 Why did prescription opioids bring so much misery to the small towns of post-industrial America? The standard narrative is to put all the blame on OxyContin, a powerful painkiller pushed on rural America by the profiteers at Purdue Pharma. Under a settlement agreement, Purdue would plead guilty to three federal criminal charges related to its role in pushing the powerful painkiller OxyContin. In this telling, the opioid epidemic is a morality tale of capitalism run amuck and regulation made toothless by anti-government zealots. Sally Sattel, a practicing psychiatrist and resident scholar at the American Enterprise Institute, has a more complicated story to tell. In 2018, she moved to Iron Tin, Ohio, a small economically depressed town in Appalachia. With the help of Hillbilly Elegy author J.D. Vance, she found a job working with patients and social service providers to better understand the opioid epidemic. Sattel says that the opioid crisis didn't start with OxyContin. It was a natural outgrowth of a century old tradition of medicating pain as a way of tending to the broken bodies of the region's laborers. All the men worked in these very physically brutal jobs, and if they couldn't work, they couldn't live there. Even though many of them were in agony, they had to work, and the Coal Camp doctor who was employed by the company had to get them into the mines, so they medicated them so that they couldn't work, which is not to say that the medication might not have been indicated alone for pain control, but it also is a way to make sure that the labor continued. There had been trafficking of prescription pills for a long time, gray market pills, mainly Percocet, Lortab, Vicodin, Roxycodone. Sattel stresses that when the Purdue Salesforce came to small towns in Appalachia, it was pushing on open clinic doors. Their product, OxyContin, was a particularly potent form of Oxycodone. Your average Percocet is 5 to 10 milligrams of Oxycodone, but an OxyContin pill can have up to 80 milligrams. But there was a reason for that potency. The drug was engineered to release the medication slowly over a longer period of time. The appeal of OxyContin is that it was long acting, so that if you had chronic pain, you had a more steady blood level that is a pharmacologically legitimate strategy. But patients started misusing it. When you chop up that pill and either snort it or inject it, mix it with water and inject it, then you're getting an enormous rush and it's a pharmaceutical grade. The common narrative is that patients with no history of addiction got duped into becoming addicts after doctors prescribed them pain medication. That's mostly a myth. Only 22% got them from a doctor. Even that doesn't mean that they did not present themselves in such a way as to get medication when they really were intending to abuse it, which is not that common. The average person who abuses these medications knows what they're doing. Just as the original formulation of OxyContin didn't create the opioid crisis, removing it from the market didn't make the problem go away. Pill prescribing peaked around 2010, 2011 and that peak or the descent after that peak really was an amalgam of several things. One OxyContin was reformulated so it couldn't be chopped up, but as pills became less available to people who abused them, heroin was there. 2015 is when you start to see the rise of heroin and it was really always waiting in the wings. Satelle also challenges the view that addiction is a disease similar to diabetes or Alzheimer's. That narrative, she says, denies the agency of individuals with substance abuse issues and makes it harder to treat them. Of course the brain has changed in addiction, but the point is the brain isn't changed to the point where a person can no longer make decisions. It's a behavioral phenomenon that responds to contingencies, that responds to consequences. If you talk to someone who drinks too much or uses drugs too much, and I emphasize the too much because that's the problem, and I'd say to them, what are you doing that? What's going on? That question makes sense. That question can be answered in existential terms. If I said to the person with Alzheimer's disease, why do you have Alzheimer's disease? Oh, maybe they'll talk to me about plaques and tangles and a kind of neuro pathology, but the answer doesn't come in the form in existential language. And that's very important because that goes to why people use and it goes to how we get them out of it. Satelle argues that substance abuse derives from both inborn predilections and environment. Effective treatment has to deal with both factors. I think the more we medicalize this problem, the more we're going to be misled, the more we're going to put emphasis on the medications, the methadones, buprenorphine, naltrexones, and I'm all in favor of those medications because they help people stand still. And if you're out, if you're craving, if you're running around, you're never going to make the first step towards stopping. So I offer the medications, but to think that could possibly be enough strikes me as incredibly naive. The National Institute on Drug Abuse, they show brain scans and they talk about this as, quote, a disease like any other, which of course it's not. And when you go to a place like, you know, Ironton, you can see how medicine and public health are necessary, but not at all sufficient because what do you do when you finally do get somebody sober, but they're in an environment that doesn't appear to offer much. In a deeply ironic way, many of the people who blame the opioid epidemic on bad pills see the solution as a different set of pills, methadone, buprenorphine, and naltrexone. Citel stresses that the best way forward is to give individuals tools to make better use decisions while improving their chances to live lives with open-ended futures. Sometimes a pill does make a massive difference, but usually so much other work needs to be done as well. But I think having a pill, quote, unquote, magic bullet, the hope of the fantasy of a magic bullet can reinforce that notion.