“Medicare for All” is often treated as shorthand for an enormous new federal expense. Critics ask an understandable question: With the national debt already on an unsustainable trajectory, how could the United States possibly afford another massive government program?

But perhaps we are asking the wrong question.

The relevant question is not simply how much a universal health care program would cost the federal government. It is how much Americans are already spending on health care—and whether there is a less expensive way to provide better care.

A provocative new analysis from researchers at the Yale School of Public Health puts that question squarely on the table.

The researchers modeled what could happen if the United States replaced its fragmented multipayer system with a national single-payer system like that proposed in the Medicare for All Act. Using 2024 spending, insurance, and mortality data, they project that such a system could reduce national health expenditures by $1.04 trillion annually—nearly 20 percent—while averting more than 100,000 deaths each year.

Those are extraordinary numbers. They should also be interpreted cautiously.

The study is a preprint and has not yet been peer reviewed. It is a modeling analysis, not an experiment demonstrating what would actually occur after such an enormous restructuring of American health care. The authors themselves acknowledge important uncertainties, including transition costs, potential administrative job losses, and how physicians, hospitals, and other providers might respond if reimbursement moved toward Medicare rates.

But those limitations are not a reason to ignore the study. They are a reason to debate its assumptions.

We Are Already Spending the Money

The idea that America cannot afford universal health care can obscure an uncomfortable fact: we already operate the most extraordinarily expensive health care system in the world.

U.S. health expenditures reached approximately $5.3 trillion in 2024—$15,474 for every person in the country—and consumed 18 percent of the entire U.S. economy. CMS projects that health spending will reach 20.6 percent of GDP by 2034 if current trends continue.

Yet spending more does not mean everyone has meaningful access to care.

The Census Bureau estimated that 27.1 million Americans were uninsured throughout 2024. The Yale researchers also emphasize another group that receives much less attention: people who technically have insurance but remain underinsured because deductibles and other out-of-pocket expenses make needed care financially inaccessible. Their analysis estimates that more than 45 million working-age Americans fall into that category.

That distinction matters.

Where Could a Trillion Dollars Come From?

The Yale model does not produce savings by simply providing less health care. In fact, it incorporates an estimated $304 billion in additional spending to meet unmet medical needs, compensate currently unpaid care, and provide universal dental coverage.

The projected savings come instead from changing how the system operates.

The researchers identify five major sources: lower pharmaceutical prices, Medicare-level reimbursement to providers, reduced administrative overhead, less fraudulent billing, and fewer preventable emergency department visits and hospitalizations. Even when they use more conservative assumptions about drug prices and fraud, they still project annual savings of at least $663 billion.

Some of those assumptions will—and should—be challenged.

Would paying hospitals and physicians at Medicare rates threaten some practices or hospitals, particularly those already operating on narrow margins? How rapidly could administrative savings realistically be achieved? What would happen to the large workforce currently employed in insurance administration and billing? How should such a system be financed, and how would the tax burden be distributed?

These are legitimate questions. Any serious proposal for reform must answer them.

But notice what kind of questions they are.

They are questions about economics, implementation, access, and outcomes—not political labels.

The Tax Question Is Not the Whole Question

Opponents of Medicare for All frequently point out that it would require substantially greater federal taxation. That is almost certainly true of any system in which government replaces private insurers as the principal payer.

But taxes alone do not tell us whether Americans would ultimately pay more or less for health care.

Today, individuals and employers finance health care through insurance premiums, deductibles, copayments, taxes, employer contributions, and the prices of goods and services that incorporate employers’ health-benefit costs. Moving money from one column called “private premiums” into another called “taxes” does not necessarily increase the country’s total health care bill.

The meaningful questions are total cost, who pays it, what care people receive in return, and whether the system produces better health.

That is why the Yale study deserves attention even from people who are deeply concerned about federal spending.

Then There Are the Lives

The most striking estimate may not involve money at all.

The researchers project that providing adequate coverage could prevent approximately 62,863 deaths each year, including nearly 30,000 among people who are already insured but inadequately protected from health care costs. When the model includes the estimated consequences of reversing recent coverage reductions and other policy changes, the projected total rises to 114,174 deaths averted annually.

Those figures are necessarily less certain than counting deaths that have already occurred. The authors acknowledge that there are no direct estimates of excess mortality specifically among the underinsured, requiring them to model that relationship.

Still, the underlying point deserves attention: inadequate access to health care has consequences measured not merely in dollars, but in human lives.

This Should Not Be an Argument About Socialism

There are aspects of the contemporary socialist political agenda that many Americans—myself included—may regard as unrealistic, unaffordable, or undesirable.

That should not prevent us from examining health care reform on its merits.

Universal health coverage is also not synonymous with one particular political ideology or even with single-payer medicine. Countries have achieved universal coverage through different combinations of public insurance, private insurance, regulated markets, and government programs. The Yale researchers studied one specific single-payer approach. Their findings should not be interpreted as proving that it is the only—or necessarily the best—way to achieve universal coverage.

But the study challenges the assumption that expanding coverage must inevitably mean spending more.

And that matters.

We face a genuine national debt problem. Fiscal responsibility will require difficult choices about taxes, defense, entitlement programs, and discretionary spending. Health care cannot somehow be excluded from that examination when it already consumes nearly one dollar out of every five produced by the American economy.

Perhaps universal health care would not save exactly $1.04 trillion. Perhaps the Yale model overestimates some savings or underestimates some costs. Peer review and independent analyses should test those assumptions.

But imagine that the real savings were only half as large.

Would we still dismiss reform because someone called it “socialism”?

That would be a mistake.

Fiscal responsibility should not mean defending the health care system we have. It should mean asking whether we can build one that costs less, works better, and keeps more Americans alive.

The new Yale study does not settle that debate.

It makes the debate much harder to avoid.

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Fentanyl is deadly. But reducing its supply cannot end an overdose crisis rooted in human suffering.

In a recent KevinMD essay, “Fentanyl interdiction will not end the overdose crisis,” I argue that America continues to confuse an important drug-control strategy with a solution to the overdose epidemic.

President Trump has repeatedly pointed to dramatic reductions in maritime drug seizures as evidence that his administration has nearly stopped drugs from entering the United States. Even setting aside questions about what those statistics actually measure, there is a more fundamental problem with the claim.

Interdiction addresses supply. It does not address demand.

Fentanyl is extraordinarily dangerous, and disrupting cartels, trafficking networks, precursor suppliers, and distribution routes can save lives. Supply matters enormously when a substance can be lethal in milligrams.

But removing fentanyl does not remove the reasons people seek drugs.

Those reasons include trauma, mental illness, chronic pain, loneliness, housing instability, economic displacement, and despair. Fentanyl did not create these conditions, and eliminating fentanyl will not make them disappear. (KevinMD.com)

We have already seen what happens when policy concentrates primarily on supply. Prescription opioid dispensing in the United States fell by more than half from its 2012 peak. Yet overdose deaths continued to rise for years as the illicit market evolved—from prescription opioids to heroin, then fentanyl, and increasingly to mixtures involving stimulants and other drugs.

The product changed. The source changed. The route changed. Demand remained.

That history should inform what we do next.

America needs vigorous efforts to reduce the lethality of the illicit drug supply. But those efforts must be matched by policies that reduce vulnerability: accessible addiction treatment, naloxone, behavioral health care, stable housing, recovery support, treatment for chronic pain and mental illness, employment opportunities, and stronger communities.

Overdose deaths have recently declined, which is welcome progress. But tens of thousands of Americans are still dying each year. A declining catastrophe remains a catastrophe. (KevinMD.com)

The question we should be asking is not only how fentanyl gets into America, but why so many Americans remain vulnerable to an illicit market they know can kill them.

Until drug policy gives equal attention to that question, the substances will continue to change as markets adapt.

We should disrupt dangerous drugs wherever we can. But we cannot interdict our way out of an epidemic rooted in human suffering.

Fentanyl may change. Demand for relief will persist until we address what creates it.

Read my full argument in KevinMD: “Fentanyl interdiction will not end the overdose crisis.” (KevinMD.com)

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I have submitted a public comment to the FDA concerning the growing use of patient-specific algorithmic risk scores in clinical care, with NarxCare as an important case study.

A risk score is a number generated from selected information about a patient to estimate the likelihood of a particular outcome. Risk scores are used throughout medicine to estimate the chances of cardiovascular disease, stroke, cancer, surgical complications, hospital readmission, and other outcomes. When properly validated, transparent, and applied to a clearly defined outcome, they can support clinical judgment and informed discussions with patients.

NarxCare is a clinical decision-support platform that analyzes controlled-substance prescription histories obtained from state prescription drug monitoring programs. It presents clinicians and pharmacists with visualizations and numerical scores—including an “Overdose Risk Score”—intended to identify prescription patterns that may warrant further evaluation. Its reach is substantial: according to its developer, NarxCare is used in more than 20 states and by five of the six largest retail pharmacy companies. (Bamboo Health)

The FDA invited comments as it prepares its congressionally required 2026 report on software functions excluded from the definition of a medical device under the 21st Century Cures Act. The agency requested information about the risks and benefits of these “non-device” software functions, their effects on patient safety, and best practices for promoting safety, education, and user competency. The request specifically includes certain forms of clinical decision-support software. (FDA)

My concern is not with risk assessment itself. Clinical decision-support software can help clinicians recognize patients who may need additional evaluation, monitoring, education, or preventive interventions. But a score that can materially influence care must be transparent in how it is derived. Clinicians and patients should be able to determine what the score means, why a patient received it, how accurately it performs, what important information it omits, and what clinical action—if any—should follow.

An “Overdose Risk Score,” for example, may appear to predict whether an individual patient will overdose. Yet NarxCare’s developer states that the score is not an individual prediction of future overdose. It is a statistical comparison based on characteristics found in prescription drug monitoring program data. That distinction can easily be lost when a seemingly precise three-digit number appears prominently in a clinician’s workflow.

My comment asks the FDA to require clearly defined outcomes, clinically meaningful transparency, independent external validation, communication of uncertainty, and safeguards against automation bias—the tendency to place too much trust in a computer-generated result. It also emphasizes that predictive validity is not the same as clinical usefulness. Even an accurate statistical association does not establish that opioids should be reduced, withheld, or discontinued.

The FDA should also examine how these systems affect access to care. Risk scores may contribute to involuntary tapering, medication denial, patient dismissal, pharmacy refusal, or clinicians’ reluctance to care for medically complex patients.

Risk assessment should help clinicians ask better questions—not convert uncertainty into an authoritative number. A risk score should never acquire more authority than the evidence supporting it.

Read my complete FDA comment here. https://www.regulations.gov/comment/FDA-2018-N-1910-0342

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“Socialism” has become one of the most effective and elastic words in American politics. It is invoked often, defined rarely, and used either to brand very different policies as a common threat or to signal aspirations for greater fairness, security, and shared responsibility. The resulting hysteria is less of a debate over policy than a tribal call. Because the term appears so routinely, especially in arguments over healthcare, it is worth asking what it actually means before judging any policy placed under that label.

The recent growth of the Democratic Socialists of America (DSA) has intensified the controversy. The DSA describes itself as the country’s largest socialist organization, with more than 120,000 members. It argues that working people should democratically control the economy and society and explicitly calls for replacing capitalism with democratic socialism.

A recent Washington Post poll found that roughly three-quarters of Democrats said they would be open to a democratic-socialist presidential candidate. That sounds important, but it does not tell us what respondents understood “democratic socialist” to mean or which policies they would support.

Some voters may hear abolition of capitalism or government control of industry. Others may hear universal healthcare, stronger worker protections, affordable housing, less inequality, or reduced corporate power. Supporting a candidate because one favors part of that agenda is not the same as endorsing the entire DSA platform.

Healthcare provides perhaps the clearest example of this confusion. Proposals ranging from modest expansions of public insurance to comprehensive single-payer plans are routinely branded “socialized medicine,” even though they differ enormously in financing, ownership, delivery, and patient choice.

At its core, socialism involves government rather than exclusively private ownership or control of the means of production. That can include state ownership, worker cooperatives, community ownership, or democratic management. But public ownership of a particular service does not by itself make an economy socialist.

The United States illustrates the point. Americans rarely describe publicly owned highways, dams, water systems, or fire departments as socialism, even though they are collectively financed and managed by government. Public provision of goods and services can coexist with a predominantly capitalist economy.

In its narrowest sense, socialized medicine describes a system in which government finances care, owns much of the infrastructure, and employs many healthcare professionals. Cuba is one example, where nearly the entire system is owned and managed by the government.

The British National Health Service also contains important elements of socialized medicine. It is financed largely through taxation, most hospitals are publicly controlled, and many hospital physicians are salaried employees, although many general practitioners work as independent contractors.

The United States already operates a similar integrated model through the Veterans Health Administration (VA). The federal government finances care, owns the facilities, and employs the clinicians. That does not mean the VA model should be extended to everyone. But sweeping denunciations of “government-run healthcare” should acknowledge that such a model already exists in the United States and serves millions of veterans.

Single-payer insurance is different. A public agency finances most covered care while hospitals and physicians remain largely outside direct government ownership. Canada follows this model: provincial governments administer public insurance, while much care is delivered by private or nonprofit providers. American “Medicare for All” proposals generally resemble this approach. They would create a national public insurance program without necessarily nationalizing hospitals or turning physicians into federal employees. That is collective financing, not government ownership of delivery.

The Nordic countries illustrate another arrangement: the social-democratic welfare state. They provide universal healthcare through substantial public financing, with care delivered through combinations of public and private organizations. Yet their broader economies remain predominantly capitalist and market-based.

Other wealthy democracies, including Germany, the Netherlands, Switzerland, Australia, and the United Kingdom, achieve universal or near-universal coverage through varying combinations of public and private financing. What they share is broad risk-pooling and access, not abolition of private enterprise.

Of the healthcare systems commonly invoked in this debate, only Cuba operates within a political-economic system derived from Marxist socialism. The British NHS, the U.S. Veterans Health Administration, Canadian single-payer insurance, and Nordic universal healthcare all operate within predominantly capitalist economies. Universal coverage, collective financing, and even public ownership of healthcare facilities do not, by themselves, constitute Marxist socialism.

The hysteria begins when these distinctions are not acknowledged. Critics may treat a public option or single-payer insurance as equivalent to Cuban central planning. Defenders may point to Nordic outcomes as proof that “socialism works,” overlooking that Nordic countries combine heavily publicly financed healthcare with market-based, privately owned economies. Both sides substitute labels for analysis.

Actual performance deserves more attention than ideological shorthand. Many Americans have been told that the United States has the best healthcare system in the world. Yet the Commonwealth Fund’s 2024 comparison ranked the United States last overall among 10 high-income countries, citing weaknesses in access, equity, administrative efficiency, and health outcomes.

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For more than a decade, the dominant explanation of the opioid crisis focused on pharmaceutical marketing and excessive prescribing. That narrative prompted sweeping supply restrictions, including dosage limits, forced opioid tapers, and heightened scrutiny of clinicians.

Prescribing subsequently fell by more than half. Yet opioid overdose deaths continued to rise, increasingly driven by illicit fentanyl and an unpredictable street-drug supply.

In my latest article for Behavioral Health News, I examine what happens when an incomplete opioid narrative becomes public policy. A supply-centered response may reduce access to one drug, but it cannot eliminate the suffering that creates demand. Poverty, trauma, unstable housing, untreated mental illness, chronic pain, and the erosion of social connection remain largely untouched.

The consequences have affected two distinct populations. People with opioid use disorder still face inadequate access to evidence-based treatment and recovery support. At the same time, some patients with severe chronic pain have experienced involuntary tapers, abandonment, and loss of individualized medical care.

The next phase of opioid policy must move beyond controlling drugs alone. It must expand addiction treatment, strengthen behavioral healthcare and recovery infrastructure, address social determinants of health, and restore clinical judgment in pain care.

The opioid crisis will not be solved simply by restricting supply. It begins with understanding—and reducing—the human need for escape and relief.

Read the full article: When Opioid Narratives Become Policy

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A Senate hearing room framed by the U.S. Capitol—where political accusation can too easily overshadow evidence, due process, and the search for truth.

Invoking the Fifth Amendment is not a confession. Suspicion is not evidence. And an unresolved question about the origin of COVID-19 does not prove that Anthony Fauci committed a crime.

The recent Senate hearing offered plenty of political drama. Senator Rand Paul portrayed Fauci’s refusal to answer as evidence of concealment. Fauci argued that years of accusations and threats of prosecution had created a perjury trap.

Lost in the spectacle were the questions Congress should be asking: Was oversight of federally funded research adequate? Were reporting requirements followed? How should high-risk pathogen research be defined and monitored? What information did China withhold? And how can public-health officials communicate uncertainty without undermining trust?

Fauci is not beyond scrutiny. Public-health institutions made serious communication mistakes during the pandemic, sometimes presenting evolving evidence with more certainty than it deserved. Those failures should be examined.

But accountability is not the same as accusation. Risky research is not proof that SARS-CoV-2 was created in a laboratory. Inadequate oversight is not proof that Fauci knew of a laboratory escape. Scientific disagreement is not evidence of conspiracy. And exercising a constitutional right is not an admission of guilt.

When congressional hearings begin with a predetermined villain, they generate heat and headlines—but rarely the knowledge needed to prevent the next catastrophe.

We need accountability without mythology, evidence without partisan storytelling, and investigations willing to accept uncertainty when the facts remain uncertain.

Read my latest article in the American Council on Science and Health:

“Fauci Senate Hearing: The Fifth, the Feud, and the Facts”

https://www.acsh.org/news/2026/07/31/fauci-senate-hearing-fifth-feud-and-facts-50259

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Most author interviews are designed to make the author comfortable. This one is not.

The questions below challenge the central argument of my book, Deconstructing Toxic Narratives—Data, Disparities, and a New Path Forward in the Opioid Crisis. They ask whether I am merely replacing one narrative with another, whether skepticism can become corrosive, and whether questioning dominant explanations might weaken trust in legitimate evidence.

These are fair questions. A book that asks readers to scrutinize familiar explanations should be willing to subject its own argument to the same examination.

My purpose is not to argue that every accepted belief is false or that expertise should be dismissed. It is to show how incomplete explanations can harden into conventional wisdom—and how those explanations have shaped opioid policy, clinical care, public attitudes, and the lives of people with pain and addiction.

“The test of a narrative is not how emotionally satisfying it is, but how accurately it explains the evidence—and what happens when policy is built around it.”

You call certain narratives “toxic,” but isn’t that just a subjective label for any story you disagree with?

That criticism would be justified if I used “toxic” merely as a synonym for “wrong” or “objectionable.” I do not. A toxic narrative is an explanation that repeatedly distorts a complex reality, excludes important counter-evidence, and produces harmful consequences when it becomes the basis for public policy or clinical practice.

The opioid crisis offers a clear example. The dominant account held that aggressive medical prescribing was the principal cause of the crisis and that sharply reducing access to prescribed opioids would therefore reduce deaths. Prescribing practices did contribute to opioid-related harm, and accountability was necessary. But the explanation became toxic when it was treated as complete. It obscured the growing role of illicit fentanyl, polysubstance use, economic dislocation, trauma, social isolation, inadequate mental-health care, and the absence of comprehensive pain treatment.

The standard is not whether a narrative agrees with me. The standard is whether it represents the evidence accurately, accommodates contradictory findings, changes when the facts change, and improves rather than harms the people affected. My own arguments should be held to exactly the same test.

Critics might say your book is itself a toxic narrative—one that promotes cynicism or leaves readers unsure what to believe. How do you respond?

Deconstruction without reconstruction can become nihilistic. That is not the purpose of this book. I am not asking readers to distrust every institution, reject expertise, or assume that all explanations are equally unreliable. I am asking them to recognize that confidence should be proportional to the quality of the evidence.

The book therefore moves from criticism to reconstruction. It offers a social-ecological framework for understanding addiction and overdose, one that considers the interaction of the drug supply with economic conditions, trauma, mental illness, physical pain, housing instability, stigma, social connection, access to treatment, and public policy. It also uses a multilevel prevention framework—from preventing the conditions that create vulnerability to reducing harm and supporting long-term recovery.

The goal is not endless doubt. It is disciplined humility: examining definitions, asking what the data can and cannot prove, and updating conclusions when better evidence appears. That approach does not leave us unmoored. It gives us a sturdier foundation than certainty built on an incomplete story.

You say the book challenges narratives across the political spectrum. Does it really, or does it ultimately serve one ideological side?

The opioid crisis does not fit neatly within a left-right framework, and neither does the book. Different institutions and political traditions have promoted different parts of the incomplete story.

I challenge the punitive narrative that treats substance use as evidence of moral failure and assumes that arrest, incarceration, or forced abstinence will correct it. I also challenge the reductionist claim that addiction is only a chronic brain disease, because biology matters but does not erase agency, environment, meaning, or the possibility of recovery.

At the same time, I question the politically powerful account that attributes the overdose crisis almost entirely to pharmaceutical misconduct and medical prescribing. That narrative can minimize the role of illicit-market transformation and the structural conditions that sustain demand. I also challenge public-health claims that present lower prescribing rates as proof of success when deaths, untreated pain, and illicit-drug exposure may move in the opposite direction.

The book does not ask which political tribe owns the better story. It asks which explanation best accounts for the evidence and leads to fewer deaths, less suffering, and more effective care.

In an era of genuine misinformation, isn’t urging people to deconstruct dominant narratives dangerous? Could it help bad actors undermine verifiable facts?

It could—if “deconstruction” meant reflexively rejecting expertise or assuming that every consensus is fraudulent. That is not the method I advocate. Responsible scrutiny begins with evidence, not suspicion.

In the overdose debate, this means examining primary data, definitions, coding practices, denominators, time periods, and the limits of causal inference. For example, death-certificate and ICD-10 data can identify the involvement of fentanyl or other synthetic opioids, but they often cannot determine whether the substance was an illicitly manufactured product or a medically prescribed formulation. Treating those categories as interchangeable can create a misleading picture of causation.

Similarly, the familiar description of three discrete “waves” of opioid deaths is useful as a teaching device but can imply cleaner transitions than actually occurred. The crisis has been a continuous and changing flow in which different drugs, combinations, and populations have become more prominent over time.

Careful deconstruction strengthens trust because it distinguishes what the evidence establishes from what has merely been repeated. Institutions preserve credibility not by discouraging questions, but by answering them transparently and correcting their claims when the evidence changes.

What do you say to readers who finish the book and ask, “Now what? What should replace these toxic narratives?”

The answer is not a single new slogan. The opioid crisis is too complex for one. What we need is a more accurate and humane framework—one that recognizes both the lethality of the drug supply and the conditions that create vulnerability to addiction, despair, and overdose.

That framework begins with better data. We should distinguish prescribed medications from illicitly manufactured drugs whenever the evidence allows, acknowledge uncertainty when it does not, and measure success by health outcomes rather than by a single policy metric such as the number of prescriptions written.

It also requires a broader response: accessible treatment for substance use disorders and mental illness; comprehensive and individualized pain care; harm-reduction services; stable housing and employment; support after incarceration or treatment; and stronger social connection. Prevention must begin before a person develops a substance use disorder and continue through treatment, recovery, and protection from avoidable medical harm.

Healthy narratives do not promise simple villains or painless solutions. They acknowledge trade-offs, preserve human dignity, and remain open to revision. Most importantly, they direct attention toward the question that should have guided opioid policy from the beginning: Which actions actually reduce suffering and save lives?

A final invitation

Every public crisis is shaped not only by events, but by the stories used to explain them. Those stories determine whom we blame, which evidence we notice, which interventions we fund, and whose suffering we are willing to overlook.

I do not expect every reader to agree with every conclusion in this book. I do hope readers will ask a harder question of every confident explanation—including mine: What evidence would cause me to change my mind?

That question is not a sign of weakness. It is where better science, better policy, and more humane public debate begin.

At a Glance

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Oregon’s Measure 110, approved by voters in 2020, removed criminal penalties for possessing small amounts of drugs and redirected marijuana tax revenue toward addiction treatment and recovery services. When overdose deaths continued to rise, many blamed the policy and called for drug possession to be recriminalized.

But the evidence tells a more complicated story. Oregon’s overdose deaths began increasing before Measure 110 took effect and followed the same fentanyl-driven pattern seen across neighboring states.

The policy was also poorly implemented. Oregon did not build enough treatment capacity, housing support, harm-reduction services, or crisis infrastructure. That failure does not prove that arresting and prosecuting people for drug possession will prevent overdose deaths.

Recriminalization may make drug use less visible, but it will not address the deeper causes of overdose: untreated addiction, poverty, isolation, unstable housing, inadequate access to care, and an increasingly lethal illicit drug supply.

Read the full article in Street Roots:
https://www.streetroots.org/opinion/2026/07/15/recriminalizing-drugs-wont-fix-oregons-overdose-crisis/

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For years, the dominant explanation of the opioid crisis focused on excessive prescribing and the availability of pharmaceutical opioids. Prescribing has since fallen dramatically—but opioid use and overdose did not disappear. Instead, the drug supply became more dangerous.

That disconnect reveals a critical weakness in our response: reducing supply does not eliminate the conditions that create demand.

People do not seek opioids because of pharmacology alone. Drug use is also shaped by physical and emotional pain, trauma, untreated mental illness, poverty, unstable housing, social isolation, stigma, and limited access to effective care. When prescription opioids became harder to obtain without corresponding investments in treatment, pain care, mental health services, and social support, demand migrated toward heroin and illicit fentanyl.

Supply still matters. Fentanyl has made every episode of drug use more lethal. But fentanyl is an accelerant, not the entire fire.

Lasting progress will require more than restricting drugs or arresting suppliers. We must keep people alive through harm reduction and evidence-based treatment while also addressing the social and economic environments that leave people vulnerable.

The opioid crisis emerged from the interaction between dangerous drugs and human vulnerability. Until policy confronts both, the substances may change, but the crisis will continue.

Read the complete article in The Good Men Project.

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For more than a decade, America’s central strategy for addressing the opioid crisis was simple: Reduce the supply of prescription opioids.

In one narrow sense, the strategy worked. Opioid prescribing fell sharply after its peak. CDC data show that national opioid dispensing declined to 35.4 prescriptions per 100 persons in 2024, far below the peak levels of the early 2010s.

But the overdose crisis did not end.

For years after prescribing declined, overdose deaths continued to rise, driven increasingly by heroin and then illicitly manufactured fentanyl. Even after the encouraging recent decline in overdose deaths, provisional CDC data still estimate 69,973 drug overdose deaths in 2025—nearly 70,000 lives lost in a single year.

That number is lower than the peak, but it remains far above where the country was when prescription opioid prescribing was at its height. In 2012, there were 41,502 drug overdose deaths in the United States.

So the question remains: Why didn’t cutting prescriptions stop the overdose crisis?

The answer is not that supply was irrelevant. Supply mattered. Pharmaceutical marketing mattered. Pill mills mattered. Medical culture changed, and prescribing increased in ways that created harm.

But a supply-only explanation was always too small.

Reducing supply does not reduce demand.

Pain does not disappear because a prescription is denied. Trauma does not resolve because a pill bottle is empty. Despair does not vanish because a physician becomes afraid to prescribe. Poverty, job loss, mental illness, unstable housing, isolation, and untreated pain do not respond to a prescription drug monitoring program.

When the medical supply was reduced, many people did not suddenly become well. Some were helped. Some were protected from unnecessary exposure. But others were abandoned, destabilized, or pushed toward a far more dangerous drug supply.

Pathways

Researchers studying pathways to illicit opioid use have documented how abrupt prescription cut-offs and loss of medical access can drive some people toward street markets, including heroin and fentanyl.

This does not mean every prescribing reduction caused harm. It means that blunt reduction, without care, treatment, tapering support, pain management, and social support, can create a predictable danger: People still seek relief, but now in an illicit market where the dose is unknown and the contents may be lethal.

That is the cruel arithmetic of the fentanyl era.

The crisis did not shrink. It mutated.

A person who once obtained pills from a clinic might later encounter counterfeit pills. A person seeking heroin might receive fentanyl. A person using cocaine or methamphetamine might be exposed to fentanyl without intending to use an opioid at all.

This is why the overdose crisis cannot be understood simply as a story of too many prescriptions. It is also a story of a changing drug supply, worsening social vulnerability, and a healthcare system that often responded to fear with abandonment.

The rise of illicit fentanyl changed the lethality of the crisis. Fentanyl is not just another opioid. Its potency, variability, and presence in counterfeit or contaminated products made accidental overdose far more likely. Supply-side victories against prescription opioids did little to protect people from an illicit market that became more toxic, more unpredictable, and more deadly.

Demand Trumps Supply

The recent decline in overdose deaths is encouraging. It deserves attention. But it should not be misread as proof that cutting prescriptions finally worked. CDC provisional data show a major decline in overdose deaths in 2025 compared with 2024, including opioid-involved deaths. But that improvement occurred years after prescription reductions had already been achieved. It likely reflects multiple factors: changes in the illicit drug supply, expanded naloxone access, shifts in drug use patterns, treatment access, harm reduction, and other local conditions.

In other words, the recent decline should deepen our analysis, not flatten it.

The most important lesson is this: overdose deaths are not driven only by what drugs are available. They are also driven by who is vulnerable, why they are vulnerable, and what supports are available before, during, and after drug use.

Communities hollowed out by deindustrialization did not suffer only because pills arrived. They suffered because jobs disappeared, social infrastructure eroded, healthcare was fragmented, mental health services were inadequate, and many people were left with pain—physical, emotional, and social—that had no meaningful outlet.

In that environment, drugs can become functional. They can offer temporary relief, energy, sleep, escape, belonging, or simply the ability to get through another day. That does not make drug use safe. It makes it understandable.

And if we refuse to understand demand, we will keep chasing supply from one molecule to the next.

Prescription opioids. Heroin. Fentanyl. Fentanyl mixed with stimulants. Nitazenes. Xylazine. Whatever comes next.

Each new substance will be treated as the crisis, rather than as the latest expression of a deeper crisis.

This is the central failure of the supply-only narrative. It confused the visible object with the underlying condition. It treated opioids as the cause of despair rather than asking why despair had become so widespread and why some communities were so vulnerable when opioids arrived.

None of this absolves pharmaceutical companies, irresponsible prescribers, or pill mills. They played a role. But assigning them the whole story allows policymakers to avoid harder questions.

People in Pain Are Collateral Damage

Why are so many Americans in untreated pain?

Why are evidence-based addiction treatments still inaccessible to many who need them?

Why do we tolerate housing instability, poverty, incarceration, stigma, and social isolation as if they are background conditions rather than active drivers of illness and death?

Why did we respond to chronic pain patients with suspicion rather than care?

And why did we assume that fewer prescriptions would equal fewer overdoses, when the underlying demand for relief remained untouched?

A better response would begin with humility.

Yes, reduce inappropriate prescribing. Yes, stop criminal prescribing and diversion. Yes, monitor risk. Yes, prevent unnecessary exposure.

But do not mistake those steps for a complete strategy.

A real overdose prevention strategy must also expand treatment for opioid use disorder, make naloxone widely available, support harm reduction, improve pain care, strengthen mental health services, address economic instability, and rebuild the social supports that protect people from despair.

Success is not merely the absence of drugs.

It is the presence of care.

It is the presence of housing, treatment, dignity, belonging, and hope.

Until we confront demand with the same intensity we brought to supply, we will continue fighting yesterday’s version of the crisis while tomorrow’s version is already taking shape.

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For years, the opioid crisis has been explained as a supply story.

Too many pills. Too many prescriptions. Too much pharmaceutical marketing. Too many doctors willing to write the script.

There is truth in that account. Supply mattered. Pharma mattered. Pill mills mattered. Aggressive marketing mattered. Medical culture changed, and prescribing increased in ways that created harm.

But a supply-only explanation has always been too simple. It cannot explain why some communities were devastated while others were not. It cannot explain why overdose deaths continued to rise even after opioid prescribing fell sharply. It cannot explain why the crisis shifted from prescription opioids to heroin and then to illicit fentanyl. And it cannot explain why pain, disability, poverty, trauma, isolation, and economic dislocation are so often present in the background of addiction.

A provocative study by Amy Finkelstein, Matthew Gentzkow, Dean Li, and Heidi Williams helps clarify the issue—but only if it is read carefully.

The paper, What Drives Prescription Opioid Abuse? Evidence from Migration, examines adults receiving Social Security Disability Insurance who were enrolled in Medicare Part D between 2006 and 2015. The authors ask a powerful question: what happens when people move from one state to another? If a person moves from a low-opioid-use state to a high-opioid-use state, does that person’s opioid use pattern begin to resemble the new place?

Their answer is yes.

People who moved to states with higher rates of claims-defined prescription opioid “abuse” became more likely to show similar claims patterns after they moved. The effect appeared quickly and continued to grow over time. In other words, the same person placed in a different environment behaved differently—or, more precisely, was treated differently, prescribed differently, monitored differently, or became embedded in a different medical and social ecosystem.

That is an important finding.

It means risk is not located only inside the individual. Place matters.

But what does “place” mean?

That is where the interpretation becomes more complicated.

In the study, “place” includes opioid availability, local prescribing patterns, physician practice style, policy environment, pill mills, peer effects, and other local factors that may influence prescription opioid use. These are not trivial distinctions. A pill mill is not the same thing as poverty. A permissive prescribing culture is not the same thing as untreated pain. A prescription monitoring program is not the same thing as social despair. But all of these can be part of the local environment in which opioid use occurs.

Two Pathways

The paper tries to separate two broad pathways.

The first is an availability pathway: how easily people already using opioids can obtain them. This is the part most people think of when they think about supply. If there are more prescribers, fewer controls, more pill mills, or weaker monitoring systems, opioids may be easier to obtain.

The second pathway is a modeled transition pathway: the factors associated with movement into claims-defined high-risk opioid use over time. It should not be read as direct evidence of addiction, physician intent, or inappropriate prescribing.

That distinction matters.

The authors use administrative claims data. Their primary outcome is not a clinical diagnosis of addiction, opioid use disorder, or compulsive use. It is a claims-based proxy. Their main measure defines prescription opioid “abuse” as an average daily morphine-equivalent dose greater than 120 mg in any calendar quarter. They also examine other proxies, such as multiple prescribers and overlapping prescriptions.

These measures may identify risk. They may correlate with adverse outcomes at the population level. They may be useful for epidemiologic analysis.

But they are not the same as a clinical assessment.

A high opioid dose may reflect unsafe prescribing. It may also reflect severe pain, tolerance, legacy therapy, failed alternatives, palliative needs, or a complex clinical history. Multiple prescribers may reflect doctor shopping. They may also reflect fragmented care, surgery, hospitalization, relocation, specialist involvement, or poor care coordination. Overlapping prescriptions may suggest misuse. They may also reflect dose adjustments, transitions between clinicians, acute-on-chronic pain, pharmacy timing, or insurance logistics.

Claims data can reveal patterns invisible at the bedside. But claims data cannot sit with a patient. They cannot assess function. They cannot distinguish relief from compulsive use. They cannot determine whether a prescription represents appropriate care, poor care, dependence, diversion, misuse, or abandonment.

This is the danger of converting administrative proxies into moral categories.

The Finkelstein study is valuable because it shows that geography matters. People do not carry all risk inside themselves. Their environments shape what happens to them. But the study should not be used to claim that high-dose prescribing automatically equals abuse, or that modeled transitions in claims data prove clinical addiction.

The language matters because policy often moves faster than nuance.

Once a prescription pattern is labeled “abuse,” the patient behind the pattern can disappear. A risk marker becomes a diagnosis. A population-level association becomes an individual judgment. A statistical proxy becomes a justification for restriction.

That is how toxic narratives are built.

The deeper lesson of the study should not be that people in high-prescribing states were simply abusing opioids because supply was available. Nor should it be that supply did not matter. The lesson is that opioid-related harm emerges from the interaction between people and places.

The same person may experience different risks depending on where they live. The same prescription may have different meaning depending on the clinical context. The same policy may reduce one form of harm while creating another. The same supply reduction may close a pill mill and also abandon a patient with severe pain.

This is why the opioid crisis cannot be understood as a simple three-act play: pills, heroin, fentanyl. Nor can it be reduced to villains and victims, doctors and dealers, supply and demand.

The Real Story is Ecological

There was supply. There was marketing. There was overprescribing. There were also patients with pain, disability, trauma, and despair. There were hollowed-out communities, fragmented health systems, inadequate addiction treatment, punitive drug policy, and a culture eager to find simple blame.

When prescribing was reduced, the underlying suffering did not disappear. In many places, it migrated into more dangerous markets.

That is why overdose deaths could continue to rise even as prescription opioid volume fell.

A supply-only strategy can reduce access to one drug source. It cannot heal despair. It cannot restore work, housing, connection, or trust. It cannot build treatment systems where none exist. It cannot make pain care humane. It cannot reverse stigma. It cannot replace a dangerous illicit market with a functioning public health infrastructure.

The Finkelstein study matters because it provides quantitative evidence that geography shapes prescription opioid patterns. But its deeper value is not that it gives us a simple supply-versus-demand answer. It does not. Its value is that it points us away from the individual alone and toward the environments in which opioid use becomes dangerous.

Place Now Matters

But place is not merely a prescription rate on a map. Place is the clinic that has time to listen—or does not. Place is whether a patient can access physical therapy, mental health care, addiction treatment, or transportation. Place is whether a community has jobs, housing, and social cohesion. Place is whether a person in pain is believed. Place is whether policy responds to suffering with care or suspicion.

The question is not whether supply or demand caused the opioid crisis.

The better question is: what conditions allowed opioid supply to become so harmful, and why were some people and communities so vulnerable to that harm?

That question leads us away from blame and toward prevention. It leads us away from slogans and toward systems. It reminds us that the opposite of addiction is not merely abstinence or reduced prescribing. It is stability, connection, purpose, care, and relief from suffering.

Supply Mattered

But supply became catastrophic because it entered environments already primed for harm.

That is the story we still have not fully confronted.

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Oregon’s drug decriminalization under Measure 110 has been widely labeled a “failed experiment.” But what does the data actually show?

New research published in Academia Global and Public Health (April 2026), along with a 2023 JAMA Psychiatry study, finds that the sharp rise in fatal overdoses began in December 2019—well before Measure 110 took effect in February 2021. Statistical analysis show Oregon’s trends closely mirrored those in neighboring states (Washington, California, Nevada, Idaho), with no detectable additional harm from decriminalization.

I examine why the failure narrative took hold despite the evidence and what this means for future drug policy discussions.

Read the full article on the American Council on Science and Health (ACSH). [here]

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In February 1968, after the Tet Offensive, CBS anchor Walter Cronkite traveled to Vietnam, surveyed the devastation, and delivered a sober on-air assessment: the war had reached a stalemate. “The only rational way out,” he concluded, “will be to negotiate, not as victors but as an honorable people who lived up to their pledge.” President Lyndon B. Johnson, watching the broadcast, reportedly turned to an aide and said, “If I’ve lost Cronkite, I’ve lost Middle America.”

That moment endures as a symbol of a vanished media landscape. We don’t need to romanticize that era—which had its own blind spots—to recognize that it possessed something today’s ecosystem lacks: a baseline of institutional trust. Journalism in that broadcast model carried a weight of authority rooted in perceived independence, institutional restraint, and a shared national vocabulary.

Today, that infrastructure has radically shifted. Journalists find themselves operating within an information engine optimized for digital connection, engagement, and narrative momentum rather than baseline truth. As Yuval Noah Harari argues in Nexus, the primary systemic purpose of media is often not to represent reality accurately but to bind people together into distinct groups. “The easiest way to connect large numbers of people,” he writes, “is not with the truth.”

In this new reality, nuanced truth is costly and time-consuming to produce. Meanwhile, virality, emotional resonance, and group identity affirmation are cheap, scalable, and incentivized by algorithms. Modern media networks—legacy outlets included—are forced to compete on a playing field that rewards outrage over accuracy.

The consequences are visible in collapsing public trust. In the 1970s, Gallup recorded roughly 70% of Americans expressing confidence in the mass media. By 2025, that figure had fallen to a record low of 28%. More than a third now say they have no trust at all. This is a crisis for newsrooms; it is also a crisis for public policy.

How Misleading Narratives Warp Public Policy

Consider the opioid crisis, a textbook case of how media incentives and misleading reporting can warp public understanding of a deadly epidemic’s true etiology and continue to harm millions.

High-profile reporting and commentary relentlessly focused on “pill mills” and doctors as unwitting accomplices. This was emotionally powerful, politically useful, and deeply engaging for audiences. It fit a clean, classic morality tale of corporate greed versus suffering patients.

However, this narrative relied heavily on flawed coding from the Centers for Disease Control and Prevention (CDC) that had long inflated prescription opioid death counts by lumping them together with illicit synthetics like fentanyl. When statisticians corrected the data, it became clear that prescription opioid deaths had remained relatively stable from 2009 onward, while illicit fentanyl and polysubstance use were driving the catastrophic surge after 2013.

By the time the data caught up, the media-driven narrative had already hardened into conventional wisdom, directly shaping the restrictive 2016 CDC guidelines and a cascade of rigid state-level policies.

The human cost of this policy mismatch has been devastating. Patients with chronic pain—people navigating cancer, arthritis, nerve damage, and post-surgical needs—faced forced tapers, pharmacy refusals, and medical abandonment. Many lost access to the only medications that allowed them to function, leading to increased disability, suicide risk, and, in some cases, a tragic shift to the far deadlier illicit market. Concurrently, the public response to addiction remained skewed toward supply-side crackdowns rather than expanded harm reduction, evidence-based treatment, and addressing the underlying social drivers (economic despair, untreated mental illness, trauma) that fuel today’s crisis. Overdose deaths, though finally falling, remain a national crisis, heavily dominated by illicit synthetics.

I explore these dynamics, and their ongoing consequences for people in pain and those battling addiction, in depth in my book, Deconstructing Toxic Narratives.

Moving Toward a Journalism of Restraint

These missteps are not isolated lapses. Across public health, economics, and public policy, newsrooms face an attention economy where nuance dies quietly, and where audience fragmentation and internal pressures reward breaking a story first over getting it entirely right. Harari’s insight cuts deep: in digital networks, success is measured by connection, not correspondence to reality. When information networks prioritize what connects over what is verified, public policy becomes reactive, societies become more polarized, and reality itself becomes harder to discern. Harari warns that we are building vast networks capable of spreading mass delusions faster than ever before.

Restoring reliability will not come from a call to nostalgia or a wish to return to a monolithic voice like Walter Cronkite’s. Instead, it requires platforms, writers, and readers to collaborate on demanding better structural incentives. This journalism of restraint should reward rigorous verification, prioritize statistical context over emotional virality, and possess the institutional humility to issue prompt, visible corrections when data change or come to light.

The “Cronkite Moment” mattered because the public trusted the messenger. In our era, that trust is thoroughly fractured. Until we shift the underlying incentives, we live in an information ecosystem where the primary question is far too seldom “Is this true?” and far too often “Does this spread?” Rebuilding public trust starts with moving past the click-driven fictions of the attention economy and returning to a shared, data-driven reality.

At a Glance

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James Chumbley did not write to me to make a political argument. He wrote because he was desperate. (Image above features a model)

James is 64 years old (note photo above is a stock image and not a photo of James), lives in San Antonio, and suffers from adhesive arachnoiditis, a painful and often disabling neurological condition. He told me he had reached out to politicians, the media, dozens of physicians, and “anyone else I could think of,” yet he still could not find a doctor willing to treat his debilitating pain.

Then he wrote a sentence that should haunt anyone who cares about health policy: “Pain patients in today’s America are treated like aliens from another galaxy.”

When I asked whether I could share his story, James was unequivocal. “You have my permission to discuss my situation with anyone,” he wrote. “It is unacceptable how people in pain are being treated. I want my story to be told.”

James’s story is just one man’s story, but it is not an isolated one.

To understand whether his experience reflects a broader pattern, I asked Scott Farmer, Chief Operating Officer of the American Chronic Pain Association (ACPA), what the organization is hearing from people with chronic pain and how common it is that they cannot find a clinician willing to treat them. His answer was blunt: “Almost everyone that reaches out is in need of our help. Extremely common.”

That observation is consistent with preliminary results from the ongoing ACPA 2026 Chronic Pain Access and Care Experiences Survey. While the full survey results will be available later, what I am reporting here is an interim sample of 144 people living with chronic pain. It is not a nationally representative prevalence study, and it should not be read as final data. However, it offers an important early signal from a population that is often invisible in public health debates. Though future data may show a broader spectrum, the majority of this current group describes their daily existence in terms of severe pain and exhausting physical limitations.

The preliminary sample shows a pattern that sounds painfully familiar to anyone who has heard stories like James’s. Nearly three-quarters of respondents said finding a clinician willing to treat their pain was somewhat difficult, very difficult, or impossible. More than half had contacted three or more clinicians or clinics while seeking care.

The barriers extend far beyond opioids. Respondents described being told their condition was too complex, that a clinic did not treat chronic pain, or that the clinic did not prescribe any controlled substances. Others lost care when a clinician retired, moved, or changed practice policies. Some encountered insurance denials, pharmacy refusals, unaffordable care, rural access problems, or abrupt dismissal from care altogether.

This is the part of the opioid crisis narrative—a narrative I’ve previously argued is fundamentally flawed—that remains poorly measured. We count prescriptions. We count overdoses. We count morphine milligram equivalents. But we do not reliably count how many people with severe pain lose access to care, stop seeking help, turn to unsafe alternatives, or disappear into isolation.

Nearly half of respondents in this interim sample reported that their pain medication had been reduced or discontinued against their wishes. Among those patients, most said they were not offered an effective alternative treatment plan.

That distinction matters. Responsible opioid stewardship should not lead to abandonment. No one should argue for careless prescribing. Opioids carry profound risks and must be used thoughtfully, when appropriate, and with rigorous monitoring. But reducing or discontinuing medication without a realistic alternative plan is not good medicine. It simply transfers responsibility from the clinician to the patient, who is left without tools or resources.

Farmer told me he often hears patients say, “I have always taken my meds responsibly and they were just taken away. Now I don’t know what to do. I’ve been abandoned by the system.”

That word—abandoned—appears again and again.

In the preliminary ACPA sample, many respondents reported feeling automatically presumed to be drug-seeking simply because they had chronic pain or used pain medication. Many said they had avoided telling clinicians how much pain they were in because they feared being judged, dismissed, or labeled. Most said their experience with pain care had decreased their trust in healthcare as a whole.

This is what toxic narratives do—a phenomenon I explore deeply in my forthcoming book. They do not remain confined to headlines, public health campaigns, documentaries, or political speeches. They enter the clinic. They shape what clinicians fear, what patients dare to say, what pharmacists are willing to fill, what insurers will cover, and what policymakers believe counts as success.

One survey respondent wrote, “Chronic pain sufferers are NOT the cause of the Opioid Crisis.”

Another wrote, “They’ve failed to treat me like a human being.”

Another explained, “You can be in severe pain and look FINE! The emergency rooms need to know you don’t have to be unconscious or screaming to be in pain. Chronic pain survivors know how to hide pain. Listen to the patient.”

That is one of the most important lessons in James’s story. Severe pain is not always visible. The cruel irony of chronic conditions is that patients often learn to mask their suffering to survive daily life, with the result that the ability to appear composed is mistaken for the absence of pain.

Such fundamental blind spots are why public discourse often misses the mark. As Farmer noted, “The pain epidemic is separate from the opioid epidemic but does however overlap.”

That distinction is essential. The opioid crisis and the pain crisis intersect, but they are not the same. Treating them as identical has produced predictable harms. People with pain become suspect. Their medications become symbols. Their clinicians become afraid. Their suffering becomes administratively inconvenient.

The ACPA survey also challenges the assumption that people with chronic pain are simply demanding opioids. When asked what would most improve their situation, respondents most often wanted more clinicians trained in chronic pain. They also wanted less stigma, clinicians who believe them, insurance coverage for recommended care, access to non-opioid treatments, interventional care, physical therapy, behavioral health support, and opioid therapy when appropriate.

In other words, they were not asking for a blank prescription. They were asking for care.

One respondent put it this way: “No one wants to deal with the stigma and hassles of taking opioids. We want solid answers so we can go back to living a productive life.”

James Chumbley wanted his story to be told because he refused to remain invisible. The interim ACPA data show that he is far from alone in a system that has favored reducing prescription numbers over actually addressing suffering.

It is entirely possible to advocate for responsible opioid stewardship while refusing to abandon patients. But when policy treats people as administrative inconveniences rather than human beings, medicine abdicates its deepest responsibility. The goal should not be more or less prescribing as an ideology; the goal should be better care.

People living with severe pain deserve to be seen, heard, and protected with the same seriousness afforded to people with heart disease, diabetes, or cancer. But we cannot protect what we refuse to see—and we will never see what we choose not to count.

At a Glance

In case you missed my launch post, here it is:

The New York Times’ account of cychlorphine deaths in Knoxville is a compelling portrait of a modern-day Sherlock Holmes investigation. A man dies with evidence at the scene strongly suggesting drug use, yet the first toxicology report shows only nicotine and caffeine. A second lab finds sedatives, but not enough to explain the death. Only after a third, more specialized laboratory is asked to “look harder” does the answer emerge: cychlorphine, a novel synthetic opioid far more potent than fentanyl and difficult to detect on standard panels. Since then, the drug has been linked to dozens of deaths in the Knoxville area.

That story matters. Communities cannot respond to threats they cannot see. If a drug does not appear on standard toxicology screens, the data we rely on to describe the overdose crisis will forever lag behind the crisis itself. This is a recurring blind spot: early in the opioid crisis, standard panels often missed oxycodone; later, fentanyl was frequently overlooked. Now that fentanyl testing is routine, cychlorphine has emerged as the new compound escaping detection.

The pattern should teach us humility: there will always be toxic drugs. Some will be more lethal than others, and some may evade standard laboratory panels for years. Illicit drug markets adapt faster than public health systems. Chemists can alter molecules faster than policymakers can enact statutes or clinicians can update testing panels. Surveillance will always be chasing a changing market.

This cycle illustrates a deeper problem in how America talks about drug deaths. Once again, the dominant narrative becomes the toxicity of the newest drug. Yesterday, it was prescription opioids. Then heroin. Then fentanyl, xylazine, and nitazenes. Now, cychlorphine. Tomorrow it will be something else.

Acknowledging this reality does not make forensic surveillance unimportant. On the contrary, it is a vital safeguard. The Knoxville medical examiner’s work is exactly the kind of vigilance every community should want. “I’ve always seen part of the medical examiner’s job as prevention, to be a public health agent,” Dr. Darinka Mileusnic-Polchan said.

While her dedication is essential, it highlights a systemic limitation: identifying the agent responsible for a death is a necessary downstream response to an upstream failure. A toxicology report can identify the substance in the bloodstream but not the circumstances that spurred the person to use it nor why earlier opportunities for prevention failed

That question becomes unavoidable in the article’s own examples. The Times notes that one resident, a landscaper, “had been seen ducking into the woods and emerging while wiping his nostrils,” while another man was “reported to be falling asleep while washing dishes.” These moments of quiet desperation should give us pause. Why were these men using substances that could kill them? Were they trying to manage withdrawal, pain, exhaustion, trauma, addiction, or despair? Were they using to escape life or simply to get through it?

Until we ask those questions, neither the medical examiner nor the public health system can truly prevent overdoses. They can identify the drug, warn the community, and distribute naloxone. They can improve surveillance. All of that is necessary. But those measures only intervene after people have already entered the zone of danger.

The overdose crisis cannot be solved by chemistry alone. A true prevention strategy must be dual-track: we must fund medical examiners and forensic tools so deaths are accurately understood, while identifying emerging drugs quickly, warning communities, and expanding naloxone access. But we must also address the conditions that make drug use appealing, compulsive, or even seem necessary to the desperate.

The lesson of cychlorphine should not be that we have found the next “villain molecule.” The lesson should be that a society built around reacting to each new drug only after people die has mistaken detection for prevention.

While the medical examiner can tell us what killed a person, public health must answer why they were vulnerable in the first place. Until we answer the “why,” there will always be another cychlorphine, another laboratory race to identify it, and another group of grieving families asking why the warning came too late

At a Glance

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If you missed my launch post, here it is:

The recent New York Times coverage of Britney Spears’ misdemeanor DUI charge—stemming from her March arrest involving alcohol and drugs—has once again thrust her long-public battle with substance use and mental health into the spotlight. Reports have revisited her 2008 conservatorship, her voluntary entry into treatment, and passages from her 2023 memoir in which she describes Adderall as her “drug of choice” because it briefly lifted her depression.

This story offers a lens into the drivers of illicit drug demand. Mental health vulnerabilities often create the most immediate and powerful pull toward substances, even for those who appear to have every socioeconomic advantage. More than one in five Americans experience mental illness annually and nearly 50% of Americans will meet the criteria for a mental health diagnosis in their lifetime. This illustrates the enormous number of Americans with a potential vulnerability to substance use disorder (SUD).

Despite her modest beginnings, Spears is now—by any measure—extraordinarily privileged. She has known immense wealth, global fame, and access to the kind of elite medical care and resources most can only imagine. She does not fit the common image of someone driven to drugs by economic hardship or structural despair. And yet her struggles continue, a poignant reminder that while poverty and disadvantage are clear risk factors for SUD, privilege offers no immunity. Wealth and status do not protect anyone from the internal torment of untreated mental illness or trauma.

At the heart of her experience are the internal drivers so many face: untreated or poorly managed mental illness, deep trauma, and the desperate urge to self-medicate. Her memoir, The Woman in Me, and public accounts describe severe postpartum depression after the births of her sons, a widely witnessed 2007 breakdown tied to that overwhelming perinatal mood disorder, and reports of a bipolar disorder diagnosis that involved lithium treatment. She has spoken candidly about turning to Adderall not for thrills, but because it offered a fleeting sense of relief from depression, calling it “the only thing that worked for me as an antidepressant” at the time. This is textbook self-medication, a profoundly human attempt to ease unbearable psychic pain when legitimate mental health support feels out of reach, fragmented, stigmatized, or even coercive.

In my previous Substack post, “The Opioid Crisis Driven by Demand, Not Just Supply,” I discussed how supply-side interventions alone cannot solve the drug crisis because they fail to address the underlying demand. Here again, demand is central. Spears illustrates this clearly: no one flooded her with unwanted pills or pushed Adderall into her life. She actively sought out substances to cope with her pain. Supply was available, but the drive came from within.

Layered onto this are significant traumas: relentless paparazzi harassment, painful custody battles, and a conservatorship she has described as deeply controlling and abusive. When emotional pain becomes overwhelming, substances—whether alcohol or illicitly obtained stimulants—can feel like the only source of immediate relief, even if they ultimately deepen the suffering. The brain’s drive for comfort does not pause to consider privilege or fame; it simply seeks to survive the hurt.

Spears is not an outlier; she represents countless “hidden” individuals who appear successful on the outside while grappling with an inner pain that drives them toward illicit substances. Emphasizing mental health risk factors helps us reject the false idea that those with privilege who struggle must simply lack willpower. Instead, her story illuminates central truths: the biological pull of addiction does not respect wealth or fame, trauma touches every community, and mental health care remains inadequate and stigmatized at every level of society.

She deserves compassion, not punitive judgment. Her life has unfolded under a microscope, turning private pain into a spectacle that would test anyone’s resilience. Recognizing her humanity—rather than condemning her as a symbol of excess—allows us to see her story for what it is: a profoundly human attempt to soothe psychological suffering.

To truly address the demand for illicit drugs, we must confront these mental health roots. Greater access to affordable, high-quality mental health treatment is essential if we are serious about solving this crisis. By responding with empathy instead of condemnation, we can foster more effective prevention, treatment, and policies that actually meet people where they hurt.

At a Glance

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I’m pleased to announce that on May 26, my latest book, Deconstructing Toxic Narratives will be available through various sellers. Click here to learn about it.


If you missed my launch post, here it is:

And here is my previous post

Sam Quinones has spent years chronicling America’s overdose epidemic, and his latest Washington Post opinion piece marks a notable evolution in his thinking. In “Overdose deaths are plummeting. Here’s what worked,” he argues that “these supplies were creating demand, not the other way around,” a reversal of the primary thesis in his groundbreaking book, Dreamland. Street opioids, he now writes, “have always been about supply creating demand. They tend to create physical dependency in ways other drugs do not, particularly when they are highly potent and widely available.” He notes that by 2016, even as doctors had slashed prescriptions, deaths rose because Mexican traffickers flooded the country with fentanyl.

Quinones is right that potent supply kills. Fentanyl’s arrival dramatically worsened an already lethal crisis. Its extreme potency—where tiny quantities can be fatal—overwhelms users with low tolerance or those consuming it unknowingly in adulterated supplies.

Yet his new emphasis on pharmacology as the primary engine of demand tells an incomplete story. Supply matters enormously when ultra-potent synthetics can cause a fatal overdose in a single dose. But demand remains the deeper driver. Without a population desperate enough, tolerant enough, or in enough physical or psychic pain to seek out these drugs, mountains of fentanyl would sit unsold. The larger question is why some individuals and communities are more exposed, more desperate, and less protected once they encounter that supply.

Quinones once appreciated this complexity. Dreamland wove together the stories of the pharmaceutical industry’s aggressive marketing of OxyContin, the hollowing-out of Rust Belt towns, and the social disintegration that left people vulnerable. Now he seems to have abandoned that nuance for a purer supply-side narrative.

Quinones suggests that street opioids uniquely “create” demand through physical dependency. However, every opioid—whether a diverted prescription pill or illicit fentanyl—produces tolerance and dependence with chronic use. As euphoria often fades, the agony of withdrawal becomes a powerful motivator to continue use.

Withdrawal from any opioid is profoundly aversive: flu-like symptoms, severe anxiety, muscle aches, insomnia, gastrointestinal distress, and intense cravings drive many users back to the drug, simply to feel “normal.” Whether fentanyl produces more intense or protracted withdrawal due to its lipophilicity and rapid receptor binding is a matter of degree, not a difference in kind. Opioid withdrawal experiences exist on a spectrum that desperate people will go to great lengths to avoid.

The 2016 inflection point Quinones cites actually undercuts a purely supply-creates-demand thesis. As doctors, chastened by guidelines and monitoring programs, slashed legitimate prescriptions, deaths did not fall—they surged. Why? Because demand was forced to migrate.

The data bear this out: supply-side interventions—prescription drug-monitoring programs, abuse-deterrent formulations, physician education—successfully reduced the diversion of pills, but by 2015, heroin had become the initiating opioid for 33.3% of new users, up sharply from 8.7% in 2005. Initiation with prescription opioids plummeted: oxycodone fell from over 42% to 24.1% while hydrocodone fell from over 42% to 27.8%. Heroin was cheaper, more available, and carried the same promise of relief or reward. Novice users with no tolerance then faced fentanyl-laced products. The supply shift did not create the demand; it redirected and amplified an existing one.

Nowhere is this clearer than in the lives of pain patients caught in the backlash. One patient in Indiana, after nearly 40 years of stable, monitored opioid prescriptions, was suddenly discharged by the only clinic in town after a single heated exchange with a staff member during a pain flare-up. Because he could not afford—and insurance would not cover—the implant the clinic demanded, he was left in crisis.

His story is not an outlier; it is the predictable consequence of a national narrative that treats every prescription pad as a gateway to overdose. When we turn the spigot of legitimate opioids too far down without addressing the underlying need, we do not shrink demand; we reroute it to far deadlier sources.

Quinones’s reporting remains invaluable, but his current framing risks reinforcing the very policies that have proven disastrous. Supply-side victories—fentanyl seizures, precursor controls, cartel disruptions—save lives in the short term and deserve credit for recent declines in overdose deaths. Yet they cannot address the underlying hunger for relief, escape, or reward.

Socio-economic despair, untreated mental health conditions, eroded community ties, and inadequate chronic-pain care all fuel demand. Pharmacology explains why fentanyl kills so efficiently; it does not explain why so many Americans are positioned to seek it out.

While we give credit where it is due as overdose deaths decline in 2026—citing interdiction, naloxone, and treatment expansion—we must avoid declaring victory through supply reduction alone. We must confront the hardest question: why do so many of our neighbors feel they need these drugs to survive? Until we invest in economic opportunity, mental-health infrastructure, compassionate pain management, and addiction treatment that reaches people before they reach the street, the next potent supply—whatever it is—will always find its market.

At a Glance

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If you missed my launch post, here it is:

After more than four decades as a practicing pain physician, and researcher I’ve launched this Substack to cut through the noise surrounding pain, opioids, addiction, and the policies that shape how we treat them.

Here’s what you can look forward to:

• Evidence-first policy analysis—Straightforward breakdowns of new laws, guidelines, and proposals and their real-world impact on people in pain and those with substance-use disorders. Too often, policy debates are driven by fear, sensational headlines, and political optics rather than rigorous data and real-world clinical outcomes. I intend to change that narrative.

• Critical takes on dominant narratives—Examining where the data supports—or contradicts—today’s headlines and helping you separate signal from noise. Many public health stories harden into conventional wisdom before the evidence has been fully examined. Here, I will question assumptions, challenge oversimplified explanations, and ask whether the policies that follow from popular narratives are actually supported by data. The goal is not to reject every mainstream account, but to insist that consequential claims deserve careful scrutiny.

• Clinical insight you won’t find elsewhere—Perspectives drawn from 350+ clinical trials, decades of patient care, and my own research on pain, analgesics, opioids, and addiction risk. Each post will examine the science, data, unintended consequences, and the human impact. Whether the topic is opioid prescribing rules, addiction-treatment policy, or emerging regulatory changes, I’ll bring the same standards I’ve applied in clinical trials and hundreds of peer-reviewed publications: facts first, context always, and ideology nowhere.

• Thoughtful essays designed to inform and sharpen your critical thinking— My promise is simple: no clickbait and no fear-mongering—just straightforward, clinically grounded perspective from someone who has spent a career balancing effective pain relief with responsible risk management.

If you’re tired of simplistic slogans and ready for thoughtful, evidence-driven conversation about one of the most important—and most misunderstood—areas of American medicine, I invite you to join me.

Let’s roll up our shirtsleeves and get to work.

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