charged them with distribution of heroin, methamphetamine and marijuana. Prosecutors believe that the cartel may have been the biggest supplier of cocaine to the New York City area for a decade or longer. In their most recent indictment of Mr. Guzmán and Mr. García, prosecutors listed 163 separate counts of distribution of cocaine in the United States, ranging from 234 kilograms to as much as 23,000 kilos.

Just as a point of reference when you say "It is widely reported that ..." that is making a claim. You could follow that up with see here, here, and here. A useful one might be the NBC link (http://www.nbcnews.com/news/world/heroin-use-grows-u-s-poppy...)

That said, the article in question points out that overdoses are more closely related to the addition of Fentanyl which is 100x more powerful than Morphine [1] and that is not manufactured in Afghanistan.

[1] http://www.deadiversion.usdoj.gov/drug_chem_info/fentanyl.pd...

Actually, no, heroin from Afghanistan travels west to Russia and Eastern Europe and creates a lot of problems there as the prices have dropped significantly, so poor people are getting hooked on it, and then can't afford the habit. In US 96% of heroin comes from Latin America, mainly Mexico. You can check it on DEA or White house official sites, for instance https://www.whitehouse.gov/ondcp/global-heroin-market

I have no idea about causal relationships but there is at least some data on opium production.

According to the UN Office on Drugs and Crime, opium production jumped from 74,000 hectares in 2002 to 224,000 hectares in 2014, a ~200% increase. [0] (p. 12)

Afghanistan is the world's largest producer of opium followed by Myanmar.

> Opium poppy cultivation in Myanmar and Lao PDR rose to 63,800 hectares (ha) in 2014 compared to 61,200 ha in 2013, increasing for the eighth consecutive year and nearly tripling the amount harvested in 2006. [1]

> In North America, although 90 per cent of the heroin in Canada originates in Afghanistan, the United States continues to be supplied by heroin manufactured in Central and South America. However, analysis of seizures indicates that while Afghan heroin currently accounts for relatively little of the heroin seized in the United States, this may be changing.

[0]: https://www.unodc.org/documents/crop-monitoring/Afghanistan/...

[1]: http://www.unodc.org/unodc/en/frontpage/2014/December/opium-...

[2]: http://www.unodc.org/wdr2015/en/opiates.html

That's really strange that Canada gets most of its heroin from Afghanistan but America doesn't.

Differences in criminal supply chains are normal. In Canada it's mainly South Asian diaspora criminal networks who import heroin, so they source from India (Afghan heroin) as they have influence in India. US it's mainly Latino networks who import heroin and have influence in Mexico and Colombia to bribe police and dockworkers thus source from there.

I think there was a conspiracy theory that the Taliban had eliminated the poppy plants rather successfully in the region, and this threatened to destroy the world economy as the opium trade provided global liquidity or something. Anyway, with the current war on drugs it is hard to prove or disprove since all of this trade is clandestine anyway. I think there was also some proof the big international banks were doing a lot of drug laundering work as well, but really all these theories do is raise more questions. If we redirect the drug trade to be out in the open, I'd hope that sunlight would be the best disinfectant.

Based on my general understanding from following the "Drug War" as it relates to Mexico and Cartels, heroin is now one of the most profitable and dominant drugs being smuggled by the Sinaloa Federation (Cartel). As in heroin is the #1 preferred drug to smuggle into the US from Mexico. This is purely anecdotal from various sources, and not to discount the Afghan opaite trade.

Afghanistan hasn't been a significant source of US heroin in decades. The majority of heroin in the US is either from Mexico or Colombia these days. Source: http://www.washingtonpost.com/sf/national/2015/09/24/pellets....

No question Afghanistan is a huge opium producer, it's just that the majority of that product ends up in Europe, not in the US. PDF source: https://www.unodc.org/documents/wdr2014/Statistics/Opium_Her...

That could still reduce the European demand for Mexican and Colombian heroin, driving down US prices, correct?

I think there certainly is a case to be made that U.S. prices are lower because there is increased global supply. That increased supply drives down competition for South American / Mexican heroin, reducing prices for the U.S. market.

I parsed the implications of the original statement as one of deployed troops picking up the habit rather than increasing the home front supply. Do you happen to have any stats about heroin abuse among Afghan vets?

I was reading it as claiming that the government that took power after the Taliban was "defeated" was ineffective at policing opium production. A glance at https://en.wikipedia.org/wiki/Opium_production_in_Afghanista... seems to support the idea that production increased substantially after the official Taliban government was removed.

The only thing I could really find is here: http://usatoday30.usatoday.com/news/military/story/2012-04-2...

Long story short, the Army investigated 56 soldiers in Afghanistan between 2010 and 2011 for using / dealing.

As for the bigger question, the military really is a subset of society. Veterans end up using the same things the rest of society does to escape their problems.

Combine that with relatively easy access to pain meds and you get the same sad story we're dealing with everywhere else. Here's more info on that angle: https://www.hrw.org/news/2014/06/30/us-half-million-drug-dep...

Absolutely. The Times ran a piece (probably a decade ago) about how heroine was becoming more popular than pot on long island because of the war in Afghanistan.

According to a UN doc cited on wikipedia, production pre-Taliban restriction reached a peak in 1999 with a bumper crop of 4,500 metric tons. [1] 99% of this was wiped out in 2000 which amounted to a 75% reduction in the world supply of opium. So total world production was ~6,000 metric tons in 1999.

According to this 2014 UN report [2] the total area of opium poppy cultivation in Afghanistan was estimated at 224,000 hectares with an average yield of 28.7kg/hectare. Converting this to metric tons: 224,000 * 28.7 / 1,000 = 6,429 metric tons of opium produced. Report cites a possible range from 5,100-7,800 metric tons produced.

So not only is Afghanistan back to pre-Taliban production levels, it is producing more than the entire world production of opium in 1999. This is just 15 years after a 99% eradication of the crop in the region.

Interestingly, the farm gate value of this opium is only $850m. Using an average of the conversion ratios cited in the report (18.5:1 for pure heroin, 9.6:1 for export-grade heroin) and a price of $60,000USD/kg of heroin [3] we get a total processed value of $27.4bn. That's a crazy amount of value locked into processing and distribution.

The Mexican govt seized ~3,600kg of opium seeds in 2014. [4] Assuming a seizure rate of 1%, we get a total opium crop of 360 metric tons, or ~5.5% of total Afghan opium production.

I'm definitely not an expert here so please correct me if I've made any mistakes in drug weight/price conversions.

[1] https://en.wikipedia.org/wiki/Opium_production_in_Afghanista...

[2] https://www.unodc.org/documents/crop-monitoring/Afghanistan/...

[3] http://www.cbsnews.com/news/the-drug-dealers-next-door-how-n...

[4] http://www.insightcrime.org/news-analysis/mexico-poppy-produ...

> The Mexican govt seized ~3,600kg of opium seeds in 2014.

Opium doesn't come from "seeds" per se. You get opium by making a cut at the base of the poppy flower, and letting the stuff ooze out like a resin.

True, but opium plants do.

Its seems this epidemic didn't start with heroin supply flooding the streets. But with prescription opioids being so casually handed out to patients. Then when all these people where hooked there became a great demand for heroin. And the invisible hand of the market took care of the rest.

They shut down the pill mills and the pain clinics, which were the one reliable source of safe opiates, and now people are dying left and right. Go figure.

Except, of course, that people were also overdosing "left and right" due to the pill mills and illegitimate pain clinics...

Edit for source: http://www.jhsph.edu/news/news-releases/2015/pill-mill-crack...

Interesting, "researchers also found substantially fewer deaths in Florida from overdoses involving either prescription painkillers or heroin during 2011 and 2012"

Thanks for the article.

"with less access to prescription painkillers, fewer people may be developing an addiction"

So we are seeing less people getting hooked on opiates. This is of course a good thing. But I still worry about those who got hooked in "the good old days" and now no longer have access to opiates in standardized doses.

Yeah, that part really caught my eye too.

Anecdotally, many heroin addicts seem to start off with prescription painkillers and then move on to heroin once their preferred pills become unavailable (crack down on scripts, price, whatever).

It would seem to make sense that by preventing some amount of painkiller addiction, you could prevent some amount of heroin addiction.

I'm curious to see the full study once it's released.

> So we are seeing less people getting hooked on opiates. This is of course a good thing.

Not necessarily. You want people in pain to be able to access opiates. And some of those are going to die from them. So the ideal number of people dying probably isn't zero.

Ideally the number IS zero. :)

The realistic number on the other hand will probably be higher, as you identify.

I'd also argue there's a difference between being 'hooked' on opiates and using them regularly for legitimate pain management.

Great point. People also turn to heroin because it's simply more affordable than a pill habit. It's an economic calculation.

There are so many things wrong with drug policy right now and we're paying the price. We could use more supervised injection sites, better access to Buprenorphine[1], etc.

[1] See: http://slatestarcodex.com/2015/02/02/practically-a-book-revi...

among the main drivers to increase street heroin consumption (and thus deaths, etc) was the change in OxyContin formulation so that it became much harder to abuse. It would be ironic if it wasn't that tragic.

http://www.unodc.org/wdr2015/en/opiates.html

I only have my one anecdote in response to this story, which does not translate into data I know. I'm from one of the counties in western NC where overdose deaths have gone from 4-8 in 100K to 20+ in 100K. I graduated from high school in 2001 so I have grown up with the rise of drug use in my home county and surrounding areas and the people affected are people that I've known all my life. I no longer live in NC and, in fact, haven't lived in the area since I was 16 (went to a live-in magnet high school and then went elsewhere for college + career).

2001- my graduating class goes off into the world, half to college, maybe 1/4 to trade school, the rest go to join a family business or into an apprenticeship into a trade. A few go into the military. A few have no idea what to do and get low-level jobs wherever they can find them.

Pre-2008- The economy is booming, people who've gone to college are either 3 years post graduating, establishing themselves in their young careers, or just graduating from grad school, or for those that have entered a trade they've worked long enough to start having some standing in their chosen line of work.

2008-2010 economy explodes. Layoffs, bankruptcies, consolidations, offshoring. Immensely decreased consumer spending hits trades particularly hard- welders, mechanics, electricians, construction workers- all take massive hits to their profits. Business is scarce. People who've graduated from college and who are establishing their careers get laid off and have to move back into the county because that's where their safety net is- grandma and grandpa can take care of the kids while they hunt for work or work a low-paying job because that's all they can get. Military service men and women get done with their tour and come back to nothing- no job prospects, community college has closed, trade schools have closed, the factories where their fathers and mothers worked have all outsourced to 3rd world countries and closed.

In my rural county suddenly there's way more idle middle to late 20-somethings with no job and no prospects. No jobs to be found, no money to move. What I saw among the people I know/knew is that it only took a few people trying meth before it was like a powder keg going off- idle hands are the Devil's plathings, after all. People I went to high school with no hope for the future were doing meth because it was 3 minutes of bliss in stark contrast to the whirlpool of suck their lives had become. Grandma and grandpa were taking it because they couldn't afford painkillers. Teenagers were taking it because they were shithead teenagers and it was more accessible than pot. The "smarter" of the people I knew were cooking it because it was the only way they knew to make money. Once the door was open to meth then "fancier" stuff like painkillers started coming in and it was a way to feel like you were "better than" everyone else you knew who was doing meth. Oh yeah you were a drug addict, but at least your pills had a brand name. Enough meth labs blow up and the more enterprising of drug distributors can come in and sell addicts anything and everything they want, so if heroin is cheap enough that's what gets sold.

This article is written from a scholarly point of view and has a lot of conjecture but I definitely don't think they had any boots on the ground to make the conclusions that they did, particularly with regards to saying the epidemic in Appalachia is a result of on the job injuries. There are no jobs to get injured on anymore.

[Edit] I also absolutely agree with onetwotree's comment downthread, this is another ENORMOUS contributor to increased and sustained drug use in my tiny county: "Recovery is hard in tiny communities. All your friends are doing drugs, there are maybe 2 or 3 12-step meetings a week, no outpatient programs that you can attend while working, no sober living facilities, and treatment involves a trip to the big city." Also worth mentioning is that often those 12-step meetings are held in the basement of a church, which in my hometown means it's either your church which your whole family goes to and you grew up in (pretty damn hard to walk in there and admit to being an addict) or your friend's church that his whole family goes to and he grew up in- in both cases it's impossible to be anonymous.

> This article is written from a scholarly point of view and has a lot of conjecture but I definitely don't think they had any boots on the ground to make the conclusions that they did, particularly with regards to saying the epidemic in Appalachia is a result of on the job injuries. There are no jobs to get injured on anymore.

They may be confusing people injured in the workplace with people receiving Social Security Disability payments:

http://www.dailyyonder.com/files/images/DisabilityMap.jpg

If you look at the map with the percentage of Americans receiving disability it does seem to correlate rather strongly with the overdose maps - at least in Appalachia.

I don't mean to detract from your anecdote but the Florida and the CDC clearly sees a link in overprescription of pain killers and the death rate. The root cause is the way we are handling opiates in general which changed in 2001 and the prioritization of "comfort" of the patient when they are in pain.

Anecdotal, I've been in pain, multiple times in my life, where Doctors were literally confused by the fact I wasn't taking pain medication and immediate would prescribe opiates without a second thought. A couple even made comments [one Doctor who used to treat soldiers assumed it was a macho thing and told me I was being silly, just take the drugs].

The main reason I don't take pain killers is I've got medical allergies so I reserve the handful of things I can take for emergencies but they'll casually try to suggest/prescribe them for trivial things.

> People I went to high school with no hope for the future were doing meth because it was 3 minutes of bliss in stark contrast to the whirlpool of suck their lives had become.

Yeah, but would you agree they would turn to drinking if they wouldn't/couldn't do illegal drugs?

http://www.cdc.gov/media/releases/2014/p0701-opioid-painkill...

> Health care providers in the highest prescribing state, Alabama, wrote almost three times as many of these prescriptions per person as those in the lowest prescribing state, Hawaii. Most of the highest prescribing states were in the South. Previous research has shown that regional variation in use of prescriptions cannot be explained by the underlying health status of the population.

> The Vital Signs report also contains a study highlighting the success of Florida in reversing prescription drug overdose trends. Results showed that after statewide legislative and enforcement actions in 2010 and 2011, the death rate from prescription drug overdose decreased 23 percent between 2010 and 2012. Florida officials had taken these actions in response to a 28 percent increase in the drug overdose death rate over the preceding years (2006-2010).

> Declines in death rates in Florida for specific prescription painkillers (oxycodone, methadone, and hydrocodone) and sedatives paralleled declines in prescribing rates for those drugs. This report was based on Florida Medical Examiners Commission data from 2006 to 2012 and IMS Health National Prescription Audit data from 2008 to 2012.

They do the same with antibiotics:

http://www.cbsnews.com/news/doctors-urged-to-stop-prescribin...

> Despite years of warnings, doctors still overprescribe antibiotics for acute respiratory infections even though most are caused by viruses that those drugs cannot help. The consequences are serious: overuse of antibiotics is fueling the rise of drug-resistant superbugs, and patients can suffer significant side effects from drugs they don't really need.

http://www.newyorker.com/business/currency/who-is-responsibl...

> The Joint Commission, which accredits health facilities, issued pain-management standards in 2001 that instructed hospitals to measure pain—you may be familiar with the smiling-to-crying faces scale—and to prioritize its treatment. Elizabeth Zhani, a spokeswoman for the Joint Commission, told me that their standards “were based upon both the emerging and compelling science of that time, and upon the consensus of a broad array of professionals.” Yet Purdue, according to a report issued by the U. S. Government Accountability Office, helped fund a “pain-management educational program” organized by the Joint Commission; a related agreement allowed Purdue to disseminate educational materials on pain management, and this, in the words of the report, “may have facilitated its access to hospitals to promote OxyContin.”

> In a policy drafted by several people with ties to narcotics makers, including Haddox, the Federation of State Medical Boards called on the boards to punish doctors for inadequately treating pain, according to the Wall Street Journal. The Federation also reportedly accepted money from pharmaceutical firms to produce and distribute narcotics-prescribing guidelines. In an e-mail, the Federation maintained: “[Our] most recent policy reflects the considerable body of research and experience accrued since our last series of formal policies related to opioid prescribing and addiction were adopted in 2004. Our latest guidelines, adopted this year, acknowledge that evidence for the risk associated with opioids has surged, while evidence for the benefits of opioids for long-term use has remained controversial and insufficient.”

> In 2007, Purdue Pharma and three of its top executives pleaded guilty to criminal charges that they had misled the F.D.A., clinicians, and patients about the risks of OxyContin addiction and abuse by aggressively marketing the drug to providers and patients as a safe alternative to short-acting narcotics. (Doctors had been taught that because OxyContin was time-released, it wouldn’t cause a high that would lead to addiction.)

"...overprescription of pain killers" Yup, definitely a problem. Not so much in my county that I saw, but definitely a problem. And then the people who have them prescribed to them are selling them to get money because they have none. Another anecdote- I did a brief stint as an in-home healthcare aide in college and the sweet old lady I took care of who was in the 1st stages of dementia sold her painkillers to her neighbor at $3 a pill "Because he says he will get them to people who can't afford to go to the doctor, poor dears." Also, if you're able-bodied and out of work, you're definitely not able to afford to go to the doctor or pay for prescription painkillers.

"...they would turn to drinking if they wouldn't/couldn't do illegal drugs?" Probably/definitely not. There's one ABC store in my entire county (population 50K now, closer to 25K in 2001) and again, really hard to be anonymous with your drinking when you went to high school with everyone who works at the ABC store and it's where everyone in the entire county goes to get their booze so chances are you'll see your brother in law and your best friend's grandmother and your ex-girlfriend's uncle while you're in there. Drugs can be done in the shadows and hidden way more effectively than booze.

RE: overprescription: I have no idea why this is a thing. Profit margins on painkillers mean salespeople give under the table kickbacks to underpaid rural doctors in return for more prescriptions? Aging population on Medicaid becomes only cash cow for rural doctors after so many people lose their jobs (and health insurance) so they have to start prescribing more pills that they know Medicaid will pay for? Lack of doctor education leads to overprescription because they don't know any better? It's a big unknown, and not addressed in the article at all.

> "...overprescription of pain killers" Yup, definitely a problem. Not so much in my county that I saw, but definitely a problem. And then the people who have them prescribed to them are selling them to get money because they have none. Another anecdote- I did a brief stint as an in-home healthcare aide in college and the sweet old lady I took care of who was in the 1st stages of dementia sold her painkillers to her neighbor at $3 a pill "Because he says he will get them to people who can't afford to go to the doctor, poor dears." Also, if you're able-bodied and out of work, you're definitely not able to afford to go to the doctor or pay for prescription painkillers.

Yeah, the New Yorker article I linked to mentioned that as well but I didn't quote it:

> And then there are the real-life Walter Whites. I once helped care for a patient with lung cancer who wasn’t taking his narcotics, unbeknownst to his doctors. This patient’s cancer had spread to his bones and other organs, which can be incredibly painful. But he was selling his prescription narcotics to help support his wife and himself. So when given these high-dose narcotics in the hospital, he overdosed—though not fatally, fortunately.

---------

> "...they would turn to drinking if they wouldn't/couldn't do illegal drugs?" Probably/definitely not. There's one ABC store in my entire county (population 50K now, closer to 25K in 2001) and again, really hard to be anonymous with your drinking when you went to high school with everyone who works at the ABC store and it's where everyone in the entire county goes to get their booze so chances are you'll see your brother in law and your best friend's grandmother and your ex-girlfriend's uncle while you're in there. Drugs can be done in the shadows and hidden way more effectively than booze.

Fair enough, the idea of literally one store for an entire county didn't occur to me honestly.

---------

> RE: overprescription: I have no idea why this is a thing. Profit margins on painkillers mean salespeople give under the table kickbacks to underpaid rural doctors in return for more prescriptions? Aging population on Medicaid becomes only cash cow for rural doctors after so many people lose their jobs (and health insurance) so they have to start prescribing more pills that they know Medicaid will pay for? Lack of doctor education leads to overprescription because they don't know any better? It's a big unknown, and not addressed in the article at all.

The pain management guidelines for hospitals was set by Big Pharma, basically. Similar tricks are used to encourage doctors to do the same.

https://www.cms.gov/openpayments/

For instance, exists because of these payments. And yes, I'd say its likely a combination of "feel good" marketing [e.g. It is safe, just give it to your patient to help the feel better] and kickbacks.

And yeah, its not addressed in the article at all. Florida [from the CDC article I linked to] ended up passing a bunch of laws which reduced overdose deaths by shutting down "pill mills" and such.

http://www.drugfree.org/join-together/florida-combats-prescr...

> After the state cracked down on pill mills and instituted other changes, the number of prescription drug-related deaths decreased in Florida in 2011. Deaths related to oxycodone decreased more than 17 percent. There are no doctors from Florida on the Drug Enforcement Administration’s (DEA) list of physicians who purchase the most oxycodone, the article notes.

Its not perfect but some combination of improved enforcement and better incentives for doctors is needed. I doubt education is the issue given the fact cash and subverting the bodies that create the standards is what Big Pharma seems to target.

For over-prescription, there's also the issue that if you don't prescribe opiates to people that ask for them, they will find another doctor who will.

I live in Florida and was deep in the pill mill culture for a time (not a user, but as a councilor). I can tell you this right now, most prescription pill ODs weren't people taking too much of one thing, it's because they mixed their prescriptions. People taking Oxycontin then taking a Xanax and then never waking up. That is the most common way to OD on prescription pills. Very rarely (almost never) do you hear of someone just ODing on a single substance. In fact, I can't recall or remember someone just taking too much oxycontin and dying from it.

I'm not saying it can't or won't happen, it has happen, and will happen, but that it's so uncommon compared to what is actually killing people (mixing prescriptions/drugs/alcohol).

> Anecdotal, I've been in pain, multiple times in my life, where Doctors were literally confused by the fact I wasn't taking pain medication and immediate would prescribe opiates without a second thought. A couple even made comments [one Doctor who used to treat soldiers assumed it was a macho thing and told me I was being silly, just take the drugs].

When I had my ACL fixed the doc was going to give me multi-days of Oxycontin. I told him I didn't want it. After some negotiation I ended up taking 6 pills over 3 days and then using normal pain meds. His point was that if the pain got too bad it might not ever go away.

Those 3 days I was a mess. I never really knew if I was awake or sleeping. Didn't really eat, it basically sucked. I am super active (hence the torn ACL), and could never see taking something like Oxy on a regular basis or for fun. I get some people have a lot of pain and that is a different situation, but normal prescriptions seem like overkill.

Yeah. The problem is the only "normal" pain medication I can use is tylenol. After that, its stuff like Oxy which completely wreck my ability to function.

doing meth because it was 3 minutes of bliss

That sounds more like crack - meth yields more like three hours of bliss or longer, depending on the method of ingestion. And it's not really bliss, either, not in the sense people mean when they talk about opiates: there's a euphoric rush, to be sure, but it's a sharp, clear feeling of strength and confidence and energy, pretty much the opposite of the dreamy sense of calm, peaceful tranquility people look for when they take heroin or painkillers.

Never done meth so wasn't sure what it was like. I can see that if you started out on meth and were feeling tweaked-out that having a dreamy sense of calm would be appealing.

What conditions pushes a drug addict to overdose? Do they all reach that point at some point or what? Is this illegal drugs or regulated ones?

Often overdoses happen when a former addict relapses. They'll take their old dose, not realizing that they have lost some of their tolerance.

Both, but for different reasons: The "overdoses" from prescription opiates are often acetaminophen vs. the opiate (no direct sources w/ numbers, but example: http://www.medscape.com/viewarticle/820039).

Whereas with illegal opiates it's often from a difference in purity from one purchase to the next. This is where a regulated drug market would alleviate that issue 100%.

Varying potency. Dealers putting in fentanyl or stronger opiates to intentionally cause an overdose as marketing hype for their product (very common). Misjudging the dose of a known product. Tolerance. Using too much after some time stopped. Mixing opiates with other substances. I'm sure there are many more.

If you're using street opiates, it's going to happen at some point, guaranteed. I've yet to meet an opiate addict who has never overdosed and I doubt I ever will. Sticking to prescription opiates helps, but even then people overdose often.

For those looking for more information, the practice is in particular making one very strong bag with a lot of fentanyl, so that a single user overdoses or dies. The idea is other users will then buy your product, thinking it's better quality. It's called a "hotshot."

I never overdosed in a year of heroin use, then again I wasn't an IV user.

Can I ask why you use heroin?

I don't use heroin any more.

* Dangerous combinations, like alcohol, can be a contributing factor.

* Black market drugs can have widely varying contents and potencies (rat poison and fentanyl).

* Tolerance changes have already been mentioned.

* Taking drugs in a consistent place and/or circumstances causes the body to prepare for consumption (like Pavlov's dogs salivating at the bell). Unfamiliar situations can catch the body off guard.

Naloxone and clean needles should be available cheaply and over the counter, no questions asked. People who help overdose victims shouldn't be charged with drug possession. Until those things happen, I have no doubt overdoses will continue to needlessly kill people while our idiot politicians stand idly by wondering what they can do because they're too fucking stupid to implement the tried and true, tested solutions for fear of looking bad. This isn't a news story about anything else than the failure of government to implement very simple solutions (as most stories about problems in the US). Instead, these idiots keep working on filling up more jails. After all, jailing people for everyday activities is the American way.

Recommended reading if this interests you: Dreamland tells the story of intersecting prescription pill and heroin use in America.

http://www.samquinones.com/books/dreamland/

It's maddening.

Prescription opiate use has gotten so bad that Big Pharma is now heavily advertising an anti-constipation pill for all these addicts, with the most ridiculous commercial I've ever seen: a woman walks around town with her opioid "bff" that happens to have muscles.

https://i.imgur.com/NMn59EC.jpg

Seriously, if this alone doesn't spell doom for your country and its health care system, I'm not sure what does.

What is the name of this anti-constipation drug and do you have a link to the commercial?

I'm guessing it's Relistor? It was recently approved for constipation caused by opioids.

To be honest, opioid constipation is a huge problem. It's a great drug to have.

Definitely not doubting that. I just hate to see solutions that treat the effect and not the cause. So. Many. Commercials.

I think for chronic constipation, you can also use this Digestic by Mimonis which is very good in treating constipation problem. I have been save from my long battle of constipation that is why I can say it has been proven by mine to be effective.

The maps on this page aren't similar to a standard population map, so that's good in a way.

Has heroin simply taken the marketshare away from meth?

https://xkcd.com/1138/

"Good" as in "good data presentation". Not "good" as in "good that heroin use is growing proportionately across the American populace", I presume.

Any "rate of change" graphic should control for the issue that xkcd mentions.

It does control for that - the rates are per hundred thousand people.

There is still a tendency for smaller populations to have larger differences from the mean. Looking at those maps, the dark red areas seem to mostly be low population areas.

What's interesting is how steady the picture stays even as it gets worse, which suggests the geography is actually meaningful in this case.

Living in NYC. What can I do tonite? 63 plays, 22 gallery openings, 18 meetups, 23 movies. 31,245 restaurants to choose from.

Northern New Hampshire: What are we going to do tonite? Nothing. Absolutely nothing going on.

Lets do some heroin.

Cool. It's all we got.

WTF.

> Northern New Hampshire: What are we going to do tonite?

There's a sale on Steam.

(I haven't checked, but there's always a sale on Steam).

New Hampshire is TREMENDOUSLY bad with heroin. I've seen it first hand and it is out of control. When I return, I always get a new list of dead people.

There are a lot of factors on this one, but at this point it's mostly a cyclical cultural problem.

An old friend of mine who grew up in Middletown, Ohio said there was "nothing to do but drugs and church." He also said there was a surprising amount of double-dipping in those things, wrecking a few stereotypes.

I grew up in an area like that. One of my goals if I ever get wealthy is to simply open up something cheap and fun to do in small towns to combat this. Like rock climbing gyms for $30 a month. Or small indoor water parks.

I wouldn't even care if that chain of businesses made much money, I'd consider it a public service.

How much do you think VR and Oculus Rift will impact the experience of growing up in a small town? A kid will be able to experience much of the world, no matter where they are.

I hope it has a positive impact; I don't see how it couldn't.

The internet has already been a massive boon to fighting boredom in general, sure. If you are highly literate (~15%) it's difficult to be bored when all of the world's knowledge is at your fingertips. Even if you aren't highly literate, there are still X-box games. ;) And you're right, VR will just help even more.

That being said, I do see some issues with our youth habitually living in gaming ecosystems rather than in the real world. For instance, a couple studies lately have noted empathetic behavior sharply dropping among millennials, [1] which I would think comes from spending far less time interacting face-to-face with anyone during their formative years -- their emotional attachments are probably not as strongly imprinted when staring at a screen all the time.

Internet and VR are still a huge net win imo. Real-life, positive social outlets are crucial as well though.

[1] http://www.ipearlab.org/media/publications/Changes_in_Dispos...

I empathize and care more about my online friends than anyone I know in real life - including most of my intermediate family. While I could be the exception to the norm, the people with whom I interact seem to be similar. Of course, we could all be exceptions to the norm...

The study you linked does mention other causes which seem more likely than device use:

>As discussed previously, narcissism, which is negatively correlated with empathy, has been rising in American college students over a similar time period (Twenge et al., 2008).

The current college generation are extreme narcissists. To a disgusting degree. Even terrible tragedies (such as the terrorist attacks in France) are met with "how can I make this about me?" attitudes. A brief browse through Twitter shows this isn't an uncommon thing.

I have no data on whether or not narcissism may or may not be correlated with internet/electronic devices. (I haven't bothered to search this statement, so if a study shows up on the first page of Google results - didn't bother looking! :) )

Either way - I look forward to habitually living in a gaming ecosystem rather than the real world.

No more than video already does. VR is a gimmick on video. It's pretty cool in and of itself, but it's not a replacement for live experience. For example, no matter how cool your VR driving simulator, you don't get the feeling of your body's inertia being shifted around. Or the experience of a place without a big plastic lump on your face :)

You could modernize an old idea that used to work pretty well for some people:

Cue the Village People singing: "Y.M.C.A...." :-)

Nowadays we live in a less Christian society that's also less accepting of even nominal gender segregation, but I think the old YMCAs and YWCAs still provide some evidence in favor of your idea.

So I hope to see the Young People's Rational Associations moving into small towns. :-)

Maybe some YMRAs can even cooperate with other educational and religious organizations that favor healthy exercise and the study of logic. :-)

Boredom is definitely part of it. This theme gets touched upon in the documentary Oxyana (http://www.imdb.com/title/tt2473486/).

Interesting that Chicago is so underrepresented in those charts. I wonder why.

My first thought is a reporting issue. Look at New York and the neighboring states for example: it is hard to believe that drug overdose deaths are so thoughtful that they respect a state border.

The drugs come from Chicago, but majority of the OD happens in the western suburbs of Chicago; mainly DuPage county.

http://wgntv.com/2013/11/19/heroine-epidemic-plaguing-dupage...

Has the legalization of cannabis made a difference in the number of overdoses? I don't have access to the numbers, but it would be an interesting question to ask from a public health perspective, if easy access to cannabis reduces OD deaths from more powerful drugs.

Edited: I mean, if access to cannabis reduces the incidents of ODing from _other_, harder drugs like heroin or fentanyl or meth.

No one has died directly of cannibus intoxication in Colorado yet. A couple have people have gone paranoid and committed suicide. And there a several ER room visits for emotional distress or catatonia every week. About of fifth of DUI convictions are now for cannabis. I presume there is a proportional fracton of drunk driving deaths.

No, I meant if the legalization of cannabis has had an affect on the OD deaths from _other_ drugs like heroin and fentanyl, etc.

It strikes me how this article uses the language of an "epidemic," as if this is a disease that happens randomly to people. It's not. These drug users are deliberately chose to inject a substance into their body, knowing full well that this is a totally unregulated illegal industry, and there is a high risk of addiction, overdose, impurities and death.

They teach kids in school that drugs are bad. Maybe they need to make the education more horrifying, with pictures and videos of people showing in gruesome detail how their minds and bodies have been permanently damaged, or the cold corpses of dead addicts. Maybe they need to better explain the nature of statistical risk, telling you that even if you're fine the first, second, and third time, the fourth, fifth, or hundredth time can still kill you.

Why are people so dumb?

Brains are machines, and drugs damage them in such a way that the damage accelerates.

If you think you are not driven by your own reward system, or that you are above it, you are laughably mistaken. By and large, you will do what your reward system tells you to, and your reserves to defy it are limited and finite.

Be happy that yours is intact and mostly tells you to do things that are good for you (which itself is only by the grace of millions of years of random variation and selection on your ancestors, who more or less knew nothing of the potent drugs that exist in our habitat today), because once that system is damaged, you cannot simply will it to become fixed.

Moreover, it looks like the Appalachian outbreak is due to patients falling into addiction as a result of established medical care, and simply falling through the cracks-- or perhaps even having dangerous addiction-risky treatments foisted on them by a drug industry overstating the safety or necessity of its products.

Have a little sympathy. If the rates shown here continue, you may one day find yourself among the affected.

"Maybe they need to make the education more horrifying"

To my understanding this does not succeed in modifying the risk behaviour of the intended target audience.

Problematic drug abuse to me seems to be a symptom of other problems, not a lifestyle choice.

Epidemic, in epidemiology, does not require random infection or innocence of victims. http://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section1...:

"Occasionally, the amount of disease in a community rises above the expected level. Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area."

I think they went that way because it is hard to separate "you should have known" from "you were unlucky". Of course, you should have known the water might be contaminated, that sex partners may carry diseases, or that jumping of high objects will kill you. The last is bloody obvious; yet, specialists talk about suicide epidemies (https://en.wikipedia.org/wiki/Suicide_epidemic)

Drug education already demonizes drugs. The problem is that eventually the people you preach to will meet someone who is doing drugs and is perfectly fine, and they'll discover that you lied to them. Then they won't believe anything you told them.

If you want to do drug education right, you need to use actual representative facts.

What they should do is sell heroin legally along with cigarettes and alcohol, and that way people won't overdose as much because they'd know exactly how much to use.

And then more people would be hooked on it.

Do you have evidence for that? Legalizing cannabis (marijuana) has resulted in slightly reduced rates of use amongst teenagers in Colorado. Now, cannabis is not opiates, but we need to see evidence before leaping to conclusions. Going with "obvious" solutions and "gut feel" answers is what got us to the place we are now.

I don't have any evidence of the trend, but Opiates are much more addictive than Marijuana in general.

Would you start to use heroin if it were legal? In 1955, the UK had 48 registered heroin addicts [source 1]. Today it's a lot more -- 33,000 seems to be a reasonable figure [source 2]. The UK prescribed heroin to addicts in the 1950s.

But those are just two numbers, you really need good evidence before claiming that regulating heroin, possibly by prescribing it through doctors, would necessarily increase the number of addicts. "Opiates are much more addictive" is a true statement, but not evidence of that.

[1] http://news.bbc.co.uk/1/hi/magazine/4647018.stm

[2] http://www.bbc.co.uk/news/uk-27235470

I know many people who would.

I don't know for sure. All I know is that you will almost definitely have a great time on opiates your first time, and it won't seem like a problem to do them again. It's a slippery slope for many from there, most people have poor self control when it comes to something like this.

Cannabis is not particularly physically addictive.

That might help to some extent, but people still overdose with prescription opioids, which are much more uniform in strength.

An effective dose, especially for someone with high tolerance, often just isn't that far from a lethal one.

Supervised injection sites, with medical professionals equipped with naloxone would help, at least for people willing to use them.

> people still overdose with prescription opioids

It's relatively rare though that someone accidentally fatally ODs on a prescription opioid other than fentanyl and that's the only drug in their system. (Especially since in the U.S. it's very difficult to buy prescription opioids without acetaminophen, promethazine, etc.)

As a historical matter, heroin used to be sold over-the-counter.[1] In some places, it was welcomed as a cure for opium addiction. Historical experience with drugs that were formerly unregulated is often part of the background for current drug regulation.

[1] https://www.historytoday.com/ian-scott/heroin-hundred-year-h...

Interestingly high rate of OD deaths in a county on the Hawaiian island of Molokai. Access is pretty restricted and the whole island has a population of less than 10,000.

With these county maps, it's easy to get very high or very low rates of anything in sparsely-populated counties (see also all those red blotches in the mountain west). Checking wikipedia, it looks like there are 90 (!!!) people in that county; you can guess what one death does to the rates-per-100k people.

Recovery is hard in tiny communities. All your friends are doing drugs, there are maybe 2 or 3 12-step meetings a week, no outpatient programs that you can attend while working, no sober living facilities, and treatment involves a trip to the big city.

Contrast this with a modest sized city like my home of Madison, WI, where there are two rehabs in town, the land of a thousand rehabs is just across the state line, hundreds of meetings a week, and there is a thriving sober living community. Small town folks make up the majority of the recovering heroin addicts I meet here. They all took the quick trip up the road to Madison for rehab, moved into sober living in town, and stayed for the recovery community.

Perhaps that's more difficult on an isolated island community?

If you think it's too hard to get the dope there, you haven't met an addict in need...

Yep, the new face of heroin is white and affluent. While I'm all for the evidence based, treatment focused approach to addiction that this has brought about, isn't it a little telling that we only switched from punishment to treatment when white people started shooting dope?

And what are the odds of switching back once the fashion moves on from heroin?

Hopefully low. The treatment focused approach works, and so once people see this they'll keep it even after the white suburban community gets over it's heroin problem.

This smug commentary is shameful. There are a variety of factors involved in this problem and why until relatively recently an interdiction approach has been taken over treatment. It afflicts all demographics in the country. Get over yourself.

I think it's quite telling that only one top level comment mentions the race of the drug users, and is at the bottom of the page. Even the article itself avoids the topic although it includes statistics of all kinds.

I don't understand your insulting tone. What do you find smug about this comment? That white people are the primary victims in the nations current epidemic? That's a simple fact. The primary reason that black people were spared this time around is simply that doctors are significantly less likely to prescribe opiate painkillers to black folks (a bit of a positive effect of stereotypes about criminality).

If you're not picking up the smugness in his two comments then you must have a tough time with reading comprehension.

Aside from that, it's not a white issue at all. Opiate addiction, including heroin, afflicts all communities, and in particular those of lesser means.

>Yep, the new face of heroin is white and affluent.

Have another look at the maps. It's white and poor.

And that is not a coincidence. People take heroin as a palliative for bleak life prospects. After a few decades of globalization life sucks for rural poor whites in much the same way it sucked for inner city blacks in the 70's.

> After a few decades of globalization life sucks for rural poor whites in much the same way it sucked for inner city blacks in the 70's.

That may be interpreted as, live for inner city blacks is now better than for rural poor whites. Otherwise, we should be seeing the same OD death rates across both populations.

Or there's something that's not being reported correctly regarding this issue in the black community.

See 'Drug Overdoses Propel Rise in Mortality Rates of Young Whites' http://www.nytimes.com/2016/01/17/science/drug-overdoses-pro...

> Drug overdoses are driving up the death rate of young white adults in the United States to levels not seen since the end of the AIDS epidemic more than two decades ago — a turn of fortune that stands in sharp contrast to falling death rates for young blacks

> Yet overdose deaths for young adult blacks have edged up only slightly. Over all, the death rate for blacks has been steadily falling, largely driven by a decline in deaths from AIDS.

> There is a reason that blacks appear to have been spared the worst of the narcotic epidemic, said Dr. Andrew Kolodny, a drug abuse expert. Studies have found that doctors are much more reluctant to prescribe painkillers to minority patients, worrying that they might sell them or become addicted. “The answer is that racial stereotypes are protecting these patients from the addiction epidemic,” said Dr. Kolodny

If not globalization, it would have been automation or something else. They were just in general underprepared for a changing economy.

Or maybe they have been mercilessly trampled underfoot by a corporatist political system on a well funded and organized campaign to crush organized labor, prevent national health insurance, and remove support systems for the working class. There's nothing inevitable about this.

What's inevitable is that they were going to lose. Life is a struggle of all against all. For some people to win, others have to lose.

In no way is it nearly as settled as your sweeping generalization suggests. Pareto-efficient outcomes exist for so many things, why should they not for society?

It should terrify all those who believe they are safe from this type of thing. Most on this forum are doing well, but there could come a time when they look upon all the people judging them for not having the 'obvious' foresight to prepare for economic changes. Thats the fun thing about economic changes, sometimes they don't go the way that the "experts" expect. Even the smartest people predict wrong.

"Bleak" is too weak a word. I think I'd probably give up, too, if I lived in the soda economy:

>It works like this: Once a month, the debit-card accounts of those receiving what we still call food stamps are credited with a few hundred dollars — about $500 for a family of four, on average — which are immediately converted into a unit of exchange, in this case cases of soda. On the day when accounts are credited, local establishments accepting EBT cards — and all across the Big White Ghetto, “We Accept Food Stamps” is the new E pluribus unum – are swamped with locals using their public benefits to buy cases and cases — reports put the number at 30 to 40 cases for some buyers — of soda. Those cases of soda then either go on to another retailer, who buys them at 50 cents on the dollar, in effect laundering those $500 in monthly benefits into $250 in cash — a considerably worse rate than your typical organized-crime money launderer offers — or else they go into the local black-market economy, where they can be used as currency in such ventures as the dealing of unauthorized prescription painkillers — by “pillbillies,” as they are known at the sympathetic establishments in Florida that do so much business with Kentucky and West Virginia that the relevant interstate bus service is nicknamed the “OxyContin Express.” A woman who is intimately familiar with the local drug economy suggests that the exchange rate between sexual favors and cases of pop — some dealers will accept either — is about 1:1, meaning that the value of a woman in the local prescription-drug economy is about $12.99 at Walmart prices.

http://www.nationalreview.com/article/367903/white-ghetto-ke...

Both, in my experience. I feel like the essential feature here is race, however.

Whites, like blacks, have always been shooting dope.

The racism implied in your comment is rooted in having harsher jail sentences for using/possessing drugs preferred by blacks. That's a fact.

Obama and Holder tried to address this not too long ago. I don't know how far they took it.

An earlier article in The New York Times touches on this aspect: 'In Heroin Crisis, White Families Seek Gentler War on Drugs' | Oct. 30, 2015 http://www.nytimes.com/2015/10/31/us/heroin-war-on-drugs-par...

> When the nation’s long-running war against drugs was defined by the crack epidemic and based in poor, predominantly black urban areas, the public response was defined by zero tolerance and stiff prison sentences. But today’s heroin crisis is different. While heroin use has climbed among all demographic groups, it has skyrocketed among whites; nearly 90 percent of those who tried heroin for the first time in the last decade were white.

> "today, with heroin ravaging largely white communities in the Northeast and Midwest, and with violent crime largely down, the mood is more forgiving. “Both the image and reality is that this is a white and often middle-class problem,” said Mr. Mauer of the Sentencing Project. “And appropriately so, we’re having a much broader conversation about prevention and treatment, and trying to be constructive in responding to this problem. This is good. I don’t think we should lock up white kids to show we’re being equal.”

> And in one of the most striking shifts in this new era, some local police departments have stopped punishing many heroin users. In Gloucester, Mass., those who walk into the police station and ask for help, even if they are carrying drugs or needles, are no longer arrested. Instead, they are diverted to treatment, despite questions about the police departments’ unilateral authority to do so. It is an approach being replicated by three dozen other police departments around the country. “How these policies evolve in the first place, and the connection with race, seems very stark,” said Marc Mauer, executive director of the Sentencing Project, which examines racial issues in the criminal justice system.

> “This new turn to a more compassionate view of those addicted to heroin is welcome,” said Kimberlé Williams Crenshaw, who specializes in racial issues at Columbia and U.C.L.A. law schools. “But,” she added, “one cannot help notice that had this compassion existed for African-Americans caught up in addiction and the behaviors it produces, the devastating impact of mass incarceration upon entire communities would never have happened.”

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