Did drug companies contribute to America’s current heroin crisis?

The numbers are beyond alarming. In 2014, more than 28,000 people died from opioid overdose, and at least half of those deaths involved a prescription opioid, the US Department of Health and Human Services reports. Many more became addicted to prescription and illegal opioids.

Heroin-related deaths have also increased sharply, more than tripling since 2010. In 2014, more than 10,500 people died from heroin.

“The United States is in the midst of a prescription opioid overdose epidemic,” says HHS.

How did we get to this point? Christopher Caldwell, a senior editor at The Weekly Standard, offers some ideas, and according to his theory, it’s not all the fault of drug cartels and street corner pushers.

Caldwell, writing in First Things magazine, updates HHS’ numbers and puts them in perspective. The 52,000 Americans who died of overdoses in 2015, he says, is about four times as many as died from gun homicides.

The town of Salisbury, Massachusetts, he writes, lost one young person in the entire time the US was involved in the Vietnam War. But over the last two years, it’s lost 15 to heroin.

The problem is only slowly beginning to get attention, perhaps because addiction to drugs like heroin has always been thought to be a problem of those on the lower rungs of society. But a picture is emerging of people of all social strata getting hooked on strong painkillers and then, when those become hard to get, finding that one formerly foreboding drug, heroin, has become cheap and accessible.

“Overdoses are churning through agricultural pockets of America like a plow through soil, tearing at rural communities and posing a new threat to the generational ties of families like the Winemillers,” states a New York Times report that came out soon after Caldwell’s article. The Winemillers are an Ohio farming family struggling to save a son after another son and a daughter died of overdoses.

Drug overdoses here have nearly tripled since 1999, and the state as a whole has been ravaged. In Ohio, 2,106 people died of opioid overdoses in 2014, more than in any other state, according to an analysis of the most recent federal data by the Kaiser Family Foundation. In rural Wayne Township, where the Winemillers and about 4,900 other people live, the local fire department answered 18 overdose calls last year. Firefighters answered three in one week this winter, and said the spikes and lulls in their overdose calls gave them a feel for when particularly noxious batches of drugs were brought out to the countryside from Cincinnati or Dayton.

The Times points to a “cascade of cheap heroin and synthetic opiates like fentanyl and carfentanil, an elephant tranquilizer, which have sent overdose rates soaring across much of the country.”

Caldwell’s reporting sheds a little light on how, as the Times put it, “particularly noxious batches of drugs” get out there. Much of what passes for heroin today is actually fentanyl, an opioid that was invented in 1959. There are different kinds of fentanyl, with varying strengths. One that is used as an animal tranquilizer is made in China and is smuggled across the Canadian border into Maine, where it undergoes “cutting,” i.e., mixing it with a neutral powder to stretch out the supply and increase the street value of the entire lot.

“It takes considerable skill to distribute the chemicals evenly throughout a package of drugs,” Caldwell says. “Since a shot of heroin involves only the tiniest little pinch of the substance, you might tap into a part of the baggie that is all cutting agent, no drug—in which case you won’t get high. On the other hand, you could get a fentanyl-intensive pinch—in which case you will be found dead soon thereafter with the needle still sticking out of your arm. This is why fentanyl-linked deaths are, in some states, multiplying year on year.”

But why are more and more people seeking it out? Caldwell lays much of the blame on the pharmaceutical industry, which, throughout the 1980s and 1990s, sought to answer a growing problem of “chronic pain” conditions with opioid products:

The American Pain Foundation, which presented itself as an advocate for patients suffering chronic conditions, was revealed by the Washington Post in 2011 to have received 90 percent of its funding from medical companies. “Pain centers” were endowed. “Chronic pain” became a condition, not just a symptom. The American Pain Society led an advertising campaign calling pain the “fifth vital sign” (after pulse, respiration, blood pressure, and temperature). Certain doctors, notoriously the anesthesiologist Russell Portenoy of the Beth Israel Medical Center, called for more aggressive pain treatment. “We had to destigmatize these drugs,” he later told the Wall Street Journal. A whole generation of doctors was schooled in the new understanding of pain. Patients threatened malpractice suits against doctors who did not prescribe pain medications liberally, and gave them bad marks on the “patient satisfaction” surveys that, in some insurance programs, determine doctor compensation. Today, more than a third of Americans are prescribed painkillers every year. Very few of them go on to a full-blown addiction. The calamity of the 1990s opioid revolution is not so much that it turned real pain patients into junkies—although that did happen. The calamity is that a broad regulatory and cultural shift released a massive quantity of addictive drugs into the public at large. Once widely available, the supply “found” people susceptible to addiction. A suburban teenager with a lot of curiosity might discover that Grandpa, who just had his knee replaced, kept a bottle of hydrocodone on the bedside table. A construction boss might hand out Vicodin at the beginning of the workday, whether as a remedy for back pain or a perquisite of the job. Pills are dosable—and they don’t require you to use needles and run the risk of getting AIDS. So a person who would never have become a heroin addict in the old days of the opioid taboo could now become the equivalent of one, in a more antiseptic way. But a shocking number of people wound up with a classic heroin problem anyway.

Meanwhile, in 1996, Purdue Pharmaceuticals came out with OxyContin, an “extended release” version of the opioid oxycodone. “The time-release formula meant companies could pack lots of oxycodone into one pill, with less risk of abuse, or so scientists claimed,” Caldwell writes. “Purdue did not reckon with the ingenuity of addicts, who by smashing or chewing or dissolving the pills could release the whole narcotic load at once.”

He continues:

Relaxed taboos and ready supply created a much wider appetite for opioids. Once that happened, heroin turned out to be very competitively priced. Not only that, it is harder to crack down on heavily armed drug gangs that sell it than on the unscrupulous doctors who turned their practices into “pill mills.” Addicts in Maine complain about the rising price of black-market pharmaceutical pills: They have risen far above the dollar-a-milligram that used to constitute a kind of “par” in the drug market. An Oxy 30 will now run you forty-five bucks. But you can shoot heroin when the pills run out, and it will save you money. A lot of money. Heroin started pouring into the eastern United States a decade ago, even before the price of pills began to climb. Since then, its price has fallen further, its purity has risen—and, lately, the number of heroin deaths is rising sharply everywhere. That is because, when we say heroin, we increasingly mean fentanyl.

Caldwell’s article got Rod Dreher thinking—and reminiscing. In the midst of a launch tour for The Benedict Option, Dreher got to wondering what the current scheme of things might have done to a kid he knew in college. He knew his friend was desperately searching for meaning in life and in fact was “in spiritual pain.” So he assumed that an offhand remark of his at the time was made in jest: “My life would be easier in one way if I had a heroin addiction. At least then I would know what to do with myself.”

This was back in the 1980s, and heroin was not easily accessible, at least not for a middle class white kid in Baton Rouge. But if this same kid were growing up now, the end of the story might be far different, Dreher muses:

Now, think about this same kid in 2017, working class version. Raised by his mother, who had a series of live-in boyfriends. No church background. Chaotic home life, with lots of TV and video games. He graduates high school, knows he’s not college material, and thinks about what he’s going to do with his life. There aren’t many good jobs for somebody like him. He’s like the young white guys that showed up at the warehouse where young J.D. Vance worked: good jobs were available, but they couldn’t hold on to them because they had no self-discipline, and a poor work ethic. Let’s not blame our hypothetical young man for that. He was not so much raised as jerked up with no parents — especially no father — to teach him this. So: he’s 21 years old, with no direction in life, with no good lifelong worth prospects, and no social pressure within his sphere to get a job (however unsatisfying), and start saving towards marriage and family. There is no expectation that his life is heading toward that purpose, or should. Do it or don’t do it: nobody cares. Most young men in that situation would be lost and hurting. And along comes the heroin dealer, offering you respite from that pain and anxiety, and giving you an extremely perverse reason to live.