Credentialism and Corruption: The Opioid Epidemic and “the Looting Professional Class”

“The ideas of the ruling class are in every epoch the ruling ideas” –Karl Marx, The German Ideology

By Lambert Strether of Corrente.

Readers liked our initial post on life under neoliberalism and the salaried (or professional (or “20%”)) classes, and the follow-up, on life under neoliberalism in the newsroom.

So Yves and I were chatting the other day, the Yves dropped the phrase “the looting professional class,” and I said “I’ve got to post on that!” This is that post, and I’m going to use that concept as a lens to examine the opioid epidemic in the white working class, since the professional classes — and not all individuals so classed! — enabled so much of it. The question we posed then as now: “How do these people live with themselves?” (For a discussion of the medical aspects of opioids in general and the regulatory state of play, see here and here.)

Deaths from Opiods are like the AIDS Epidemic

Let’s start by looking at the briefly famous Case-Deaton study, and its study of mortality in the white working class, taking education levels as a proxy for class[1]. (For NC’s late 2015 discussion of the Case-Deaton study, with an embedded copy of the study itself, see here, and for a follow-up from Barbara Ehrenreich, see here.) From WaPo, on the study and its interpretation:

The research showed that the mortality rate for whites between the ages of 45 and 54 with a high school education or less rose dramatically between 1999 and 2013, after falling even more sharply for two decades before that.

That reversal, almost unknown for any large demographic group in an advanced nation, has not been seen in blacks or Hispanics or among Europeans, government data show. The report points to a surge in overdoses from opioid medication and heroin, liver disease and other problems that stem from alcohol abuse, and suicides.

[Deaton’s] analysis: “There’s this widening between people at the top and the people who have a ho-hum education and they’re not tooled up to compete in a technological economy. … Not only are these people struggling economically, but they’re experiencing this health catastrophe too, so they’re being hammered twice.”

Another economist who reviewed the study for PNAS used almost the same words.

“An increasingly pessimistic view of their financial future combined with the increased availability of opioid drugs has created this kind of perfect storm of adverse outcomes,” said Jonathan Skinner, a professor of economics at Dartmouth College.

(The Case-Deaton study had a moment in early 2016, as pundits connected it to Trump voters (“America’s Self-Destructive Whites”), and then dropped off the radar. And it wasn’t all that easy to get Case-Deaton on the radar in the first place; it was instantly rejected by the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine (NEJM), before being published in the less prestigious Proceedings of the National Academy of Science.)

Let’s look more closely at the potential role of opiods, and in particular OxyContin, in Case-Deaton results. Kevin Drum writes:

On a related note, the famous Case/Deaton paper showing a rise in white mortality since 2000 breaks out three categories of death: suicides, liver disease (a proxy for alcohol abuse), and drug poisoning. All three have gone up, but poisoning has gone up far, far more than the others. The first two have increased about 50 percent since 2000. Poisoning has increased about 1,500 percent. This coincides with the period when Oxy became popular, and probably accounts for a big part of the difference between increased white mortality in America vs. other countries. Oxy is a famously white drug, and may also account for the fact that mortality has increased among whites but not blacks or Hispanics.

The New Yorker is more circumspect:

Based purely on timing, it seems likely that developments in the medical and pharmaceutical industries played a significant role in setting off the epidemic of drug poisonings, which increased more than sixfold in the white-middle-aged demographic between 1999 and 2013, and which played an important role in raising its over-all mortality rate. By many accounts, the widespread misuse of prescription drugs, particularly opioid painkillers, such as OxyContin, began in the late nineties and rapidly became a chronic problem.

And the Times does some genuine reporting. While not mentioning OxyContin specifically:

The Times analyzed nearly 60 million death certificates collected by the Centers for Disease Control and Prevention from 1990 to 2014…

The analysis shows that the rise in white mortality extends well beyond the 45- to 54-year-old age group documented by a pair of Princeton economists in a research paper that startled policy makers and politicians two months ago…

While the death rate among young whites rose for every age group over the five years before 2014, it rose faster by any measure for the less educated, by 23 percent for those without a high school education, compared with only 4 percent for those with a college degree or more.

The drug overdose numbers were stark. In 2014, the overdose death rate for whites ages 25 to 34 was five times its level in 1999, and the rate for 35- to 44-year-old whites tripled during that period. The numbers cover both illegal and prescription drugs.

Rising rates of overdose deaths and suicide appear to have erased the benefits from advances in medical treatment for most age groups of whites. Death rates for drug overdoses and suicides “are running counter to those of chronic diseases,” like heart disease, said Ian Rockett, an epidemiologist at West Virginia University.

In fact, graphs of the drug overdose deaths look like those of deaths from a new infectious disease, said Jonathan Skinner, a Dartmouth economist. “It is like an infection model, diffusing out and catching more and more people,” he said.

And why the white working class? OxyContin and opiod prescription patterns by doctors:

There is, however, something that does make white men and women in the U.S. unique compared with other demographics around the world: their consumption of prescription opioids. Although the U.S. constitutes only 4.6 percent of the world’s population, Americans use 80 percent of the world’s opioids. As Skinner and Meara point out in their study, a disproportionate amount of these opioid users are white, and past studies have shown that doctors are much more willing to treat pain in white patients than in blacks.

Putting a new spin on the word “privilege,” eh?

The body count is comparable to the AIDS epidemic. Slate interviewed Dr. Angus Deaton:

You told the New York Times that HIV/AIDS is the only good analogue as far as these death rates go. Can you expand on that comparison?

We calculated that about 500,000 middle-age Americans died who would still be alive. AIDS has killed more than that but the numbers are in the same ballpark. The comparison is useful because people have a hard time thinking about changes in mortality rates—so many per 100,000. And everyone knows about HIV/AIDS: People wear ribbons and it is seen as a national tragedy. But there are no ribbons, no awareness for this, and there should be.

“No ribbons.” Odd, that. Or not[3].

Summing up: We’re looking at a deadly epidemic, in the white working class, previously unnoticed, fueled in part by OxyContin[2], and only briefly “on the radar.” So where does the “looting professional class” come in? To understand that, let’s turn to how Oxycontin is marketed and delivered through the pharmaceutical supply chain.

The “Looting Professional Class” as a Transmission Vector

OxyContin was successfully marketed by Purdue Pharma (“successfully” rather in the way that HIV is successful, only with different transmission vectors). Pacific Standard has a fine summary:

Starting in 1996, Purdue Pharma expanded its sales department to coincide with the debut of its new drug. According to an article published in The American Journal of Public Health, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” Purdue increased its number of sales representatives from 318 in 1996 to 671 in 2000. By 2001, when OxyContin was hitting its stride, these sales reps received annual bonuses averaging over $70,000, with some bonuses nearing a quarter of a million dollars. In that year Purdue Pharma spent $200 million marketing its golden goose. Pouring money into marketing is not uncommon for Big Pharma, but proportionate to the size of the company, Purdue’s OxyContin push was substantial.

Boots on the ground was not the only stratagem employed by Purdue to increase sales for OxyContin. Long before the rise of big data, Purdue was compiling profiles of doctors and their prescribing habits into databases. These databases then organized the information based on location to indicate the spectrum of prescribing patterns in a given state or county. The idea was to pinpoint the doctors prescribing the most pain medication and target them for the company’s marketing onslaught.

That the databases couldn’t distinguish between doctors who were prescribing more pain meds because they were seeing more patients with chronic pain or were simply looser with their signatures didn’t matter to Purdue. The Los Angeles Times reported that by 2002 Purdue Pharma had identified hundreds of doctors who were prescribing OxyContin recklessly, yet they did little about it. The same article notes that it wasn’t until June of 2013, at a drug dependency conference in San Diego, that the database was ever even discussed in public.

Combining the physician database with its expanded marketing, it would become one of Purdue’s preeminent missions to make primary care doctors less judicious when it came to handing out OxyContin prescriptions.

Beginning around 1980, one of the more significant trends in pain pharmacology was the increased use of opioids for chronic non-cancer pain. Like other pharmaceutical companies, Purdue likely sought to capitalize on the abundant financial opportunities of this trend. The logic was simple: While the number of cancer patients was not likely to increase drastically from one year to the next, if a company could expand the indications for use of a particular drug, then it could boost sales exponentially without any real change in the country’s health demography.

This was indeed one of OxyContin’s greatest tactical successes. According to “The Promotion and Marketing of OxyContin,” from 1997 to 2002 prescriptions of OxyContin for non-cancer pain increased almost tenfold.

(These people are super-smart, and you’ve got to admire the brilliance. It’s shiny!) Pulling out the professionals from that narrative, we have:

  • CEOs
  • Marketing executives
  • Database developers
  • Marketing collateral designers
  • The sales force
  • Middle managers of all kinds.
  • And doctors.

But Purdue Pharma’s marketing effort is not the only transmission vector. Let’s look at the entire supply chain. From a report (PDF) by Kaiser titled “Follow the Pill” (and which might more useful be titled “From Vat to Vein”):

The pharmaceutical supply chain is the means through which prescription medicines are delivered to patients. Pharmaceuticals originate in manufacturing sites; are transferred to wholesale distributors; stocked at retail, mail-order, and other types of pharmacies; subject to price negotiations and processed through quality and utilization management screens by pharmacy benefit management companies (PBMs); dispensed by pharmacies; and ultimately delivered to and taken by patients. There are many variations on this basic structure, as the players in the supply chain are constantly evolving, and commercial relationships vary considerably by geography, type of medication, and other factors. ….

The pharmaceutical supply system is complex, and involves multiple organizations that play differing but sometimes overlapping roles in drug distribution and contracting. This complexity results in considerable price variability across different types of consumers, and the supply chain is not well understood by patients or policymakers. Increased understanding of these issues on the part of policymakers should assist in making rational policy decisions for the Medicare and Medicaid programs.

It certainly should, given that the entire supply chain is a vector for an AIDS-like epidemic, eh? So, again, we have:

  • CEOs
  • Marketing executives
  • Database developers
  • Marketing collateral designers
  • The sales force
  • Middle managers of all kinds.

Except now not merely for Purdue’s marketing effort, but for OxyContin manufacturers, wholesale distributors, pharmacy benefit management companies, and pharmacies. That’s a biggish tranche of the 10%, no?

Conclusion

CEOs, marketing executives, database developers, marketing collateral designers, the sales force, middle managers of all kinds, and doctor: All these professions are highly credentialed. And all have, or should have, different levels of responsibility for the mortality rates from the opoid epidemic; executives have fiduciary responsibility; doctors take the Hippocratic Oath; those highly commissioned sales people knew or should have known what they were selling. Farther down the line, to a database designer, OXYCONTIN_DEATH_RATE might be just another field. Or not! And due to information asymmetries in corporate structures, the different professions once had different levels of knowledge. For some it can be said they did not know. But now they know; the story is out there. As reader Clive wrote:

Increasingly, if you want to get and hang on to a middle class job, that job will involve dishonesty or exploitation of others in some way.

And you’ve got to admit that serving as a transmission vector for an epidemic falls into the category of “exploitation of others.”

But where does the actual looting come in? The easiest answer is through our regimen of intellectual property rights. Pacific Standard once again:

In its first year, OxyContin accounted for $45 million in sales for its manufacturer, Stamford, Connecticut-based pharmaceutical company Purdue Pharma. By 2000 that number would balloon to $1.1 billion, an increase of well over 2,000 percent in a span of just four years. Ten years later, the profits would inflate still further, to $3.1 billion. By then the potent opioid accounted for about 30 percent of the painkiller market. What’s more, Purdue Pharma’s patent for the original OxyContin formula didn’t expire until 2013. This meant that a single private, family-owned pharmaceutical company with non-descript headquarters in the Northeast controlled nearly a third of the entire United States market for pain pills.

Would Purdue’s CEOs (and sales force) have been so incentivized to loot profit from the suffering flesh of working class people without that looming patent expiration? Probably not. The epidemic, then, might not have been so virulent. But I think the issue of looting is both deeper and more pervasive. Returning to the story of Tony, the stressed-out pharmacist who wanted to do right by his patients, instead of following the profit-driven scripts of his managers:

Recall again that corruption, as Zephyr Teachout explains, is not a quid pro quo, but the use of public office for private ends. I think the point of credentials is to create the expectation that the credentialed is in some sense acting in a quasi-official capacity, even if not an agent of the state. Tony, a good pharmacist, was and is trying to maintain a public good, on behalf of the public: Not merely the right pill for the patient, but the public good of trust between professional and citizen, which Boots is trying to destroy, on behalf of the ruling idea of “shareholder value.” Ka-ching.

And:

If economists ask themselves “What good is a degree?” the answer is “to signal a requirement for a higher salary!” (because it’s not easy to rank the professions by the quality of what they deliver). We as citizens might answer that professionals are in some ways amphibians: They serve both private ends and preserve public goods, and the education for which they are granted their credentials forms them for this service. For example, a doctor who prescribes medications for his patients because Big Pharma takes him golfing is no doctor but corrupt; he’s mixed up public and private. He didn’t follow his oath.

Consider trust as a public good. We might, then, look at that public good as “good will” on the balance sheet of the professional class. The looting comes as professionals draw down the good will for (as executives) stock options, for (as managers) bonuses, for (as sales people) commissions, and for the small fry salaries, wages, and the wonderful gift of continued employment status. And all the professionals who willingly served as transmission vectors for the AIDS-like opioid epidemic will be seen to have looted their professional balance sheet as the workings of the system of which they were a part become matters of public knowledge.

How do they live with themselves?[4]

NOTES

[1] The New Yorker does this beautifully exactly because it’s so unconscious of its moves: “The big puzzle is why the recent experience of middle-aged white Americans with modest educations has been so different.” Always credentials, eh?

[2] I don’t want to get into a chicken-or-egg discussion of whether working class suffering fueled the drugs, or working class drugs the suffering. Linear thinking isn’t useful when an epidemic has complex causes, so I say both, mutually reinforcing each other. For a humane look at the epidemic in context, see the writing, the tweeting, and the photography of Chris Arnade, former bond trader.

[3] The facts that researchers were “startled” by the Case-Deaton results, and that both NEJM and JAMA immediately rejected their paper — on an epidemic of an AIDS-like scale, too — really does cry out for explanation. Since it would be irresponsible not to speculate, I’d urge that consideration be given to the idea that (vulgar) identity politics, which is one of the “ruling ideas” in the professional classes, makes virtue signalling by professionals on working class topics difficult, and virtue signalling on white working class issues nearly impossible. Professors Case and Deaton are exceptions to this rule, of course, but perhaps they were not virtue signalling at all, but acting as disinterested, honorable scholars. There is always that possibility, even today!

[4] Let me issue my ritual disclaimer: I don’t want to come off as priggish. If I had hostages to fortune, and especailly if I had to support a family, especially in today’s new normal, I might put my head down and save ethics for the home. “Person must not do what person cannot do.” — Marge Piercy, Woman on the Edge of Time.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

91 comments

    1. Nealser

      I was shocked by the LA Times reporting on Purdue.
      They clearly knew that they were part of the supply chain with Distributors, Pharmacies, Doctors and old fashioned drug dealers who were facilitating thousands of deaths though Oxycontin addiction and overdoses. They set up safety monitoring committees which did practically nothing by design.
      Selling death for profit. Shame on them.

    2. MyLessThanPrimeBeef

      Is this pharmaceutical, and many others, like the gun-makers in this case?

      Should they not be excluded, but should be held accountable, as Hillary claims regarding gunmakers?

    3. Left in Wisconsin

      Having read to the end of comments below and not seeing this info, I think it is worthwhile noting a couple of the identities of specific class agents who have had a hand in this. From Part 1 of the LA Times series:

      1.To obtain FDA approval, Purdue had to demonstrate that OxyContin was safe and as effective as other pain drugs on the market. Under agency guidelines for establishing duration, the company had to show that OxyContin lasted 12 hours for at least half of patients. Purdue submitted the Puerto Rico study, which showed that.

      The FDA approved the application in 1995.

      Dr. Curtis Wright, who led the agency’s medical review of the drug, declined to comment for this article. Shortly after OxyContin’s approval, he left the FDA and, within two years, was working for Purdue in new product development, according to his sworn testimony in a lawsuit a decade ago.

      2. In the fall of 2004, in a remote courthouse in Appalachia, the 12-hour dosing issue came close to a public airing. The West Virginia attorney general was pressing a lawsuit against Purdue demanding reimbursement of “excessive prescription costs” paid by the state through programs for the poor and elderly. The state accused the company of deceptive marketing, including the 12­-hour claim.

      Purdue’s legal team made numerous attempts to get the suit dismissed or moved from state to federal court, where the company had succeeded in getting many cases tossed out. All these efforts failed.

      Purdue had one final shot at avoiding trial: A motion for summary judgment. … To make this critical argument, the company tapped Eric Holder Jr., who had been the nation’s first African American deputy attorney general. On Oct. 13, 2004, the man who would become President Obama’s attorney general argued that West Virginia prosecutors didn’t have sufficient evidence to warrant a trial.

      I’m not saying the computer programmer doesn’t have a moral obligation to do the right thing. But some class agents are clearly more powerful than others.

  1. Tim

    I’m sure a Psychologist could say this more factually than I, but if you job depends on it or at least benefits from it, 2 degrees of separation from cause and effect is enough to declare moral innocence in ones mind.

    Professionals are intelligent enough to fool themselves into believing this with hi consistency. In that respect they are no different from the looting bankers.

    1. Lambert Strether Post author

      > 2 degrees of separation from cause and effect

      Excellent formulation, but can anybody back it up with analysis? (The nice thing about formulating this as a supply chain is that the degrees of separation become quite evident.)

      1. grizziz

        You might consider Construal Level Theory which considers psychological distance. The general idea is that the more distant an object is from the individual, the more abstract it will be thought of, while the closer the object is, the more concretely it will be thought of.
        And of course as part of our increasingly mapped human nature there is Ethical Amnesia.

        Although you are making a strong argument against our particular credentialed class, my sense is that this behavior will arise in any social hierarchy with more than four or five levels.

        1. MyLessThanPrimeBeef

          Distance makes it abstract.

          The dangerous part is when abstraction makes it distant…like when a human is reduced to ‘what do you do for a living?’ – the polite version of ‘How much do you make?’

          “I am a professor.”

          “Hey, I think that enhances your chance, as the spouse or partner, of getting on that last ship out of a dying Earth.”

          (Instead of abstraction, an example is offered here).

          1. cnchal

            “I am a professor.”

            Does the professor know how many molecules have to be moved to make a buck?

            Not too many, with oxycontin. A particularly efficient enterprise whose externality is the exact opposite of a ride on the last ship out.

      2. Crazy Horse

        Remember the famous Millgram experiment? Two degrees of separation— Physical because the subject was behind a mirror in a “laboratory” observation room, and psychological because the “scientist” in a lab coat supported and encouraged extreme levels of torture which the subjects complied with.

        Rather similar to the level of detachment exhibited by Obama when he participates in selecting targets for assassination by remote control drone. Or Hellary Clinton chortling as she recalls viewing video of Gaddafi being sodomized with a bayonet.

        Self-delusion is the opium of the people.

    2. Uahsenaa

      I’m not sure it’s simply a matter of obliviousness. In the case of the database designer, the institution feeding him/her the data needs him/her to not get too curious, in other words to willfully remain oblivious. This is quite often achieved by means of an implicit threat: in tech, it’s usually the threat of being replaced by someone much younger or by a H1B visa holder. In sales, individuals and teams are often pitted against each other in strict competition, a practice that has ruined several companies, most notably Sears. Marketing is an extremely cutthroat field, and firms will do practically anything to one up each other, including the unethical and illegal. The implicit war of all against all creates a Zeitgeist of insecurity that incentivizes looking the other way or adopting a cultivated obliviousness.

      Even in the hallowed halls of academe, you see this play out. When the graduate student union was negotiating its most recent contract with the U of Iowa, the dean of the graduate college said straight out that the contract they wanted would “price them out of the market.” Lo and behold, since then, the University has met all of the increased demand on teaching (higher enrollment=more classes) by hiring ad hoc contingent faculty. The number of permanent positions created to meet this demand is functionally zero.

      1. Alex morfesis

        Purdue pharma saleswoman Kimberly workman…involved in first case of pill mill dox charged with murder, dr denis deonanine (acquitted)…in sun sentinal article, june 11,2002, she is quoted as having testified when confronted by pharmacist kenneth zie***** that deonanine was overboard and going to be a problem…

        her response was…

        “well that’s really a shame”…

        but during trial pharmacist kenneth also testified kimberly called complaining when he stopped selling the 160 dosage…

        It appears that “in theory” she was not working for purdue as the trial progressed…

        But…she $hows up on a web search as having submitted and funded a research study for purdue in 2013.

        as its original patent expired purdue arranged with the fda to “ban” any generics as being:

        “too dangerous”…

        but the new and improved(vit dem helpz oft demz german koompanee tex-know-low-geez) oxykraken which now prevents the capacity to melt it on a spoon and shoot it up, is available with the new expandapatent program from the fda (federal dollar addition) program…

      2. jrs

        Yes those professions didn’t strike me as too hot either. I.T. fields are flooded with H1Bs, being a salesrep can at times be an easy job to get but often isn’t (and so salesreps often put up with a lot of crazy) etc..

        We all pick our poison and how much we can live with. And yet most people believe in the ideology of making people scramble for money. They think it makes people “work hard” or “compete” or “add value” but just as absolutely it will make people cut corners. Because they have to because they need that money to live. And yet we still think completion is good.

        1. MyLessThanPrimeBeef

          Competition will get tough, when in the future, everyone needs to get a college degree, and lacking money for tuition is no longer a setback, except the ‘IQ not sufficiently high’ barrier (for those not taking the less traveled path).

          Then, you will need a master’s or a Ph.D. to beat back your fellow serf-competitors for that money to live.

    3. MyLessThanPrimeBeef

      Professionals, credentialism – what kind of free college education have they gotten, that will be free in the future?

    4. jrs

      Maybe they are no different from the minimum wage worker who takes a job at McDonalds. We know McDonalds food isn’t healthy, it likely increases heart attacks, strokes, cancer, diabetes etc. So is the minimum wage worker who is helping this by taking a job at Mikey D’s also intelligent enough to fool themselves into believing this with consistency and no different than the looting bankers?

      Oh the minimum wage worker might be more desperate for work, but frankly while they may pay more, half the professions listed above don’t have a good job market either if we are actually going to be honest about things.

      1. NoOne InParticular

        As a life-long member of this credentialed professional class (specifically, media, even though the credentials are informal at best), I can say from experience at several of the large media corporations that many, if not most, employees in the editorial ranks are well aware of the damage the industry does to this country (it’s more abstract, perhaps, than the pharma example, but it’s real). Many speak up, but no one can speak up every time they are asked to execute an unethical or mindless order whose sole goal is to increase ratings and, by extension, “shareholder value.” The chronic complainer will be considered a narcissistic idealist and eventually be fired (typically in a downsizing purge) or, at best, be marginalized. The only hope for those honest people in the ranks is to find an ally slightly higher in the food chain who is willing to fight some of these battles. And that person, in turn, is also in the same boat anyway. The people with families are in the tightest bind and I’ve never envied them (I have no family to take care of). For years now I went home at night ashamed of what I do. The only satisfying days were those in which I did speak up and someone above welcomed my opinion or even agreed. The worst days were when someone above just laughed dismissively at my concerns.

      2. Ike

        Not to mention the Military-Industrial Complex where I think this type of analysis is directly applicable, only the degree of separation is 3 or 4. I see this type of behavior in the building industry. But with this Industry, Errors & Omissions Insurance tends to keep malfeasance and ignorance at bay. Since my work has to be documented and the results are relatively immediate and prominent in the Environment, the degree of separation is kept to one or zero. And maybe that is the solution? Keeping the degree of separation at a negligible number?

  2. Northeaster

    The campaign contributions to both my state and CONgress Members by the opiate industry is extensive. Which of course makes sense, as Massachusetts has a large footprint in this industry, as well as opiate overdoses/deaths.

    A recent article featuring a local police chief here shows that Narcan must now be used 2-3 times to revive folks. However, quantifying what an “epidemic” is has been difficult. If a friend or family member has died from opiate over dosage, then it would probably appear to be an epidemic.

    Then again, now that drug cartels from all corners of the globe can now manufacture opiates, supply & demand rules, along with unfettered access to a market where appetites to get high need to be satiated.

  3. Anon

    The lack of ethical behavior from the credentialed class has many origins. The best attitude when dealing with the credentialed class is caveat emptor . Especially in a society where accumulation of money (and celebrity) is the pinnacle of “success”.

    I’m part of the credentialed class, but after sour experience with other doctors, lawyers, architects, priests, and politicians the only prudent path is to watch what they do, not what they say.

  4. cocomaan

    Call me a freaky conspiracy theorist, but the availability first of oxy and then later of heroin in North America coincides with the US occupation of Afghanistan. That’s not an accident. Thebaine isn’t something we can synthesize yet, so it has to come from somewhere.

    1. bob k

      well most heroin in the usa comes from mexico and the Jalisco Boys cartel, helped by nafta. afghani heroin supplies europe and asia. just an fyi.

      1. cocomaan

        The cartels get it from Afghanistan, though, because Afghanistan supplies the lion’s share of opium.

        1. nowhere

          It’s weird that it doesn’t seem to be accounted though:

          pg 160 Table VII
          pg 164 Table VIII

          Where does all of that poppy production go?

        2. JS

          Actually, no, the black tar that most poor people in the heartland turn to after they can no longer afford Oxy is grown in Mexico, not Afghanistan.

          In an added irony, Mexican farmers turned to it after NAFTA destroyed their ability to make a living growing their traditional crops.

          Dreamland: The True Tale of America’s Opiate Epidemic by Sam Quinones does a good job of describing how Oxy and then Mexican black tar took over the U.S: https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidemic/dp/1620402521/

          1. bob k

            thank you for clarifying. now the mexican cartels are producing fentanyl which is even stronger than heroin and adding it to heroin. police are reporting more overdoses because of this deadly combo.

            I remember a movie the panic in needle park where the junkies were always worried about then the shipment would arrive. you might remember the french connection. that was the 70s when poppies were grown in places like turkey.

            Now there are never panics. there’s always mexican black tar.

    2. fajensen

      Sure “we” can, see here:

      “A microbial biomanufacturing platform for natural and semisynthetic opioids”
      http://www.nature.com/nchembio/journal/v10/n10/full/nchembio.1613.html

      I checked it out a bit too, out of professional interest. To get started, one would need two courses: “Introductory laboratory techniques” and “Experimental synthetic biology” both available at the “Danish Technical University” (DTU) for a modest fee (About 800 USD). If there is enough people signing up, they will run these courses over the summer holidays (usually, there is, the summer courses are supplementary lessons for students who flunked their semester exams).

      Part of the reason for the collapse and trouble we are in, is that scarcity is more or less over, so, it has to be manufactured to protect all the investments in obsolete thinking and no-longer-needed imperial acquisitions.

  5. bob k

    as to “how do they live with themselves'” let’s turn to the immortal John Lennon:

    Living is easy with eyes closed
    Misunderstanding all you see
    It’s getting hard to be someone but it all works out
    It doesn’t matter much to me

  6. Dwight

    This analysis applies to the epidemic of doctor-prescribed amphetamines by adolescents and increasingly younger children. Dr. Peter Breggin is a source for informed outrage on this issue.

  7. xformbykr

    “before being published in the less prestigious Proceedings of the National Academy of Science.)”
    this raised an eyebrow, since the PNAS was about the most prestigious place to publish among biochemists (when I was in that world, back in the 70s);

    1. Uahsenaa

      Prestige seems not to be the appropriate angle here, since the journals in question are all in the same echelon. What’s more interesting is a point Deaton himself makes about the second rejection, namely that simply identifying an alarming phenomenon was insufficient in itself, that they had to additionally provide some kind of causal justification for this phenomenon. This is beyond strange and seems to indicate what you imply elsewhere in that paragraph, that there seems to be a willful desire not to know this analogous to the way “education reformers” constantly overlook the fact that poverty is the only reliable indicator of failing or sub par schools.

      I presume education and neoliberalism is on the docket at some point? It’s probably to most well-documented example of crapification.

  8. xformbykr

    PS above comment was only a ‘nit’, issued before finishing reading the story; the ‘nit’ does not subtract from the impact of the story!

  9. Shilo

    The Times analyzed nearly 60 MILLION? death certificates? Sounds like there are jobs for data serfs at the New York Times!

    p.s. Lambert: My relative in the coding field reports that hospitals are beginning to outsource that job overseas.

  10. dk

    I appreciate this article in several ways, but you lose me with “Consider trust as a public good”.

    This goes in contrast to the quote from Clive:

    Increasingly, if you want to get and hang on to a middle class job, that job will involve dishonesty or exploitation of others in some way.

    We’re over-populated and competing with each other, how could it be otherwise? Trust, without some amount of research, coupled with a period of observation, is a completely naive idea. It always entails risk. The conflation of “trust” with some kind of faith that has an actual consequent effect is mystical thinking.

    Trust can be observed in small isolated communities where everyone knows each other; in that kind of context, dishonesty and exploitation are quickly recognized. That’s the context from which it entered our cultures and “moralities”. But increase population drastically, and also increase the range of movement between regions, and and the research and observation become complex, more difficult to perform and even more difficult to persist. Socio-economic complexities make it easier and easier to avoid the encumberments of past error, or dishonesty. (I hope I don’t have to explain how the internet fails to solve this problem, and also can’t).

    And even further, a form of trust is actually operating within exploitative groups like the aggregates of CEOs/Marketing executives/Database developers/Marketing collateral designers/The sales force/Middle managers of all kinds. The trusted principle is, play along and we’ll all make some money, and woe to the one that upsets our apple cart. To the extent that trust exists and operates, it’s not necessarily a good thing.

    I would love to live in a world where trust, as a discrete positive value, was more viable, but at the moment, this isn’t it. So let’s please get past that, and look at how we can conduct ourselves as a community in which the members must continue to prove themselves in every instance. Because that is what is required in any case.

    Okay I lied. I actually like this world. The pretenses of trust are being shown for what they are (which is, false and lazy). I think it’s a good time to be alive and seek dignity; the fact that it’s becoming more difficult just makes it more important and worthwhile to do so. And global warming, too? Bring it!

    1. Lambert Strether Post author

      Hmm. I’m not sure that’s true. I was thinking of what Graeber IIRC calls everyday communism; the idea that stranger A asking B for directions to the post office gets directions to the post office. Well, granted, not in some cultures that are really people pleasing, but at least you won’t get directions that take you over a hidden pit of knives, or under a tripwire that will explode a bomb. That’s a basic level of trust, society-wide, and I think these professionals are violating it.

      Now, if there’s some economist-techie-geeky reason why that’s not a public good I need to think again, but it certainly seems like a public good to me.

      1. dk

        No argument that the individuals in question (pros or otherwise) are violating trust, at least collectively, and in some cases individually.But this doesn’t mean that credentials are a good medium for establishing trust. My argument is that short of verification by reference and observation, there is no sure and durable source for trust (other than faith, which can even be maintained after the trust has been violated). Verification and observation, those are the “public goods”; “trust” is their abstract product.

        My travelling experiences suggest that asking a stranger for post office directions is considerably more risky if one is clearly an outsider to the community (language, dress, complexion, etc). No pits or bombs, but knives and similar weapons were involved more than once. But then, I do not limit myself to the touristy destinations (in tourist context, the visitor is considered to be something of a community member).

        I think the ideal that a stranger will, or even should, get equal treatment with established community members is suspect. It’s one of the fallacies in the imperialist capitalist dream of access to everywhere (and look, they have a McDonalds!), king for a day every day, no matter where I go, because my money is good. Bourgeois socialists have funny blind spots in the vicinity of conceits they retain from their native cultural contexts, I think this is one of them.

        Strangers are either guests (which requires some kind of sponsorship, with conventions applying to both courtesy and restraint), or potentially hostile until proven otherwise. This is the rule of the road, and not just for humans. And the reasons for this go back to research (reference, or the absence of it) and observation over time being the basis for valid trust. An ignorant visitor and ignorant local are both at risk until sufficient information has been exchanged and accepted. The risk may have nothing to do with malign intent; disease, ignorance of local safety concerns, protection of natural resources…

        The locals that waylaid me were (trying to) retain some of the wealth passing through their turf for their local economy; the profits of tourist hotels and shops largely bypassed their communities. I had absolutely no problem in principle with them doing it, and on some occasions made friends from these initial encounters (in other cases merely escaping).

        To tail it back to the original topic, then value of credentials (as a trust medium) weakens in relation to the sizes of the population and the region. Hucksters busted in one town move on to the next; the larger their range of options and marks, the easier it is for them. Credentials can be forged, their references can be corrupted, their media can be hacked. As tokens of trust, they’re problematic at best. Credentials may not be intrinsically useless, but unless we understand the operation of trust (by any media) in practice, and how it can fail, we shouldn’t invoke them as either a solution or a problem.

        I think that the idea that fraud and corruption can be safely curtailed by philosophy or legislation (something of a static trust mechanism) alone is also suspect; we’re inquisitive problem solvers and keen observers, any weaknesses of flaws in a system will eventually be discovered, and unless understood and addressed, exploited. All living things do this (although not always as individuals, or even at the phenotype level).

        So what’s the solution to corruption and fraud? Pay freakin attention and check the math. On everything. Expect problems, and solve them as you go…. people make honest mistakes, too. But don’t get fooled twice.

  11. elime divad

    The story of oxycodone is one of rampant criminality: the clinical trials, the approval process, and the marketing are all riddled with probable fabrications and manifest misrepresentations.
    Thanks for this useful summary!
    Maybe someday our country will have a criminal justice system to punish acts like mass murder.

  12. PQS

    Very good analysis and piece, LS.

    “Shareholder value” = 5th Horseman of the Apocalypse, IMO.

  13. readerOfTeaLeaves

    If you are a doctor seeing 4 patients per hour, 8+ hours per working day, and also covering weekend rotations, you are time constrained. Given the brief time you are able to spend with patients (plus the fact that the drug rep dropped in earlier), it is simpler for most doctors to write one more prescription; they do it all day.

    Having been looted for tens of thousands of dollars in out-of-pocket medical costs over the past five years, this post hits home. Like other patients fed up with being on meds, I started looking for alternatives. They exist.

    Prediction: one of the next shifts in health care will be called Functional Medicine.
    And it is one response, one ‘push back’ to the incentivized looting and drug dependency of current medical care.

    Here is a one-minute clip from a BBC series of a doctor taking a Functional Medicine approach:
    https://www.youtube.com/watch?v=e3JNtgbT234
    Note the absence of exam room settings; the doctor is going out into the community, including people’s homes.
    And at no point does he simply hand out prescriptions; he dumps the crap out of their kitchen cupboards, advises them on how to shop for groceries, introduces patients to new foods, works out with at least one of them, and provides feedback about their progress.

    His patients are far, far less likely to be looted than your conventional patient.
    And he is able to develop the insight, time, and trust to be able to help patients make choices that improve their health – in some cases, tremendously.

    My link is to a BBC video, because I’m unaware of a US equivalent for this content.
    I am, however, very aware of doctors in the US who are implementing versions of this, or trying new ways to make more time to meet with patients, and create lifestyle-oriented interventions (as opposed to writing prescriptions).

    This is the future of health care, partly because the greed of looting is killing the Golden Goose of the (insured) American middle class.

    Good and decent people do not spend years of their lives in medical school in order to become part of an entrenched system of looting: the people that I know, who are passionate about health care, do not want to play by The Looting Rules. Those crappified rules lead to poor patient outcomes.

    Smart, competent doctors do not want to squander their talent by enabling looters.
    There are brilliant, insightful people who are thinking hard, and risking plenty, to develop new means of health care delivery. They are gutsy as hell, and determined.

    I think that this post could be multiple by 1,000,000 if you think of all the people who are actively attempting to revitalize health care and make it more patient-focused. This post has a tiger by the tail.
    Kudos to Yves and Lambert for this gem.

    1. jrs

      For providing symptom relief to actual physical pain obviously marijuana is an alternative to opiates, maybe not strong enough for late stage cancer and the like so opiates still have their limited and legitimate uses, but an alternative for many other things being treated with opiates. We’re only allowed to legalize it now that the Oxy patent has worn off.

      Minor semi-opiates like Kratum can also sometimes be used an alternative although they have more addictive potential than marijuana.

  14. Vatch

    “the looting professional class”

    the salaried (or professional (or “20%”)) classes

    The behavior described in this article is clearly terrible, but it doesn’t seem fair to blame 20% of the population for this type of thing. You often advise us that generations don’t have agency, and the same can be said for economic classes. Most of the people in the richest 20% could be classified as “professionals”, as in doctors, lawyers, stock brokers, engineers, managers, etc., but I suspect there are some master plumbers and electricians in that category as well.

    1. Lambert Strether Post author

      We don’t have clear language for this (for some reason). I’m trying to tease it out by contextualizing the professions in the supply chain, and by underlining that there are honorable professionals in every field. I’m aware that the language is deeply imperfect — people have trouble speaking in Venn diagrams, it seems to be a feature that English doesn’t support — but I’m working to improve it. As the granularity improves, the sense of agency improves. (Of course, I can think of professions that shouldn’t exist at all, like “Concentration Camp Guard” or “Trofim Lysenko Chair of Genetics” but those are edge cases.)

      Adding, income is a poor proxy for social relations, sadly. It’s what we have!

      1. CraaaaaaaaaaazyChris

        This exchange and the one above with ‘dk’ pulled me in. I fear I don’t have clear language either, but I want to add this about ‘trust’ and the professional class:

        I think (a) the lessons of the Milgram experiment (trust your boss; go with the program) and (b) the U. Sinclair notion of can’t believe X if you’re paycheck depends on not-X … these 2 factors have a lot to do with the separation of the 20% from the 80%. They don’t explain the origin, but I think they speak to the persistence.

    1. Marc

      I would also refer to recent medical study on pain medications’ effect on continuation of pain sensation after pain relief occurring in placebo groups.

  15. gardenbreads

    It is not surprising that JAMA and NEJM immediately rejected the paper. From the health care community point of view Case-Deaton
    (1) just tabulated the same CDC data that thousands of other people also do routinely in the same way as soon as it is published each year – epidemiologists, actuaries, public health planners etc. who also routinely do population adjustments and look at trends for the total population and sub-populations. This isn’t publishable. It’s the equivalent of publishing baseball standings. These trends were no secret.
    (2) Everyone in actual health care besides the data tabulators already knew this – everyone except the health care pundit class. All the emergency department staff and morgue staff and pathologists and managers and people handling death certificates knew these as routine deaths – especially in small town and rustbelt hospitals. Hospital mortality and underlying etiology – both for patients and DOAs – is a big deal in every hospital and is reviewed by many people.

    Thus their paper produced a “so tell me what I don’t know” reaction in people in actual healthcare.

    1. gardenbreads

      I totally agree with describing this as looting. It disgusts nearly everyone who have had to deal with the results.

      CDC has been publishing reports on the incredibly rising incidence in non-Hispanic whites for years.

      NCHS Data Brief ■ No. 22 ■ September 2009
      Increase in Fatal Poisonings Involving Opioid Analgesics in the United States, 1999–2006
      Margaret Warner, Lli Hui Chen and Diane m. Makuc

      Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008
      Weekly. Mortality and Morbidity Weekly Report, November 4, 2011 / 60(43);1487-1492

  16. Russ Gibson

    The inclusion of database developers as a responsible party is absolutely absurd, and it betrays an ignorance of what database (and software) developers do. We build the informational “machinery” that stores and retrieves data, according to the specs handed to us by business types. We do not typically monitor/summarize/report on the data itself as it rolls in, unless we happen to be specifically tasked with such a thing.

      1. jrs

        It only proves the point if the McDonalds burger flipper is also guilty for also working for a firm of questionable morality. Now of course one could argue that it’s a lot different to work at a firm producing Oxy than in fast food (even though the later does kill) and I don’t think that’s unreasonable.

        I just think that has absolutely NOTHING to do with being a professional or being a working class prole. That factor is irrelevant.

        What about if you work on the database for Coca Cola, are you guilty of increasing diabetes? What about if you work upselling it (ie management says you must ask customers if they would like to supersize their soda or something) at McDonalds?

        Oxy may be worse that such things. We all pick our poison. Some people’s picks go far further than our conscience would ever allow us to go. Sometimes professionals have more wiggle room financially but the stats on how few people have a few hundred or thousand bucks in savings makes that questionable.

        I honestly suspect most jobs are a bit corrupt. Even if one works for a non-profit,even many non-profits are stealing massive amounts of the donations for administration. Etc.

        1. JTFaraday

          I agree. If you are living hand to mouth on a middle / professional class salary, you are poor. If you are ideologically committed to the idea that jobs cure all economic, social, and cultural ills– and that correspondingly, the lack of good middle class jobs cause all ills– you won’t want to look too closely at that.

          That said, the question is what is the purpose of a given profession? Is it solely to maximize financial return to the members of the profession? Or is it to hold up certain values that the profession is said to guard?

          In order to fulfill the last, what I consider to be the true purpose of the profession, you need to be sufficiently organized to collectively resist the overweening crush of capital, which has looting as its (at present sole) definition.

          Almost none are.

          1. JTFaraday

            The difference, then, between the professional and the soda jerk, is that the professional ostensibly has the education, knowledge, experience and connection to other similarly situated persons that enables them to individually and collectively act with some authority.

            The professional’s relationship with the money power should be qualitatively different. But we see it ain’t necessarily so.

            Therefore, I have suggested that part of what is wrong today is that the working class, soda jerk mentality has polluted all vocational endeavors.

            And so I also decline to get on board with valorizing the working class. No working class identity politics for me, thanks.

      2. Berial

        So you get asked to create a database that tracks sales rep’s visits to specific doctors and a doctor’s number of prescriptions of all drugs and some specific drugs, (undoubtedly from a long list) and from doing that, the developers are supposed to know that they just helped push opiod addiction?

        I’m REALLY not seeing your point.

        The people that PLANNED this system MIGHT have known the purpose, and the system architect, maybe, but the guys pushing out the code and making sure the database does what is asked probably have NO IDEA about things like that. It’s just not something they would even notice.

        1. jrs

          It seems to become a non-obvious question. We need MORE DATA :). No really we just need more information.

          Is the only med Purdue Pharma makes opiates? Then one could say one is working for an opiate provider. Were the employees even full time employees of Purdue Pharma? Sure they might be H1Bs, but also for a time limited database development job they are often 3-6 month contractors, it’s VERY common. You could argue the 1099s have some guilt even so though. There is even a possiblity the database development was contracted out to an external firm.

          Is it obvious the harm opiates cause? Well it is NOW. I guess it’s why I tend to latch on to the question of if the firm one works for is ethical because I don’t believe the wrongdoing is always obvious from say the data. But a firm itself could be said to be unethical and thus it could be argued it is unethical to work for an unethical firm.

    1. dk

      But if you don’t understand what the functions the specs are describing, how can you build a good database? And summarizing and reporting are often in the purview of the developer.

      There is a point to be made here. Managed structures can insulate task fulfillers from the full context(s) of their work. The implementors may not be immediately aware of or fully understand the consequences and implications of their work.

      But there are many scenarios where the database developer has, or should have, full knowledge of the operational aspects of their work relating to compliance, safety, and contractual/fiduciary responsibilities.

      Take for example HIPAA, with several defined rules required for compliant implementation of data management. The database developer should be at least aware of the specifics of the requirements, since they directly address significant aspects of storage and retrieval functions. HIPAA compliance is required by law for handling of any patient, treatment, provider, or payment information (protected health information (PHI)).

      Another example: political fundraising. It is explicitly illegal to sell or use names and addresses of individuals from FEC records as a primary source for solicitations (http://www.fec.gov/pages/brochures/saleuse.shtml). However it is very easy to do so, and the data manager that does it is breaking the law, as much as a person (or document) instructing them (who actually gets prosecuted is another matter entirely).

      1. jrs

        Yea HIPPA requires compliance and knowledge on the part of a lot of involved employees, that is part of the law itself. But that workers have knowledge of all aspects of a business is NOT part of the law. So on the other hand management may be scamming the shareholders say and a database developer might not know depending, just because knowledge is shielded in many ways.

    2. AnEducatedFool

      In essence you are arguing that it is acceptable that your profession is fine and that you can all be little Eichmanns now. Your profession has plausible deniablity built into its structure.

  17. JohnnyGL

    http://www.npr.org/sections/health-shots/2016/03/31/469525114/inside-a-small-brick-house-at-the-heart-of-indianas-opioid-crisis

    http://www.npr.org/sections/health-shots/2015/05/01/403474785/indiana-struggles-to-control-hiv-outbreak-linked-to-injected-drug-use

    I keep seeing this talk of HIV/AIDS as a comparison. Referencing how it spreads through disease-like-vectors

    You guys are missing the ACTUAL spread of HIV/AIDS in some places where the addiction is raging. Sharing needles….

    Very good story, Lambert, keep piecing the puzzle together.

  18. Katharine

    Speaking of credentialism, it was “prestigious” JAMA (and I would suggest applying the term to an academic journal automatically casts doubt on its intellectual respectability) that once rushed to publish a badly designed “study” ostensibly by a child who apparently was actually coached by her mother’s MD boyfriend, all to discredit an alternative medicine therapy because the AMA hates alternative medicine. The method has continued to be studied, with intriguing articles being published occasionally in less political, more research-oriented journals such as the Journal of Orthopaedic Research and Annals of Internal Medicine.

    For those interested in the subject, Therapeutic Touch International Association, therapeutic-touch.org, provides some literature citations and an 89-page (pdf) copyrighted bibliography.

    Moral: Avoid prestige (and Google ratings) when seeking information.

  19. vegasmike

    I know there’s a problem with opioids. But for some of us its very beneficial, provided you have a certain amount of self-discipline. Two years ago I was diagnosed with severe spinal stenosis. It was so bad that I could hold a fork, button my shirt , or zipper my fly. If I didn’t have surgery. I would have been paralyzed and incontinent. The surgery worked. I lead a normal life. But without Percocet, the pain would be unbearable. I’ve tried marijuana. It’s not that effective. I do Tai-Chi and physical therapy exercises. I even walk and swim. I worry that the pain puritans will take power and insist that I must suffer.

  20. VietnamVet

    The major changes that I have seen since 1961 include widespread pornography, casino gambling, drug addiction, homelessness, forever wars, economic crashes and student debt. In each case someone is making money and the costs to society are discounted. Privatizing gains. Socializing costs. This post on the opioid epidemic is an excellent specific example of this. The gutting of the Western Middle Class and the economy and morality that support it is extremely destabilizing. Either there is a restoration of the rule of law and punishment for crimes against society or “Peace and Prosperity” will be a quaint phrase from half a century ago. That is if mankind survives climate change and/or the Cold War 2.0 with Russia.

  21. henry_hill

    “Although the U.S. constitutes only 4.6 percent of the world’s population, Americans use 80 percent of the world’s opioids.”

    Eighty percent? I’d love to see the data mining in that study. That’s a ridiculous number. Opioids are used in almost every culture, just not the drive-thru pharmacy variety.

    1. fajensen

      My American colleagues, at the same age as me, are all, with a few exceptions, consuming a ridiculous amount of prescription medicine for all manner of things.

      My prejudiced opinion (because I don’t really know) is that many of them started off with some minor but chronic disease, then they got side-effects from the treatment, then they get treated for the side effects, etcetera. The whole thing escalates and they are now bound to eating 15+ different “meds”.

      My father was trapped in this bullshit for maybe 20 years, before the government created “palliative teams” – a team of doctors who will go through the medication and illness history of chronic patients. They re-evaluate and re-design their treatment. Usually with life-saving effects, as in: Unexpected years of improved quality of life.

      The cause of the “minor, but chronic disease” is (again in my biased opinion) probably due to unhealthy food; The medicated men can’t cook, their wives cannot cook anything “from scratch”. They rely on food items in bags, boxes or frozen “because the nutritional values are printed on them, so we know what we are getting(!)”.

      The exceptions … they can cook proper food.

      In my opinion, Americans are getting slowly poisoned and they are not getting any help either because the US food industry is allowed to sabotage the access to unadulterated foodstuff. This is one of many reasons that people “here” hate the TTIP & Co: We don’t want to be American! We don’t want US business practices.

  22. JimTan

    Looting is definitely the right term here. I suspect there are many actors who became fabulously wealthy from the prescription opioid (and amphetamine – ADD medications like Adderal are analogues to street Methamphetamine) scam.
    Just to put the scale of looting into perspective it should be noted, for readers that live in New York City, that the Sackler family which founded Purdue Pharma funded the Sackler Wing at the Metropolitan Museum of Art which houses the Egyptian Temple of Dendur and study centers for Chinese and Japanese Art History. They are truly magnificent for those who have never visited. Below is a link to additional organizations the Sackler family has endowed:

    https://en.wikipedia.org/wiki/Raymond_Sackler#Philanthropy

    From the Wikipedia link they include:

    • The Raymond and Beverly Sackler Foundation Fellowship at Institut des Hautes Études Scientifiques (IHÉS), France, to fund invited researchers from Israel at IHÉS, 1990
    • The Raymond and Beverly Sackler American Fellowship at IHÉS, France, to fund invited researchers from the USA at IHÉS, 2002
    • Raymond and Beverly Sackler Institute of Biophysics, Raymond and Beverly Sackler Faculty of Exact Sciences, Tel Aviv University, 2004
    • The Raymond and Beverly Sackler Distinguished Lectureship at IHÉS, France, 2004
    • The Raymond & Beverly Sackler Institute for Biological, Physical, and Engineering Sciences, Yale University, 2008
    • Raymond & Beverly Sackler Laboratories of Biomedical and Biophysical Studies, Rockefeller University, 2008
    • Raymond and Beverly Sackler Center for Biomedical and Physical Sciences, Weill Cornell Medical College, including a program in cardiac stem cell research dedicated to friend and colleague Professor Isadore Rosenfeld, 2008
    • Raymond and Beverly Sackler Fund for Biomedical and Physical Sciences (in honor of Phillip A. Sharp), Massachusetts Institute of Technology, Cambridge, Massachusetts, 2010
    • Raymond and Beverly Sackler Laboratory of Biomedical and Physical Sciences, University of Washington, Seattle, Washington, 2010
    • Raymond and Beverly Sackler Laboratories in the Physics of Medicine, University of Cambridge, Cambridge, United Kingdom, 2010
    • Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, Connecticut, 2011
    • Raymond and Beverly Sackler Center for Biomedical, Physical and Engineering Sciences in honor of Emilio Segre, University of California, Berkeley, 2011
    • Raymond and Beverly Sackler Laboratories for Biomedical, Physical and Engineering Sciences in honor of Saul J. Farber, New York University, School of Medicine, 2011
    • Raymond and Beverly Sackler Center for Convergence of Biomedical, Physical and Engineering Sciences in honor of David Baltimore, California Institute of Technology, 2012
    • Raymond and Beverly Sackler Center for Convergence of Biomedical, Physical and Engineering Sciences in honor of Herbert Pardes, New York Presbyterian Hospital, Columbia University Medical Center, 2012
    • The Raymond & Beverly Sackler Convergence Laboratory, Tufts University School of Medicine, 2013

    Not a bad payday for facilitating worldwide opioid addiction.

    1. JimTan

      https://en.wikipedia.org/wiki/Arthur_M._Sackler

      “He endowed galleries at the Metropolitan Museum of Art and Princeton University, the Arthur M. Sackler Museum at Harvard University in Cambridge, Massachusetts, the Arthur M. Sackler Museum of Art and Archaeology at Peking University in Beijing, the Arthur M. Sackler Gallery of the Smithsonian Institution, in Washington, D.C., and the Jillian & Arthur M. Sackler Wing at the Royal Academy, London. ”

      https://en.wikipedia.org/wiki/Mortimer_Sackler

      • Sackler Library at the University of Oxford
      • Sackler Laboratories at the University of Reading
      • Sackler Musculoskeletal Research Centre, University College London
      • Sackler Institute of Pulmonary Pharmacology at King’s College London[2]
      • Sackler Crossing – a walkway over the lake at the Royal Botanic Gardens, Kew
      • Sackler Biodiversity Imaging Laboratory at the Natural History Museum, London

  23. Rick Cass

    The kind of destructive social conduct was noted by cultural anthropologists studying cultures affected by Euopean colonization. As the meaning of the culture was drained by colonial predation, the societies degraded, people lost direction, language changed rapidly and the previous social networks unraveled. Essentially, the colonized no longer saw or felt that there was a place for them. In the present case, the working class that formed out of and as a consequence of two world wars no longer has a place in this country. Thus, similar responses to this displacement. In the present case, the colonizers are the credentialed class of mandarins who see themselves as separate from their fellow citizens.

  24. Pespi

    Something I think is lost in the opioid deaths discussion is the fact that these people had real pain. Terrible pain. Treating that pain is good. But a doctor can’t change a sedentary culture that creates much of that pain. Everything about constant sitting is bad for the body, and when the sedentary body starts moving, things get worse, because terrible movement patterns are ingrained. There’d have to be nationwide physical therapy to solve it. I recommend reading and following ‘deskbound’ by Kelly Starrett, if you’re a sedentary person.

  25. JimTan

    Many Doctors and Pharmacists are well aware they are selling pain medication to drug addicts:

    http://www.nydailynews.com/new-york/nyc-crime/couple-made-millions-running-nyc-pill-mills-prosecutors-article-1.2415980

    Quote from a 2012 Bloomberg article about South Florida pain ‘Pill Mills’:

    http://www.bloomberg.com/news/articles/2012-06-06/american-pain-the-largest-u-dot-s-dot-pill-mills-rise-and-fall

    “To move large amounts of prescription painkillers in America, you need somebody to write the prescriptions. You need doctors. Hiring doctors to sell drugs is easy, says George. He found his doctors by posting ads on Craigslist. At their peak, when they were running the largest pill mill operation in the U.S., the George twins had roughly a dozen doctors working for them.

    George says not a single doctor he interviewed ever turned down a job offer. Although he was always younger than the doctors he was interviewing—he was in his late twenties at the time—George says he made a professional impression. “I had such a big office; it was an easy sell,” says George. “They didn’t walk into some hole-in-the-wall place. The hours were good. The pay was good.”

    What the jobs lacked in prestige, they made up for in wages. According to George’s indictment, doctors at his clinics were paid a flat fee for each opioid prescription they wrote—typically, $75 to $100 a pop. To help maximize their efficiency, doctors were given prescription stamps they could use quickly, over and over. It was common for physicians at American Pain to see 100 patients a day, he says. At that rate a doctor would earn roughly $37,500 a week—or $1.95 million a year.

    It was a doctor who first advised him to go into the industry. At the time, he and his brother were running a hormone-replacement therapy business and selling steroids online. Along the way they got to know a doctor who told them that painkillers were a much bigger market and advised them on how to get started. The doctor later died in a car crash overseas, but he left the George brothers with a lucrative business model. According to prosecutors, the twins’ pain clinics, over their two-year run, sold 20 million oxycodone pills and brought in $40 million.”

  26. barrisj

    One minor cavil in your article, Lambert, and that concerns labelling PNAS a “less prestigious journal”, as opposed to JAMA or NEJM. Back in the day when I was an active research scientist, publication of original work in PNAS was considered a very worthy accomplishment indeed, as were papers published in Nature, Science, etc. It is a multidiscipline journal, taking in a broad cross-section of the physical and social sciences, as well as medical research, wherein submission of articles for publication must be done by a member of the National Academy of Sciences, a very “prestigious” group, to say the least…peer-review and all that, of course. Now, whatever the reasons for manuscript rejection by the two strictly medical journals, only their respective editors would know; but I suspect it may have to do with…yes, “credentials”, as neither of the two authors have any sort of specialised medical background or even one in epidemiology, but are economists, not the usual senior authors JAMA prefers. And, “failure” – a rather loaded word – to gain acceptance in a specialty journal in no way reflects the essential merits of the work, which clearly has been reflected in the immense reception and subsequent citations received in the lay press and media. I look at this as JAMA/NEJM’s loss, and PNAS’s gain, quite simply.

    1. barrisj

      And, BTW, not to pull rank, or anything as crass as all that, but I’ve been published in both PNAS and Science, if my “credentials” are at all in dispute…look here, old boy, I’ll send you by PM the references, right?

      Cheers,
      your faithful correspondent

  27. Rick Cass

    Well, this epidemic seems to be targeting those no longer economically useful to the 1%. There will be much handwringing, and posturing on the Nightly News, but not much actually done.

  28. Fiver

    While there are many excellent reasons to detest Big Pharma, I am very uncomfortable with the idea that just because a drug could be addictive, and some people misuse it, some deliberately, with deadly results, it is therefore unethical to produce, use or prescribe for use. If Oxycontin is what it takes to alleviate an individual’s serious pain, then Oxycontin is what that person gets – nobody has the right to decide someone else will just have to suck it up and embrace their pain. I have absolutely no use for the thinking of the person who, having ‘toughed out’ some major pain or other, believes those in longer-term pain are wimps or frauds, the imagination having failed to provide the key thought: suppose the pain never ends? To that idiot I say ‘Here, let’s trade bodies.’ (within limits, of course)

    Opioids have been miracle drugs for a very, very long time. And so has pain. However, I’d suggest there’s never been so high a percentage of the population with serious pain issues as there are now in the ‘advanced’ industrialized nations. While a combination of perverse industry and professional practices has indeed created a problem, I’m more concerned as to why so many people are suffering from so many relatively new physical and mental/emotional syndromes to begin with, pain being one major group. I rather expect it’s a life-times’ absorption of thousands of toxic compounds we pour out, which just might connect with another major group or two or three.

  29. rwv

    “If I had hostages to fortune, and especailly if I had to support a family, especially in today’s new normal, I might put my head down and save ethics for the home.”

    I guess that’s what got us here in the first place; the Eichmann defence

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