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The “Street” Economics Of Drug Abuse

I’ve discovered over the years that I really like economics. I never took an econ class in my entire life, since I was pretty focused on the life sciences, but I’ve picked up a fair amount informally over the years. Fortunately I have a strong background in statistics and math, and I’ve done a lot of reading on economics. I wouldn’t say that I have any special level of understanding or credibility on the topic. Perhaps it should be noted that my wife took away the checkbook for good reason. But I enjoy it as a topic, as something to read about and a powerful tool for understanding how the world works.

One consequence of being an ER doc is that you are pretty close to “the street,” and I don’t mean Wall Street. I mean the folks living and scrounging on the streets. As a matter of functioning in the job, you learn the street jargon, you learn what drugs people are using and why, and what the effects of those drugs look like.

The other day I saw a middle-aged guy brought in for acting really weird. Though everything in his social history argued against it, he just looked like he was on meth. I checked a tox, and sure enough, it came back positive. He strenuously denied any drugs, but eventually gave in and admitted the meth use.

I remember in residency walking through downtown Baltimore with a fellow resident and our spouses, and we amazed them by serially identifying the likely drug of choice of the various street people we passed, based on casual observation of their behavior. It’s just what we do. Baltimore was a heroin town.

I remember a statistic that of the population of 700,000 in Baltimore, there were 70,000 actively using heroin, though I am not sure if that was true. It seemed an underestimate based on the folks we saw at our inner-city hospital. There was a bit of coke and the ever-present alcohol, but heroin was the epidemic. (Ever see The Wire? That show used to send shivers down my back it was so accurate; The Corner is maybe even better.)

Chicago, where I did med school, was more of a cocaine town. But when I moved to the Pac NW, the whole matrix shifted. There was no heroin — literally none. We had a meth epidemic, and if I am not mistaken, the Pac NW was the first region where meth was really big. Cocaine was also unheard of in our town. A bit of prescription drug abuse, oxycontin and xanax rounded out the stable of abused substances (in addition to the ever-present alcohol).

So it went for the better part of a decade. We saw an occasional heroin addict, the meth population waxed and waned, and the oxycontin abuse really became frightening in its dramatic increase.  The heroin addicts were a tough bunch — the only heroin available in our state was “Black tar,” which is thick and sludgy and very sclerotic to the veins. Basically it destroys the veins quickly and users have to switch to IM administration, and they got these terrifying deep facial plane abscesses that needed to be drained in the OR. No wonder it was unpopular!  So these users were hard-core, long-time addicts, really committed to their drug. In Baltimore, they had the highly refined “China White” which was practically pharmaceutical-grade and could be used IV for 30+ years. I didn’t miss dealing with heroin addicts, but the oxycontin addicts were nearly as challenging to treat.

So it went — until recently. Over the last eight months, something changed. All of a sudden, we started seeing large numbers of herion users, many of them “novice” injectors, still using their veins. Most of them were pretty frank that they had only recently started using heroin, and few of them had any record of ER visits for drugs in the past.  So, amateur economist that I am, I started systematically asking the heroin users how long they had been using, whether and what they had used before, and why they changed. I was surprised how consistent the answers were: they were nearly all former oxycontin users. Until this year, Oxycontin was easily available and cheap in our area. The users knew their doses and were able to carefully calibrate their intake to avoid accidental ODs or other misadventures. Few injected — most chewed, smoked or simply swallowed the drug. For most, it was safe and simple and they stayed out of trouble (and out of my ER).

Then recently, Oxys became nearly unavailable, and scarcity drove the price way up. Previously, our community had a going rate of about a dollar a milligram for oxycodone, and at the epidemic’s peak, the price was half that. Now, I was informed, it was triple, if you could find them at all. “So we all switched to heroin,” one pretty eighteen-year-old with track marks up both her arms glumly informed me.  Heroin was much cheaper, and apparently the local suppliers were more than able to accommodate the sudden spike in demand.

Of course, the dosing of heroin is harder to titrate, being of variable purity and quality, so people started OD’ing more regularly. And injecting causes all sorts of complications like abscesses. And while pill popping (or smoking) can for some be easily hidden from family, track marks are harder to explain away. So they started appearing in the ER.

There you have it: Economics in action. If I were a clever, real economist, I might neatly package the conclusion along the lines of the demand for opiates being relatively inelastic, but the brand (?) sensitivity is low, and once the incidental costs of heroin (inconvenience, lower quality, abscesses, disease, visibility) became lower than the absolute cost of oxycontin, the market suddenly tilted. (That’s probably mostly gibberish, but it sounds economish.) As it is, I just shake my head at the sadness of it all and the seeming futility of interdiction as a strategy for dealing with drug abuse. Cut off one drug, and people switch to another, more harmful one. A funny sort of progress.

*This blog post was originally published at Movin' Meat*

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