Recently I finished a book about the opioid crisis in the US: Dreamland by Sam Quinones. I found it pretty much unputdownable, and while it’s certainly essential reading for anyone interested in its subject matter, I also found that it provoked thoughts on larger matters, on which I have blogged recently. I’m going to try to give a brief account of those thoughts here.
First, an overview of the book. The problems with opiates started back in the 80’s, when a movement in medicine set out to turn back what was thought an irrational prejudice against prescribing painkillers. Before this, doctors had been taught that patients could easily become addicted to these drugs, and were accordingly quite reluctant to give them out. In the course of the 90’s, however, this reluctance was overcome, thanks not only to the genuine desire of many doctors to help people in pain, but also to a certain laziness in reading the research (more on this below) and funding from drug companies. The result was that doctors came to believe that the addiction risk was not so great as had previously been thought, and began to prescribe opiates on a considerable scale. Unfortunately, the pills actually were quite addictive. Worse yet, they turned out to be an ideal gateway to heroin – OxyContin, the prescription drug with the biggest role in this story, “contained a large whack of a drug virtually identical to heroin.”
Soon, thanks both to honest doctors and to those who ran “pill mills,” dolling out pain medication for a fee to anyone who asked for it, parts of America were awash in prescription pills, and thus in people addicted to painkillers (Quinones tells of how pain pills were so plentiful in Portsmouth Ohio that they actually became a currency with which anything could be bought). Enter the Mexicans. Families from a single town in Mexico called Xalisco began to develop novel heroin-delivery networks across America that brought small amounts of the drug virtually to customers’ doors in the manner of a pizza-delivery service. Eschewing violence, these new dealers avoided major cities where markets in illegal drugs were already controlled by gangs (they also avoided black people, for their prejudices had caused them to believe black people violent). Instead, they set out to develop new markets across the country in places where heroin had scarcely been seen, paying particular attention to those already caught up in the opioid crisis.
The result was an epidemic of addiction in places that had never seen such a thing, one that hit not only poor people in cities, but also rich – and largely white – people in rural settings. Quinones has many sad stories to tell, of the children of lawyers or police officers getting hooked and dying, of college students who can’t kick the habit, of people stealing from their children or even from their dying parents to maintain their addiction. But the epidemic is not only remarkable in claiming victims from such a wide variety of backgrounds, but also in its sheer scale: “the number of Ohioans dead from drug overdoses between 2003 and 2008 was 50 percent higher than the number of U.S. soldiers who died in the entire Iraq War. Three times as many people died of prescription pill overdoses between 1999 and 2008 as died in the eight peak years of the crack cocaine epidemic.”
This, then, is the shape of the story Quinones has to tell. There is a lot to think about here, but I found myself returning to one thought in particular: its connection with Patrick Deneen’s book, Why Liberalism Failed, which I wrote about a last month. In that post, I discussed the peculiar conception of freedom that defines what Deneen calls ‘liberalism,’ and this included (and implied) a notion of mastery in modern science, a mastery of the natural world. In that post, I reflected a bit on how this striving for mastery played itself out in environmental concerns (inter alia), but the very same concern with mastery seems to me to lie at the heart of the opioid crisis.
For consider: the decision in medical circles to start taking a different approach to opiates is clearly a decisive moment in the whole story. (At one point, we here of a doctor who suddenly found himself confronted by “what was unthinkable a few years before: rural, white heroin junkies. ‘I’ve yet to find one who didn’t start with OxyContin,’ he said. ‘They wouldn’t be selling this quantity of heroin on the street right now if they hadn’t made these decisions in the boardroom.’”) But what was the motive force behind that decision? It might seem tempting to just hang the whole thing on the greed of drug companies – and that greed certainly is part of the story – but Quinones avoids such a simple and easy path, and tells a deeper story, one going back decades:
“World War I had … demonstrated to doctors the merciful painkilling benefits the morphine molecule provided. Fresh, too, in their memory were heroin’s first decades, which showed just as clearly that addiction too often bedeviled those who used opiates. Try as they might—with strategies as varied as farm work, group therapy, or prison—rehabilitation specialists never graduated much more than 10 percent of their addicts to true opiate freedom. The rest relapsed, slaves, it appeared, to the morphine molecule. This seemed a shame to scientists and physicians. Was mankind really doomed to not have it all? Couldn’t it have heaven without hell? Couldn’t the best scientists find a way of extracting the painkilling attributes from the molecule while discarding its miserable addictiveness?”
That is, the dream is of being able simply to escape pain, with no side-effects. This dream is a form of the striving after mastery I discussed in my post on Deneen, the aim of simply liberating ourselves from our natural limits. The story of the opioid crisis is a story of how the pursuit of this goal without sufficient attention to its risks leads to a new sort of hell: as Quinones says, “In heroin addicts, I had seen the debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain.” This idea is not at all new, for one repeatedly encounters talk of enslavement to pleasure (or the appetites) in ancient philosophy. What is new is that in a premodern context, such talk can often seem counterintuitive, and usually needs some explanation or thought before it seems an appropriate way to speak; modern science, however, has produced drugs that make it immediately obvious that it is correct to speak of ‘enslavement.’ On this basis, Quinones makes a more general point about human nature: “man’s decay has always begun as soon as he has it all, and is free of friction, pain and the deprivation that temper his behaviour.” This would not be news to the ancients, and it is part of the problem that Deneen sees in certain ideas that have helped drive the West in the last 500 years or so.
Think about what Quinones says about “man’s decay” for a moment, in the context of pain. What is being said is that we need pain. Certainly this is true in a superficial sense – e.g., pain tells us when something is going wrong with our body, and without that we might easily die of internal injuries or by failing to learn to avoid excessive risks, etc. But there is a deeper point here: Quinones speaks of man’s decay and debasement: human dignity disappears as people become enslaved to the escape from pain. That is, the need for pain is not simply instrumental. Our nature as creatures with a certain dignity does not seem to endure a total release from pain. To the extent that we’re capable of liberating ourselves from pain, we seem to become reduced to that attempt at liberation. In describing the search for a non-addictive painkiller, Quinones repeatedly speaks of the “Holy Grail,” a deeply appropriate term in that it suggests a quest for something beyond what is possible for humans.
Of course, the striving after the Holy Grail, the attempt to push beyond what is possible, is remarkable not only for the harm that it directly produces, but also for the humbler, less dangerous pursuit it discourages: Quinones explains how a multidisciplinary, holistic approach to pain, one that would not have produced an opiate crisis, was pushed aside and abandoned for decades because people thought these pills were a straightforward fix.
In the context of all this, I found myself seeing a wisdom in the old “just say no” slogan: not many of us are likely to be stronger than heroin – anyone who uses it a few times is likely to find himself unable to stop, enslaved to it [ed. I’m told it takes more like a month]. However, there is one way that anyone can attain a sort of mastery over heroin, simply by realising that here is something stronger than one’s will, and that one should therefore avoid it. Heroin has no power over such a person: real mastery, real freedom, involves recognising one’s limits and acting within them.
Quinones’ account includes a simply magnificent example of a sort of motivated reasoning (or at least motivated intellectual sloth), which I mention here because it seems to be driven by the striving towards mastery I described above. Those who led the movement to make prescribing painkillers more permissible beginning in the 80’s didn’t have as much evidence as they thought they did. One particularly influential piece of work was known as ‘Porter & Jick,’ which was cited and re-cited in papers and presentations until it seems to have attained a sort of legendary status, in which it bore considerable weight as an argument against the addictive potential of opiates. “Medical professionals,” Quinones tells us, “assumed everyone else had read it,” and it was referred to as “an extensive study” or “a landmark report.” In fact, it was a single paragraph letter to a medical journal, published in 1980; it seems that scarcely anyone had actually bothered to read it. One can imagine that if it had said something unpopular, something that people didn’t want to believe, many would have found time to read it, and read it critically. But of course, everyone wanted to believe that the Holy Grail had been found, that a simple liberation from pain was at hand with no side-effects to worry about – and so Porter and Jick remained unread even as its authority grew.
From the opiate crisis, then, we have another perspective from which to contemplate a truth introduced in my post on Deneen: the striving for a mastery of nature can be a very dangerous matter indeed. There is a need for a moment of acceptance, or perhaps of resignation, a recognition that we are not entirely in control. I’m reading Steven Pinker’s Enlightenment Now at the moment (a review will follow in some weeks/months as time permits), and one of my main problems with the book is that it seems to lack precisely this moment of acceptance.
And finally, since my last post was about the great English essayist, Theodore Dalrymple, here’s a short piece of his from a few days ago on the opioid crisis.