Medical Examiner

Is 20.8 Million Pain Pills Over a Decade a Lot for One Town? It Depends.

Over-prescription is a real danger, but reducing the opioid crisis to a numbers game won’t bring about a solution.

Photo illustration: A man walking alone down an alley in Huntington, WV, with pills superimposed.
A man walks down an alley near a CVS Pharmacy on April 20 in Huntington, West Virginia. Huntington has been portrayed as the epicenter of the opioid crisis. Photo illustration by Slate. Photo by Brendan Smialowski/AFP/Getty Images.

West Virginia has long been considered one of the epicenters of America’s opioid crisis, so when a local paper, the Charleston Gazette-Mail, published a piece titled “Drug firms shipped 20.8M pain pills to WV town with 2,900 people,” it was bound to raise eyebrows. It’s already the website’s most read piece, with good reason.

On the surface, this reads like a terrifying figure. 20.8 million is, of course, a very big number—for citizens of Williamson, the tiny town described, that would mean upward of 7,000 pills each. It’s the kind of link that gets breathlessly passed around on social media without much further scrutiny, and the story has already been picked up—and the headline echoed—by outlets as disparate as Vox and Fox News. But the reality requires some unpacking: The titular 20.8 million is a total over a 10-year period, from 2006 to 2016, and Williamson residents aren’t the only ones who rely on that supply. One of the two pharmacies implicated, the Hurley Drug Company, appears to be the only one in the county that offers free prescription delivery service to the area and 24-hour care; for inhabitants of Williamson and the surrounding area, the second-nearest provider of the same services is the next state over, in Kentucky.

This kind of context is crucial. To start with, 20.8 million pills divided by 10 years and then by 365 days means just under 5,700 pills per day. For Williamson alone, that would still be worryingly high—but for Mingo County, with a population of more than 25,000, it becomes a little less alarming: 5698.63 divided by the county’s 25,292 residents = 0.225, or about one-fifth of one pill per person per day. People managing chronic pain, or recovering from work injuries or surgery, might take two tablets per day; thus, the terrifying number from the headline could be accounted for by 2,849 people from the region, about 10 percent of the population, using opioids as prescribed each day over the course of a decade.

Of course, that best-case scenario is unlikely to be the reality here—there are some other drug stores the residents of Mingo County can turn to, even if they lack Hurley’s reach, and Tug Valley Pharmacy, the second named in the piece, is in fact notorious as a “pill mill.” But it’s a useful exercise for understanding what 20.8 million pills over one decade can look like and why pill count isn’t the best metric for assessing a crisis. Perhaps most notably, we’re given no frame of reference: What would be an expected and acceptable number of pills for a town the size of Williamson, or a county the size of Mingo? What percentage of people should take an opioid? And without such a control, how can we judge the scale of the problem beyond our reflexive human reaction to eight digits’ worth of pills?

None of this is to suggest that the crisis in West Virginia isn’t serious. The Charleston Gazette-Mail’s coverage on the opioid crisis has been spectacular—the paper won a Pulitzer for a reason. But headlines focusing only on the glut of medication set the wrong tone—at the wrong targets. There are people who need such medication, particularly in a coal town like Williamson, where rates of disability and pain are far above the national average. For some, the crackdown on prescription pills means they might be denied treatment, and that could have consequences just as dire as the opioid crisis we’re trying to fight, as chronic pain patients struggle mightily without the medications they need, some even turning to suicide. In other cases, the crackdown on prescription painkillers has shunted addicts to other, more dangerous drugs. As Vox summarized last year, “As opioid painkiller deaths leveled off over the past few years, heroin and particularly fentanyl deaths have rapidly increased.” Simply driving down the total pills prescribed, then, isn’t a solution.

Over-prescription is a real problem, but it’s not the only problem. Incentivizing a net decrease in pills (or shaming those who authorize them) makes doctors skittish about offering opioids even to those who truly need them. That leaves the kinds of people for whom these treatments were first conceived—including cancer patients with acute pain, and Williamson’s coal miners, reckoning with the effects of decades of backbreaking labor—with nowhere to turn.

The complicated nature of the opioid crisis has made it tricky to understand, and harder still to untangle. “We don’t do well with nuance,” Dr. Sean Mackey, director of Stanford University’s Pain Management Center, told STAT. “And this is an incredibly nuanced issue.” Numbers like 20.8 million are attention-grabbing, and the opioid epidemic is certainly worthy of our attention—but to frame it in this way discourages the multifaceted approach that will be necessary to understand it, and ultimately to beat it.