This chart was designed by two infectious disease modelers, Hawre Jalal and Donald S. Burke, who made a grim discovery while examining the leading causes of death in America. They plotted drug-overdose deaths from 1979 to 2016, and what they found was utterly baffling: deaths consistently rose 7 percent each year, doubling every eight to ten years, for more than four decades. Nothing else—not gun deaths, not suicide, not AIDS, not car crashes—adheres to an exponential curve for this long. Since 1999, more than one million people have died from overdoses.
But in the United States, we don’t tend to think of this decades-long emergency as a continually accelerating death toll; it gets framed as a series of discrete, though sometimes overlapping, epidemics, implying a predictable arc that spikes, plateaus, and eventually falls. First, as the
New York Times warned on the front page in 1971, there was a “G.I. heroin addiction epidemic” in Vietnam. The drug’s use was also on the rise in places like New York, where, in the following year, at least 95 percent of those admitted to drug addiction treatment reported using it. The crack cocaine epidemic arrived in the next decade, followed by a rise in the use of methamphetamines, which the late senator Dianne Feinstein would call the “drug epidemic of the nineties.” But these were soon displaced in the popular imagination by OxyContin, which hit the market in 1996 and set off successive waves of what came to be known as the opioid epidemic, something we’re still struggling through. The past forty-five years of drug use in America does not match this relatively tidy narrative—in reality, there’s a beginning and middle, with no end on the horizon.
But in a strange way,
this exponential curve told a story the Sackler family could get behind, one that made them look less culpable: How could Purdue be responsible for the opioid epidemic if overdose deaths were rising for more than a decade before OxyContin was even brought to market? “We were contacted by [Purdue] lawyers,” Burke told me. “It was my sense that they would like us to testify that it wasn’t their fault.” They declined the offer.
Still, Purdue was right about something. Drug mortality in America neither begins nor ends with the company’s actions. What pharmaceutical manufacturers, drug distributors, insurance companies, doctors, and pharmacies—the entire profit-mad medical system—collectively accomplished was to accelerate a train that was already speeding off the rails. But it’s hardly an absolution to argue that you did not start the fire, only poured gasoline on it for personal gain. With corporate power unchallenged and regulators asleep at the wheel, drug markets, like so many other consumer markets, have become more deadly, more dangerous, and, despite decades of aggressive and costly drug enforcement, more ubiquitous.
Jalal and Burke’s finding also presented a paradox. How could four decades of seemingly distinct epidemics—from heroin and cocaine to meth and fentanyl—aggregate into one giant wave of death? How is this wave still gaining power, and when will it crash? When we zoom out, we have what looks less like a collection of epidemics involving a series of novel, addictive drugs, and something more like a chronic social crisis exacerbated by market conditions. Underlying sociological and economic drivers must be at work.
“We can come up with explanations that are specific to some era,” Peter Reuter, a veteran drug policy researcher, told me. For instance, consider how in the 1970s, cocaine manufacturing and trafficking networks in Latin America advanced alongside growing demand for the drug in America. “But then, it’s very hard to find something that goes on for forty-five years now.” David Herzberg, a historian of the pharmaceutical industry and author of
White Market Drugs: Big Pharma and the Hidden History of Addiction in America, has an idea. He proposes that drug markets are behaving the way other consumer markets have since the neoliberal turn, when “free enterprise” was unleashed to work its unholy magic. “The rise in overdoses tracks a time period in which corporations that organize human labor and human activity were increasingly given carte blanche,” Herzberg told me. “While OxyContin is an example of a corporation taking advantage of this,” he said, “Purdue didn’t create the conditions that enabled it to do what it did.” Hence the irony of the Sackler family’s lawyers holding up a chart where time begins in 1979.
Across this period, illicit market innovations have mirrored many of the same ones seen in legal markets: sophisticated supply chains, efficiencies in manufacturing, technological advances in communications and transportation, and mass production leading to lower prices. Meanwhile, the social dislocation and alienation of consumer society has left millions of Americans unmoored, adrift, or otherwise floundering.
Contrary to popular rhetoric, drug addiction is not the cause of poverty but one of its chief consequences. Studying the dynamics of crack houses in New York and open-air drug markets in Kensington, Philadelphia, the ethnographer Philippe Bourgois found a pattern of lives scarred by a combination of state neglect and violence: abusive childhoods, crumbling schools, abandoned neighborhoods, all aided by government-incentivized white flight. The historian Nancy Campbell, author of
OD: Naloxone and the Politics of Overdose, uses the phrase “unlivable lives” when talking about the increasing immiseration of Americans. “Drugs are powerful ways people use to mitigate their circumstances,” Campbell told me. Opioids work as a salve for pain both physical and psychic. (...)
The public is led to believe that the usual responses to epidemics will somehow work for drug addiction: isolate, quarantine, and treat the sick. This almost always means criminalization, incarceration, and compulsory treatment—or else bizarre interventions like the Department of Defense’s quixotic search for a fentanyl “vaccine.” The endless declaration of one drug epidemic after another also perpetuates a blinkered state of emergency, necessitating the spectacle of a disaster response to yet another drug “outbreak.” This not only forecloses the possibility of a response that’s actually effective, it precludes a deeper understanding of the role of drugs in American life. What Jalal and Burke’s exponential curve lays bare is the accumulation of our long, slow, and violent history. (...)
The idea that we’re living through exceptional times isn’t exactly wrong. The mathematics and physics of fentanyl are unprecedented. The total amount of the synthetic opioids consumed in the United States each year is estimated to be in the single-digit metric tons. By comparison, Americans annually consume an estimated 145 tons of cocaine and 47 tons of heroin. That means all the fentanyl consumed by Americans in just one year can fit inside a single twenty-foot cargo container. Some fifty million shipping containers arrive in America by land, air, and sea every year. Because fentanyl is so potent—with doses measured in micrograms—very small amounts can supply vast numbers of customers. Counterfeit fentanyl pills contain about two milligrams of fentanyl. There are 28,350 milligrams in an ounce, which means one dose amounts to one ten-thousandth of a single ounce. Authorities could barely keep up with cocaine and heroin. To say fentanyl detection is like finding a needle in a haystack is to vastly underestimate the scale of the problem before us.
To add another layer to this already impossible scenario, fentanyl is unlike cocaine and heroin in that it is synthetic, odorless, and tasteless, making shipments even more difficult to detect. And the supply has no real upper limit: production is only tied to the amount of precursor chemicals available, which seem pretty much limitless. Any nation with a pharmaceutical or chemical manufacturing industry can theoretically produce the necessary precursors and ship them to suppliers around the world. If one country cracks down on precursor chemicals, another can fill the void. At this time, India and China manufacture much of America’s generic drug supply.
The global market’s rapid acceleration underscores the folly and futility of relying on the same enforcement tactics on the supply side, and the same medical and health interventions on the demand side. The U.S. policy response has never been this nakedly outmatched and unsuited for the task at hand. Still, authorities boast of massive investments to curb the fentanyl crisis. They champion handshake deals with foreign leaders to staunch the flow of the drug into the country. They publicize record-breaking fentanyl seizures, only to turn around and report record-breaking overdose figures. For example, the state of California’s 2023 “Master Plan” for tackling drugs includes more than $1 billion, from overdose prevention efforts to interdiction and enforcement. The California National Guard seized 62,224 pounds of fentanyl that year, a 1,066 percent increase from 2021. And yet overdose deaths continue to climb across the state, increasing by 121 percent between 2019 and 2021. Conventional enforcement and seizure methods have done little to contain the spread.
The Need for New DirectionIn 2022, the disease modelers Jalal and Burke projected that half a million Americans would die of drug overdoses between 2021 and 2025. So far, the data supports this estimate. “Dismayingly predictable,” as they put it. Unless something drastically changes, the curve will keep rising. Drug mortality alarmed officials in 2010 when thirty-eight thousand people died in a single year. Drug deaths were declared a “national health emergency” in 2017, when the annual death toll topped seventy thousand. In 2022, overdose deaths nearly reached 110,000. My fear is that we’ll learn to live with these figures as just another grim and inevitable feature of American life. File drug overdoses away under “intractable problem,” somewhere between gun violence and the climate crisis.
Something obviously needs to change, but American drug policy feels stuck, mired in disproven and outdated modes of thinking. Briefly, it seemed there was real movement toward treating addiction as a public health issue, but the sheer lethality of fentanyl, in part, snapped policy back to the mode of coercive criminalization, derailing newer, progressive reform efforts to roll back racist drug enforcement through decriminalization, with an emphasis on expanding public health, harm reduction, and treatment. The tide of reaction against these nascent efforts has been swift and effective. San Francisco voters passed a measure to drug test welfare recipients. Oregon has ended their decriminalization experiment. With social approaches in retreat, the idea of full-on legalization feels increasingly out of touch with today’s reality.
But is complete legalization even desirable? Every time the left brings up the idea, two substances come to mind: alcohol and tobacco. These two perfectly legal, regulated products are immensely hazardous to individual health and society at large. Tobacco kills nearly five hundred thousand people every year; that’s more than alcohol and every other drug combined. Drinking, meanwhile, kills nearly five hundred Americans a day: more than every illicit substance, including fentanyl, combined. During the pandemic lockdowns, people drank more, and they drank more alone. The trend did not reverse once we returned to “normal.” Contrary to all the buzz around nonalcoholic bars, millennials and Gen X are binge drinking at historic levels. The same set of social, psychological, and economic factors at work in illicit drug use, magnified by the market’s invisible hand, are also apply to alcohol: people are more alone and more stressed, with access to a cheap, heavily marketed product that, thanks to on-demand home delivery, is easier than ever to access. Advertisers spent nearly $1.7 billion marketing alcohol in 2022 alone.
How, then, is the legalization and regulation of drugs going to help us? Benjamin Fong, in
Quick Fixes, summarizes the debacle:
A more rational society would undoubtedly minimize the impacts of black markets by regulating all psychoactive drugs (and, perhaps, controlling their sale through state monopolies or public trust systems), but legalization in this society likely means bringing highly potent substances into the purview of profit extraction.
It is clear we live in the worst of all worlds. Black markets flood the country with mass-produced and highly lethal substances, but legal, “regulated” markets do the same. Both are turning record profits. Consumers are at the wrong end either way. It’s hard to not feel deep pessimism about where things go from here. Cringey, commercialized marijuana; the glut of ketamine infusion clinics; venture capital closing in on psychedelics; Adderall and Xanax prescriptions being handed out by telemedicine companies over Zoom. It’s precisely more of what got us here: a bewildering array of addictive products unleashed onto anxious, isolated consumers who are groping in the dark for relief from physical and psychic pain, coping with unlivable lives. Fortunately, it’s almost impossible to fatally overdose on many of these substances, but death shouldn’t be the only way to measure the consequences of the great American drug binge.
The current rhetorical, legal, and medical framework is simply no match for the deep malaise driving the problem. Root causes are downplayed, millions are left untreated, and thousands of preventable deaths are unprevented. We need a stronger, more expansive paradigm for understanding the exponentially increasing number of overdose deaths. A new language of substance use and drug policy that encompasses, and is responsive to, market dynamics and the social dysfunction to which they give rise. A consumer-protection model that does not criminalize the suffering, but also addresses the anxiety and dread that leads to compulsive, chaotic, and risky substance use. There must be something beyond, on the one hand, prohibition by brute force, and on the other, free-for-all drug markets ruled by profit. How can we create a world where people don’t need to use drugs to cope, or when they do use them, whether for relief, enhancement, or plain old fun, the penalty isn’t addiction, prison, or death?
by Zachary Siegel, The Baffler |
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