How pharma greed, government subsidies, and a push to make pain the “fifth vital sign” kicked off a crisis that costs $80 billion a year and has killed hundreds of thousands of Americans.

Listen and subscribe to our podcast at Apple Podcasts, Stitcher, or elsewhere. Below is a transcript of the episode, edited for readability. For more information on the people and ideas in the episode, see the links at the bottom of this post.

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Stephen DUBNER: So, what do you expect we’ll see here today? Jeanmarie PERRONE: I don’t know. I called a colleague who’s working right now, and he said he was about to call Nicole. So the person that he would be calling about is either an overdose or someone seeking treatment.

Dr. Jeanmarie Perrone runs a medical toxicology and addiction department in the University of Pennsylvania’s medical system. This means she’s an E.R. doctor as well as a UPenn professor and researcher who knows a great deal about — and who’s seen a great deal of the opioid crisis up close.

PERRONE: So, we have about 1,000 or 1,200 patients who visited our three hospitals last year, and about 400 of them were overdoses. Probably 200 or 300 of them were seeking treatment. And then another 400 were seeking treatment for a complication: skin infections, fevers, abdominal pain, nausea vomiting, withdrawal symptoms.

Perrone recently walked us through the E.R. at one of the UPenn hospitals. She introduced us to the team working that day. Here’s Dr. Kit Delgado:

Kit DELGADO: Just right now, I have a patient who came in who had stopped taking methadone, because it was interfering with his job. And he’s now having opioid-withdrawal symptoms. He actually came in for a different complaint, but — DUBNER: Unrelated? DELGADO: Somewhat — you know, had some nausea, chest pain, and got his normal emergency-department evaluation. I was just about to discharge him, and sort of realized that this is the root cause. DUBNER: So the patient you mentioned is here now? DELGADO: He’s here now. And our recovery specialist is actually meeting with him to try to seek out a better option.

A few minutes later, this “recovery specialist” appeared. Her name is Nicole O’Donnell.

DUBNER: How’s your day? Nicole O’DONNELL: It’s good. Busy. PERRONE: Saving lives. DUBNER: We heard you just were with someone that was a fairly complicated case? O’DONNELL: Not a complicated case. He’s okay. DUBNER: Yeah. So what happened? O’DONNELL: He was willing to talk. So I just went in and kind of triaged the situation with him to find out what was going to work for him. And the stipulations around methadone weren’t realistic and that’s why he stopped taking it.

“The stipulations around methadone” were established back in the 1970’s, when methadone was increasingly used to fight heroin addiction. Methadone is itself an opioid, so it was required to be dispensed by a doctor, typically at a clinic. Which means that a patient has to go to the clinic every day for treatment. And if you stop going — as the patient in the E.R. today apparently did — you can suffer the same nasty withdrawal symptoms as you’ll get from a drug like heroin.

DUBNER: I gather every story is — every case is entirely different? O’DONNELL: Entirely, yes. DUBNER Do you tell them early in the conversation that you have had similar experience? O’DONNELL It depends on the situation. Barriers come down a little bit when you do disclose that. I — sometimes I don’t have to say. They just know. It’s language. It’s, you know, it’s compassion. Like, I understand how you feel that you’re in withdrawal. So it is a little bit different.

The team at UPenn has been willing to try different things because, when it comes to opioid addiction, what’s been tried thus far has not been working so well. As you’ve surely heard, the U.S. has been in the throes of a full-blown crisis in opioid overuse, abuse, damage, and death. As far back as 2006, federal health institutes flagged what they called “disturbing” data about a spike in opioid addictions. But the message didn’t seem to get through. Prescriptions for opioids continued to rise, and during the Obama administration, opioid abuse was declared an epidemic.

Barack OBAMA: We are seeing more people killed because of opioid overdose than traffic accidents.

The crisis has persisted under the Trump administration:

Donald TRUMP: Last year, we lost at least 64,000 Americans to overdoses. That’s 175 lost American lives per day.

The good news is that overdose deaths have finally stopped increasing, for the first time since 1990. Still, tens of thousands of people each year are dying from opioids — especially the street drugs heroin and synthetic fentanyl but also prescription painkillers like Oxycontin and Percocet and Vicodin.

Opioids are hardly our greatest public-health hazard, even if you’re just talking substance abuse. Smoking is still the leading cause of preventable death in the U.S.; and alcohol abuse is third. If you’re wondering what’s second: poor nutrition.

But the spike in opioid deaths is different. For one, it’s been relatively sudden. There’s also a brutal paradox with opioids: pills that were legally prescribed as medicine — sanctioned by doctors and government-funded healthcare providers — this medicine has led to hundreds of thousands of deaths, whether directly or via an addiction to prescription drugs that leads to using heroin or fentanyl.

All of which has led people like Jeanmarie Perrone at UPenn to try some new things. Like: bringing into the E.R. a recovery specialist who is herself a recovering addict. Like adopting a new addiction-treatment protocol — even as this protocol faces regulatory pushback from state legislators. Like trying to process, and interrogate, the entire story of how we got here.

So … how did we get here? Today on Freakonomics Radio: the first installment of a two-part series on the opioid crisis. In this episode, we will focus on the complicated dance between supply and demand. Because, when you dig down, you see that none of this was predestined:

PERRONE: They really somehow fooled us into thinking that pain was a vital sign as well, and that we needed to treat it more liberally. Tomas PHILIPSON: What they implicitly did was to subsidize the growth of an addictive substance as opposed to tax it.

Aside from the loss of life, the broken families, consider the economic cost of prescription-opioid abuse. The Centers for Disease Control and Prevention recently put that number at nearly $80 billion a year, once you add up the healthcare costs, addiction treatment, lost productivity, and policing and imprisonment. When it comes to unintended consequences, this one is hard to beat: $80 billion a year to treat the pain and suffering of a product intended to treat pain and suffering.

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When it comes to opioid addiction, Jeanmarie Perrone is one of the most active researchers and practitioners around. That’s in part because the University of Pennsylvania medical center is in Philadelphia, which has a particularly high rate of opioid abuse. In one recent year, for instance, twice as many people died in Philadelphia from drug overdose — most involving opioids — as from homicide. The city’s health department estimates that some 75,000 Philadelphians are addicted to heroin or other opioids: that’s nearly five percent of the population. This large demand is met by abundant supply, most famously the open-air market in the Kensington neighborhood; it’s been called the “Walmart of heroin.” We asked Perrone why the problem is so pronounced in Philadelphia.

PERRONE: I think partly, we always had a heroin community, just like Baltimore and a couple other cities on the East Coast, maybe because we’re a port, or some way that traditionally opioids were getting here. But I don’t think I’ve really read anything that makes me understand why it, you know, proliferated to the extent that that we’re currently seeing. DUBNER: So you’ve said that you’ve seen the opioid crisis kind of happen in real time. Can you just describe when you first saw it being the issue that it’s become? PERRONE: In the beginning, which I am talking between 2000 and 2008, what we saw was the results of doctor overprescribing. And then as a result, in the emergency departments, we would see patients coming in for something like a migraine headache requesting I.V. doses of an opioid, and not just that they were requesting I.V. doses but repeated doses. And we were operating under this paradigm that if they still said they had 10 out of 10 pain, we still needed to give them, you know, intravenous opioids. DUBNER: When someone says they’re in pain 10 on a scale of 10, the last thing I’m assuming you want to do is not give them something to treat the pain. But I understand that has something to do with how pain began to be used as an indicator in medical circumstances where it hadn’t been earlier, yes? PERRONE: Yes. A lot of lobbying to medical boards and the Joint Commission led to this idea that we’re going to use a pain scale and that we’re going to count a pain scale as a vital sign. You know, vital signs are blood pressure, heart rate, respiratory rate, and temperature. And pain scores, are subjective. Whereas vital signs are objective. But they really somehow fooled us into thinking that pain was a vital sign as well, and that we needed to treat it more liberally. DUBNER: When you say “they,” in terms of making the pain score a vital sign, who is the “they” there? PERRONE: So the Joint Commission that accredits hospitals was a big player. Medical advisory boards were involved. There were fines. There was at least this threat of fines to physicians who weren’t treating pain appropriately. And then there were patients who could complain to hospitals that they thought they weren’t getting their pain well treated. And that led to sanctions against clinicians. DUBNER: Were these institutions however, that were promoting it, were they influenced by pharmaceutical money? PERRONE: I believe it’s pretty well-documented that they were . DUBNER: When we were speaking earlier, you told me that pharmaceutical companies in the 90s started telling a new story about opioids — that the new generation of these drugs were not only more versatile but also safer and less subject to addiction. How true was that new story? PERRONE: Very untrue. Very untrue in many different ways. So we now know that the rate of continued use of opioids depends a little bit on the dose and the exposure. But patients who get exposed in a prescribed way — so you know, not intending to misuse — may actually be on opioids six months later, after just a therapeutic exposure for a minor procedure. And there have been multiple studies that have really demonstrated that just that exposure in a benign setting leads people to chronic use. Which is not the same as addiction, but a fraction of them do end up having addiction.

So the story Perrone tells goes something like this: The Joint Commission, the medical-accreditation agency, pushed doctors to adopt pain as a new vital sign even though, in retrospect at least, this is an obviously problematic idea. For one thing, it’s hard to reliably measure pain, and especially hard to measure it consistently across patients, the way you can measure blood pressure or heart rate. There’s also the fact that painkillers are, by their nature, a desirable medication — they literally make your pain stop — so you can imagine patients demanding them a bit more adamantly than they’d demand a statin or an ACE inhibitor. But there were other players, beyond the Joint Commission.

Organizations like the American Pain Foundation and the American Pain Society, advocacy groups that received funding from — I hope this doesn’t shock you — from pharmaceutical companies, like Purdue, which makes OxyContin. It was the American Pain Society that trademarked the phrase “Pain: The Fifth Vital Sign.” In one of the many, many opioid lawsuits now underway, the American Pain Society was called a “front group defendant” — that is, a front group for the pharmaceutical companies whose products they promoted, even though the Society presented itself as a professional medical membership organization with an academic thrust. So how did it come to this? How did a seemingly sensible, even noble scientific pursuit — the alleviation of physical pain — how did that turn into an orgy of overprescription, addiction, and death? It might help to take a step back and consider the history and the science of what we call opioids.

An opioid is any chemical that binds to opioid receptors on nerve cells, thereby blocking pain signals. Opium, a naturally occurring secretion of the opium poppy, has been used in medicine for a long time. Ancient Sumerian texts called the poppy the “joy plant.” But one big, underlying problem with opium is that it is highly addictive and, therefore, dangerous. For many, many years, scientists have been chasing the goal of a non-addictive opioid. In the early twentieth century, several semi-synthetic opioids were invented: oxycodone in 1916 and hydrocodone in 1920; a fully synthetic fentanyl was developed in 1959. While none of these new drugs proved to be non-addictive, they did become very useful in the medical management of acute pain.

Then, in the 1990s — when pain was being pushed as the fifth vital sign — Purdue Pharma brought Oxycontin to market. Oxycontin was a time-released version of oxycodone that Purdue aggressively marketed to the medical community, saying it “might” be less addictive than other opioids. This was a claim the FDA allowed despite a lack of evidence. And the claim worked, at least from a sales perspective. In 1996, Purdue sold $48 million worth of Oxycontin; just four years later: $1.1 billion worth. If you want to look for the starting point of the opioid crisis, it wouldn’t be a terrible idea to look back to the introduction of Oxycontin. And if you want to get a grip on the scope of the crisis, and how it grew, it wouldn’t be a bad idea to start here:

Alicia MODESTINO: About 70,000 individuals died from a drug overdose just in 2017. That’s more Americans than were ever killed by guns, car crashes, or HIV AIDS in a single year. And this annual death toll is higher than all U.S. military casualties in Vietnam and Iraq combined.

That’s Alicia Sasser Modestino. She’s a health economist at Northeastern University in Boston. As she sees it, the opioid crisis has occurred in three distinct waves.

MODESTINO: The first wave began with the increased prescribing of opioids in the 1990s, with overdose deaths that involve prescription opioids increasing since at least 1999, 2000. And since 2010, that death rate has actually leveled off. It hasn’t declined, but it’s leveled off.

So deaths from pharmaceutical opioids, like OxyContin, have at least plateaued. Wave number two:

MODESTINO The second wave began in 2010 with rapid increases in overdose deaths involving heroin. And the reason why we saw this second wave was because we realized that people were suffering from opioid-use disorder from the prescription medications. And so we removed people from those medications and then they went and sought drugs on the street.

When you hear about people using, and dying from, heroin — an illegal drug — you might think of them as a different category of drug user than the people who take legal prescription painkillers. But it’s intellectually dishonest to divorce those two populations. The fact is that roughly 80 percent of Americans who use heroin started down the path with prescription opioids. And that path was laid by the promiscuous dispensation of prescription opioids in hospitals and doctors’ offices. Jeanmarie Perrone at UPenn did one study, starting in 2011, that looked at patients who went to the E.R. for a sprained ankle.

PERRONE: And over the course of about four years, what we found was that up to 40 percent of patients who visited an emergency department got opioids for ankle sprain. And of those, they got somewhere between 10 and 30 tablets. And so, I think most of us would not want our loved one — brother, sister, child — to get a prescription for opioids for an ankle sprain. However, if they did, their risk of long-term use after that is, if you get a 30-day supply of opioids, you have a 30 percent risk of being on opioids at six months, and then about 6 percent for 10 or 12 pills to be still on opioids at six months. So you know, the more you get exposed, the more likely you are to create this default in your mind that, you know, acetaminophen or ibuprofen don’t work for me. I really do better with oxycodone.

The medical establishment did finally recognize the dangers of prescription-opioid abuse, and started scaling back. The rate of opioid prescribing has been falling steadily since its peak in 2012. The CDC has issued guidelines that recommend the lowest effective dose of opioids — if any at all; many states and hospital networks now limit the number and potency of pain pills that are dispensed to patients. So: deaths from prescription opioids have at least leveled off. And, more recently, heroin deaths have also plateaued. Here is Modestino again:

MODESTINO: As of 2016, the death rate for heroin has leveled off and declined somewhat, at least in Massachusetts.

But by then, wave number three had already arrived.

MODESTINO: The third wave began in 2013, when we saw significant increases in overdose deaths involving synthetic opioids. And so those are things like fentanyl. And the thing that’s very distinct between heroin and fentanyl is how powerful fentanyl, and how deadly, fentanyl can be. So it’s a much stronger high than you would find with heroin. And so people have quickly moved from heroin to fentanyl but because it is a more dangerous medication, we’re seeing a lot more overdose deaths from fentanyl. They have really spiked in the last four years. PHILIPSON: Fentanyl is essentially an innovation by illegal manufacturers or distributors, which lowered both the price of the product and also increased the quality.

That’s another healthcare economist, Tomas Philipson. He can usually be found at the University of Chicago. But these days, he’s the acting chairman of the Council of Economic Advisers, in the White House.

PHILIPSON: So the price of a high, if you want, went through the floor from that innovation. Now, a big part of that is that 90 percent of this stuff comes through the southern border.

That’s because the trafficking of illicit fentanyl has recently shifted from China to Mexico.

PHILIPSON: And the President is obviously very concerned with illegal goods coming over that border, and has been involved in trying to secure the border for illegal goods .

This form of fentanyl is so potent that it’s hard to tell the difference between the amount that will get you high and the amount that will kill you. Medical fentanyl has long been used to treat pain in cancer patients and people who’ve undergone intensive surgery; in those cases, doctors carefully calibrate the dosage. Illicit fentanyl, meanwhile, is often sold over the dark web using cryptocurrencies, and shipped to its final destination in the mail. So: fentanyl, heroin, and prescription pills: these are the three components that make up the “opioid epidemic.” What proportion of opioid deaths are they each responsible for?

MODESTINO: So of the roughly 2,000 or so deaths that we see on an annual basis in Massachusetts that are related to opioids, about 1,600 are related to synthetic opioids, primarily fentanyl. About 450 are related to heroin and about 350 are related to prescription opioids.

Yes, those numbers — 1,600, 450, and 350 — add up to more than the 2,000 total annual deaths in Massachusetts. When someone dies of a drug overdose and has multiple substances in their system, the death gets counted in multiple categories. In any case, illicit synthetic fentanyl is very dangerous. Massachusetts has more than its share of deaths.

MODESTINO: Yeah, right now, we rank 10th in terms of the death rate, which is, you know, not the kind of ranking that we really like.

One reason, Modestino suggests, is that prescription opioids were also very popular in Massachusetts.

MODESTINO: I think part of it is that we are early adopters of medical technology. So when you look at the marketing of this, you know, they went to where people would be easy to sell to, and would be early adopters.

Meaning: Massachusetts, with a proliferation of pharmaceutical firms and medical services generally, was essentially a target market.

MODESTINO: So we were the first to get into the opioid crisis, and we were the first to realize it was a crisis, and the first to develop any number of different interventions to try to deal with it. We were one of the first states to limit prescriptions to seven days for a new opioid. We were one of the first states to put in a prescription-monitoring program. DUBNER: Can you tell us anything about the characteristics of a population where opioid abuse is very high? MODESTINO: It does affect different communities within the state. You see a higher rate of prescribing in rural areas. And the greatest number of suspected overdoses treated by emergency rooms are mostly among males, aged 25 to 34.

These data line up with another startling set of data from the opioid crisis. A recent working paper by three economists found that American military personnel, especially those who had been deployed to Iraq or Afghanistan, have “an overdose rate twice that of civilians,” having been regularly “exposed … to injury-related chronic pain, psychological trauma, and cheap opium supplies.” I asked Modestino where else the crisis has hit particularly hard.

MODESTINO: Low-income communities as well. And what’s been kind of interesting is there’s been a reverse trend in terms of racial differences. So it’s something that’s affecting the white community more than the African-American or Hispanic community. DUBNER: Any idea why? MODESTINO: You know, oddly enough, it seems that discrimination perhaps, in terms of prescribing for pain, or the ease of giving these kinds of medications to people of different races, had a perverse outcome that actually protected African-Americans. DUBNER: Meaning, white privilege would make one more likely to get hold of an opioid prescription in the first place, yes? MODESTINO: Yes, yep.

Opioid addiction is not unique to the United States. Overdose rates have also risen in Canada and Australia and Europe. But we are, unfortunately, the world leader, and by quite a margin. With just 4.4 percent of the global population, we consume more than 80 percent of the world’s opioids.

MODESTINO: I think demand across the world is probably pretty much the same for addictive types of substances. I think in the United States, you know, in particular the way the pharmaceutical industry operates — we have lots of supply-induced demand for medical care and opioids is a part of that, certainly.

“Supply-induced demand … for opioids” is an economist’s anodyne way of saying that firms like Purdue Pharma and advocacy groups like the American Pain Foundation and the American Pain Society were for years encouraging doctors and hospitals to pass out pain pills like candy. As far back as 2007, a Purdue affiliate and three executives from the parent company pled guilty to criminal charges for false claims about the addictiveness of OxyContin; they paid more than $600 million in fines. Last year, Purdue filed for bankruptcy, but not before members of the Sackler family, the company’s owners, redirected more than $10 billion from the firm’s accounts into their own. Thousands of state and local governments have sued Purdue and others involved in the legal-opioid trade. The American Pain Foundation and American Pain Society have shut down amidst federal investigations and lawsuits — and they also lost their pharmaceutical funding. On the day that I interviewed Alicia Sasser Modestino last summer, it had just been announced that three huge drug distributors — McKesson, Cardinal Health, and AmerisourceBergen — were proposing to pay a $10 billion settlement over their role in the opioid crisis. The National Association of Attorneys General, negotiating on behalf of more than 35 states, had countered with a demand for $45 billion. As of today, the settlement still hasn’t been worked out. I asked Modestino what she thought of these proposed dollar figures.

MODESTINO: I think it’s hard to put the dollar figure on it, and you would almost think that there should be a long-term settlement that’s directly related to the treatment that individuals are going to have to undergo for the rest of their lives. Because we have an entire generation that we’ve addicted at this point.

In addition to the pharma manufacturers, and distributors, and advocates, there’s one more institution that played a very large role in the massive uptake of prescription opioids.

PHILIPSON: What happened during that growth was that prices for opioids came way down due to government subsidies.

That, again, is Tomas Philipson, acting chair of the Council of Economic Advisors.

PHILIPSON: So basically you had an 81 percent decline in the price of opioids between 2001 and 2010, which is sort of the massive growth in the prescription epidemic. Essentially we had an increased government funding of drugs through Part D of Medicare, which also covered the disabled, which has a lot of pain, obviously, which is pain management. But a lot of those pills made it out from that population into the secondary market. And that was the big problem. Now what they implicitly did was to subsidize the growth of an addictive substance as opposed to tax it, which is what we’re doing for alcohol and cigarettes and other addictive substances. But once this epidemic was recognized and we started clamping down on prescription, which we’ve been very successful in the administration in doing, then it wasn’t that the subsidies stopped, it was more that the prescribing patterns stopped.

By then, however, there was already a huge population of opioid addicts — who started losing access to drugs.

PHILIPSON: So when the prescription market contracted by regulation and policies, you had a big opportunity for these other people to come in with higher quality and lower-priced product..

The “other people” Philipson is talking about here are the producers of illegal fentanyl.

PHILIPSON: They were basically innovating for this large prescription market.

So while it may be tempting to look at every fentanyl overdose and heroin overdose as the result of a poor decision — the decision to use an illegal, dangerous drug — it would be disingenuous to ignore the fact that for many people, that decision grew out of what happened back in the doctor’s office, with a federally-subsidized medicine that was advertised as safe and non-addictive. And it’s not just the person with their name on the prescription who’s proven susceptible:

MODESTINO: About 50 percent of abusers receive their painkillers from family and friends. About half of them get it because of just improper disposal. They just find it in the medicine cabinet.

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We’re talking about the opioid crisis, in the first of two episodes. We’ve already heard a lot about the suppliers and their accomplices. Now let’s hear how the demand happens — how the addiction happens. Here’s a man named Stephen Loyd:

Stephen LOYD: I was driving home from work one day and I opened a glove compartment in my truck, and I had some old hydrocodone in there from a dental visit. And really, by the time I got home, about a 10-minute drive, I felt like I’d have found a cure for my anxiety and my depression. Suddenly my wife and I were getting along better. My kids were better-behaved. Work wasn’t as hard. And so it just relieved the anxiety and stress of life. The problem is that within three years, I took that two-and-a-half milligrams of hydrocodone, I was taking 500 milligrams of OxyContin a day. And so it progressed very, very quickly. And I couldn’t stop. DUBNER: I’ve read that at one point at the peak of your addiction, you were taking about 100 pills a day. Is that a typo? LOYD: No, I wish it was a typo, but it’s not — 500 milligrams of OxyContin would be about 100 Vicodin a day. So yeah, that was my day. And you got to remember what I was doing at the time, Stephen. I was seeing patients every day.

That’s right. Stephen Loyd is a doctor in Tennessee.

LOYD: I was an attending physician, rounding in patients in the hospital ward service, and in the ICU. I taught medical students, medical residents, pharmacy students, pharmacy residents. So I did that for about three years. DUBNER: Can you describe the addiction itself? Because you know, I don’t mean to sound naïve, I believe I understand what addiction is. But as someone who’s not addicted to substances, I don’t understand, I guess, the feeling or the sensations of inevitability. How regular was the decision to take the pill or not take the pill? Did you feel there was any way you could get through the day without taking the pill? And so on. LOYD: Stephen, there was no way to get through the day without taking the pill. For one thing, after several hours, you start to get sick. You start to go through a withdrawal syndrome that we all know as being dope-sick. So never could go through a full day. And basically I took pills all day long. When I got out of bed in the morning, I had withdrawn during the night, so I was sweating. I felt, you know, I felt like an 80-year-old man, and I was in my early 30s. And so I couldn’t feel normal until I got the pill in me. And this is what people don’t realize. I mean, imagine what you would do to get something you thought you would die without. Okay, you’re going to die if you don’t have this. What would you do to get it? And that’s really the desperation of addiction, because the cravings for the pill were 10 times stronger than my cravings were for food. For you, as somebody who has never had an issue with addiction, imagine going without food, and you get out to day two, and you haven’t had food in two days. What would you do to eat? And so that’s what you’re stuck with every single day. DUBNER: And I understand it was your dad who ultimately kind of urged or pushed you into treatment. How did he find out? LOYD: He confronted me after he saw me take 15 10-milligram oxycodone all at one time. And I didn’t know he was there. DUBNER: And how were you getting hold of all these drugs? LOYD: Well you know, that’s what people need to understand. At first it was out of people’s medicine cabinets. So for the longest time, I had a pretty much endless supply. If I came in your house and you had your medicine cabinet there and you had an old prescription left over, I walked out the door with it. And so that was how I got them at first. And then the other way was doctor-shopping. You know, all my friends were doctors. And so I would, you know, just hit them up at different times for prescriptions. And of course they didn’t think, “Well that’s Steve. There’s no way that, you know, he has this problem. He knows what he’s doing.” But the truth is, Stephen, they didn’t know. And so you know, it becomes very difficult to get your hands on that many pills, because at the end, if I’m going to be on vacation for a week, I need 700 pills. I mean, that’s a hard — it’s hard to get your hands on. DUBNER: It sounds like you were taking enough pills to die from, to overdose from. Why did you not? And did you ever come close? LOYD: I’ve asked myself that question, I can’t tell you how many times. At the very least, I should have a liver that doesn’t exist from all the hydrocodone and oxycodone. But I never overdosed. And the tolerance built over time. And it’s amazing what our tolerance can get to when we have access. And that’s where I was. Stephen, the night before I went to treatment, I had — you know, my dad had confronted me. I had a place to go. I was leaving the next morning. I was laying in bed that night by myself, and I took three OxyContin 80s — 240 milligrams of OxyContin all in one blast. If I did that right now, I’d die. DUBNER: Why did you take that many that night? LOYD: Well, I thought my life was over. You know, I had a medical license and now I’ve got this drug issue, and I felt like I was going to lose everything. And actually told my dad that. I said, “You know Dad, I’m going to lose my medical license, I’m going to lose my cars, and lose my wife, going to lose my house.” And he looked at me and he said, “Steve,” he said, “none of that stuff’s gonna do you any good if you’re dead.” And I really haven’t come up with a good retort to that question even today. And so at that moment, Stephen, I just didn’t want to feel. So I took everything I had.

Loyd went into a detox program at Vanderbilt, and then a 30-day stay at a residential rehab facility. He recognizes this level of care is an opportunity that many addicts will not have. Loyd also got to keep his medical license and today, he’s the medical director for a network of addiction-treatment centers. One important point his story illustrates is that the prescription opioids that flooded the U.S. didn’t just affect the people who the prescriptions were written out to.

MODESTINO: So when we think about prescription opioids we usually think about the initial patient and whether or not they’re going to become addicted.

That, again, is the healthcare economist Alicia Sasser Modestino.

MODESTINO: But often what happens is someone gets prescribed an opioid, they typically have more medication than they need, and they keep that extra medication in their medicine cabinet. And it can either become diverted by a family member or a friend who takes that medication, maybe in response to some kind of pain, not knowing what this medication is. Or it could even be diverted and sold explicitly on the black market. About 50 percent of abusers receive their painkillers from family and friends. About half of them get it because of just improper disposal. They just find it in the medicine cabinet. About 10 percent are actually paying their relative to obtain this medication. And 5 percent just say they outright stole it.

That 50 percent figure is, to me, shockingly high: half of all opioid abusers lifting the drugs from a friend or family member. Are there really that many opioids just lying around in America’s medicine cabinet? We asked our listeners to tell us if they had any. Here’s a very, very, very small sampling of what we heard back:

Listener 1: I have two whole drawers full of opiates, four different kinds of opiates. I had some back issues and over the years, this is what I accumulated. Listener 2: I currently have almost a completely full bottle of Percocet in my medicine cabinet. I had to use it for recovering from a shoulder operation. Listener 3: I had minor knee surgery to repair a torn meniscus. Sure enough I have a whole big container full of Percocet. . Listener 4: I have at home quite a few, maybe four, bottles of opioid pills which I got from various dentists, I think my wife’s broken wrist, stuff like that. Listener 5: At this point, I have hydromorphone left over. I’ve got Oxycodone.

Here’s another hard-to-believe statistic from Modestino:

MODESTINO: So even though we’ve seen about a 20 percent reduction in annual prescribing from 2006 to 2017, as of 2017, more than one in five Americans had at least one opioid prescription that was filled, with an average of about 3.4 prescriptions per patient. And even probably more importantly, the average daily amount that’s in those prescriptions was higher than the recommended level that the CDC says is necessary for treating chronic pain. DUBNER: Let’s say I’m a patient and I had some ankle surgery and I got a prescription for 30 days’ worth of opioids. And I don’t like that idea. That sounds like way too much for me. I don’t want to become dependent. And after two or three days I say, “I can handle this with Aleve or Advil or whatnot.” And then I have 27- or 28-days’ worth left in my medicine cabinet. What’s wrong with just dumping those pills in the garbage or flushing them in the toilet? MODESTINO: Well, that gets into the water supply. That’s not a great thing. Dumping them in the trash, again, goes into potentially a landfill or some other place that eventually could contaminate groundwater and other types of things. So in general you know physicians will tell you not to dispose of medication in those ways but that it should be disposed of safely. So it’s not just opioids but everything from antibiotics to, you know, other types of medications that you’re taking.

The FDA, we should note, does recommend flushing opioids down the toilet as a final option, but what other choices are there?

MODESTINO: So there are take-back kiosks that you can find in some pharmacies. Most police departments will take back any kind of medication with no questions asked. We do have a national take-back day that people might not be aware of. They will record how many pounds of medication comes back. But we don’t have any really good record of whether or not that’s dangerous medication, whether it’s opioids or if it’s baby aspirin or, like I said, antibiotics. DUBNER: What share of unused prescription drugs end up in a take-back kiosk or some other appropriate disposal place? MODESTINO: So we don’t know what share of prescribed drugs end up back in the kiosk. But I can tell you that for pharmacies, where there’s just a kiosk sitting there, about 10 percent of patients will make use of it at some point. And that’s about it.

So, considering how many opioids are still out there, and how many more are still being prescribed, Modestino had an idea to try to sop up some of that surplus: a buyback program. She and some colleagues recently launched an experiment, in Massachusetts, hoping to increase the number of pills brought back to pharmacies.

MODESTINO: So we got the general idea for this buyback program because of the secondary users of prescription opioids — just taking it out of the medicine cabinet. And as a mom with four kids, I found that particularly horrifying because I have recently had surgery and I did have opioids in my medicine cabinet. And it wasn’t really clear what you should do with those or where you should bring them back. So the way our program is constructed is that when you pick up your prescription for an opioid, as an acute user — so this means you had surgery or you had an injury that you’ve been prescribed an opioid for a very limited amount of time, like maybe two weeks, maybe 20 pills — at the point that you pick up your prescription, the pharmacist will tell you, “This is an opioid.” A lot of people don’t know they’re getting an opioid. “This is an addictive medication. You don’t want this in your house because other people might take it by accident. So bring it right back here to your community health center and we’ll give you a $10 gift card.” DUBNER: As an economist, how important do you think is that financial incentive? MODESTINO: Well, we are actually testing how important the financial incentive is. So we have two arms of the intervention. We have five different locations with this community health center, with five different pharmacies. At their largest location, we’re offering this $10 financial incentive. At the other locations, we’re not offering any financial incentive at all. We’re just providing them with information that this is an opioid, it’s addictive, it’s dangerous, you should bring it back. And part of the reason why we did this is because sometimes using financial incentives can have perverse impacts and create sort of unintended consequences, right? So one of the things that the Board of Pharmacy was a little bit worried about, and we had to get their approval for this program, was that it might actually kind of remind people that they could sell this medication. DUBNER: What does one pill typically go for when you’re buying it from the original user? MODESTINO: Yeah, the black-market price is about $20 per pill on the street. We are not going to get people who are already abusing opioids bringing this medication back, but we will get people who might then have their opioids diverted to a family member who is already addicted, or whose opioids might be taken out of their medicine cabinet by a teenager who becomes addicted.

In setting up the buyback experiment, there were also restrictions on how the returned medicine was handled.

MODESTINO: One of the key important elements is that pharmacists may not touch the medication when it comes back to the pharmacy. DUBNER: Because why? MODESTINO: There is such concern about diversion, and about — DUBNER: Diversion meaning that the pharmacist will take some and do something with it themselves? MODESTINO: That’s right. There’s a heightened sensitivity around these kinds of medications and substances, and making sure that they don’t get diverted in any way, shape, or form. DUBNER: If the pharmacist can’t actually touch them, what’s to stop me from putting, you know, baby aspirin into my opioid bottle and returning it and getting the $10 for that? MODESTINO: There is nothing stopping you from that. DUBNER: Awesome. MODESTINO: But we will — we will take anything back. If you tell us you’re bringing an opioid back, we will just take it and give you your $10. It’s a pilot. We’re not going to argue with patients about what they’re bringing back. But what they will be required to do is dump the medication out into their hand, the patient, so that the pharmacist can visually verify it. DUBNER: I see. MODESTINO: And the pharmacists know exactly what they’re dispensing. They know exactly what it looks like. How it’s stamped. And so they will track whether or not it is an opioid. But if you bring back baby medicine at this point, or baby aspirin, we will give you $10 and send you on your way.

There hasn’t been a lot of rigorous research to date on a medicine-buyback program. The evidence from gun buybacks is enlightening.

MODESTINO: So, early gun-buyback programs found that most of the firearms were old, broken, low-ammunition capacity, and most of the owners were not bringing back the kinds of guns that you wanted to get off the street. And so those programs were redesigned to target young people in urban neighborhoods. So they went to these neighborhoods. They also structured the incentives to encourage people to turn in the kinds of guns that they wanted to take off the streets. So handguns and assault weapons and guns of those types. And so we drew on those lessons to think about how we designed our programs. So we’re targeting acute patients for whom the risk of passing opioids on to the secondary market is very high. And we’re also going right to their community. We’re going to their neighborhood, we’re going to their community health center to talk about the buyback program.

Modestino’s opioid-buyback program is still in its early days. She did share with us some preliminary data. So far, the return rate is only about five percent — so, not very encouraging. The returners are more likely to be young and female. Three-quarters of the returns came to the site with the financial incentive. So: the incentive seems to be working, at least. And here’s a really amazing statistic, which sadly seems to sum up the entire prescription-opioid problem. At least half the patients who did return their pills brought back the entire number of pills they’d been prescribed. Meaning: they did not feel the need to take a single pill. And yet: those pills still got prescribed. So despite all the new prescribing guidelines; despite all the lawsuits against opioid makers and promoters and distributors; and despite all the deaths — you sense this crisis is a long, long way from over.

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Freakonomics Radio is produced by Stitcher and Dubner Productions. This episode was produced by Zack Lapinski, with help from Miles Bryan. Our staff also includes Alison Craiglow, Greg Rippin, Harry Huggins, Matt Hickey, Daphne Chen, and Corinne Wallace; we had help this week from James Foster. Our theme song is “Mr. Fortune,” by the Hitchhikers; all the other music was composed by Luis Guerra. You can subscribe to Freakonomics Radio on Apple Podcasts, Stitcher, or wherever you get your podcasts.