The content of the previous chapter centered mostly around opioids and opioid-based medicines as a means to present the commonly abused branch of pharmaceuticals as exemplary of the issue of marketed substance overdoses. The present chapter will share the focus, this time containing a more detailed description, in order to provide the explanation for the previously portrayed problem, and to provide one with the basis for understanding not only the causes of opioid-based medicine addiction, but also similar issues with other types of pharmaceuticals (discussed more broadly in the final chapter).
In order to provide the best approach to comprehending the question correctly, it is necessary to begin with numbers.
The chart displayed below (obtained from the official website of Centers for Disease Control and Prevention (CDC)) discloses the number of various opioid-based medicines prescribed yearly in the United States.
According to the data, between the years 2010 to 2012, the numbers of submitted prescriptions seem to have reached their peak, decreasing steadily in the following years. It is substantial to notice that the statistics for the time of opioids being prescribed the most often correspond with the input from the graph included in the previous chapter regarding the highest number of deaths due to prescription opioids.
But the raw numbers alone do not fully illustrate such widespread issue. The featured map, originally published by Market Watch, cites the concentration of patients dependent and/or addicted to prescription opioids per state (years 2012 to 2014).
By studying the map, three patterns can be recognised. The density seems to be the highest (marked dark red and dark orange) in some of the most populated states, noticeably California and New York. However, the highest recorded figure for opioid dependence (both pathological and for medical reasons) remains in West Virginia, together with several other states (Kentucky, Tennessee, Louisiana); all of them have a considerably smaller number of inhabitants than the locations mentioned before. Furthermore, except for Nevada, they are all located in the east coast of the United States. Yet another indication that can be derived from the map suggests the issue to be of much less prevalence in the mid-country, notably in Wyoming, South Dakota, Nebraska, Kansas, and Iowa (as well as in Hawaii and Alabama).
Now that the data presented above has been detailed, the reason for the phenomenon must be identified as well. Is the given states being affected (or safe from) the opioid epidemic a purely coincidental occurrence, or is there a factor, or even a number of factors, that contribute to the problem and the lack of thereof in the specific areas?
For the purpose of presenting the question in a clear and easily understandable manner, one should start the analysis with the human factor, as those affected are the core focus of the issue.
The map included above depicts the United States population as divided by ethnicity. Noticeably, the states described as the most affected by prescription opiate addiction are mostly inhabited by white people of European descent (in regards of the “American” ethnicity: those are the Americans of overwhelmingly white European heritage that do not refer to themselves as e.g. Polish American or being a person of French, Czech, and Portuguese descent, but instead choose to identify as simply American, thus not entertaining the fact of the United States being a “nation of immigrants”). California and New York appear to be the exceptions, however this is due to the large populations of these areas: the states have subsequently 72.7 and 58.3 percent of inhabitants of Caucasian origin.
Besides the racial aspect, there are few more similarities that need to be touched on; the most significant ones can be found in the article Why does opioid dependence vary so dramatically by U.S. State? by Allesandra Malito and Quentin Fottrell (2018) of Market Watch.
The authors mention the poor financial situation of the inhabitants of certain states as one of the most important factors leading to opioid abuse. At first, such statement might seem contradictory – since developing prescription opiate addiction requires frequent use of the medicine, normally with dosages increasing over time, struggling financially should prevent the pathological behaviour, not prompt it. Malito and Fottrell puncture the discrepancy; it is the alternative ways of treatment that are expensive, or at least more expensive than opioid-based painkillers.
“Americans on a low income may not be able to afford alternative care or surgery, which effectively means they would have more need for opioid prescriptions to deal with chronic pain. Another problem: Some people may not be able to take time off work and/or may not be able to pay to travel to clinics for regular care.”
To illustrate the issue in a greater detail, and bring a compelling perspective to the question, essential to study and compare the average income in the areas influenced by opioid painkiller abuse, with those where the problem is not as severe.
The census provided by United States Census Bureau (USCB), covering the years 2013-2017, (USCB divides its directory of places ranked by household income for 56 areas – including five unincorporated territories of the United States, e.g. Guam Island, and Puerto Rico) positions the most affected state, West Virginia, as 51st (1st being the highest household income) – making it the most financially underprivileged of all states. Other areas concerned with a large scale of the issue, Louisiana, Kentucky, and Tennessee, were ranked subsequently 48th, 45th, and 42nd, further proving the point of the lack of money being one of the causes of pathological painkiller used.
To create a comparison, the states mentioned above as those with the least amount of opioid prescription addicts, rank at 4th (Hawaii), 20th (Wyoming), 22nd (Nebraska), 26th (Iowa), 30th (South Dakota), and 31st (Kansas).
Another point brought up by the authors of the article, is the correlation between the amount of time spent filling in a prescription, and the time that further examination or introducing the patients to alternative methods of treatment require. Clearly, prescribing a medicine (which, as acknowledged in the previous chapter, is usually the one the patient has known and used for the longest time, and trusts its properties) is a lot less time-consuming practice than recommending treatment based on the individual's specific needs and abilities (most of the time also financial). Such process might, paradoxically, steam from the doctor's desire to treat as many sufferers as possible – a prescription will help alleviate the pain at least temporarily for a large number of people, while focusing on a single case for a longer period of time is likely to prevent some of the patients from receiving even a short-lived relief. Malito and Fottrell call such system “drive-by appointments”.
Sadly, the problem with physicians being at least partially responsible for the opioid epidemic is not limited to just their lack of time – the lack of proper care and the absence of doctors themselves are also the deciding factors.
The authors quote Dr Akash Bajaj's analysis of the issue, which also connects it to the previous point:
“In less populated states like Kentucky and West Virginia, there is a tendency to practice more traditional pain management techniques, which may rely heavily on medications as this approach is quick, cheap and, in the short run, can be effective (...) However, as we have seen this problem can quickly spiral out of control due to the need to take more medication to achieve the same effect.” He insists that instead of practicing the "drive-by appointments", doctors should rather “(...) focus more on definitive therapy, identifying the problem and treating as specifically as possible, without medication management.”
Dr Bajaj also discloses another malpractice that can be observed among physicians, presumably the most vile one of those already mentioned in the chapter. He suggests that certain doctors might take advantage of their patients being reliant on opioid-based painkillers, whether because of their financial struggle, not being suggested any alternative treatment, or already developed physical and/or mental dependence, to assure the sufferers would need their service again. The doctor describes the process with an evident critique of it:
“There are some doctors who will indulge a patient’s desire for painkillers, which often take the form of opioids, in order to keep their practices afloat. This is not good for the patient or the practice. (...) Of course, this is not good for the patient or the practice and, thankfully, there has been a crackdown on such practices.”
As, after presenting the data, certain painkiller abuse appears to take on the most severe form in particular areas, most of the time linked together by the aspects of household income and ethnicity, with the situation worsened by medical malpractices, one cannot forget the places that do not necessarily meet the criteria for being at risk of facing the abuse (at least as long as the financial aspect is taken into consideration), yet a part of their inhabitants still suffers from prescription addiction.
Dr Bajaj, who works in California, thus presumably being familiar with the inconsistency, characterises its most probable cause:
“(...) it’s easier for patients to find opioids when there are more physicians to choose from. In more populated states like California (...) patients are more willing to doctor shop until they find someone willing to give them what they think they need. This is not only a violation of ethics, but can put the patient’s life in danger.”
However, keeping in mind the specifications of prescription abuse demonstrated by Malito and Fottrell, such analysis would imply that those already suffering from opioid dependence, would chose searching highly populated areas as a means of acquiring the medicine; them permanently residing in California or New York would not be the cause of their problem, but rather fuel it shall it already exist.
The authors, however, begin to clarify the inconsistency at the end of their article – more specifically, when they refer to Dr Bajaj's statement about “doctor shopping”.
In more populated areas the number of physicians is, undoubtedly, considerably bigger than in less inhabited states; consequently, the number of patients rises as well, but with more doctors to chose from they are generally not forced to wait for treatment, such as those in the areas where there are no alternatives. This situation eliminates the issue of “drive-by appointments”, allowing the doctors to focus on an individual and suggest various methods of therapy (even the costly ones – the average household income in California places the state at the 5th place, whereas New York ranks 15th).
Sadly, with one problem being solved, another seems to have occurred; doctors being able to pay the patient the appropriate amount of time, supposedly lowering the amount of opioids being prescribed, did not cause the number of white people from highly populated areas overdosing on prescription painkillers to decrease.
Thus, the cause of the problem appears to have no logical connection to any of the reasons presented by Malito and Fottrell – the arguments of low income, medical malpractice, and lack of medical centers are no longer.
The 2019 investigation by Joseph Friedman, David Kim, Todd Schneberk, Philippe Bourgois, Michael Shin, Aaron Celious, and David Schriger, Assessment of Racial/Ethnic and Income Disparities in the Prescription of Opioids and Other Controlled Medications in California, introduces the reader to an intriguing hypothesis that aims to answer the raised question. According to the authors, what propels the epidemic in the particular community, are not reasons of the affected living in a specific place, with certain living conditions; rather, it is the racial bias towards ethnicities other than Caucasian expressed by the doctors in charge.
One might yet again notice a discrepancy in such account. Had the physicians' decisions been fueled by racial antipathy towards a given group, in this instance, all except Caucasians, they would prescribe addictive substances to patients of ethnicities other than white – which, considering the racial component of the opioid epidemic, seems to be the exact opposite. While this perspective is legitimate, the authors suggest a contrasting approach to understanding the dilemma:
“(...) Hispanic patients were 2 times less likely to receive analgesics following long bone fractures than white patients, after accounting for other factors. Similar discrepancies in pain medication prescribing were found for black patients relative to white patients. Recent studies have found that healthcare professionals often underestimate the pain of black patients when compared with white patients and that such racial/ethnic biases in the detection of pain are seen among healthcare professionals who report no explicit racial/ethnic biases. These gaps, coupled with decreased access to the healthcare system for many racial/ethnic minority groups, have led several authors to suggest that there is a national crisis of insufficiently medicated pain among minority communities in the United States. In light of a similar gradient in opioid overdose deaths, these disparities in opioid prescription may have played an accidental protective role in minimizing the opioid epidemic among minority communities.”
The detailing of the approach does, in fact, inform one of the existence of the issue, as well as helps recognise the reason for excuse for other ethnic groups being less likely to be affected by the epidemic. Nonetheless, the authors do not provide any interpretation as to why such bias would be held and executed by physicians (“the roots of this racial/ethnic phenomenon have not been adequately explained”).
The answer seems to be at least suggested in the 2017 interview Dr Andrew Kolodny gave for the National Public Radio:
“Something that we do know is that doctors prescribe narcotics more cautiously to their non-white patients. It would seem that if the patient is black, the doctor is more concerned about the patient becoming addicted, or maybe they're more concerned about the patient selling their pills, or maybe they are less concerned about pain in that population. But the black patient is less likely to be prescribed narcotics, and therefore less likely to wind up becoming addicted to the medication. So what I believe is happening is that racial stereotyping is having a protective effect on non-white populations.”
Kolodny's commentary grants a sensible resolution to the aforementioned hypothesis. The reason for such perception or prejudice in physicians remains the matter of discussion that would no longer center around prescription opioid abuse, however, assuming that the objective is valid, the painkiller abuse in highly populated areas that maintain a high household income appears to be logically justified.
Nevertheless, one should keep in mind, that even though Caucasians might be perceived as more responsible and less likely to be involved in drug abuse and trafficking by physicians, they should not be blamed for the practice; unless there is a legitimate, proven case of a white patient persuading the doctor to be prescribed a medicine for the reasons acknowledged above, no group can not be held accountable for the favouritism of other group (particularly if such bias is inclined to lead to a damaging outcome, indicating that Caucasians suffer the effects of the epidemic regardles of their financial status and various external factors).
After detailing the exception of California and New York being included in the list of places severely affected by opioid prescription abuse, it is pertinent to concentrate back on the prevalent form of the problem. It remains a fact that financially underprivileged eastern states continue to be at the top of the record of suffering areas. Malito and Fottrell's article contributes greatly to the justification of the phenomenon; it does, however, paint only the general picture of the issue. It does not introduce one to any individual case of a suffering person that would expose their feelings (towards their own struggle, as well as the opiate epidemic in a more broad sense), and maybe even provide examples of instances leading to the problem that the article failed to include. Focusing on a personal account of those directly involved is crucial to understanding not only the issue presented in the thesis, but should also be considered as the leading method in familiarising oneself with any given point of interest.
The 2013 documentary Oxyana allows one to be meet with the opportunity to do so.
Although the makers of the movie did not state it in any public statement, the viewer might assume that the year the film was released was not chosen coincidentally. Obviously, the general time of the release is consistent with the time of the opioid epidemic being treated as a widespread issue in the United States, but, more precisely, 2013 marks a spike in the abuse after its decrease in the prior few years (as depicted in the diagram presented in the previous chapter). Albeit it only a hypothesis, the production of the film might have been scheduled as such for a reason similar to the picture being analysed in this chapter – to help those interested in the issue (but also the people affected by it, as their involvement does not necessarily equal a full comprehension of the reason for the situation they found themselves in) understand its causes and ramifications more easily, while not omitting any significant facts that are seemingly too detailed or unaffiliated.
Even though the analysis itself is going to comprise of the first-hand experience of those affected, as stated earlier, their accounts might be occasionally supported by scientific data and other external piece of information. Such exercise is not by any means supposed to suggest that the individual struggle of the people presented in the film can only be considered valid if it has been officially recognised by external sources, but to yet again demonstrate that the mechanics of addiction are similar in both illegal substance and prescription abuse.
The official statement of Sean Dunne, the director of the film, lets the viewers familiarise themselves with the incentive that prompted the production, as well as allows for the anticipation of even more personal experience, as it corresponds with the victims' own accounts presented in the picture.
Taken from the official website for the film:
“It wasn’t long after I first set foot in Oceana, WV that I knew something wasn’t right. In fact, something was desperately wrong. This was one of the most beautiful places I had ever seen, filled with hands down the most honest and welcoming people I had ever met. Yet there it was, a constant and growing hum of anxiety. So we started to ask questions, and we started to get answers, all pointing towards a familiar narrative. Greed that led to overprescribing pharmaceuticals that led to addiction that led to poverty, lawlessness and hopelessness. Each story we’ve heard is more harrowing and haunting than the previous. Here is a place that represents our failures as a country, a microcosm of everything that’s gone wrong with the American Dream. Oxyana. These stories needed to be seen; they needed to be heard. Residents who were once talented, charismatic, hard working, God fearing, normal people have been reduced to nothing by the uncontrollable lure of this pill. There are high school girls with $800/day habits and families, who literally can’t provide food for their children, yet have full prescription bottles. There are former miners who have turned to dealing to make ends meet and pregnant women selling their bodies for another fix. It is a seemingly endless line of people who have lost the will to live.”
Obviously, the analysis will start at the very beginning – of the statement and of the film.
The action takes place in a relatively small town, Oceana. The viewer is probably not going to be surprised to discover that Oceana is situated in West Virginia, the state where the issue of opioid painkiller addiction has been proven to be the most prevalent and severe.
The title of the film, however, seems to be a word play on the name of the town. The place's “new” name comes from the drug OxyContin – which is another unsurprising fact when one takes into account the data presented earlier in the chapter (however, the director made opioid painkillers the main focus of his production, but the story touches on other types of abused medicines as well).
The film begins with various shots depicting Oceana – presented in an ominous, quiet, almost unsettling manner that one might interpret as a cinematic metaphor for the lethargic state opioids bring the user into. Overall, the film comprises of series of interviews given by the residents of the town that have been affected by prescription abuse (for easier differentiation, some of the interviewees will be given a fictional name, since their actual identities have not been revealed in the production); each one of them shares their exclusive experience, concentrating on a specific issue they struggle with the most.
The first interviewees, Patrick and Courtney, share their feelings towards Oceana as their hometown. Their account appears to be nothing short of positive – they praise the landscape, the long-lasting friendships, even the strong desire to keep coming back to the town, which, yet again, suggests the viewer the analogy of the early relationship between the user and the drug, when the former is usually still oblivious to the negative consequences of the still-developing habit.
According to Mayo Clinic's report on the development of opioid addiction:
“The length of time you use prescribed opioids also plays a role. Researchers have found that taking opioid medications for more than a few days increases your risk of long-term use, which increases your risk of addiction. The odds you'll still be on opioids a year after starting a short course increase after only five days on opioids.
A number of additional factors — genetic, psychological and environmental — play a role in addiction (...)”
Taking a habit that can sometimes last for years (as documented later in the film) into account, a few days might not seem to be a long period of time. However, the recreational effects of the medicine can easily be noticed during even a short-time treatment (especially in a first-time user that has not developed any kind of substance tolerance in the past), and the decision of continuing the use for non-medical purposes can clearly be made.
It is also worth mentioning that Patrick and Courtney's initial praise of Oceana as a place located in a beautiful natural environment which was once great and safe for raising children suggests a person's usual original perception of legally marketed medicines as not being harmful to the customer.
The next interviewee, Dominic, the local dentist, supports his neighbours' view of the town as something they are very attached to, at the same time realising that such mindset creates a sort of a contradiction, the existence of something an outsider would not suspect when experiencing the life in the town only superficially. He voices his concern:
“There's this darkness that has come over it, that has affected all those things in a way that it's even affected the natural beauty of this place, because as a person that lives here I almost can't look at it the same, because the people don't trust each other as they used to (…) there's more crime, the “us against them” mentality, and it's incredible, and amazing, and awful, all at the same time.”
The director then shows Courtney again (for future reference, she is the mother of another interviewee, Jason), who, referring to Dominic's statement, describes the beginnings of the epidemic in Oceana.
According to the woman, the town fallen victim to the phenomenon about fifteen years ago. She admits that at first she believed overprescribing the medicines was to blame, yet diminished the belief later, as even before the start of the epidemic, the use of cannabis and alcohol was prevalent in Oceana, but was noticeably less damaging than opioid abuse – therefore, she was not convinced that overuse of the medicines would be more risky than smoking or drinking. Some time later, however, she realised that the substances were considerably different from each other, and that the consequences of abusing prescription opioids were evidently more severe.
Business Insider (2016) provides a chart – a comparison of the level of addictiveness among chosen groups of substances – that validates Courtney's reflection:
All three components – pleasure, psychological dependence, and physical dependence – are marked as having the strongest properties when attributed to heroin, i.e. an opioid based substance. In comparison, the two other substances of interest, alcohol and tobacco, possess a lower risk of addiction, and, interestingly, a visibly smaller level of pleasure derived from the use. Such combination of factors seems to have contributed not only to heroin/opioids being placed at the top of the chart, but also to have explained what happened in Oceana.
Following Courtney's remark, the viewer is introduced to a twenty-three years old man, Aidan, who brings up his perspective concerning the lethality of prescription abuse in Oceana.
Aidan's age seems to have been mentioned purposefully. He remembers his expectations concerning high school – picturing it like the stereotypical American schools one can see in a film for teenagers and young adults – that, sadly, were not met at all. Instead, what he encountered was “kids would just slap the pills down your hand”. Now, few years after graduating, he tells the interviewer about the shock he experienced when he found out that numerous of his high school friends were already dead (which means they died before the age of twenty three) due to prescription opioid overdose.
His surprised reaction, while justified as a personal experience, involves a phenomenon that has already been unveiled and described by professionals.
As reported by Henry J Kaiser Family Foundation, the number of fatal opioid overdoses in West Virginia tends to be the highest among young adults (followed by people after the age of thirty-five up to forty-four).
The testimony and data presented above – as in several other cases described earlier – seems to be contradictory to the consensus or the generally held perception regarding the portrayed issue. Why would high school graduates, or even those who are still students, that most probably have already made plans for their future, be it academic or private, indulge in such destructive behaviour?
While the film does not directly answer the question – it does not describe the exact causes of the decision – it does in fact detail the palpable conditions that accompany the situation.
As stated by an Oceana native, Nikolai:
“When the prescription drug pill OxyContin hit the market the whole game changed. People started ripping each other off, they started breaking into people's homes, to fuel the addiction. That, to me, has been the biggest downfall of the area.”
Furthermore, the following account of two next interviewees, Vivienne and Isabel, supports Nikolai's statement by omnipresence (also among the young) of the problem, and touches on the root of it:
“It's an epidemic here. Anybody you could talk to here will tell you that they've at least dabbled in something [some prescription medicine]. They might not have gotten addicted to it, but they at least fooled around it. (…) Because there's nothing to do, this is such a small place, you look around, there's mountains everywhere. In big cities they've got movie theatres, and malls – we don't have anything like that to go and just do something.”
Although resorting to substance abuse as a result of boredom might seem reckless and worthy of contempt, especially in the age of easily accessible digital entertainment and means of communication whose use is almost effortless, it is not a rare occurrence.
Boredom, as understood by its traditional definition – lack of stimuli providing entertainment – does indeed play a role in developing addiction, however, to fully comprehend the issue, one should look for a broader interpretation of idleness.
Overwhelming routine – be it, as in the case of Oceana, plain, usually unenjoyable environment, or hours spent daily in a mundane workplace – can also create the feeling or emptiness and stagnation. Additionally, when worsened by the experience of abuse (of any kind and severity), the sense of boredom can evolve into the impression of being trapped, which, naturally, leads to the affected being tempted to employ whatever form of escape they are able to find, physical or, as in the situation in question, psychological.
In her piece for MedMark, Holly Holloway (2018) provides more details related to the connection of addiction and the provided, wider definition of boredom:
“Doing drugs or drinking can provide somewhat of a mental vacation from people’s current situation. When someone feels trapped and doesn’t know what to do with themselves, getting high or drinking can provide the same kind of mental stimulation as doing a fun activity. Many of these people are also dealing with profound loneliness, anxiety, or are suffering from other situations that prevent them from being involved with hobbies or activities. People with anxiety and depression may feel that leaving their homes to engage in social activities is too stressful, and instead, prefer to stay home and numb themselves.”
Even though job-related routine was mentioned earlier as one of the reasons for developing addiction, lack of employment contributes to the issue as well (which might seem likely, if one associates unemployment with lack of sufficient physical activity or failing to pursue other areas of interest – such assumption might be, to a degree, correct, if individual cases are being taken into account, however, that is not what contributed to the development of the prescription addiction epidemic in Oceana.)
The city of Oceana, as one can derive from the film, used to be the place that profited mainly from coal mining. When, no longer than three decades ago, the industry in the area decreased in profitability, the problem of unemployment became evident, as most of the inhabitants were not trained in alternative employment fields.
Such kind of material hopelessness, as Erika – a single mother – and Stacy – pregnant at the time of the interview, as well as one of the earlier interviewees, Vivienne – describe, lead to rapid increase of women that decided to become prostitutes (all three of them admit to having been involved in the practice).
Nonetheless, the additional income they received from prostitution, was not solely supposed to support the basic needs of the household. That was, as Vivienne describes, the time when the abuse of various other prescription medicines increased in Oceana. She describes the situation as a simple action-consequence equation: the inability to find employment fuelled depressive tendencies in inhabitants, who, consequently, turned to professional help. Yet, as mentioned earlier in the thesis, the people fell victim to drive-by appointments, where they did, in fact, receive the necessary prescription, but were not provided with sufficient guidance as to how to benefit from the medicines safely; therefore, the misuse of the drugs put the patients at the risk of developing dependence, which, in many instances, became the case.
This does not mean, obviously, that misuse of antidepressants and other non-opioid medicines did not exist in Oceana at the time when the coal mining industry was flourishing – the interviewees, however, try to paint the picture of what they themselves experienced. They did allocate their newly earned money to their and their families' needs, but the “needs” had become more than bills and food – they had to also include the obtained prescription. At the beginning, to improve their mental well-being, and later – to support the addiction (although, in the vast majority of cases, in order to produce desired effects, non-opioids were abused as simply an addition to opioids – not separately; this resulted in even bigger financial problems, as those struggling with dependence had to be able to purchase more medications).
In the interview, Vivienne relives her family's material striving:
“My dad is also addicted, me and him used together. [We] won the lottery, twelve thousand dollars (…) in one week it was gone, we had nothing left, we did 1080s [a reference to the dose of the abused medicine] every day. (…) I was scared, because... my husband, the reason he went to jail was because he was trying to support my pill habit, and I didn't have to do nothing, I sat at home all day, and he went out and robbed coal mines (…) so when he went to prison I had to step up and take that responsibility. (…) I sold one OxyContin for eighty dollars once and there were five people fighting over it. (…) I needed six to eight hundred dollars to actually get high. If I was lucky then I would actually get high daily.”
It is worth nothing that Vivienne mentions selling a single pill for a high price – such a black market for medicines also came to existence in Oceana. It was not often comprised of people like Vivienne, who decided to give up one need to satisfy another – instead, even those that were not affected by the epidemic directly, still participated and contributed to its escalation. By taking advantage of “drive-by appointments”, they would easily obtain the required prescription, to later illegally sell the medicine by highly inflated price.
Such activity, however, is not exclusive to places like Oceana, where the opioid epidemic has spread on such enormous scale – the data presented below, provided by United States Sentencing Commission (USSC), outlines the details of the felony, and further clarifies the reasons as to why it would eventually take place in Oceana.
USSC reveals that:
⦁ the majority of those convicted with illegal prescription opioid trade (as of 2018) were Caucasians (contributing to over fifty percent of the convicts); interestingly, the figure for black people was also considerably high: over thirty two percent (whereas Hispanics make up to slightly over ten percent of the convicted),
⦁ almost all of the convicts were American citizens (nearly ninety seven percent); USSC did not, however, disclose the nationality of the remaining three percent,
⦁ half of the convicted had no prior criminal records (a situation comparable to the position of the women in Oceana that had decided to get involved in prostitution, and then unlawfully sell some of their medicines); less than five percent of the convicts were disclosed as career offenders,
⦁ West Virginia was revealed to be the state with the third highest number of the people charged with the offence (nineteen convicts) – overtaken by Kentucky (twenty six) and Pennsylvania (thirty).
Additionally, almost seventy percent of the prison sentences related to the offence were shorter than five years; only thirteen percent of the prison sentences surpassed ten years of imprisonment.
One can yet again notice the pattern already discussed in the thesis several times. In this instance, however, Caucasians seem to contribute directly to the development of the epidemic (high number of convicts); similarly, the sole involvement of black people appears to be greater as the ones distributing the drug than those abusing it.
As presented before, the race of the addicted plays a significant role in distinguishing the opioid epidemic from other issues of said type. Whereas it is mainly considered as the factor contributing to the proneness to establish dependence, Oxyana presents the racial aspect as not only a cause of the problem, but also an obstacle in overcoming it.
In their interview, Joy and Victoria, a couple, describe how the negative stereotype associated with Caucasians and eastern states like West Virginia pertain to the issue of prescription opioid addiction being overlooked and downplayed by the general population of the US:
“If you had a quarter of addiction that we've been through, you would understand completely, you wouldn't even ask that question, you'd be like, damn, how are you still alive? (…) You know what? Nobody's going to care, you know, this is West Virginia, they think we're all much inbred pieces of shit. People are actually trying [to overcome the addiction], but you cannot get anywhere... It just sucks, man.”
Such approach to the issue – the diminishment and contempt preventing the victims from getting much needed help – together with other aspects contributing to the problem, yet again outside of the sufferers' control, (namely lack of proper medical care in their area of living) is likely to help one become more aware of the severity of it in terms of external factors being partially responsible for the victims' hardship.
It is vital to recognise that the word “partially”, pertaining to the fault of extrinsic factors contributing to the scale of the problem within certain individuals, was not used coincidentally. The thesis neither supports, nor suggests victim blaming, both as a general point of view, as well as in the question examined; nevertheless, in order to properly explain and understand the given subject, all aspects and sides of it need to be presented (especially when the direct account of those involved is available).
This specific point in question is being discussed in the film by yet another couple, James and Rena. After introducing himself, James provides the brief description of his current and past position:
“I have a problem, I have cancer, and I've been on drugs since I was twelve years old, but I've been on oxycodone since two thousand and seven. I have an addiction, plus I'm fighting cancer. So these are two fifteens [shows the drugs on the table], I'm ready to do one for me and one for my wife. This is how I do it [injects himself, then Rena, in the back of the palm].”
That short scene raises several points that ought to be detailed further, together with the main issue of personal responsibility.
James admits to have been involved in the consumption of drugs as early as in middle school. While such statement might appear shocking to the viewer, drug abuse in children is, in fact, an authentic phenomenon. An article from The Journal of the British Paediatric Association, Drug Abuse In Children And Adolescents, published in 1992 (which is probably the approximate time of James' childhood), provides the figures and specific elements for the abuse in the US:
“National American surveys usually report higher rates [as compared to Great Britain]. Most dramatic in the USA is the increase in cocaine use: in 1985, over 1,1 million 12-17 year old adolescents had tried cocaine. (...) Overall about 5% of adolescent drug abusers in the USA meet the criteria for 'dependency', with multiple drug abuse being the rule rather than the exception. The age at which adolescents start drug taking is getting lower: an average of 13-15 years. Girls are less likely to use drugs and start later than boys. (...) Earlier illicit drug abuse is often associated with heavier subsequent drug abuse, more persistent abuse, and the abuse of 'harder' drugs.” (p. 1245)
The reader should pay special attention to the mentioned proneness for continued and/or aggravated drug abuse later in life – the fact most probably played a significant role (among other factors) in James falling victim to the opioid epidemic several years later.
Another, probably less surprising, point raised by the interviewee is him struggling with cancer; he does not state it directly, however, taking into account the sole nature of the issue – addiction to prescribed opioids – as well as the condition of medical facilities and care in certain areas, it can be safely assumed that the painkillers James had been prescribed to alleviate the pain related to his illness, were responsible for him developing addiction.
Finally, what the viewer might find unusual, is the method of consuming the drug. In most cases, commonly used prescription painkillers are to be taken orally; obviously, there are certain cases and doses of the medicines that are to be injected, but the injection is usually done by a nurse or another medical professional legally allowed to perform injections (which, in case of opioid painkillers, are muscle injections; James injecting palm suggests that he aims to insert the substance directly into the vein).
The film does also depict one of further interviewees preparing the injection – his method is identical to that of assembling the form of illegal drugs, most notably diacetylmorphine (heroin), that is ready to consume. One can conclude that the director's decision to film the process was supposed to draw similarities between prescription opioids and illicit substances of said type.
But what does James' story include, that would indicate at least a part of the responsibility of developing addiction lies with the person affected? The question seems to be answered by Rena.
The woman shares her experience with lack of self-confidence and being self-conscious of her physical appearance as a teenager. She admits that said struggles contributed to her decision to try self-harming as a method of relieving the mental anguish; as the results of physical pain resulting from the self-inflicted injuries, she was prescribed opioid painkillers. Soon after she began the treatment, she claims to have realised that whereas the medicine did manage to alleviate the bodily discomfort, the side effects – the reason why prescription opioids are used recreationally – provided her with psychological ease much stronger than the one she was able to achieve through self-harming.
Rena also asserts that the prescription abuse – more specifically, the financial struggle that it caused – started the chain of events that lead to her meeting James, her current husband, whom, she claims, helped her finally overcome the self-confidence issues instead of simply temporarily suppressing them with medicine abuse. She did not, however, stop the misuse of OxyContin, and they both have no intention of doing so in the near future. Rena even calls the substance their “love drug”, as she believes that not only did it guide her to encountering James, but also is one of the reasons they still deeply love each other (James agrees with the statement).
Rena's story does in fact provide an example of misusing prescription medicines, and, as a consequence, becoming addicted to them as a result of choosing the misuse as a means of overcoming a problem that concerns a specific individual and/or that could be resolved by other ways of treatment, designed specifically to settling it. Certainly, one could argue that “drive-by appointments” are most probably an issue present in mental health facilities as well, so that even if Rena willed to turn to a professional that would help her accept and admire her physical appearance, the treatment she would have received would not be sufficient, or would even lead to the worsening of the problem. While the point of “drive-by appointments” affecting the quality of the services provided by therapists are satisfactory, the viewer is not introduced to the basis of the woman's decision to start her own “treatment” - while it might have been fuelled by the unavailability of professional help, it might have as well be built upon her own choice not to try any suggested approach.
Furthermore, what also supports the theory of personal responsibility, is the notice of OxyContin being one of the foundations of the couple's successful relationship – a scenario that is rather absurd.
The differentiation between opioid addiction caused by both external and internal (personal) factors was necessary to characterise the issue in greater detail, depicting its vast extent and obstacles in overcoming it caused by the need to find various solutions, suitable for diversified cases.
Both aspects lead to a similar outcome – addiction – that might be discerned by the level of severity associated with surmounting the dependence; the problem itself, however, can result in a condition closely related to, especially psychological, dependence, that should not be omitted when trying to fully understand the dilemma.
According to MedicineNet, substance withdrawal can be defined as:
“Abnormal physical or psychological features that follow the abrupt discontinuation of a drug that has the capability of producing physical dependence.”
Withdrawal occurs in all kinds of abused substances, and thus might vary in severity, length, and symptoms. In case of opioids (both prescription painkillers, and illegal kinds), sudden cease to consume the required item is likely to cause (following Treatment 4 Addiction, An American Addiction Centers Resource)
⦁ excessive sweating, independent of the external conditions, occurring usually during the night,
⦁ other physical manifestations of withdrawal, namely muscle pain, flu-like symptoms, nausea, diarrhoea, and cramping in lower abdomen,
⦁ psychological discomfort – increased anxiety, agitation, insomnia, as well as inability to concentrate.
The aforementioned conditions are of highest intensity during the first five days after stopping the consumption of the substance; next, the individual's body and brain start adapting to function properly without the required intake of the drug.
Nonetheless, there are medicines supposed to nullify the symptoms, and help the addict fight the urge to alleviate physical and mental discomfort by relapsing on opioids. Interestingly, the medicine used in the treatment, Subtex (and several other of its brands), consists mainly of another opioid, buprenorphine; that specific extract of papaver somniferum, while matching the definition for an opioid, does not produce the effects desired to be acquired from recreational use. Such quality allows the body to register the needed dose of opioid, with the individual being unable to achieve any previously seeked reaction, thus allowing the withdrawal period to pass almost unnoticeably (the effectiveness of the treatment varies due to the dose of the opioid the patient was used to receiving).
Naturally, as with any other treatment, no success is guaranteed, since each individual's physical and mental properties might affect the quality of the process. Whereas in most cases the disturbance of the therapy of the discussed condition will lead to temporary noticeable uneasiness and pain, there is a risk of a patient (either subjected to treatment or not) not only being immune to the provided remedy, but also establishing a syndrome including symptoms of severity much greater than those present in classic opioid withdrawal.
In rare cases, the sudden cease of opioid intake might lead to withdrawal-induced psychosis, a state which, in general, can be defined as:
“a loss of contact with reality, usually including false beliefs about what is taking place or who one is and seeing, and hearing things that are not there.”
Psychosis induced by opioids, according to Treatment 4 Addiction, usually manifests with severity greater than the same state induced by other drugs with sedative properties:
“Opiate withdrawal induced psychosis is very different (...). It derives from a place of mental instability and severe anxiety. A sense of hopelessness is very common when in a withdrawal induced psychosis. Judgment and logical thinking are not present during a state of psychosis and can lead to impulsive actions. Depending on the circumstances and possible pre-disposed mental illnesses, a state of psychosis, especially in withdraw, can be extremely dangerous. (...) It is this desperation and hopelessness that will cause an addict to make decisions that may go against their morals or values. (...) This can be very dangerous. Someone in a state of psychosis is extremely unpredictable. Addicts in opiate withdrawal induced psychosis will go to any length to get what they desire.”
Such description – especially regarding making impulsive and hazardous decisions – matches the confession of one of the interviewees, Kurt.
The man describes himself as being in his mid-thirties, and addicted to opioid painkillers (he even shows the drug packages, detailing the doses of the medicine each of them contains, and how much they cost), as well as to unspecified antidepressants.
Before beginning to tell his story, he – similarly to James – injects himself in the back of his palm with a dose of medicines (a painkiller mixed with antidepressants). The viewer might notice that, despite the period of time that has passed since the injection, Kurt does not show any signs of drowsiness, or other symptoms of being under the influence of the substances he has taken. This might suggest that the purpose of the dose in question was to simply avoid the discomfort of withdrawal, not to satisfy the need for the desired effect.
Kurt describes his teenage years in Oceana; the man has never moved out of the town. He used to live with his parents and younger brother, Eric. Both his mother and father were addicted to illegal opioids, which they later replaced with prescription painkillers. His father was also an alcoholic.
In spite of his parents' addiction, the family life was fairly undisturbed by the condition. However, one night, probably as a consequence of a lack of professional help, Kurt's father suffered psychosis caused by untreated withdrawal. The interviewee was not at home that particular night, and, as he now confesses, because of what he discovered after having been back, he believes it was only because of God's providence.
Kurt's father body was scattered on the kitchen floor, next to an empty bottle of an opioid painkiller, and a pistol; his head had a noticeable gunshot wound. The body of the mother was in her bed, dressed in pyjamas – Kurt claims that she was murdered in her sleep. Finally, he found Eric, also dead, lying next to his bed; the body expressed the signs of struggle or defence.
The police concluded that the father, paranoid and desperate to find the drug he needed, found out earlier that his younger son, who had started to grow concern over the parents' dependence, hid the painkillers under his bed. After refusing to give the medicines back to the father, Eric was shot by his father. Next, the man went to the bedroom he shared with his wife, realised she was not woken up by the gunshot, and also murdered her. Eventually, he consumed the medicine he forcefully took from his son, and committed suicide shortly after.
The tragic story of Kurt's family, in its atrociousness, might appear to be an exception, or a part of the very low percentage of extreme cases of prescription abuse. While, according to Bureau of Justice Statistics (BJS), the crimes related to substance abuse (both legal and illegal) in the USA make up only about eighteen percent of all offences, like any other issue, it should not be neglected.
A adduction of a case from outside Oceana might help one realise the severity and omnipresence of this seemingly minor phenomenon.
The city of Mishawaka, Indiana (interestingly, it was not put on the list of the states that are most affected by the opioid epidemic; a proof of the ubiquity of the problem), is one of the places that experienced the issue. An article by Megan Thielking (2017) for Stat News, A Doctor’s Murder Over An Opioid Prescription Leaves An Indiana City With No Easy Answers, quotes the harrowing story of Dr Todd Graham.
“Dr. Todd Graham wasn’t yet halfway through his workday at South Bend Orthopaedics when a new patient came into his office here complaining of chronic pain. Heeding the many warnings of health officials, he told her opioids weren’t the appropriate treatment. But she was accompanied by her husband, who insisted on a prescription. Graham held his ground. The husband grew irate. The argument escalated to the point that Graham pulled out his phone and started recording audio until the couple left. Two hours later, the husband would return, armed. (...) the incident wasn’t out of the ordinary - physicians here and across the country have grown increasingly accustomed to disputes over opioids. (...) Two hours after their verbal scuffle in the orthopaedics office, Michael Jarvis - who had wanted that prescription so badly - had come after him again, this time in the parking lot. Again, Jarvis shouted. He ordered two people at a nearby picnic table to leave. Then he pulled out a semiautomatic weapon and shot the doctor who wouldn’t give his wife pain pills.”
The case quoted above demonstrates even more hazardous side of severe opioid addiction. While the author does not state whether the man who threatened doctor Graham was in the midst of withdrawal, and, consequentially, psychosis, the reader should acknowledge that the prescription Jarvis was demanding was not intended for him, but for his wife. This fact generates several questions – was the culprit lying, as he was convinced the doctor would have been more likely to prescribe the desired medicine for his wife? If so, what was his reason for believing so? Was his mere presence during the appointment supposed to intimidate the doctor and pressure him into providing the prescription? Or was Jarvis addicted to illicit opiates that were not available for him at the moment, and tried to take advantage of the fact that his wife's condition required medical attention? Had he hurt or abused her particularly for this reason?
In the article, the reader will not find the answer for any of the cited questions, which, in fact, makes the specific case – and the whole issue of painkiller addiction and withdrawal – even more horrifying. Each scenario could possibly be true, and, taking into consideration the scale of the epidemic, it can be assumed that that all of the aforementioned probabilities have took place in other cases that did not receive any or enough media attention.
What is more, Doctor Graham's example encourages one to recognise that not only those in close vicinity of the sufferer of psychosis are in immediate danger. The doctor was not in any way related to the murderer, and met his tragic fate only because of trying to properly execute the medical practice by not providing the patient with treatment that would be improper or even harmful for her. Yet again, the scenario establishes another possible one – what if Jarvis learnt about a person, not necessarily associated with medicine, that was currently in possession of an opioid painkiller, and decided to threaten them instead? Such possibility appears even more random, but definitely not absurd, and thus, more alarming.
To support the concept of the jeopardy a third party can be put in because of opioid prescription addiction, Thileking refers to the figures associated with physical and verbal attacks aimed at individuals in their workplace, with the focus on patient-on-doctor violence:
“Health care workers face a disproportionate share of violence in the workplace: An average of 146 attacks for every 10,000 workers, compared to seven assaults per 10,000 workers across the entire U.S. labour force.”
She also mentions the dilemma physicians are often met with when trying to execute the proper treatment:
“First-time patients [such as Jarvis' wife] who are seeking painkillers present a tricky problem for doctors who say they often need considerable time to diagnose what’s wrong with the patient and figure out how best to help. If a patient demands the quick fix of an opioid prescription instead, the situation can swiftly escalate. But doctors say they’re not sure what to do when that happens. They often don’t want to call the police on a patient. Yet they don’t want to give in and write an unnecessary prescription, either.”
Presumably, such puzzling situation doctors are likely to find themselves in, might be the factor that discourages those interested from pursuing a career in medicine; ergo, causing the lack of physicians (“drive-by appointments”) not only in the areas that are affected by the opioid epidemic the most, but also creating the problem in seemingly unaffected areas of The United States.
In order to conclude the analysis of the film in a coherent and logical way, it is best to yet again touch on what commenced it – a statement from the director. This time, Sean Dunne, in an interview with Nick Dawson (2013), rightfully pays respect to those that participated in the production, and, at the same time, restates what has already been aforementioned in the chapter, regarding the cases of the people that might have not been the victims of the phenomenon themselves – how the opioid epidemic affected him both personally and by proxy:
“Certain people were aware of us before we got there and wanted to have their voices heard. Others took a bit more time to warm up to us. But once we got going and got a few interviews under our belt the tide started to shift in our favour, word spread that what we were doing was legit and people began to embrace us. Once our cameras were rolling I couldn’t believe how candid everyone was. We treated them with respect and they did the same in return. (…) The Oxycontin epidemic was somewhat on my radar from personal experiences, but I wasn’t really aware of the full extent of the situation in West Virginia until we went there and saw it firsthand. (...) Obviously when you’re infiltrating and documenting a subject as sensitive as this you are going to be met with some resistance. We had some threats of violence that were very real and extremely nerve wrecking; we even had two death threats. In a town as small as Oceana there is really nowhere to hide, especially with a film crew, so we had to face that stuff head on.”
Later in the interview, Dunne remembers how difficult the process of editing the film was for him and the rest of the filming crew due to the affecting and tragic subject matter, but, in addition to that, he mentions that he is happy for introducing the issue to a large audience.
As the main representative of the problem, included in the present chapter, Oxyana helps the reader in a way infiltrate, as the director himself has mentioned, the psyche and sensitivity of those that were personally involved in prescription opioid abuse, whether by choice, or by the affection of unfortunate circumstances. It rehashes the data presented at the beginning of the chapter – the effects opioids have on the user, their similarity to illegal drugs of the same kind, as well as the problems related solely to the situation a given area struggles with due to the lack of sufficient professional help – and also introduces one to entirely new elements the epidemic, namely the cost of the addiction (financial, as well as health-wise) in an individual, and the black marked of reselling the medicines in question, and means of making money.
In general, the aim of the chapter was to detail the widespread and highly lethal, albeit usually underdiscussed, issue of prescription opioid abuse, by focusing on the most affected demographics and the interesting factors contributing to the people in question falling victim to the epidemic. The presented data has been supported by introducing official statistics that – although most probably not as powerful and emotion-inducing as the direct testimonies provided by Oxyana – prove the unambiguous, yet seemingly contradictory, connection between trying to treat the pain without the adequate supervision and care of a professional, but also with the abundance of physicians to choose from – with developing opioid addiction, the consequences of which are not only detrimental to physical health, but also to the victim's mental condition.
