The Sunday San Diego Union-Tribune on Dec. 18, 2016, carried two stories related to opioid overdoses.
One was from the Associated Press, headlined "DRUG OVERDOSE DEATHS UP 33% NATIONWIDE." According to the CDC, 30 states saw heroin and opioid overdose deaths increase and four had death rates jump more than 100%.
The second story was reprinted from The Washington Post with the title "STOCKING UP ON OVERDOSE KITS." The fentanyl crisis was so bad in Canada, according to the Post, that funeral homes were now keeping kits on hand. Apparently there was some risk of absorption by embalmers or police officers so the kits would be there for them. They might also come in handy "in case a grieving funeral attendee overdoses during services."
These articles brought to mind Sam Quinones' detailed and terrifying non-fiction book published in 2015, Dreamland, The True Tale of America's Opiate Epidemic.
Quinones lives in Southern California and started his investigation of drug abuse over five years ending in 2014 as a reporter for the Los Angeles Times. He points out that "abuse of prescription painkillers was behind 488,000 emergency room visits in 2011, almost triple the number of seven years before. Overdose deaths involving opiates rose from ten a day in 1999 to one every half hour by 2012."
The story of the black tar heroin epidemic across the United States that began in the 1980s parallels the sweeping prescription opiate epidemic in America because the lined-up clientele was the same group. And the product, whether natural like heroin or manufactured like Purdue opiate pill, is the very same companion to all those Americans who wanted Better Living Through Chemistry. But heroin was cheaper, Quinones observed, and the opiate prescriptions had already "tenderized" those who would want heroin.
It's a long, frightening story, moving backwards and forwards from how a small group of heroin growers in the villages of Xalisco on the west coast of Nayarit in Mexico started their business with family members and became successful in America by selling and delivering heroin like pizza to how Big Pharm discovered erroneous data to suggest that addicting narcotics were not really addicting whereupon manufacturer Purdue manipulated the data further.
The book is painstakingly, carefully, and accurately written. It is fascinating. And it is horrifying. It also requires some understanding because Quinones wrote two books at the same time: how easily the poppy grew in the high altitudes of coastal Nayarit, where rural Mexicans chose low-key family members to develop a heroin supply service for Americans, and how this all tied in with what some physicians thought should become a more generous and kindly professional pain relief package, even one that finally showed it was a mistake.
Agriculture is a hard life. Mexican heroin drivers "found selling heroin was just easier than growing sugar cane; it was more adventurous, and involved more cash." An equally easy job for some doctors was starting program pain relief programs. Quinones quotes Andrew Kolodny, MD, an addiction specialist critical of the new opiate prescribing, as saying, "You now have an industry of pain specialists and this is their business model. They have a practice of patients who'll never miss an appointment and who pay in cash."
Quinones spoke to Nathaniel Katz, a pain specialist in Boston, who said his Harvard Medical School instructors told him people can't become addicted because pain absorbs the euphoria. "It was all rubbish, we all know now," he told Quinones. "We wanted [it] to be true."
The Jick Letter
In 1980 the NEJM published a short letter to the editor from Hershel Jick, MD, a Boston University School of Medicine database physician, with his comment that patients in severe pain and under close observation had not become addicted to the given narcotic opiate.
Jick is still around, perplexed as to how or why colleagues turned his simple unsubstantiated brief paragraph into what became a "clear study" when physicians from Harvard and Johns Hopkins wrote a pain monograph later for the NIH. Scientific American called it "an extensive study." The Institute for Clinical Systems Improvement described it as a "landmark report."
It was a single paragraph.
Asked why doctors believed the Jick letter, Katz told Quinones: "The paragraph gives you relief from your inner conflict. It's like drinking from the breast. All of a sudden the comfort washes over you."
The Mexican black tar heroin epidemic was a somewhat similar story to the OxyContin plague because the two forms of narcotic had comparable effects and were obtained by persons of similar personalities. Drug abusers were everywhere and ready for academic medicine's grievous errors in understanding pain and for Mexican business savvy in the drug trade.
In 1984 Purdue released the narcotic OxyContin, possibly the biggest therapeutic disaster in my lifetime (not because it didn't work but because it did and was so addicting). Purdue claimed it was excited because it had created a delayed absorption slow release form of oxycodone such that there were only mild peaks and troughs in the blood levels; there was no euphoria to cause addiction. A New York City attorney, Paul Hanly, suing Purdue later in a class action lawsuit, claimed Purdue had created falsified, "ponied up" graphs. The details are murky. But Purdue Pharma pleaded guilty to a felony count of "misbranding" OxyContin and paid a fine of $634.5 million to prevent their executives being sent to prison.
Purdue could afford the fine. Quinones said "the decade of the 1990s was era of the blockbuster drug, the billion-dollar pill and a pharmaceutical sales force arms race was part of the excess of the time." In 1995 there were 35,000 drug representatives and by 2005, 110,000. It was "feet on the street and a pharmaceutical wild west emerged ...as salespeople stampeded into offices." Sales quotas increased. Purdue paid out an additional 1$ million in 1996 for bonuses for oxy sales and in 2001, $40 million. Some Purdue reps made $100,000 in bonuses in one quarter.
"Purdue bonuses in certain areas had little relation to those paid at most U.S. companies but bore instead a striking similarity to the kinds of profits in the drug underworld," Quinones wrote.
He is an experienced investigative reporter and presumably knows the best protection against slander or libel is the truth. His book calls a spade a spade, naming the physicians in this story who went to prison and those responsible for this harrowing, almost unbelievable account when doctors forgot the Hippocratic rule, "first, do no harm." And Quinones understand that time is not the doctor's friend: "Nothing cuts short a patient visit like a prescription pad!"
As a practicing physician during this period I had no idea of the extent of the problem. Quinones again: "A government survey found the number of people who reported using heroin in the previous year rose from 373,000 in 2007 to 620,000 in 2011. Eighty percent had used a prescription painkiller first. But all this took years to become clear."
This might be a good place to pause and sort all this out because this is a most complicated and ugly story that starts with academic stupidity, continues with medical profession incompetence and individual physician greed.
Eric Anderson, MD, now retired, is a past president of the New Hampshire Academy of Family Physicians. He has also written five books, the last called The Man Who Cried Orange: Stories from a Doctor's Life. He lives in San Diego.