A COHORT THEORY OF DRUG-DEATH EPIDEMICS

How supply shocks create them and generational turnover ends them

‘There’s a hole in Daddy’s arm where all the money goes, Jesus Christ died for nothing, I suppose’

(‘Sam Stone’ by John Prine)

INTRODUCTION

Why do drug-death epidemics begin, and why do they end? Drug-death epidemics do not arise simply because the demand for drugs shifts; they arise because the market abruptly makes more, cheaper, stronger drugs available. In other words, a supply shock. The general trajectory of public discourse has inverted this reality. We search for explanations rooted in demand-side factors (such as the personal dysfunctions of the users themselves) while neglecting the structural/systemic conditions that make mass intoxication possible in the first place.

Yet history shows that no major wave of drug deaths has ever begun simply with a spontaneous shift in demand. Rather, it begins when supply floods the market: when injected morphine replaces smoked opium, when heroin replaces morphine, when crack cocaine replaces powder cocaine, when synthetic opioids displace both. The crisis starts with a supply shock (such as a disruption in purity, potency, or price) and the death curve follows.

But these waves do not last forever. They recede not necessarily simply because society finds an effective health cure or public policy response (although they can obviously help,) but because, generally speaking, the generation most exposed to the glut is eventually replaced by a new generational cohort who come of age in its aftermath and who have learned to associate the drug in question with an older generation and its associated ills. In short: supply shocks create drug-death epidemics, and generational turnover ends them.

THE PREHISTORY OF THE DRUG-DEATH EPIDEMIC

Drug-death epidemics are not a modern invention. Long before the age of synthetic chemistry, early-modern societies experienced sudden floods of intoxicants that reshaped behaviour, public health, and mortality. Each wave began, not with new cravings, but with new access and each ended, not so much with reform, as with generational replacement. The cohort that drowned in one intoxicant left behind another that had learned to eschew it.

18TH CENTURY GIN CRAZE

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In eighteenth-century London, the ‘Gin Craze’ offered the first clear example of an early-modern drug-death epidemic. It did not arise simply because Londoners suddenly desired alcohol more intensely, but because government deregulation resulted in a supply-shock. In the 1690s, William III, determined to weaken France’s brandy trade (Britain was at war with France at the time) and find an outlet for surplus grain, deregulated distillation. The 1690 distillation deregulation meant that any subject could make gin (gin was a Dutch drink and William III was a Dutch king) with minimal restriction and little to no taxation. Unforeseen at the time, this liberalisation had subsequent far-reaching implications.

As Patrick Dillon has put it in his book on the Gin Craze:-

‘Spirits weren’t just stronger versions of wine or beer; they were different in kind, more destabilising, more dangerous. Beer and wine had been around for centuries. They were hallowed by tradition, ingrained in the woodwork; the tavern and alehouse reeked of them. Beer-drinkers raised their flagons in the same room where their grandfathers had drunk…Instead of good cheer and old drinking songs, spirits offered quick intoxication, then long oblivion.

Dillon reports that by 1720, two and a half million gallons of proof spirit a year were being distilled in a city with a population of barely more than 600,000. By 1723, each man, woman, child, in London was getting through something like a pint of gin a week. By 1726, in St Giles-in-the-Fields, you could buy a dram of gin in every fifth house. By 1736, there were now 7,022 gin-sellers in Middlesex alone. By 1751, Dillon reports that (since 1725) 84,000 children had died as a result of gin-drinking. 

Parliament finally reimposed licensing and excise controls in the Gin Acts of 1751. However, the subsequent decline in the consumption of gin was likely as much demographic as legislative. The rise in popularity of Methodism during this period provides us with a clue. Methodist emphasis on sobriety was surely formed as part of a wider cultural backlash to the Gin craze (how else to explain it?,) given that the two historical phenomena were coterminous, and the Wesleyan advocation of temperance is surely explicable in this light. A surefire indicator of the likelihood that the Gin Craze ended via means of generational turnover as much as through legislation. The generation that had built its habits around cheap spirits gradually disappeared, and the next generation grew up wary of repeating them. 

As Jennifer Warner has put it in her book ‘Craze - Gin and Debauchery in an Age of Reason’:-

‘The gin craze followed the trajectory of other and more recent drug epidemics: that is, it lasted for the span of one generation.’

AMERICAN OPIOID EPIDEMIC

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The 18th century London Gin Craze provides a template that we can use to discern the trajectory of modern-day drug-death epidemics. The American Opioid epidemic provides the clearest example of such a trajectory.  As countless books, films and documentaries have outlined, the modern-day American Opioid Epidemic did not occur with a shift in demand but with a (iatrogenic) supply-shock. Whereas the Gin Craze started with a flood of cheap spirits made possible by distillation deregulation, the American opioid epidemic began with a flood of prescription narcotics made possible by a wave of overprescribing. Beginning in the late 1990s, pharmaceutical companies (most infamously Purdue Pharma) worked to redefine pain as a ‘fifth vital sign,’ marketing long-acting, highly potent opioids as ‘nonaddictive’ in certain preparations (drugs that were hitherto restricted to smaller doses and only for patients who were terminally ill) and as a safe solution to a much wider range of ills for a much broader range of patients at increasingly mega-doses. 

Predictably, as the inflated profits started to roll in, and the marketing for these drugs went into over-drive, the subsequent glut of over-prescribing, not least via the proliferation of pill-mills—-Sam Quinones writes in his book ‘Dreamland’ that in one three-month period in the 2000s fully 11% of all Ohioans were prescribed opiates—-ultimately led to an epidemic of opioid addiction which eventually shifted to heroin by roughly 2007-2010 (as the supply of medically prescribed opioids was restricted and Mexican-supplied black tar heroin filled the void) and then to synthetic opioids, such as fentanyl, by 2014/15-onwards, as the suppliers of illicit opioids grew more sophisticated and efficient. Fentanyl, the main synthetic opioid of choice, is x50 more potent than Heroin, x100 more potent than Morphine. It is also estimated that all the Fentanyl entering America annually could fit into just 15 or 20 cars. Which means that Fentanyl is therefore ideal for drug smugglers. 

By 2021, American drug overdose deaths had surged more than 400% to over 108K overdose deaths in that year alone. The opioid epidemic has been a social and economic catastrophe. It is estimated to account for 43% of the decline in men’s labor force participation rate between 1999 and 2015, and 25% of the decline for women, and has also resulted in a substantial number of children being placed in care. Between 1999 and 2020, over 932,000 Americans have died of drug poisonings, about the same number of American soldiers that died in all armed conflicts from the Civil War through to the present day. By 2021, one in twenty-two deaths in the US was attributable to unintentional opioid toxicity and it ranked as the number one cause of death for Americans aged 18 to 49. 

The important point to emphasise is that the American Opioid crisis, like the London Gin craze before it, was not caused by a shift in demand, but in supply. Even in 2025, over a quarter of a century after the Opioid crisis began, it remains the case that a large proportion of illicit Fentanyl users began their addiction journeys via prescribed Opioids. Demand was initially stimulated by supply, facilitated by the medico-pharma complex, and then maintained via proximity to a narco-state where the drugs that kill Americans are made and then transported. To put things into perspective, in Mexico (a country which has seven of the ten cities with the highest murder rate in the world,) drug cartels are the 5th biggest employer and are estimated to control up to 35% of the country. The relationship between Mexico and America (arguably made worse by NAFTA) is mutually dysfunctional. Mexico floods America with drugs (not just Opioids but also Methamphetamine,) whilst America floods Mexico with guns. 

The two salient facts of the American opioid epidemic are both supply-side factors. Before the mass-marketing of highly potent opioids as a mega-dose, long-term treatment for moderate pain (as opposed to a small-dose, short-term treatment reserved for patients dying of terminal illnesses,) and before their inevitable diversion into use as a street-drug, there was no huge public demand for the flooding of America with powerful opioids ( nor was there an opioid epidemic.) That's the first salient fact.

This iatrogenic supply-shock (Purdue Pharma and pill mills) created a whole new generational cohort of opioid addicts in America. Previously, illicit opioid use in America was socio-demographically concentrated. It primarily took place in a few big cities (New York in particular) and was largely a behavioural pattern engaged in by people (an ageing cohort of heroin addicts) further down the socio-economic ladder. The Oxycontin supply shock democratised opioid use in America, spreading it all over the country to virtually all social groups, and once this new market was created, the fact that America shared a border with a veritable narco-state, ensured that the supply of opioids was reliably maintained, this time via illicit channels. Which is the second salient fact of the American opioid crisis. 

THE STRUCTURAL PATTERN OF DRUG-DEATH EPIDEMICS

Virtually every major drug-death epidemic follows the same structural logic: it begins not with a spontaneous surge in craving, but with a technological or institutional expansion of supply. Most street drugs, after all, begin life as pharma/medical innovations. Cocaine, amphetamines, benzodiazepines, ketamine, gabapentinoids; each entered the world through the clinic before spilling into the street. The American opioid epidemic is simply the latest and most lethal iteration of this pattern: it began with oxycodone, moved to heroin, and culminated in fentanyl; all three, in their origins, medical drugs. 

The previous American Opioid epidemic in the 19th century started in exactly the same way, as David Courtwright observes in ‘Dark Paradise: A History of Opiate Addiction in America’:-

‘The administration of opium and morphine by physicians was the leading cause of addiction in the nineteenth century…estimates of the number of opium and morphine addicts who could trace their plight back to their doctor ranged from a simple majority to 99 percent. The problem became particularly acute with the spread of hypodermic medication during the 1860s and 1870s, when morphine injection became a virtual panacea. In spite of repeated warnings, therapeutically engendered addiction remained a serious problem until the early twentieth century, when the American medical profession largely abandoned its liberal use of opium and morphine.’

David Courtwrights’s conclusion is that drug addiction is an illness of exposure:-

‘Over and over again the epidemiologic data affirm a simple truth: those groups who, for whatever reason, have had the greatest exposure to opiates have had the highest rates of opiate addiction. This is as true of doctors and their patients in the nineteenth century as it is of delinquents and slum dwellers in our own day. There is little need to posit elaborate personality theories, as a number of psychologists and psychiatrists have done.’

GENERATIONAL TURNOVER

If the past is any guide, the American opioid epidemic will end much as its predecessors did i.e not simply through the sudden success of policy, but also through the slow arithmetic of generational turnover. The cohort most exposed to OxyContin, heroin, and fentanyl will eventually age out, and those who follow them (shaped by the devastation they witnessed) will be more wary of repeating it.

Early evidence already suggests that younger Americans, particularly Gen Z, are drinking less, smoking less, and using fewer illicit drugs than any generation before them. As in previous centuries, what begins with a flood ends with fatigue. The memory of loss becomes its own deterrent, and the social meaning of intoxication shifts from glamour to caution. The epidemic, in other words, will not be cured so much as outlived.

David Courtwright’s account of how the first American opioid crisis ended (in the late-19th and early-20th centuries) echoes this. He reports that a generational turnover in the medical profession who had overprescribed opiates, and also in the addicted population, created what he described as a newfound ‘narcotic conservatism’ in the generation that replaced them.

Younger physicians, trained after the dangers of morphine and laudanum were well known, became far more cautious in their prescribing habits. At the same time, the cohort of older addicts (many of whom had first become dependent through iatrogenic means during the Civil War or through Victorian patent medicines) gradually died out.

By the 1920s, a combination of demographic attrition, professional reform, and tighter legal control had reduced opioid addiction to a small, socially marginal phenomenon. The epidemic did not end through mass recovery but through generational replacement.

David Farber, in his book ‘Crack: Rock Cocaine, Street Capitalism, and the Decade of Greed’ reports that the crack cocaine epidemic ended in much the same way:-

‘Between 1988 and 1992, the number of high school seniors who disapproved of any kind of cocaine use had increased 47 percent. Cocaine, in general, was losing its allure. Crack was ever more perceived as a drug for life’s losers. Too many people had watched what crack could do to you.’

THE TRAINSPOTTING GENERATION

We see the same phenomenon when we look at British drug-deaths. Prior to the late 1970s, heroin use in Britain was largely confined to small, metropolitan circles in London and a few other major cities, sustained mainly by diverted medical supplies and a limited black market. But a sudden supply shock in the wake of the 1979 Iranian Revolution and the Soviet invasion of Afghanistan flooded Western Europe with cheap, smokable ‘brown’ heroin from Southwest Asia. This influx (refined in Pakistan from Afghan opium and trafficked through newly destabilised Iranian and Pakistani routes) spread heroin use rapidly beyond the capital, seeding new epidemics in the deindustrialised cities of northern England and Scotland. The cohort of young users who emerged in this period would define the British heroin problem of the 1980s and 1990s. 

Scotland has the highest drug-death rate in Europe as a result of an ageing cohort of heroin users (Generation X born roughly between 1964 and 1980) who started using during the 1980s and early 1990s. The same pattern of elevated Gen X drug death rates can also be observed in England and Wales incidentally. In Scotland the data shows that most drug-misuse deaths in recent years has occurred among users aged between 35-54 (65% in 2021) and that the average age of death has risen from 32 to 44 over two decades. This strongly suggests that the Scottish drug-death problem is, to a large extent, a generational cohort effect i.e linked to an ageing cohort of users (born in the 1960s and 1970s) who initiated use during the influx of cheap, smokable heroin in the 1980s. 

The Scottish drug-death problem shows signs of the same process of generational replacement akin to what David Courtwright called the rise of “narcotic conservatism” in early-20th-century America. The same cohort who began using during the supply shock of the 1980s are now in midlife or older, carrying the long-term consequences of that era’s abundance. As their numbers dwindle, a new generation, socialised in the shadow of that devastation, inherits a different moral landscape: less permissive, more cautious, often turning to other substances or avoiding them altogether. Drug epidemics, in this view, do not end so much with the triumph of policy as with the exhaustion of a generation. One age drinks, injects, and dies; the next watches, recoils, and abstains, the grim rhythm by which intoxicated societies learn restraint.

CONCLUSION

If there is a pattern to be found across the centuries, from gin to morphine, from crack to fentanyl, it is that intoxicated societies recover not so much via policy as through exhaustion. Each epidemic consumes a generation and leaves a cautionary imprint on the one that follows. The substance changes, the delivery mechanism evolves, but the rhythm remains the same: a supply shock ignites the blaze, and generational turnover snuffs it out. The American opioid crisis will likely end, as other crises have, when the memory of loss becomes heavier than the promise of relief, and a younger cohort, wary of what their elders endured, quietly declines the offer.

‘My heart aches, and a drowsy numbness pains, My sense, as though of hemlock I had drunk, Or emptied some dull opiate to the drains’ 

(‘Ode to a Nightingale’ by John Keats.)