To express the ambient feeling that “things are getting worse,” there exists, of course, a meme. It plots iterations of a chart, and on its x-axis floats the disembodied, smiling face of President Ronald Reagan. After his inauguration, watch the data veer up and off into oblivion: from health care spending, executive pay, and the size of the federal government, to the privatization of public services, social isolation, and economic inequality. The bottom line: only half of babies born in 1980—today’s forty-four-year-olds—will make as much money as their parents did.
I was surprised, then, to learn that publicists for the Sackler family—the owners of Purdue, which manufactures OxyContin, and, as the purported architects of the “opioid epidemic,” the epitome of contemporary capitalist villainy—presented a Reaganesque chart in a 2021 PR offensive called “Judge For Yourselves.” The project aimed to “correct falsehoods” and push back against a tidal wave of press that presented OxyContin as the epidemic’s singular culprit. Purdue, to be sure, did not literally present a chart with a smiling Reagan, but they might as well have.
This chart was designed by two infectious disease modelers, Hawre Jalal and Donald S. Burke, who made a grim discovery while examining the leading causes of death in America. They plotted drug-overdose deaths from 1979 to 2016, and what they found was utterly baffling: deaths consistently rose 7 percent each year, doubling every eight to ten years, for more than four decades. Nothing else—not gun deaths, not suicide, not AIDS, not car crashes—adheres to an exponential curve for this long. Since 1999, more than one million people have died from overdoses.
But in the United States, we don’t tend to think of this decades-long emergency as a continually accelerating death toll; it gets framed as a series of discrete, though sometimes overlapping, epidemics, implying a predictable arc that spikes, plateaus, and eventually falls. First, as the New York Times warned on the front page in 1971, there was a “G.I. heroin addiction epidemic” in Vietnam. The drug’s use was also on the rise in places like New York, where, in the following year, at least 95 percent of those admitted to drug addiction treatment reported using it. The crack cocaine epidemic arrived in the next decade, followed by a rise in the use of methamphetamines, which the late senator Dianne Feinstein would call the “drug epidemic of the nineties.” But these were soon displaced in the popular imagination by OxyContin, which hit the market in 1996 and set off successive waves of what came to be known as the opioid epidemic, something we’re still struggling through. The past forty-five years of drug use in America does not match this relatively tidy narrative—in reality, there’s a beginning and middle, with no end on the horizon.
But in a strange way, this exponential curve told a story the Sackler family could get behind, one that made them look less culpable: How could Purdue be responsible for the opioid epidemic if overdose deaths were rising for more than a decade before OxyContin was even brought to market? “We were contacted by [Purdue] lawyers,” Burke told me. “It was my sense that they would like us to testify that it wasn’t their fault.” They declined the offer.
Still, Purdue was right about something. Drug mortality in America neither begins nor ends with the company’s actions. What pharmaceutical manufacturers, drug distributors, insurance companies, doctors, and pharmacies—the entire profit-mad medical system—collectively accomplished was to accelerate a train that was already speeding off the rails. But it’s hardly an absolution to argue that you did not start the fire, only poured gasoline on it for personal gain. With corporate power unchallenged and regulators asleep at the wheel, drug markets, like so many other consumer markets, have become more deadly, more dangerous, and, despite decades of aggressive and costly drug enforcement, more ubiquitous.
Jalal and Burke’s finding also presented a paradox. How could four decades of seemingly distinct epidemics—from heroin and cocaine to meth and fentanyl—aggregate into one giant wave of death? How is this wave still gaining power, and when will it crash? When we zoom out, we have what looks less like a collection of epidemics involving a series of novel, addictive drugs, and something more like a chronic social crisis exacerbated by market conditions. Underlying sociological and economic drivers must be at work.
“We can come up with explanations that are specific to some era,” Peter Reuter, a veteran drug policy researcher, told me. For instance, consider how in the 1970s, cocaine manufacturing and trafficking networks in Latin America advanced alongside growing demand for the drug in America. “But then, it’s very hard to find something that goes on for forty-five years now.” David Herzberg, a historian of the pharmaceutical industry and author of White Market Drugs: Big Pharma and the Hidden History of Addiction in America, has an idea. He proposes that drug markets are behaving the way other consumer markets have since the neoliberal turn, when “free enterprise” was unleashed to work its unholy magic. “The rise in overdoses tracks a time period in which corporations that organize human labor and human activity were increasingly given carte blanche,” Herzberg told me. “While OxyContin is an example of a corporation taking advantage of this,” he said, “Purdue didn’t create the conditions that enabled it to do what it did.” Hence the irony of the Sackler family’s lawyers holding up a chart where time begins in 1979.
Across this period, illicit market innovations have mirrored many of the same ones seen in legal markets: sophisticated supply chains, efficiencies in manufacturing, technological advances in communications and transportation, and mass production leading to lower prices. Meanwhile, the social dislocation and alienation of consumer society has left millions of Americans unmoored, adrift, or otherwise floundering.
Contrary to popular rhetoric, drug addiction is not the cause of poverty but one of its chief consequences. Studying the dynamics of crack houses in New York and open-air drug markets in Kensington, Philadelphia, the ethnographer Philippe Bourgois found a pattern of lives scarred by a combination of state neglect and violence: abusive childhoods, crumbling schools, abandoned neighborhoods, all aided by government-incentivized white flight. The historian Nancy Campbell, author of OD: Naloxone and the Politics of Overdose, uses the phrase “unlivable lives” when talking about the increasing immiseration of Americans. “Drugs are powerful ways people use to mitigate their circumstances,” Campbell told me. Opioids work as a salve for pain both physical and psychic. It’s no surprise that overdose deaths repeatedly occur in the deepest cracks and faults in American society. The rise in deaths, for instance, has been steepest in Black and Indigenous communities, which bear the brunt of concentrated poverty, cycles of state violence, and intergenerational inequality.
This decades-long rise in drug mortality has yet to have any substantive influence on the United States’ sclerotic drug policy; the current crisis remains widely viewed as a discrete epidemic, disconnected from the history that precedes it. Rather than ask what lies at the root of persistent substance use, this myopic framework—peddled by the Centers for Disease Control and Prevention, parroted by politicians and industry leaders—focuses on individual drugs as causative vectors, while locking addiction in the realm of individual neurobiology.
The public is led to believe that the usual responses to epidemics will somehow work for drug addiction: isolate, quarantine, and treat the sick. This almost always means criminalization, incarceration, and compulsory treatment—or else bizarre interventions like the Department of Defense’s quixotic search for a fentanyl “vaccine.” The endless declaration of one drug epidemic after another also perpetuates a blinkered state of emergency, necessitating the spectacle of a disaster response to yet another drug “outbreak.” This not only forecloses the possibility of a response that’s actually effective, it precludes a deeper understanding of the role of drugs in American life. What Jalal and Burke’s exponential curve lays bare is the accumulation of our long, slow, and violent history.
Linguistic Misdirections
When a problem is big, bad, and mysterious enough, Americans tend to reach for the metaphor of the epidemic. Mass shootings and gun violence are an epidemic. Suicide is an epidemic. There’s an epidemic of loneliness. Between guns, drugs, and despair, not to mention the actual viruses and diseases out there, America is awash in epidemics. Susan Sontag famously argued in Illness as Metaphor, “Any disease that is treated as a mystery and acutely enough feared will be felt to be morally, if not literally, contagious.” Though neuroscience has shed some light on the inner workings of addiction in the brain, the metaphorical baggage persists: drugs “hijack” the brain, creating a “disease of free will” that saps the host of human agency. The loss of control over one’s desire feels bound to the insistence that those who succumb to addiction are morally weak and spiritually sick.
“To see the opioid crisis as new and unprecedented in this way required a radical act of forgetting.”
Anxiety over drugs has dominated public discourse for as long as Americans have used them—to the extent that the New York City health commissioner labeled substance use “emphatically an American disease” back in 1919. But we lose something by relying on this kind of language. There is no need to find a rationale for why a virus leaps from person to person; it’s what they are programmed to do. So what is the rationale for drugs and addiction?
When it comes to opioids, they have a much longer history in the United States than is commonly assumed. “To see the opioid crisis as new and unprecedented in this way required a radical act of forgetting,” Herzberg writes in White Market Drugs. Herzberg had noticed that the news media continually rediscovers the fact of opioid use by white people, women, and affluent suburban and rural users. This was most stark during the early wave of overdoses attributed to pharmaceutical opioids, when news outlets ran with the story that opioid addiction had suddenly found “a new face.” In a 2015 segment by 60 Minutes on “Heroin in the Heartland,” the surge in opioid use was described as “an inner-city problem” that spiraled outward and into the “biggest drug epidemic today.” But this was not the first national struggle with opioids.
The earliest recorded “opioid epidemic” in the United States dates back to the nineteenth century, when rapid industrialization led to an explosion of consumer goods. “Among these commodities and consumer goods were derivatives of the opium poppy and the coca plant,” Herzberg writes, noting that opioid use tripled from 1870 to the mid-1890s. “Drug consumers, like consumers of other goods, faced a bewildering variety of new and often dangerous products.” The market was flooded with tonics and elixirs containing stimulants like cocaine and opioids like heroin that promised to cure everyday illnesses and ailments. The proliferation of drugs in a rapidly industrializing America soon led to the first attempts to regulate and curb their use.
But drugs are never just about drugs, as Benjamin Fong writes in Quick Fixes: Drugs in America from Prohibition to the 21st Century Binge: “When people aim to control or regulate drugs, they are actually aiming to control or regulate other things about society.” The earliest crackdowns were tied to racial panics. The United States’ first known drug law (pertaining to a substance other than alcohol) banned opium dens in San Francisco in 1875. It was enacted less out of concern over the effects of the drug than unfounded fears that young white women and men were getting “stoned in fetid [Chinese] dens,” as the law scholar George Fisher summarized it. In The American Disease, a sweeping analysis of the foundation of American drug policy published in 1973, the historian and psychiatrist David F. Musto closely tracked the regulation of cocaine, which began in 1914 and stemmed largely from a Southern white population fearmongering over a rebellion among “cocainized blacks,” who were purportedly imbued with superhuman strength by the stimulant. The cycle of drug laws targeting racial minorities continued into the 1930s with the federal prohibition of marijuana. This time, the federal government and temperance advocates produced and distributed propaganda about how Mexicans, high on pot, were driven to senseless murder. By 1937, a year after the film Reefer Madness terrified American parents of the drug’s destructive properties, marijuana was federally prohibited.
Despite these efforts, drug use continued. As did fearmongering around them to achieve political ends. In 1969, President Richard Nixon undertook an enforcement scheme called Operation Intercept, in which he sent two thousand customs agents to execute a zero-tolerance inspection policy for every vehicle entering the United States from Mexico, ostensibly to disrupt the flow of illicit drugs. But checking every vehicle was impossible back then, just as it is now. Nevertheless, for three weeks, traffic ground to a halt—until Mexico ultimately relented and agreed to sign an agreement against drug trafficking called Operation Cooperation.
It’s unclear what effect, if any, either operation had on the drug supply. While the former failed to yield any major drug seizures, there are some reports, written mostly by hippies, of a “marijuana famine.” Some speculate that new smuggling channels opened up in response, with rising hashish imports from Vietnam and North Africa. Still, Nixon aide G. Gordon Liddy concluded that Operation Intercept was a success, writing in his memoir that it “was an exercise in international extortion, pure, simple, and effective, designed to bend Mexico to our will.” The other victory was rhetorical. Operation Intercept reframed drug use as what scholar Daniel Weimer called a “foreign danger”: something that was being done to us rather than something we were doing to ourselves.
Two years later, Nixon codified this framing when he launched the war on drugs, which instrumentalized the false connection between race and drug use to ramp up police enforcement and incarceration. Another Nixon aide (and Watergate co-conspirator), John Ehrlichman, admitted as much in 1994, when he told the writer Dan Baum that by “getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.” Drug policy is driven as much by a compulsion to revile and vilify drugs as it is to keep people from using them. The ulterior motives behind the history of drug regulation and enforcement raises the question of what is ideologically and politically embedded in the popular “drug epidemic” framework, which licenses punitive measures against those drawn to drug use.
New Dog, Old Tricks
In the 2010s, the market shift to illicitly manufactured fentanyl reinvigorated drug war rhetoric. The idea that we’re living through something singular gave the government ammunition to double down on existing tactics. The thinking goes: because fentanyl is so lethal, we must go harder on enforcement than ever before. Across the country, states are adopting harsher laws to combat the supposed crisis: thirty of them now have drug homicide laws on the books, allowing prosecutors to charge those who use and share drugs together with murder.
Contrary to popular rhetoric, drug addiction is not the cause of poverty but one of its chief consequences.
The idea that we’re living through exceptional times isn’t exactly wrong. The mathematics and physics of fentanyl are unprecedented. The total amount of the synthetic opioids consumed in the United States each year is estimated to be in the single-digit metric tons. By comparison, Americans annually consume an estimated 145 tons of cocaine and 47 tons of heroin. That means all the fentanyl consumed by Americans in just one year can fit inside a single twenty-foot cargo container. Some fifty million shipping containers arrive in America by land, air, and sea every year. Because fentanyl is so potent—with doses measured in micrograms—very small amounts can supply vast numbers of customers. Counterfeit fentanyl pills contain about two milligrams of fentanyl. There are 28,350 milligrams in an ounce, which means one dose amounts to one ten-thousandth of a single ounce. Authorities could barely keep up with cocaine and heroin. To say fentanyl detection is like finding a needle in a haystack is to vastly underestimate the scale of the problem before us.
To add another layer to this already impossible scenario, fentanyl is unlike cocaine and heroin in that it is synthetic, odorless, and tasteless, making shipments even more difficult to detect. And the supply has no real upper limit: production is only tied to the amount of precursor chemicals available, which seem pretty much limitless. Any nation with a pharmaceutical or chemical manufacturing industry can theoretically produce the necessary precursors and ship them to suppliers around the world. If one country cracks down on precursor chemicals, another can fill the void. At this time, India and China manufacture much of America’s generic drug supply.
The global market’s rapid acceleration underscores the folly and futility of relying on the same enforcement tactics on the supply side, and the same medical and health interventions on the demand side. The U.S. policy response has never been this nakedly outmatched and unsuited for the task at hand. Still, authorities boast of massive investments to curb the fentanyl crisis. They champion handshake deals with foreign leaders to staunch the flow of the drug into the country. They publicize record-breaking fentanyl seizures, only to turn around and report record-breaking overdose figures. For example, the state of California’s 2023 “Master Plan” for tackling drugs includes more than $1 billion, from overdose prevention efforts to interdiction and enforcement. The California National Guard seized 62,224 pounds of fentanyl that year, a 1,066 percent increase from 2021. And yet overdose deaths continue to climb across the state, increasing by 121 percent between 2019 and 2021. Conventional enforcement and seizure methods have done little to contain the spread.
I thought about the daunting scale of the fentanyl problem when a father in Oklahoma, who lost his son to the drug, told me, “If the goal is supply interdiction, search every vehicle,” referring to the thousands of cars and trucks that cross the U.S.-Mexico border every day. “Do 112,000 deaths warrant the interruption to commerce and commuters?” he asked. “What about 600,000? Or 1,000,000?”
The question points to a crucial and oft neglected tension: the symbiotic relationship between legal and illegal markets. It’s one reason why U.S. drug policy cannot actually disrupt the fentanyl market. To attempt to do so would hobble commercial trade between Mexico and the United States. The vast majority of fentanyl seizures occur at legal ports of entry and interior vehicle checkpoints. U.S. citizens, not migrants, are also much more likely to traffic drugs across the border. Typically left out of the debate around the crisis at the border is that federal law is expressly designed this way: for U.S. citizens to receive consumer goods manufactured in Mexico. For the first time in two decades, imports from Mexico are outpacing imports from China. The flow of illicit drugs follows the flow of consumer products. Hidden in avocados, cheap cars, home appliances, and LCD screens that our economy depends on is the very same stuff that’s killing tens of thousands of people each year.
The Need for New Direction
In 2022, the disease modelers Jalal and Burke projected that half a million Americans would die of drug overdoses between 2021 and 2025. So far, the data supports this estimate. “Dismayingly predictable,” as they put it. Unless something drastically changes, the curve will keep rising. Drug mortality alarmed officials in 2010 when thirty-eight thousand people died in a single year. Drug deaths were declared a “national health emergency” in 2017, when the annual death toll topped seventy thousand. In 2022, overdose deaths nearly reached 110,000. My fear is that we’ll learn to live with these figures as just another grim and inevitable feature of American life. File drug overdoses away under “intractable problem,” somewhere between gun violence and the climate crisis.
Drinking kills nearly five hundred Americans a day: more than every illicit substance, including fentanyl, combined.
Something obviously needs to change, but American drug policy feels stuck, mired in disproven and outdated modes of thinking. Briefly, it seemed there was real movement toward treating addiction as a public health issue, but the sheer lethality of fentanyl, in part, snapped policy back to the mode of coercive criminalization, derailing newer, progressive reform efforts to roll back racist drug enforcement through decriminalization, with an emphasis on expanding public health, harm reduction, and treatment. The tide of reaction against these nascent efforts has been swift and effective. San Francisco voters passed a measure to drug test welfare recipients. Oregon has ended their decriminalization experiment. With social approaches in retreat, the idea of full-on legalization feels increasingly out of touch with today’s reality.
But is complete legalization even desirable? Every time the left brings up the idea, two substances come to mind: alcohol and tobacco. These two perfectly legal, regulated products are immensely hazardous to individual health and society at large. Tobacco kills nearly five hundred thousand people every year; that’s more than alcohol and every other drug combined. Drinking, meanwhile, kills nearly five hundred Americans a day: more than every illicit substance, including fentanyl, combined. During the pandemic lockdowns, people drank more, and they drank more alone. The trend did not reverse once we returned to “normal.” Contrary to all the buzz around nonalcoholic bars, millennials and Gen X are binge drinking at historic levels. The same set of social, psychological, and economic factors at work in illicit drug use, magnified by the market’s invisible hand, are also apply to alcohol: people are more alone and more stressed, with access to a cheap, heavily marketed product that, thanks to on-demand home delivery, is easier than ever to access. Advertisers spent nearly $1.7 billion marketing alcohol in 2022 alone.
How, then, is the legalization and regulation of drugs going to help us? Benjamin Fong, in Quick Fixes, summarizes the debacle:
A more rational society would undoubtedly minimize the impacts of black markets by regulating all psychoactive drugs (and, perhaps, controlling their sale through state monopolies or public trust systems), but legalization in this society likely means bringing highly potent substances into the purview of profit extraction.
It is clear we live in the worst of all worlds. Black markets flood the country with mass-produced and highly lethal substances, but legal, “regulated” markets do the same. Both are turning record profits. Consumers are at the wrong end either way. It’s hard to not feel deep pessimism about where things go from here. Cringey, commercialized marijuana; the glut of ketamine infusion clinics; venture capital closing in on psychedelics; Adderall and Xanax prescriptions being handed out by telemedicine companies over Zoom. It’s precisely more of what got us here: a bewildering array of addictive products unleashed onto anxious, isolated consumers who are groping in the dark for relief from physical and psychic pain, coping with unlivable lives. Fortunately, it’s almost impossible to fatally overdose on many of these substances, but death shouldn’t be the only way to measure the consequences of the great American drug binge.
The current rhetorical, legal, and medical framework is simply no match for the deep malaise driving the problem. Root causes are downplayed, millions are left untreated, and thousands of preventable deaths are unprevented. We need a stronger, more expansive paradigm for understanding the exponentially increasing number of overdose deaths. A new language of substance use and drug policy that encompasses, and is responsive to, market dynamics and the social dysfunction to which they give rise. A consumer-protection model that does not criminalize the suffering, but also addresses the anxiety and dread that leads to compulsive, chaotic, and risky substance use. There must be something beyond, on the one hand, prohibition by brute force, and on the other, free-for-all drug markets ruled by profit. How can we create a world where people don’t need to use drugs to cope, or when they do use them, whether for relief, enhancement, or plain old fun, the penalty isn’t addiction, prison, or death?
Purdue lawyers thought the Jalal and Burke chart could absolve the Sackler family. Instead, it indicts its rapacious behavior along with the entire economic, political, and social system that’s come of age in the decades since 1979 as well. We’re not, in fact, living through an opioid epidemic that started in 1999, or even a fentanyl epidemic that started in 2014; something else, something fundamental, is deeply wrong. Responding to each and every successive wave of drug use as an acute, discrete crisis has failed for the past forty-five years. And it will continue to fail so long as we continue responding to the wrong problem.
This story was supported by the journalism non-profit the Economic Hardship Reporting Project.