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by
Beth Macy
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August 6 - August 25, 2023
Until then, 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.
Until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment.
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.
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.
The sun’s rays stuck out helter-skelter, like a country boy’s cowlick, as if it were running and winking at you all at once.
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.
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.’”
Below the story, on the same newspaper page, appeared an ad for an opium “sanitorium,” a sprawling Victorian home in Richmond in which Dr. H. L. Devine promised that he could cure opium addiction in ten days to three weeks.
But the yellowed newspaper warnings would become moot, like so many historical footnotes—destined to repeat themselves as soon...
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“I can remember telling my residents, ‘A patient can’t get hooked on fourteen days’ worth of [opioid] pills.’ And I was absolutely wrong.”
“I did it myself, though I knew it was not the right thing to do. It was pushed on us big time, the idea that they can’t become addicted if you’re using opioids to treat legitimate pain. The advent of the pain score, we now think, got patients used to the idea that zero pain was the goal, whereas now doctors focus more on function if the pain score is three or four.”
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.
“It is tempting to dismiss all concerns regarding therapeutic opioid use as irrelevant,” she wrote in a physician journal in 1996. “That would clearly be a mistake.” A colleague argued in the same paper that there simply wasn’t enough good data available to make a case for or against liberal opiate prescribing.
The first real dissent would come soon, though, in the unlikely form of a country doctor and one thoroughly pissed-off Catholic-nun-turned-drug counselor.
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.
For a chance to pitch their wonder drug, reps had long offered free dinners at fancy restaurants. But soon, to-go options abounded, too, for a busy doctor’s convenience. Reps began coming by before holidays to drop off a turkey or beef tenderloin that a doctor could take home to the family—even a Christmas tree. Driving home from the office, doctors were also invited to stop by the nearest gas station to get their tanks topped off—while listening to a drug rep’s pitch at the pump, a variation the reps nicknamed Gas ’n’ Go.
Purdue’s head of pain care sales signed his memos simply “King.”
She even accepted cartons of cigarettes emblazoned with a sticker for Celexa,
Huff was “deluged” with young-adult and middle-aged patients who’d been prescribed large amounts of OxyContin by his predecessors, concurrently with benzodiazepines such as Xanax, Klonopin, and Valium—“nerve pills,” as most in Appalachia call them. There was nothing in their charts to justify why they were getting so many prescriptions,
“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.
Within two years of the drug’s release, 24 percent of Lee High School juniors reported trying OxyContin, and so had 9 percent of the county’s seventh-graders.
In a place where people had once left keys in cars and didn’t bother locking their homes, a forty-one-year-old resident told the Globe reporter, he now kept a loaded gun inside the house. A quarter of his former high school classmates had developed addictions to Oxy.
When the researchers recommended that area doctors prescribe other, less abuse-prone drugs to patients with severe pain, a Purdue Pharma rep who’d been sitting incognito in the crowd rose to sharply challenge him. The problem was inadequate pain treatment, he insisted, not OxyContin’s abuse.
pills,” Van Zee said. Van Zee didn’t yet grasp what was truly driving the furious rate of overprescription. Sales-rep bonuses were growing exponentially, from $1 million in 1996, the year OxyContin hit the market, to $40 million in 2001. New patients were given OxyContin “starter coupons” for free prescriptions—redeemable for a thirty-day supply—
expenses paid. “The doctors started prostituting themselves for a few free trips to Florida,”
By the end of 2000, Purdue had passed out fifteen thousand copies of an OxyContin video called “I Got My Life Back: Patients in Pain Tell Their Story,” without submitting it to the FDA for review, as required by the agency. The video, available for checkout from doctors’ offices, lauded OxyContin’s effect on patients’ quality of life and minimized its risks. The doctor-narrator heralded the new term “pseudo addiction,” wherein opioid-seeking patients “look like a drug addict because they’re pursuing pain relief…[when in reality] it’s relief-seeking behavior mistaken as drug addiction.” He then
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A year after starring in the Purdue Pharma video, that same doctor, South Carolina pain specialist Dr. Alan Spanos, gave a lecture insisting that patients with chronic noncancer pain should be trusted to decide for themselves how many painkillers they could take without overdosing—just as the morphine-dispensing doctors had said of wounded Civil War veterans a century before. He reasoned that the patients would simply “go to sleep” before they stopped breathing.
While attempting to make a night deposit at the bank next door, the manager of Payless Supermarket in nearby Coeburn was gunned down by a masked robber trying to fund his next Oxy fix.
A half hour away in Clintwood, a man made the bold move of throwing a cement block through the front door of a pharmacy, even though it was across the street from the courthouse and the sheriff’s department. “A deputy heard the alarm go off, and here’s this guy running away and dropping pill bottles along the way, he’s so high,”
In small towns where residents were used to leaving their doors unlocked, patrol officers were suddenly seeing people pushing stolen lawnmowers, four-wheeler...
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A man in Dryden killed a young man attempting to break into his house to steal his wife’s prescription drugs, which he’d spotted above the kitchen-sink windowsill—
And as metal prices rose, Sheriff Parsons reported thieves stealing everything from copper cemetery vases to wires plucked from a telephone pole that addicted users had chopped down.
“There is literally not a family in this county that has not been impacted by this drug,” he told me in 2017, a statement I heard in every Appalachian county I visited.
The real victims, executives said time and again, were their “legitimate patients,” who would be denied OxyContin if its distribution were restricted.
It was now possible for a rep who called on indiscriminate prescribers to earn as much as $100,000 a quarter in bonus pay alone, the rep told me.
He’d already been the victim of two robbery attempts, including one by the son of a neighboring hair-salon owner who crawled in through the ceiling vents connecting the salon to Stewart’s store.
“pharming,” as the practice of passing random pills around in hats was known (ironically in farming communities).
It would fall, ultimately, to the parents of the dead to organize the first national response,
The first time Ed Bisch heard the word “OxyContin,” his son was dead from it.
