America’s Health Fix:
Case & Deaton’s Deaths of Despair, Part II

Anne Case and Angus Deaton.

3,201 words

Part I [1]

When Purdue Pharmaceutical introduced OxyContin, their marketing for the drug was aggressive, efficient, unscrupulous, and amoral. Resources were poured into advertising; the company spent $200 million on marketing in 2001. Sales grew from $48 million in 1996 to $1.1 billion in 2000, according to information revealed in a Senate hearing.

The introduction of OxyContin, write Case and Deaton, “was met by a seemingly unlimited demand by patients in pain.” (p. 117). Even arthritis and toothache sufferers were prescribed the new wonder drug. Case and Deacon note the role of, but nowhere challenge the legitimacy of, the special relationship between physicians and pharmaceutical agencies in enabling pharmaceutical companies to promote often unnecessary — and sometimes dangerous — medicines.

Case and Deaton do not comment on the change in attitudes to pain on the one hand and the significance of rising life expectancy and sinking mortality within elder age groups on the other, factors which surely contributed to making the “pain business” more lucrative. People were living longer, as Case and Deaton note and even stress, without seeming to realize that this in itself is a significant factor in boosting the demand for analgesics.

Doctors were not slow to prescribe the new drug, nor pharmacies to stock it, and there is talk of “pill mills” (sometimes called in the euphemistic marketing language of our time, “pain management clinics”) swamping West Virginian pharmacies with OxyContin. The total production of OxyContin and similar drugs was put at 76 billion by the Washington Post, which does not publish a time figure for this number. Abuse of such easily available clinical heroin, needless to say, skyrocketed. Were doctors really surprised, given the addictive qualities of such an opioid? Were they really fooled by reports of the relatively low addiction peril? Case and Deaton make every possible allowance for medical practitioners:

It is arguably possible for a doctor to assess which patients are at risk for addiction, but not in a few minutes. . . Doctors may not even know that their patients have died from drugs they have prescribed; when they are sent a letter informing them, many reduce their prescribing of opioids. (p. 118)

How reassuring.

Sometimes the facts that Case and Deaton are too honest to conceal run counter to the mild tone of their book. Their belief that the opioid crisis was one waiting to happen because of flaws in the health care system with rent-seeking and corruption as contributory factors implies a more fundamental system failure than just a singular flaw in the health care system requiring readjustment:

The epidemic would not have happened without the carelessness of doctors, without a flawed approval process at the FDA, or without the pursuit of profits by the industry at whatever human cost. The story of that industry, unrestrained and running amok, is being told in American courtrooms today as pharmaceutical executives are being pursued for accountability and compensation by nearly two thousand municipalities. . . . One story is that misbehavior poured smoke on the fire, making the epidemic worse, rather than creating the conditions under which such an epidemic could have taken place in the first place. The people who used the opioids, the many millions who became abusers or became addicted, who became zombies walking the streets of once-prosperous towns, were those who lives had already come apart, whose economic and social lives were no longer supporting them. The supply side of the epidemic was important. . . but so was the demand side, the white working class, less-educated people, whose already distressed lives were fertile ground for corporate greed, a dysfunctional regulatory system, and a flawed medical system.” (pp. 125-26)

This comment is followed by a questionable expression of faith in the integrity of systems abroad:

The opioid epidemic did not happen in other countries both because they had not destroyed their working class and because their pharmaceutical companies are better controlled and their governments are less easily influenced by the corporations seeking profits. (p. 126)

The marketing campaign undoubtedly explains OxyContin’s phenomenal success. Raymond Sackler, who became a company executive, said that the marketing campaign, which included remorseless pressure on sales agents and on physicians, assured executives that it “will be followed by a blizzard of prescriptions that will bury the competition.” Prescriptions indeed surged, and the use of opioids to treat all kinds of chronic pain became widespread. “Overdose deaths began to rise in the early 1990s, gathering real momentum after 2000, a year in which more than 14,000 people died of accidental overdoses. . . . In 2000, between a third and a half of all accidental overdoses involved (mostly prescription) opioids.” (p. 118)

Case and Deaton are restrained in their condemnation. They do not mention an especially vicious tactic of Sackler’s to combat criticism. The journalist Andrew Joseph does so. Writing for Stat News Online in 2019, he says:

Five years later, as questions were raised about the risk of addiction and overdoses that came with taking OxyContin and opioid medications, Sackler outlined a strategy that critics have long accused the company of unleashing: divert the blame onto others, particularly the people who became addicted to opioids themselves.

“We have to hammer on the abusers in every way possible,” Sackler wrote in an email in February 2001. “They are the culprits and the problem. They are reckless criminals.”

Raymond and Mortimer, and Raymond’s son Richard, controlled Purdue Pharmaceutical during the launch and marketing of OxyContin. Both Raymond and Mortimer were knighted by Queen Elizabeth and the name Sackler (dis)graces many galleries and colleges. Purdue filed for Chapter 11 on September 15, 2019, in the wake of a public outcry and numerous public and private suits, notably concerning the claim that OxyContin was much less addictive than other synthetic opioids. The supposedly low-addictive characteristic of OxyContin played a major role in Purdue’s marketing.

Case and Deaton make comparisons to important mortality “culprits” in the past, such as tuberculosis in the nineteenth century and heart diseases and cancer in the twentieth century thanks in part to widespread heavy smoking. As might be expected, the writers repeatedly mention smoking as another example of rent-seeking bringing about disease. However, these comparisons tend to cloud the peculiarly fatal feature of opioids, whether natural or synthetic; namely, their progressively addictive quality. Opioids have addictive characteristics that force the user to crave ever-stronger doses to achieve the same desired effect. This well-recorded aspect of opioid addiction means that the median health hazard of opioid consumption is considerably higher than that of alcohol or tobacco. Case and Deaton might have noted, but did not, the irony that opioids certainly enjoyed and perhaps to some extent still enjoy a lower level of social opprobrium in the United States than nicotine.

It was not long before OxyContin created a staggering addiction problem in the US. Some pharmacies were providing what amounted to little less than a self-service store for addicts. By describing how the drug should not be used, the company provided addicts with instructions as to how to obtain the best fix — for example, by crushing the tablets, heating them and injecting them, or by snorting the powder.

After years of soaring addiction rates among working-class whites (Case and Deaton do not closely examine why blacks and Hispanics from the same social class were so much less affected), measures were taken to restrict the prescription of the drug, make prescription hopping harder, and OxyContin was refashioned, making it less easy to crush it into a powder. This change coincidentally provided the Sacklers with the chance to renew their about-to-expire patent, which was something “possibly of more concern to the company than saving lives.” (p. 119)

In 2007, the company and three current and former executives were found guilty of fraudulent marketing practices and fined $600 million. The fine could not have unduly hurt the company financially, however. It spent a billion dollars in marketing in 1990 alone, and had an income of 45 million from OxyContin in its first year. The Sackler family fortune was assessed at 13 billion by Forbes. Opprobrium was another matter. More and more questions were being asked about the use of the drug and its long-term health consequences, and about the company that promoted it. More suits were likely to follow, so the company filed for bankruptcy and the family relocated to Switzerland. The authors cite Jan van Reenan: “Like an eighteenth-century wig, the perfume disguises, but does not eliminate, the stench of moral decay.” (p. 128).

The moral decay does not even stop there. Case and Deaton write:

The pharmaceutical companies, having made so much money from creating the crisis, now stand ready to profit from its treatment. There are no easy or sure-fire cures for addiction, but the best available, albeit on relatively weak evidence, is known as medical assisted treatment (MAT), whereby those with addictions use different opioids, methadone or buprenorphine, to control their craving while quitting. . . it takes a strong stomach to watch pharma and their allies push MAT so that they can profit from causing the epidemic and from curing it. Indeed, in the summer of 2018, Purdue Pharmaceutical was granted a patent for a variety of MAD, setting itself to repeat its earlier success with OxyContin. It is as if the poisoner of the water supply, having killed and sickened tens of thousands, were to demand a huge ransom for the antidote to save the survivors.” (p. 129)

Measures to halt the epidemic might perversely be said to have been too effective. The genie was out of the bottle; widespread drug addiction in specific and often isolated communities was a fact. When doctors’ supplies became harder to obtain, addicts looked elsewhere. The market for heroin picked up the slack. Heroin was cheaper than OxyContin, but more dangerous, because anyone buying heroin on the street could not be sure of what they were getting. A cheap booster began to be added to heroin — a highly potent opioid called fentanyl. Fentanyl is significantly more powerful than heroin and is very cheap to manufacture. In short, opioid drug addiction has developed over some 30 years in three stages: First, prescription opioids courtesy of the Sackler family; second, heroin, mostly shipped across the Mexican border; and third, the most potent opioid of all, fentanyl.

Case and Deaton, so adroit at providing detail in their description of the crisis, are vague about the solutions they offer to halt it. They are surely right in their demand that medication and medical produce should not be allowed to find its level in the market in the same manner as comestibles or luxury goods. It is additionally this reviewer’s belief that a system should not be tolerated which permits pharmaceutical companies in any manner whatsoever to approach practicing physicians with a view to promoting their products.

“Rent-seeking” is an expression that Case and Deaton regularly use. All-out competition in the field of medication opens the way to it. This study also shows up the shortcomings of comparative tests in drug assessment and approval; for example, the failure of the FDA to properly investigate the recommended usage of OxyContin and the hazard of using it in a non-recommended way, and perhaps most importantly, what the long-term and non-tangible effects of OxyContin might be.

What was so special about the United States that allowed such a tragedy to happen and above all, on such a scale? Case and Deaton had stated at the beginning of the book that they were looking for a key factor, a “culprit.” Surprisingly, the reader is not presented at the end of the book with one. The authors concede, rather, that various factors had a part to play.

Several times, Case and Deaton stress their admiration for NICE (National Institute for Health and Care Evidence), a UK government body attached to the Department of Health which investigates the very broad implications of a new medication. It sets up committees to invite interested parties to share their views and perspective, including representatives of local government, voluntary care organizations, and what NICE on its web site calls “unpaid carers.” The NICE remit is obviously considerably wider than that of the FDA. Case and Deaton write:

As part of healthcare reform more generally, America needs an agency such as Britain’s NICE that assesses the benefits and costs of treatments whose benefits fail to exceed their costs. This is of course, an example of government interference in the market. Yet, as we have already argued, the market for pharmaceuticals is nothing like a free market, nor could it ever be. (p. 247)

A weakness of Deaths of Despair is that it almost exclusively looks at the United States. There are no comparative studies. Suffice to say that the US system from what they have to say here is especially susceptible to influence and lobbying, not to say corruption, and the medication approval and classification procedure operates within a too-narrow frame of reference and is too close to big pharma. The writers imply, although they do not state in so many words, that an organization such as NICE would not have permitted OxyContin to become a widely available standard prescription drug in the first place.

The writers are also very critical of America’s health insurance provision. They draw attention to the notoriously high costs of health insurance in the United States, linked to disappointing results. Their view of US health care provision compared to other Western countries may be summed up as “higher costs, worse results.” An important factor that the writers examine is the decline in the US of employer-based insurance because of economic shifts. If not uniquely American, it certainly has an importance in the US because of the dominant role played by employers in offering medical insurance schemes. In most European countries, the state is the major player. This means, as Case and Deaton rightly note, that the American health system is peculiarly vulnerable to recent economic shifts towards a more free-market economy. One aspect of health care and costs not touched on here — though should surely be mentioned — is the general level of health and morbidity in the US compared to other countries. Huge costs are incurred by having an unhealthy and/or hypochondriac population, many of whom are overweight, and living on an unhealthy diet; something which can play a role in swift access to wonder drugs and the quick fix when health issues arise out of, for example, a “sedentary lifestyle.” So Case and Deaton downplay obesity as a factor in life expectancy:

. . .deaths associated with obesity could perhaps be included as deaths of despair. We do not take that route here, in part because it is so difficult to calculate which of the deaths from heart disease are related to overeating. But the obesity explanation is far from complete. The obesity gloom-mongers have been crying wolf a long time and were predicting that life expectancy would start falling long before there was any sign of it.” (p. 44)

This is not good enough. Is it not a question to be considered that the rise of obesity may have brought about an increase in the demand for analgesic medication? Is it not possible that adipose patients are more likely, for social as well as pathological reasons, to become addicts to such medication? More likely to die from drug abuse? These and similar questions are not posed. Deaths of Despair offers only a superficial and totally inadequate overview of the American healthcare system in its entirety. That the crisis in American health care might be the symptom of a sickness in the democratic capitalist system as a whole is something the writers will not for a moment countenance. However, their own statistics will not permit of doubt that there is a drug crisis of horrendous proportions in the United States and it will not go away just because the original arsonists, the Sacklers, have gone away. In 2017, the writers tell us, there were 70,237 “accidental deaths” from drug overdose in the United States. By comparison, there were 40,100 traffic fatalities and 19,510 homicides recorded in the same year. (p. 97)

“Working-class life is certainly under threat from automation and from globalization but healthcare costs are both precipitating and accelerating the decline.” (p. 187) Such facts may, and probably do, result in the non-assured seeking illicit ways to relieve pain if they cannot afford proper medical treatment. Case and Deaton note that middle America is especially vulnerable in this respect because a widespread dependence on company health insurance schemes in the United States makes unemployment a graver economic and health menace than in Europe, where the loss of a job does not, as a rule, entail the loss of medical insurance.

Lawsuits against the pharmaceutical companies responsible for aggressively promoting highly addictive drugs will have the effect (it has already begun) of companies like Purdue moving business and marketing to other countries. Besides, addiction itself has moved beyond prescription drugs. “It would be a tragedy,” warn the writers, “if the profits of the drug trade were allowed to corrupt America and were later seen, as was the case in China a century and a half ago, as the beginning of a hundred years of humiliation and decline.” (p. 130) This seems to be in contradiction with their own statement that the genie is already out of the bottle, and makes one wonder if the title “the future of capitalism” is as necessarily optimistic as the writers wish it be.

The writers do examine the other aspect of the case; namely, the conditions which made susceptibility so high in the first place. They describe the prominence of what they call “monopsony,” a term coined by the economist Joan Robinson to describe a monopoly of buyers — in this case, of labor. Labor mobility is in decline for the less educated, with fewer low-paying jobs available. Temporary workers are hired from agencies. Zero hour contracts are on the rise, and at the same time, unions are in decline.

Those developments have now reached America’s small-town white communities, and with it, the drugs which will help anyone in despair to ease his pain and remove what dignity he has left at the same time. The authors’ silence regarding the populist protest against the downward slide in the fortunes of the working-class white, reflected in the Brexit referendum, the rise of populist movements in Europe, and the election of Donald Trump, is deafening.

The Sacklers have moved on, although not without having profited from the lucrative businesses of supplying the medical industry with a product, another opioid, which relieves the agony of those in withdrawal symptoms from their original products. According to the Drug Enforcement Administration, in 2017, 14.6 prescriptions for buprenorphine were recorded selling under the brand name Subutex.

A possible side effect of Subutex is, apparently, addiction.

Finally, from the web site of Purdue Pharmaceutical:

The nation’s opioid addiction crisis is a significant and urgent public health challenge, and Purdue Pharma is deeply concerned about the toll it is having on communities.

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