A few years ago, I talked to three retired federal law enforcement agents who had each spent 20+ years fighting the cartels that were bringing drugs into the US from Mexico and South America. All three felt betrayed by the US government. They said, essentially, "We put our lives on the line many times to try to stop the flow of drugs. Then the government turned around and basically gave the pharmaceuticals license to sell this stuff professionally, through people's personal physicians."
These retired agents didn't see the drug war as a war on "bad guys," but as an effort to stop the destruction drugs wrought in people's lives. After all their work, their own government undermined their efforts.
My own doctor was taken in by Big Pharma's sales pitch and wound up going to prison for over-prescribing their pills. https://en.wikipedia.org/wiki/William_Hurwitz. Though to hear Big Pharma tell it, there was no such thing as over-prescribing.
If you want to get an idea of how out-of-hand the prescription frenzy got, take a look at John Temple's book American Pain, which describes the pill mills in South Florida. Towns in Appalachia used to send charter buses to these pharmacies. After a 12-20 hour bus ride, each passenger would pick up hundreds or thousands of pills, then ride home to sell them in their small country towns.
Some of the pill mills, which were fully licensed by the state of Florida, were cash-only and would haul garbage bags full of money to the bank each day at closing. For a summary of Temple's book, see https://adiamond.me/2020/01/american-pain-by-john-temple/
My mom worked as an ER physician in Pennington Gap, VA during the early years of opioid abuse there (late nineties through through the early oughts) [1]. She would constantly complain about drug seekers there and refused to give out pain meds. According to her, she was the only doctor who would refuse to give out pain meds.
Fast forward to 2022, she needed heart surgery and was in the ICU for three weeks afterward. She never asked for pain meds and regularly refused them when asked. I think she had became so accustomed to denying people pain meds, that she even denied herself, though it was clear she was in pain.
One can learn how to handle pain yourself. Some people went very far with this.
While younger, I was a bit advanced in those technics - basically it is about accepting the pain and working with it.
In my theory, pain was like a alarm sound - and a painkiller just deactivating the alarm, but therefore maybe stopping a adequate body response.
Nowdays I got a bit softer as currently I am on weak painkillers, but a very low dose compared to the recommendations. And for my (disease related) empty stomach, this is probably way better. Also less extra stress on the liver and kidneys.
But even so, I experienced the feeling, that can put people into the path of addiction. Just one more pill and everything feels fine again. No more struggle, being calm again. But this is dangerous.
I'm not sure where I would have learned it in my life, but this is very similar to my experience with pain so far. I'll definitely feel it but I do experience it more like an alarm, and once I recognize what happened the pain signal seems to go away after about 30 seconds.
To this day I'm still surprised by it, and appreciative for whatever it is that allows my body to apparently recognize and then silence the pain signals.
If she never explained what was happening there, public ERs cannot refuse service to anybody for any reason. So drug addicts will use ERs as an attempt to score drugs by pretending to have some illness or another. If they fail, they'll just go to another one. And then repeat the circle. Even when the people at the ER know they're faking and they're there solely to try to get drugs, they have to continue trying to treat them in good faith. It's a major source of burn-out for ER workers, because it's just never-ending and a complete waste of resources.
That's not quite accurate. Under EMTALA, ERs are only required to stabilize patients. Once an indigent patient is stabilized and no longer at immediate risk, the hospital is free to discharge them even if they have serious medical conditions.
There's a much more informative article available here. [1] Stabilization does not have the colloquial meaning. It's defined as, "To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition..."
So somebody with a serious medial condition could be discharged, but only once that condition was treated and unlikely to further deteriorate. And then there's also a bunch of other rules hospitals that accept medicare have to follow for all patients, which are similar in spirit to EMTALA. And then there are going to state rules on top of all of this. Violations are severe with penalties able to be imposed on both the hospital and the doctors/staff involved - up to and including loss of license, and they are not covered by malpractice insurance. And the courts have invariably ruled on the side of patients, so I don't think there's any doctor that's going to be looking to try to short-serve the requirements of the law. Part of the reason you can find a million negative articles about it!
I'd say it's fairly accurate. It's difficult to confidently establish "stable" in a patient with possibly feigned or exaggerated symptoms based on history and exam alone. It is generally agreed that pain management is part of managing an emergency, and so if an emergency has not been confidently excluded, it is usually part of care until a workup is concluded.
If one could know from the initial evaluation that an emergency could not possibly be present, one could certainly discharge without additional care, but that can be impossible to know immediately (even with highly trained and calibrated eyeballs).
I remember going to the dentist a number of times a few years back and they always prescribed me something crazy like percs, vicodin, oxy, etc. I never actually got any of the scripts filled because by then I had read too may stories about the opioid crisis and was determined to never venture down that road. I did notice once the opioid crisis really hit the mainstream press, my dentist stopped prescribing those strong painkillers and prescribed prescription grade tylenol or ibuprofen instead. Never filled those prescriptions either because the prescription grade stuff was the same as taking more of the regular OTC medicine.
Back in 2007 an oral surgeon gave me an opioid painkiller prescription after a routine tooth extraction. I never filled it but in retrospect it seems crazy how they were handing out those scripts like nothing.
It hit this area hard. I’m from neighboring Scott County and I left in 2015 to pursue a job in a larger market. When I brought my family back in 2021 we shocked to see just how much the opioid crisis had hollowed out the community. Whatever big pharma has paid it’s not enough to repair the generations of damage it’s done to the area. I am on the local Board of Supervisors and I’m trying my best (along with the rest of the board) to get everything running back in the right direction.
Last I heard, culprits are arguing at SCOTUS that they should get immunity for a fraction of their gains. Also, some payouts will come from selling more of the same, which is nuts. It’s pretty hopeless…
Just a point - the same people who thought they were “saving” people with a drug war were destroying lives themselves over drugs that not so many years later are legal and accepted to possess. Somehow they’re not harmful anymore. It’s all BS.
Excellent point, and it's not just a thing of the past, it's still happening right now. Cannabis might be at various stages of legalization throughout the US, but there are countless other substances that are criminalized without any justification, like psychedelics.
The damage that the US-led war on drugs has done throughout the world is staggering. It's probably going to take decades until all the brainwashing and propaganda washes away and we get some form of legalization in Europe, not to mention other parts of the world that take it even more seriously.
The war on drugs is also just a much more active participant in harming people vs the drugs themselves.
The drugs aren’t making a conscious choice of destroying someone’s life. Those agents are. They’re by definition worse than the drugs (premeditated vs not).
Drug policy is complicated. Amphetamines and opioids certainly have very valid medical uses - but also giving the public unrestricted access to them is a complete disaster.
Psychedelics likely have various mental health treatment uses but they are for some bizarre historical reasons considered dangerous.
Mental health medication like benzos are also tricky. They are amazingly affective but also amazingly addictive and withdrawals can be fatal
Having been a cannabis smoker myself for years, I can understand the danger of self-medicating with psychedelics. They aren’t entirely harmless.
Any drug with a high is a dopamine button. It’s easy to hit that button instead of doing something else to feel good. It’s easy to stop doing other things in favor of just hitting that button all day. But the effects of that button diminish over time, so you hit it more often, and the more you hit it the less other things you want to do.
Psychedelics powerfully activate and deactivate different parts of the brain, changing the way you think and process information. Controlled and intentional, this has huge potential for positive mental health outcomes. With chronic recreational use, cannabis leads toward negative mental health outcomes like depression, disordered thinking, anxiety, and low agency.
Quitting is an interesting grey area for cannabis; culturally and functionally people misusing the drug are able to do so indefinitely, usually not reaching the “rock bottom” emergency state that other drugs (hopefully) convince the user to seek treatment. So it feels like “just weed” isn’t serious enough to warrant a 30 day treatment center, but the behavior patterns can be so ingrained it can be hard to see breaking them without.
I haven’t quit but have pulled back and am using it far more occasionally rather than most of the time.
The sense of increased focus after smoking is a big plus for me, but the decrease in focus after that coupled with the overall disorganized thinking is a big minus. Disorganized thinking can be great if you are trying to generate a variety of ideas, but bad if you are trying to communicate them. Learning more about what is actually happening in my brain with focus, memory, agency, etc has been one of the biggest motivators in pulling back from chronic use. I don’t enjoy it much knowing that I’m avoiding other things or going to be grumpy and depressed later because of it.
Agree about the grey area for quitting. There isn’t a rock bottom, but with chronic use there is a kind of dull limbo where everything feels harder to do, but you’re demotivated to make a change. It is literally a drag - it slows and lessens you overall.
For me after daily use for 6 months or so I just had a realization that it’s a net negative. I was always tired, cranky, forgetful, and the highs weren’t that high - more like maintaining some rather low level of life satisfaction. If you use it a lot there is probably some root cause why you think you need to get fucked up all the time.
What helped me quit was really seeing it for what it is - it was making a few hedonistic experiences “richer” but kind of draining the color out of all the experiences outside of that. I never had any negative effects while high - like anxiety so it seemed harmless. For practical tips think of something to do for the first few days at least when you’d normally toke up if youre just bored at home. Out with friends, walking, playing a new game, hobbies, etc
In the early 2000s I was a pharmacist intern and then early in my career working retail pharmacy as a PharmD. I knew the pill mills around me, I would provide DEA agents with clear examples and little to nothing was done about it. What I did get were credible legal threats from patients and physicians for not carte blanche filling what was written by their doc and then I started getting pressure from my district manager (after all I was denying big fat cash payers!). At the same time I saw pharmacist going to jail for "inappropriate dispensing" while the doctors who were running the pill mills were getting in no trouble at all. I left outpatient pharmacy as fast as I could. It was clear no on wanted to do anything to actually solve the issues at hand.
I also get so frustrated with all the border bullshit. Doing anything at the border is trying to solve the problem two thousand miles from the root cause. And pretending that migrants (people trying to come to the US permanently) have anything to do with drug runners is about as stupid as it gets.
The idea of someone going to a bank with a garbage bag full of cash and depositing it into a pharmacy's business account is insane. That's the kind of thing that can only happen when the system is fundamentally corrupt.
A friend of mine was a mechanic in the air Force and took a wrench to the knee. The VA basically prescribed him a giant bottle of benzos and told him to take them as needed.
Young man laid up at home with nothing to do but sit on the couch playing video games and drink beer. Add in a big bottle of pain pills to take "as needed" and you've got an addict.
Because people form their impressions of what the world is like by continually reading anecdotes like this, I'd like to at least throw my own experience out there. I (not my friend) got out of the Army needing three spine surgeries in the span of 16 months, after years of increasingly worthless non-invasive treatments. This involved daily percocet for a very long time along with periods of time in which I couldn't do much beyond mindlessly watch television while falling in and out of sleep.
I did recover, though. Today, I run 40-50 miles a week, lift 6 days a week, work in software making five times what the Army ever paid me, haven't touched a painkiller in 7 years, and don't even drink.
Make of it what you will, but people are individuals and medical policy should reflect this. Pill mills are a problem but physicians deserve the judgment and discretion you should expect of someone we spend up to a decade training and licensing.
Yes, a lot of the problems with drugs is probably cultural. We decided to convince people that they are absolutely powerless against addiction, that this is a disease they were born with it and there's no much they can do themselves, that they can't have absolutely no agency.
Benzos are not pain meds. Might make you an addict, but if that’s what was prescribed, it wasn’t for pain. Dunk on the VA all you like, but they’re not that bad.
You're right, I got my wires crossed for some reason. Pretty sure it was either for Percocet or the generic equivalent.
When he recounted this to be, he was frustrated that they didn't give him a small prescription to start with, but more or less gave him a large quantity up front and let him dose himself.
He managed to beat the addiction, and when I'd met him it was in a software development gig so it's not like it ruined his life or anything. He certainly wasn't happy with how casually he'd been treated was the jist of the story.
Edit: just realized I had a different friend at the same company who had been on benzos and dealt with the withdrawal... The three of us chatted quite a bit and I imagine that was the context for the conversation but it's been a decade or so.
That makes more sense. As for why, just look at the responses to my other comment saying that opioids aren’t generally warranted for weeks after a dental extraction.
sounds like the only difference between the Columbian Drug Cartels (cocaine producers and street pushers distribution network) and the American Drug Cartels (Big Pharma and pill mill distribution network) is the latter paid taxes
And funny enough, here I was just thinking about how these jerks are making it so that, after the midwit backlash against all the criminal behavior encouraged by the Biden admin, I'll get to just live in pain the next time I have an injury!
… Eh? Purdue Pharma’s downfall was long and protracted, but it started in 2007 and ended in 2019; presumably Biden was encouraging it using his time machine? Like, the US opioid crisis isn’t exactly _new_.
I was in the care of a pain clinic when the fire hose was abruptly shut off. I wasn't being given oxycontin, but I still suffered from the sudden change. I went from sustainable maintenance to a drug that gave me serious side effects, but the doctors refused to listen. Even when a sleep study objectively showed the damage the buprenorphine was doing, I was told it's that or nothing. The doctors were terrified of new scrutiny of their prescription activity, so they just cut people off.
Do no harm was destroyed by the knee jerk reaction by the government.
Now, my poor wife is in constant debilitating pain from hypermobile Ehlers-Danlos but gets treated like she's drug seeking. While multiple joints are dislocated.
I wish everyone who made decisions that led to this mess would suffer what my wife suffers, and get treated the same way by the medical establishment.
The harm to society of people who need them not getting pain drugs far outweighs the pain to society of those who don’t need them abusing them.
I’ve had similar experiences with them not giving me proper painmeds are having all 4 of my wisdom teeth removed. They gave me 2 weeks of Tylenol #3 and some homeopathic bullshit and expected that to be good enough. Luckily my stepdad is a serious medical patient with lots of the good stuff, but it’s bad when I’m raiding my own parents pill closet to get any sort of relief after that many wisdom teeth came out all at once.
> The harm to society of people who need them not getting pain drugs far outweighs the pain to society of those who don’t need them abusing them.
How do you measure that? Opioid overdoses accounted for at least 72,800 deaths last year [0] and there are countless more addicts out there whose entire lives are ruined because of that addiction. Many of those people, if they ever recover, will never take opioids again for any real medical pain relief like you did for your wisdom teeth because of the very real risk of relapse. Additionally, opioid withdrawal is, according to almost everyone who's gone through it, is one of the worst experiences you can feel.
I'm not taking the side that it definitely doesn't outwheigh the need of those who genuinely need them. On the whole I actually probably agree with that. But stating that so confidently and ignoring the very real pain, lost lives, and broken families caused by opioid addiction because you had your wisdom teeth pulled and wanted opioids feels pretty dismissive and not a serious argument.
> The harm to society of people who need them not getting pain drugs far outweighs the pain to society of those who don’t need them abusing them.
I can see the argument here morally (and I agree with it), but in practice I know far more people negatively affected by drug addictions and drug addicts than I know people unable to get pain management medication they need. I imagine my experience may be typical, and so I am unsurprised the pendulum has swung so far.
One question to ask yourself though is whether you're experience both confirmation bias and a bias brought about by visibility and/or age. If you're younger, you're less likely to know people with conditions that require pain management. Likewise the people around you suffering from such conditions might not be open about it because either they've already been told they just have to suck it up and live with the pain, or because they've learned that complaining/being assertive about their pain is a good way to get labeled an addict and get even worse treatment.
I was arguing that such a complaint will fall flat with many people if they share the same general experience as me. Not that it’s “objectively” true or false, assuming you can find something objective to measure. In fact I don’t think you can find something useful to measure objectively, and will necessarily fall back on subjective arguments about what is better, more important, more moral.
You'll pardon me for saying something that sounds a little "woo," but what will enlighten you the most is regarding Group B (who get opioids or benzos or whatever and suffer addiction) as a subset of Group A (who need treatment and medication but aren't getting it), namely that Group B is not getting something in their lives which they desperately need.
Then you may see the unitary flaw in the system, at perhaps a larger scale, wherein people are not receiving what they need. One "right-sized" problem, not two problems. Why addiction, or better, why addiction now, what has caused the rise in such? Whatever that need was, were it met, would prevent addiction and we might then cease adding yet one more special of lenses, mirrors, and films to our ever-evolving panopticon, one more trackable in the Salesforce of the Surveillance State.
We need to look at some reasons as to why people can see, say, Tranq in Philadelphia and say, "That looks like my best option, there."
I don’t disagree that addiction indicates a lack of something broadly related to “care”. I just take issue with claiming “it is necessarily better that people in pain receive care, and addicts do what addicts do”.
If this is indeed a spectrum (certainly debatable), with increased access definitionally increasing addiction, the argument that one side of the spectrum is strictly better is wrong.
That’s great for you. My partner was also not given anything when her wisdom teeth were removed. As the dentists anesthetic wore off, on the drive home, she started crying, then screaming as we pulled into the driveway. I got her in bed and gave her Tylenol (dentists recommendation), but she was crying, curled up in a ball, unable to move and barely talk, couldn’t drink water, just grasping her legs and suffering with tears streaming down her face.
Luckily, when I called the dentist back and frantically explained the situation, they let us get an opioid. She took a minimal amount, and was able to function normally. She only used a few pills in total over the course of a couple days, but it prevented absolute heartbreaking agony.
So that’s great that it worked for you. But your case has no bearing on somebody in the other situations either, so you don’t need to bring it up as a gotcha.
That is well out of the norm and should be treated as such. Some people will need it, but that’s no reason to spew opioids on anyone who has a small procedure.
You don’t and your judgement of someone else’s pain is not relevant to this thread or respectful and is the exact line of thinking that leads to people’s pain not being taken seriously.
And if we take pain “seriously” and give opioids for what should be minimal pain, we are facilitating addiction. I’m not judging the pain, only the response of giving a prescription off the bat.
I mentioned this elsewhere, but I had wisdom teeth out recently, and took ibuprofen and nothing else (they did give me a prescription for a heavier-duty NSAID, but from past experience those are no fun). It was _fine_, there was some pain, but that’s par for the course.
Opiods seem to be treated as almost essential for dental surgery in the US, and as a rare escalation path elsewhere.
I'm glad this article is highlighting the environment that this happened in. The lack of hope is what is at the root of the issue for many. If you have no decent job prospects and multiple issues in your life, you won't care about what a drug will do to you as long as you get to forget those problems for a while. Pretty similar for alcohol too.
They blame the coal barrons for not leaving anything behind. They certainly had some problems, but many of those were handled a generation before the closures, especially for the union mines. The problem was more systemic than just coal barrons leaving nothing there. You had multiple entire industries essentially die off. Mines closed, steel mills closed, many factories closed (a lot of shoe, textile, and home goods). Part of that was consolidation from local and regional brands into national ones. Another large part of it was globalization and outsourcing manufacturing to cheaper markets. So what were these barrons expected to leave behind if there were no jobs to create? It seems to me the blame lies more with the CEOs of the national brands and the sectors that replaced manufacturing. We don't see any real tech presence in the smaller Appalachian cities (aside from some pork barrel defense firms in a couple). Instead, we have a vicious cycle of population concentration and all the problems that come with that.
I am more aghast at the pharma barons that have retained their wealth, as that was a quick cycle of unequal riches and ruin that looked nothing like the impact of coal upon society (as it was able to empower industrialization for a long duration). There was no long-duration benefit to OxyContin mass-marketing.
That the Sackler family remains at liberty is conclusive proof that the FDA was bought and owned on the question of opioids, and had no ability or intention of acting in the public good. Most other countries would have stopped this.
A similar theme pervades most of the checks and balances of the U.S. Constitution in general. These were brilliant controls in 1789 that have long since been disabled by an ocean of cash.
The biggest problem is/was the quest for greater corporate profits, which drives consolidation, cost-cutting, offshore outsourcing, reducing the power of the unions, product enshittification, etc.). When the mission of a company is to deliver value to its shareholders -- the mantra of capitalism -- this is the end result, and it's highly destructive. We saw it at the end of the 19th century, and we're seeing it again from the end of the 20thC until now.
While that is largely true, I don't see another scheme that would be unaffected. For example, a lot of what happened with consolidation was also due to efficiency and economy of scale, which would still be desirable even if profits weren't the main motive. The offshore and outsourcing has more to due with trade imbalance (not necessarily overall, but within specific sectors) and consumer preference (race to the bottom) than with profits. I think imbalance of where the profits end up is the bigger issue than profits themselves - the higher ups and the people with capital make sure they get a bigger slice of the pie while the average people/workers are left behind.
“It’s so easy to demonise Purdue and the Sacklers. I agree that what they did was terrible. I think a number of them should be in jail. But I’ve thought for some time that the issue behind it all is the structure of the system,” he said.
I really do get that sentiment, but IF the USA legal system had properly prosecuted Purdue execs from the get-go - there's a reasonable chance others would have been less inclined to also play the 'but what we're doing is technically not too illegal' card and try to run the same playbook.
The structure is doubtless a legal manifestation of Swiss cheese, but that doesn't mean the state can't react violently to a violent attack against its most vulnerable citizens.
Check out the book empire of pain. It goes back the beginning of the Sackler rise and covers how we go to where we are today.
The problem I have with your statement about the legal system is IMO Purdue and the Sacklers corrupted the justice department, legal system, and various Federal agencies. This was not some overnight thing. This took decades of works by multiple generation of the family. The system we have today is in large part thanks to the Sacklers.
Thanks for the recommendation - added to my burgeoning tbr list. I've seen some dramatised documentaries on the subject (I think it's pulled ahead of Theranos documentaries now), and I'm sure there's a lot more nuance than is covered in screen retellings.
Though Dopesick did make it fairly clear that federal agencies had been corrupted, as part of the original approval granting process. They didn't properly explore that angle, unfortunately.
I see this as analogous to the Dust Bowl, where the politicians and coastal elite ignored or dismissed the growing problem until it was too big to ignore.
The center of this country (outside of a few major urban/sub-urban areas) is hollow.
Between the loss of agriculture as a family job, loss of industrial jobs, and opioid use after decades of methamphetamine use, it's bleak.
And no one really cares. As a general rule, we're told, "just move to Chicago (St. Louis, Kansas City, wherever)". That's not a solution, or a possibility for a lot of folks.
> That's not a solution, or a possibility for a lot of folks.
Then we need to work to make it a solution and a possibility, because I don't know what the alternative is. I'm from Appalachia, though my former oil-town retains a meager amount of relevance via the nearby industrial dairy farm. The owner of the only grocery store retired and nobody was interested in taking over, so the storefront laid empty until the government gave tax breaks to a hardware chain to set up shop and stock a little corner in the back with groceries so that it wouldn't become a food desert. But the situation isn't sustainable; there's not enough jobs. The population is declining. Most everybody drives to neighboring towns to work. I got out and moved to a big city, and wild horses couldn't drag me back.
I love the idea of small towns; not everyone needs to live in a big city (and almost nobody should be living in a remote cabin in the woods either; what an isolating experience). But if they're not economically viable, I'm not going to pay people to live there just so that small towns can continue to exist as a concept. What I will pay people to do is move to a city where they can find opportunity, and fight for more housing so that it's more affordable to do so.
> But if they're not economically viable, I'm not going to pay people to live there just so that small towns can continue to exist as a concept.
these things are not written in stone, or the laws of physics. Layers of policy and taxation choices have led to this. Nothing says that the current system is stable, either.
Take this for what you will, but my parents (deceased) and I are immigrants to the US. I sympathize greatly--not exclusively--with the problems facing most of the non-coastal US but you're not doing any favors by not adding any nuance or thought.
I’m also an immigrant. Average Americans outside the coasts (and even many of the people on the coasts, like black people[1]) are not benefiting from immigration. Immigration is generating benefits for the top 10-15% in the form of profits, jobs in knowledge work industries, and cheaper products. It’s not a comment about individual immigrants, it’s a comment about economics and political economy.
From the article, it seems the issue isn't immigration per-say but a lack of social services (education, housing guarantees, family benefits, healthcare, childcare, vocational training programs, transit accessibility) amongst the poorer strata of Americans.
That is, we could minimize immigration to perhaps produce a constrained labor market (though that would induce negative population growth, which comes with a host of economic issues), or we could simply redirect capitol to turn unskilled workers into skilled workers.
IMO improving economic (and de-facto social) mobility is a much more sensible policy than inducing negative population growth. An added side benefit would be an overall increase in worker productivity and commensurate economic growth.
You can’t have an economy with only knowledge workers. (Unskilled isn’t a correct term since many of these jobs, like construction, are skilled work.) Your choices are to have an economy with a large class of foreign workers with little political leverage, or an economy with a smaller class of native born workers with more leverage.
Social services don’t fix the underlying economic problems. For example, you can invest in schools, but at the end of the day those kids would have been better off being raised in a two-person family where the parents have access to well-paying jobs that don’t require a college education, than being raised by a single parent receiving a welfare check. Social services can’t replace everything you get from a functioning community where people have meaningful work.
The Great Society programs caused social welfare spending to dramatically increase starting around the same time as the 1965 INS dramatically increased immigration. But during that time, the upward mobility of black Americans in deindustrializing cities (look at Baltimore, Philly, etc.) decreased from what was happening a generation before.
To a small extent you are correct, but a larger factor is automaton. It doesn't take that many people to grow food or extract resources anymore. The people that don't exist don't need grocery stores, bars, restaurants, or barbers either.
We would still be in this situation even without immigration or overseas trade.
That seems unlikely. Americans don't want to do these jobs. And this article suggests that, were wages to rise sufficiently to entice Americans, the economics would justify automation.
Besides, with the rate of progress in robotics, I doubt there will be much labor-intensive farm-work left to do in 10 years anyway.
I agree with your overall point, but not a great example: in NL we also import seasonal labour from Eastern European countries, for the exact same reason and with the exact same effect as you pointed out. Even when it's season all-year round (because we have greenhouses).
I didn’t say it’s true of all European countries. To my knowledge, France or Italy for example isn’t nearly as reliant on seasonal farm labor. The Netherlands has always been more in the neoliberal side of the line for Europe.
> And no one really cares. As a general rule, we're told, "just move to Chicago (St. Louis, Kansas City, wherever)". That's not a solution, or a possibility for a lot of folks.
The problem is this is completely untrue. One party had been talking about coal-mining industry ending and promoting job retraining for over a decade if not longer. Federal funds were administered to pre-empt this exact problem that was foreseen. That same party had frequently about the need for social programs to support this transition so people can still be productive. The problem is, this party never wins in Appalachia - all of their policies are ignored. Nobody takes the job training. Everyone locally votes against it and opposes those social support systems.
The problem isn't costal elites ignoring the issue, it's that no matter what one party does to help resolve the problem the other party says don't trust them do it on your own. Which isn't possible when entire industries aren't viable any more.
It's pretty similar to people desperately needing health care in the same regions and yet refusing to get it because it's been slandered by the party they vote for.
Fundamentally the issue is that one party has not supported policies to help this region for ages, but still gets voted for due to a few key touch button issues.
> The problem is, this party never wins in Appalachia - all of their policies are ignored. Nobody takes the job training. Everyone locally votes against it and opposes those social support systems.
What are you talking about? Appalachia was a core part of the FDR coalition. From 1932 until 2000, West Virginia voted Republican just three times: Reagan, Nixon, and Eisenhower (each just once, in landslide re-elections for those candidates).
West Virginia and similar places were the base that provided the majorities for Democrats’ social welfare programs of the 20th century. Who is more qualified to conclude that whatever crumbs they get from social welfare don’t compensate for the downsides of economic change from globalism and social change from immigration?
"just move to Chicago (St. Louis, Kansas City, wherever)"
When my wife and I drove to Kentucky--from NYC--for a road trip in the late 2000s, it was disappointing just how much more of the same we saw. Back then, it was strip malls. Walmarts.
A lot of the day-to-day Americana and culture we were hoping to see was simply fantasy or diluted, as most of the money--and therefore the culture--comes from large companies and interests.
This seems like the standard shift seen in all industrialized countries. Rural areas and small towns don't have the density to maintain economic viability. There just aren't enough labor-intensive jobs to keep small towns afloat.
I would imagine the American development pattern makes the economics even less favorable. Cars are very expensive and most (all?) small towns are designed exclusively for car-dependency. Infrastructure cost scales with sprawl too, so city costs to maintain infra are presumably high per-capita.
I'm not sure what the solution is. We could subsidize rural areas more (we already do quite significantly, but clearly the handouts aren't sufficient). But I think in the end we have to accept that times change, and certain lifestyles just aren't sustainable.
As a Scandinavian I find this an odd take on the situation. To me it seems like the US has a very, very, broken healthcare system that you’ve chosen to have by electing politicians who aren’t going to reform it into something reasonable.
My wife and I presently had twins, and we spent 7 days living in the hospital with a lot of help from nurses and so on, and it cost us $130. Which was me paying for 3 days of living there because the 3 days was the max you had to pay. Sure I pay 39% in taxes on the first $120k of my yearly income and then around 55% on anything above this (well except for a bunch of sort of loop holes to invest before taxes), but it’s basically still pretty nice to have that sort of healthcare system.
I’m bipolar type 2 and I have ADHS. Now in case you don’t know, this involved a lot of trial and error with a psychiatrist to find the best medication for me. During this I learned that many prescription medications which are “normal” in the US are illegal or at least only used in extremely severe cases here in Denmark, because of how dangerous the side effects are. This is due to heavy government regulation, because we don’t elect politicians the way you do. We don’t have a winners takes all system which tends to lead to conservative governments which are heavily influenced by the private sector. Hell, you can even see it in our own local “opioid crisis” which was caused by deregulation by right leaning government (though to be fair, Danish conservatives would probably be considered communists by US standards).
As I understand it, you Americans have the ability to both influence national and stateside policies. So that if your national government fails you, then you can still regulate your local laws. Which probably should have meant voting for politicians who would regulate your healthcare system in your states and ban medicine that is clearly a threat to public health. That you chose to not do this, and then blame your costal elites is just baffling to me.
But maybe I just don’t understand your country well enough?
As a fellow Dane, you must also know how close our public healthcare is to crumbling, how long wait times are for care, our record highest cancer rate in the world of any nation, and a policy of treating only acute conditions (no cancer screenings deemed "unnecessary" etc.)
I have been misdiagnosed a number of times and was finally treated in the US for a major condition the doctors missed here in Denmark.
We get a number of privileges for our very high tax: childcare is cheap, education is free, and births cost us virtually nothing but let's not try and overstate the value of our system to theirs. Ours too is broken, it's just a matter of degrees and where.
Our middle-class, in return, gets taxed to high heaven while our income disparity between rich and poor continues to widen.
I know someone in the US who is currently being treated for cancer. His chemo drugs have been hit by shortages and he has to beg his insurance company to approve of a different chemo drug for this life saving treatment.
While all systems have their issues, it cannot be undersold how absolutely captive American health is to the profit motive of private companies. If it does not leave room for profit in the US, we are told to die.
This is a good point but you really need to have a comparison when you say your healthcare is crumbling. Are you talking about specialized care?
I think healthcare in the US is beyond messed up. In my area which is a large city in the North East US it is very difficult to be able to get into ER because rooms are filled with people who are trying to get non-urgent care. These people have no money, no insurance and their only way to get care is to go to ER. System is rotten to the core.
I also did not get your last paragraph are you talking about the US or Denmark? I would be shocked to hear income inequality problem is worse in Denmark.
I'm talking about general and specialist care in the public system. Our private system is pretty good but you either need to pay insurance for it or, if the public wait-list extends beyond 6 months for surgical treatment, our public healthcare will pay for you to be referred to a private hospital.
The less said about our mental healthcare the better.
> I also did not get your last paragraph are you talking about the US or Denmark? I would be shocked to hear income inequality problem is worse in Denmark.
I was shocked too when I first heard it but live here long enough and it's very obvious. Income inequality has increased over the last thirty years with a Gini coefficient of 30 [1] in 2022.
That's what we get for letting Lars Løkke destroy our health system for over two decades. Remember that the US way was the explicit goal of Fogh's government. Venstre is sister parties with the Democrates after all. Our issues are just underscoring the dangers of privatization, new public management, and liberalism.
Yes, every reason why we don't have universal healthcare comes down to voting in politicians that are against it, but what outsiders and party hardliners fail to appreciate is where the resistance comes. When the Democrats controlled the presidency and both houses, we failed to push out any reasonable form of universal healthcare and that is due to several specific interests that have a hold on the Democrat party then and today.
I would love a Medicare for all, because that's the most cost-effective system we can possibly get short of having no system at all. It'd also increase job mobility--nobody tied to their jobs for "benefits"--and put a sane check the price of basic-level care.
However not all countries with public healthcare are drug-free--Portugal just manages, not solves, its problem despite 50 years of public health--and that's because the incentives to both sell and use these powerful painkillers don't merely go away with a public system. Medical doctors were also complicit; or the more responsible ones, yanked-away the prescription out of caution but unintentionally drove their patients to the black market.
I'll concede that a streamlined system would have helped alert the powers that be sooner, but I'm not convinced that the powers-that-be would have done anything concrete until it became a crisis.
Universal healthcare is a disaster in every country similar to the US (UK, Canada). The Scandinavian model is an exception, and would never work here given social factors such as population makeup and numbers.
I'll keep my reasonable tax rates and absolutely top notch health care I receive through my employer, thank you very much.
Yes, our country is a mess. I don't think that the states currently have the power to oppose and reverse the directives of the FDA. That will shortly come to a head with the abortion drugs.
Fun fact... many people know that Coca-Cola originally included cocaine as an ingredient, but fewer are aware that 7-Up was originally made with lithium.
"The product, originally named "Bib-Label Lithiated Lemon-Lime Soda", was launched two weeks before the Wall Street Crash of 1929. It contained lithium citrate, a mood-stabilizing drug, until 1948... Its name was later shortened to "7 Up Lithiated Lemon Soda" before being further shortened to just "7 Up" by 1936."
We are having a discussion about opiate addiction, and you have failed to explain why the US's broken healthcare system is an important contributor to that problem. I certainly don't see how your experience with childbirth is relevant -- or bipolar disorder or ADHD.
Do you imagine for example that the non-broken healthcare systems of the world are what is preventing opiate addiction there from becoming as severe as it is in the US?
I mean, if medical care were expensive and difficult to access, you’d certainly expect more use of opioids, because they’re a cheap solution to chronic pain relative to more measured approaches. And it certainly does seem that the US opioid crisis was worst in extremely poor areas with limited medical care available.
Sure, but opioids are also a cheap solution to loneliness and to a chronic feeling of alienation and of "not belonging" caused by living in a society optimized for individual freedom and economic efficiency. I have yet to see reasons in this comment section to believe that access to healthcare specifically is the human need whose lack is driving most of the cases addiction in the US.
Most young adults have no pressing need for healthcare except possibly birth-control pills for the young women (since those require a prescription in the US) and if the millions of young adults in the US who have become addicts during this crisis had unmet health-care needs at a significantly higher rate than their counterparts who did not become addicts, addiction researchers would almost certainly have noticed by now, and I probably would've heard about it from journalists who cover the issue.
> . I have yet to see reasons in this comment section to believe that access to healthcare specifically is the human need whose lack is driving most of the cases addiction in the US.
Oh, yeah, I’m not saying that healthcare is the only factor or even the most important factor, just that it is relevant (and it does seem to be where the US opioid crisis _started_; oxycodone and similar were made available in ludicrous quantities as a substitute for actual medical care).
Granted, it is probably much harder to put the genie back in the bottle now it’s out there.
Addicted youth do have more unmet healthcare needs than youth without addiction.
Anecdotally: cardiologist, inpatient rehab, dental work, maintenance medication, labs/blood work, mental health meds/counseling, ER visits and ambulance rides, and more.
These are things that non-addict young people do not usually need unless they’re big athletes or suffer from serious trauma.
Having access to these things also improves the likelihood of a full recovery from addiction (IMO).
Healthcare has to be fixed at the state and national level. There's not much that can be done at a lower level. There are a lot of rules around what states can do to regulate interstate commerce. There's also the situation we're in with pot, where it's legal in many state, but still illegal at the federal level.
The other big issue, is like a lot of things in the US, if someone has money healthcare is great. It's probably the best in the world. Those who get elected have money and don't personally feel the healthcare issue. Heck, politicians at the federal level have their own healthcare system making them even further removed.
One of the biggest voting blocks is seniors, and they have already have access to what many say could be a step towards universal healthcare if opened to everyone. So they are also not inclined to think about it too much.
>But maybe I just don’t understand your country well enough?
You really don't. You live in a country that is either 11 million or 6 million people with fully enforceable border controls and immigration controls. You can control who comes into you country. You can control the goods that come into your country. Your population rivals one of the larger metropolitan areas of the USA.
Problems don't scale linearly. At 6 million people you can afford to fund pensions through nothing but an oil extracting operation out of your country. 7.7% Unemployment at 11 million people is, believe it or not, much less debilitating than 4% unemployment at 332 million people. There are more unemployed persons than the entire population of Sweden. And these populations cluster, and they depress local economies, and they drain their local workforce and social services. Then crime happens, and populations move, and housing prices fluctuate, and then this spreads. But here's the trick: You only need so much space to live. So much money to eat. So much space to grow food. You only have so many hours in the day you can work. Any doctor can see 20 patients a day, spending 30 minutes on each consultation. You don't need that many doctors to meet that demand at 6 million people. You need a lot more doctors to meet that demand at 332 million. Costs and living standards are relatively fixed beyond a tolerable level of comfort. Scandinavian countries achieved this comfort. But this comfort doesn't scale. Because problems don't scale linearly.
Back to borders and immigration: You control your borders. You can say that drugs don't enter your country. And they won't (at scale, at least). In the USA that's not enforceable because the country is so large. Illinois can say that they ban guns. But that doesn't stop them from going to Indiana and getting them. Or Kentucky. Or Missouri. Your local change can only accomplish so much when you are against the tide of your neighbors. You can say that you want to control your borders. But your neighbors disagree. So they go around you controls and infiltrate your economy anyway. And you don't know how bad it really is. Because statistics are an approximation of a segment of a population that doesn't want to be tracked. But these people still get sick. And some costs are fixed. So your publicly funded hospitals still need money to cover their costs by people who will flee and not pay. So you privatize and offset the burden on the patient. Because people can pay for themselves to get a blood test. You relieve your burden on the system, for the moment. But now companies charge more because they also know that certain costs are fixed and people are willing to tolerate more costs for a relatively inexpensive service. And of course, they optimize. Because there's nothing stopping them. Since you can't tell them not to do something when you can't solve the problem yourself. And here we are.
> You live in a country that is either 11 million or 6 million people with fully enforceable border controls and immigration controls.
It's the opposite, actually. Denmark is a part of Shengen zone, which means it has no border controls at all. When you enter neighboring country, you'll only know this because a sign on the road will tell you so. Similarly, migrants are free to roam entire Shengen zone and get in and out of Denmark as they please (unless emergency measures are introduced to stop them).
> You control your borders. You can say that drugs don't enter your country.
I’m not sure where you got the idea that we have right border control, we basically have no border control. Sometimes we have temporary border controls, but typically your only checked if you’re “suspicious” (which means non-Scandinavian looking, in a weird car or transporting goods”, or very unlucky. It’s been like this since the EU opened its internal borders. I’m usually not even checked in border control when I fly within Europe.
As far as keeping illegal drugs out, well, I imagine we’re like every country considering we can’t even keep drugs out of our prisons.
The US is a massive, new, mostly empty frontier nation. It's ridiculous to expect the same level of social support as one has in relatively small, old, well-developed European nations.
The GDP difference seems more than enough to counter it, maybe, but socially, geographically, and historically, the US is a relatively libertarian project where "high taxes and free healthcare" are anathema.
> the US is a relatively libertarian project where "high taxes and free healthcare" are anathema.
Isn't that just the last 4 decades though? Before that, US had very high taxes and was not against spending on social programs. That all changed with Reagan and after, but it's not some set of core American values, but rather just the current, and relatively recent, dogma.
I want to help this train of thought along because this is interesting to me and I'd love to get a discussion going.
> Back to borders and immigration: You control your borders. You can say that drugs don't enter your country. And they won't (at scale, at least). In the USA that's not enforceable because the country is so large. Illinois can say that they ban guns. But that doesn't stop them from going to Indiana and getting them. Or Kentucky. Or Missouri.
Short of draconian measures like in China (also a very large country), which nobody wants.
> Your local change can only accomplish so much when you are against the tide of your neighbors. You can say that you want to control your borders. But your neighbors disagree. So they go around you controls and infiltrate your economy anyway. And you don't know how bad it really is. Because statistics are an approximation of a segment of a population that doesn't want to be tracked. But these people still get sick. And some costs are fixed. So your publicly funded hospitals still need money to cover their costs by people who will flee and not pay. So you privatize and offset the burden on the patient. Because people can pay for themselves to get a blood test. You relieve your burden on the system, for the moment. But now companies charge more because they also know that certain costs are fixed and people are willing to tolerate more costs for a relatively inexpensive service. And of course, they optimize. Because there's nothing stopping them. Since you can't tell them not to do something when you can't solve the problem yourself. And here we are.
This is what I want to dig into. The heart of this argument is that publicly funded hospitals are forced to cover for those who neither contributing to the system nor are paying out-of-pocket for it.
> So your publicly funded hospitals still need money to cover their costs by people who will flee and not pay. So you privatize and offset the burden on the patient.
Are you certain the EMTALA is really the cause of the problems we see today? I agree that it made it worse, but the cost of medical care was ballooning before the 1980s. I'm not sure what it was so I'd love to hear input from you or others.
Still, you do bring up a good point: Given that you have individuals that can't contribute to the system even if they would otherwise and given that it will also balloon costs, how do we solve this?
Perhaps its a taxation issue.
I doubt this will ever get traction but I'd love to see a compromise where we replace the blanket constitutional right where "you're a citizen if you're born here" with something different but equivalent at the amendment level.
Chasing down and returning migrants--this just funds the very problematic human traffickers--is a bandaid solution; it's inefficient; and it doesn't solve the needs of both Americans as well as our neighbors.
Instead, why not just ID them on the spot--state level with RealID, to make it palatable--make them pay a fine that is effectively the cost of a tax to fund the public infrastructure; and make such an ID either the requirement of using the triage service.
Or if they're undocumented, just treat them once and give them a choice after triage: Deportation or ID.
Carelessly thought out, I think that this sets up a two-tier residency system ripe for abuse: If said "temp" residents had children, what's the status of their children, for example.
The ugly dirty truth is that illegal immigrants form the underclass of the USA that allow for the relative cheap formation of small (otherwise noncompetitive) businesses when it comes to manual labor. Restaurants, cleaning, construction, automotive, farming, etc. It's a complete race to the bottom. But...if you can't stop people crossing the border...why not stop the people hiring them? Put them in jail?
But that's an incredibly unpopular solution. Every politician goes around orally fellating the small business ethos because it feeds into the meritocratic delirium. So essentially, Americans will backhandedly wail about illegal immigration while eating cheap fast food and hiring them to paint their walls.
There have been attempts to implement an ID system, especially when it comes to voting locally. But it was deemed racist. Because it meant only citizens who had the ID could vote. And some citizens didn't have IDs. And a portion of those people were poor minorities. And they didn't want to get them because it infringed on some rights. Or something. So America has this contrived system of registering to vote where people get tricked into also registering their political affiliation which is often used by politicians to sling mud at other politicians and political statisticians to pull slightly more accurate numbers out of their asses.
In some locales you straight up have to register with your affiliation to be able to vote. There's a significant segment of illegal immigrants who may or may not vote to support local political constituents that have their interests at heart, and a political party that appeals to those illegal voters. This political party uses this voter demographic for their benefit, because these local political constituents that are voted in have a voice in who the party as a whole can nominate for higher political parties. Since part of the political establishment is based on elections are based on representatives who then choose other representatives. And so the cycle continues.
Also, since USA is a Union of States, it's weird that no single state managed to set up a state-wide socialized health-care. Is there some reason why it hadn't happened?
Cities see this as much as rural areas, especially cities like San Francisco. It's absurd to frame this as a "coastal elite" vs rural problem.
Politically, it's nearly the opposite, where conservatives use the outcome of the epidemic as evidence that cities are dangerous hellholes, and actively fight solutions to minimize harm (monitored usage sites, needle exchanges, etc).
In terms of generally ignoring solutions to the problem, politicians as a whole seem to be the problem, rather than it being a city vs rural thing. Most likely liberals don't care about rural areas because they aren't winning those voters, and conservatives need the epidemic to harm cities so they can use it as fodder, so they won't help the rural areas, especially since they're going to win those areas anyway.
Also, it's kind of wild to blame the dust bowl on politicians and the coastal elite when it was primarily farming practices to blame. Why are coastal cities to blame for ignoring a problem that doesn't directly affect them when the affected areas are actively causing the problem, and not solving their problem locally? In the end it was the politicians who solved that problem.
Every problem has a different solution, but our inability to mobilize and solve the problem before it becomes a crisis seems to share a common theme.
Namely that our representatives and government officials have chosen to ignore the problem; I feel journalists have played a large part in exposing the problem and even then it's been an uphill battle.
> Or do people just not know how to solve it? What would you propose as a solution?
The political will to treat our fentanyl and opioid addicts is sort of there but the funding is not. Right now governments have been battling the Sacklers in court and it seems our collective state and federal government isn't really winning.
I'll go back to the Dust Bowl: My fantasy is to bus all of the addicts to the people who need to see this non-stop. No violence.
Bring them to the state/Federal officials where they work of course, but I'd love to see them bused to near the Sacklers' home; and to their retreats of choice. Non-stop. Until there's nowhere for them to run except out of the country.
And the opioid-wealthy become pariah until they clean-up their own mess.
As an immigrant who never learned how to be politically active and am a bit old and crusty now, I wouldn't even know where to start; but it's a fun fantasy at least.
The flip side of this and something that is barely ever talked about, is that for patients with severe chronic pain, access to medicine for relief has become nearly impossible. Often even if you get a legitimate prescription pharmacies will not fill it due to fear/quotas being enforced.
This fear was so pervasive they had my terminally ill father on stupidly high doses of methadone which nearly killed him, simply because they were too afraid of prescribing more traditional opioids.
I had surgery and the pharmacy didn't want to fill my real legit oxycodone prescription until after they'd talked to someone at the OR. We overcompensating and went too far the other way.
A while back I was having wisdom teeth removed, and fell down a bit of a rabbithole looking for coherent guidance on what you can do afterwards (this ranged from the HSE and NHS websites saying “don’t drink alcohol or smoke for a couple of days” to dentist websites giving dire warnings about drinking coffee within the first week - the answer seems to be “no-one really knows”).
One thing that was jarring, though, was that American sites tended to talk about strong opioids as aftercare as a matter of course; European ones never mentioned them. I got by on ibuprofen, myself.
It ends with an effective, non-addictive alternative to opioids for pain management + more funding and care for rehab (including the drugs to wean opioid users off them, like methadone) to current addicts. [1] explains why the first part is difficult. The second part is difficult because many opioid addicts are already in marginalized areas or groups (ex. rural Appalachia) that don't get much of any support.
You're missing one major piece to make it end - hope. These marginalized places need decent jobs so people have hope for the future. Otherwise we'll have the same problems with different substances, including alcohol.
Doubly marginalized because if you point out they are marginalized some joker will come in and claim they are an overclass and don’t deserve any sympathy.
Methadone is far more habit forming and difficult to quit than any other opioid out there. It has a dose-independent severe withdrawal that can last for months compared to “traditional” opioids that last maybe a week or two at most. If you are on it for any length of time it’s extremely improbable you are getting off of it, and it comes with many of the same dangers as traditional opioids do.
In the USA if your problem can’t be solved in a way that produces a profit, you must solve it yourself or live with the consequences.
Our society is too heterogenous for us to make public benefit a goal. Every type of benefit is perceived as a zero-sum game.
Add in the fact that Americans tend to vote against their self-interest(1) in order to conform to the ideology with which they identify, and it’s turtles all the way down.
(1)This is more easily recognized when viewing the behavior of some other group, but it’s identifiable among all groups.
In Australia, I had septoplasty surgery for my deviated septum and was prescribed 3 different pain meds: oxycodone, tramadol, and something else I don't remember for about 2 weeks (with an invitation to call back if I needed more).
While I feel blessed my healing went well, I was only in pain that might've warranted more than a NSAID for about a day. With nothing to do as I was on leave from work, I enjoyed the bliss of the opioid high, but thankfully did not became an addict.
lets not forget how the US government first forced doctors to give out more and stronger pain medications by
1)issuing edicts that “pain is the fifth vital sign” (i.e. equivalent to pulse, bp, temp, respiratory rate), AND
2) tying reimbursement to “patient satisfaction”
Both ideas could have helped improve healthcare, but without safeguards, they became a way to empower drug addicts to demand strong pain meds, and empowered pharmaceutical companies to supply them - a great example of what Thomas Sowell would call “second order effects” that are almost never considered when enacting new government policies
I'd wager that Europe and most of the world was slower--thankfully--in adopting a new painkiller like Oxycontin and dodged a bullet, by seeing what the US was already facing.
We start with over-prescription of opioids. Pharma companies make money selling them. Doctors may even make money in kickbacks (a practice that should be illegal).
The disastrous War on Drugs that made opioids cheaper and easier to obtain (eg black tar heroin) than cannabis.
Those who became addicts from a legal prescription turn to illegal products. Illegal pills are expensive. Street heroin is much cheaper.
To feed this habit, it eventually leads to crime. And what do we do with petty criminals including those charged with drug posession? Whey we incarcerate them of course. That's expensive and ineffective but prisons create jobs. Some private prisons have a direct profit motive to fill their prisons as they're paid by the state per-inmate.
Oh and convict labor is yet another profit opportunity.
A lot of people self-medicate because of unresolved trauma, just as a coping mechanism or whatever. If you're an average worker this might be just going to a bar and having a few drinks. But that's relatively expensive. Poorer folks would once sit out on the streets or in a park, often in a group, and do the exact same thing except it would be a bottle in a brown paper bag. If you're homeless, you're even more likely to self-medicate.
Yet police harass the second groupo. We criminalize all sorts of things, including feeding people [1].
Fentanyl makes all of this worse because it's so cheap to produce that it laces other drugs to give them a kick. The amount can wildly vary so you may accidentally get a lethal dose.
We have a societal failure by robbing people of basic hope and dignity and then profiting off incarcerating them.
Just FYI, kickbacks to doctors are illegal. Currently the most pharma can do is send reps to "educate" doctors and include a lunch under a certain price point.
They downvoted him because they hated hearing the truth.
The Sackler family was shielded from any consequence solely because they have money and power.
People will sometimes ask me why I sound so pro-China at times. It's not that I'm pro-China, its that I'm jealous of China. That if this happened in China, the Sacklers would have been executed by the state for the substantial harm they caused to society to make a buck and the message sent to others that they will not get away with this anti-social behavior.
In China, the Sacklers would have been a SOE (State-Owned Enterprise). The Chinese gov is no better than the Sacklers, but the big difference is they have to consider the social threat to their authority that the consequences of their actions would create.
I lived in China for years; it's the ultimate authoritarian state--the amount of control, and the degree to which it has been perfected, is astounding--far beyond what Russia or any other authoritarian gov has.
I agree with the conclusion of your argument. Everyone does deserve to die with dignity. That said, now doesn’t have to be the “right” time for you.
You should consider talking to someone with experience with these feelings. You can call 988 and talk through the logic. There are lots of people who felt the way you’re describing and came to conclude a different path was actually better in the meantime.
Right now it is likely the best its been for the most people ever. And not by a small way. And yes, for so many its also horrible right now. Made more depressing cause we see so much via the internet which tends to focus on the negative and we see this misery in 1920px 24/7.... its horrible.
I'm not the best to talk about these things...so would suggest talking to a professional if your this down, but for what its worth I do know there is a great world out there. I feel what you talk about sometimes and realise people need to shut of the global noise and do what you can to make your local patch a little better. The worlds always a mess, it always will be, and there's nothing you or I can do at that scale. But you can help out at a homeless shelter, or an old folk home etc and make a real different for many people. That and sadly, ignorance is bliss, get outta the depressing news cycle and limit yourself there a little to spend more time with family and/or friends if you can.
I truly hope things can brighten a little for you as there is also so much great around us!
However, you must realize that if you were living in 1924 instead of 2024, the outlook for humanity would be far more bleak. Penicillin wouldn't be invented for another four years, so bacteriological infections were lethal. Measles, mumps, or rubella had likely claimed the lives of your siblings or neighbors. And your life would be bracketed by the world paroxysm of war that you had just endured, and the paroxysm that was to come.
Compared to that life, we are free from disease, the food supply is more vast and diverse, and the technology is simply stunning.
But, in a particularly human way, we dig for misery and we are very good at finding it.
I don't know what to tell you, except maybe put the shovel down for a little while, if you can.
Drugs aren’t a solution, they’re just treating the symptom not the cause. It might help for a short while, but all you’re doing is delaying having to deal with your shit; it also gets harder the longer you leave it.
Been there, got all the shirts, there’s no shortcut to getting out of it.
Drugs are great. You are entitled to your opinion, and so am I. There's nothing morally wrong with not wanting to participate in a society based on suffering and exploitation of poor people in far away places.
Hello, I suspect your first comment is flagged because of this second one. I do not agree with the flagging decision, you are definitely entitled to your opinion.
My opinion is that the world is not nearly as messed up as the news and the social media outrage cycle will lead you to believe. Humans have always inflicted suffering on others knowingly or unknowingly and the world has always been messed up to some degree.
Addiction replaces this existential pain with other problems, be it addiction to chemical substances, gambling or even internet addiction (which is likely the opiate of choice for a lot of us here including me).
IAC I hope you do take a break from news and social media at least and feel better. Best wishes.
Opioids are incredibly addictive. At one point something like 25% of the male population of China 'regularly consumed' opium, i.e. they were addicted to it, and China has always been a country with at least a certain sense of order.
Opium is also special, even among other dangerous drugs. It takes over your brain's reward system and makes things you previously regarded as pleasurable as uninteresting compared to opium. It permanently destroys people.
Making it common as beer is a terrible idea. Rather I think it's likely that the opium sellers and everyone associated with the distribution and marketing of opioids need to be dealt with quite brutally.
Don't think of things like carfentanil as a drugs. Think of them as chemical weapons.
Honestly I think much of the harm has been from overreaction to the first wave. People who could have been stable on a dose of OxyContin or some other moderate strength opioid, and instead are getting whatever on the street.
When people take prescription opioids, the dose is right there on the pill. People are going to take them anyway, wouldn't you prefer they know what they are taking? That will never happen in the US because we consider it a moral failing, but it's obvious that taking a drug with a dosage stamped on it is better than taking something mixed in a basement somewhere.
Let's take the moral failure out of it. Imagine if Tylenol was random dosages that ranged from fake to a dosage that would induce total liver failure. That would be absurd.
Opioids are almost certainly worse than antidepressants, and I don't see why you appear to believe that they are alternatives to each other.
Any entity participating in an endeavour which as part of its activities distributes, markets or which through propaganda or political action defends the use of opioids must be destroyed, because opioids are a chemical weapon.
They aren't 'illegal drugs'. They're a means to destroy somebody, and that is all they are.
I am not greatly familiar with the dangers of antidepressants. I do know that abruptly lowering the dose for some can cause thoughts of suicide. Some have side effects of sexual dysfunction. Some cause weight gain. That's about the limit of my knowledge.
What I know about the opioid class of drugs is that tolerance builds so the dosages commonly increase, too much stops the heart, and trying to stop causes violent withdrawal.
To me, opioids sound far more dangerous, enough to get its very own disorder.
At the risk of pedantry, opioids don't work directly on heart function.
Too much opioids in the system cause respiratory depression. That can go on to become respiratory arrest, which can then cause cardiac arrest.
Same end result, but the point is, opioid overdose is primarily a respiratory concern. In my county some EMS do not even carry Narcan (which is a debate in itself) but are directed to focus on positive pressure ventilation and transport to ER or, if carried, to gently titrate Narcan such that the person becomes gradually more alert at the ER and may be more open to addiction help, rather than the "heroic dose" that you get with IN (intra-nasal) Narcan.
I think a two-prong approach is necessary and I worry about the perverse incentive of healthcare specialists or medication experts wanting to maintain a pool of addicts long-term.
I had an informal debate with a former roommate--and to help him along the above was the one counterargument I thought of and I still don't have a good solution. Opiods are in a class of their own.
It doesn’t stop OD, but it reduces OD because it eliminates one type of very common OD: people taking seemingly safe quantities of drugs that have been laced with fentanyl.
Statistics are fuzzy on this, because you can’t always positively determine intent, to separate accidental overdose from suicide.
The number of overdose deaths are spiking, driven by fentanyl. That is 100% fact based.
Now you have to make a qualitative judgement: I think most ODs are accidental when this is studied. Did a whole shitload of drug users just become unusually suicidal? I would say it’s safer to assume “no” unless you see evidence to the contrary.
If you have good opioids in hand then there's no need to buy opioids of uncertain strength from dubious sources. Thus your dosage is more controllable.
If your supply is reliable then there is no seesaw of deprivation when you're out and overindulgence when you're flush.
For further data, apply the same logic that keeps people from oding on alchohol.
I think clinics with pills are the best compromise here. It would be insane to have otc access to opioids. It's not like addicts live normal lives and OD'ing is the only danger.
Is that the metric we care about? Wouldn't "amount of people dying of opiods" and "amount of people having their lives ruined by opiods" be better ones?
Th way I see it, alcohol issues wouldn't be reduced if you made it illegal and less people drank it, but now people are drinking unregulated moonshine that makes them blind or kills them because it contains methanol and isopropanol.
The counter to this boomer MD complaining about opioids, is that this crap is making getting legitimate painkilling for pain damn near impossible. Now, unless your injury is obviously painful, you're just drug seeking, etc etc.
But again, it's not about solving pain or helping people. It's all about the puritanical abstention of all substances.
Oxycontin was misclassified due to fraudulent reportings of the drug's capabilities and marketing campaign. However that should have never affected people getting legit pain care, but it definitely did.
Indeed. It’s created a system where everyone’s scared. So those who need it legitimately often cannot get it. Which honestly is a false sense of security at this point as it’s easier to get these drugs on the street rather than legitimately through a doctor and that’s what most now do. If anything, the abrupt disappearance of legitimate pharmacy grade drugs made way for the current problem Fentnyl. Taking away and restricting OxyContin literally made the issue worse. Almost no one can get their hands on pharmaceutics opioids and yet the overdose rate has skyrocketed! People just don’t learn… You take something away and people only tend to want it more. Prohibition simply does not work and we have years of experience and history to show this time and time again and yet not a single thing has changed. Never see any new approaches or ideas to fix this issue because it goes far deeper than drugs themselves. People want to self medicate because they suffer, but we haven’t discussed why so many suffered and what we could do about it. Probably because the answer to that question isn’t going to be easy and hard work will be involved.
Don't forget pharmacy chains use a mathematic naive formula to stop selling opioids. As seen in HN a few months ago, if one kind HNer can add the link here.
That is what happens when the government hits them with nebulous liability for political points.
Government leaders do not want to clearly define the rules, but still want to pin the problem on others. If the government makes the rules clear, and the policies result in failure, then they get blamed.
If the government outsources the policing, then the government leaders can point fingers and satisfy public outrage, at the expense of the affected public which is not politically powerful enough to do anything about it.
Do you have any evidence to show the blame lies somewhere in the middle?
As far as I can tell, a retail pharmacy’s role is to dispense medication per a prescription, while avoiding errors caused by mixing medicines and advising people how to take medicine.
A retail pharmacy’s role is not to be the de facto front line workers for the DEA. So when our government collects fines from businesses for not policing their customers, expect the business to start discriminating against the customers, due to the lack of liability shield the government has.
An even simpler way to put it is, why would a business that earns money selling things want to sell less of those things (legitimate prescriptions)? The answer has to be the risk of selling is too high.
I cannot read the article. What is the pharmacy’s role? OxyContin requires a prescription, so did the pharmacy sell
without prescriptions?
Bottom line is, do you want pharmacies to be making non medical judgment calls on which prescriptions to fill and not fill? If so, then don’t complain when they exercise judgment.
I, for one, would rather not deputize everyone I interact with.
Prescription drugs are dispensed by a pharmacist for a reason. In the US, they are legally required to report any unusually large, frequent or suspicious orders to the government. Many pharmacies were found to have neglected that responsibility so they could sell more drugs.
Believe it or not, this concept of having strong pain killers available to the public is somewhat American-centric. Much of Europe does not consider the need for strong pain killers available in society, and pain tolerance is quite different in, for example Germany or the Netherlands, where it has been nearly impossible to get anything strong for pain for many decades.
While it’s definitely more difficult to have more pain, it also guides your recovery much better. You are much more aware of what you should or shouldn’t be doing while you rehabilitate, instead of numbing everything.
Unless it’s absolutely chronic pain, I think we’ve definitely over prescribed even in Europe. (Source: german)
I think your argument is only partly true. In Europe doctors prescribe a lot of ibuprofen, because opiates are considered "dangerous". However, ibuprofen is a really nasty medication causing kidney and stomach damage in many patients. I think especially for short term treatment, sometimes opiates would be better for public health. Also different medications treat different pain best, so choice shouldn't be limited by reluctance over false risk assessments.
But I agree, being completely pain free shouldn't be an expectation unless you are terminally ill. Much less for acute or injury related pain.
On a side note, in hospitals they probably wouldn't need as much pain medication, if they invested in better mattresses, lighting and food.
I guess the central point is that us very hard to distinguish between genuine and fraudulent use cases; in absence of infallible diagnostics, doctors can choose to move the know to "stricter" (decreasing fraudulent use, but making genuine use much harder) or "looser" (viceversa). I see a similar problem with mental diseases, where the common pattern nowadays is 1) get convinced that you are neurodivergent 2) iterate n doctors until you find the diagnosis you like.
"Oxycontin was misclassified due to fraudulent reportings of the drug's capabilities and marketing campaign. However that should have never affected people getting legit pain care, but it definitely did."
What does legit pain care look like? Does it include the prescription of narcotics to outpatients on an ongoing basis, or for more than a couple days? While the safety of oxycontin was misrepresented, I assume there are still some problems with how other narcotics are administered to outpatients.
Perhaps that was the dosing or your siblings biology. Hydrocodone is also a narcotic that is potentially habit forming. The addictive potential of oxycodone is supposed to be very similar or only slightly higher than that of hydrocodone.
I'd say it probably is/would have been very difficult to stop, but the dose was low and consistent. My fear is people like that who get cut off, then resort to illegal drugs.
I realize this begs the question of is "chronic pain" basically just an addiction? I'm not qualified to answer that though.
Ideally they shouldn't be cut off. I would think we should look into a different prescription and payment paradigm where the meds required for weaning them off (based on the protocols for how long they were on them and what dose) should be part of the initial prescription. That way if you lose coverage or something you can't just be cold turkey.
I also wonder how many people, including physicians, really understand the transition required. I had an elderly friend who went on some sort of narcotic after a surgery. They were told after the fact that since they were on it for a month, it would take them a year to wean them off. I don't have the dosing or med name, but that seemed insane to me. It was ultimately a contributing factor in their death due to some side effects and other complications.
What I'm saying is, if it wasn't oxy, it would have been vicodin or some other narcotic. The problem is how they are prescribed and the social environment. Sure oxy misrepresented safety which lead to some increase in outpatient prescription, but this is still a major source of the problem. Oxy is just the scapegoat for much larger systemic issue since they got caught misrepresenting safety. Nobody has any actual solution to this problem so far.
I don’t think it’s puritanical at all as narcotics for painkillers are dangerous.
Imagine if handguns were really good at treating pain, but had like a 30% chance of killing the patient. Would it be puritanical to not prescribe handguns to everyone with pain?
And if patients who thought they would not ruin their lives were upset about not being able to get handguns and complained about engaging in “handgun seeking behavior?”
Because that’s the deal here. Prescription painkillers are effective and easy, but are extremely dangerous. Pain protocols now feature OTC stuff even though they result in more pain in patients because they are equally effective but have no chance of death or life ruining addiction.
OxyContin should have been used for legit pain care.
>Pain protocols now feature OTC stuff even though they result in more pain in patients because they are equally effective but have no chance of death or life ruining addiction.
If they were "as effective" they would not result in more pain.
Additionally, pain ruins more lives than opioids and has been doing so for thousands of years. Ever tried to hold a job when you're in agony and have only slept a few hours that week?
People with untreated or untreatable pain tend to just kill themselves. That is NOT a better outcome than addiction.
At present removing pain from people requires highly addictive substances that I consider to be chemical weapons or tools for destroying a person. Without a breakthrough-- some kind of non-opioid non-brain affecting painkiller, there's no way to achieve pain reduction without destroying the person.
It might be puritanical, but puritanism worked. A society with opioids doesn't.
These retired agents didn't see the drug war as a war on "bad guys," but as an effort to stop the destruction drugs wrought in people's lives. After all their work, their own government undermined their efforts.
My own doctor was taken in by Big Pharma's sales pitch and wound up going to prison for over-prescribing their pills. https://en.wikipedia.org/wiki/William_Hurwitz. Though to hear Big Pharma tell it, there was no such thing as over-prescribing.
If you want to get an idea of how out-of-hand the prescription frenzy got, take a look at John Temple's book American Pain, which describes the pill mills in South Florida. Towns in Appalachia used to send charter buses to these pharmacies. After a 12-20 hour bus ride, each passenger would pick up hundreds or thousands of pills, then ride home to sell them in their small country towns.
Some of the pill mills, which were fully licensed by the state of Florida, were cash-only and would haul garbage bags full of money to the bank each day at closing. For a summary of Temple's book, see https://adiamond.me/2020/01/american-pain-by-john-temple/