American Overdose: The Opioid Tragedy in Three Acts

by Chris McGreal

The ascendancy of prescription painkillers was driven, at first at least, by one drug, OxyContin—the most poweful narcotic painkiller ever released for routine prescribing.

It wasn’t the only opioid, but it was the game changer because of its strength and because the manufacturer, Purdue Pharma, unleashed a marketing campaign like no other to make it the go-to drug for pain treatment.

As grief gave way to anger, the families of the dead and the survivors wanted to know why opioids were so easily prescribed, and why doctors told them these pills were safe.

This book is an investigation of those questions and one in particular: How was the greatest drug epidemic in American history allowed to grow virtually unchecked for nearly two decades with no end in sight?

More in a single year than the total number of American soldiers killed in the entire Vietnam War.

The crude calculation is that opioids have claimed more than 400,000 American lives since 1999, although there are good reasons to believe the toll is higher because of underreporting and stigma. That’s equivalent to all the US military deaths in World War II.

More than half of those who overdosed and died were killed by...

The legal drugs then drove a second wave of heroin use and the rise of illicit synthetic opioids, principally fentanyl, which...

Overdoses are now the leading killer of people under the age of fifty, dragging down life expectancy in the United States, a phen...

A former head of the Food and Drug Administration has called America’s opioid epidemic “one of the greatest mistakes of modern medicine.” It is neither a mistake nor the kind of catastrophe born of some ghastly accident. It is a tragedy forged by the capture of medical policy by corporations and the failure of institutions in their duty to protect Americans.

The US consumes more than 80 percent of the world’s supply of oxycodone and hydrocodone, the two most commonly prescribed narcotics in the country.

At the peak, US physicians wrote more than 250 million opioid prescriptions a year.

As Congressman Harold “Hal” Rogers put it, “That’s enough painkillers to medicate every American adult ...

The Drug Enforcement Administration (DEA) classifies each drug according to how dangerous it is. Vicodin and similar hydrocodone pills were placed in a lower category than painkillers made from another opioid, oxycodone, even though there was little practical difference. That created a perception among some doctors that hydrocodone was more effective than over-the-counter medicines but safer than oxycodone and so a natural first stop for prescribing. The classification also allowed doctors to write scripts for a supply of up to six months and renew prescriptions by phone. Vicodin rapidly became the go-to painkiller for doctors alongside another hydrocodone pill, Lortab.

Within a decade Valium was the most prescribed drug in the country, as millions of people could apparently not get through the day without it. By 1978 it was selling more than 2 billion pills a year and was immortalized in the Rolling Stones song “Mother’s Little Helper.”

One Night cough syrup mixed morphine, cannabis, and alcohol. Mrs. Winslow’s Soothing Syrup used morphine to treat teething babies. With no restrictions on their sale and little guidance on dosages, Americans were left to take as much as they saw fit or craved.

“In your mind you think there’s something wrong here, but the addiction part of you tells you, ‘I don’t care. They’re giving it to me, and I have it now,’” he said.

The dosages kept rising until even what he could get on prescription was not enough. So he turned to the street.

PURDUE’S AGGRESSIVE SALES strategy grew out of the hurdles the company faced as it submitted its application for approval of OxyContin to the FDA back in December 1994. The company saw no great problem in getting permission to sell the drug. It was pretty similar to opioids already on the market, only stronger. The narcotic at its core, oxycodone, was known and approved for use in other painkillers, including Percocet.

Yet ultimately, Wright did approve OxyContin for wide use. He deemed it an appropriate remedy for moderate to severe pain—a departure from the FDA’s usual practice. Shortly afterward he left the FDA. Within two years he was working at Purdue.

Sales reps were instructed to tell physicians there was no need to try a lower-dose pill first; they could go straight to OxyContin because it was safer. The drug was pushed as “the opioid to start with” and the “opioid to stay with.” A drug for life. A perpetual payout for Purdue.

Purdue bought up the stats on where Vicodin, Percocet, and other instant-release opioids were dispensed and which doctors were the most common prescribers and pointed its sales reps in that direction. First they looked for the physicians prescribing the most opioids and worked on getting them to switch from Vicodin or Percocet to OxyContin. Then the reps put the squeeze on other physicians in the same area by suggesting they were letting their patients down by not prescribing narcotics at the same rate as their colleagues down the road.

this is crazy

For years, doctors have insisted that prescribing is not influenced by such practices, but studies show otherwise. Dr. Rajan Masih found that if he raised concerns about levels of prescribing or that a patient might be addicted, the Purdue rep had a ready answer. “That New England Journal of Medicine article saying that people don’t get addicted, if they have legitimate pain they won’t get addicted, that got handed out to everybody.”

Purdue’s marketing was far more successful than it predicted. The company had estimated it would earn $350 million from OxyContin in the first five years. The little opioid pill pulled in more than $2 billion in sales, accounting for 80 percent of Purdue’s revenue. The drug maker rushed to expand production.

OxyContin was different. It took a hold of people’s lives and turned them into thieves who stole from their families and neighbors to meet the cost of feeding an ever-demanding habit.

But once a high-potency drug like OxyContin that was easy to abuse become highly available, it changed recreational users to addicted individuals in a very short time,” said Van Zee.

The drug engulfed parents and their children. In the three years after OxyContin made its appearance, the number of Lee County children placed in foster care was up 300 percent. A survey of students in the county school system in 2000 found that 20 percent of twelfth graders and 9 percent of seventh graders had used OxyContin.

Overdoses were up. Hepatitis C, a sometimes fatal liver infection transmitted by needles, was escalating as more people sought the power and speed of the high from injecting.

At the core of Haddox’s defense of OxyContin was a variation on the National Rifle Association’s claim that guns don’t kill people; people kill people. It was not the drugs causing the addiction and overdoses but the users. The problem was the people, not the pills.

The way these people act and speak so irresponsibly makes me incredibly angry.

In reviewing Purdue’s sales materials, Van Zee noted a systematic effort to play down the risk of addiction.

“There are many many people that were thought leaders that are bright guys that could be good doctors, but they’re so tied to the industry in terms of shared interests, in terms of currying favor for funding for their career or their research, that they can’t be unbiased about things, and they would overlook or minimize the problems at the beginning of this opioid tragedy.”

This was disingenuous. It was undoubtedly true that people getting high on OxyContin would switch to other drugs if it weren’t available. After all, many of them came to it from other narcotics. But they were weaker and therefore less risky than OxyContin. Its strength was tipping people over the edge. It was only when OxyContin came on the scene that the death toll surged to the heights then being seen.

The sales force was telling doctors OxyContin was the drug to begin with and stay with. Purdue was desperate to make sure that prescribing of OxyContin was not limited to trained pain specialists. It was profiting hugely from wide prescribing by primary care doctors.

By the early 2000s, there was a growing body of evidence calling into question the claims made for opioids. A study in the Medical Letter on Drugs and Therapeutics concluded that OxyContin held no advantage either in effectiveness or in safety over other opioids. Other studies showed the risk of addiction was considerably higher than the claims being made for OxyContin.

It was to become a familiar argument. Opiates had been around for thousands of years. Their effectiveness was not in question. But that long history also presented compelling evidence of the addictive qualities of those same drugs. Haddox acknowledged there was a need to study opioid addiction but questioned whether it was the pharmaceutical industry’s duty to fund it, knowing well that if the drug companies didn’t, then it probably wouldn’t happen.

There was too much talk about the addicted and the overdosed as victims. The opioid evangelists and the narcotics manufacturers embraced a strategy to shift the attention to those they said were the real victims—the millions of people in chronic pain whose access to painkillers should not be impeded by the sins of others.

The strategy separated the addicted from the patient, when in many cases one was becoming the other. It kept the blame on the user, not the pill. Above all, it pushed aside questions about whether opioids worked as the drug makers claimed.

The epidemic sapped the energy and time of police departments and social services. West Virginia calculated it cost the public purse hundreds of millions of dollars a year.

Smith talked to the users. It became clear to him that many didn’t understand the power of opioids, particularly OxyContin, until it was too late. “I don’t know how many people I’ve spoken to who wouldn’t touch drugs for nothing and got injured and went to doctor and first thing doctor did was write oxycodone.

Overdose deaths in West Virginia had risen 550 percent since 2000 and even higher in Mingo and the surrounding counties. The state government estimated the crisis was costing it more than a half-billion dollars a year.

A patch of ground outside the Wellness clinic served as a dealing site. Many people could make more money trading in pills than working full-time. “We saw so many parents getting prescribed OxyContin, selling their prescriptions. Times was hard. It paid the rent. You get ninety OxyContin and could sell them for $100 a piece. That’s $9,000. Think about that. Some of them were drawing $650 a month in Social Security, and they can sell their prescription for $9,000,” Hannah said.

Ciccarelli noticed. He followed the money and saw that Henry Vinson and Diane Shafer were pouring substantial sums of money, presumably part of the profits from the clinics, into local politics.

“Shafer was the cash cow. She was where everybody went to get money to fund their campaigns. So she was a big player in town in a lot of different ways,” he said.

“Let’s call this whole thing what it is. It’s pretty much a cartel. It was a DTO, a drug trafficking organization,” said Sergeant Mike Smith. “Then right in the middle of this drug trafficking organization, you have a little pharmacy that pops up and everybody’s okay with it. I think that they needed another pharmacy because the other pharmacies couldn’t keep up with the amount of pills they were doing, and they needed to bring somebody in. I’m sitting here looking at this. It’s hard to believe that was allowed.”

Pain relief was supposed to free the patient, not imprison them. The Harvard specialist began recording her findings.

Purdue funded more than twenty thousand pain-related educational programs. Some doctors came to regard them as little more than a sales pitch for OxyContin.

the focus on pain caused patients to give it greater weight than made sense. “When you start asking people, ‘How much pain are you having?’ every time they come into the hospital, then people start thinking, ‘Well, maybe I shouldn’t be having this little ache I’ve been having. Maybe there’s something wrong.’ You’re medicalizing what’s a normal part of life. You’re looking for something when there may not be anything there.”

One consequence was that people with relatively minor pain were increasingly directed toward medicinal treatment, while consideration of safer and more effective alternatives were marginalized.

Chou said that chasing the lowest score on the pain chart often came at the expense of quality of life as opioid doses increased. “It’s better to have a little bit of pain and be functional than to have no pain and be completely unfunctional.”

Ballantyne wrote that there was evidence that putting some patients on serial prescriptions of strong opioids has the opposite of the intended effect. High doses not only build up a tolerance to the drug but cause increased sensitivity to pain. Opioids were actually making things worse while becoming less effective. The drugs were defeating themselves.