Widespread addiction to harmful drugs is a major factor impeding the U.S. economy. Millions of people are out of the workforce or have low productivity because of their addictions. Employers spend large sums on drug tests for job applicants and workers and suffer from poor performance by workers with addiction problems.
Governments at all levels spend increasing amounts on public services needed to even cope with its problems on a day-to-day basis, much less treat the addicted or find other measures to reduce the level of drug abuse. These costs at the local level may involve police, emergency medical services, clinics and hospitals. Addictions lead to family neglect, crime to support habits and other harmful behaviors. All these are overwhelming local and state governments in some areas.
The problem is ubiquitous. There are people with addictions in every county of the nation. A new database of opioid use shows one aspect of this. Compiled by the Drug Enforcement Administration and secured and published, after an arduous fight, by the Washington Post and HD Media, which publishes the Charleston (West Virginia) Gazette-Mail, the data detail sales of opioids by manufacturer, state, county and drug store for the years 2006 through 2012. Of course, the problem has gotten more severe in the ensuing seven years. It would be useful to see more recent patterns, but these earlier data still are instructive.
Opioid use is not equally severe all over. There are remarkable differences from region to region and state to state. These embody useful insights about the economic, social and cultural determinants of addiction. There also is information by county. In some cases, this reveals real levels of use, but it many others the county-to-county variation is driven more by rural shopping patterns and not any underlying disparities in addiction.
The Washington Post has placed the entire database online and it is downloadable (subscription required). One also can view national maps with county-level data for the whole nation without downloading or searching the database. Just move your cursor over the map.
Looking at the national map, one is struck by huge regional differences. Appalachian regions of West Virginia, Virginia, Kentucky, Tennessee and western North Carolina show per capita use of around 150 oxycodone or hydrocodone pills per year. A few hit 168 per person per year. Levels are also high in the Ohio River Valley and in a band across the northern edge of the deep south into Oklahoma. There are patches of high use in Nevada, northern California and southwest Oregon.
But other areas show little use. A few counties show zero average use. Dewey County, in north-central South Dakota, shows 0.2. Murray County, my hometown, shows six while Nobles, just to the south has 13.9 and Pipestone to the west is listed as 23.5 opioid pills per person per year. People familiar with the region will immediately see that this reflects where people go to shop and not some fundamental differences in the cultures or economies of these counties. Many of the pills sold in Pipestone probably went to Murray County to the east and Lincoln County to the north, both of which have county seats that have fewer people and more limited retail businesses than Pipestone. The same is true in thinly-populated areas of the Dakotas that
show zero sales.
In general, the Upper Midwest, from Nebraska and Iowa on north showed remarkably low levels of use, at least over the seven years tabulated. So do New York and all the New England states to its north and east.
A cursory look at the map makes one realize that the problem escalates relative to generally lower education levels and incomes. Appalachian counties were poor when Harry Caudill’s gripping “Night Comes to the Cumberlands” was published in 1962, focusing national attention on the region and leading the Kennedy administration to make the region the center of its anti-poverty programs. These counties remain poor now in relative terms and attained education levels remain among the lowest in the nation.
One is struck however, by the fact that major cities with poor inner-city populations do not stand out. New York, Detroit, Chicago, Milwaukee and Los Angeles may be slightly above rural Iowa in opioid use, but are not nearly as high as the Appalachian and Ohio Valley counties.
One factor may be that the dispersion of poverty in the most afflicted areas is very different than in Chicago’s Cook County or the five -counties New York City metropolitan area. These urban counties have desperately poor and undereducated residents, but they also have a much higher proportion of middle-class and wealthy people in their populations. So averaging out use of drugs that are very related to low-incomes is a different matter.
Remember also, that this particular set of data tabulated only opioid use, and not all legal or illegal abused drugs. Use of cannabis, meth, cocaine and heroin are not included. If it were possible to secure reliable information on levels of use of these historic illegal substances, more inferences could be made.
That, however, is difficult. The opioid addiction wave differs from the 1980s crack cocaine epidemic, the 1960s heroin wave in cities or ongoing use of cannabis, meth and cocaine. Nearly all opioid addictions, at least until recently, began and were sustained with pills manufactured by reputable pharmaceutical firms, prescribed by credentialed physicians and dispensed from established pharmacies. So there are detailed records of the problem. Surveys and other data, including that from law enforcement agencies, give us much information about use of illegal drugs, but not with the same certainty or degree of resolution that this DEA database contains for opioids.
Some patterns seem to be sustained by the data. There are vicious circles in addiction cycles, meaning that negative conditions tend to perpetuate themselves. Poor, unemployed people in areas with declining industries are more apt to become addicted than those in areas with healthy job markets. Public- and private-sector leaders make statements about the need to bring in new industries. But employers are loath to locate factories in regions where drug addiction is known, or thought, to be rampant. And so, unemployment and poverty remain intractable.
There also seem to be “demonstration effects” in addiction. One couple coming from my grandfather’s village in the Netherlands led to three more the next year and then a group of 14, including my grandmother the next. One farmer in the Punjab adopting high-yielding rice varieties led to a few others in the village the next season and then many. So too does addiction spread geometrically across friends and families. The more people one knows who use drugs, the more likely one is to use; the more drugs used in one’s community, the easier it is to buy them.
The demonstration effect may be part of the spread of abuse from initial centers of high use across the country. One can look at maps of use by year from 2006 through 2012 and see higher levels of use spread, just like water filling a dry pond. The relative patterns between regions remains, but absolute levels of use rise in nearly all.
Drug abuse and addiction issues, especially those related to opioids are some of the toughest challenges our nation faces. We know from experience that trying to eradicate supply without reducing demand is doomed to failure. But reducing demand depends on treatment programs that are expensive. We are not yet willing to spend the levels of tax money that are necessary. Regardless of which party has control of which branches of government, this is not going to go away. And it will continue to sap economic productivity in addition to well-known social harms.
St. Paul economist and writer Edward Lotterman can be reached at stpaul@edlotterman.com.