Jay Kuten
Poverty defined as an income level of or below US$24,600 per annum by the United States government, certainly plays a role in the opioid issue.
But it's also the perception of poverty, or rather the fear that is engendered in people who find their economic and social status slipping. That is: The sense of becoming poor by comparison.
In the May 2016 Atlantic Monthly, writer and television-based movie critic Neal Gabler revealed that he would be hard pressed to come up with $400 to deal with a perceived emergency (The Secret Shame of Middle-Class Americans).
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While Gabler had been successful in the past, raised two daughters and given them university educations, a series of bad financial decisions, plus the very weakened economy, left him in a precarious financial position wherein he had to borrow money for his mortgage payments from his grown-up daughters.
His shame at his circumstance is palpable. And, as he tells us, he is not alone.
Many, many formerly comfortable middle-class people have suffered not only economic hardship but a perceived slippage down the social ladder, partly due to external factors (the great recession), partly due to some personal circumstance (sudden, uninsured illness), leaving them bewildered, embarrassed, strapped, and also angry that their previous hard work or good education had not protected them from the ill wind of economic misfortune.
A brilliant blogger, Rima Rigas (Blog #42) has come up with the term Precariat for this new group of the former relatively well-off who are now barely making it through gigs, part-time work, or down-skilled work.
As stressful as is the life of anyone in poverty, the experience of chronic poverty, like other long-lasting experiences, becomes adaptive and accepted as normality. Not so for the newly precarious.
Added to the physiology is the perception of personal failure, the sense that the "American Dream" has become either a nightmare or simply has an unhappy ending.
The striving, the "playing by the rules" has not led to a safe harbour. Quite the contrary, it's led to more, not less, uncertainty and forced decision-making, living from paycheck to paycheck, and often the paycheck is an unemployment check.
This sense of personal failure and comparisons with others -- both more and even less fortunate -- has both political (Trump voters) and personal implications. In both domains there is a theme of betrayal.
It's a small step from the experience of precarious living to experiencing the body as a source of discomfort or even pain. The somatisation of inchoate experience that seeks expression is a long known but poorly understood phenomenon.
In underdeveloped countries, psychiatrists are attuned to recognising the patient who presents with pain with only vague anatomic connection as suffering from depression. In psychologically sophisticated countries, like the US, these somatic symptoms are often accepted at face value, with the result that patients receive a prescription for an opioid.
That may be the first step to a new long road of imposing an iatrogenic illness on an economic and social and psychologic one. Iatrogenic illness is illness caused inadvertently through medical treatment.
Here is where the concept of "cui bono?, who benefits?" comes into play.
In the 1990s, medical practitioners, long accustomed to caution in prescribing opioids, were encouraged by the marketing campaign of Purdue Pharma to prescribe its then new drug, Oxycontin, which Purdue claimed falsely (they were fined $635 million for misleading the public) was non-addictive. Doctors under the pressure of time -- the 12-minute visit -- went along.
In 2010, Purdue made US$3.1 billion from Oxycontin sales alone. By 2016 the total market for pharmaceutical sales of opioids was worth US$8.1 billion.
Next week: Part 3 -- The human cost, the opioid treatment industry and the options for rational outcomes.
Jay Kuten is an American-trained forensic psychiatrist who emigrated to New Zealand for the fly fishing. He spent 40 years comforting the afflicted and intends to spend the rest afflicting the comfortable.