“The secret of change is to focus all of your energy not on fighting the old, but on building the new.” ― Socrates
I know that I am late with this post but I wanted to finish an excellent book that was recommended to me before writing this post. The truth is when I find the time to sit down and read, I don’t last long before I fall asleep. The book is called Dreamland by Sam Quinones and it was recommended to me by a friend. If you will recall, the last book that I discussed in this blog (Counterpoint – 9/10/2018) did not exactly agree with my understanding of addiction. I wanted to update my views on “who’s to blame?” because of some recent revelations about Purdue Pharma and this book discusses the origins of the current opiate crisis.
I don’t like scapegoating because things are rarely that simple. I don’t like massive lawsuits because I think that the money rarely goes where it belongs, rather it disappears into the pockets of attorneys and pet political projects. I do, however, believe that people/corporations need to be accountable for their actions and if they got rich by creating a crisis, they should be penalized by losing some/most/all of those fortunes. Given the lawsuit underway against Purdue Pharma, I wanted to get a better understanding of their role in the opiate crisis.
What did I learn from Dreamland?
This book gives a fascinating account of the origins of our current opiate crisis based on two parallel tracks. One is the change in the way that opiate pain relievers and pain in general were viewed. The second track involved the influx of black tar heroin from Mexico and the way it was “marketed”.
Pain and Opiates
I like simple stories, but life rarely works that way, and this is the case with opiates. Historically, doctors were afraid to prescribe opiates out of a fear of addiction. In 1980, a letter to the editor was published in the New England Journal of Medicine that became known by its author’s names as Porter and Jick. The letter was literally a paragraph and it said the data from one hospital revealed that less than one percent of patients that received opiates in the hospital became addicted. This was a small set of data and not of profound significance.
In the 1980s, there arose a distinct change in the way that we viewed pain. The World Health Organization (WHO) declared that all people had a right to be free from pain, primarily based on the suffering of terminal cancer patients. The field of pain management arose and pain became the fifth vital sign. In addition to pulse, blood pressure, temperature, and respiratory rate, patients were asked to rate their pain on a scale of 1 to 10.
By the late 1980s, some researchers had begun to conclude that opiates were not addictive if they were controlling pain and they cited Porter and Jick as evidence that less than 1% of patients would become addicted. The concept that opiates would function differently if you are in pain sounds ludicrous given what we now know about addiction but it was accepted as truth back then. Few if any of those citing Porter and Jick realized that this was not an extensive study of opiates and pain but rather a summary of the data from one hospital. Around the same time, insurance companies began to exert more control of doctor costs including mechanisms like HMOs. Doctors were getting squeezed by the need to see more patients in less time and the very time-consuming demands of chronic pain patients. The concept that opiates could be freely given to fight chronic pain was a Godsend to doctors but many remained skeptical.
The company now known as Purdue Pharma (Purdue), in its earlier iterations had developed a timed-release opiate called Oxycontin. Purdue’s owner had already revolutionized pharmaceutical sales by sending sales representatives out to aggressively lobby the use of their products. As competition increased, pharmaceutical companies began to sponsor seminars and other percs for doctors. Purdue saw the opportunity to market Oxycontin to doctors as a safe and easy (quick) means of dealing with chronic pain patients. Seizing the concepts mistakenly attributed to Porter and Jick and the claim that Oxycontin could not be abused because of the timed-release mechanism, Purdue began a very aggressive and lucrative marketing campaign.
Less than scrupulous entrepreneurs combined with less than ethical doctors created an explosion of pain clinics, some of whose sole purpose was to prescribe opiates to anyone that felt they needed them, pill mills. There was nothing wrong with prescribing opiates where needed but pill mills did not bother to diagnose the need. Pill mills made massive profits based on volume sales. People on public assistance or disability could get very large prescriptions of opiate pain relievers for very low cost. It was not uncommon for a person on public assistance that had become addicted to opiates to regularly obtain large prescriptions in order to use half and sell half to supplement their income. Some people would organize transportation and pay the copay for many people in that situation and they would receive half of the prescription so that they could sell it for huge profits.
In addition to illegally obtained prescription opiates, opiates were often found by curious adolescents in their parent’s medicine cabinets or prescribed for pain such as injuries or wisdom tooth removals.
The initiation of the explosion in the use of prescription opiates can be seen as a huge misunderstanding about the addictive nature of opiates driven to exorbitant proportions by the marketing of Purdue. Unethical medical practices on the part of pill mills used this somewhat innocent misunderstanding and created an addiction crisis of proportions that were never seen before. As this crisis grew, it must have been obvious to Purdue that they were selling far too many opiates but greed can blind us to what we do not want to see. The owners of Purdue and their families became billionaires..with a B.
That Purdue is in part responsible for the opiate crisis is in little doubt but to what degree is Purdue responsible is open to interpretation. My interpretation is that they are not the Satan that they are portrayed but they do not deserve to have profited so handsomely from business practices that became unethical and caused misery and death on such a large scale.
Black Tar Heroin from Mexico
Traditionally, illegal drug importation and sales in the USA are controlled by foreign cartels and large gangs. These groups flaunt their success and defend their territory with violence and murder. They are intentionally visible in order to scare off competition. The heroin that these groups sold was grown and refined in Asia or Columbia and was generally a white or tan powder. This heroin lost its potency every time it was cut/diluted as it passed through another middle man (stepped on).
In a poor area of Mexico where the economy was largely based on growing sugar cane, the local residents discovered that they had optimal growing conditions for opium poppies. Opium poppies are the raw material for producing opiates including heroin. With minimal processing, they could make black tar heroin, a name that was an accurate description. Being less refined, it wasn’t as potent as the Asian or Columbian heroin, but the Mexicans brought the black tar heroin to the USA and sold it directly. So, without middlemen the heroin was not stepped on and the product on the street was more potent than the white powdered heroin.
These black tar heroin producers kept a low profile, sold in less populated areas not controlled by cartels or gangs, targeted wealthier suburban buyers, and never carried much product or money on them. They even delivered the heroin like pizza to buyers who did not have to go to dangerous neighborhoods and the dealers were not conspicuously waiting on a street corner for a buyer to come to them.
Being inconspicuous, they were less of a target for law enforcement and if a delivery man did get arrested, it did not matter because there was a large pool of poor farm boys wanting to come up north to make money. These black tar heroin producers worked in small individual cells much as terrorists do, making it nearly impossible to eradicate them. Instead, the cells expanded across the country virtually everywhere except large cities. No one paid much attention to them or their black tar heroin until deaths by overdose began to climb dramatically in areas that had not previously had a major heroin problem.
Pill Mills and Black Tar Heroin Collide
I said earlier that Purdue claimed that Oxycontin was difficult to abuse because it was timed-release. But everyone, especially the dealers and the addicts, knew that all you had to do was crush the pills and snort them to defeat the timed-release mechanism. Being designed for a slow release, Oxycontin pills had high content of opiates in order to provide lasting relief. As doctors became more comfortable with opiates, they were willing to prescribe more potent pills. Eventually, it became obvious that prescription opiates were causing widespread problems with addiction and overdose.
Oxycontin and other opiate pain relievers such as Percocet generally cost about $1 per milligram of opiate on the street, so a 40 milligram pill costs about $40. Heroin on the other hand costs about $10 per hit. People addicted to opiates soon found that prescription opiates were harder to get in addition to being more costly.
Enter black tar heroin. Whether by design or by chance, the producers/sellers of black tar heroin found themselves following the spread of pill mills. As people addicted to prescription opiates were priced out of the market or their supply became unreliable, they rapidly turned to heroin. As I have said in prior posts, the move from prescription opiates to heroin is typically an economic decision.
Heroin has always been available in big cities from dangerous gangs and cartels, so it was typically an urban problem of limited scale. The producers/sellers of black tar heroin targeted wealthier suburban areas and made the transaction safe and easy. For this reason, the opiate epidemic is roughly ten times greater than the crack epidemic of the late 1990s and 2000s and it includes all races and economic sectors.
Who is to Blame?
So how has everything that I learned from Dreamland and the current revelations about Purdue changed my view of who is to blame?
- I think that in my previous post I may have been too easy on big pharmaceutical companies. Some companies got caught up in a misunderstanding about the dangers of opiates, but they were blinded by greed and ignored obvious signs. They are not the entirety of the problem, but some had a significant role and profited handsomely.
- Drug cartels are always going to be a problem, but the suppliers that caused this epidemic to grow to such large proportions were lots of relatively small-time producers with an incredible talent for giving their clients what they wanted. Of course they are responsible in some way, but as I said before if there was no demand, there would be no supply. They did exploit the situation and they expanded the market.
- The Government? Hell, they can’t even agree on how to tell what bathroom we should use. I believe that we must continue to try to stop the influx of illegal drugs, but we cannot fully succeed.
- As I said before, there are some bad physicians out there who overprescribe, run pill mills, but most doctors are conscientious and truly care about the well-being of their patients. Doctors were under a lot of pressure and they were misled about the risks associated with prescription opiates. But now that they know, a few doctors still over-prescribe. Shame on them.
- To my surprise, when I got to the end of Dreamland, the author said something very similar to my previous conclusion. I said “Our expectations of the health care system are too high. We want something outside of ourselves to “fix what ails us”, rather than putting forth the very heavy effort of working through it ourselves.” Sam Quinones says something very similar, except he places the origin on the over-protectiveness of our society and our desire to never be uncomfortable. I think that we are both right and that makes me feel like a cranky old guy, who walked 5 miles to school..in the snow..uphill both ways.
This post has been to some degree a short book report on Dreamland by Sam Quinones. I highly recommend this book, it was incredibly insightful, and it was fascinating to read. It is 362 pages long, so I clearly have left a lot of information out, but I tried to summarize the information that is relevant to this discussion. I hope that Mr. Quinones will forgive me. I think that I will reach out for his feedback on how I did.
Mr. Quinones is probably too busy to answer me, but I hope that you are not. Do you have thoughts to share? Please comment, let’s work together and help each other to solve this problem. r