A Blizzard of Prescriptions
- Dopesick by Beth Macy
Head of Zeus, 376 pp, £9.99, March, ISBN 978 1 78854 942 4
- American Overdose: The Opioid Tragedy in Three Acts by Chris McGreal
Faber, 316 pp, £12.99, November 2018, ISBN 978 1 78335 168 8
- Dreamland: The True Tale of America’s Opiate Epidemic by Sam Quinones
Bloomsbury, 400 pp, £12.99, June 2016, ISBN 978 1 62040 252 8
In 1996, a company called Purdue Pharmaceutical launched a new opiate painkiller called OxyContin. At a party celebrating its release to the public, Richard Sackler, a scion of the family that owns the company and its senior vice president of sales, made exuberant predictions about its success. ‘The launch of OxyContin tablets will be followed by a blizzard of prescriptions that will bury the competition,’ he said, according to a lawsuit recently filed against Purdue. ‘The prescription blizzard will be so deep, dense, and white …’
The active ingredient of OxyContin is oxycodone, a semi-synthetic opiate (an ‘opioid’) first synthesised in Germany in 1916. Prior to OxyContin’s launch, oxycodone had been marketed as a painkiller in various pill forms for years, including Percocet (where it is mixed with paracetamol), Percodan (where it is mixed with aspirin) and Roxycodone (where it is dispensed pure in small doses of 15 to 30 milligrams). Other kinds of opiate painkillers, like the hydrocodone-based Vicodin, were also mixed with aspirin and came in small doses. While people did become addicted to these pills, the low doses of opiates they contained made it hard to overdose on them, and the paracetamol and aspirin would cause liver damage if the drugs were taken for a long time.
OxyContin distinguished itself from these medications, and received a patent, on the basis of an extended-release technology, the ‘contin’ of the drug’s suffix. Purdue developed OxyContin not to serve an urgent public health need but because the patent was expiring on its most profitable drug, a time-release morphine pill called MS Contin. Pharmaceutical patents, which last twenty years, allow pharmaceutical companies to maintain a monopoly on a drug and avoid competition from generic manufacturers. When a patent on a popular drug expires, its price can drop by as much as 90 per cent. To maintain monopolies, the industry often makes small adjustments to existing medications in order to patent and market them as new. OxyContin was one such drug.
OxyContin dissolves slowly in the digestive system, titrating the oxycodone into the body. Instead of taking a conventional painkiller like Vicodin or Percocet every few hours, the manufacturers claimed a patient could take OxyContin once in the morning and once at night and experience long-lasting pain relief. The slower-acting nature of OxyContin justified the manufacture of pills that contained much higher quantities of oxycodone than had ever been available in a single dose: up to 80 milligrams at first; 160 milligrams a few years later.
‘It was the cleanest drug I’d ever met,’ the artist Nan Goldin wrote in a column for Artforum describing the addiction she developed to OxyContin after an operation. Goldin writes that she took 40 mg doses and was addicted ‘overnight’. She went from taking three pills a day to as many as 18 of them. Not everyone is partial to the feeling produced by morphine derivatives, but for the people who like it, OxyContin seems to represent an apex. ‘Oxycodone provides the most glowing and rapturous high I have experienced in my very thorough career as a recreational drug user,’ a report on the online drug encyclopedia Erowid begins. The writer, under the pseudonym RighteousDopeFiend, describes the aftermath of snorting an 80 mg OxyContin tablet:
The oxycodone experience is difficult to describe to an opiate virgin. Personally, I feel as if I have suddenly gained all that I want in life and no longer have anything to fear. I am perfectly content both mentally and emotionally. All the tension slips from my body and I feel warm and utterly comfortable, as if I were sitting beside a roaring fire, wrapped in a delicate cashmere blanket, rocking gently back and forth. Communication is pleasant but unnecessary. Under the influence of oxycodone, no companionship is needed. I accept myself and the world just as we are, not begrudgingly, but eagerly, ecstatically even.
Since OxyContin’s arrival on the US market in 1996, a widespread increase in opiate use in America has killed more than 400,000 people. Drug overdoses have been the leading cause of accidental death in the United States since 2008, when they surpassed deaths from road accidents. In 2017, more than 49,000 Americans died of opiate-related overdoses.
The epidemic has a narrative, divided into three waves of molecularly similar drugs: first, OxyContin and other prescription pills; then heroin; and now, especially since 2016, an opioid called fentanyl that is more potent in smaller quantities, and therefore easier to smuggle and also more likely to kill. There is also now an established genre of newspaper stories that tell of overflowing morgues in the Rust Belt, of parents overdosing at Little League baseball games, of once safe rural areas overtaken by criminal junkies, of open-air heroin markets in homeless encampments in major cities, of public librarians and Starbucks employees who have learned how to revive an overdosing patron with naloxone.
The horror of a video showing a toddler tugging at her mother’s unconscious form in a supermarket conveys more easily the horror of the corruption, avarice, poverty and stupidity that created the problem in the first place. How this happened – how the number of deaths from opiate overdoses increased by a factor of six in the US between 1999 and 2017 – is the subject of several recent books. Dopesick, by Beth Macy, describes the effects of opiate use in Appalachia, where she worked as a newspaper reporter. Dreamland, by Sam Quinones, describes the rise of a super-efficient network of dealers of Mexican black tar heroin in the US and its effects on one particular town in Ohio. American Overdose, by Chris McGreal, a correspondent for the Guardian, offers a more detailed view of the corruption that enabled the spread of opiates to go unchecked by the healthcare industry, government or law enforcement.
Each of these books devotes chapters to the history of OxyContin, a so-called blockbuster drug whose lamentable success was owed to a confluence of factors particular to the US. They include, but are not limited to: the country’s dysfunctional privatised healthcare system, which makes it possible for addicts to accumulate doctors willing to prescribe painkillers in a way they can’t in the UK; a corrupt regulatory agency beholden to the industry it was tasked with regulating; a punitive legal paradigm that criminalises drug users instead of helping them; an abstinence-only approach to treating drug addiction that impedes evidence-based medication-assisted treatment; corporate greed; a political class that takes marching orders from the lobbyists of said corporations; entrenched poverty, joblessness and hopelessness; and a general epistemological failure when it comes to ideas about what ‘drugs’ are, which psychoactive chemicals are safe and which are dangerous, and what a drug dealer is supposed to look like. These factors converged in such a way as to unleash hundreds of millions of potent pills out into the world in the late 1990s and 2000s, which in turn prepared a consumer market for heroin. Hundreds of thousands of lives have been lost, each one of them a world.
OxyContin arrived on the market at an auspicious time, when doctors were re-examining a taboo against prescribing opiates that had lasted for a hundred years. The first big wave of morphine addiction in the US was in the 1870s, after the drug was offered as treatment to veterans of the Civil War. Diacetylmorphine, also known as heroin, was first synthesised in 1874. It was stronger than morphine (which itself was much stronger than opium), but was initially thought to be less addictive. Doctors distributed heroin widely, including in cough drops and tonics, until a wave of doctor-caused addiction culminated in a ban in 1924. Heroin never went away completely, but its use was limited to small countercultural pockets, and deeply stigmatised. For decades, the heroin available in the US came mostly from Asia. Dealers adulterated it at each step of the supply chain, so when it reached users it wasn’t especially potent, reducing the potential for overdose. Macy writes that while as many as 20 per cent of the veterans of the Vietnam War returned to the US with symptoms of heroin dependence, the lack of availability meant that most did not end up as lifelong addicts. By 1990, heroin use was limited in large part to big cities. Doctors were very wary of addiction when prescribing morphine-derived painkillers, and mostly did so only for people with terminal illnesses.
That changed in the 1980s and 1990s, when the problem of untreated chronic pain began to be discussed in the medical profession. Some doctors argued for a holistic approach, but the insurance companies preferred pills (the most economical form of treatment), and physical therapy and other strategies soon fell out of favour. The American Pain Society trademarked a slogan describing pain as the ‘fifth vital sign’. But as Quinones points out: ‘In fact, pain was really not a vital sign … for unlike the four real vital signs it cannot be measured objectively and with exactitude.’ A scale was devised nonetheless, and pain assessment charts became part of doctors’ examinations.
Doctors also began to re-examine the stigma surrounding the use of opiate painkillers in anything other than cases of terminal illness. Three studies, none of them at all comprehensive, were used to bolster arguments for more access to the drugs. One was a paper published in 1986 which found that of 38 cancer patients treated with opiate painkillers only two developed an addiction, both of whom already had a history of drug use. But ‘the study was small,’ as McGreal writes, ‘and lacked the usual scientific rigour of control groups using alternative therapies or placebos.’ A second piece of evidence was a letter by two doctors, Jane Porter and Hershel Jick, which appeared in the New England Journal of Medicine in 1980. They said that of 11,882 patients at the Boston University Medical Centre treated with opiate painkillers, only four had become addicted. ‘All it offered was a snapshot of a particular set of patients in a hospital setting,’ McGreal continues. ‘That did not stop advocates of looser use of opioids from doing a quick calculation and pronouncing the Porter and Jick letter as evidence that less than one per cent of prescription narcotics users became addicted.’ The third pillar of research that would go on to justify the widespread prescription of opiate painkillers is perhaps the most ridiculous of them all. In 1989, a doctor named David Haddox developed a theory about opiates he called ‘pseudoaddiction’. The theory, which according to McGreal was based on the observation of a single cancer patient, said that if a patient was showing signs of tolerance and craving larger doses of an opiate painkiller, it wasn’t a sign that the patient was forming a drug habit, but rather that his pain was not being sufficiently treated. ‘An idea advanced that pain counteracted opiates’ euphoric effect and thus reduced the risk of addiction,’ Quinones writes. The American Pain Society, he continues, even promoted the idea that pain ‘acted against the tendency of opiates to stop the lungs from breathing’.
After OxyContin was approved by the FDA, Purdue spent millions of dollars to promote these theories. They convinced the FDA to allow the label included with the drug to claim, without any clinical evidence, that ‘delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of the drug.’ The FDA did not seem bothered by how easily the drug could be used by people who wanted to take OxyContin for pleasure instead of pain (the adulterants in previous iterations of oxycodone pills had made this less easy to do). The warning on the label that ‘taking broken, chewed or crushed OxyContin tablets could lead to the rapid release and absorption of a potentially toxic dose of oxycodone’ was a clear indication of how easily the time-release coating could be circumvented, and the agency appeared not to be aware that the drug could be crushed up, mixed with water and injected without much trouble. (Curtis Wright, the FDA examiner who approved Purdue’s drug application for OxyContin, began to work as a consultant for the company two years later.)
In the late 1990s, the government also lifted advertising restrictions on pharmaceuticals. The amount of money spent on drug ads increased from $360 million in 1995 to $1.3 billion in 1998. Following OxyContin’s approval by the FDA, Purdue launched an extensive marketing effort to convince family physicians that the drug was practically risk-free, and safe to prescribe for anything from back pain to carpal tunnel syndrome to migraine. The company purchased data that told it which physicians prescribed the most Vicodins or Percocets, and targeted them for sales. The campaign to win over doctors included dinners, gifts and sponsored conferences at tropical resorts. The company’s sales representatives gave doctors OxyContin-branded sunshades for their car windscreens, OxyContin bum bags, OxyContin mugs, water bottles, pens and a compilation of big-band music that encouraged doctors to ‘Swing in the right direction with OxyContin.’ (I recently browsed the ‘Pharmaceutical Collectibles’ section on eBay, where I found some OxyContin pens, a computer mouse advertising the antidepressant Zoloft, and a stuffed toy promoting the sleeping pill Ambien.) Purdue distributed thousands of copies of a video called ‘I got my life back: Patients in pain tell their story’ and coupons that gave a thirty-day supply of OxyContin for free. The video repeated the claim that the risk of addiction was less than one per cent, and included interviews with patients and a doctor named Alan Spanos who describes ‘pseudoaddiction’ as ‘relief-seeking behaviour mistaken as drug addiction’. (Fifteen years later, a newspaper tracked down the patients in the video and found that two had died from their opiate addictions and a third had lost her job and home before successfully quitting the drug.)
Purdue’s marketing campaign was very successful. By 2003, more than half of the prescribers of OxyContin were primary care doctors. In 1997, doctors wrote 670,000 prescriptions for OxyContin; by 2002 they were writing 6.2 million prescriptions per year. Quinones writes that in 1996 Purdue paid out $1 million in sales bonuses to its drug reps and $40 million to them five years later. Salespeople in the parts of the country where the first waves of addiction emerged were clearing $100,000 bonuses every quarter. ‘The bonuses to Purdue salespeople in these regions had little relation to those paid at most US drug companies,’ Quinones writes. ‘They bore instead a striking similarity to the kinds of profits made in the drug underworld.’
McGreal, Macy and Quinones all document the rise in the late 1990s of pill mills, where in some instances doctors dispensed as many as 200,000 prescriptions for painkillers over the course of a few years. Complicit with the doctors were pharmacies, drug distribution companies, sales representatives and, of course, Purdue itself, whose executives knew very well they were flooding the market with a highly addictive substance. Young people used to pilfering a Xanax from their parents’ medicine cabinet or sharing out an Adderall prescription at a party were now taking a much more dangerous drug. People who had occasionally taken a stray Percocet or Vicodin from a friend who had had her wisdom teeth taken out had no reason to suspect that OxyContin would affect them differently. A common theme in interviews in these books reveals how little scepticism there is towards pills – many people had no idea what they were taking until they were deep into their habit. A generation raised on televised ‘this is your brain on drugs’ propaganda and pop cultural depictions of addicts had no warning system in place for prescription drugs. It is common in the US for people who would never dabble in cocaine or LSD to take psychoactive pills without shame or suspicion.
Macy describes a woman whose doctor treats her for pain following gall bladder surgery with a 30-day prescription of 10 mg OxyContin, followed by another 30-day prescription of 40 mg Oxy, along with a supplemental prescription for Percocets for when the Oxys wore off and she experienced ‘breakthrough pain’. When the prescriptions ran out, the patient began experiencing the symptoms of withdrawal, and learned to visit emergency rooms feigning acute crises before eventually finding a more unscrupulous practitioner who would write her opiate prescriptions on a regular basis. People who thought they were being treated for pain assumed their withdrawal symptoms were pain, failing at first to recognise their own dope sickness. ‘One way to view all that had happened,’ Quinones writes, ‘was as some enormous social experiment to see how many Americans had the propensity for addiction.’
Doctors, public health officials, law enforcement officers, the parents of teenagers who overdosed, community activists and others who objected to OxyContin early on found themselves ignored. Macy writes about the efforts of Sue Cantrell, a Virginia public health officer who tried to warn state officials in the late 1990s, and Sister Beth Davies, an activist nun with a history of confronting the coal industry. She also writes about a rural health practitioner named Art Van Zee, who came to Appalachia in the 1970s because he wanted to work in a medically underserved community. Van Zee was also the subject of a book called Pain Killer (2003) by a New York Times reporter named Barry Meier, a book now recognised as one of the earliest documents of the epidemic.
Van Zee, who ran an early campaign to get OxyContin recalled, emerges as one of the most admirable people in this story of greed and corruption. ‘Tales of Van Zee’s dedication are as common in Virginia’s coalfields as the rusted-out coal tipples that blanket the bluffs,’ Macy writes. But when he testified before the FDA in 2002, his warnings, and his person (he wore a Jerry Garcia-themed tie), were dismissed. ‘A lot of people discounted Art as a rabble-rouser and a kook,’ a healthcare administrator tells Macy. Purdue funded groups of patients with chronic pain to lobby lawmakers for their right to treatment. The chemical illiteracy of the general public also helped propagate the myth that ‘legitimate pain patients’ are a different species from ‘drug abusers’.
By the early 2000s, the first lawsuits against Purdue were being filed. Some of them were wrongful death lawsuits brought by the families of people who had overdosed on OxyContin. Others were from within the company: a sales rep, for example, who claimed she was fired for refusing to sell to doctors she knew were overprescribing. For the first ten years of Oxy’s existence, Purdue successfully fended off all legal challenges, though the company did hire Rudy Giuliani to help with its image. It wasn’t until 2006 that a US attorney in Virginia successfully prosecuted Purdue executives for misbranding OxyContin as safer than the instant-release versions of the drug. Purdue paid a fine of $600 million.
Macy is the author of another book, Factory Man (2014), about the effects of globalisation, automation and the decline of coal in Virginia, which once had thriving textile and furniture industries. Dopesick could be read, in part, as a sequel to that book. ‘The federal disability programme was becoming a de facto safety net for the formerly employed,’ she writes, ‘a well-intentioned but ultimately disastrous way of incentivising poor people to stay sick with mental illness and chronic pain.’ In both the Ohio towns Quinones writes about, as well as the Appalachian towns described by Macy, pills became currency. Elderly people or those on disability who received government-funded health insurance through Medicare or Medicaid would get prescriptions for pain pills that were paid for by the government. At a going rate of $1 per milligram on the black market, thousands of dollars could be made from a 30-day OxyContin prescription. ‘Peddling pills was now the modern-day moonshining,’ Macy writes. In small towns where independent commerce had disappeared, addicts would shoplift goods from under the noses of unmotivated, underpaid Walmart employees and trade them for pills. Pill dealers would keep stores of stolen goods, where pills could buy everything from stolen televisions to nappies to laundry detergent – all at a discount. ‘Some large though immeasurable amount of the merchandise supporting addiction, as the opiates settled on heartland America, was mined from the aisles of Walmart, where Main Streets had gone to die,’ Quinones writes. ‘The opiate scourge might never have spread as quickly had these rural areas where it all started possessed a diversity of small retailers, whose owners had invested their lives in their stores, knew the addicts personally, and stood ready to defend against them.’
In 2010, Purdue introduced an ‘abuse deterrent’ to the drug which caused it to congeal when crushed, making snorting or injecting impossible. Conveniently, this also allowed Purdue to renew OxyContin’s patent, which was on the verge of expiring. (Through minor tweaks and reformulations, Purdue has re-patented OxyContin 13 times. Under its original patent the company would have lost exclusive rights to the drug in 2013. Now it maintains them until 2030.) It was in part the 2010 reformulation that provoked many users of OxyContin to try heroin and realise that it could also sate their cravings. By 2010 most of the pill mills had finally been shut down. Heroin was also significantly cheaper, especially for people who had built up tolerance to Oxy and required multiple pills a day to avoid the debilitating symptoms of withdrawal.
As the market for opiates expanded, heroin dealers stepped in to supplement the pharmaceutical supply. Of all the books available about the epidemic, Dreamland is by far the best account of how heroin dealers quickly came to understand the market opened up for them by prescription opiate painkillers. Quinones was a reporter for the LA Times when he first wrote about a network of heroin dealers who came from a small city in Mexico called Xalisco, in the state of Nayarit, where a sticky kind of heroin known as black tar is made from poppies that grow in the hills. The Xalisco boys, as Quinones calls them, were no Medellin cartel. They ran efficient, low-profile businesses, averse to violence and with a premium placed on customer service.
In the late 1990s, OxyContin helped them expand their market from California east across the Mississippi River, where dealers distributed free samples with their phone numbers outside methadone clinics, with the help of veteran addicts. The Xalisco network was comprised of a series of cells, each with an owner back in Mexico. The owner would hire a Mexican immigrant as a manager, who would run the business for him in Denver, Colorado, or Columbus, Ohio, or any one of more than a dozen other American cities. Quinones sets out how an informant first described the network to a police officer in Denver:
Beneath the cell manager is a telephone operator, the informant said. The operator stays in an apartment all day and takes calls. The calls come from addicts, ordering their dope. Under the operator are several drivers, paid a weekly wage and given housing and food. Their job is to drive the city with their mouths full of little uninflated balloons of black tar heroin, 25 or 30 at a time in one mouth. They look like chipmunks. They have a bottle of water at the ready so if police pull them over, they swig the water and swallow the balloons.
When a call came in, the dispatcher would send the driver, always a migrant worker from Xalisco, to meet the buyer. The cells kept regular business hours, 8 a.m. to 8 p.m. The drivers didn’t carry guns or use the product. They drove used sedans, and would only stay in a city for a few months before being switched out and sent home. They were encouraged to offer deals to loyal customers, such as a free bag on Sunday for someone who bought from Monday to Saturday. They would give freebies to addicts who talked seriously of going to rehab, and would welcome addicts home on their return. That the heroin epidemic initially hit African Americans much less hard than white Americans was in part because both doctors and the Xalisco boys were racist: doctors were less likely to prescribe painkillers to black people and the Xalisco boys didn’t sell heroin to them. The Xalisco dealers also avoided major cities, like New York and Baltimore, where gangs that sold heroin were already well established.
As good as Quinones’s book is, the world it describes is already dated. Around the time it was published another chemical, fentanyl, began killing heroin users in North America. Fentanyl does not require a poppy harvest to produce and it is far more potent than heroin, which means that it can be smuggled in small quantities. It is also far more dangerous, and its appearance in the drug supply has been accompanied by a sharp uptick in the rate of overdose. Among those being killed are older African Americans, whom researchers think might represent a population of veteran heroin addicts only now affected by the change in the drug supply.
The response to all of these deaths has been slow, but there has been some progress. The US ended a ban on federal funding for needle exchanges. The US and Canada have made naloxone, which can reverse an opiate overdose in an emergency, available without a prescription. The US federal government has allotted some funds to train doctors in medication-assisted treatment options. Other countries have tried to reduce deaths by distributing clean drugs to addicts. In seven European countries, including the UK, doctors are able to prescribe medical-grade heroin to treatment-resistant patients, offering them much greater stability and safety in the maintenance of their addictions. In Canada, where tens of thousands of people have died of fentanyl-related overdoses, the government has also begun trials which treat heroin addicts with heroin. To keep its addicts from buying drugs tainted with fentanyl, the city of Vancouver has begun an experiment with street vending machines that dispense limited doses of hydromorphone to pre-approved patients.
The US is not culturally prepared for solutions of this sort. In 2015, it took Mike Pence, then the governor of Indiana, two months to authorise a needle exchange programme to stop a growing HIV epidemic among intravenous drug users in his state. While more than a hundred people acquired the virus, Pence deliberated. He said he needed to ‘pray on it’. Among the general population the old biases are still intact: one study found that support for prescribing heroin to dependent users in the US was very low, although the numbers improved when the researchers called it ‘diamorphine’ instead of ‘heroin’.
Over the past several years, Purdue has become mired in lawsuits from states for its promotion of OxyContin. Some of the evidence has implicated the billionaires who own the company, the Sackler family, who have wings of museums named for them around the world. (In March, London’s National Portrait Gallery said that a planned £1 million donation from the Sackler family would not proceed; Tate, too, has said that it will no longer be accepting donations from the Sacklers.) The most prominent of these is a lawsuit filed in June 2018 by the state of Massachusetts that directly implicates eight members of the Sackler family, claiming that from 2007 to 2016 they were among those at Purdue who ‘engaged in a deadly and illegal scheme to deceive doctors and patients’, by encouraging sales reps to pitch OxyContin at higher doses even when its dangers were well known. During these years the family paid itself more than four billion dollars in profits.
The Centers for Disease Control tallied that more than 191 million opiate prescriptions were dispensed in 2017, a rate of 58.7 prescriptions for every hundred Americans (and the lowest rate in ten years). Purdue claims that only two per cent of opiate prescriptions written in the year ending in September 2018 were for OxyContin. According to a Reuters report, sales from OxyContin were $1.7 billion in 2017, down from $2.6 billion five years earlier. In mid-February, Nan Goldin led a protest at the Guggenheim in New York, showering its lobby with a deep, dense and white blizzard of fake prescriptions that quoted an email exchange between Robert Kaiko, the inventor of OxyContin, and Richard Sackler. ‘If OxyContin is uncontrolled, it is highly likely that it will eventually be abused,’ Kaiko wrote, with apparent concern. ‘How substantially would it improve our sales?’ Sackler replied. Purdue issued a statement describing the lawsuit as ‘part of a continuing effort to single out Purdue, blame it for the entire opioid crisis, and try the case in the court of public opinion rather than the justice system’. Even if the lawsuits succeed they have come too late.
In 2018, a subsidiary of Purdue filed a patent for a fast-acting version of buprenorphine, a variation on the opiate addiction treatment drug Suboxone. The FDA continues to approve new opiate painkillers. The most recent, late last year, was a drug called Dsuvia, a painkiller so potent its doses are measured in micrograms.