Why Did the Opioid Epidemic Start in the Rust Belt?
Far more Americans now die of opioid overdoses than in traffic accidents.
IN JANUARY 2018, U.S. DISTRICT JUDGE DAN POLSTER gathered litigants representing nearly four hundred cases in his Cleveland courtroom to address the horrible realities that had brought them there. Cities and counties and states were suing businesses at all levels of the opioid drug industry—prescription drug painkiller makers, distributors of such drugs, and the pharmacies that put them in the public’s bathroom medicine cabinets—to help pay for costly crises that pain meds like OxyContin had brought upon their communities.
Judge Polster pointed out that more than 50,000 opioid users were fatally overdosing each year, about 150 deaths a day from the opioid crisis. And the rate of death—and the associated costs, which include everything from hospital and morgue expenses to the cost of foster care—were only increasing. “I don’t think anyone in the country is interested in a whole lot of finger-pointing at this point,” he said, “Because sadly, every day more and more people are being addicted, and they need treatment.”
Since that initial hearing more than five years ago, Polster has been proven right about the grim trendline of addiction. The annual fatal OD rate ballooned to exceed 107,000 in 2022, more than double what Polster was dealing with in 2018. More than two-thirds of those deaths involved fentanyl. That means this country saw 300 drug overdose deaths every day last year, about one person every five minutes. And I have a feeling that rate has continued to accelerate in 2023.
One important thing has changed since 2018. The hundreds of cases before Polster that day in January—they were all brought together in something known as a multidistrict litigation—have so far resulted in numerous, very costly settlements amounting to more than $50 billion. That money is being sent to the cities, counties, and states. (Not sent all at once, to be clear; most of the settlements are being paid out over an 18-year period.) But there is a policy oddity in these settlements that many observers are missing, and it has to do with transparency on the part of those receiving the money. While sixteen states are reporting on how 100 percent of their settlement award is being spent, another sixteen states are not reporting any of their spending plans for their settlement money, and eighteen states are reporting “some” of their spending.
That means two thirds of the American states aren’t telling their residents their plans for the money.
The obvious problem here is that anytime a government agency gets an influx of cash, open hands suddenly appear all over city hall. In the case of the opioid settlements, states are deciding which counties get more than others, cities are deciding if treatment for drug addicts should see more or less funding than neighborhood action groups, and they are also considering whether the opioid settlement money should be used to prioritize law enforcement expenses (and expanding jail capacity) over inpatient medical treatment.
The problem here is a huge one: Over the past five years, $50 billion has become part of the plan for states and local governments to combat the opioid epidemic; in the same time frame, as we’ve seen, the drug OD death rate has doubled. But while the money couldn’t come at a better time, many states are simply not engaging in public discussion over how their share of that $50 billion will be used to cut that terrible number down.
“Public reporting of opioid settlement expenditures is not required by the settlement agreements themselves. So, we’re in wild, wild West territory,” said Christine Minhee, who founded the (very thorough) Opioid Settlement Tracker in 2019. “It’s nearly impossible to truly figure out exactly what’s going on.”
I DEALT WITH AN ALCOHOL ADDICTION PROBLEM of my own about a decade ago, and I was amazed by the sheer number of Oxy addicts I found alongside me during rehab. Most had eerily vacant stares, and I wished goodbye to quite a few of them at their funerals. I wrote a long piece in 2015 about what I learned from them during our joint experience. This sums it all up:
Americans are addicted to pain meds—legal and illegal—because the United States’ medical community had redefined who needed these meds and who didn’t.
In effect, doctors had been prescribing pain meds for everything and anything for so long, patients have now come to expect a pain pill for, well, everything and anything.
The now-familiar story goes as follows: Industrial America was flooded with OxyContin in areas where hard occupations had given rise to gnarled hands and hurting backs, but over time, that legal and regulated (if endlessly abused) prescription drug was replaced with illegal and unregulated drugs with comparable features: heroin and, later on, our current scourge, fentanyl. Right now, the central zone of the crisis seems to be Appalachia and the Rust Belt regions, something that has remained consistent as the overdose epidemic has spread. Of the metro areas with the highest rates of overdose deaths, the Midwestern cities of Cleveland, Columbus, Louisville, Detroit, Milwaukee, and Indianapolis are all in the top ten. By state, the top ten include West Virginia, Tennessee, Kentucky, Ohio, Indiana, and Pennsylvania.
While these states share the problem of high OD rates, they have drastically different approaches to public information on their use of opioid settlement funds. In Pennsylvania, 85 percent of the spending is publicly accounted for; 72.5 percent in West Virginia; half in Kentucky; and none at all in Tennessee, Ohio, or Indiana. It almost seems fitting that companies like Purdue Pharma hid information about what was killing us, and now our governments are hiding information about how they plan to make us better.
THIS PAST SPRING, Sally Satel, a psychiatrist and senior fellow at the American Enterprise Institute, analyzed how Appalachia has long been the source of addiction epidemics, as painkiller profiteers replaced the coal barons:
The history of opioid pain relievers in Appalachia is a prime illustration of the fact that drug epidemics rarely burst onto the scene out of nowhere. Instead, they find their place in regions that are already home to an established base of individuals who abuse similar drugs. Thus illicit OxyContin, a more potent opioid, efficiently gained popularity over Percocet and Vicodin in the same way heroin would substitute for prescription opioids as the latter grew scarce after 2010.
Satel is clearly right to say that when one is working in the coal mines—when the pay is okay but the pain endured is not—then pain pills are easy to get, easy to share with others, and easy to get addicted to. The same holds for the Detroit automobile factories and the Pittsburgh and Cleveland steel mills. Drugs and alcohol and prescription drugs get one through the day when the days are identical for decades.But what this process can’t explain is why, as the number of coal miners and lathe operators and rebar casters keeps declining, the number of addicts in these regions keeps going up.
I have long suspected that stability is the key to a healthy community, and even though many Midwesterners complained about their factory jobs, there was a predictability to what those jobs brought. Decades of clock punching, a house in the suburbs, kids having a shot at college, a stable retirement, and maybe winters in Florida. Those expectations don’t really exist in the Rust Belt anymore.
An essay in the New York Times by Thomas B. Edsall helped me connect instability to addiction, especially in places like Ohio and West Virginia. Edsall writes that the reason once-vibrant cities like Cleveland, Baltimore, and St. Louis have suffered from poverty, crime, depopulation, social dysfunction, and homelessness is because of “the erosion of the local establishment and the loss of civic and corporate elites.”
Another way to put it, in the words of demographer Aaron M. Renn, is that “civic leadership has been bureaucratized.”
When the Midwest was at its peak,—when the jobs were good and plentiful and the rich were getting richer—the locally owned banks, department stores, and manufacturers realized that the moral and physical health of the population was a clear basis for a healthy regional economy. The civic leadership knew that a vibrant population meant a vibrant economy.
But the last fifty years has pushed the local economy to a much smaller percentage of what it once was. Mark Muro, a Brookings Institution senior fellow, told Edsall that
Many metros have lost pieces of their leadership and lost sources of the wherewithal, capital, know-how and prestige so important to advancing regional initiatives, including ones to bolster local prosperity and autonomy. All in all, the loss of core corporate and other institutions erodes the capacity of the regions most in need of active work to maintain and grow their economic and social health.
Of course, there’s no way to draw a definitive line of causation between a region’s economic health and its fatal OD rates, but I am convinced that public perceptions of an unstable, unappealing, dim future contributes to people dying from drug addictions. Meanwhile, crumbling local leadership Muro describes may explain why so many states are hiding how they spend their settlement money.
THE RUST BELT MAY BE WHERE the opioid epidemic began, but it certainly didn’t stay there. Overdose deaths are increasing in big and small towns, among every age and race and gender, rural and urban, and at every income level. Eight students at Park View High School in Washington, D.C. suburb of Sterling, Virginia—in the country’s wealthiest county—have (non-fatally) overdosed on fentanyl-laced pills in the past three weeks. Virginia had more than 2,600 drug overdose deaths in 2021, and the state is receiving $532.9 million in settlement funds over the next two decades for overdose prevention. It has promised to make 55 percent of its settlement spending public.
Drug overdose deaths, mostly from drugs like fentanyl, are now more than twice the annual number of breast cancer, car crash, or suicide deaths and roughly five times the number of homicides. Yet when asked a few weeks ago why Congress had let a $20 billion program for opioid addiction treatment, prevention, and recovery expire at the end of September, Sen. Bernie Sanders said other priorities had precedence, and, “We’re working on a myriad of problems.”
The $50 billion the states are spending likely won’t be enough to solve a problem this big, even if they spent all of it wisely and efficiently. Their lack of transparency makes that unlikely. Congress backing out of even a modest program will exacerbate the problem. As Judge Polster found years ago, the financial costs of letting the problem continue are greater than solving it, because it isn’t solving itself.
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