Opioid Crisis Shows How Economic Inequality Kills

By Lynn Parramore, Senior Research Analyst at the Institute for New Economic Thinking. Originally published at the Institute for New Economic Thinking website

Pharmaceutical pushers like Purdue Pharma “couldn’t have done their dirty work” without America’s increasingly unbalanced economy

America’s growing rate of economic inequality is more than a numerical ratio that worries economists or a trendy political talking point. The phenomenon has been linked to human tragedies ranging from higher murder rates to growing gaps in life expectancy.

Add death by opioids to the list.

In recent years, social scientists have been debating why more people have been dying from drug overdoses. Does the increased availability of highly addictive opioids fully explain the rise? Not entirely, it turns out.

Sociologist Shannon Monnat is author of a new study with the Institute for New Economic Thinking that examines county-level drug deaths in the U.S. Her research reveals that while overprescribing doctors, pharmaceutical pushers and illegal dealers are highly significant, a big part of what makes a community susceptible to the opioid scourge is recent patterns of economic distress — the kind inflicted by decades of bad policy.

A recent flurry of headlines about the billionaire Sackler family, whose members own Purdue Pharma, the company that created the powerful opioid painkiller OxyContin, highlights the ugliness of drug sales representatives promoting dangerously high doses to boost profits. “Supply is certainly important,” says Monnat, “but Big Pharma couldn’t do its dirty work without America’s increasing economic inequality.”

Monnat’s research examines U.S. drug fatalities from 2000-02 and 2014-16, two-thirds of which were caused by heroin, fentanyl, and prescription opiates. She concentrates on non-Hispanic whites because other than American Indians, that group has suffered the highest drug mortality rates of anybody over the last two decades.

Several of her findings complicate the common media narratives. Despite the characterization of opioids as “hillbilly heroin,” most deaths and the biggest increase in fatalities among whites since 2000 were actually in urban counties. Rural areas saw fewer deaths overall, but the rates varied widely from one region to another. Some rural counties have the highest opioid mortality rates in the country, while others enjoy the lowest.

Why would opioids be raging through some predominately rural states, like Maine and Kentucky, but not others, like Idaho and Iowa?

Among non-urban counties, drug mortality rates appear to spike in two types of places: economically beaten-down communities centered on mining and distressed areas where people increasingly depend on service jobs. In these corners of America, economic anxiety matters more in terms of how many will die from opioid overdoses than supply factors, which tend to drive death rates more around big cities.

Monnat explains how despair builds in areas like Appalachia, where residents have seen mining jobs disappear and there are fewer ways for people without a college degree to make a living. In regions where manufacturing jobs were once abundant, like Pennsylvania, people have to rely on badly paid service jobs that offer few benefits.

Communities facing these challenges begin to implode. The best and brightest young people tend to leave to find jobs elsewhere. Families break apart. The tax base shrinks and social services disappear. Economic policies that support disinvestment in the public sphere, along with those that disfavor workers and allow corporations — like greedy pharmaceutical companies — to run roughshod over communities make everything worse. Distress spreads across generations.

On the other hand, rural areas where people are more reliant on farming or where there are a wider variety of jobs tend have a lower rate of death from opioids. The quality of labor markets matters, it turns out. Monnat also thinks that that greater social cohesion in these communities may help people stay more resilient when economic strains develop. Having a more robust social safety net helps, too. Elsewhere, she has shown that places where religion and sports are more of a focus also tend to have lower rates of drug fatalities. Maybe going to church or rooting for the local team gives people meaning and a sense identity, which helps them cope better when other sources of these human needs disappear.

The opioid crisis is really a “tale of two rural Americas,” says Monnat. In places where economic inequality has thrown more lives into chaos, a greater number of lives will be snuffed out by this deadly strain of drugs. (Methamphetamines, she notes, cause slower deaths, so we may not have the full story of their impact on drug fatalities yet).

Her findings suggest that no matter how well intentioned the efforts to limit supply or provide treatment to the addicted, places where the economy isn’t working for most people may continue to see high opioid fatalities.

Research like hers underscores the reality that policymakers in both political parties are going to have to move beyond the neoliberal framework popularized in the Reagan era that promotes corporate deregulation, shrunken social safety nets, and trade and labor policies that hurt ordinary workers. Such policies were meant to spark growth, but instead they have only made a thin slice of people wealthy and socked America with inequality that has disproportionately hit certain regions of the country.

Pro-worker policies, investments in public services like health and education, fairer tax systems, and re-establishing sensible rules for how companies do business are all part of a much-needed prescription for a healthier society.

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  1. Gregory Etchason

    It is similar to Peruvian Indians chewing Coca leaves daily for centuries just to make a life of drudgery tolerable.

    1. Joe Well

      I lived in Peru and coca is a very mild stimulant, like coffee without the edge. It also has vitamins and minerals like most leaves. It does help with coping with low oxygen at high altitudes. I doubt the lives of the people of Peru have any more drudgery than the lives of people anywhere.

      Coca tea is on the menu at most cafes and restaurants in the country. It is not just for rural consumption.

      Once I went traveling in North America with a friend from Peru. He was literally brought to tears by the sight of the drug addicts one place we went to. That level of addiction is rare in Peru though not everywhere in Latin America.

    2. Wukchumni

      Many friends have hiked the Andes and all talked of how chewing coca leaves allowed the drudgery of high altitude to not be the burden it can be. It wasn’t a matter of cost either, a big paper sack full was a few bucks.

  2. JEHR

    We have a vicious circle going on here: the rich create drugs and in order to increase profits from year to year describe the drugs as non-addictive, which proves false. The rich pharmaceutical inventors and other distributors of drugs want more profits so they sell more drugs again insisting on their non-addictiveness. The poor, who no longer have good-paying jobs because these jobs have been moved overseas so that the companies can save money and make bigger profit by paying overseas workers less, are filled with despair and depression and are prescribed the “non-additive” drugs in order to maintain some degree of normality of being. Hence, the pharmaceutical developers sell more and get richer and the drug users die a miserable death too early. Nice, hey?

  3. thesaucymugwump

    The opioid crisis is only one consequence of allowing selfish, ignorant libertarians to make policy. Anyone older than 50 remembers a pre-Walmart country where most things were made in the US. When most jobs are part-time, low-paid ones with no benefits, despair grows.

      1. thesaucymugwump

        Alan Greenspan, Phil Gramm, Paul Ryan, and Christopher Cox, just to name a few, not to mention the Cato Institute the members of which said things like:

        Daniel J. Ikenson: “In fact, since China joined the WTO in 2001, U.S. exports to China have more than doubled. … And the notion that importing from and offshoring to China is hollowing out American manufacturing is not supported by the facts.”

        Doug Bandow: “The silliest argument against PNTR is that Chinese imports would overwhelm U.S. industry. In fact, American workers are far more productive than their Chinese counterparts … Moreover, Beijing’s manufacturing exports to the United States remain small, about half the level of those from Mexico.”

        Deroy Murdock professing that PNTR “will pressure China from inside and out” and that “Americans will enjoy more Chinese-made apparel and appliances at reasonable prices if PNTR passes.”

        Census Bureau data clearly shows that in 1985, the year data first became available, trade with China became negative and never looked back.

  4. Joe Well

    I wish I had more time to read more on this. I wonder how deep the authors go in their emphasis on “inequality” rather than “poverty” or “low incomes.” I’m from the Boston area, where the opioid crisis has hit hard, and there is low poverty but high inequality.

    One thing about high inequality that I wish got discussed more here: it drives up the cost of housing (and to a lesser extent, most other things), which totally undercuts the buying power of wages. Massachusetts is moving toward a $15/hour statewide minimum wage (it’s at $12/hour now). I strongly suspect that residential rents will rise to suck up a large part of that unless we have the kind of downturn that pushes luxury apartments into the lower rungs of the market.

    1. DHG

      Prices seek equilibrium to the dollars chasing an item, the rich are able to chase much more than any wage earner can hence the wage earner is cut out from access to things more and more.

      1. Joe Well

        DHG, that is true, but the definition of “rich” needs to be pinned down. Boston has a lot of households making over $100k/year and the housing market is geared toward extracting rent from them. I doubt most of them would consider themselves rich, but that’s where the fault line is.

    2. Jerry B

      ====One thing about high inequality that I wish got discussed more here: it drives up the cost of housing (and to a lesser extent, most other things), which totally undercuts the buying power of wages====

      Thanks Joe. I agree with your comment completely. The cost of living drum is one I have been banging on in comments on NC. In this country and the world we have a income and wealth redistribution problem.

      The solutions to the problem need to be addressed on multiple fronts. The fight for a higher minimum wage, higher income taxes on the upper classes, and a wealth tax, etc, are important but we also have to stop the soaring increase in cost of living. If we do not begin to contain soaring prices for things such as housing, healthcare, transportation, college, food, etc. where does it end?

      In 1979 the average monthly rent in Chicago was $279. In 2019 the average rent in Chicago is roughly $1200. Ten years from now when the average rent in Chicago is $2000 are we going to raise the minimum wage to $20, $30? $30,000 for a new car, $40,000 for a new pickup truck, $25,000 per year for college tuition and room and board, and soaring healthcare costs that bankrupt many people.

      To borrow concepts from I think Marx. What we are paying in the US for many basic needs is exchange value and not use value. My father used to say that a car is something to take you from Point A to Point B and it just depends on how much you want to pay. I live in the far northwest suburbs of Chicago and I see a lot of GMC Yukons/Chevy Suburbans usually with one person in it. A 2018 GMC Yukon is $50,000. That is obscene. Even if a person could afford it, by paying it they are enabling the car manufacturers to charge what they want.

      When I was in high school in the 70’s you could buy a beater car for a couple thousand dollars. Now?? Go to any used car lot but bring smelling salts with you. I would venture that the supply of used cars far outstrips demand so something else is keeping car prices high.

      I am no economist or finance expert so I am light on solutions but something has to change or the bubble will burst. As Lambert, Thomas Franks, and other have pointed out, many in government are part of the affluent, credentialed, elitist upper classes so as I am not optimistic for solutions from the government anytime soon. And I do not think socialist type price controls are an answer but as I said that is out of my knowledge area.

      Thanks again for your comment Joe! The other half of the inequality equation, costs of living, needs to be addressed.

      There is a good book called Dream Hoarders that discusses some of what I mentioned above.

      1. Joe Well

        I will definitely check out that book. I thought I was the only one banging this particular drum in comments. This problem is invisible to many because it disproportionately affects the young (but is by no means limited to the young! I just listened to an NPR interview with a retired woman who has to live with her brother! She cant even get subsidized housing for retirees).

        The cost of cars in inflation adjusted dollars is controversial because cars are just so much more reliable now, apples and oranges comparisons are almost impossible. But the national policy of encouraging SUV and pickup ownership is one of the most absurd aspects of our national mismanagement. Imagine if you told someone in 1977 that the average car in the 21st century would be just as fuel inefficient (OK, not sure about the exact numbers).

        As for rent control, what we had in Greater Boston before 1995 was both market driven housing construction with few impediments to development and rent control. So there was plentiful supply at reasonable cost. But rent control was abolished through a campaign funded by small landlords who then took the opportunity to fight new construction so they could rent gouge. Any incumbent fights competition and small landlords are no different. The insidious thing was they mastered the language of community, preservation, smart growth, etc. that appealed to the racist and classist sensibilities of many residents of affluent places like Cambridge while giving them progressive cover.

  5. Tomonthebeach

    Basically, this is a rehash of Monnat’s little study which is far from convincing and seems to be cherry-picking to support Case and Deaton’s despair hypothesis. Case and Deaton are more convincing.

    If I was reviewing Monnat’s paper, I would recommend major revisions to better explain how slicing up her data pie does not render degrees of freedom impotent as far a significance goes. So you can find both urban and rural counties with lots of ODs, and alas many more with not so many – so what? That hardly justifies expounding on how economic factors cause ODs.

  6. William Hunter Duncan

    This is why I condemn liberal/Dem ideology as much or more than Republican. Two major parties to sell out Americans and America to corporations, banks, billionaires and an eternal privatized war machine. Growth and progress ideologies building on and reinforcing the pathological and ecocidal.

    So god damned sure of themselves, so arrogant and condescending. Contempt does not even begin to describe what I feel about the leadership of this empire.

    Even now I can hear liberals and Dems justifying the economics that leads to such destitution for so many.

    1. Sol

      “It’s okay when we get bad results. We’re the good guys, we use the right words, and we meant well.”


  7. run75441

    In 1980, this particular letter to the editor was published in the NEJM. Two doctors authored it. Everything said in it is true. I would not contest it.

    “Addiction Rare in Patients Treated with Narcotics

    Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction. Jane Porter; Herschel Jick; MD Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Waltham, MA.

    It was cited a few times from 1981 to 1988 each year.”In 1989, the numbers of citations doubled and at certain points tripled. From 1981 to 2017, this letter was cited 608 times. 72.2% (439) of the citations, quoted the letter or used it as evidence addiction was rare in patients when treated with opioids such as oxycodone. 80.8% or 491 of the citations failed to note the patients described in the letter were hospitalized at the time they received the prescription.” The median number of citations for a NEJM letter is 11 times.

    OxyContin was introduced in 1996 by Purdue Pharma and aggressively sold to doctors. Sold as a less-addictive alternative to other painkillers as it was made in a time-release formulation, allowing for a slow onset of the drug, and not a hit all at once which is more likely to lead to abuse. When used as prescribed, Oxycontin was safe. When ground up, it’s slow release characteristics were marginalized. Shortly after 1996, Porter and Jick’s letter citations doubled and continued to be cited in a positive fashion with few negative citations and a failure to mention the hospital setting where the drugs were administered.

    In 2007 in the pharmaceutical industry, “the manufacturer of OxyContin and three senior executives of Purdue Pharma plead guilty to federal criminal charges that they misled regulators, doctors, and patients about the risk of addiction associated with OxyContin. Even then the lobbying to restrict state laws regulating opioids continued. From 2006 to 2015, pharmaceutical companies spent $880 million in lobbying state and federal legislatures and contributing to campaigns to prevent laws restricting Opioid prescriptions. Their lobbying expenditures has outstripped those advocating for greater controls on prescriptions by 200 times giving them greater influence at the state level.

    In 2018 law makers questioned Miami-Luken and H.D. Smith wanting to know why millions of hydrocodone and oxycodone pills were sent (2006 to 2016) to five pharmacies in four tiny West Virginia towns having a total population of about 22,000. Ten million pills were shipped to two small pharmacies in Williamson, West Virginia. The number of deaths increased along with the company and wholesaler profits.

    This crap does end up in rural areas and it does impact the poor. As tends to happen with public health epidemics, overdoses have an outsize effect in certain regions. For instance, the biggest spike in fatalities by percentage occurred in Nebraska, North Carolina, New Jersey, Indiana, and West Virginia (33.3%, 22.5%, 21.1%, 15.1%, and 11.2% rises, respectively). But areas like Wyoming, Utah, and Oklahoma experienced declines of 9.2% to 33%.

    These are just bits and pieces of what I have written on the topic of opioids and its impact all over America. “60% of opioid deaths occur in those who were given a prescription by a physician. The other 40% of deaths are caused by people who obtained opioids by “doctor shopping,” and receive multiple scripts at once.

    Usually someone will show up and start to argue with your comments or the numbers of deaths.

  8. John M

    “Add death by opioids to the list”

    Wonder if it is possible to recreate a list of all of those who have died because opioids/fentanyl overdose?
    Remembering those we have lost (especially in such high numbers) reminds us of the collective and specific areas of communal loss in this country (i.e. West Virginia etc.) instead of the same type of sad individualized they-should-have-known-better pretension that often masks addiction/substance use in this country, especially as the aim of neoliberalism’s second tenant — please die — is always operating.

    Also, a running list might allow for more examination of each current death in context (pusher, supplier, distribution and invisible institutions enabling system to perpetuate for profit).

  9. BoyDownTheLane

    Did anyone mention the clipper ship barons who made fortunes off opium? The original families locked into Skull & Bones (arguably a foreign intervention linked to Marxism, the Rothschilds and later the CFR, the Trilateralists, and the Rhodes gang)? Or the massive trafficking in illicit narcotgics by the nation’s intelligence agencies?

    1. JBird4049

      I don’t know about Marxism of all things being a connection unless you mean Karl Marx started his work after seeing the misery of the Industrial Revolution; a revolution partially fueled by the Chinese money the British got after starting and winning the Opium Wars. So I guess opium is partly responsible for Marxism.

  10. Bob Anderson

    I don’t agree. what, they couldn’t afford “better” drugs where you would not OD? The consumerism is what causes OD. Cheaper drugs just make it easier.

    The drug culture has been around since the mid-70’s in terms of hard drugs. That correlates well the surge in single mother births and divorces. Matter of fact, everything goes back to the mid-70’s.

    1. JBird4049

      Not quite. It’s confusing correlation with causation. The social problems might have increased because of the increase in hard drugs. Maybe, but drugs and addiction was always prevalent.

      The British had an awful problem with alcohol especially gin in the general population 1700’s, and later in 1800’s with morphine, opium, and cocaine. The Americans had similar problems, although not with the extremely cheap gin that used to be sold in Britain. After the American Civil War addiction to morphine increased with the millions of injured soldiers/addicts.

      All of the older hard drugs were sold over the counter and with no prescription. Indeed, they were added to everyday medicine. Teething problems? Womanly complaints? 14 hour work shifts at the factory? They had the medicine just for you! Coca-Cola had cocaine in it originally and (I believe) a pharmacist created it.

      It was with such legislation as the Food and Drug Safety Act in the early 1900s, the general improvement in working conditions, and having all the old addicts die, hopefully of old age, that decreased the levels of addiction. The problem never went away. The hard drugs were always around and used. It only declined and shifted to the more socially acceptable alcohol and nicotine. You might say that those manufacturers won the lobbying wars.

  11. Jack Gavin

    I realize that opiods are the topic here. But crystal meth has to be included in any discussion regarding drugs and death. Also, I wonder if crystal meth and its cousins are more prevalent in those places where opiods are less of an issue.

  12. VietnamVet

    If it makes money, neoliberalism deregulated it. In the case of fentanyl, prescription restrictions were ignored. FDA looked the other way. Manufacturers and prescribers got richer. China is now meeting the users demand for the drug. The enablers of this have all imbibed the global aristocrat’s contempt of the little people. Lexus lanes, housing, medical care, student loans, casinos and drugs are all extortion schemes to extract what little wealth that is left. Poor Americans are dying earlier with $15,000 of debt.

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