Letter from

interdict the supply of prescription opioids, the thinking goes, we can stanch the epidemic. But that is unlikely to work for two reasons. First, as I pointed out, this is no longer mainly an epidemic of prescription drugs but of street drugs. And second, it creates an onerous obstacle for doctors and outpatients who require pain treatment. More and more, they have to satisfy regulations expressly designed to restrict access to prescription opioids. Some make sense. For example, it’s reasonable to monitor opioid prescriptions to detect pill mills. It’s also reasonable to flag users who “doctorshop,” that is, see several doctors at once to try to get multiple doses of opioids.

But other requirements are meant simply to inconvenience both doctors and patients until they give up. For example, in Massachusetts doctors must limit their first-time opioid prescriptions to seven days. That can be more than an inconvenience for ill patients in pain. Macy quotes a letter from a friend with severe back pain from scoliosis. “‘My life is not less important than that of an addict,’ my friend wrote,... explaining that her new practitioner requires her to submit to pill counts, lower-dose prescriptions, and more frequent visits for refills, which increase her out-of-pocket expense.” Even more serious is a new shortage of opioids for injection in cancer centers.

For physicians, who are already weighed down by innumerable bureaucratic requirements, these restrictions present one more hoop to jump through, and many simply won’t do it. Instead, they’ll send the patient away with some Advil and hope it does the trick, even though they know it probably won’t. The regulations are having their intended effect. In Massachusetts, opioid prescribing has decreased by 30 percent. Meanwhile, the epidemic of street drugs continues apace. McGreal raises the possibility that reducing access to prescription opioids might feed the demand for heroin. Macy quotes an addiction specialist who laments that “our wacky culture can’t seem to do anything in a nuanced way.”

I believe the modern opioid epidemic is now more a demand problem than a supply problem. Three years ago, the Princeton economists Anne Case and Angus Deaton published an explosive paper about the surprising rise in mortality, starting at the turn of this century, among middle-aged white non-Hispanic men and women. The increase was greater in women than in men. They found three main causes: drug and alcohol overdoses, suicide, and alcohol-associated liver disease. They later called these “deaths of despair,” because they were most common among workers in tenuous jobs, with only a high school education or less, who were struggling to stay afloat in isolated regions of the country. Dragged down by these deaths, in the past three years overall life expectancy in the United States has started to drop.

It’s not hard to see reasons for the despair. Most working-class Americans have not benefited from our booming economy, the fruits of which have gone almost entirely to the richest 10 percent. For the bottom half of the population, income has scarcely budged since the 1970s, while expenses for necessities like housing, health care, education, and child care have skyrocketed. In Appalachia, where the opioid epidemic first took hold, many coal miners were unemployed and would probably remain so. People expected they wouldn’t live as well as their parents had, and had little hope for their children. It is true that African-Americans still have higher overall mortality rates than whites, but that gap is closing rapidly for people under the age of sixty-five, particularly for women. By 2027, white women will have higher mortality rates than African-American women. Mortality for African-American men is falling even faster than for AfricanAmerican women; it is projected to be equal to that of white men by 2030. But the epidemic has extended to all parts of the country and to all ethnic groups, so it’s unclear how the effects will be distributed in the future.

By the middle of this decade, the grotesque inequality in this country began to get the attention it deserves. And the growing awareness of that inequality fed the populist passion that, when twisted and distorted, produced the election of Donald J. Trump. It’s probably not coincidental, then, that the opioid epidemic got its second wind at about that time. It certainly marks the time when the opioids of choice changed from prescription drugs to the witches’ brew of street drugs. Did the epidemic explode because people were becoming aware that the American Dream was no longer theirs to dream? As long as this country tolerates the chasm between the rich and the poor, and fails even to pretend to provide for the most basic needs of our citizens, such as health care, education, and child care, some people will want to use drugs to escape. This increasingly seems to me not a legal or medical problem, nor even a public health problem. It’s a political problem. We need a government dedicated to policies that will narrow the gap between the rich and the poor and ensure basic services for everyone. To end the epidemic of deaths of despair, we need to target the sources of the despair.