The Washington Post says that counties with the highest level of legal opioid use from 2006-2013 (i.e., oxycontin) now have the highest level of fentanyl overdoses:
According to the Post, "The data confirms what’s long been known about the arc of the nation’s addiction crisis: Users first got hooked by pain pills saturating the nation, then turned to cheaper and more readily available street drugs."
I get exasperated at the mindless repetition of "correlation is not causation" from people with no real reason to say it, but in this case I really do doubt the causation that runs from oxy to fentanyl. All this chart shows is that counties with low drug use in 2006 also had low drug use in 2019. Conversely, counties with high drug use in 2006 also had high drug use in 2019. It was just a different drug. But one of the best known findings in illicit drug research is that drug use is faddish. Over the past few decades we've seen waves of crack, followed by marijuana, followed by meth, followed by oxy, and finally followed by fentanyl and heroin.
It's possible that oxy led to fentanyl, but there are also good reasons for the fentanyl crisis to have started around 2014 that are based on chemistry and supply chains and have nothing to do with the oxy crackdown.
I'm not sure what data you'd need to figure out causation here. In the meantime, I'd be a little cautious about accepting the just-so story that says oxy users all switched to fentanyl because they could no longer get their pills.
I'm struggling to understand where the confusion is here.
The counties with the most opioid prescriptions means the counties *with the most addicts*. Addiction to opioids is usually a lifelong problem. Fentanyl is a synthetic opioid that is cheap and easily available, so it was a natural substitute when pain pills were harder to get... it also tends to kill you pretty easily.
Seems to me like a pretty bright line from A to B.
If I recall, it was oxy to heroin to fentanyl--the latter being cheaper to make.
These come under deaths of despair. So was Oxy prescriptions (and pill mills) creating or just feeding addictions? Once the mind is re-wired, addictions are hard to break.
Charts of drug overdose tend to show a slow rise of prescription opioid death from 2000 to 2017, followed by a slight drop.
Heroin deaths pick up around 2010 and also peak around 2017.
Fentanyl and other synthetic opioid deaths start rising in 2013, but pick up speed in 2015.
Prescription opioid sales peak in 2011.
That is all pretty consistent with users shifting where they get their opioid. Perhaps there is some faddishness here, but it seems more likely to be about cost/access.
There was a real crackdown on prescribing opioids by medical professionals around 2010. Heroin was the available substitute for many people, and you could watch the spread of fentanyl-laced heroin as it moved from the east coast to the west coast. Today they don't always bother with the heroin. And they put the fentanyl in everything.
There is no proof of people shifting their use, but it's hard to come up with a better narrative that fits the existing data.
Seems to me like a pretty bright line from A to B
Maybe. But plenty of people in America managed to become addicted to heroin—without first trying prescription opioids—in the days before fentanyl arrived.
One would imagine it should be possible to investigate how many people who have OD'd on fentanyl at one point had Oxy prescriptions.
Fentanyl is a better party.
The piece says "The data confirms" the hypothesis that fentanyl replaced opioids. This is not technically correct - it should be "the data is consistent with". If the geographic distribution had not been the same, the hypothesis might have been falsified, but it passed that test. Passing repeated tests is all that can really be done in science.
But how does Kevin's preferred hypothesis, that fentanyl use exploded when synthesis became cheap, explain the geographic distribution? Does he think that opioid and fentanyl users are different sets of people? The two hypotheses may not be mutually exclusive.
But how does Kevin's preferred hypothesis, that fentanyl use exploded when synthesis became cheap, explain the geographic distribution? Does he think that opioid and fentanyl users are different sets of people?
They're not 100% of the time the same people, but yes, that's a good point: intuitively we'd expect a lot of overlap between these two groups, especially the further back we go toward the introduction of Oxycontin. My understanding is that prescription opioids are now much more tightly controlled, so more recently, I'd expect we see significantly more "straight to Fentanyl" users.
There was a book by the editors of Consumer Reports called Licit and Illicit Drugs, and published in 1973. It looked at everything from cocaine in the late 1800s to morphine and heroin, along with amphetamines. The obligate conclusion at the time was that every time you suppress a drug, the substitute grows in usage and popularity. You might say its a perpetual game of whack a mole. At the time amphetamines were available by prescription but were under attack within the medical establishment. I can remember thinking that if the future (post-1973) was like the past, then cocaine would be the substitute as amphetamines were removed from the market. The parallel illicit production of methamphetamine wasn't obvious, but is obvious in retrospect.
The other lesson of that book was that sustained high level use of opiates could be tolerated by some people as a way to handle addictions. They mention the case of William Halstead, the father of modern American surgery, who experimented with cocaine (much like Freud), became addicted (like Freud), and maintained himself by taking high doses of morphine for the rest of his life. It didn't kill him, and he kept up his surgical career.
Suppression of opiates functions much like Prohibition functioned in the 1920s, but with even more lethal results. If heroin were sold in pharmacies in pill form, addicts could function without paying a lot, and most of them could survive. It wouldn't prevent the occasional overdose, but the current system, with a much more dangerous opiate, is more deadly, as all those overdose statistics in Ohio and elsewhere show.
It is probably true that fentanyl can be synthesized more cheaply than production of morphine or heroin, but the cost difference wouldn't be that much.
https://www.amazon.com/Consumers-Narcotics-Stimulants-Depressants-Hallucinogens/dp/0316107174
"If heroin were sold in pharmacies in pill form, addicts could function without paying a lot, and most of them could survive."
Isn't this the exact purpose of Methadone and Suboxone use to treat opioid addiction?
I think the ‘advantage’ of fentanyl over other opioids is that you need a lot less so it’s a lot easier to smuggle into the US.
Fentanyl isn't just a fad, it is actually a crisis.
The "drugs are faddish" hypothesis confuses me as well.
People already addicted to opioids before Fentanyl became widespread probably switched to Fentanyl out of convenience. But I don't think Kevin is entirely wrong by saying drugs having a fad component to it, meaning that those just getting hooked on the drug (new users) are likely to do so on the drug that is the most popular and/or easily available at the time and place they live at.
The "drugs are faddish" hypothesis confuses me as well.
Popularity leads to more popularity: the more widely a drug is consumed, the more it is supplied into the marketplace, and is in circulation. Which increases its availability, and also increases the number of persons who will end up trying it.
Rinse and repeat. A fad, albeit not a fun one like hula hoops or mood rings.
Fentanyl is a synthetic opioid that is substantially cheaper and more potent. Seems pretty obvious why drug users would replace Oxy w/ "blues".