By now, we’ve all heard the story.
In 1995, Purdue Pharma came out with a new drug: OxyContin. A high-powered, long-lasting painkiller, the drug was almost miraculous – suddenly people who’d suffered for years with chronic pain could live a life without suffering. The Sackler family, who owned the company, had an amazing blockbuster of a drug on their hands. In the years since, the family has taken in more than $35 Billion in revenues off the sale of it.
The problem, of course, is that the drug was also highly addictive.
In 2007, Purdue was sentenced to pay $634.5 million in fines, one of the largest fines ever levied against a pharmaceutical firm, for claiming the drug was less addictive and less subject to abuse than other pain medications. But, far from being the end of the saga, within a few years, the undeterred Sackler family just revamped their marketing of the drug to physicians, spending $121.6 million on sales reps in 2010, and paying themselves $335 million that year alone.
If only opioids had never been made so freely available, goes the story we’ve all heard, millions of Americans never would have gotten hooked on them. How could we ever have allowed opioids to be sold so freely like this?
In recent years, Joe Rannazzisi, the former head of the Office of Diversion Control for the Drug Enforcement Administration, has spoken out about the federal government’s failure to stop companies like Purdue from selling so many of these pills. “There were just too many bad practitioners,” he says. “Too many bad pharmacies, and too many bad wholesalers and distributors.” The government could have stepped in and stopped the pills from coming to market in such massive quantities, he says. But they didn’t. And now we have millions of people hooked on opioids and living drastically diminished lives as a result.
But what if this is only half the story?
Sure, there never should have been so many opioid pills prescribed in the first place, but, once they were, there’s no reason that so many of the people who became hooked on opioids as a result should have had their whole lives burn down around them. The ugliest parts of the “epidemic” came later.
To grasp the whole story, you’ve got to understand this graph:
OxyContin is contained in the purple line – it hits the market in 1996, and its use and the coinciding rate of fatal overdose rise steadily until the big lawsuits in 2007, which lead to regulatory controls that slow down its availability. By 2010, overdoses from it largely level out.
So, problem solved?
Hardly. A lot of what’s actually happening here is that, over the last decade, many doctors have become increasingly reluctant to prescribe opioids. Much of that is good, but some of it has led to people who’d been prescribed opioids for years losing their prescriptions as doctors have become more and more constrained, with 33 states enacting legislation and the federal Center for Disease Control stipulating official opioid prescription guidelines in 2016.
Although the CDC has now issued subsequent statements clarifying that patients should not actually be cut off immediately, These announcements came as “too little too late,” said Gary Jay, MD, of the University of North Carolina in Chapel Hill. In effect, Jay said, the guidelines have left many high-impact chronic pain patients, who commonly have difficulty accomplishing work and self-care activities, “essentially function-less.”
In addition, when an opioid-dependent brain is first cut off from the drug, the person goes into withdrawal. Their muscles cramp and burn. They vomit and have diarrhea. They sweat. Their heart races. They can’t sleep. Its awful. After the worst of it subsides, which can take a few weeks, the body then experiences Post-Acute Withdrawal Syndrome. As the chemicals in the brain readjust to equilibrium, the person can experience rapid mood swings, exhaustion, insomnia, difficulty focusing – often for two years or more.
People don’t experience these symptoms because they’re bad people. It’s a biochemical thing. The symptoms are involuntary. The question is how they live with them.
As painful as the symptoms of opioid withdrawal can be, there are some people who transition off the drugs without too much difficulty. But a lot don’t. In fact, it’s not uncommon for people who’ve been using opioids for a while and stop abruptly to be in so much pain that they commit suicide. Here’s a list, compiled by Thomas Kline, PhD, MD, of 41 such people.
Many others, looking to reduce their pain and treat their withdrawal symptoms, turn to the street in search of drugs that can take the place of the legal opioids that they no longer have access to. Those illegal substitute street drugs take two main forms: heroin (the orange line in the graph), from the war-torn fields of Afghanistan, and fentanyl (the blue line), largely from unregulated laboratories in China.
Heroin came first. Afghanistan has long been the world’s leading producer of heroin, but in 2000, in the face of a massive drought, the Taliban banned opium poppy cultivation, shrinking it by 94%. The US invaded the following year, following the terrorist attacks of September 11, and, in the carnage and chaos created by the occupation, opium production quickly came back to life. From 180 tons in 2001, Afghanistan’s opium production grew to more than 3,000 tons a year after the invasion, up to more than 8,000 by 2007, to more than 9,000 in 2017.
At the same time, in 2008, just as heroin was flooding into the US from Afghanistan, a Japanese computer programmer operating under the pseudonym Satoshi released a paper describing an idea for a new digital currency called Bitcoin. Coded in a way that made financial transactions difficult to trace, Bitcoin quickly became the backbone of a new illegal digital economy, and in 2011, the website Silk Road launched. Accessible only through a special, anonymous browser called Tor that had been developed by the US Government, Silk Road offered users a way to buy illegal goods using Bitcoin from around the world without ever leaving a paper trail.
Although Silk Road was shut down in 2013 by the FBI, the dark web is still alive and well. According to the State Department, China has between 160,000 and 400,000 chemical companies operating legally, illegally or somewhere in between – many of which are happy to manufacture illegal drugs, like fentanyl, a synthetic opioid much more powerful than OxyContin, and the dark web offers them a powerful, secure way to sell those drugs to American consumers.
This sort of fentanyl has become one of the most popular drugs in Maine today. Whereas a heroin dealer usually needs to be connected, however tenuously, to a global drug cartel in order to remain supplied, any tech-savvy 12 year old with a bitcoin account, a computer and a secure place to receive mail can order as much fentanyl as they can afford, right from the privacy of their own home. That’s how, a few months ago, a few hooligans in Waterville were found with enough fentanyl to kill 15,000 people – they aren’t Lex Luthor; the stuff’s just really powerful and really easy to get.
As I see it, as evil as the Sacklers are, the only thing worse than getting so many people hooked on opioids, in the first place, was abruptly cutting them off of it, plunging them into the misery of withdrawal, with nowhere to turn for help but the street. With street drugs, it’s impossible to know for sure how strong they are – there’s no scientifically measured “ACTIVE INGREDIENT” label on the side of a plastic bag of white powder that you buy in a parking lot. You just take your chances. And, a lot of the time, you might die.
To me, that’s the bigger failing.
Patients never should have been cut off like that.
Chemical dependency, as rough as it is, need not be a death sentence. If offered good support and resources, more people could have made it out alive, recovered and ultimately thrived. If only the medical establishment had possessed the courage and humility to turn to their patients and just say, we made a mistake. Your brain is now chemically dependent on these pills. What do you want to do?
Many patients, once told about the dangers of opioids, likely would have wanted help getting off. Had cannabis been freely available, plenty might have chosen that as an alternative. Some might have chosen to be on a “maintenance” medication, like Suboxone or Methadone, at least temporarily, while they got their lives back on track. Other people with chronic pain might have done fine with just over the counter pain medication but still could have used a physician’s help to make the transition off of opioids safely.
A lot of people who actively seek opioids also have other challenges they’re wrestling with, like mental illness, chronic physical health problems, unprocessed trauma, addictive tendencies, the list goes on. Many are socially isolated, lonely and sad. Some have criminal records. If we actually want to help such people stay sober, we can’t just take the drugs away – we actually need to be serious about helping them overcome these challenges and live good lives despite them.
Some people, if given the choice, might decide to stay on drugs like OxyContin, despite the risks. I believe strongly that, especially in light of what occurred when so many people were cut off of it, patients should have the right to make that call for themselves. Not everybody is able to or even wants to start their life over drug-free.
Whatever path they choose, if patients are allowed to make their own decisions, nobody would ever get cut off abruptly. As I see it, there are lots of situations where a doctor might prescribe an opioid; zero where the right course of action is to take an opioid-dependent person and suddenly cut them off entirely. That can kill people. Few patients would choose to go through that if they were in the driver’s seat.
But instead of approaching the people suffering with respect, much of our society moralized the whole thing as being about either evil hedonistic pill poppers or evil physicians in the pocket of big pharma. Instead of helping our country recover from the over-prescription crisis, too many of our leaders just threw their collective hands up, cut the cord and walked away, leaving people with intense chemical dependencies to fend for themselves with almost no healthy way available to do so.
In the decades since the initial over-prescription crisis, we’ve seen some significant efforts at accountability. Purdue Pharma, the Sackler family company that originally manufactured OxyContin, has now filed for Chapter 11 bankruptcy. There’s currently a massively complicated federal court case being adjudicated in Ohio that brings together more than 2,500 cities, counties, tribal authorities and individuals from across the US as plaintiffs against a number of huge pharmaceutical manufacturers and distributors. By the time its settled, the companies will likely be liable for tens of billions of dollars in damages.
I support that. God knows, those companies are greedy, and our public institutions need that money if we’re going to stand a chance at adequately funding recovery services.
But we also need to accept the harsh reality that we now live in a country where millions of Americans are chemically dependent on opioids, and, however we got here, simply taking away the drugs won’t magically make those people’s lives better. A lot of the time, doing so will just make their lives more painful. If we’re going to recover from this crisis, we need to foster a culture that is prepared to genuinely listen to people using opioids and stick with them through their struggles. These problems don’t go away overnight.