President Donald Trump has repeatedly threatened to declare a national emergency if Congress refuses to pony up $5.7 billion to build the “great, great wall” he promised his base during the 2016 election campaign. In an apocalyptic televised address early in January, he even warned -- falsely, as fact checkers revealed during the speech -- that a tsunami of hard-core criminals and drugs was sweeping across the U.S.-Mexican border.
Fabricating national emergencies is unconscionable, especially when there are real ones requiring urgent attention.
Here’s an example: since 1999, 400,000 Americans have died from overdoses of opioids, including pain medications obtained legally through prescriptions or illegally, as well as from heroin, an illicit opioid. The Centers for Disease Control (CDC) notes that prescription medications were involved in 218,000 of those fatalities.
Even the president labeled opioid addiction a “public health emergency” after a commission he appointed in March 2017 issued a report detailing its horrific consequences. Trump’s efforts led Congress to allocate $6 billion to combat the crisis in 2018 and 2019, and the president sought another $7 billion for 2019. Since then, however, his attention has turned to the “emergency” along the border with Mexico, the equivalent, by comparison, of a gnat bite on an elephant.
His initial urgency regarding the opioid epidemic seems to have dissipated, though not his propensity for making false claims. At a May 2018 rally, for instance, he declared that, thanks to the $6 billion, “the numbers are way down.” If the president meant overdose deaths, however, his claim was blatantly false. Data from the CDC show that, between 2016 and 2017, prescription opioid overdose deaths decreased by a mere 58 from 17,087 to 17,029. As for overdose deaths from opioids of all sorts (whether legal and doctor-prescribed or illegal, as with heroin), they increased by 12%.
Congressional critics charge that the commission’s raft of recommendations hasn’t been implemented energetically, noting in particular Trump's proposed $340-million cut to the budget of the White House Office of National Drug Control Policy, which coordinates the government’s anti-opioid campaign. And given the scale of the epidemic, experts maintain that $6 billion over two years doesn’t come close to what’s needed to make a real difference.
The Toll Taken on Trump’s Base
High-voltage opioid painkillers were once derisively labeled “hillbilly heroin,” but that moniker has become archaic and misleading. While the misuse of such medications tends to be proportionately higher among the poor and in areas with high unemployment, it now spans classes and regions. In the late 1990s, the surge in overdose deaths did start in economically depressed rural communities and small towns -- in Appalachia in particular. Since then, however, the crisis has spread to suburbs and cities across the country.
Still, a strong correlation does exist between opioid addiction, overdose death rates, and economic distress, especially in small towns and rural regions, including Maine’s logging communities, areas reliant on commercial fishing, and Appalachian coal towns. In rural New Hampshire, where I spend part of the year, it doesn’t take long to start hearing about, or meeting, people whose lives have been upended by opioid addiction. Such communities were the first victims of the epidemic because their economic decline produced despair, hopelessness, and diminished self-worth. Moreover, plenty of people suffered chronic pain, whether from workplace accidents or physically demanding jobs.
President Trump ought to be particularly attentive to the country’s raging opioid addiction. Many of the hardest hit places are home to the very voters who helped elect him. During the 2016 presidential campaign, he presented himself as their champion, bemoaning the hardships of factory workers, miners, loggers, and others zapped by layoffs or wage cuts and living in communities in which the better-paying jobs on which they had depended, often for generations, were disappearing.
Data from the National Institutes of Health reveal that overdose deaths from all categories of opioid drugs -- legal and illegal -- soared from 10,000 in 1999 to 49,068 in 2017, with the numbers consistently higher for men. But heroin fatalities (15,958 in 2017) must be included in the mix because the use of that drug and of prescription opioids has become intertwined.
Although less than 5% of those who misuse opioid pain medications drift to heroin, nearly 80% of heroin users start by misusing opioids. In addition, both people hooked on such painkillers and recreational users often combine them with heroin to boost their highs.
Addicts tend to rely on heroin only when they can no longer afford to buy opioids but are still desperate to feed their habit and so stave off “dope sickness.” (Its wrenching withdrawal symptoms include nausea, chills, and diarrhea, as well as extreme anxiety and panic attacks.) Heroin dealers charge a fraction per fix of what illicit suppliers of the popular oxycodone- and hydrocodone-based analgesics demand per pill.
Consider Oxycontin. An 80-milligram pill costs about $6.00 at a pharmacy, but as much as $80 on the street. Compare that to the $15-$20 that will get you a hit of heroin. The price difference matters. Many opioid addicts end up putting the bulk of their earnings into purchasing the pills illegally, depleting their savings accounts. As a result, some end up resorting to selling personal possessions or even stolen machinery parts, piping, and copper wiring (for which there’s a large black market).
Unfortunately, even the 49,068 deaths in 2017 don’t provide the full picture. Additional fatalities result from combining painkillers with cocaine (4,184) or benzodiazepines (roughly 9,000). Add those into the mix and the total number of lives lost to the epidemic in this country reached 62,252 in 2017, the last year for which we have complete data. That figure soars higher yet if you include the nearly 16,000 deaths resulting from heroin.
To put the total number of opioid-related fatalities in perspective consider this: vehicular accidents killed 40,100 people in 2017. The decade-long Vietnam War resulted in 58,220 American deaths. More than five times as many Americans died from opioid-powered painkillers in 2017 alone as in the 9/11 attacks and the wars in Iraq and Afghanistan combined.
As for the economic consequences, a 2017 report by the president’s Council of Economic Advisors pegged the total costs of the crisis, including medical services, lost earnings and productivity, and law enforcement, at $504 billion in 2015.
In other words, unlike what’s happening on the southern border, this isn’t a faux emergency.
The Pathway to Crisis
In nineteenth-century America, opiates were widely prescribed to treat many afflictions: pain from wounds or injuries sustained by Civil War veterans, menstrual cramps, asthma, anxiety, even babies’ teething pains. But as doctors became more aware of a growing wave of addiction, the federal government imposed restrictive regulations on such medicines, culminating in the 1914 Harrison Narcotics Act.
Though that legislation didn’t fully stamp out opiate use, it did mark a turning point. Medical opinion would not revert to a favorable view of such drugs until the 1970s, after which numerous opioid painkillers hit the market. The Federal Drug Administration (FDA) approved Lortab in 1982, Vicodin in 1983, MS Contin in 1987, and Percocet in 1999. Fentanyl was first introduced in 1959 and its skin patch variant received official approval in 1990 for the treatment of acute pain.
The current epidemic didn’t start revving up until Purdue Pharma, owned by the Sackler family, developed Oxycontin, an oxycodone-based painkiller. Following FDA approval in December 1996, it became available, in varying strengths ranging from 10 to 160 milligrams. Compared to previous opioid treatments, Oxycontin was in a league of its own when it came to its potency. Doctors quickly started prescribing it, not a few with stunning abandon: in one instance 335,000 prescriptions over eight years. Within five years of its appearance, prescriptions had skyrocketed from 670,000 to 6.2 million.
Purdue claimed that Oxy, as it came to be known, was special and better than its predecessors because it worked through an extended, 12-hour time release, which would effectively eliminate addiction: the drug would neither provide a quick high nor have to be taken as often. In fact, the drug’s efficacy often petered out well short of the touted timespan. Purdue became aware of this but stuck to its claim.
By 2001, Oxycontin sales surpassed $1 billion a year. The boom was not spontaneous, but owed much to Purdue’s zealous product promotion. An army of sales representatives, deployed after being trained to convince doctors of the drug’s safety and efficacy, often offered those same doctors free meals, holiday gifts, trinkets, junkets, and more. Those sales agents did not lack for incentive; they received hefty bonuses pegged to their success. Top performers raked in more than their annual salaries in extra cash.
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Purdue also trained thousands of doctors, nurses, and pharmacists at numerous conclaves in beautiful venues -- all organized and paid for by the company -- to spread the word that Oxy was effective and safe, not only against the extreme pain produced by surgery or terminal illness but also more mundane varieties of pain caused, for instance, by back injuries or arthritis.
The strategy proved wildly successful. Sales revenues climbed because the pill was widely prescribed not just by those treating terminally ill patients, but also by family doctors who were already responsible for nearly half of all Oxycontin prescriptions by 2003.
The Devastation Becomes Undeniable
Doctors increasingly prescribed Oxy to treat pain (often from work-related injuries) and their patients quickly became addicted. Gripped by the drug, some feigned continuing pain in a frantic effort to get fresh supplies. “Doctor shopping” became common as well. Others stole pills from relatives or friends or bought them from illegal dealers, including those selling through the Internet at, among other places, social media sites like Facebook. Addicts also snorted pulverized pills or liquefied them and injected them intravenously, risking Hepatitis B or C or HIV/AIDS from shared needles. Still others turned to heroin.
Obviously, not everyone who took Oxycontin for pain got hooked, let alone died from an overdose. But when addiction did strike, it could ruin lives, as some addicts even fed their habit through petty crime or prostitution. The children of addicts often suffered from neglect or mistreatment as well -- an estimated 676,000 of them in 2016 -- or became the responsibility of grandparents or ended up in foster care.
As the evidence of a disaster mounted, some intrepid doctors, along with the relatives of people who had died from overdoses, started sounding the alarm. But Purdue had a formidable PR machine, the big bucks needed to hire top-flight attorneys, and the determination to fight back. As for clout in Washington, the company’s wealth and access to power far exceeded anything its adversaries could muster.
Yet as the addiction wave began to sweep the country and the death toll rose, medical researchers began highlighting the risks posed by Oxy and questioning its efficacy compared to less potent opioids. The FDA, the Justice Department, and the attorneys general of various states also began to pay attention. In 2007, following charges that it had failed to provide adequate warnings about the risk of addiction, Purdue paid $634.5 million as part of a plea deal with the feds. Three of its senior employees were fined a total of $34.5 million, which Purdue covered (though they avoided jail time). The company itself did not cop to any wrongdoing.
Numerous states also initiated lawsuits against the company, insisting that it was aware of the dangers of Oxycontin addiction but made misleading or false claims to deny or downplay the risks. In 2007, Purdue negotiated a $19.5 million settlement with 25 states and the District of Columbia, again without admitting to any wrongdoing. In 2015, it settled with Kentucky for $24 million. In 2018, six more states initiated lawsuits against the company.
In 2010, the FDA approved an addiction-resistant -- that is, harder to snort or inject -- version of Oxy and the original version was pulled from the market. As part of its legal settlements, Purdue also agreed to stop pitching opioid medications to physicians and slashed its sales staff.
Lest you feel any sympathy for the embattled pharmaceutical giant, know this: by 2001, addiction to oxycodone (the active agent in Oxycontin) had already increased five-fold. Yet Purdue and its experts-for-hire downplayed the danger and kept promoting the drug vigorously. According to a Justice Department report, the company also knew early on that the drug was being snorted or liquefied and injected, but did not think it useful to divulge news of the abuse. It also sat on evidence its own investigators amassed on the criminal trafficking of Oxy and on cases of doctors or drugstores dispensing it recklessly.
As for those fines, they amounted to chump change for the company, which by 2017 had amassed $35 billion in revenue, largely from Oxycontin sales in the United States and elsewhere. And the Sackler family? None of its members were ever charged, let alone convicted of anything; and, with a net worth of $14 billion, in 2015 they first made the Forbes list of the 20 wealthiest families in America.
The current opioid crisis transcends Purdue. For one thing, there are numerous, widely prescribed opioid medications out there besides Oxy, even though the number of annual prescriptions for opioid painkillers has actually declined since 2012. According to a report issued by the Surgeon General, they totaled 289 million in that year compared to 76 million in 1991. The CDC reports that they had fallen to 191 million in 2017. But as the agency notes, that still makes for a stunning 58.7 prescriptions for every 100 people in the United States, which remains peerless in the global consumption of opioid pain medications.
Since perhaps 2013, another problem has amplified the opioid crisis: the abuse, illicit manufacture, and smuggling of Fentanyl, a synthetic opioid analgesic whose potency exceeds morphine’s by 50 to 100 times and oxycodone’s by a factor of 1.5. A two-milligram dose can prove fatal.
Deaths linked to synthetic opioids, mainly Fentanyl, reached 29,406 in 2017, a nearly six-fold increase since 2014. The CDC found that Fentanyl was implicated in at least three-fifths of opioid overdose fatalities in 10 states during the last half of 2016 alone. The drug’s wallop and widespread availability from illicit Internet sites only heightens the risk of addiction and fatalities. Meanwhile, heroin overdose deaths, which started to increase sharply at about the same time as opioid-related fatalities, reached 15,958 in 2017 -- a three-fold increase from 2014.
To make matters worse, there are numerous Fentanyl analogs, including 3-Methylfentanyl, four times more powerful than Fentanyl itself. Though its illegal manufacture dates to the 1970s, it has recently made a comeback on the street and via the Internet. Then there’s Carfentanil. Used to tranquilize elephants and other large animals, it’s 100 times stronger than Fentanyl and it, too, has begun to make its deadly mark. In the first half of 2017, Carfentanil-related deaths nearly doubled, reaching 815. Just how deadly is it? For sedating an adult elephant, the safe dose is 13 milligrams. Just .05milligrams will kill a human being, scientists warn.
Those two drugs and other Fentanyl analogs are manufactured and trafficked illegally to underground networks in the United States or directly to individual users. China has become a key source of such illegal shipments. Contrary to President Trump’s claim -- as part of his pitch for his “big, fat, beautiful wall” -- only a small proportion of such illicit opioid drugs, including heroin, are ever carried across the border into the United States by undocumented immigrants. The bulk of what enters through Mexico comes hidden in vehicles that cross at legal entry points. There are many other modes of smuggling as well. A Senate report found that the U.S. postal service has become an unwitting conduit, as have commercial carriers like FedEx and UPS. Illicit sellers also operate through Internet sites and the Dark Web. When it comes to such drugs, a wall will make no difference.
The opioid crisis has now entered an even more dangerous phase. Doctor-prescribed opioid pain killers are no longer its main driver, and even when they are, they’re often combined with cocaine or benzodiazepines. Moreover, in 2016, illicit Fentanyl and heroin accounted for two-thirds of opioid-related deaths. Illicitly produced and trafficked Fentanyl and Carfentanil and their chemical kin may, in the end, dwarf the Oxycontin catastrophe.
And newer forms of high-potency painkillers will undoubtedly emerge as well. Take Dsuvia, which received FDA approval late in 2018 amid considerable controversy created by fears of addiction. It’s 500 times stronger than morphine and 10 times as potent as Fentanyl. How long before Dsuvia produces its own addiction and illegal trafficking problem?
No Easy Fix
The opioid emergency requires a multi-faceted and sustained solution. Addiction treatment would have to become better in quality and more equitably available. Because opioid misuse and addiction are particularly prevalent in parts of the country suffering from job cuts and low incomes, they would have to become a focal point for public investment and job retraining. The shape-shifting inflow of opioids from abroad would have to be stanched through measures that went beyond punishment. Corporations that endanger public health through their negligence and chicanery would have to face more than a rap on the knuckles.
In addition, a political order rigged by money and lobbyists would have to be revamped. From 2000 through 2018, companies making pharmaceuticals and health products spent a total of $3.8 billion lobbying in Washington, employing 1,407 lobbyists, not a few of whom had once worked in various capacities in the federal government, including as members of Congress. In 2018 alone, the amount devoted to lobbying just by the pharmaceutical firms that were among the top ten spenders came to $58 million -- and that doesn’t count the $21.8 million mustered by the Pharmaceutical Research and Manufacturers of America (PhRMA), which represents drug and biotech companies.
Given the scale, multiple causes, and consequences of the opioid crisis, the $6 billion earmarked for it isn’t remotely sufficient, while the moves the Trump administration and the Republican Party have made to cripple the Affordable Care Act will only hurt the effort. Meanwhile, every day, 130 people in the United States die from opioid overdoses and 70% of those battling addiction don’t receive long-term treatment, even though the necessary medicines are available.
So, Mr. President, if you want to tackle a genuine national emergency and are eager to spend another $5.7 billion or far more on a project that will, in the end, make you look better to everybody, including your base, take on the opioid epidemic -- and forget that useless wall.