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 Opioids 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. (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 wasinstantly 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 opioids, 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.
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.
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.
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.
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.
Summing up: We're looking at a deadly epidemic, in the white working class, previously unnoticed, fueled in part by OxyContin, 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:
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 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:
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?
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.
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?
 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 has been so different." Always credentials, eh?
 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.
 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!
 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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