AMERICANS AS THE CAUSE, II

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on the responsibilities Americans bear for its tragic consequences.]

This blog is currently about tracing the responsibility of Americans in the initiation and continuation of the opioid epidemic.  To this point, specifically in the last posting, this account has traced how heightened use of opioids came about.  It, for example, pointed out the role the government and medical profession played in encouraging and prescribing these drugs.  Attention now shifts to the actual acquisition of opioids.

          To assist in this inquiry, one can cite a number of studies.  In turn, these studies are not totally in agreement with each other.  An earlier study in 2013 reported that opioids were being attained, at a 74% rate, from a variety of sources:  a doctor, a friend, or perhaps a relative.  The origins of these sources were often a clinic or one its workers.[1]  But since then there have been evidence of other sources.

          The biggest “scoundrel” is prescription providers.  Usually that would be a doctor or a clinician.  In addition, there has been illegal sources playing a significant part.  Here the drugs most often provided has been heroin and illicit fentanyl.  A lot of this portion of that market are users who, under prescription regimens (even if abused), became addicted.  More recent policies, given the resulting drug problem, have restricted legal sourcing and, those who are already addicted have turned to illicit sellers of these two opioids.[2]

          An interesting statistic is that in 2015, fifty percent of drug overdoses did not occur from taking prescribed opioid drugs – which on the surface seems to cast an accusatory finger at their users – most of them got started with a lawful prescription.[3]  So, it is difficult to say that those who early on were caught up in this nightmare of opioid abuse, are totally at fault for the ensuing epidemic.  As has been either hinted or right out claimed, both the medical profession and the drug companies can be held highly responsible for what has resulted.

          But this cannot be said for how the epidemic has progressed.  Since the early days, other evidence has emerged that shifts more of the responsibility to newer users.  In 2018, a study informs that up to 75% of opioid abusers began using that drug without a legitimate prescription.  Apparently, as the opioids became popular for their inducement of euphoric highs, consumers did not begin obtaining and using the opioids for medical reasons but for recreational purposes.  Therefore, one can judge these newer users as being more responsible.

          As such, they, to a great degree, are causing many deleterious effects associated with this epidemic.  Among them are high death rates, higher incidences of spreading communicable diseases, and the various economic costs attributable to the epidemic.  These effects take on various forms.  Some are direct, some are indirect costs.

Currently, more people die of overdoses – in 2015, 33,000 – than die of car accidents.  Heroin deaths outnumber of deaths caused by gun fire.[4]  Economic and tragically intense emotional costs are those emanating from orphan children who find themselves without parents due to overdosing.[5]

As one analyzes the costs, they pop up in varying forms.  So, reported in 2013, once all the costs attributed to the health care, funds expended on related criminal justice expenses, and other related costs are totaled, that figure was $78.5 billion.  Again, that was a while ago.  The progression of the epidemic has grown significantly since then.  For example, just two years later, the estimated cost rose to $504 billion.

So, overall there is enough blame to spread among various parties:  the pharmaceutical companies, medical professionals, slack family members and friends who do not secure their opioids, and the users themselves.  The last area of historical facts this account will review – in the next posting – will be demographic information.

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[1] Edward A. Shipton, Espeth I. Shipton, and Ashleigh J. Shipton, “A Review of the Opioid Epidemic:  What Do We Do About It?”  Pain and Therapy, June 2018, vol. 7, no. 1, 23-36, accessed July 24, 2018, https://link.springer.com/article/10.1007%2Fs40122-018-0096-7 .

[2] Jonathan Reiss, “Opioid Crisis:  What People Don’t Know about Heroin,” May 18, 2018, accessed July 24, 2018, https://www.rollingstone.com/culture/culture-features/opioid-crisis-what-people-dont-know-about-heroin-630430/ .

[3] Edward A. Shipton, Espeth I. Shipton, and Ashleigh J. Shipton, “A Review of the Opioid Epidemic:  What Do We Do About It?”

[4] Christopher Ingraham, “Heroin Deaths Surpass Gun Homicides for the First Time, CDC Data Shows,” December 8, 2016, accessed July 24, 2018, https://www.washingtonpost.com/ .  A reported number of US deaths in 2016 was 64,070.

[5] Jeanne Whalen, “The Children of the Opioid Crisis,” The Wall Street Journal, December 15, 2016, accessed July 24, 2018, https://www.wsj.com/articles/the-children-of-the-opioid-crisis-1481816178.

AMERICANS AS THE CAUSE, I

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on the responsibilities Americans bear for its tragic consequences.]

The last posting that addressed the opioid epidemic, July 13, 2018, a brief description was given on how modest amounts of abusing prescribed doses of opioids can easily lead to addiction.  This posting will begin looking at the responsibility consumers of opioids have in causing the accompanying epidemic.  Central to understanding this addiction problem is to gather a sense of its magnitude.  And this has led observers to the eyepopping numbers of people being addicted. 

A few of those numbers give one a sense to the extent this epidemic has grown.  Initially, opioid consumption did not begin on its own impetus; Americans did not wake up one morning and decide to take these drugs.  Reacting to the reported incidence of chronic pain in the late 1990s – in the neighborhood of 100 million people – both the drug companies and the federal government began to encourage these afflicted people to take painkilling opioids.[1] 

To what degree?  Here is part of the statistics:  from 1991 to 2011 prescriptions rose from 76 million per year to 219 million and then to 289 million in the year 2016.[2]

          As this volume rose, the numbers of people being treated for substance abuse followed as well as those of deaths due to opioid overdoses – as reported in previous postings.  Not surprising given the fact that from 2002 to 2012 the rate of drug users being prescribed drugs more powerful than morphine jumped from one-in-six drug users to one-in-three.  Most common drugs prescribed were oxycodone and hydrocodone.[3]

          An angle to this problem that has been given little attention is how Americans dispense healthcare.  This nation’s system often leaves individuals to obtain private insurance and, in turn, these companies heavily favor drug treatment over costly therapies.  According to the expert, Judith Feinberg of West Virginia University, “Most insurance, especially for poor people, won’t pay for anything but a pill.”[4]  This bias places the US with a 40 percent higher rate of prescribing opioids than Germany or Canada.[5]

          Another expert from University of Utah, Josef Stehlik, chimes in: 

Opioids are treated differently [in the US].  First, there’s much less prescription of opioid for pain in Europe, so there’s less chance of addiction from people who started opioid use in a legal, medical way.  Second, in many but not all European countries, the rate of illicit opioid use is either stagnant or decreasing.[6]

And one can ask:  does this prescription rate in the US lead to less reported incidences of pain?  Given that with the increase of opioid prescriptions there has been a decrease in non-opioid prescriptions, such as for aspirin or ibuprofen, has there been noted change in reported pain?  In the US, the answer is no.  This has caused many to question the curative effectiveness of opioids.[7]

With these factoids established, one can better answer the question with which this posting began:  what is the responsibility of Americans in causing the outbreak of this epidemic?  This blog will take up the rest of the answer in the next posting.

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[1] “America’s Opioid Epidemic Is Worsening,” The Economist, March 6, 2017, accessed July 19, 2018, https://www.economist.com/graphic-detail/2017/03/06/americas-opioid-epidemic-is-worsening .

[2] “Opioid Epidemic,” Wikipedia, accessed July 18, 2018, https://en.wikipedia.org/wiki/Opioid_epidemic .

[3] “America’s Opioid Epidemic Is Worsening,” The Economist.  Of note:  oxycodone sells under the brand name OxyContin or Percocet and hydrocodone under Vicodin.

[4] Owen Amos, “Why Opioids Are Such an American Problem,” BBC, October 25, 2017, accessed July 19, 2018, https://www.bbc.com/news/world-us-canada-41701718 .

[5] Amanda Erickson, “Opioid Abuse in the U. S. Is so Bad It’s Lowering Life Expectancy:  Why Hasn’t the Epidemic Hit Other Countries?,”  Washington Post, December 28, 2017, accessed July 19, 2018, https://www.washingtonpost.com/news/worldviews/wp/2017/12/28/opioid-abuse-in-america-is-so-bad-its-lowering-our-life-expectancy-why-hasnt-the-epidemic-hit-other-countries/?utm_term=.c5d14bc5db2c .

[6] Ed Cara, “The U. S. Opioid Crisis Is So Devasting, It’s Made More Organ Available for Transplant,” Gizmodo, May 16, 2018, https://gizmodo.com/the-u-s-opioid-crisis-is-so-devastating-its-made-more-1826053571 .

[7] Matthew Daubresse, Hsien-Yen Chang, Yuping Yu, and George Caleb Alexander, “Ambulatory Diagnosis and Treatment of Non-Malignant Pain in the United States, 2000-2010,” Medical Care, vol. 51, no. 10, October, 2013, accessed July 19, 2018, https://www.researchgate.net/publication/256500618_Ambulatory_Diagnosis_and_Treatment_of_Non-Malignant_Pain_in_the_United_States_2000-2010 , AND Robert Gebolhoff, “The Opioid Epidemic Could Turn into a Pandemic If We’re Not Careful,” Washington Post, February 9, 2017 AND “Facing Addiction in America,” U. S. Surgeon General (SurgeonGeneral.com), 2016, site page no longer posted, see https://addiction.surgeongeneral.gov/executive-summary .  Reported decreases of prescribed non-opioids range from 38% to 29%.

HOW TO DEFINE AND EVALUATE THEORIES

[Note:  At the end of the last posting the reader was advised that this posting would continue this blog’s report on the development of a civics unit of study.  Due to certain requests, this will happen next posting.  As for this posting, the following is an overview of what a political construct is; what is the function of a political construct; and how to evaluate a construct.]

Theories, models, and often constructs are explanations of some set of phenomena.  One such example in the field of political science is cybernetics which is an off-shoot of systems theory.  It deals with communication and control.  It does not pretend to explain all political phenomena, but through its lens it does shed light on most aspects of political behavior.  In turn, this explanation can be the source of political research, analysis, and even attempts at predicting a relevant future.

          In terms of research, a theory, through its explanatory quality, suggests or directly provides hypothetical relationships between or among factors.  Usually, in terms of supporting an explanation, the aim is at establishing cause and effect relationships; factor A causes factor B to happen.  While this is fine within the context of a model – its hypothetical nature does not oversell its view of reality as necessarily being reality – a study that gathers relevant information usually attempts to establish a correlation or, more technically, to disprove (falsify) a relationship.[1] 

Of course, protocol provisions in such studies are developed to strive to account for all nuances; i.e., exceptions or the identification of other factors that lead to both A and B are hopefully detected.  Of course, such study or research is prone to problems, as all human endeavors are.  One problem is the function theories, as they were described, play is that political scientists with such a view favor the positivist approach.  Political scientists who use positivist protocols adopt, to the extent possible, the methods used by natural scientists such biologists and physicists. 

A term used to describe this approach is reductionist studies.  They reduce the effort to focusing on those factors the scientist is testing.  A historical note:  political science was not always so “scientific.”  Before the behaviorist revolution in the mid-twentieth century, political science was more historical.  And this fact is relevant to what is being emphasized with this blog’s call for the utilization of federation theory.

For example, not all political questions can be reduced.  Why?  A way to view this shortcoming is offered by the political scientist, Daniel J. Elazar.  He claims that political science is not only interested in answering the questions:  how and why does political phenomena operate as they do, but, also, how should governance and politics be conducted?  Often, these “should” questions, while, at times, assisted by asking reductionist questions, cannot be fully answered by them.[2]

So, scholars that utilize the non-reductionist, federalist model to guide their research, such political scientists as Elazar, Donald Lutz, Martin Diamond, and Stephen L. Schechter, tend to be more historical in their approaches as they ask federalist questions of the past.  But as is the case, the federalist model is one of many models and, given the purposes of a consumer of such models might have, such as the case of a civics teacher, what questions should he/she ask of a political science model?

Eugene J. Meehan[3] offers such a criteria:

·        Comprehension:  Does the explanation explain as many phenomena as possible which are related to the area of concern?

·        Power:  Does the explanation control the explanatory effort by being valid and complete in its component parts and in the relations between those parts?

·        Precision:  Does the explanation specifically and precisely treat its concepts, making them clear in their use?

·        Consistency or Reliability:  Does the explanation explain its components and their relations the same way time after time?

·        Isomorphism:  Does the explanation contain a one to one correspondence with that portion of reality it is trying to explain?

·        Compatibility:  Does the explanation align with other responsible explanations of the same phenomena?

·        Predictability:  Does the explanation predict conditions associated with the phenomena in question?

·        Control:  Does the construct imply ways of controlling the phenomena in question?

These criteria are geared to assist social scientists in terms of them evaluating the various explanations their discipline hold or propose given the areas of concern the discipline studies.  But given the above concern of Elazar, might there be one more criterion?  Here is what it could be:

·        Normative determination:  Does the construct indicate what normative/moral political behavior is and how the subject of the model’s use – the polity and its participants – measure up to that standard?

Different consumers, given their reasons for utilizing these criteria will have different needs.  Not all the criteria above will have the same salience for all consumers.  As a list, this seems to be fairly complete, but users of the list might find some criterion to be unimportant or the entire list might be seen as lacking some concern.  The judgement here is that each of the above concerns should be of some relevance to a teacher.

But civics teachers don’t conduct political science research.  Instead, they can rely on these models to assist them in making sense of what they teach.  They do want to be responsible in the substantive information he/she is imparting or otherwise implementing in their lesson plans.  So, the above criteria can be helpful.  As a matter of fact, his/her concerns do not end with this list.  One can add two more criteria:

·        Abstraction Level:  Does the construct’s abstraction level allow students to comprehend it?

·        Motivation:  Does the construct’s content sufficiently motivate students to study it?

Each of these standards might deserve a separate section to further explain it and to go into the implications each might have on the social sciences or, more importantly here, civics education.  As it is being used here, the idea is for a teacher to have a handle on how to critically judge what a federation approach has to offer since it is offering a construct.  That is, this blog explains what federation theory is and how it is useful in meeting the challenges civics education is facing in today’s classrooms. 

So, a teacher or curriculum developer becomes aware of a political theory or model – an explanation or construct – what then?  This now turns to be a curriculum and instruction concern.  In the curriculum literature, there are a variety of curriculum developmental models.  One that has received a bit criticism – as being too constrained – is suitable for establishing the connection between the demands of offering meaningful content material and the demands of teaching it.  That is the developmental model offered by Ralph Tyler.[4]

The Tyler model identifies three sources of curriculum:  the relevant attributes of the society/community in which the curriculum is to be utilized, the distinguishing, relevant attributes of the students to be served, and the subject matter’s elements that are to be taught.  Of most relevancy here is the last of these three – the subject matter.  It is in this way that Meehan/Elazar/ (and this writer humbly adds) Gutierrez’s criteria can be helpful.

But Tyler’s model goes on; it assumes that if one is reflecting on these three sources of curriculum, a teacher or curriculum developer will be likely to arrive at an overwhelming number of instructional objectives.  Therefore, to be more focused and direct, this number of objectives needs to be whittled down.  To do this, Tyler inserted two “screens” by which to evaluate each objective:  social philosophy (in terms of scope) and psychology (in terms of sequence).  Of course, for the purposes here, social philosophy is more important.

By social philosophy, Tyler refers to a school’s sense of its mission.  Each school – and this is generally required by accreditation bodies – has a school philosophy.  The school is to abide by the philosophy’s espoused values in the various operations or activities it either performs or sanctions.  So, if a school (usually a decision made by state or district authorities) is committed to abide by the C3 Framework,[5] this or, at least, the framework’s substantive prescriptions, would be a set of elements within a school’s philosophy.

What about schools that have not made such a formal commitment?  Chances are such schools can still implement the prescriptions of the framework since what districts, states, and even schools have in place are so vague.  All that needs to be done is interpret the wordage of district or state standards – or school philosophies – to include federalist ideas and ideals.  This is not being dishonest.  The authorities have purposefully been this vague in order not to squelch school initiatives.

          Hopefully, this overview of the functions of a political model, criteria by which to judge the usefulness of political models, and the role political models play in civics curriculum, the reader can apply these ideas in considering and, perhaps, implementing the tenets of federation theory.

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[1] Or as Karl Popper states it:  falsify a hypothesis.  See “Falsifiability,” WhatIs.com, n. d., accessed July 14, 2018, https://whatis.techtarget.com/definition/falsifiability .

[2] Daniel J. Elazar, Exploring Federalism (Tuscaloosa, AL:  The University of Alabama Press, 1987).

[3] Eugene J. Meehan, Explanations in Social Science: A System Paradigm (Homewood, IL: The Dorsey Press, 1969).

[4] Ralph W. Tyler, Basic Principles of Curriculum and Instruction (Chicago, IL:  University of Chicago Press, 1969/1949).

[5] National Council for the Social Studies, “Preparing Students for College, Career, and Civic Life,” (Washington, D. C.:  NCSS, 2013), accessed April 16, 2018, https://www.socialstudies.org/c3.  This framework is offered as part of the Common Core project by the US Department of Education.

PHYSICAL COSTS AND RESULTING DEMAND

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a mode of dispensing illicit opioids which is a contributing element of this epidemic.]

Before continuing this report, this posting adds a few words on the extent of the opioid epidemic in the US.  This epidemic has been characterized as a crisis.  This word was used by the US Surgeon General as a reaction to the observed over-prescription of opioid pain pills back in the 1990s.  As early as those years, opioids became the most prescribed type or class of medications in this country.  Over-use, regardless of whether the user seeks pain relief or to induce euphoric feelings, is likely to lead to an addiction.[1]

          As with other addictive drugs, the over-user builds a tolerance and, in turn, needs higher doses of the drug to achieve the intended results.  The user becomes dependent on the drug; further consumption relieves or avoids withdrawal symptoms.  Those symptoms are very serious.  To begin with, over-use of the various opiates “changes how brain chemistry work leading to physical and psychological dependence.”[2] 

Dividing opiates between short acting ones and long acting ones, the onset of symptoms varies:  short-acting ones start within 6 to 12 hours while it takes 30 hours for the longer-acting types.  Immediate symptoms are tearing up, muscle aches, agitation, interrupted sleep routines, excessive yawning, anxiety, nose running, sweats, racing heart, hypertension, and fever.  Longer lasting symptoms (peaking within 72 hours and last for about a week) are nausea, muscle cramping, depression, agitation, anxiety, and further opiate cravings.[3]

There have been cases where users intentionally inflict horrendous injuries to themselves to get prescriptions for more opioids.[4]  This, of course, reflects serious demand.  And where there is a demand, a segment of the population that is willing to buy a product, there will be suppliers of that product.  At times, that includes illicit products, such as illegal opioids.  The prime source of the opiates is Mexico.

There, the role of drug cartels is central.  They are held responsible for providing a virtual “flood” of these drugs.  Their initial interest was to significantly increase heroin supplies.  Now, heroin is not a prescribed drug, so why emphasize its export into the US?  It turns out that heroin is cheaper, more potent, and easier for perspective or established users to acquire than other – prescribed – opioids.[5]  There has been some speculation that the increase in heroin was due to tightening prescription policies; CDC reports this is not the case.[6]

Heroin makes its way into the US from various other nations, but Mexico leads that list.  Between the years 2005-2009, there has been increased production in Mexico of heroin from 8 metric tons to 50 metric tons, an over 600% increase.[7]  Another figure reflecting this increased traffic of heroin is how much more of the opioid has been seized at the border; it doubled between 2010 and 2014.[8]  With those types of numbers, according to DEA, it is not hard to believe that profits from this trade has become central to the fate of Mexican cartels.[9]

Mexican criminal organizations, primarily the Sinaloa Cartel, makeup the primary traffickers of the other insidious opioid drug, fentanyl.  By one account, 80 percent of seized fentanyl in New York is linked to that cartel.[10]  And, are the profits these criminal organizations reeking from Americans all due to irresponsible behaviors on the part of those Americans?  The next posting will address this question.

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[1] Jacqueline Howard, “Why Opioid Overdose Deaths Seem to Happen in Spurts,” CNN, February 8, 2017, accessed July 11, 2018, https://www.cnn.com/2017/02/08/health/opioids-overdose-deaths-epidemic-explainer/ .

[2] “Opiate Withdrawal Timelines, Symptoms and Treatment,” American Addiction Centers, n.d., accessed July 11, 2018, https://americanaddictioncenters.org/withdrawal-timelines-treatments/opiate/ .

[3] Ibid.

[4] The writer has seen these ads on TV.

[5] Dan Nolan and Chris Amico, “How Bad Is the Opioid Epidemic?” Frontline, February  23, 2016, accessed July 12, 2018, https://www.pbs.org/wgbh/frontline/article/how-bad-is-the-opioid-epidemic/ .

[6] Abby Goodnough, “Opioid Prescriptions Fall after 2010 Peak, C. D. C. Report Finds,” The New York Times, July 6, 2017, accessed July 12, 2018, https://www.nytimes.com/2017/07/06/health/opioid-painkillers-prescriptions-united-states.html?ribbon-ad-idx=5&rref=us&module=Ribbon&version=context&region=Header&action=click&contentCollection=U.S.&pgtype=article .

[7] Dan Nolan and Chris Amico, “How Bad Is the Opioid Epidemic?”

[8] Clare Ribando Seelke and Liana W. Rosen, “Heroin Production in Mexico and U. S. Policy,” CRS Insight, March 3, 2016, accessed July 12, 2018, https://fas.org/sgp/crs/row/IN10456.pdf .

[9] “2015 National Drug Threat Assessment Summary,” Drug Enforcement Administration, October 2015, https://www.dea.gov/docs/2015%20NDTA%20Report.pdf .

[10] Joel Achenbach, “Wave of Addiction Linked to Fentanyl Worsens As Drugs, Distribution, Evolve,” The Washington Post, October 24, 2017, accessed July 12, 2018, https://www.washingtonpost.com/national/wave-of-addiction-linked-to-fentanyl-worsens-as-drugs-distribution-evolve/2017/10/24/5bedbcf0-9c97-11e7-8ea1-ed975285475e_story.html?utm_term=.15ed0524413b AND Nick Miroff, “Mexican Traffickers Making New York a Hub for Lucrative – and Deadly – Fentanyl,” The Washington Post, November 13, 2017.

A DANGEROUS MILL

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a mode of dispensing illicit opioids which is a contributing element of this epidemic.]

In the existing opioid distribution network, there are various players, some in places as far away as China, some closer to home.  Neighborhood distributors have carved for themselves a meaningful niche in this supplier system.  They are called “pill mills.”  They are clinics or doctors’ offices in which the people working in them are willing to provide opioid prescriptions to “patients” who are willing to pay for them.  That is, they are distributed without a bona fide medical reason.

          Usually, the process entails a person going to those medical facilities, being subjected to an extremely superficial exam, and getting a prescription for painkillers.  For this service, the person can be charged a fee ranging from $200 to $400.  It has been reported that these facilities can deal with 60 patients per day – a profitable day’s business.[1] And their role in the overall distribution chain extends to being suppliers to street sellers.  This maneuver may call on a dealer to hire third parties to go to pill mills to acquire the painkiller prescriptions.[2]

          Of course, these activities are illegal and with the large volumes involved, the authorities are aware of the activities.  This has resulted in attempts to shut down such prescription sources.  Florida has made a concerted effort.  In the year 2015, the authorities there closed 250 pill mills.[3] The state has altered its regulations to prohibit clinics from issuing opioid prescriptions and this, in turn, has notably lowered the dispensing of prescription opiates.[4] Florida’s efforts have garnered it some attention. 

          The Journal of the International Society for Pharmacoepidemiology, PDS, reports that due to that state’s laws and its drug monitoring efforts, high-risk individuals – users of high opioid doses over extended periods of time – or those people who are classified as “opioid shoppers” through various suppliers are recording reduced levels of consumption.  That journal concludes:  “Compared with Georgia, Florida’s prescription drug monitoring program and pill mill law were associated with large reductions in prescription opioid utilization among high-risk patients.”[5]

          How bad have some cases of these pill mill distributions been?  One case of note has been that of a Pennsylvania doctor.  He prescribed about 3 million pills in a 19-month period to about 2800 patients.  He has been arrested and his attorney is reported as saying the doctor hopes to be released on bail – his patients need care.  Oh, to date, the authorities are charging the doctor with the deaths of five of his patients.[6]

          The next posting will look at supply chains or trafficking.

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[1] “Signs of a Pill Mill in Your Community,” Kentucky Government Publication, pdf, n.d., accessed July 8, 2018, https://docjt.ky.gov/Magazines/Issue%2041/files/assets/downloads/page0019.pdf .

[2] Sam Quinones, Dreamland:  The True Tale of America’s Opiate Epidemic (New York, NY:  Bloomsbury Press, 2015).  This source has an extended timeline of this epidemic in the introductory pages of the book.

[3] “America’s Pill Mills:  A Look into the Prescription Opioid Problem,” DrugAbuse.Com, n.d., accessed July 8, 2018, https://drugabuse.com/featured/americas-pill-mills/ .

[4] “More ‘Pill Mill’ Doctors Prosecuted Amid Opioid Epidemic,” Healthline, May 19, 2016, accessed July 8, 2018, https://www.healthline.com/health-news/pill-mill-doctors-prosecuted-amid-opioid-epidemic#1 .

[5] “Impact of Florida’s Prescription Drug Monitoring Program and Pill Mill Law on High-Risk Patients:  A Comparative Interrupted Time Series Analysis,” Pharmacoepidemiology and Drug Safety (PDS), February 28, 2018, accessed July 8, 2018, https://onlinelibrary.wiley.com/doi/abs/10.1002/pds.4404 .

[6] “Doctor Charged in Deaths of 5 Patients from Opioid Overdoses,” Associated Press/CBS News release, December 22, 2017, accessed July 8, 2018, https://www.cbsnews.com/news/doctor-raymond-kraynak-charged-deaths-patients-opioid-overdoses-pennsylvania/ .  For another case study see Sam Quinones, “Dr. Procter’s House,” Dreamland – a blog, October 3, 2016, accessed July 8, 2018, http://samquinones.com/reporters-blog/2016/10/03/dr-procters-house/ .