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Kindle Notes & Highlights
by
Beth Macy
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January 8 - February 7, 2023
A few interviewees died before I had time to transcribe my notes, including one by his own hand after relapsing and fearing that his wife—whom he loved more than anything in the world—would divorce him.
they hoped their children’s stories would illuminate the need for patients not only to become more discerning consumers of health care but also to employ a healthy skepticism the next time a pharmaceutical company announces its latest wonder drug.
I didn’t yet know that a single batch of heroin was about to land in Huntington, West Virginia, four hours west of Jones’s cell, that would halt the breathing of twenty-six people in a single day, before the week was out. Those overdoses were fueled by the latest synthetic opioid, carfentanil, imported from China with a stroke on a computer keyboard. Carfentanil is an elephant sedative one hundred times stronger than fentanyl, which is twenty-five to fifty times stronger than heroin.
For the fifth year in a row, the state of West Virginia’s indigent burial-assistance program was about to exhaust its funds from interring opioid-overdose victims.
Drug overdose had already taken the lives of 300,000 Americans over the past fifteen years, and experts now predicted that 300,000 more would die in only the next five. It is now the leading cause of death for Americans under the age of fifty, killing more people than guns or car accidents, at a rate higher than the HIV epidemic at its peak.
Working-class families who were traditionally dependent on jobs in high-risk industries to pay their bills—coal mining in southwest Virginia, steel milling in western Pennsylvania, logging in Maine—weren’t just the first to experience the epidemic of drug overdose; they also happened to live in politically unimportant places, hollows and towns and fishing villages where the treatment options were likely to be hours from home.
While more and more Americans die of drug overdose, it is impossible to not look back at the early days of what we now recognize as an epidemic and wonder what might have been done to slow or stop it.
Until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment.
The transition here, in the quiet town of Woodstock, was driven by the same twisted math I’d witnessed elsewhere, as many users began with prescriptions, then resorted to buying heroin from dealers and selling portions of their supply to fuel their next purchase. Because the most important thing for the morphine-hijacked brain is, always, not to experience the crushing physical and psychological pain of withdrawal: to avoid dopesickness at any cost.
I head northwest toward West Virginia, the crumbling landscape like so many of the distressed towns I’ve already traversed in Virginia some four hundred miles south, down to the same HILLARY FOR PRISON signs and the same Confederate flags waving presciently from their posts.
Though the opioid epidemic would go on to spare no segment of America, nowhere has it settled in and extracted as steep a toll as in the depressed former mill and mining communities of central Appalachia, where the desperate and jobless rip copper wire out of abandoned factories to resell on the black market and jimmy large-screen TVs through a Walmart garden-center fence crack to keep from “fiending for dope.”
In a region where few businesses dare to set up shop because it’s hard to find workers who can pass a drug test, young parents can die of heroin overdose one day, leaving their untended baby to succumb to dehydration and starvation three days later.
Nationwide, the difference in life expectancy between the poorest fifth of Americans by income and the richest fifth widened from 1980 to 2010 by thirteen years. For a long time, it was assumed that the core driver of this differential was access to health care and other protective benefits of relative wealth. But in Appalachia, those disparities are even starker, with overdose mortality rates 65 percent higher than in the rest of the nation. Clearly, the problem wasn’t just of some people dying sooner; it was of white Americans dying in their prime.
Whereas half the region lived in poverty in 1964 and hunger abounded, it now held national records for obesity, disability rates, and drug diversion, the practice of using and/or selling prescriptions for nonmedical purposes.
If fat was the new skinny, pills were becoming the new coal.
The pharmacist had read the FDA-approved package insert for OxyContin. Most pain pills lasted only four hours, but OxyContin was supposed to provide steady relief three times as long, giving people in serious pain the miracle of uninterrupted sleep. In an early concession to the potential for its abuse, the makers of OxyContin claimed the slow-release delivery mechanism would frustrate drug abusers chasing a euphoric rush.
Purdue Pharma touted the safety of its new opioid-delivery system everywhere its merchants went. “If you take the medicine like it is prescribed, the risk of addiction when taking an opioid is one-half of 1 percent,” said Dr. J. David Haddox, a pain specialist who became the company’s point man for the drug.
So when doctors departed from the homes of the injured Civil War veterans they were treating, it became standard practice to leave behind both morphine and hypodermic needles, with instructions to use as needed. An estimated hundred thousand veterans became addicted, many identifiable not by shirt smudges of orange and green but by the leather bags they carried, containing needles and morphine tablets, dangling from cords around their neck.
“Since the close of the war, men once wealthy, but impoverished by the rebellion, have taken to eating and drinking opium to drown their sorrows,” lamented an opium dealer in New York.
The almost total lack of regulatory oversight created a kind of Wild West for patent medicines, with morphine and opium pills available at the nearest drugstore counter, no prescription necessary. As long as a doctor initially OK’d the practice, even injected morphine was utterly accepted. Daily users were not socially stigmatized, because reliance on the drug was iatrogenic.
Late 1800s
I know persons who have been opium-eaters for some years who now daily consume enough of this poison in the form of morphine to kill a half dozen robust men not used to the poison. I have heard them, with tears in their eyes, say that they wished it had never been prescribed for them, and…many of them [have] inserted into the flesh frequently during each day, in spite of the painful abscesses it often causes, until in some instances the whole surface of the body seems to be tattooed. I have heard one exclaim with sorrow that there was no longer a place to put it. Whilst they know it is killing
...more
W.g. Rogers , richmond 1884
Diacetylmorphine—aka heroin—was more than twice as powerful as morphine, which was already ten times stronger than opium. At a time when pneumonia and tuberculosis were the leading causes of death and antibiotics didn’t yet exist, Dreser believed he had unearthed the recipe for an elixir that would suppress coughing as effectively as codeine, an opium derivative, but without codeine’s well-known addictive qualities.
If they could pitch heroin as a new and nonaddictive substitute for morphine, Dreser and Bayer would both strike it rich.
By 1899, Bayer was cranking out a ton of heroin a year and selling it in twenty-three countries. In the United States, cough drops and even baby-soothing syrups were laced with heroin, ballyhooed at a time when typical opioid consumers were by now not only war veterans but also middle-aged barbers and teachers, shopkeepers and housewives. Many were mostly functioning, doctor-approved users, able to hide their habits—as long as their supply remained steady, and as long as they didn’t overdo.
By 1900, more than 250,000 Americans were addicted to opium-derived painkillers.
Though a few researchers warned about possible addiction—“the toxic properties of the drug are not thoroughly known,” one noted in 1900—for eight years you could buy heroin at any American drugstore or by mail order.
The Harrison Narcotics Act of 1914 severely restricted the sale and possession of heroin and other narcotic drugs, and by 1924 the manufacture of heroin was outlawed, twenty-six years after Bayer’s pill came to market.
The addicted were now termed “junkies,” inner-city users who supported their habit by collecting and selling scrap metal.
The “respectable” upper- and middle-class opium and morphine addicts having died out, the remaining addicted were reclassified as criminals, not patients.
Think of the time in 1914, decades before the term “neonatal abstinence syndrome” was coined (to describe the withdrawal of a baby born drug-dependent), when a Washington official wrote that it was “almost unbelievable that anyone for the sake of a few dollars would concoct for infant use a pernicious mixture containing…morphine, codeine, opium, cannabis indica, and heroin, which are widely advertised and which are accompanied by the assertion that they ‘contain nothing injurious to the youngest babe.’”
Despite all the technical, medical, and political sophistication developed over the past century, despite the regulatory initiatives and the so-called War on Drugs, few people batted an eye in the late 1990s as a new wave of opioid addiction crept onto the prescription pads of America’s doctors, then morphed into an all-out epidemic of OxyContin’s chemical cousin: Heinrich Dreser’s drug.
The 1996 introduction of OxyContin coincided with the moment in medical history when doctors, hospitals, and accreditation boards were adopting the notion of pain as “the fifth vital sign,” developing new standards for pain assessment and treatment that gave pain equal status with blood pressure, heart rate, respiratory rate, and temperature.
The seismic shift toward thinking of patients as health care consumers was already under way, as patients now rated their health care experiences in formal surveys, Press Ganey the largest among them, and doctors and hospitals alike competed to see who could engender the highest scores, incentivizing nurses and doctors to treat pain liberally or risk losing reimbursements.
“Many health care workers still erroneously believe that adequate pain relief can leave patients addicted to the drugs.”
NYT, 2000
Quantifying pain made it easy to standardize procedures, but experts would later concede that it was objective only in appearance—transition labor and a stubbed toe could both measure as a ten, depending on a person’s tolerance.
“Every single physician I knew at the time was told to be much more serious about making pain a priority,” said Dr. John Burton, the head of emergency medicine for Carilion Clinic, the largest medical provider in western Virginia. “All it did was drive up our opioid prescribing without really understanding the consequences of what we were doing.
“I can remember telling my residents, ‘A patient can’t get hooked on fourteen days’ worth of [opioid] pills.’ And I was absolutely wrong.”
Compared with the New Zealand hospitals where Davis worked earlier in his career—often prescribing physical therapy, anti-inflammatories, biofeedback, or acupuncture as a first-line measure—American insurance companies in the age of managed care were more likely to cover opioid pills, which were not only cheaper but also considered a much quicker fix.
Little did Davis or the other ER docs understand that the routine practice of sending patients home with a two-week supply of oxycodone or hydrocodone would culminate by the year 2017 in a financial toll of $1 trillion as measured in lost productivity and increased health care, social services, education, and law enforcement costs.
Drug advertising ballooned from $360 million in 1995 to $1.3 billion in 1998, and nearly all pharmaceutical companies spent more plying doctors with freebies. At a time when there were scant industry or federal guidelines regulating the promotion of prescription drugs, the new sales strategies pushed the narrative of curing every ill with a pill and emboldened many patients to seek medicines unnecessarily.
Purdue handpicked the physicians who were most susceptible to their marketing, using information it bought from a data-mining network, IMS Health, to determine which doctors in which towns prescribed the most competing painkillers.
Diabolically evil
The practice became standard in rural Virginia towns like Big Stone Gap, Lebanon, and St. Charles—places that already claimed higher numbers, per capita, of dislocated workers and work-related disability claims. Now Purdue reps were navigating the winding roads and hilly towns in company-rented Ford Explorers, some pulling down annual bonuses of $70,000—the higher the milligrams a doctor prescribed, the larger the bonus.
Five years earlier, cancer doctors had been by far the biggest prescribers of long-acting opioids, but by 2000 the company’s positioning goals had been nailed, with family doctors now the largest single group of OxyContin prescribers.
Industrywide, pharmaceutical companies spent $4.04 billion in direct marketing to doctors in 2000, up 64 percent from 1996.
Internal documents referred to reps as royal crusaders and knights, and supervisors went by such nicknames as the Wizard of OxyContin, the Supreme Sovereign of Pain Management, and the Empress of Analgesia. Purdue’s head of pain care sales signed his memos simply “King.”
“We were impressionable young doctors, fresh meat with a lifetime of prescribing ahead, and they flocked to us,” he told me. “They took us golfing. It was standard to have a free lunch most days of the week because the drug companies were always buying, then you’d have a short educational seminar going on [about their drugs] while you ate.”
By the time he progressed to a family practice, Huff decided the free meals were wrong and said so repeatedly, making a show of retrieving his cold leftovers from home from the office fridge, he told me. When he set about trying to coax the other doctors in his practice to ban the lunches, they demurred, saying the staff would be so disappointed if we “took away their free meals,” Huff said.
“They were bubbly, they’d flirt a little bit, and it really would make you feel special. And yet intertwined in all those feelings is the name of a drug, which the rep is repeating over and over while you’re eating this delicious, savory meal. And even if you say you’re not swayed by such things, there is no doubt in my mind that you’re more than likely to prescribe it,” Huff added.
As one recovering addict in Lee County schooled me: “Around here, pairing an Oxy with a nerve pill—we call that the Cadillac high. If you’re gonna write this book, honey, you better learn the lingo.”
“People freaked out on me,” he recalled. They were sick and in withdrawal, some of them not yet understanding they were addicted. “Just about every day I was having to go in and face another ten people, and tell most of them, ‘I’m discontinuing your narcotics.’ It was really strenuous. It drained me,” he remembered. One period was so awful that he got in his car and drove to Mississippi to see his sister for a long weekend. Two patients had threatened his life that week.
