Opioid Crisis By Design

The opioid crisis was not accidental it was manufactured. Years of national debates on the nature of pain, drug company payoffs, and coverups have allowed the epidemic to grow, flourish, and evade serious long-term solutions. Instead, communities are being devastated by deaths that affect people of every age, race and gender. This destructive and unsustainable course stemmed from a seemingly positive idea: that being immune from pain was a human right.

In the 1950’s, president Dwight Eisenhower signed Social Security Disability Insurance into law, influenced by the many veterans of World War 2 who were suffering from injuries both mental and physical. In the following two decades, as fatal diseases disappeared and chronic illnesses became the norm, pain became less a fact of life and more an ailment to be treated. Medicare and Medicaid bore the brunt of this shift, as more and more people relied on the government to help ease their pain.

Then came President Ronald Reagan, who viewed the aforementioned government programs as wasteful and full of corruption. Keith Wailoo, the author of Pain: A Political History, wrote that “the pain of the fetus and the pain of the taxpayer mattered most; the addict’s pain was suspect, the housewife’s pain imagined, the disabled worker’s pain symptomatic of a weak society.” In other words, in an attempt to slim down the user rolls of these government programs, the Reagan administration imposed harsh standards to determine who was in “true” pain, resulting in millions of people having to find their own way to ease their suffering. The resulting vacuum was filled by pharmaceutical companies.

As more and more people turned to those companies to provide relief, newer and more potent drugs were being manufactured. The process was sped up during the administration of President Bill Clinton, who, as a candidate running for the presidency, had famously told an AIDS activist, “I feel your pain”. The activist had been complaining about years of government neglect under presidents Reagan and George H.W. Bush, the result of the harsh cuts to government programs. Clinton’s response exemplified the attitude of the era: pain was widespread, understood, and in need of a cure.

The mid-1990’s seemed to provide just that in the form of a pill called Oxycontin. The drug, produced by the pharmaceutical company Purdue Pharma, seemed to be the perfect response to the growing demand. It was marketed as a 12-hour relief pill, with powerful effects and immune to abuse and addiction, giving it an advantage over other pain pills at the time. Doctors had viewed pain pills as a last-resort solution for terminally-ill patients, fearing the addictive qualities of the medications. Purdue Pharma, not wanting their new (and expensive) product to be confined to this small market, invested heavily in advertising to reverse that view. They sent sales representatives directly to family doctors and general practitioners, advising them to recommend Oxycontin for common problems such as back aches and knee pain.

This was, in effect, the culmination of decades of shifting debates on the nature of pain. Though it had for so long been viewed as an unavoidable fact of life, the introduction of analgesia as a human right inspired millions of Americans to rely first on the government and then on pharmaceutical companies to fill their need. Drug companies did all they could to foster the adoption of this idea, funding the creation of groups such as the American Pain Society, which push to “increase the knowledge of pain and transform public policy and clinical practice to reduce pain-related suffering.” (In 2012, a ProPublica and the Washington Post investigation discovered that the APS received 90% of its funding from the drug and medical instrument industry).

If the Oxycontin pill seemed too good to be true, that’s because it was. During tests, the company found that the pill frequently only provided around 8 hours of relief, making it similar to other drugs on the market. Realizing that all of their sales hinged on the idea that the pills provided 12-hour relief, the company covered up those results. In seeking approval from the U.S. drug regulatory agency, the Food and Drug Administration, they submitted an outlier test that showed most of their patients experiencing 12-hour relief. Dr. Curtis Wright, who was director of the FDA’s Center for Drug Evaluation and Research at the time, and who led the effort to approve the drug, was hired by Purdue Pharma just two years later. He would not be the last agency official to walk through the “revolving door” between the government’s regulatory agencies and private business.

With the drug’s FDA approval, the company’s sales pitch was not questioned. Oxycontin soon flooded the market, dwarfing the competition. After just 5 years, the pill was generating over one billion dollars in revenue for the company. This was due to the successful marketing campaign, which encouraged doctors to prescribe the pills at increasing rates. Yet as the sales boomed, so did the complaints. Doctor after doctor reported that their patients were experiencing only 8 hours of relief, if not less.

At first, the company attempted to simply reassure doctors that the drug was working fine. When this didn’t work, however, the company began recommending that doctors increase the prescription for anyone who complained. Upping the prescription still did not guarantee longer relief, but it did mean that the company made more money. Revealed memos have exposed that the culture at Purdue encouraged selling more pills to generate more revenue, regardless of the effects on patients.

On the patient side of the equation, the picture was not rosy. People began to suffer withdrawals as the pain relief wore off, taking more pills to alleviate the pain. Now, the patient was dealing with both the pain of their ailment and the pain of withdrawal.

In addition, people soon began to discover that the pill could be crushed and snorted or melted and injected, producing effects similar to heroin. Purdue Pharma still refused to back down from their 12-hour relief assessment. They dismissed stories of addiction in hearings before the American Congress, with one executive saying “addiction is not common, addiction is rare in the pain patient who is properly managed.”

People began using the drug far more than prescribed, but because of the company’s insistence that the drug’s effects lasted for 12 hours, they could not refill their prescriptions before the allotted time. Thus, patients began to turn to pill mills pain clinics with rogue doctors and pharmacists who, for a fee, would write and fill prescriptions for desperate people. It was in these pill mills that the opioid epidemic flourished.

Opioid distributors, such as Cardinal Health, McKesson, and AmerisourceBergen, were in charge of getting the pills from Purdue Pharma and other manufacturers to these pain clinics. Although there were obvious signs that certain pain clinics had gone rogue (such as large and frequent shipments to clinics in very small communities), those signs were often ignored. For example, distributors shipped over 9 million hydrocodone pills over a two year period to a pharmacy in West Virginia located in a town of just 400 people, demonstrating that the opioid crisis is not limited to just Purdue Pharma and Oxycontin. It is an industry-wide phenomenon, stemming from the same industry-wide incentive to make money, whatever the human cost.

The only obstacle in the way of these companies has been the federal government, and its reputation has been mixed. In 2007, federal prosecutors got several top Purdue executives to plead guilty to advertising the drug “with the intent to defraud or mislead” doctors and the public. Among those officials was the man who had proclaimed that addiction “is not common.” The company paid over $600 million in fines.

Yet the crisis has ballooned since then, largely because of the government’s sporadic enforcement of the law. In 2008, the government hit drug distributors with million-dollar fines for ignoring blatant examples of pill abuse. Just a few years later, those same distributors used their money and influence to push back against the U.S. Justice Department’s Drug Enforcement Administration, the DEA, urging federal lawyers to take a different approach to their investigations. Beginning in 2013, top lawyers at the DEA demanded that their investigators provide more and more evidence of malpractice, even when the case seemed clear. Punishments for the distributors began to grind to a halt.

This was possible because of the revolving door between the government and these drug agencies. Since 2005, 42 DEA agents have been hired by pharmaceutical companies, mirroring Dr. Curtis Wright’s 1998 move from the DEA to Purdue Pharma. This revolving door has hurt government efforts to punish drug companies, because the newly-hired ex-agents often remain friendly “colleagues” with the very same agents who regulate these companies. Also, former agents are very aware of drug law loopholes, which their new employers then spend hundreds of millions of dollars to exploit. They pressure the government to ignore or widen these loopholes, such as in the so-called “Marino Law,” which makes it almost impossible for the DEA to freeze suspicious shipments of drugs. Congressman Marino’s chief of staff, William Tighe, went to work for the National Association of Chain Drug Stores only 7 months after the bill’s passage. (Menino himself almost became Donald Trump’s “drug czar” in combating the opioid crisis, but public backlash forced him to withdraw his application).

The opioid crisis was manufactured, fed, and promoted by pharmaceutical and distribution companies. Although we have concentrated heavily here on Purdue Pharma, they are far from the only company guilty of these misdeeds. The pharmaceutical industry has valued profits over health for years, willing to lie to doctors and patients alike in order to maintain their sales and their reputations.

15,000 people die of prescription pill overdoses each year.  As long as the revolving door keeps swinging, and these companies keep lobbying, that number will just keep growing.

David Fadul  (Well, The Netherlands)

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