Life in the American Rat Park

It'd be a lot nicer here if we took care of each other, instead of chasing every last dollar

Scientists, who can be thoughtlessly sadistic, demonstrated more than 50 years ago that if you put a rat alone in a cage, and offer her a choice between plain old clean water and water laced with drugs, she will choose the drugs. She’ll drink cocaine or heroin steadily, obsessively, until she overdoses and dies.

Then a kinder scientist came along and asked: What if the problem is not access to drugs — but the loneliness, and the cage?

His team repeated the experiments, but they made the rat’s home far less prison-like. In what came to be called “the Rat Park”, male and female rats were set up in a stimulating and vibrant community, where they were free to cavort, explore, have sex and socialize. In this improved environment, the rats mostly preferred water. Some would still partake of the available cocaine or heroin — but more, ah, recreationally. And they never overdosed or died.

Apparently rats, like humans, need social relationships and a community. When we are denied this — when life feels unsatisfying, unfair, lonely, inauthentic — we check out of it with intoxicants.

Over the past 20 years, many millions of Americans became addicted to hard drugs and alcohol. Millions more also embraced cannabis as a new cure-all. When it comes to America’s Rat Park, there’s apparently a lot that’s unsatisfying, unfair, lonely or inauthentic, and so best checked out of.

But is that the whole story?

Five years ago, the soaring rates of opioid abuse and associated deaths provoked the declaration of a national public health emergency. By that time, annual drug overdose deaths had more than tripled, from about 20,000 a year in the 1990s to about 70,000 by 2017. Some of those deaths were driven by cocaine or methamphetamine, but the vast majority were from opioids.

Seventy thousand lost souls every year — that’s a lot of pointless and avoidable death. For context, just before COVID-19, we were losing more American lives to opioids in a single year than to combat operations over more than 20 years, across all of our post-9/11 wars.

In fact, we lost far more veterans to opioids than we did to war-fighting. It’s pretty shocking that for every one soldier who has died in combat in recent years, four more committed suicide, and it looks like at least six or seven died of a drug overdose.

Enter the Coronavirus

Then came the stresses and dislocations of the COVID-19 pandemic. Suddenly, there was a lot less cavorting, exploring, sex or socializing to be had. Workplaces closed. Vacations and family trips were cancelled. Book clubs, church services, gym classes, kids’ schools and sports, neighborhood cookouts — all of that was curtailed. Weddings were canceled, and even funerals were unattended, or virtual-only. It was like everyone had been yanked out of the Rat Park and shoved back into a cage of no-socializing, complete with a choice of either clean water from the tap, or home delivery of every kind of intoxicant.

Alcohol consumption, particularly binge drinking, took flight. One study in January 2022 calculated that the early COVID-era increase in drinking would eventually cause 8,000 additional deaths and nearly 20,000 additional liver failures or cancers. That’s on top of the roughly 140,000 annual deaths the CDC already attributes to alcohol abuse — yes, legal alcohol has all along had a far higher death toll than all illegal drugs combined. There’s a good reason that we once briefly amended the U.S. Constitution itself to make alcohol illegal across the nation.

Drug overdose deaths during COVID-19 also skyrocketed. Remember it was declared a nationwide emergency in 2017 when we saw 70,000 annual overdose deaths? In 2020, we hit 92,000, and in 2021 we hit 107,000. It appears for 2022 and 2023 to have plateaued for now at this new shocking high.

This is CDC data. It was an emergency in 2017. Look at what’s happened since!

Consider too that for every drug-overdose death, there are 20-30 overdoses we revive in the field or the emergency department — but how many of those have at least a mild hypoxic brain injury? For every 100,000 deaths, are there also, say, a million “near-deaths” who are now a cognitive step slower? It’s not well-studied.

Is OxyContin™ Worse Than COVID-19?

It’s hard to compare the toll of COVID-19 to that of addictive substances. These are all moving targets, and the mortality falls disproportionately on different populations. Is it fair to equate the premature coronavirus-associated death of a 99-year-old to the premature fentanyl-associated death of a 20-year-old? How about the virus-associated death of an active, pillar-of-the-community retiree — compared to the overdose death of someone with psychopathic tendencies who spent years engaged in substance abuse, repeatedly refused addiction care, and was in and out of prison for violence? (What about morbidity? How do we compare the suffering of “long COVID”, or a COVID-associated pulmonary embolus, to that of a drug-associated endocarditis or a spinal epidural abscess?)

All such nuances aside: 1.4 million Americans died from COVID-19 over about a 2.5-year period. Back-of-the-envelope math shows that equals about 450,000 a year over that time, against about 230,000-240,000 annual deaths from drugs and alcohol.

But COVID-19 appears to be less relevant every day (fingers crossed) — while the misery of addiction only grows.

And we haven’t even talked about nicotine addiction. The CDC says the U.S. annual death toll of cigarettes is 480,000 — five times higher than the opioid death tolls, and comparable to a fresh COVID-19 pandemic — every year — for decades now. The death toll just from second-hand smoke is a staggering 41,000 people a year. That’s deadlier than either motor vehicle accidents or firearms. Americans are literally in more danger from other people’s cigarettes than from other people’s guns.

Graphic of avoidable annual mortality.

The Rat Park Needs a Reboot

With COVID-19 basically over, everyone’s been released from their cages and back into the wilds of America’s Rat Park — the same place that was already so unsatisfying to so many. Coronavirus-exhausted doctors and public health experts are now turning a weary gaze back to “the old pandemics” of deadly addictions.

But there’s an uncomfortable reality awaiting us: The evidence is overwhelming that millions of Americans became addicted because some in the House Medicine eagerly encouraged that outcome, for their own profit, while the rest of us doctors mostly stayed silent.

The chief villain remains the Sackler family-owned Purdue Pharma. But many others made millions selling addiction in the Sacklers’ wake, including other pharmaceutical companies like Allergan and Johnson & Johnson, retail pharmacies like CVS and Walmart, and various corporate sharks like those at Mackenzie Consulting. They were helped along by corrupt officials at the U.S. Food and Drug Administration, by the pompous and ignorant Joint Commission (“a trusted partner in patient care”), and by physician shills like those with the Purdue-financed American Pain Society.

Surveying this ever since, our response as a medical profession has been a continued deafening silence. We prefer not to talk about it very much — we’ll just leave it to the lawyers.

Instead, we have our own solution to the opioid crisis: more for-profit drugs.

Narcan™ intranasal is now available over-the-counter — usually as a two-pack, for the introductory price of about $45. Generic injectable naloxone costs about $6 a dose, but the proprietary plastic squirt gun of intranasal Narcan™ somehow justifies a seven-fold upcharge. (It’s mind-blowing that Purdue Pharma’s international wing also sells a pricey brand-name naloxone abroad.)

Suboxone™ (buprenorphine-naloxone) is also to be aggressively marketed by all of us in the emergency department.

As a physician double-boarded in both emergency and addiction medicine, I can’t argue against expanded use of buprenorphine. The data — which, it must be said, is so far over relatively short-term horizons — shows it prevents death and disability. Of course, it is also addictive. So, the plan we confidently propose is to stay on this admittedly ingenious and excellent medication, at an average cost of about $150 a month … forever. What’s not to like?

Yet I wonder: How does all this come across to everyone else in the American Rat Park? Our fellow citizens watch “Painkiller” on Netflix, and “Dopesick” on Hulu, read Patrick Keefe’s bestselling “Empire of Pain,” and shake their heads ruefully over the latest overdose death in the local news. Then we arrive and our solution to the crisis created by aggressively selling addictive medication is … to aggressively sell more addictive medication?

This as more than half of adults have been pushed into debt specifically by medical bills, and one in five of them say they’ll never be able to pay them off. Medical overbilling is a catastrophe, and a major reason why people living in the American Rat Park opt by the millions to get drunk or stoned.

How about we doctors try offering a little therapeutic honesty along with the pills?

A version of this article is also available at Emergency Medicine News.