NOTE TO EMAIL SUBSCRIBERS – apologies if you were sent the work-in-progress last week. This is the finished article!

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This post is a brief summary of the famous American Opioid Epidemic – the OxyContin part, anyway. I became hugely interested in it a couple of years ago and read and watched everything I could.

If you don’t want to read through all of my ramblings, here are some of the great resources I used if you want to find out about it yourself.

Every single one of these is highly recommended.

• Empire of Pain by Patrick Radden Keefe — the book which kicked me off. A detailed but absorbing account of the scandal from start to finish.
• Dopesick (Disney+) — a dramatized series starring Michael Keaton as a doctor on the Appalachians (Dolly Parton country!) who succumbed to addiction himself. Excellent.
• Painkiller (Netflix) — basically another dramatisation of the OxyContin story, similar to Dopesick, but honestly, once I was down this rabbit hole I couldn’t get enough.
• All the Beauty and the Bloodshed (Amazon Prime) — a documentary film about photographer and activist Nan Goldin, who became addicted to OxyContin and subsequently led a campaign against Purdue Pharma and the Sackler family.
• The Pharmacist (Netflix) — documentary about a father trying to solve his son’s murder who ends up exposing the corruption surrounding opioid prescribing.
• Demon Copperhead by Barbara Kingsolver — an absolutely cracking read. One of my favourite novels of recent years. Don’t be put off by the cover: it’s a modern-day David Copperfield about growing up in poverty-stricken America and the devastation wrought by opioid addiction.

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Now read on….

Painkillers, to me, have always basically meant nurofen or paracetemol; aspirin if you want to play Russian Roulette with a stomach bleed. So years ago, when people began to say Hollywood stars had painkiller addictions, I didn’t really get it. I knew that drugs like co-codamol were very powerful, and I knew my mother couldn’t go to sleep without her super-duper Solpadeine fix, but I couldn’t quite see it as a proper drug addiction – something you just couldn’t stop. I thought people were addicted because they were in so much pain that life would be unbearable without the drug to control the symptoms.

And then I noticed reports of vast numbers of people in poor areas in the United States falling prey to this painkiller addiction, or “opioid epidemic” as it seemed to be becoming known. Oh dear, I thought. People were so depressed or stressed by the dreadful economic circumstances in these beaten down areas that they were manifesting fibromyalgia symptoms in droves and relying on these drugs to alleviate the suffering.

Then one day I heard a man on the radio, in the UK, saying he was addicted to painkillers, years after his initial pain problem began. He literally had no physical pain any more, but just couldn’t come off the drugs because he’d become physically dependent on them. I was even more confused.

When a friend recommended me the wonderful book Empire of Pain by investigative journalist Patrick Radden Keefe I finally discovered what it was actually all about.

The story starts with a family. The Sackler family. There were several doctors amongst them who trained in medicine but then became involved in the pharmaceutical business. Two Sackler brothers, Raymond and Mortimer, acquired a company called Purdue Frederick. Another brother, Arthur, was a psychiatrist, and he also had something of the Midas touch. He was a pioneer of drug advertising and had his own advertising firm. His approach was to target doctors rather than consumers. This was revolutionary. He gave away pens with the names of drugs on them; he placed ads in medical journals, alongside favourable research articles, and set up a kind of merry go round of allied interests – doctors, advertisers, medical journals, and regulators. He worked for Pfizer and Roche, and helped to promote Librium, for anxiety and Valium, for a condition described as being a “prisoner of stress of society”, or for “psychic tension.” “Psychic tension” is a highly underused diagnosis in my opinion, which appeared in the advertising but never seems to have made it into the DSM manuals, and tragically seems to have fallen out of fashion. Ever since I heard it I have frequently diagnosed myself as psychically tense – whenever I feel at odds with myself, the world, or anyone in it, in fact. But I have never taken Valium for this, as we know now that it is a more problematic drug than they thought back then.

Along with Arthur’s marketing help, Valium became one of the most widely prescribed drugs in the US. But at the time, the phenomenon of withdrawal was not always recognized. So if people suffered symptoms when they stopped taking it, it was presumed that the original symptoms had simply come back to the surface, so the solution might be ….yes….more valium. To be fair to him, Arthur Sackler had worked in psychiatry and was familiar with the treatments administered. At the time they were still doing frontal lobotomies. He is reported to have felt there must be a gentler approach i.e. pharmaceuticals, and to be honest, I think Valium has the edge over having a lump of your brain cut out.

Arthur Sackler died before anybody had even thought about OxyContin, but he had developed some powerful marketing techniques. Purdue Frederick evolved into Purdue Pharma, which came up with OxyContin. OxyContin is an opioid, a powerful painkiller in the same family as morphine and heroin. The active ingredient is oxycodone. But it was designed to be slow-release. This was its USP, differentiating it from other opioids – the delayed absorption was marketed as a feature which would make the drug less likely to be abused. Additionally, you only had to take it twice a day. Once every 12 hours was deemed to be the right interval.

Purdue Pharma marketed it with genius. They provided a context, setting up pain groups, drawing attention to the prevalence of chronic pain and the dire need for better treatment.

The FDA approved the drug in 1995, and included a reassuring, yet noncommittal, statement in the label:

“The delayed absorption as provided by OxyContin tablets is believed to reduce the abuse liability of a drug.”

Hmmm…that word, “believed”. Not exactly cast iron conclusive is it? It didn’t actually say that the FDA claimed it was not addictive or liable to be abused.

The Purdue people trained up sales reps. They held glitzy conferences. The company also paid certain doctors through its speaker programme to induce them to prescribe more of its opioid products. Purdue informed doctors that this new drug was less addictive, less subject to abuse, and less likely to cause dependence and withdrawal than other pain medicines. In fact, one of the figures that became hugely influential was the claim that addiction occurred in less than 1% of patients receiving opioids for pain.

What was this based on, you ask, in these days of rigorous evidence-based medicine and scrupulously tight regulation? Well, it was based in part on a 1980 letter to the New England Journal of Medicine. That’s right. A letter, not a study.

Now infamously known as the Porter and Jick letter, it was one paragraph describing hospital patients who had received “narcotics.” Not OxyContin. Other drugs. Retrospective records of more than 11,000 hospital patients who had received at least one “narcotic” identified only four cases of addiction in patients without a previous history of addiction. Well, great.

Except that the letter wasn’t about OxyContin, it wasn’t a clinical trial, and it wasn’t even a study of people taking opioids at home, the way OxyContin was being prescribed. It was a retrospective review of hospital records involving patients receiving opioids under medical supervision. Not the same thing at all.

Yet this little letter did a lot of heavy lifting in persuading people that addiction was extremely rare when opioids were prescribed for pain. In 2017 the NEJM said it had been cited 608 times, over 70% of those claiming that it suggested that this was evidence that addiction was rare in opioid-treated patients. Over 80% of these failed to mention that these were opioids administered in hospital under medical supervision.

Doctors began prescribing it. But problems soon arose.

1. The tablets didn’t necessarily provide the promised 12 hours of pain relief for everyone. Some patients found that the effect wore off sooner and wanted more. Purdue advised dose adjustments (i.e. increasing the dose) and additional medication when patients experienced what doctors called “breakthrough pain”.
2. Some people also learnt very quickly that they could crush the tablets, releasing oxycodone rapidly into their system and producing an intense effect; an immediate high. The delayed absorption which was supposed to reduce the drug’s abuse liability, and which was its key safety feature, was, in other words, surprisingly easy to circumvent.

Still, the sales reps were excited about making money and the Sackler family was excited about making money. Big pharma had quite a bit of influence. Many doctors trusted the regulator and the pharmaceutical company, and were happy to find such a safe and powerful painkiller to help their patients. Everyone was happy, except the poor people who found their lives taken over by needing the next Oxy fix.

Talk about the banality of evil.

As lives were ruined, and children lost parents, and parents lost children, the Sackler family carried on making lots and lots and lots of money. (Total from OxyContin sales was $35 billion – the Sackler family personally received a chunk of that). But hey, they ploughed huge amounts into philanthropic donations: museums, universities, cultural institutions. After all, no-one can say anything against people who give lots of money to good causes, can they? Their tentacles must have spread far. We even had a Sackler Centre of Consciousness Science here in Brighton, on the South Coast of England. (Renamed the Sussex Centre of Consciousness now).

But gradually people became aware of the problems. Doctors realised that it wasn’t just the usual suspects having problems with the drugs. The rate of overdose-related deaths rose. Journalists noticed. People began to ask questions. Some OxyContin users went onto heroin. And then the lawsuits began. Photographer Nan Goldin staged dramatic, installation-style, artistic protests at places like the Metropolitan Museum of Art. The Sackler name became toxic and the whole thing unravelled.

Purdue Pharma is now restructured, and is involved in trying to help mop up the mess, with proceeds going to help opioid abatement programmes. The Sacklers are no longer involved. But the opioid crisis in general hasn’t gone away. Fentanyl is now the name on everyone’s lips. Every so often I see odd pictures of adults standing as if playing “statues”, and this is apparently the effect of Fentanyl.

I’ll be back when I’ve learnt a bit about that!

But for now, thanks for reading all this. I hope you’re better informed, and please go to watch or read some of the sources listed above, they are truly fascinating.