“I take drugs just because ... in a technological age living in the city there are certain drugs you have to take just to keep yourself normal like a caveman. Just to bring yourself up or down, but to attain equilibrium you need to take certain drugs. They don’t getcha high even, they just getcha normal.”
- Lou Reed, quoted in “Deaf-Mute in a Telephone Booth: A Perfect Day with Lou Reed” by Lester Bangs. Reprinted in “Mainlines, Blood Feasts, and Bad Taste: A Lester Bangs Reader” Edited by John Morthland, Anchor Books, 2003.
Researched and written for The SumAll Foundation.
I'm working for SumAll about the ecosystem of prescription drug use. Since late spring The SumAll Foundation and SumAll.com team members have been working with The Bill, Hillary, & Chelsea Clinton Foundation's Health Matters Initiative (CHMI) to better understand the state of the prescription drug ecosystem. This first post of the series serves as an introduction to our work.
Over the summer, the SumAll team analyzed many database tables and created models around the issue of prescription drug use. While SumAll and our sister foundation will use this data to publish additional projects, I've been tasked with writing a few articles about the nature of prescription drug use. My research will be supported by analysis derived from SumAll's engineers.
In broad terms, attempting to draw conclusions about the nuances of prescription drug use is a laughably overwhelming task. Yet summer research has evolved to include modeling, and we can examine a few interesting types of behavior - say, addiction and abuse - as well as outcomes - say, deaths from overdose, or academic performance enhancement.
The research process has synthesized three big topics:
- How Prescription Drug Use Works - How big and how much.
- How Diversion Works - How we get our drugs.
- How Opiates and Neuroenhancers Work - Down and up.
My methodology is pretty simple: I look for systemic issues, then drill down to find granular expressions and sources. Each of these prescription drug themes will function as a broad topical overview and discussion point intended to help the layperson grasp the issues in play. I'm not yet sure if these will shake down in to three individual posts, or amalgamate in to one piece. Each topic is related and interdependent. I don't feel confident in claiming to understand the entire prescription drug environment. However, after several weeks of research and work creating models, I am confident that our work can help uniquely illuminate the issue.
When attacking stories, I try to develop a relative understanding of the topic. The work itself has involved a few weeks of reading, phone calls and email chats with professors and students alike, interviews with doctors and pain management specialists, and a few chats with characters on the gray side of the law. As always, sourcing requires mutual trust. On record sources are explicitly and directly quoted. Quotes will be cross-checked prior to publication, and I always stipulate background, deep background, and off record status prior to advancing a relationship with a source. This method of reporting is slower and requires more energy, but is also one that emphasizes trust equity between all parties.
Effective reporting also requires a trust relationship between the reader and author, and because of this I strongly encourage you to get involved in the comments by contributing your thoughts and anecdotes on the issue of prescription drug use. I have been given great access to data provided by CHMI as well as to SumAll's engineers and analysts. Their knowledge has been instrumental in the research process as well as in the creation of data models. However, I also encourage you to vet both of these organizations and their models.
When creating models and conducting research, we've asked a few basic questions about the ecosystem, and attempted to avoid making big assumptions. Analysts like SumAll's Matt Law have run the numbers to help define just how big the market for prescription drugs is, and who consumes what drugs.
The first challenge in creating a model comes with establishing standards. Municipal governments, states, and the Federal government use a variety of different standards to account for negative outcomes like addiction and death.
"We can procedurally index an issue to get a good sense of what the problem is," said Law, "but the biggest problem is normalizing the data and settling on standards."
Just like defining terms in an Oxford-style debate, we must define what the market is before we can draw conclusions. Once data has been normalized an indexing protocol can help us have a more detailed understanding of the ecosystem. Law's indexing model looks something like this:
- Look at the overall economic and consumptive market size.
- Examine the negative consequences of drug use, such as deaths, arrests, arrests and convictions, hospitalizations, et al.
- Take in to account known systemic issues with # 2, above.
- Adjust result to account for known biases and other issues with available datasets.
- Extrapolate the data to find patterns.
- Run the numbers.
Attempting to define just what drug abuse is has the potential to be topically treacherous. That prescription drugs are abused is nigh-undeniable. But differentiating types of abuse is essential. For example, there seems to be unanimity that there is a crisis around opiate addiction and unintentional death, but the systemic causes and potential solutions are widely debated. Are opiates like Percocet over-prescribed, or simply more likely to be used off-label? Additionally, is there really an opiate-related 'formula for death' that includes dose, alcohol, BMI, and other factors? If so, is it ethical to disclose this 'formula,' for fear of intentional suicide? These questions are as practical as they are rhetorical.
"Thousands of people are addicted or die each year from opiate misuse," pain management expert Dr. Lora Brown told me during a phone interview, "there is absolutely an epidemic." The Bill, Hillary, & Chelsea Clinton Foundation and the Centers for Disease Control and Prevention both reinforce the claim that opiate abuse has reached epidemic status.
Potential solutions, however, are more ambiguous. CHMI and Dr. Brown both advocate for systemic, education-focused solutions, with an emphasis on youth and college markets. Others, like New York City Policy Commissioner Ray Kelly focus on policy and law enforcement solutions.
Opiates are far from the only abused prescription drug category. Drugs know colloquially as 'legal speed' - Adderall, Ritalin, Vyvanse, and others - are also abused by users with a similar, though distinct demographic profiles as opiate consumers. The results, however, could not draw more stark of a contrast. Where opiates often lead to a deterioration in quality of life, addiction, and sometimes death, uppers and speedy drugs can often have the opposite effect. In fact, a cursory look at Google search data indicates that demand for upper Adderall far outstrips demand for downer Percocet.
The brand and use perception of uppers is vastly different from downers as well. On background, several sources who teach at major public universities shared stories about student performance enhancement, or 'academic doping.' The potential negative consequences of so-called nootropics, or neuroenhancers, vastly differ from opiates. Publications like Slate and The New Yorker have tacitly amped the sex appeal of neuroenhancers by running long form articles that detail the positive effects and questionable ethics of prolonged use of drugs like Adderall.
We studied opiates and neuroenhancers specifically because of the respective market size and stark use-to-outcome contrast. But the market for and impact of anti-psychotics and mood leveling drugs like Klonopin and Welbutrin is not to be understated. SumAll's institutional knowledge of and data access to these types of drugs is limited. But we found enough incidental data to warrant discussions of these drugs in the context of our two target categories. Some research also indicates - though does not conclusively prove - that use of these drugs is also on the rise.
Drugs are obtained in a number of different ways. Divergence is the euphemism du jour for the practice of obtaining drugs outside of a doctor's prescription and the intended use. Doctor shopping and the over-prescribing of certain medications are often blamed for the perceived glut of illicit prescription drugs in the general market. But according to Dr. Brown, these methods tend to point the finger at well-intentioned doctors, without examining other methods of procurement.
"You'd be totally amazed at who buys drugs from me," said one source who agreed to be quoted on the condition of anonymity. "Clean cut dudes with 'good jobs' come through here every week because they want the pill, but don't want the stigma of a prescription."
When asked what drugs are most popular, without missing a beat my source rattled off a list of drugs that included the usual suspects like marijuana and cocaine, but made a point to exclaim, "I can't keep Adderall and Vyvanse in stock."
Our research touches on pharmaceutical industry marketing and public relations tactics. Undoubtedly, pharmaceutical drugs contributed directly and indirectly to social good and individual well-being. Drugs cost money to develop and market. But interesting patterns tend to emerge when we look how and where particular types of drugs are marketed. Without presumptuously attempting to understand the nuances of the marketing industry, our engineers at SumAll will contrast a few basic stats like regional marketing spends (where data is available) to factors like prescription volume, overdoses, addiction, death, and academic performance enhancement. We're not sure exactly what we'll find, but analyzing the publicly available data will undoubtedly yield fascinating results.
Finally, on a personal level, studying the use, misuse, and spread of prescription drugs has been a fascinating experience. Like every interesting research project, my team and I have learned more this summer than we can possibly express with a few interesting data models and a few thousand words of copy. The topic of prescription drug use is deep, nuanced, and fascinating. To some, I'm sure our work will seem broad and general. And doctors and policy makers involved with the issue of prescription drug use are surely experts with much to contribute to the discourse. Without judgment or prejudice, it is my sincere hope that our research is able to lend clarity to the issue of prescription drug use, and open doors of inquiry to the general public. I look forward to publishing a few interesting articles over the next few weeks.
Thanks for reading.
- Dan Patterson
New York, New York
Disclosures: I am employed by The SumAll Foundation, though my reporting remains editorially independent. I work closely with employees of SumAll.com, though am not employed by nor am I invested in the company. SumAll maintains a professional working relationship with The Bill, Hillary & Chelsea Clinton Foundation. Please feel free to contact me any time if you have specific questions regarding ethical disclosures.