America coefficient of the day

We find that as the county unemployment rate increases by 1 percentage point, the opioid death rate (per 100,000) rises by 0.19 (3.6%) and the ED visit rate for opioid overdoses (per 100,000) increases by 0.95 (7.0%).

That is from a new NBER working paper by Alex Hollingsworth, Christopher J. Ruhm, and Kosali Simon.


One big question is how much of the White Death is demand-driven (e.g., by unemployment, as in this study) and how much is supply driven. Sam Quinones' award-winning book "Dreamland: The True Tale of America's Opiate Epidemic" demonstrates that we shouldn't ignore the entrepreneurial efforts of Mexican drug retailers in Middle America. Which parts of the country are most affected by the White Death is to some extent dependent upon which areas are targeted by the Mexican cartels.

Quinones notes that the Mexican dealers typically avoid cities with large black populations, viewing them as too violent and too attention-getting, and instead concentrate upon beaten-down flyover whites as not very violent and not very publicized.

Not the Mexicans.

Big pharma.

There is no complacent in big pharma drug detail men and drug marketeers and Lawyers in pushing opiates to doctors with claims the new opiates are not addictive.

The spikes in deaths follow soon after a State implements a State database tracking opiate prescriptions filled.

The database flags prescriptions that druggists must not fill, with doctors who write too many being sanctioned worse than if they are totally incompetent due to being drunk frequently.

Quinones's book has a lot on the one-two punch of OxyContin followed by Mexican heroin and how they work together so that Americans wind up dead.

And is the PPACA a factor?

'demonstrates that we shouldn’t ignore the entrepreneurial efforts of Mexican drug retailers in Middle America'

Who still pale in comparison to these people - 'In 2012, New England Journal of Medicine published a study that found that "76 percent of those seeking help for heroin addiction began by abusing pharmaceutical narcotics, primarily OxyContin", and draws a direct line between Purdue's marketing of OxyContin and the subsequent heroin epidemic in the U.S.'

The market was created by old fashioned American capitalism for those 'entrepreneurial efforts,' it was not created by them.

Right, it's a one-two combo, Oxy->smack.

And until 2000, the evidence was that doctors were massively under-prescribing opiates. Primarily due to DEA intimidation. Nothing better than glorified cops getting to dictate the private decisions of the doctor-patient. I'm an atheist, but never forget that opiates are a gift from God. They're probably alleviated more human suffering than nearly any other medical invention. But every time this Reefer Madness-esque pendulum swings away from the moderate prohibitionists, we get ignorant crackdowns and Kafa-esque absurdity. Think oncologists giving terminal cancer patients a pep talk and a few days worth of Tylenol IIIs, because they're too scared to go over their DEA quota.

Every time you see an MS patient who isn't in writhing pain, send a thank you note to Purdue for changing the national conversation on pain management. Even among chronic pain patients, i.e. people repeatedly taking high doses of opiates, long-term addiction rates are less than 10%. Without a doubt, on the margin medical opiate use has huge benefits relative to its risks. The sizable majority of doctors are far too reticent to control patients' pain. Same for patients who are afraid they're going to turn into junkies if they take a Vicodin after major surgery.

Want to reduce recreational opiate deaths? Stop harassing doctors and elderly, sick people. First decriminalize heroin; Portugal has about an 80% lower drug overdose rate than the US. Second set up safe injection sites, where users can be assured of a clean, safe, supervised environment. Third give out Naltoxtrene and clean needles like candy. Fourth highly prioritize traffickers that cut with fentanyl or RC-opiates, much longer sentences, and much higher police focus. Dealers and traffickers that sell clean product should be ignored until fentanyl deaths drop to 0. Legalize and subsidize Ibogaine treatment.

Enough said.

+1 yes the demonization of drug companies is excessive.

This is correct. People react to opiates differently. I have had opiates prescribed after wisdom tooth removal, knee surgery, a broken toe and a back injury. I never had any addictive tendencies and the pain relief provided by the opiates was sufficient.

My co-worker got Oxycontin prescribed after a surgery and he descended into heroin abuse soon afterwards. He insists on blaming on his doctor for the initial prescription.

It is possible that a version of the "gateway drug" argument applies to prescription opioids. People who are unhappy with life or depressed and who receive a legitimate prescription for pain like the way the drug makes them feel and crave the feeling even after they no longer need the drug for pain management. Anecdotally, I have heard from a few people who have histories of heavy drinking and recreational drug use that they really liked the psychological side-effects of their painkillers when they took them while recovering from surgeries or injuries.

If the users could still get OxyContin of commercially produced heroin they might not be ODing so much.

I have trouble understanding how opiate dependency can be supply-driven. You don't buy stuff just because it's offered to you, you buy it because you want it. And everybody knows opiates are really easy to get hooked on and potentially deadly. People using opiates are operating in a self-destructive mode and that is not something that neither Big Pharma or the Cartels can induce, but they are more than happy to supply the product to meet the incredibly large demand.

Much/most of illegal drug use is driving by welfare. The author is looking at the wrong metric. The real harm is done by the free stuff the government hands out and the free time that comes with it. If we ended all welfare tomorrow the drug trafficking would go bankrupt.

All I know is it's the non-white's faults.

People does not get into opiates because friends share a bit in parties. Opiates addiction may start as pain treatment recommended by a doctor. What is the cause of the first prescription? Pain caused by injuries from physically demanding jobs?

See here:

Most opioid addicts do not start out by abusing drugs they were prescribed by a doctor. They start by abusing someone else's prescription drugs.

Still not seeing those Mexicans, though. Really, it is just so easy to blame them for all that ails America, at least these days, where a new version of PC is arising. The one where white people are excused from any responsibility for their actions, particularly those related to getting rich from selling Oxycontin.

Why not? Americans want to go back to the good old times when it was fair for a Western power to wage war to sell opium to the Chinese. Why wouldn't it be far to sell opium to Whites? As a Chinese leader may have said, "to get rich is glorious". Why wouldn't it be glorious for Whites, too?

I think the US does tend to think that if there is a massive market for prescription drugs, they must be good.

Direct marketing of prescription drugs to the population just greases the wheels a bit.

If you're not seeing how it's Mexican's fault, you're not looking hard enough.

Can I get an amen? Sam Haysom? Jim Jones?

Thanks Ricardo.Only 12-13% of people with chronic pain gets addicted or overdoses. The other 85+% people with opioid addiction is people with "at least one severely traumatic childhood experience" to solve distress and despair? This issue is well beyond the reach of economics.

"Only" and "12-13%" don't really go together for me.

This is an astonishing number, especially as an ongoing source of addiction.

It is important to point out that most addicts and people who overdose are not and were not legitimate pain patients and, conversely, most pain patients do not develop addiction and do not use illegally obtained drugs. I think it is a good thing that American society has started treating pain as a legitimate medical and ethical issue and would hate to see that progress rolled back in another drug war overreaction.

That's absolute nonsense. There may be a few here and there that get hooked to it that way, but most are daredevils that decide to experiment with deadly drugs and get hooked on them.

Sam Quinones wrote in the NYT:

"The most important traffickers in this story hail from Xalisco, a county of 49,000 people near the Pacific Coast. They have devised a system for selling heroin across the United States that resembles pizza delivery.

"Dealers circulate a number around town. An addict calls, and an operator directs him to an intersection or a parking lot. The operator dispatches a driver, who tools around town, his mouth full of tiny balloons of heroin, with a bottle of water nearby to swig them down with if cops stop him. (“It’s amazing how many balloons you can learn to carry in your mouth,” said one dealer, who told me he could fit more than 30.)

"The driver meets the addict, spits out the required balloons, takes the money and that’s that. It happens every day — from 7 a.m. to 7 p.m., because these guys keep business hours.

"The Xalisco Boys, as one cop I know has nicknamed them, are far from our only heroin traffickers. But they may be our most prolific. As relentless as Amway salesmen, they embody our new drug-plague paradigm.

"Xalisco dealers are low profile — the anti-Scarface. Back home they are bakers, butchers and farm workers, part of a vast labor pool in Xalisco and surrounding towns, who hire on as heroin drivers for $300 to $500 a week. The drug trade offers them a shot at their own business, or simply a chance to make some money to show off back home — kings until the cash goes. Meanwhile, in the United States, they drive old cars with their cheeks packed like chipmunks’, and dress like the day workers in front of your Home Depot.

"The heroin delivery system appeals to them mainly because there is no cartel kingpin, no jefe máximo. It is meritocratic — so unlike Mexico. They are “people acting as individuals who are doing it on their own: micro-entrepreneurs,” said one phone operator for a crew who I interviewed while he was in prison. They are “looking for places where there’s no people, no competition,” he said. “Anyone can be boss of a network.” Thus the system distills what appeals to immigrants generally about America: It is a way to translate wits and hard work into real economic gain. …

"They are decidedly nonviolent — terrified, in fact, of battles for street corners with armed gangs. They don’t carry guns. They also have rules against selling to African-Americans because, as one dealer put it, “they’ll steal from you, and beat you.”" ...

The Xalisco Boys migrated instead to prosperous midsize cities. These cities were predominantly white, but had large Mexican populations where the Boys could blend in. They were the first to open these markets to cheap, potent black-tar heroin in a sustained way. The map of their outposts amounts to a tour through our new heroin hubs: Nashville, Columbus and Charlotte, as well as Salt Lake City, Portland and Denver."

I’m reminded of Walmart’s strategy in the 1960s through the 1980s of avoiding obviously appealing but highly competitive retail markets like Southern California in favor of obscure, unfashionable locales underserved by metropolitan-oriented retailers.

This might help explain certain anomalies in where the White Death is bad (Appalachia) and not bad (Northern Plains). It could be that the Northern Plains haven’t succumbed as badly due to the more prosperous economy there. On the other hand, it could be that the Mexican retailers just haven’t expanded there yet.

One of the oddities I noticed studying Raj Chetty's IRS data on income mobility is that treeless parts of the country tended to be doing better in 2011-12 relative to 1996-2000 than heavily forested parts. The Carolinas, for example, were hit really hard by the domestic housing collapse and outsourcing of furniture factories to China, while the farm and fracking belts in the north central were buoyed by Chinese demand.

This is a recycled newspaper article - 'Mexican cartels have overtaken the U.S. heroin trade, imposing an almost corporate discipline. They grow and process the drug themselves, increasingly replacing their traditional black tar with an innovative high-quality powder with mass market appeal: It can be smoked or snorted by newcomers as well as shot up by hard-core addicts.

They have broadened distribution beyond the old big-city heroin centers like Chicago or New York to target unlikely places such as Dayton. The midsize Midwestern city today is considered to be an epicenter of the heroin problem, with addicts buying and overdosing in unsettling droves. Crack dealers on street corners have been supplanted by heroin dealers ranging across a far wider landscape, almost invisible to law enforcement. They arrange deals by cellphone and deliver heroin like pizza.'

Oops - not that one.

It was this one, 6 years ago -

Demonstrating that this aspect of the opoid wave is largely due to the unstinting efforts of Purdue Pharma, as reported in medical literature from 2012.

Yeah, Quinones is indeed a newspaper reporter, and a good one. I started reading him in the L.A. Times a decade ago. He has been researching both sides of the White Death story -- Oxy and heroin -- for many years. He finally brought out his big book in April 2015 and it won the National Book Critics Circle Award for General Nonfiction.

Zerohedge is saying that legalizing marijuana would cut the opioid death rate, people who are depressed would certainly be better off relaxing with a spliff

I can remember when I had cancer in 1997 and worried about dying painfully in the near future reading a lot of articles in highly respectable magazines about how America needed to loosen up on prescription pain medicines because synthetic opioids weren't addictive. Fortunately, most of the articles concluded, respectable opinion was now uniformly in favor of this change, so liberalization was going to happen real soon.

And it did.

And, now, 20 years later, here we are.

Weed can't kill you, but I do expect to read a lot of articles titled "the rise in marijuana use had nothing to do with the legalization of marijuana. "

Yeah, in my younger days I was attracted to arguments along those lines, "marijuana legalization will actually reduce marijuana use!" Not only is it probably bullshit, but it lets the prohibitionists establish the terms of debate. The correct response to "Well more people will smoke pot if it's legal" is "So what?"

It [extent of cannibis use] hasn't in CO.

When did the change take place? I think it was not that many years ago that I was still reading American articles talking about Americans writhing in pain being denied pain-relief drugs because the guys in Washington are square.

Around the turn of the century, I vaguely recall. Then after a decade or s,o the feds tried to crack down on opiate pharmaceuticals, and Mexican heroin started to fill the gap.

It's really a nightmare tale of good intentions having bad knock-on effects.

For example, when I was reading up on pain medications 20 years ago because I had cancer, I totally believed the new orthodoxy that the current limitations on pharmaceutical pain pills were outmoded.

One complication worth investigating further is that the White Death hit white males earlier, but lately has been hitting white females hard.

My impression from looking at the data is that the White Death rate is worse among people born after about 1950, which I suspect may have to do with being 18 in about 1968, a key dividing year in terms of countercultural norms. People born before about 1950 may stick to alcohol and the like for their troubles, while people who were 18 in 1968 or after may try a wider range of self-medications, sometimes even including the Big H.

But it was about 18 months ago that I looked at all this data so I may be remembering it wrong.

Personally, being born in late 1958 and growing up in the wake of about a decade of drug wreckage (e.g., Hendrix, Joplin, Morrison in 1970-71), I was almost always quite anti-drug, a Straight Edge punk avant la lettre.

On the other hand, I figured back then, if I had terminal cancer, I wouldn't worry about whether the newish pain pills were addictive.

It's a tough issue.

The best information I have found on the subject suggests that the opioid epidemic is not a direct result of people receiving prescription opioids from doctors for legitimate medical conditions. The Scientific American blog post I linked to earlier says only 13% of addicts have a chronic pain condition and a similarly small percentage of people prescribed pain killers for pain end up becoming addicted.

So what is happening is that legitimately prescribed drugs are being diverted. People raid their relatives' medicine cabinets or people with serious but temporary pain conditions get prescribed unnecessarily large quantities of pain killers from which they might be tempted to give or sell the excess to their friends and acquaintances. Once people get hooked, some try faking or exaggerated medical conditions and doctor-shopping while others wind up on the black market. All this suggests the way to cut down on addiction and overdoses is to try to limit opportunities for diversion -- for instance, prescribe small amounts at once and require more frequent follow-up visits and re-fills. Or require someone who has filled more than a certain threshold of prescription pain killers in a given year to see a pain specialist to limit opportunities for doctor-shopping or faking a condition. Legalizing marijuana may help cut both the medical and recreational demand for opioids as well.

I understand. Thank you.

I told you Tyler would develop a Sudden New Interest in American opioid deaths!

I think we can all agree the six-figure death count over the last 8 years was entirely forgettable. But now... we have a HUGE problem!

My memory is that Tyler reported the Deaton data as soon as it appeared.

So what? Trump has been inaugurated. Reporting bad news ia anti-American now.

Drug use in a Complacent Class world

This is why Trump needs to be badass on illegals. Get them out of the country, and create a massive labor shortage that forces employers to hire and deal with all of our unemployables.

Combine that with welfare and disability "insurance" reform, and get more of these unemployables back into the labor force.

The culture of work needs to be made stronger at the same time that labor shortages are created, it's the only way to solve the problem of our shrunken labor participation rate.

And then white boys from Appalachia and the Northeast will go to California to pick fruit? Don't think so.

Grapes of Wrath, dude. They did it before.

There are black guys without jobs too.

Yeah, jobs picking fruit in the central valley or cleaning offices in Atlanta or Charlotte, certainly looks like something that will motivate the white kids in Appalachia or the rust-belt to ditch their deadly attitudes and habits and join the persuit of the American Dream.

What about the black kids?

Death by heroin overdose in Appalachia and death by drive-by shooting in Chicago are symptoms of the same problem, and neither would be fixed by giving young men minimum wage dead end jobs in the farms or restaurants.

There are no dead end jobs. Proverbs 12:24 Diligent hands will rule, but laziness ends in forced labor.

All jobs are dead-end.

"Mortality data show that there was a 6 percent increase in drug overdose deaths between 2012 and 2013 (see Table 1). Approximately 37 percent (16,235) of overdose deaths involved prescription opioids, a number essentially unchanged from 2012. However, the mortality rate from heroin overdose increased each year from 2010 to 2013. Deaths from heroin overdoses increased by 39 percent from 2012 to 2013 alone and were approximately 19 percent (8,257) of all drug overdose deaths in 2013."

So about 17,000 drug users overdose and die annually. And I should care because...why?

Because they're your fellow Americans and its indicative that there is something deeply wrong in this country.

+1. Something wrong, but perhaps more manageable by traditional means than is sometimes feared. Adjust opiate prescription rules. Target heroin smugglers. Make sure help is in place, offered for every addict who needs it. Make sure jobs programs provide a last place to go.

'round the back solutions, like cutting down on the number of Mexican orange pickers, seem like longshots to me.

Opiates enter the black market when men on disability and Medicaid sell their presecriptions on the black market. Getting these men off disability and back to work is a twofer!

I don't know any of these "fellow Americans". If I am going to have sympathy for anyone it would be the poor in the undeveloped world rather than folks living in the wealthiest country on earth who choose to abuse drugs. And the deaths of 17,000 folks who engage in a risky pastime does not say anything about this country beyond that they have the freedom to do that to themselves.

Without a source of identity and meaning, and something to keep them busy, some people opt to nullify their lives.

How would universally available employment change this picture?

Government as Employer of Last Resort: Full Employment Without Inflation

It is one thing to hope you can create that opportunity everywhere, it is another to just do it

"How would universally available employment change this picture?"

That was tried in the Soviet Union for 70 years or so.

I try not to answer every little question, but obviously no, it was not. The paper presents a "last resort" job with a "bottom of the market" price. It is not the employer of everyone. I does not compete with anyone who would pay more than minimum wage. So no. Read the paper.

How quickly we forget our safety rules. Correlation is not causation and even when causation is present we get the arrow pointed the wrong way half the time. Maybe the drug-prone are unemployment-prone. Maybe those prone to over-discount the future price of are prone to over-discount the future price of failing to get a good education. Dunno.

There are three competing explanations for the increase in prescription opioid deaths. Not all of them make sense in an “economic misery is driving people to drug use” narrative.

1) These deaths are coming from normal users with legitimate prescriptions. The increase is just tracking an increase in the sheer tonnage of opiates prescribed. These new opioid prescriptions are interacting with other prescriptions and alcohol and illnesses (like sleep apnea) already present in the population. They are being used carelessly, but not “abused” in the sense of a drug habit.
2) These deaths are coming from illicit users. These are people with dangerous drug habits who may or may not currently have a prescription.
3) These deaths are coming from people who used to have a legitimate prescription but have been cut off by their doctor (or their doctor has been “cut off” by the authorities). These people then try to score whatever they can and indulge risky behavior they otherwise wouldn’t.

If the deaths are supposedly tracking a sense of macroeconomic despair, only explanation 2) makes sense. But there are reasons to doubt this, because according to two large drug surveys (SAMHSA and Monitoring the Future) illicit use of prescription opioids isn’t increasing. Explanation 3) doesn’t comport with this study, unless there’s some reason why high unemployment would cause a bunch of people to get cut off by their doctors. (Lack of funds maybe, but Medicaid doesn’t seem to have a problem with buying prescription painkillers for the patients it covers.) Some people who I know and respect prefer explanation 3, but I’m not sure it explains the bulk of the overdoses.

My preferred explanation is 1). The risk of an overdosing on prescription painkillers hasn’t really increased in the past 15 years on a per-kilogram or per-prescription basis. There are about 2 deaths per kilogram prescribed or 4-5 deaths per 100k legal prescriptions, which is holding steady. And once again, there is a lack of any indication of increased illicit use of these drugs in the two major surveys. The SAMHSA survey asks about *any* illicit use and about substance abuse disorders, and both of these are holding flat. The MTF survey, which focuses on youths, asks about illicit use and availability (among other things), both of which are actually *down* in recent years. As I see it, there is a medicine with a known risk and we’re just using it more. It’s as if people are freaking out about a particular surgery quadrupling in frequency because the death rate due to that surgery also quadrupled. It doesn’t make sense to just look at the raw death toll; you have to interpret it in terms of the risk per treatment.

I can’t tell from the abstract if the study is mixing together heroin and prescription narcotics the way some confused analyses do. Heroin is a high-risk habit applied to a small population. (About a 1-2% mortality per year per user applied to ~half a million users, if you believe the use survey data.) Prescription opioid use is a low-risk activity applied to a large population (5 deaths per 100k prescriptions with about 200 million legal prescriptions). I also can’t tell if they sorted out suicides and accidents; the CDC’s mortality data files code for this. I’d expect suicides to track more closely with “misery” than total overdoses.

Jeff Miron is doing some good work in the opioid “crisis.” There are serious questions about the accuracy of the cause of death determination. Mistakes here could be driving part of the overdose trend. The authors of this paper should give Miron a ring.

My guess would be that one factor is as wages have flattened out due to immigration, outsourcing, de-unionization, etc., more people look to get on the disability gravy train. One way to do that is to convince doctors that you have debilitating pain that would keep you from working. That leads doctors to prescribe pain pills.

Idle hands?
How about low wages? What does this mean for minimum wage?

Also for SSDI?

We find that as the opioid death rate (per 100,000) rises by 0.19 (3.6%) and the ED visit rate for opioid overdoses (per 100,000) increases by 0.95 (7.0%), the county unemployment rate increases by 1 percentage point.

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