19.04.2018
Oxycontin is the opium of the masses
James Linney looks at the American opioid crisis and the cynical role played by big pharma
There has been a steady flow of media stories over the past year about the ‘opioid crisis’ in America.
In general, the mainstream media only has a couple of ways of portraying illicit drug use in their coverage: either to present the drug users as deranged, violent lunatics or to characterise the drug (whether it be crack, crystal meth or opioids) as a previously unimaginably destructive agent that is going to spread though society like wildfire. This is summed up, albeit in an extreme way, by a recent Daily Mirror headline: “Drug blamed for cannibal plague: panic spreads over mind-bending bath salts linked to zombie-style attacks.”1
There is, however, more to the current abuse of opioids in America than the media’s usual idiotic sensationalising and moral panic: namely, both the extent of the problem and (as is much less often reported) the role the pharmaceutical industry has played in creating and profiting from it.
Humans have been harvesting the thick latex produced by opium poppies (Papaver somniferum) for as long as written history has existed. It is believed that the Sumerians, inhabiting what is today Iraq, were the first civilisation to cultivate opium from poppy seeds in the third millennium BC. But it was similarly used in the Egyptian, Assyrian, Greek, Roman and Persian empires. Opium was initially eaten, drunk or inhaled via heated vessels by priests during religious rituals. Its therapeutic properties were appreciated from the start, as demonstrated by Homer: in The Odyssey he has Helen administer the drug to Telemachus to help him overcome his distress at Odysseus’s absence: “Presently she cast the drug into the wine of which they drank, to lull all pain and bring forgetfulness of every sorrow.”
Over the centuries opium has been manipulated to increase its potency, but the production process has changed very little. Small chemical alterations have created synthetic and semi-synthetic derivates. Morphine, heroin, codeine, tramadol, oxycodone and fentanyl are all essentially the same as opium, but with varying potencies that can be smoked, taken as a pill, absorbed through a skin patch or injected. It is primarily for opium’s action on receptors in the central nervous system, thus inhibiting pain, that it is used by modern medicine.
But it has other effects too: it can produce euphoria and cause nausea, constipation and itching. Opioids can also suppress the respiratory system and it is in this way that an overdose can be fatal. That is something that almost never happens when people take opioids in controlled medically prescribed doses, but it occurs routinely when opioids containing unknown concentrations are bought illicitly. These are often mixed with very potent formulations: fentanyl, for example, is up to a hundred times more potent than morphine; a few grains can be fatal. Yet the majority of heroin in the US is now cut with varying amounts of fentanyl, because that makes production cheaper and less space-consuming.
The Centre for Disease Control reports that in 2016 there were 42,000 opioid overdoses in the US.2 In the same year there were 11.5 million Americans who misused prescription opioids, compared to 948,000 heroin users.3
Purdue Pharma
When examining how the situation in America became so dire, two questions are key: why are so many people addicted to opioids and how did so many prescription opioids get onto the black market? The answer to both questions can be found by analysing the role of the pharmaceutical manufacturing and distribution industry.
A good place to start is to look at the role that Purdue Pharma played in developing and promoting its star product - Oxycontin. Before getting into the opioid business Purdue was a small fish in the pharmaceutical pond. But in the 1980s it produced a drug called MS Contin - a variant of morphine that is released into the bloodstream at a slower rate than conventional morphine pills. That meant that cancer patients, for whom it was originally designed, would need to take fewer tablets. By the late 1990s though there was a problem on the horizon: the ending of the MS Contin patent. Meaning that soon other drug companies could produce the same drug but cheaper.
Purdue’s answer was twofold: firstly to manufacture a new drug that it would claim is released into the system even more slowly, giving 12 hours of pain relief; and secondly to promote the drug as less addictive and therefore safer for use in more conditions than just terminal illness or cancer. This new blockbuster drug, Oxycontin, was produced through some minor chemical tweaks of an old out-of-favour variation of morphine called oxycodone. It would become the most profitable drug of all time, reportedly creating $36 billion profit for Purdue4 and in many ways was the catalyst for the opioid crisis.
On Oxycontin’s release Purdue’s team came out all guns blazing, spending $207 million on its promotion alone. Using techniques honed over decades by pharmaceutical companies to sell their products, Purdue inserted into medical journals promotional brochures designed to appear like academic studies, sponsored educational events and paid prominent doctors large sums to attend conferences in order to spread the gospel of Oxycontin. The company doubled its sales team to 600 people, who were sent into hospitals and surgeries en masse. They enthused about Oxycontin’s amazing, long-lasting pain relief and how it was far less addictive than morphine, so it could be prescribed for all kinds of problems for which it would never even have been considered previously. Prescriptions of strong opioids started to soar - they were given to patients with less serious conditions, such as arthritis, headaches, chronic back pain or sports injuries.
There were two slight drawbacks, however: Oxycontin did not provide the 12 hours of pain relief claimed by the company; and, just as with other strong opioids, regular use led to ferocious addiction. In 2007 Purdue had to pay $634.5 million in fines for its use of grossly misleading advertising - a tiny fraction of the profits it continues to reap. Court documents revealed that the company had been aware of the addictiveness since the drug’s trials in 1995,5 but by 2007 hundreds of thousands of unsuspecting patients were addicted. The use of strong opioids continued to grow exponentially, as other pharmaceutical companies released similar products - also benefiting from the new, more relaxed attitude to the prescription of powerful opioids.
As any drug-dealing cartel knows, the manufacturing of a product is useless without a good distribution network. In the USA pharmaceutical industry 80%-90% of this distribution is done by three Fortune 500 companies: Cardinal Health, McKesson, and AmerisourceBergen. They are responsible for delivering the drugs to pharmacies and specialist clinics all over America. In theory, when delivering orders for drugs like opioids they are supposed to flag up any suspiciously large orders, where pharmacies may be leaking them onto the black market. But historically these companies have distributed millions of opioids to single pharmacies where such leaks were likely - they were safe in the knowledge that the Drug Enforcement Agency (DEA) would only be able to punish them with token fines.
Eventually the industry found even that unacceptable and started to lobby for a reduction in the already meagre DEA powers. In October 2016, Barack Obama signed a new law - one sponsored by the pharmaceutical industry - that vastly curtailed the DEA’s ability to stop the distribution of opioid pills. It introduced a much higher burden of proof that a drug being suspiciously distributed would cause “immediate harm”. The chief advocate of this hobbling of the DEA was Republican senator Tom Marino, who received nearly $100,000 of donations from the sponsors of the bill. Perversely Marino was later chosen by Donald Trump to be his drug tsar, but he was forced to withdraw in 2017, when The Washington Post ran a story about his links to the drug industry and the legal amendment he sponsored.6
But the damage was already done and the law remains in place. As a result hundreds of millions of non-prescribed opioid pills are sold each year - contributing to the 200,000 opioid overdose deaths since 1995, whilst ensuring continued demand and profit for the manufacturers. In a particularly Orwellian twist, the pharmaceutical companies have simultaneously developed new treatments for the effect of opioid overdose: for example, Naloxone is a drug that blocks the respiratory depression effects of opioids, meaning that if it is administered in time it can save a person’s life. However, as the opioid crisis escalated and the need for Naloxone increased, the price has also skyrocketed. Pushing both addiction and its ever increasingly expensive antidote simultaneously is something that would have challenged the morals of even Pablo Escobar.7
One other thing distinguishing the current opioid problem from the use of other illicit drugs in America - for example, the spike in heroin consumption in the 1970s and crack in the 1980s - is the type of localities affected. Those earlier epidemics were largely confined to the poorest communities in the largest cities, with the burden of harm falling disproportionately on the poorest, African-American communities. By contrast, the highest overdose and death rates from the current opioid crisis are smaller towns in West Virginia, New Hampshire and Ohio. Huntington, West Virginia has the highest per-capita overdose rate in the whole country: 35.3 deaths per 100,000 - well over double the national average of 15 per 100,000.8
Of course, it is still the poorest in these states that are affected the most, but there has also been a widening out to white working class communities - one reason why the media and politicians have been more interested in the story. And Trump has had to show he is taking the problem seriously, because it is affecting people who voted for him. Hence his declaration of a public health emergency in October 2017. Yet, as we have come to expect from the current president, the bold tweets and press releases hold no perceivable substance. The $1 billion promised by Trump to help combat the problem had actually already been allocated, through the 21st Century Cures Act that was passed at the end of 2016, before he became president.
Predictably Trump’s response will largely involve increasingly punitive measures for those people addicted to the opioids - in other words, a rerun of Ronald Reagan’s disastrous ‘war on drugs’ in the 1980s, the result of which was the mass imprisonment of those most in need of treatment and an adverse impact on already struggling communities. A particularly ominous part of Trump’s plan is his intention to introduce the death penalty for drug dealers, mirroring the brutal policies adopted in the Philippines. In fact, a month after this announcement Trump visited the Philippines and expressed his admiration for president Rodrigo Duterte and hailed their “great relationship”. So the best we can hope for is that Trump will do nothing at all in response to the opioid problem - which, given his attention span, is a real possibility too.
Our response
What then should we on the left be calling for to help end the thousands of daily opioid overdoses in America? Certainly not for greater powers for the DEA - an organisation whose main role has always been to criminalise drug users, whose policies are dictated by those in power: prioritising the needs of the drug industry over those suffering from drug addiction. We must instead call for the immediate decriminalisation of all currently illicit drug use.
Many deaths occur because people are injecting heroin mixed with stronger opioids and because some who are prescribed opioids by their doctors turn to the street for heroin when such prescriptions are no longer adequate or affordable. The vast majority of deaths could be prevented by the legalisation of all opioids (and all other banned drugs) and prescribing them for free in less harmful concentrations, where they can be taken in a safe, clean environment with a hygienic needle. This would be the first step in getting people onto a more long-term opioid replacement treatment, such as methadone. We must also demand the immediate nationalisation of the pharmaceutical industries, thus ending the current pharmaceuticals’ ability to profit from the suffering of millions of people.
Ultimately though, the problems associated with opioid use can only be overcome when the conditions that lead people to seek the numbing euphoria they produce are themselves alleviated. The opioid crisis is specific to the conditions in capitalist America in the 21st century - just as the Chinese opium crisis of the 17th and 18th centuries was a result of the conditions created by domestic feudalism plus the impact of British imperialism.
Of course, I am not claiming that in some utopian communist future we will not need drugs because we will all be walking around getting high off life itself. As we have seen, drug use - that is, ingesting substances that have a reality-altering effect - is as old as human culture and there is no reason to suggest that it will not continue to be part of that culture in the future. That is partly because humans have always manipulated their chemical environment as a way of exploring and learning from it and communicating with each other - but also because sometimes drugs can be fun.
However, the habitual use of drugs to escape reality at the expense of the user’s health can only be achieved by overcoming the current alienating reality in favour of a genuinely humane and democratic alternative.
Notes
1. www.mirror.co.uk/news/weird-news/drug-thats-turning-users-into-cannibals-867128.
2. www.cdc.gov/drugoverdose/index.html.
3. www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf.
4. www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain.
5. www.cnbc.com/id/18591525.
6. www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/?utm_term=.670759697355.
7. https://en.wikipedia.org/wiki/Pablo_Escobar.
8. www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state.