American Overdose: The Opioid Tragedy in Three Acts

Recommendation: I was torn about whether to go with this or with Dopesick and I suspect either would work just fine. It is very good though

Read with: The “Swing in the right direction with Oxycontin” CD

Where to read: In the vicinity of one of those axe-throwing places cause you’re gunna need it

In brief: What the actual fuck Obama. What the actual fuck FDA. But also, who’s surprised really. And fuck Trump.

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American Overdose reflects and contributes to the current focus on the causes of the opioid epidemic, particularly Purdue Pharma and their conduct. To be honest, there’s not much in this narrative you couldn’t also find in late night shows (see John Oliver Parts I and II and Hassan Minhaj) however McGreal’s narrative, stripped of comedic asides and cathartic rants, is particularly stark.

Pain

For a start, and setting aside the risk of misuse and addiction, opioids are a terrible way of managing long term pain because a) you build a tolerance and require increasingly large doses (see the seven something seasons of House) and b) it may actually increase sensitivity to that pain in the long run.

But there is an argument for their use in limited circumstance, for terminal patients in palliative care for instance, and from the late 1970s and 80s onwards there was a push to allow more opioid use in end-of-life care. Of course, if the market is comprised entirely of patients in their last month of life, you’re probably not going to make a huge amount of money. The more patients you can get it to, the better off you’re going to be.

Percocet and Vicodin paved the way, as relatively low dose opioids mixed with acetaminophen (Panadol), marketed for cancer or short term post-operative pain. They were relatively hard to crush and inject and people with serious addictions tended to box their livers rather than overdose (though it happened). And the number of pain patients was increasing – by the late 1990s it had become accepted wisdom that around 100 million Americans suffered from chronic pain and 90-something% of opioid prescriptions were written for non-cancer pain.

Oxycontin launched in 1996 with a marketing budget north of $200 million. The sell was simple – with a slow-release capsule, the oxycodone would be released slowly over 8-12 hours so patients could take 2 pills a day and avoid the “high” straight after taking it. Without the “high”, or so the spin went, there was a very low risk of addiction or dependence.

By the early 2000s, the emphasis on pain reached it’s apotheosis with the recognition of pain as “the fifth vital sign” by the Joint Commission (which matters because Joint Commission accreditation is a prerequisite for Medicare participation for hospitals). Pain management became a key part of doctor evaluations and hospital lawyers were telling doctors to prescribe opioids for pain or risk law suits.

Addiction

The astounding thing about the opioid epidemic is that people are astounded.

For as long as opioids have been available, people have used them to deal with agonising pain and people have become addicted. America has been here before – morphine was the wonder-drug of late 1800s America, triggering a moral panic and legislative measures to curb its use. A century of attempts to find the perfect drug, relieving pain without addicting anyone, produced more and more opioid variants (morphine, oxycodone, hydrocodone, fentanyl etc). Some were supposed to be non-addictive, none were.

There is also precedent for drug pushers railroading government authorities trying to stop or mitigate opioid addiction. Perdue and Walgreens don’t have gunboats and redcoats like the British during the Opium Wars, but in the age of big-money politics and user-pays regulation, the regulatory capture of the FDA and the sway lobbyists held over politicians is hardly surprising.

And there are also plenty of examples of drugs becoming wildly popular among people they were not designed for – by the late 1970s, more than 2 billion Valium pills were sold every year, for off-label use (insomnia, vague depression etc) as well as on-label use (anxiety, acute alcohol withdrawal or convulsive disorders etc). Oxy became another example of pharmaceutical mission-creep, with patients sent home from minor surgery clutching bottles of pills and prescriptions lasting for months, to be used at home, without medical supervision. Or for chronic pain, in escalating doses month after month as patients’ tolerance increased, for years without any kind of management or reassessment. Sometimes this was by design, as in the pill-mills of Ohio and Kentucky, but sometimes it was because doctors bought into the idea that these things were safe.

A letter to the editor in the New England Journal of Medicine in 1980 reported that of 11,882 hospitalized people who were prescribed opioids, only four became addicted. Of course, Porter and Jick were observing patients who received opioids while in one hospital under supervision by doctors who were probably fairly suspicious of opioids. The point of the letter was probably to note the relatively low risk of giving opioids to people for, say, two days after surgery, but that was not the reception it got. By 2001, Time was referring to it as a “landmark study” and Purdue was using it as evidence for the extremely low danger of addiction, giving doctors comfort that they could prescribe the drugs their patients demanded.

If doctors started to feel queasy about their prescription practices, or started noticing the kinds of drug-seeking behaviours common in addicts, there was a new theory to explain that too – pseudo-addiction. Pseudo-addiction, or so went the story, occurred where the patient was experiencing such significant pain that they acted like a drug addict. They weren’t craving the drug, they were craving the pain relief, so the appropriate treatment really was more drugs (preferably more Oxycontin).

Overdose

It was difficult, possible but difficult, to OD on Vicodin. Overdosing on Oxy was much easier, partly because the doses were much higher and partly because the pills contained nothing but oxycodone – all you had to do was suck off the slow-release coating and crush it up. Addiction and overdose rates tracked up for prescription drugs and as public (and government) awareness of the scope of the epidemic increased, action was taken to reduce the availability of opioids. Street prices for oxy went up and addicts turned to cheap black tar heroin. Life expectancy in the US went down for the first time in decades and overdose overtook car accidents as the leading cause of accidental death in many states. The response from the Obama White House was deeply unimpressive.

Trying to differentiate their product (and cut costs in a competitive market), dealers started cutting their heroin with synthetics, notoriously fentanyl and later carfentanil. And this introduces a whole new risk – oxy pills were predictable, the dosage stamped on the pill, heroin was dangerous but still easier to judge but with fentanyl involved, the chance of receiving a comparatively low dose in one batch and an extremely high (over)dose in the next increased.

There’s an additional layer of tragedy as well – your risk of dying of an overdose goes up (albeit temporarily) after rehab. Parents mortgage their houses and spend their life savings trying to get their kids clean, the kids do the culturally entrenched and expected 30-day or 90-day rehab, come out and die from a dose they would have tolerated before detox.

Hypocrisy

The face of the opioid epidemic is young and white and from the “Heartland”. And people care, and include rehab in Obamacare and write books about it and create drug courts and talk about it as a health issue. No-one is increasing prison terms for users and no-one is ascribing it to racial weakness or talking coyly about “urban” depravity.

Purdue Pharma filed for bankruptcy at the end of 2019. The Sackler family are alleged to have taken between $12 billion to $13 billion in cash out of Purdue Pharma before the filing and are strenuously resisting attempts to target them personally.

Trump pretended to give a shit, declared a state of emergency and has done fuck all. If he manages to get rid of, or weaken, Obamacare and Medicare, the situation will get even worse as rehab becomes less and less available. He uses the crisis to justify racism and the ridiculous border wall but I’ll eat my hat if he takes any meaningful action to reign in the depredations of pharmaceutical companies.

Tldr, this was me at the end of this all