5 ms·

Why do americans make so much use of opioids? For me it sounds like crack. No sane person tries crack, most people are already in the lowest point in their life

Why do americans make so much use of opioids? For me it sounds like crack. No sane person tries crack, most people are already in the lowest point in their life when they are presented to the "opportunity". Is it similar with opioids?

analog31 2y ago
I think a major contributor is actual pain, from the workplace, perhaps obesity, perhaps poor health in general.
- ceejayoz 2y ago
  A major contributor was also Purdue Pharma and the Sackler family, who got rich off getting people started on prescription opioids.
  - WarOnPrivacy 2y ago
    > A major contributor was also Purdue Pharma and the Sackler family, Their 1980s and 1990s actions led to the pill mill event. The feds sharply reversed it before "opioid crisis" became a trending term. Over the last 15+ years, Fentanyl has been the (primary) physical driver. The list of social drivers is fairly unchanged. me: https://news.ycombinator.com/item?id=41578349#41579772 https://news.ycombinator.com/item?id=41578349#41579772
    - ceejayoz 2y ago
      > Their 1980s and 1990s actions led to the pill mill event. Oxycontin was approved by the FDA in 1995. The FDA dinged them for misleading marketing claims in 2003. https://www.fda.gov/drugs/food-and-drug-administration-overdose-prevention-framework/timeline-selected-fda-activities-and-significant-events-addressing-substance-use-and-overdose https://www.fda.gov/drugs/food-and-drug-administration-overd... https://en.wikipedia.org/wiki/Opioid_epidemic https://en.wikipedia.org/wiki/Opioid_epidemic > Between 1991 and 2011, painkiller prescriptions in the U.S. tripled from 76 million to 219 million per year, and as of 2016 more than 289 million prescriptions were written for opioid drugs per year. I don't doubt that fentanyl kills a lot of people today, but a lot of those currently addicted got started on pills legally prescribed to them.
      - WarOnPrivacy 2y ago
        Pill mills notoriously maxed out count and dosage (per script) ratios. A single Rx could be for a jar of the highest dosage.¹ This was common. Scripts written outside of pill mills were orders of magnitude lower in dosage and quantity. Lumping these very different numbers together paints a simplistic view of a complex issue. > Between 1991 and 2011 painkiller prescriptions in the U.S. tripled Years that include the rise/fall of pill mills. > as of 2016 more than 289 million prescriptions 289M is a single broad number representing complex and distinct things. To determine opioid use trend, some of the things we need to know are count per Rx, dosage, med type and treatment type. Institution (eg:ALF,hospice,VA) trends are distinct from public-facing doctors but we don't even look at them. We just lump their Rx #s into the pot. An important number we don't have: Denial counts for reasonable need. Single-figure opioid views don't leave us room to consider it. Chronic pain patients (who responsibly used pain relief for years) started getting shut out before 2016. That trend ratcheted one way. Their choice was losing what productivity they had or seeking illegal+risky options.¹ But as ever, the public and news orgs are much more interested in billionaires than vulnerable people in need. ¹These are things I personally witnessed.
dylan604 2y ago
If you're using "sane" as a limiter in your understanding, then you'll never understand. There are many reasons people try opioids. A large percentage of opioid addiction came from being prescribed by a doctor. Some people try it because they are looking for a way to make their situation in life not hurt so much. It's what their friends/family do. I'm not going to attempt to go into all of the reasons any one has ever used, but you should be more empathetic than your use of sane
- rob74 2y ago
  > A large percentage of opioid addiction came from being prescribed by a doctor. I think that's the main factor which differentiates the US from the rest of the world. IANAD, but as far as I know at least here in Europe opioid painkillers are reserved for the terminally ill (mostly cancer), and the US shows why "normalizing" their use is a very bad idea...
  - camdenreslink 2y ago
    Opioids aren't even used post-surgery for pain management? I have to think they are at least used in hospitals still. Maybe not prescribed as much for home use...
    - rauljordan2020 2y ago
      They are not, not even in other parts of the world. It is also very rare in Asia. Folks tough it up and are fine, as the risks of opioids are not worth it
  - lumb63 2y ago
    They’ve definitely been overprescribed here (and the drug companies making the opioids pushed them knowing they were addictive, and downplayed the risks). One of my best friends’ cousins died in his 20s of a heroin overdose. He got addicted to opioids after being prescribed painkillers following a shoulder surgery. He was a baseball player, in good shape, young. To me, overdose deaths in people prescribed them by doctors are some of the worst. They’re frequently in younger individuals, meaning more life cut short; they were indirectly caused by a profession whose ethos is “first, do no harm”. To me, it is a sign that something has gone badly wrong in the medical profession and society at large and sows major distrust in our institutions.
hiddencost 2y ago
I knew a homeless guy who abused heroin. The thing that got him off the street was seeing a dentist, who pulled an infected tooth. Turns out he was in extreme pain at all times, but didn't know it. If we'd had universal health care he wouldn't have ended up homeless.
- ghastmaster 2y ago
  If he did not know he was in pain, how would universal healthcare have helped?
  - teddyh 2y ago
    Presumably he knew he had a bad tooth, which was probably why he finally did go to a dentist.
  - muststopmyths 2y ago
    Usually regular dental checkups include x-rays every year. The biggest value proposition of universal healthcare (IMO) is preventive care, stopping minor issues from getting to the point of hospitalization.
  - alistairSH 2y ago
    Regular dental check-ups likely would have caught the tooth rot before it led to opioid addiction. Hopefully in time that a simple filling would suffice, but even a non-urgent extraction or root canal is better than months/years of chronic pain. From what I can tell, chronic pain eventually morphs into "background noise" in a person's life. It's there, but similar to depression or anxiety, it just becomes a new normal and people develop strategies to deal with it. Often that's drug abuse.
    - ghastmaster 2y ago
      > Regular dental check-ups likely would have caught the tooth rot before it led to opioid addiction. Hopefully in time that a simple filling would suffice, but even a non-urgent extraction or root canal is better than months/years of chronic pain. Quoting from this paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10035485/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10035485/ ...we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC... Anecdotally, I have had access to rather cheap healthcare almost my entire life, but opted not to visit a dentist for 15 years. > From what I can tell, chronic pain eventually morphs into "background noise" in a person's life. This has been my experience, personally and vicariously. Edit: I realized the linked paper refers to lack of data on outcomes. That is not really the question here. However, it would be nice to get more data on outcomes. The question here is whether the individual would have visited a dentist without knowing there is an issue. I tried to find data on dental visits in universal healthcare systems vs non and could not find anything.
jajko 2y ago
Prescription opioids without good controls ended up with tons of folks addicted, then moving to heroine/fentanyl once doctors woke up and stopped further prescription. I don't think anybody can judge deep opioid addiction without walking the proverbial line, most folks fail to ever shed even cigarettes or alcohol. Second reason, ie compared to Europe is that US society is much less social, much more focused on oneself and inward, and if you fail there, you fail hard and very easily end up on street even from good white collar life. Nobody really bats an eye. Once down, its very hard to ever get up from the street, misery compounds and hard drugs offer some form of temporary 'escape'.
ratedgene 2y ago
I can give you my perspective. We're fed this grandiose American dream (at least in my generation), and when we fall short of achieving that we feel like we've lost. Nothing else matters, we're not a part of the lucky. We're inherently unlucky. Then it starts as just taking the edge off, trying to cope with these feelings, and soon enough it spirals and builds momentum, then you find yourself losing your grip on why you even got up in the morning or wanted to pursue anything at all. What's the point in trying if you'll fail again? But the escape offered by addiction outweighs any reasonable or rational thought, it's just a foot out of this hell of trauma, depression, guilt, and shame. Our country doesn't have safety nets (for the most part) and is survival of the fittest. It's difficult to struggle constantly, knowing that what you want to be is always out of reach.
- meiraleal 2y ago
  Thanks for the sincere reply. I hope, if you are struggling, you find the motivation to enjoy life. I have noticed a recent trend (after pandemic) of unhappy Americans moving to Rio de Janeiro looking for their lost will to live. And actually I have seen this working miraculously well for them.
  - ratedgene 2y ago
    Hey thanks, I appreciate that advice. I am in a really great place in my life now, and sure enough it was traveling that lead to this. There's still stress and anxiety, but a change of culture helped give me perspective.
alphazard 2y ago
They are routinely administered in hospitals and for recovering from most traumatic injuries. For people who frame the use as episodic e.g. "until my leg heals" and try to get back to their lives as quickly as possible, there is rarely a problem. For some people the drugs are better than the life they had before and so getting off them is very difficult. They are a poor choice for chronic pain, since that population doesn't have particularly high life satisfaction. But they are an excellent choice for acute pain e.g post surgery, tooth extraction, etc. and people shouldn't be afraid of taking them in that context. The epidemic you have heard about in the US is incentivized malpractice. Doctors giving a class of drugs which should not be used habitually to people with shitty lives.
Clubber 2y ago
It's a cheap escape from the horrors of their lives. Most people in the US have amazingly shitty lives and it's a constant struggle, even without the drugs.
gedy 2y ago
It's just really easily available, and lots of money in the US economy. It feels good so people get hooked. It would be the same in wherever you are from if the streets were flooded with this stuff.
ChumpGPT 2y ago
A lot of the users are people who transitioned from other habits to Opioid use. Or it is people who started out being treated for some kind of pain and then cascades into a full blown addiction. I will say that there are people who have no bottom, they can just keep digging a hole deeper and deeper. There is also the fact that China ships an enormous amount of drugs through Mexico into the USA. They use it as a weapon to weaken society. It's sort of a payback for their humiliation in the last century and it causes issues for everyone, not just the users. Police, regular people, jails, court system, strains society and the costs of dealing with it are enormous.
- thijson 2y ago
  This video talks about how the money is laundered: https://youtu.be/pEyQRl7lcjc https://youtu.be/pEyQRl7lcjc
matwood 2y ago
I've used opioids twice in my life. First time was when I had ACL surgery. The pain actually wasn't that bad, but a few Oxy's help me sleep the first couple nights post-op until the swelling went down. The second time is when I had a bulging disc pressing on a nerve. My leg felt like it was on fire 24/7. It was at this point I understood how people could get addicted. Luckily I only need the opioids for a few days until the anti-inflammatories did their thing. There are some types of pain that are only dulled with opioids. With that said, the US overprescribed for many years. In both my cases I was given way too many Oxys that I eventually threw away.
0xcde4c3db 2y ago
There was a big push in the '90s (partly out of genuine concern for patients and partly as guerrilla marketing for pharmaceutical companies) for doctors to treat pain as the "fifth vital sign", i.e. assess it routinely and move quickly to address any issues with it. When Purdue Pharma introduced OxyContin, it was claimed to have low-to-no risk of dependence and abuse. This led to prolific use of prescription opioids for even minor pain. The dangerous thing about opioids is that they're equally effective for both physical and emotional pain, and everything else we have to treat emotional pain might as well be a placebo by comparison. So some people with chronic emotional pain got prescribed opioids for their physical pain post-injury/surgery and found that the experience of life on opioids is just better, and the only immediate options they have at that point are either to manage chronic opioid use or go back to their life constantly sucking. In such cases it's tempting to pontificate about "root causes", but in my experience people tend to steer that toward their own political/sociological/psychological hobby horses and quickly lose focus on the problem at hand. Also, while crack cocaine is far from harmless, its dangers have been overblown for political reasons, especially compared to the perception of powder cocaine.
- meiraleal 2y ago
  That's the best explanation I've read so far, thanks for taking the time to explain. > From conversations I've had with users, when you have internal voice that you can't make stop without the use of drugs then you look for anything. Coming from a South american country I have to disagree. Cocaine is terrible (especially when is filthy cheap) and crack is even worse, because it costs like 1 dollar. Crackheads steal anything they can for crack and after smoking they terrorize the population like walking dead zombies, soon looking for more money, any money or anything that can be exchanged for more crack.
mrguyorama 2y ago
The majority of opioid addicts in the US were legally prescribed them by their doctor. Oxycontin was lied about to medical professionals, so it was commonly prescribed in ways that significantly increase your likelihood of developing a dependence, which means following your doctor's explicit instructions could cause you to become addicted to Oxycontin.
tetromino_ 2y ago
There are excellent descriptions of a "sane" person becoming addicted to opioids even in classical literature. Start by reading Bulgakov's "Morphine" (1926) - and note that he wrote from personal experience with addiction.
- meiraleal 2y ago
  That's why I'm asking because that's not the case for crack addiction (there are exceptions to the rule, of course).

analog31 2y ago

I think a major contributor is actual pain, from the workplace, perhaps obesity, perhaps poor health in general.

ceejayoz 2y ago
A major contributor was also Purdue Pharma and the Sackler family, who got rich off getting people started on prescription opioids.
- WarOnPrivacy 2y ago
  > A major contributor was also Purdue Pharma and the Sackler family, Their 1980s and 1990s actions led to the pill mill event. The feds sharply reversed it before "opioid crisis" became a trending term. Over the last 15+ years, Fentanyl has been the (primary) physical driver. The list of social drivers is fairly unchanged. me: https://news.ycombinator.com/item?id=41578349#41579772 https://news.ycombinator.com/item?id=41578349#41579772
  - ceejayoz 2y ago
    > Their 1980s and 1990s actions led to the pill mill event. Oxycontin was approved by the FDA in 1995. The FDA dinged them for misleading marketing claims in 2003. https://www.fda.gov/drugs/food-and-drug-administration-overdose-prevention-framework/timeline-selected-fda-activities-and-significant-events-addressing-substance-use-and-overdose https://www.fda.gov/drugs/food-and-drug-administration-overd... https://en.wikipedia.org/wiki/Opioid_epidemic https://en.wikipedia.org/wiki/Opioid_epidemic > Between 1991 and 2011, painkiller prescriptions in the U.S. tripled from 76 million to 219 million per year, and as of 2016 more than 289 million prescriptions were written for opioid drugs per year. I don't doubt that fentanyl kills a lot of people today, but a lot of those currently addicted got started on pills legally prescribed to them.
    - WarOnPrivacy 2y ago
      Pill mills notoriously maxed out count and dosage (per script) ratios. A single Rx could be for a jar of the highest dosage.¹ This was common. Scripts written outside of pill mills were orders of magnitude lower in dosage and quantity. Lumping these very different numbers together paints a simplistic view of a complex issue. > Between 1991 and 2011 painkiller prescriptions in the U.S. tripled Years that include the rise/fall of pill mills. > as of 2016 more than 289 million prescriptions 289M is a single broad number representing complex and distinct things. To determine opioid use trend, some of the things we need to know are count per Rx, dosage, med type and treatment type. Institution (eg:ALF,hospice,VA) trends are distinct from public-facing doctors but we don't even look at them. We just lump their Rx #s into the pot. An important number we don't have: Denial counts for reasonable need. Single-figure opioid views don't leave us room to consider it. Chronic pain patients (who responsibly used pain relief for years) started getting shut out before 2016. That trend ratcheted one way. Their choice was losing what productivity they had or seeking illegal+risky options.¹ But as ever, the public and news orgs are much more interested in billionaires than vulnerable people in need. ¹These are things I personally witnessed.

dylan604 2y ago

If you're using "sane" as a limiter in your understanding, then you'll never understand. There are many reasons people try opioids. A large percentage of opioid addiction came from being prescribed by a doctor. Some people try it because they are looking for a way to make their situation in life not hurt so much. It's what their friends/family do. I'm not going to attempt to go into all of the reasons any one has ever used, but you should be more empathetic than your use of sane

rob74 2y ago
> A large percentage of opioid addiction came from being prescribed by a doctor. I think that's the main factor which differentiates the US from the rest of the world. IANAD, but as far as I know at least here in Europe opioid painkillers are reserved for the terminally ill (mostly cancer), and the US shows why "normalizing" their use is a very bad idea...
- camdenreslink 2y ago
  Opioids aren't even used post-surgery for pain management? I have to think they are at least used in hospitals still. Maybe not prescribed as much for home use...
  - rauljordan2020 2y ago
    They are not, not even in other parts of the world. It is also very rare in Asia. Folks tough it up and are fine, as the risks of opioids are not worth it
- lumb63 2y ago
  They’ve definitely been overprescribed here (and the drug companies making the opioids pushed them knowing they were addictive, and downplayed the risks). One of my best friends’ cousins died in his 20s of a heroin overdose. He got addicted to opioids after being prescribed painkillers following a shoulder surgery. He was a baseball player, in good shape, young. To me, overdose deaths in people prescribed them by doctors are some of the worst. They’re frequently in younger individuals, meaning more life cut short; they were indirectly caused by a profession whose ethos is “first, do no harm”. To me, it is a sign that something has gone badly wrong in the medical profession and society at large and sows major distrust in our institutions.

hiddencost 2y ago

I knew a homeless guy who abused heroin. The thing that got him off the street was seeing a dentist, who pulled an infected tooth. Turns out he was in extreme pain at all times, but didn't know it. If we'd had universal health care he wouldn't have ended up homeless.

ghastmaster 2y ago
If he did not know he was in pain, how would universal healthcare have helped?
- teddyh 2y ago
  Presumably he knew he had a bad tooth, which was probably why he finally did go to a dentist.
- muststopmyths 2y ago
  Usually regular dental checkups include x-rays every year. The biggest value proposition of universal healthcare (IMO) is preventive care, stopping minor issues from getting to the point of hospitalization.
- alistairSH 2y ago
  Regular dental check-ups likely would have caught the tooth rot before it led to opioid addiction. Hopefully in time that a simple filling would suffice, but even a non-urgent extraction or root canal is better than months/years of chronic pain. From what I can tell, chronic pain eventually morphs into "background noise" in a person's life. It's there, but similar to depression or anxiety, it just becomes a new normal and people develop strategies to deal with it. Often that's drug abuse.
  - ghastmaster 2y ago
    > Regular dental check-ups likely would have caught the tooth rot before it led to opioid addiction. Hopefully in time that a simple filling would suffice, but even a non-urgent extraction or root canal is better than months/years of chronic pain. Quoting from this paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10035485/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10035485/ ...we found that limited information was reported on health outcomes in relation to quality of care within the context of UHC. In addition, there was a global lack of evidence on measures of quality of care related to UHC... Anecdotally, I have had access to rather cheap healthcare almost my entire life, but opted not to visit a dentist for 15 years. > From what I can tell, chronic pain eventually morphs into "background noise" in a person's life. This has been my experience, personally and vicariously. Edit: I realized the linked paper refers to lack of data on outcomes. That is not really the question here. However, it would be nice to get more data on outcomes. The question here is whether the individual would have visited a dentist without knowing there is an issue. I tried to find data on dental visits in universal healthcare systems vs non and could not find anything.

jajko 2y ago

Prescription opioids without good controls ended up with tons of folks addicted, then moving to heroine/fentanyl once doctors woke up and stopped further prescription. I don't think anybody can judge deep opioid addiction without walking the proverbial line, most folks fail to ever shed even cigarettes or alcohol. Second reason, ie compared to Europe is that US society is much less social, much more focused on oneself and inward, and if you fail there, you fail hard and very easily end up on street even from good white collar life. Nobody really bats an eye. Once down, its very hard to ever get up from the street, misery compounds and hard drugs offer some form of temporary 'escape'.

ratedgene 2y ago

I can give you my perspective. We're fed this grandiose American dream (at least in my generation), and when we fall short of achieving that we feel like we've lost. Nothing else matters, we're not a part of the lucky. We're inherently unlucky. Then it starts as just taking the edge off, trying to cope with these feelings, and soon enough it spirals and builds momentum, then you find yourself losing your grip on why you even got up in the morning or wanted to pursue anything at all. What's the point in trying if you'll fail again? But the escape offered by addiction outweighs any reasonable or rational thought, it's just a foot out of this hell of trauma, depression, guilt, and shame. Our country doesn't have safety nets (for the most part) and is survival of the fittest. It's difficult to struggle constantly, knowing that what you want to be is always out of reach.

meiraleal 2y ago
Thanks for the sincere reply. I hope, if you are struggling, you find the motivation to enjoy life. I have noticed a recent trend (after pandemic) of unhappy Americans moving to Rio de Janeiro looking for their lost will to live. And actually I have seen this working miraculously well for them.
- ratedgene 2y ago
  Hey thanks, I appreciate that advice. I am in a really great place in my life now, and sure enough it was traveling that lead to this. There's still stress and anxiety, but a change of culture helped give me perspective.

alphazard 2y ago

They are routinely administered in hospitals and for recovering from most traumatic injuries. For people who frame the use as episodic e.g. "until my leg heals" and try to get back to their lives as quickly as possible, there is rarely a problem. For some people the drugs are better than the life they had before and so getting off them is very difficult. They are a poor choice for chronic pain, since that population doesn't have particularly high life satisfaction. But they are an excellent choice for acute pain e.g post surgery, tooth extraction, etc. and people shouldn't be afraid of taking them in that context. The epidemic you have heard about in the US is incentivized malpractice. Doctors giving a class of drugs which should not be used habitually to people with shitty lives.

Clubber 2y ago

It's a cheap escape from the horrors of their lives. Most people in the US have amazingly shitty lives and it's a constant struggle, even without the drugs.

gedy 2y ago

It's just really easily available, and lots of money in the US economy. It feels good so people get hooked. It would be the same in wherever you are from if the streets were flooded with this stuff.

ChumpGPT 2y ago

A lot of the users are people who transitioned from other habits to Opioid use. Or it is people who started out being treated for some kind of pain and then cascades into a full blown addiction. I will say that there are people who have no bottom, they can just keep digging a hole deeper and deeper. There is also the fact that China ships an enormous amount of drugs through Mexico into the USA. They use it as a weapon to weaken society. It's sort of a payback for their humiliation in the last century and it causes issues for everyone, not just the users. Police, regular people, jails, court system, strains society and the costs of dealing with it are enormous.

thijson 2y ago
This video talks about how the money is laundered: https://youtu.be/pEyQRl7lcjc https://youtu.be/pEyQRl7lcjc

matwood 2y ago

I've used opioids twice in my life. First time was when I had ACL surgery. The pain actually wasn't that bad, but a few Oxy's help me sleep the first couple nights post-op until the swelling went down. The second time is when I had a bulging disc pressing on a nerve. My leg felt like it was on fire 24/7. It was at this point I understood how people could get addicted. Luckily I only need the opioids for a few days until the anti-inflammatories did their thing. There are some types of pain that are only dulled with opioids. With that said, the US overprescribed for many years. In both my cases I was given way too many Oxys that I eventually threw away.

0xcde4c3db 2y ago

There was a big push in the '90s (partly out of genuine concern for patients and partly as guerrilla marketing for pharmaceutical companies) for doctors to treat pain as the "fifth vital sign", i.e. assess it routinely and move quickly to address any issues with it. When Purdue Pharma introduced OxyContin, it was claimed to have low-to-no risk of dependence and abuse. This led to prolific use of prescription opioids for even minor pain. The dangerous thing about opioids is that they're equally effective for both physical and emotional pain, and everything else we have to treat emotional pain might as well be a placebo by comparison. So some people with chronic emotional pain got prescribed opioids for their physical pain post-injury/surgery and found that the experience of life on opioids is just better, and the only immediate options they have at that point are either to manage chronic opioid use or go back to their life constantly sucking. In such cases it's tempting to pontificate about "root causes", but in my experience people tend to steer that toward their own political/sociological/psychological hobby horses and quickly lose focus on the problem at hand. Also, while crack cocaine is far from harmless, its dangers have been overblown for political reasons, especially compared to the perception of powder cocaine.

meiraleal 2y ago
That's the best explanation I've read so far, thanks for taking the time to explain. > From conversations I've had with users, when you have internal voice that you can't make stop without the use of drugs then you look for anything. Coming from a South american country I have to disagree. Cocaine is terrible (especially when is filthy cheap) and crack is even worse, because it costs like 1 dollar. Crackheads steal anything they can for crack and after smoking they terrorize the population like walking dead zombies, soon looking for more money, any money or anything that can be exchanged for more crack.

mrguyorama 2y ago

The majority of opioid addicts in the US were legally prescribed them by their doctor. Oxycontin was lied about to medical professionals, so it was commonly prescribed in ways that significantly increase your likelihood of developing a dependence, which means following your doctor's explicit instructions could cause you to become addicted to Oxycontin.

tetromino_ 2y ago

There are excellent descriptions of a "sane" person becoming addicted to opioids even in classical literature. Start by reading Bulgakov's "Morphine" (1926) - and note that he wrote from personal experience with addiction.

meiraleal 2y ago
That's why I'm asking because that's not the case for crack addiction (there are exceptions to the rule, of course).