Chasing the Scream: The First and Last Days of the War on Drugs (46 page)

This leads to the second question: Why did the prescription drug crisis radically accelerate in the past decade? There are two possible explanations. The first is the only one any of us have ever heard. It says that doctors—urged on by the greed of Big Pharma—have been handing out these legal opiates for conditions such as back pain without properly warning their patients about the risk of addiction, and as a result, lots of people are becoming accidentally addicted. You go to the doctor, you take a painkiller believing it’ll only deal with your slipped disk, after a few months of taking it, you find that your body needs these chemicals in a very real physical sense—and you can’t give them up without going into terrible withdrawal and panic. This is what most people believe has driven this crisis, and it seems like common sense.

But there’s a crucial piece of evidence that has been omitted from this picture. As we saw earlier, in hospitals across the West, people are given much more powerful opiates than Oxycontin and Vicodin day in, day out. For example, the diamorphine—heroin—you will be given if you have a knee replacement is a really powerful opiate, agreed by doctors to be around three times more powerful
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than Oxycontin, and you will often take it for a long time as you recover. Yet—as we saw before, and has been proven beyond doubt—this almost never turns people
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into addicts. So how could a really powerful opiate cause virtually no addiction when given out by doctors, and an opiate that is three times weaker cause so much?

This suggests we should look at the other possible explanation—a story taught to me by Bruce Alexander back on the streets of the Downtown Eastside. Bruce showed that at any given time, you and I and everyone around us has access to a huge array of chemicals that could drive away our pain for a while, from vodka to valium. Almost all of the time, we leave them on the shelf, unused. So the question is: Why are there sudden moments when large numbers of people, scattered across different bathrooms and barrooms, suddenly pick them up and swallow them compulsively, all at once? The answer doesn’t lie in access. It lies in agony. Outbreaks of drug addiction have always taken place, he proved, when there was a sudden rise is isolation and distress—from the gin-soaked slums of London in the eighteenth century to the terrified troops in Vietnam.

This raises the question: Has anything happened in the United States in the past decade that could be the deep driver of the prescription drug crisis? It’s not hard to find the answer. The American middle class had been painfully crumbling even before the Great Crash produced the worst economic crisis since the Great Depression.
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Ordinary Americans are finding themselves flooded with stress and fear. That, Bruce’s theory suggests, is why they are leaning more and more heavily on Oxycontin and Vicodin to numb their pain.

This insight puts the prescription drug crisis in a different light. All those stressed-out moms hooked on Vicodin and all those truck drivers hooked on Oxycontin have been seeing their incomes shrink and their abilities to look after their families wither for years as their status and security in American society shrivel away. If Oxy had never been invented, Bruce’s evidence suggests, at a moment like this, they would have found something else in their bathroom or liquor cabinet to give them some relief—because in every previous crisis like this, people have found something similar.

It is not that the specific drug plays no effect—clearly it does. Vicodin and Oxycontin do contain chemical hooks, and those do play some role in the addiction. Remember the evidence from earlier, about how just 17 percent of tobacco addiction is caused by the chemical hooks in the drug? Given that tobacco is the most addictive drug, we would expect at most that the chemicals in Oxycontin play—at worst—a similar role in causing Oxycontin addiction. Now, 17 percent is a lot, and doctors should be conscious of it when they are prescribing these drugs to people who could be offered milder painkillers first, with fewer chemical hooks. But whichever way you cut it, 17 percent is still a small part of the effect. Focusing only on this smaller aspect and ignoring the much larger causes is one of the reasons why our responses to this crisis are failing so badly.

Yet even after finding this out, I still had a nagging sense that there was something I was not understanding about the prescription drug crisis. So I researched more, and I kept bumping up against the third question thrown up by this crisis: Why are so many people starting with Oxycontin and Vicodin and ending up using heroin?

This conveyor belt from prescription drugs to more potent stuff has been well documented—nobody can deny it—and at first it seems to refute everything I learned in Switzerland. Indeed, this dynamic is so intense it has become the dominant issue in several states. The crisis is so severe in Vermont, for example, that the governor in 2014 dedicated his entire State of the State address to the surge in heroin use, and it was widely claimed that prescription opiates had been a major cause.

Again, I discovered there are two stories about why this has happened. The first story is that this epidemic proves that the crisis is driven by chemicals. As your body becomes hooked, it clearly needs more and more powerful drugs to hit the same sweet spot. So your Oxy doesn’t do it for you anymore, and you turn to heroin. This is what happens when you let the genie of access to drugs out of the bottle—it runs away with you. Again, it sounds reasonable.

But there is another story about what has happened—one that requires you to understand a very different effect of our drug policy. This will sound weird at first—it did to me, at least—but it is a well-proven effect. In fact, if you want to see it in action, you can go to any college football game
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in the United States, any weekend of the year, and watch it with your own eyes. This effect is called “the iron law of prohibition.”
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To understand it, we have to first go back to the early 1920s, and the reign of Arnold Rothstein, where our story began.

The day before alcohol prohibition
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was introduced, the most popular drink in the United States was beer, but as soon as alcohol was banned, hard liquor soared from 40 percent of all drinks that were sold to 90 percent. People responded to a change in the law by shifting from a milder drink to a stronger drink. This seems puzzling. Why would a change in the law change people’s tastes in alcohol?

It turns out it didn’t change their tastes. It changed something else: the range of drinks that were offered to them. The reason is surprisingly simple. One of the best analysts of the drug war, the writer Mike Gray, explains it in his book
Drug Crazy
. When you are smuggling a substance into a country, and transporting it in secret, “you have to put the maximum bang in the smallest possible package,” he writes.

Imagine secretly transporting a trunkload of beer across the United States. You will be able to get, say, a hundred people their drink for the night. But load the same trunk with whisky, and you will be able to get a thousand people their drink for the night. So you’re going to smuggle the whisky—and when your drinkers come into your speakeasy, that’s all that you will be able to offer them, along with even more toxic drinks like Billie Holiday’s favorite, White Lightning, a booze so strong that even hard-core alcoholics would turn it down today.

Most people want to get mildly intoxicated. Relatively few of us want to get totally shit-faced. But if no mild intoxicants are available, plenty of people will use a more extreme intoxicant, because it’s better than nothing. Prohibition always narrows the market to the most potent possible substance. It’s the iron law.

Here’s how you can see it for yourself, as I promised before, at a college football game in the United States. As Gray explains: “Students are normally beer drinkers, but since alcohol is prohibited at the stadium, they sneak in a flask and become whisky drinkers.” The stadium is a zone of alcohol prohibition—and
⁹²
the college kids end up drinking a much stronger kind of alcohol than they’d prefer, because it’s better than nothing.

It works exactly the same way when you ban other drugs. Before drugs were criminalized, the most popular way to consume opiates was through very mild opiate teas, syrups, and wines. The bestselling Mrs. Winslow’s Soothing Syrup,
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for example, contained 0.16 grain of morphine. One wine laced with cocaine—Vin Mariani—was
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publicly recommended by Queen Victoria and Pope Leo XIII. The most popular way to consume coca was in teas and soft drinks.
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But within a few years of the introduction of prohibition, these milder forms of the drug had vanished. They were too bulky to smuggle: even though there was more demand for them, they weren’t worth the risk for dealers like Arnold Rothstein. That’s when coca tea was replaced by powder cocaine, and Mrs. Winslow’s Soothing Syrup was replaced by injectable heroin.

The harder you crack down, the stronger the drugs become. The crackdown on cannabis in the 1970s triggered the rise of skunk and superskunk. The crackdown on powder cocaine in the early 1980s led to the creation of crack, a more compact form of the drug. Many drug users want and prefer the milder forms of their drug—but they can’t get them under prohibition, so they are pressed onto harder drugs.

This is where the prescription drug crisis comes in—and we are forced to see it in a radically different light. Almost everyone who is addicted to Oxycontin, and gets cut off by their doctor, wants to carry on using Oxycontin. But under prohibition, it’s really hard to get a mild opiate like Oxy, and pretty easy to get a hard opiate like heroin. That’s how prohibited markets work: it’s the iron law. Dr. Hal Vorse, who treats drug addicts in Oklahoma City, talked me through the economics of it bluntly, as his patents explain it to him day in, day out. On the streets, Oxy is three times more expensive than heroin—way beyond the price range of most addicts. So, he told me, they “switch to heroin, just because of the economics of it.”

Just as when all legal routes to alcohol were cut off, beer disappeared and whisky won, when all legal routes to opiates are cut off, Oxy disappears, and heroin prevails. This isn’t a law of nature, and it isn’t caused by the drug—it is caused by the drug policy we have chosen. After the end of alcohol prohibition, White Lightning vanished—who’s even heard of it now?—and beer went back to being America’s favorite alcoholic drink. There are heroin addicts all across the United States today who would have stayed happily on Oxy if there had been a legal route to it.

This is worth repeating, because it is so striking, and we hear it so rarely, despite all the evidence. The war on drugs makes it almost impossible for drug users to get milder forms of their drug—and it pushes them inexorably toward harder drugs.

After absorbing all this, I realize we have been told a story about the prescription drug crisis that doesn’t graft onto reality. It has been presented to us through the old drug war story—the chemical is to blame, and if only we could eradicate the chemical, we could eradicate the problem.

It is a tempting story, because it is so simple—and allows us to avert our eyes from how much of this problem was created not by pills, but by people. The Swiss heroin experiment, combined with Rat Park, offers us the best answer not only to heroin, but to the prescription drug crisis, too.