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Prologue by R Carter

Between 1999 and 2010 the primary driving force behind believing opioid prescribing was the cause for opioid overdose deaths, were the trend lines between rising numbers of prescriptions written when compared to the number of opioid overdose deaths occurring. Not a rock solid, "you can definitely connect the dots conclusion", but a matter worthy of further investigation. Yet this narrative is the one cemented in the minds of health professionals and the public alike, due to how information was presented by the media. 

This article, "The True Cause of the Opioid Epidemic", published in The Atlantic January 2020, covers Jennifer Silva, a professor of sociology and anthropology at Bucknell University and what she discovered when she began interviewing people in the coal region of northeastern Pennsylvania, about how the poor and working-class Americans were affected by the collapse of the coal industry. Common sense applies that if job loss alone is driving Americans to abuse illegal opioids out of despair, then those with legitimate medical need who have been abandoned by their doctors, have in essence, been thrown to the wolves by our counties policies on prescribing for chronic pain conditions. Fueling a problem that was supposed to be a solution.

Now, twenty years later, a similar loose connection is being drawn by many journalist between personal economic loss, as in joblessness, and the rise in heroin overdoses in both rural communities and large cities, which have collectively been labeled, "deaths of despair".

What makes this perspective worthy of NIH funding to support further investigation, is how the US has broached the opioid overdose problem, with an intense crackdown on prescribing physicians and by reducing US production of medicinal opioids used in healthcare. By failing to make a clear distinction between prescription opioid abuse while providing appropriate allowances for medicinal opioids, used by compliant doctors and patients, our government has decimated the medical specialty of pain management and caused millions of US citizens to be abandoned by their providers. 

A survey of 813 chronic pain patients in 2019, in part, took a measurement on the financial impact these policies were having on US citizens who use opioids to help them remain functionally employed. The survey showed 74% were left unemployable and 11% were forced into lower paying jobs. 59.7% had financial losses in excess of $30K per year, 34.3% with a loss in excess of $50K, 20.2% with more than a $70K loss and 5.3% with more than a $90K loss per year. In total, 100% of the 813 surveyed had some level of financial loss due to an inability to work in positions they previously held. When applied to a government estimate of 15 million Americans who use opioids for chronic pain, that comes out to $900 million a year in pre 2018 lost wages.

The True Cause of the Opioid Epidemic

In 2015, Jennifer Silva, a professor of sociology and anthropology at Bucknell University, began interviewing people in the coal region of northeastern Pennsylvania. She was working on a project, which would become the book We’re Still Here, about how poor and working-class Americans were affected by the collapse of the coal industry—the major job provider in the region.

She was curious how the regional decline might have shaped her subjects’ politics. But she quickly noticed a startling trend alongside the growing unemployment: Her subjects and their families were struggling with opioid abuse. At community meetings, doctors and coroners would debate solutions to the problem. Should they be arresting people? Should they be creating support groups? She describes one desperate parent who asked whether Donald Trump’s proposed border wall would keep black tar heroin from getting to Pennsylvania.

Silva’s interviewees might have been representative of an awful connection between job loss and opioid abuse, a connection that continues to be bolstered by research. A study published on Monday in the journal JAMA found that counties with automotive assembly plants that closed had, five years after the closure, 85 percent higher rates of opioid-overdose mortality, relative to counties where automotive assembly plants remained open.

While the study authors can’t say that it was the laid-off autoworkers, specifically, who died of overdoses, the findings gave the researchers the sense that declining economic opportunities are a big part of what drove the opioid epidemic. After all, there are a number of potential connections between joblessness and addiction, says Atheendar S. Venkataramani, an assistant professor of health policy at the University of Pennsylvania and the lead author of the study. Losing a job might mean losing access to health insurance. It could lead to isolation and loneliness, or a sense that there’s little left to live for. “If you feel like the American dream is no longer accessible,” Venkataramani says, “then one may also feel that, Well, it’s not really worth investing in myself ... because investing in yourself is one way to access the fruits of the American dream.

Venkataramani’s study can be read as yet another sign that Americans are dying “deaths of despair”—that the reason the life expectancies of poor Americans are stagnating or declining is that their dwindling economic opportunities spur them toward drugs, alcohol, and suicide. Many other studies have also found connections between different types of job loss and different types of drug abuse. One 2017 paper, which I wrote about at the time, found that with each percentage-point increase in the unemployment rate, the death rate from opioids rises by 3.6 percent. Another found that economic downturns that lower housing prices, such as the Great Recession, are associated with more opioid-related deaths. A meta-analysis published in the International Journal of Drug Policy examined 28 studies published from 1990 to 2015 in 12 different countries and found that both economic recessions and individual unemployment increases illegal drug use of various kinds. And late last year, another paper found that a rise in manufacturing-related job loss corresponded with an increase in opioid-related deaths.

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