Revenge of the Tipping Point: Overstories, Superspreaders, and the Rise of Social Engineering

by Malcolm Gladwell

The launch of OxyContin—one of the most sophisticated and aggressive drug-marketing campaigns the world of medicine has ever seen—was targeted at states without triplicate laws. So, no big push in New York State. But yes to West Virginia. No to Illinois. But yes to Indiana. No to California. But yes to Nevada. No to Texas and Idaho. But yes to Oklahoma and Tennessee—with the result that the opioid epidemic did not hit the entire United States equally.

That simple bureaucratic intervention evolves into an overstory—a narrative that says opioids are different, spurring the physician to pause and think before prescribing them. And that overstory is so compelling that when Purdue tests its new painkiller in a triplicate state half a century later, it runs into a brick wall. Overstories matter. You can create them. They can spread. They are powerful. And they can endure for decades.

Economic growth has been stronger in triplicate states during the opioid crisis. The health outcomes of babies were better there. Neglect of children was lower. Workforce participation was higher.

OxyContin’s success didn’t ride on the backs of most American doctors, or even some American doctors. It was an epidemic driven by the tiny fraction of doctors in Deciles 8, 9, and 10—roughly 2,500 doctors who among them wrote a staggering number of prescriptions.

superspreaders are profoundly different from the rest of us: There is something inherent in their physiology that makes them capable of producing orders of magnitude more virus than everyone else. The same was true of their superspreaders, Purdue discovered: They weren’t wired like most doctors.

The assumption was that the group proportions of the opioid crisis were relatively fixed, meaning that if you cracked down on one class of user then the overall size of the problem would shrink. But that turned out to be terribly wrong. The group proportions weren’t fixed at all.

epidemics are acutely sensitive to shifts in group proportions.

As strange as it is to say this, if you must have an opioid epidemic, these are the group proportions you want: You want the majority of users to be dependent on prescription drugs.

Against all expectations, prescription-drug users who couldn’t crush up their OxyContin pills simply switched to heroin and fentanyl.

The opioid problem is now so bad that the early days of the epidemic—when it was all just OxyContin—look positively bucolic by comparison. We would have been better off had we said no to Purdue’s reformulation in 2010 and kept things the way they were.

we were slowly winning the war on opioids. But we never really had an honest conversation about how epidemics work. So along came OxyContin OP, and everything went sideways.