American plague: a special report on the US opioid addiction crisis
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The war on drugs is no longer just going after the usual suspects. ANDREW PURCELL reports on the opioid crisis gripping the States and the role played by the pharmaceutical industry.
The 'War On Drugs' has been a cornerstone of US criminal justice since Richard Nixon coined the phrase in 1969, and every president since has made incarcerating drug-dealers and users a priority.
Now, as an unprecedented epidemic of addiction sweeps the country, prosecutors and legislators are belatedly realising that pharmaceutical companies must also be held responsible.
In a case due to be heard next year, the state of New Jersey is suing Purdue Pharma LP, one of the country's biggest pharmaceutical companies and maker of the opioid painkiller Oxycontin. The firm is accused of 'almost inconceivable callousness and irresponsibility' in the aggressive promoting of a drug it knew to be addictive, thereby contributing to a crisis now gripping every corner of the United States.
Opioids are narcotic drugs that affect the nervous system and act as a pain reliever. They can be vital in the treatment of cancer, for instance, and for patients recovering from surgery.
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But, like all drugs, they are open to abuse and over-use. For every one million Americans, almost 50,000 doses of opioids are taken every day – four times the rate in the UK.
The drugs are creating addicts, many of whom move to illegal opioids like heroin, and illegal synthetic opioids such as Fentanyl, thus blurring the lines between legal and illegal substances. In the process, they are taking many lives and destroying others, and hollowing out communities throughout the States. In two years, one pharmacy in the town of Kermit in West Virginia – home to just 400 people – received almost nine million opioid pills.
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The New Jersey case represents a growing understanding that those implicated in America's drug problems are not just the criminal elements of the old days, but the pharmaceutical industry, one of the country's most powerful.
As New Jersey Attorney General Chris Porrino put it, when he laid out his case against Purdue: 'When we point the finger of blame for the deadly epidemic that has killed thousands in New Jersey, Purdue is in the bullseye of the target.'
The case is not the only line of attack. A few weeks before it was launched, 41 States announced a joint investigation into whether pharmaceutical companies misled doctors and patients about the risks associated with prescribing opioids. 'I believe we are reaching a tipping point where even pharma, which is legendary for its power on Capitol Hill, ought to begin looking over their shoulder,' Missouri Senator Clare McCaskill said.
Andrew Kolodny, now an opioid policy expert at Brandeis University, in Massachusetts, was formerly the Chief Medical Officer at Phoenix House in New York. The recovery centre was founded in 1967 by six heroin addicts who resolved to kick the habit together.
In half a century of helping crack, PCP, cocaine and methamphetamine users get clean, it has never faced anything like the current wave of opiate addiction.
'This is the worst drug addiction in United States history. It's affecting every state in the country. It's affecting far more people,' Kolodny said. He also said, unequivocally, that pharmaceutical companies are to blame. 'Our opioid addiction epidemic has been caused almost entirely from use of prescription opioids.'
But despite widespread acknowledgement that this represents an unprecedented public health crisis, more resources are being devoted to assigning blame than to bringing the epidemic under control.
In August, President Donald Trump referred to the opioid crisis as a 'national emergency' and promised to spend 'a lot of time, a lot of effort and a lot of money' on resolving it. But by late October, when his opioid commission's findings were made public at a White House ceremony attended by former drug users and the families of overdose victims, this had been downgraded to a 'public health emergency', meaning there will be no immediate infusion of federal funds to deal with it. 'No part of our society – not young or old, rich or poor, urban or rural – has been spared this plague of drug addiction,' Trump observed. In a Pew poll this year, 46% of the people surveyed said that either a member of their family or a close friend has been addicted to drugs.
According to the International Narcotics Control Board, Americans consume 80% of the world's prescription opioids, including 99% of the hydrocodone, sold under the brand names Vicodin, Norco and Xodol. In 2015, one in three adults received a prescription for painkillers.
As Patrick Radden Keefe outlined in a superb New Yorker article, this market has been decades in the making. Oxycontin was launched in 1995, at a time when doctors were being told to treat pain as 'the fifth vital sign' by respected colleagues (many of them in the pay of Purdue) who assured them that 'opiophobia' was outdated and the risk of addiction much lower than previously feared. An insert in Oxycontin's packaging, approved by the Federal Drug Administration, stated that the slow-release mechanism 'is believed to reduce the abuse liability'.
Salesmen and women, many of whom earned six figures in commissions, were taught to tell doctors, dentists and osteopaths that the drug was 'virtually non-addicting' and appropriate to treat all kinds of chronic pain.
In 2007, Purdue acknowledged that it had marketed Oxycontin 'with the intent to defraud or mislead,' pleaded guilty to criminal charges of misbranding and paid fines worth $634 million.
Three years later, it reformulated the drug, so that it could no longer be crushed and snorted, reducing the potential for abuse. But by then, it was too late: millions of Americans were hooked, and the Mexican drug cartels were flooding the market with heroin to fill the gap.
Much attention has focused on Rust Belt states reeling from the addiction crisis such as Ohio and West Virginia. Middle-aged white men are the demographic most likely to abuse opioids, and economists Anne Case and Angus Deaton have concluded that 'deaths of despair', including overdoses, suicide and liver failure are responsible for declining mortality rates among white working-class Americans.
But no state has been spared, and no demographic group untouched. On Long Island, in the New York exurbs – the prosperous areas beyond the suburbs – there were almost 500 overdose deaths last year, and a further 770 people were brought back from the brink by Narcan, a life-saving nasal spray that reverses the effects of heroin overdoses.
Earlier this year, I spent the day at Thrive, a community centre for people recovering from addiction near the town of Islip on Long Island. When I arrived, a Heroin Anonymous meeting was in progress. Afterwards, some of the group hurried off, but others were keen to talk.
No two addiction stories are the same, but the basic arc soon became familiar: first prescription pills, then heroin, and eventually 'surrender' – an acceptance of powerlessness that is the first of the Twelve Steps to recovery. Krystle Stoddard first took Vicodin in her early 20s. She was waitressing, making good money. 'Someone said 'hey, take this, it'll make you work better, faster, longer,' and I fell in love. It became a necessity, for every day.' Within a year, she had progressed to 'Roxies' – 30mg Oxycontin pills, crushed and snorted.
A close friend died of a heroin overdose, so when she was offered smack herself, she said no, until a woman she met in rehab persuaded her there was no difference between legal and illegal opiates. The pills cost $30 each. Better to buy three bags of heroin. 'You think of heroin, you think of someone homeless on the street corner, begging for money. Now it's almost a kitchen table kind of conversation. It's so socially acceptable. Everybody knows somebody that's using,' Stoddard said.
Michael Ferraro, a former stockbroker, said at the peak of his OxyContin addiction, he was taking ten pills a day. 'You know if you put a frog in water and you turn it up slow and he doesn't realise he's screwed until it's too late? That's what the painkillers are like,' he told me.
For a while, he could maintain his habit by going to multiple doctors, showing them an MRI scan of his herniated disc and circling the crying face on the pain chart to indicate he was in agony, but before long, the pills weren't enough.
He rolled up his shirt to show me the track marks on his arms. 'When you start to inject heroin, you know that your life is unmanageable,' he said. 'You can go to a doctor, go to a pharmacy and think 'it's OK' but when you're meeting the guy on the street before you go to work and injecting heroin in parking lots…' By the time he quit, he had lost his wife, his house and his business.
Ceire Corcoran, a former teenage alcoholic, had a boyfriend who 'started with marijuana, then was prescribed pills by a doctor, and before my eyes he became a full-blown heroin addict,' eventually dying of an overdose after a failed stint in rehab.
Teri Kroll's son, Tim, was a 'straight edge' kid who didn't touch drink or drugs until a doctor prescribed an opioid to treat his migraines. He too died of an overdose, after switching to heroin, trying desperately to get clean, and relapsing. 'Purdue, big pharma, they push this stuff out big time. They sold us a lie,' said Nora Milligan, a registered nurse in recovery from decades of on-and-off addiction. 'They came out with big sales pitches to doctors, and they marketed their product as safe. I think every state in the USA right now should be suing them.'
In 2011, a pill addict, David Laffer, shot up a chemist's on Long Island, killing four people. The following year, New York's state legislature passed I-STOP, a law designed to prevent people getting prescriptions from multiple doctors.
Prescribing rules have tightened nationwide, and prosecutions of 'pill mills' – places were the narcotics are dispensed – have dissuaded some of the most unscrupulous, profiteering doctors. The cartels, never slow to spot an opportunity, have stepped in. Heroin is cheaper, stronger and more easily available than ever.
'We dried up the source of the pills, and then everybody moved over to what they're buying on the street, which is laced with fentanyl, and we wonder why we have so many overdoses,' said Milligan.
Fentanyl is a synthetic opioid, 40-100 times more potent than heroin, so strong that cops searching for it must wear rubber gloves to avoid contact overdoses. Carfentanil, a close cousin, was developed as an elephant tranquilliser.
'To a heroin addict, it's like 'mix me a stiffer drink, make it a double.' You've got all these at-home chemists that are adding it in. And what they're putting in it is too much,' Milligan told me. Last year, for the first time, fentanyl was responsible for more fatal overdoses than any other drug: around 20,000, compared to 15,000 due to heroin and 15,000 more due to prescription pills.
The total number of overdose deaths continues to rise sharply every year. Medical magazine Stat estimated that in the next decade, up to 650,000 Americans will take a fatal shot of drugs. As Special Agent James Hunt put it to me, when we talked at the Drug Enforcement Agency's New York bureau: 'You'd have a tough time finding somebody in the United States that doesn't know somebody, or have a friend, or the child of a friend, who's addicted to heroin. It's that rampant and big a problem right now.'
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