Drug dealers among us: Look for those wearing lab coats or pinstripe suits

In his State of the Union speech, President Trump cited the 64,000 drug overdose deaths that occurred in 2016 and enjoined, “We must get much tougher on drug dealers and pushers.”

Members of Congress applauded, but neither the president nor Congress appears to notice that the biggest drug dealers wear white lab coats or pinstripe suits, not hoodies or the gang garb of street-level dealers. The majority of those 64,000 victims first became addicted while using drugs that were produced by pharmaceutical companies and prescribed by doctors.

{mosads}In the 1990s, U.S. opioid manufacturers successfully convinced a generation of doctors that opioids could be safely prescribed in ways they never had been before. Before that time, opioids were used primarily to treat acute pain, cancer pain and the terminally ill. Then the health care system began giving these highly addictive drugs to people with chronic conditions, prescribing daily doses for indefinite periods. Sales rose to nearly a quarter of a billion prescriptions per year, equivalent to one for every American adult, and an epidemic of addiction and overdose followed.

The authors of this disaster have never really been held responsible. Purdue Pharma did pay a $600 million federal fine for overstating the benefits and understating the risks of OxyContin. But that is less than 2 percent of the estimated $35 billion in revenue earned from the drug to date. While several company executives were held criminally liable, they didn’t spend a day in jail. By contrast, selling $35,000 worth of heroin — just one millionth as much — triggers a five-year federal mandatory minimum sentence.

That is not because prescription opioids have done less damage than heroin. Every year, more heroin purchases are made than opioid prescriptions are written, but until dealers began adulterating heroin with fentanyl, prescription opioids killed more people.  

Political economy and political blind spots work together to prevent action.

Trump decrying “bad hombres” and planning to “build a wall” fits with a long history of blaming U.S. drug problems on people from other countries, and resonates with ugly nativist sentiments. Mexican gangs (and others) do deal drugs, but as Sam Quinones documents in his book “Dreamland,” heroin dealers expanded their distribution networks after prescription pills greatly swelled the pool of opioid-addicted people. Those pills didn’t come from Mexico; they came from Connecticut.

The pharmaceutical industry’s political influence, maintained through lobbyists and eye-popping campaign contributions, gives it protection that Mexican drug traffickers could only dream of. As the Washington Post and 60 Minutes have reported, when the Drug Enforcement Administration tried to stop companies that distribute opioids from shipping millions of pills to small towns in opioid-wracked regions of the country, Congress blocked those efforts by unanimously passing legislation stripping the DEA of authority to protect those communities. The effort was led in the House by Rep. Tom Marino (R-Pa.), who not incidentally was President Trump’s nominee for drug czar before the scandal forced him to withdraw his name.

Finally, there is a strange convergence between Trump’s worldview and that of a subset of the generally anti-Trump elites who retreat to the Swiss Alps once a year. Trump is an uncritical booster of American business. That can blind him to the predations of corporations that enriched themselves by spreading opioid addiction. Some of the Davos set, exemplified by the well-heeled Global Commission on Drug Policy, are equally uncomfortable with acknowledging the evils of the legal drug industry, because it would reveal the folly of thinking that the only problem with heroin is that we haven’t legalized its sale and manufacture.  

To their credit, some former proponents of legalized heroin production have recanted in light of evidence that when you let free-market capitalism peddle opioids you get hundreds of thousands of premature deaths, not a libertarian Eden. But others refuse to face up to the abundant, tragic evidence that letting legal corporations sell heroin as if it were bubble gum would be a public health disaster.

To be clear, we have no sympathy for transnational criminal organizations that traffic fentanyl. But Americans don’t wake up one day and suddenly decide to seek out such a deadly drug. They typically reach that state after first becoming addicted to opioids that are legally manufactured, distributed and prescribed by a doctor. Until our national political leaders show the courage to hold the pharmaceutical industry to account, pounding the table about street corner heroin dealers will be an exercise in hypocrisy.

Jonathan P. Caulkins is the H. Guyford Stever University Professor of Operations Research and Public Policy at Carnegie Mellon University’s Heinz College. His research includes modeling the effectiveness of interventions related to drugs, crime, violence, delinquency and prevention.

Keith Humphreys, Ph.D., is the Esther Ting Memorial Professor at Stanford University School of Medicine. He researches interventions for substance abuse and psychiatric disorders.