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Opioid and Heroin Addiction in the US: The Perfect Storm of Greed and Medical Malpractice

As a child, one of the many tasks we were given on a daily basis was to run to the local pharmacy to pick up Vicodin at the local pharmacy for my parents.   It was New Orleans in 1970s and we were nine, ten and fourteen-year-old children “running errands” for our parents.  The local pharmacist saw cute kids with a prescription in hand, written by a doctor who happened to be our father, for Vicodin.  What could be wrong with that?  Between running to the pharmacy for Vicodin and the supermarket for Dixie beer, our common errands throughout childhood, it was not until many years later, well into adulthood, that we realized that our parents were not only Vicodin addicts, partially the reason behind much of the abuse we suffered as children, but we discovered that our father was an Indian version of Gregory House.  And years later, watching the television show, House, depicting of a physician who harmed the self did not task in the least my suspension of disbelief.

Now, many years later, we are living in a collective hyper-real world where the addictions once cast as something of the past, secured behind the rhetoric of Nancy Reagan’s “Just Say No” campaign and specifically racialized images of the “crack addict,” are very much with us in the present. Just like the “abstinence-only sex education” programs did nothing to lower the rates of teen pregnancy, “saying no” to one form of drug only resulted in a saying yes to another, and a market being created just for those individuals who sought a “legitimate high.”  In today’s world, the reality is quite daunting when we scratch the surface to see how this form of opioid addiction was manufactured and not at all an oversight of governmental agencies.

On 7 May, 2016, former F.D.A Commissioner (1990-1997), David A. Kessler, elaborated the opioid epidemic in the United States at a time when the crisis was mounting, yet still under-reported.  In the New York Times, he writes:  “Beginning in the late 1990s, pharmaceutical companies selling high-dose opioids seized upon a notion, based on flimsy scientific evidence, that regardless of the length of treatment, patients would not become addicted to opioids. It has proved to be one of the biggest mistakes in modern medicine.”

Nayvin Gordon takes Kessler to task for these comments, stating:

We beg to differ. This was no mistake.   The reality is that physicians in the leadership of the F.D.A., A.M.A., and The Federation of State Medical Boards,   willfully abandoned their scientific integrity and over 150 years of wisdom regarding the dangers of opioids.   This was simply a catastrophic violation of their duty to “do no harm.”  In their complicity with the Pharmaceutical Companies, many physicians and nurses abandoned their responsibility to their patients by writing prescriptions for addiction. The consequences are now staring us in the face. Well over a hundred thousand people have overdosed and died, and there are now 3 million addicts as the epidemic continues to devastate families across the nation.

How did the F.D.A. so miserably neglect its duty of care while allowing pharmaceutical companies to dictate the policies that have led to the greatest numbers of opioid addicts in recent history?  We are living through a major health crisis where the facts are chilling:  since 1999 over two hundred thousand Americans have died from overdoses related to oxycodone and other prescription opioids; 37% of Americans know someone addicted to prescription opioids or painkillers; approximately one in four Americans know someone who has overdosed on these drugs; and roughly 1,000 people a week are dying in the U.S. as a result of drug overdoses.  And of those who are surviving, many are getting involved in drug-related crimes, losing their families, and some are amassing credit card debt.  And it has reached epic proportions where the crisis has hit communities so severely, that in Middleton, Ohio, for instance, politicians like Dan Picard are now advocating a “three-strike” policy where overdose victims, on the third call to 911, are left to die due to the economic toll on community resources.

This tragedy in American history is linked to the rise of oxycodone, a semi-synthetic opioid which is loosely related to morphine and based on certain elements of the opium poppy. Strong painkillers like oxycodone were traditionally used to ease  and end-of-life palliative care pain, but from the mid-1990s, pain killers based on oxycodone and a similar compound, hydrocodone, were being branded and aggressively marketed for chronic pain instead of uniquely for pain resulting from cancer.  This is where oxycodone became the “ground zero” for the current addiction crisis.  While there addiction crises historically in the U.S. with other drugs such as Valium in the 1960s and early 1970s, primarily among housewives who were being shut down medically from participating in civil society, the rise of oxycodone is unique in the way that this addiction was orchestrated by a wide range of marketing campaigns which set the rich terrain for long-time dependency and lifelong clients for big pharma.

And here is the tie-in as to how these addictions were choreographed through a vast marketing campaign which enlisted the help of medical practitioners.  Between 1996 and 2001, the American drug firm, Purdue Pharma, hosted more than 40 national “pain management symposia” at resorts around the United States, inviting thousands of doctors, nurses, and pharmacists to take part. It is well-documented how oxycodone (also written as Oxycontin) was marketed, creating a future army of medical practitioners who would advocate for this drug, despite the belief that such enticements to luxurious retreats would not alter the doctor’s prescription habits. The goal of these conferences was clear: to influence legions of doctors to over-prescribe pain medication, as noted in “The promotion and marketing of OxyContin: commercial triumph, public health tragedy”:

One of the cornerstones of Purdue’s marketing plan was the use of sophisticated marketing data to influence physicians’ prescribing. Drug companies compile prescriber profiles on individual physicians—detailing the prescribing patterns of physicians nationwide—in an effort to influence doctors’ prescribing habits. Through these profiles, a drug company can identify the highest and lowest prescribers of particular drugs in a single zip code, county, state, or the entire country.  One of the critical foundations of Purdue’s marketing plan for OxyContin was to target the physicians who were the highest prescribers for opioids across the country.  The resulting database would help identify physicians with large numbers of chronic-pain patients. Unfortunately, this same database would also identify which physicians were simply the most frequent prescribers of opioids and, in some cases, the least discriminate prescribers.

And if this were not aggressive enough, Purdue encouraged its sales reps to oversell oxycodone to such lengths that even beyond the average salary of $55,000 per sales rep, the annual bonuses ranged from approximately $15,000 to $240,000:

Purdue paid $40 million in sales incentive bonuses to its sales representatives that year.  From 1996 to 2000, Purdue increased its internal sales force from 318 sales representatives to 671, and its total physician call list from approximately 33 400 to 44 500 to approximately 70 500 to 94 000 physicians. Through the sales representatives, Purdue used a patient starter coupon program for OxyContin that provided patients with a free limited-time prescription for a 7- to 30-day supply. By 2001, when the program was ended, approximately 34 000 coupons had been redeemed nationally.

Prescriptions written for OxyContin in the US alone increased ten times from 1996 to 2002 with revenue rising from $670,000 a year to more than $6m. While Purdue had entirely elided the risks of addiction in its conferences over the years, in May 2007 the company was fined in more than $600m for misleading and defrauding the public. U.S. Attorney John Brownlee stated, “With its OxyContin, Purdue unleashed a highly abusable, addictive and potentially dangerous drug on an unsuspecting and unknowing public. For these misrepresentations and crimes, Purdue and its executives have been brought to justice.”  Still, Purdue was raking billions from high-strength opioids for years and this was a tiny economic hit for the company.

And who had the foresight from the 1990s to see how addictive these drugs were?  In 2014, Michelle Lofwall, Associate Professor in the Center on Drug and Alcohol Research at the University of Kentucky School of Medicine, told the Guardian, “At the time, it wasn’t understood how addicting these prescription pain medications were…But they really hurt people here and across the nation.”  And in the new millennium, addiction spread widely and quickly across the country as the distribution of pills moved from the hands of primary-care doctors’ offices and hospitals to street corners and “pain treatment centers” in places like Florida, which became known as “pill mills.”  In 2015 alone more than 250 clinics were shut down in Florida.

Florida, a place my own father spent his final years in retreat from his own addiction, was the the epicenter of addiction. Even the prescribed “therapy” to overcome substance abuse and opioid addiction was overstated. I remember going with my father once to his therapist’s office.  I brought a book, excited to read a piece of fiction for the first time in years.  His name was called, I sat back, found my first chapter with the title taking up half the page and I started reading.  I didn’t even get to finish that half-page when my father walked back out of his doctor’s office with a prescription for pain killers.  Indeed, like many others who found themselves in the clutches of medical intervention when seeking to leave its clutches, there is a familiar pattern with opioid addiction in the U.S. where as Robert Eaton also came to realize,“that the doctor wasn’t so much treating him as taking his money, writing a prescription, and getting him out of the door as fast as possible in order to get the next patient in.” In short, there is no economic incentive to stop this practice of addiction medicine.

These conferences training healthcare professionals to overprescribe oxycodone and the vast misuse overprescribing of this medication are just part of the problem.  All of this “misinformation” was engineered since the sales campaigns of OxyContin dictated that this medication should not be prescribed only for severe short-term pain that is often associated with recovery from surgery or cancer, but Purdue put emphasis on its sales campaigns that OxyContin should be prescribed for less acute and longer-lasting pain such as arthritis, back pain, fibromyalgia and any sort of minor injury. According to Patrick Radden Keefe’s research, he discovered that “[t]he number of conditions that OxyContin could treat seemed almost unlimited. According to internal documents, Purdue officials discovered that many doctors wrongly assumed that oxycodone was less potent than morphine—a misconception that the company exploited.”  This was a perfect storm where just the right amount of under or mis-information led to a medical culture of doctors operating outside the speciality of pain management were made to feel as if their mini-training in oxycodone would actually help, not harm, their patients.

Where pharmaceutical companies were allowed a bird eye’s view into how medical institutions and hierarchies functioned, Purdue set its sights not on the experts of pain management within the medical institutions across the country, but rather they honed in on the generalists who had little to no training in pain management.  In this way and according to Purdue’s 2002 budget outline, their aim was to “broaden” the use of OxyContin: “Future growth of OxyContin Tablets will be achieved through targeted efforts to penetrate: primary care, rheumatology, OB/GYN, surgical, oncology and sports/physical medicine/rehabilitation.”  The FDA labelled Purdue’s techniques as “aggressive marketing” with the U.S. General Accounting Office report stating that “OxyContin prescriptions, particularly those for noncancer pain, grew rapidly, and by 2003 nearly half of all OxyContin prescribers were primary care physicians.”  This mirrors very recent trends of medical practitioners who are not experts in a certain field, but who get quick “qualifications” in a certain area at the behest of pharmaceutical companies looking to extend their field of patients or more indirectly through lobby groups who are in turn heavily funded by big pharma.

While there is a modern opioid epidemic facing countries like the US and the UK, the solution to the problem of opioid addiction has only worsened the situation, creating a new market of addiction—heroin.  Where patients are prescribed strong opiates in response to an illness or accident, the opiates are eventually either not enough or the prescription comes to a sudden end due to a doctor’s intervention in shutting down future prescriptions or medical insurance fails to pay due to a limited coverage on opioid prescriptions and the refusal to cover alternative non-opioid treatments.  Dependent upon pain relief, these patients are forced to turn to heroin just to survive.  As the prescription and use of opioids surged from late 1990s through 2010, the numbers of people seeking addiction treatment and experiencing overdoses went through the ceiling.  The problem remains: how to treat such widespread addiction, especially when current “treatments” are merely creating newer addictions?

Places like Huntington, West Virginia are home to some of the highest rates of heroin addiction in the US. with one in four addicted to heroin in that town alone. In August, the city had twenty-seven heroin overdoses in the within four hours.  Yet, there are measured approaches to this crisis being undertaken by many in the field of care work are notable and stand out in respect to the severe countermeasures being invoked in Ohio. With the number of opioid overdoses in the U.S. now equal to gun deaths, it is important to understand the causes behind substance addictions as well as the businesses and industries invested in making a profit from human life.

In West Virginia, the rates of unemployment are a huge factor in this region’s opioid crisis. But the analysis must go much further, as we are seeing similar rates of addiction amongst demographics far wealthier than these West Virginians from the coal mining country. Indeed, this is perceived by many specialists as a primarily middle-class epidemic. But what if the roots might be much more deeply rooted in lack of community and capitalism?  What if it is not the amount of money one does not have, but rather the measure of human worth through money in a society largely disemboweled by virtual reality as a surrogate for the social, with the masses, rich and poor, largely driven down by debt which fuels some of the dependency we are currently witnessing?

Rather than take a measured approach, government officials instead pursued policies aimed at restricting access to prescription painkillers, criminalizing and arresting doctors and patients in the process. The continued rise in overdose deaths only indicates these approaches haven’t worked to curtail abuse or death from opioid use and misuse.

Instead, individuals who previously used pharmaceutical opioids have increasingly been pushed towards heroin use, with heroin use in the United States the highest its been in 20 years.  According to the Drug Policy Alliance, “Ninety-four percent of opioid-addicted individuals who switched from prescription opioids to heroin reported doing so because prescription opioids ‘were far more expensive and harder to obtain.’” Of course, for people who have switched from pharmaceuticals to heroin due to lack of access to legal pain medication, or those who abuse either pharmaceuticals or heroin for whatever reason, government policy has only made them less safe.

So over the past 18 months we have been fed headlines about “America’s heroin trail: A new generation of heroin addicts” with accompanying image of seedy bedroom with a man preparing his injection, the subtitle reads: “More Americans now die from drugs than from guns or in car accidents, and increasingly, reports Ian Pannell, the victims are young, white and middle class.” And the reality is that heroin is a cheaper option for those who suffer from opioid dependency. It is not, however, a solution to what has been an elaborately structured culture of addiction.

We need to demand that the F.D.A. hold pharmaceutical companies responsible for the proper education, testing, and marketing of their products. The F.D.A. also needs to look beyond these companies as big pharma knows how to throw off investigations. For instance, out of the patient advocacy organizations in the U.S. who participated in this survey, more than two-thirds indicated that they had received industry funding in the last financial year with 12 percent stating that the monies received was more than half of what they received from big pharma.  This means that the network of infiltration goes far beyond direct donations, sponsoring of doctors in luxurious resorts, bizarre online training that can be completed within an hour or two, and even the backdoor sponsorship of lobby groups.

While Trump gave the appearance of cracking down on this crisis through the sharing of his personal experiences of his own brother suffering due to this tragedy, there were virtually no measures taken.  The interim report that was delivered was in fact stalled from its original June delivery date to 31 July which means that the words of this administration do not correspond to its actions. With drug overdoses in the U.S. being the leading cause of death for Americans under the age of 50, it is no surprise that politicians and advocacy groups have urged Trump to declare the opioid crisis a “national emergency” for months.

If this had been declared a national emergency, this would have allowed the Secretary of Heath and Human Services to place affected persons on Medicare and to reduce the price of primary prescription medication to ease off the addictive medications in addition to providing countermeasures to protect patient privacy and reporting requirements. Instead, Trump did just the opposite.  He hedged on the language of this crisis and called it a “health emergency” which merely calls attention to the crisis while allowing no federal funds to be diverted towards helping those caught within this situation.

It is imperative that we hold big pharma and the U.S. government accountable for the bodies they have amassed while demanding a tighter regulation of opioids and more strict controls placed on pharmaceutical companies. Now!

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Julian Vigo is a scholar, film-maker and human rights consultant. Her latest book is Earthquake in Haiti: The Pornography of Poverty and the Politics of Development (2015). She can be reached at: julian.vigo@gmail.com

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