Opium’s murderous brood

My cousin come up from Knoxville

And taught me a thing or two

Now I’m headed nowhere but downhill

With the Oxycontin blues – Steve Earle

When Adam Smith published The Wealth of Nations in 1776, it was not only a primer in what later became known as political economy, but, as well, a hint to the historians. History was not centrally an epic of the doings of kings and warriors, in Adam’s p.o.v., but a progress (or regress) concerning the construction of our material life. Adam Smith’s book was a founding text for economics, but the historians took longer to wean themselves from writing fan-fact about all the great men. Even today, there are many more histories dedicated to the rise and fall of nations than to the rise and fall of trade routes; and histories that synthesize politics, material life, and the life of nations – that touch on massive changes in collective private lives as well as the rulers of nations – are rare.

If you look at standard histories of the 90s and the 00s – the Clinton and Bush eras – the concentration is on the great men, the impeachment, foreign policy, Katrina, while little or no time is devoted to the consequences of an little remarked event that occurred in December of 1995, when the FDA approved a drug created by a minor player in the Big Pharma landscape, Purdue Pharma. The name of the drug was Oxycontin. Its gimmick was that it provided time release of oxycodone, which, the company claimed, minimized addiction risk. The packaging of the drug aroused misgiving by some at the FDA. A memo was written about how easy it was to crush the tablets, which would allow the oxycodone to be liquified and injected. But Curtis Wright IV, Oxycontin’s advocate at the Agency, overrode these objections; Purdue did not have to tweak its drug. It did not have to ensure it against crushing or, as had happened before with other powerful painkillers, add naloxone as a narcotic blocker to prevent any spillover effect from the pills.

From that approval sprang billions of dollars for Purdue. Curtis Wright IV did all right, too – two years later, he landed a job with Purdue that paid him approximately  $379,000 per in salary and bonuses. Undoubtedly, some chronic pain sufferers were relieved. But it was the aleatory affect of the drug that is important: the wholesale debauching of the ethics of  thousands of doctors who fell for one of the most frenzied marketing campaigns in medical history; mass overprescription of painkillers on a scale never seen before; and an epidemic of addiction and overdose deaths that took us from 4.8 deaths per 100,000 people in 1994 to 19.8 in 2017. It is arguable that this is a more important part of the American story than Bill Clinton’s impeachment, or the intervention in Kosovo, or the budget fight of 1998, or hanging chads.

Three books by journalists have helpfully plotted the journey from 4.8 to 19.8: Barry Meier’s Pain Killer: An Empire of Deceit and The Origin of America’s Opioid Epidemic, which was published in 2003, with an expanded edition in 2018; Dreamland, The True Tale of America’s Opiate Epidemic, by Sam Quinones, 2015; and now Beth Macy’s Dopesick: Dealers, Doctors, and the Drug Company that Addicted America.

Having finished all three in an epic read, I’m here to tell you that the story they tell is a bummer, like a world historical bummer. Yet it is one you should know about, because it is almost certainly going to happen to someone you know. It might happen to you.

There are two starting places in the story, and for that, Meier’s and Quinone’s books are best. Quinones is the better writer, a natural storyteller with a novelist’s sense of setting and symbol. His book begins with a story that must have been hell to piece together: the astonishing rise of a new kind of heroin drug cartel based in the state of Xalisco in the state of Narayit, Mexico. Cartel brings to mind images of submachine guns, sybaritic luxury, and drugged dealers – so perhaps I should start again and call it the black heroin equivalent of Amazon or Pizza King. The Xalisco boys, as Quinones calls them, started a home delivery service in the United States precisely to avoid all the cartel and gang shoot em ups. They had a good quality product, black tar heroin, with a cheap price , and they had crews of delivery boys who would come around to your residence with limited amounts of the stuff. They’d put the heroin, which was molded into the shape of a little candybar in Xarisco, in small balloons, which they would keep in their mouths, making it easier to dispose of the evidence (swallowing it) if the cops pulled them over. The delivery boys were clean – basically, the same kind of rural kids, religious, outdoorsy, fans of Mexico’s version of country and western, that you’d find in any Midwest town playing football in highschool and driving pickups. The Xalisco crews flew under the radar of both the street mafias and of the cops. After starting out in California,  they increasingly picked virgin territories, where the violent kind of drug dealer didn’t exist. The Xalisco  boys were polite. They would call their clients to check on product quality. Good clients would get bonuses. When a customer complained, a  “manager” would hear him out, just like the guy at the complaint desk in Office Depot.  It was smuggling without anxieties. It was the New Economy model of drugdealing. Nobody had ever seen anything like it.

Slowly, it came to the attention of the police in mid-sized cities that they were seeing more and more heroin. It was happening in Pocatello, Idaho. It was happening in Santa Fe. It was not supposed to be happening there, but it was. And the Xalisco boys kept heading east.

Even with the advantages of their business model, however,  the market would never have been so good if their enterprise hadn’t overlapped with the Oxycontin fiasco.

Barry Meier’s book provides the most detailed account of the Sackler family, and their privately owned Purdue Pharma, which made Oxycontin. Like the obscure marketing geniuses in Xalisco, Arthur Sackler, the maverick entrepreneur who laid the foundation for the Sackler fortune, knew that the drug business was not just about healing and palliating pain. It was also about marketing and connections. In the fifties, Sackler went near the line, and sometime over, in the regulated environment of marketing medicines, with color page advertisements in medical journals, at that time unheard of, and sales pitches to doctors. Arthur Sackler died before the company developed Oxycontin. It was his older brother, Raymond, who presided, at the age of 80, at the great expansion of Purdue, in Arthur Sackler’s spirit. The story of that expansion is a sad x-ray of greed in the healthcare industry, a story of good intentions gone disastrously wrong. Purdue encouraged research that supposedly showed sufferers from pain – not just terminal cancer patients, but people with back pain or other chronic pain – could not become addicted to opioids. They infamously rode a one paragraph letter written to the Journal of New England Medicine in 1979, which seemed to downplay the addiction risk for patients with pain:

Of almost twelve thousand patients treated with opiates while in a hospital before 1979, and whose records were in the Boston database, only four had grown addicted. There was no data about how often, how long, or at what dose these patients were given opiates, nor the ailments the drugs treated. The paragraph simply cited the numbers and made no claim beyond that.

The Jinks and Porter letter, named for its authors, became a foundation stone for the claim that doctors didn’t have to worry about overprescribing Oxycontin. Rather, the problem was underprescribing. The scandal, Purdue marketers said, was that medicine had been ignoring pain under the Puritanical impression that pain patients were either malingering or had simply to deal with their affliction with stiff upper lips.

Under the aegis of this premise, which turned its back on one hundred years of medical practice, Oxycontin was off to a running start. The bonuses to salesmen and the perks to doctors didn’t hurt, either. Just as the Xalisco boys were basically country kids ethically debauched by the promise of wealth, so, too, were thousands of healthcare workers debauched by a marketing campaign that seem to promise a two-fer: a new way to treat pain and a plentiful flow of customers and money. Just as certain FDA officials had worried in 1995, the spillover use soon followed. Not only did patients themselves, often suffering from minor injuries or chronic pain that was formerly treated with physical therapy or milder painkillers, often find their drug craving outweighing first their jobs, then their loved ones, then every scruple and their reputations entirely, but even those who took the pills until they didn’t need them would have hundreds of extra pills to store in medicine cabinets that would soon “leak” to friends, to the kids, to the friends of kids, etc.

In this landscape of mega-nod, the black heroin from Xalisco made an explosive entrance.

What that landscape was like is shown by Beth Macy’s book. The story in Quinones and Meier straddles the nation, with concentration on certain exemplary spots: Philadelphia in Meier, Portsmouth, Ohio in Quinones. Macy’s story is mostly confined to her region of Virginia, extending from Roanoke, where she worked as a journalist, into West Virginia. The time frame is approximately the same: 1996 to 2017. The first half of Macy’s book tells the story of the intertwined factors that are devastating Appalachia: the decline in jobs that pay a living wage and provide symbolic status; the rise of disability as a substitute for an occupation; the flooding of the region with pain killers by Purdue; and the subsequent narcotic culture that proceeded to harvest not only the progeny of the coal miners but, as well, the kids who came from the minimansion set, the professionals. The second half of the book follows a number of families as they make herculean, bankrupting and mostly futile efforts to rescue their already addicted children and the children of their community. They get little help from the government, and none from Purdue Pharma either.

Macy’s book is more intimate than Meier’s or Quinone’s. And it breaks new ground by showing how inefficient abstinence-only treatment is, a 35 billion dollar recovery industry that is mostly, as one of her interviewees says, a sham. She advocates, here, for MAT – Medically Assisted Treatment. MAT has an ambiguous reputation, since it involves treating addicts with pills that still, often, contain opiates. For some, this is substituting one addiction for another. Macy is aware of that objection. As well, she is aware of the spillover effects from the benzodiazepines that are often used to treat addicts. Like methadone, the drugs can kill you; they can also end up on the street, sold for a recreational high. However, Macy clearly sees that drug addiction is physiologically based, in the chemistry of the brain, even as it is morally expressed, in the behavior of the addict. Both have to be engaged, but without using the evidence-based, physical instruments we have, our chance of treating drug addicts, of returning their lives to them (and the lives of people around them), are slim. Although our moral outrage at the drug companies may be great, we can’t satisfy that outrage at the expense of those people who are addicted. The moral tantrum as public policy is the specialty of politicians, but in the real world, it is we who pay the price.

“We” – I’ve used that word to signify myself and the reader, but this is an easy way to avoid who this “we” really is. Unlike the crack epidemic, or the heroin epidemic in the 70s and 80s, this “we” is predominantly white. The response to crack was the mass incarceration of African-Americans, and the mass shaming of the community. As many African-Americans have pointed out, now that the epidemic is mainly white, the angle on the story has changed to one of treatment and compassion. Macy is uncomfortably aware of this herself. Visiting a black man named Ronnie Jones who dealt in heroin in the communities near Roanoke, she checks her own prejudices and assumptions:

’We can’t arrest our way out of this problem,” I’d heard again and again, from everyone from police chiefs to public health providers. But that sentiment seemed to apply only to the mostly white group of opioid users who were dealing or committing property crimes to stave off dopesickness—not to people like Ronnie, in prison for armed heroin distribution, or to the majority of other black and brown people arrested for selling the drugs, even though they were statistically less likely to use or to deal.”

Macy’s account does not end on an upbeat note, even though her attitude commits her, rightly, to the belief that the human qualities of mercy and compassion will eventually find a way. All three books instinctively correlate the epidemic to the decline of manufacturing and the culture around manufacturing in America. Overdose deaths seem eerily coordinated with the death of manufacturing. In a sense, what we are seeing is the meeting of the industrial revolution, which, in the global system, has left us with an army of the unemployed and a  world wide pollution problem, with another powerful but less recognized revolution, dubbed the “psychoactive revolution” by the historian David

Courtwright in his 2001 book, Forces of Habit: drugs and the making of the modern world.  Courtwright shows how a number of basic substances that alter our waking consciousnesses (tobacco, alcohol, caffeine, coca, cannabis, opiates and sugar) were the drivers of the first world economy in the wake of the European discovery of the Americas. Indeed, it was the primitive capital derived from the trade in alcohol (which involved sugar), tobacco, tea, and coffee that provided the material basis upon which the industrial revolution, with its synthesis of technology and mass production, was able to flourish. These substances are now firmly entrenched in the world trade system, whether licitly or illicitly, where they are being joined by a variety of synthetic drugs. In the long run, it is probably the connection between the accidental consequences of these two revolutions that will dominate our politics in the next fifty years. The rise and fall of empires and the rise and fall of trade routes are two sides of the same coin.

Image of Beth Macy courtesy of Deadline Hollywood.