Opioid Nation

Jerome Sessini/Magnum Photos
A man who has just taken heroin, Philadelphia, April 2018

The National Institute on Drug Abuse estimates that 72,000 Americans died from drug overdoses in 2017, up from some 64,000 the previous year and 52,000 the year before that—a staggering increase with no end in sight. Most involved opioids.

A few definitions are in order. The term opioid is now used to include opiates, which are derivatives of the opium poppy, and opioids, which originally referred only to synthesized drugs that act in the same way as opiates do. Opium, the sap from the poppy, has been used throughout the world for thousands of years to treat pain and shortness of breath, suppress cough and diarrhea, and, maybe most often, simply for its tranquilizing effect. The active constituent of opium, morphine, was not identified until 1806. Soon a variety of morphine tinctures became readily available without any social opprobrium, used, in some accounts, to combat the travails and boredom of Victorian women. (Thomas Jefferson was also an enthusiast of laudanum, one of the morphine tinctures.) Heroin, a stronger opiate made from morphine, entered the market later in the nineteenth century. It wasn’t until the twentieth century that synthetic or partially synthetic opioids, including fentanyl, methadone, oxycodone (Percocet), hydrocodone (Vicodin), and hydromorphone (Dilaudid), were developed.

In 1996 a new form of oxycodone called OxyContin came on the market, and three recent books—Beth Macy’s Dopesick, Chris McGreal’s American Overdose, and Barry Meier’s Pain Killer—blame the opioid epidemic almost entirely on its maker, Purdue Pharma. OxyContin is formulated to be released more slowly and therefore lasts longer. The company claimed that the drug’s slow release would make it less addictive than ordinary oxycodone, since the initial euphoria—the high—would be muted. Based on this theory and little else, the FDA permitted OxyContin to contain twice the usual dose of oxycodone and carry on the label this statement: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” (The FDA official who oversaw OxyContin’s approval later got a plum job at Purdue Pharma.)

The company launched an extraordinarily aggressive and successful marketing campaign to convince physicians that they had the holy grail of a nonaddictive opioid. It sent hundreds of sales representatives to doctors’ offices to tout OxyContin, and offered doctors dinners and trips to meetings at luxury resorts. And it paid more than five thousand doctors, pharmacists, and nurses to train as speakers to tour the country promoting OxyContin. But like all opioids, OxyContin is addictive. And soon enough, users found that they could crush the pills or dissolve the coating, then snort the drug like cocaine or inject it like heroin. Each pill would then become essentially an instantaneous double dose of oxycodone.

OxyContin almost immediately became a blockbuster—that is, a prescription drug with annual sales of more than…


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