The Deafening Silence of a Pharmaceutical Company in the Face of the Opioid Crisis

In 1995, two brothers, Raymond and Mortimer Sackler, were made honorary Knight Commanders of the Order of the British Empire by Queen Elizabeth II in honor of their “professional, humanitarian and exploration” achievements—an award that has been bestowed on an eclectic assortment of luminaries including Mother Theresa, Bono, and J. Edgar Hoover.

The same year, Purdue Pharma, a company owned by the Sacklers, received approval from the FDA for OxyContin, a new extended-release painkiller that would later be blamed for starting an epidemic of opioid addiction and overdoses that America and many other countries continue to spend vast resources trying to contain today.

Since then, Purdue has been sued, vilified, and held up as a poster child for everything wrong with the healthcare system in general and pharmaceutical companies in particular.

The research scientists at Purdue who developed OxyContin made the same mistake Frederick Sertürner had made when he developed morphine in 1803; the same mistake Heinrich Dreser at the Bayer Company had made when he synthesized heroin in 1895; the same mistake Martin Freund and Edmund Speyer had made in 1916 when they synthesized oxycodone; the same mistake Otto Eisleb and Otto Schaumann had made in 1939 when they synthesized meperidine (Demerol); and the same mistake Carl Mannich and Helene Lowenheim had made when they synthesized hydrocodone in 1943.

All of them believed they were developing less addictive and more effective alternatives to existing opioids. All of them were wrong.

In terms of marketing and sales, the timing of OxyContin’s release could not have been better. In the late 1990s, the VA hospital system began to consider pain the fifth vital sign (along with pulse, temperature, respiration, and blood pressure). Doctors were encouraged to deal with pain more aggressively, which meant walking an even finer line between providing relief and risking addiction. Purdue argued that, as an extended release version of oxycodone (which had been a standard opioid medication in America since 1939), OxyContin would be less addictive because it delivered lower doses of the drug over longer time periods. They, too, were wrong.

Patients had become addicted to prescription opioids such as oxycodone and hydrocodone throughout the 20th century as well as barbiturates (e.g., Seconal and Nembutal) and benzodiazepines e.g., Valium). But the numbers were minimal compared to the epidemic of opioid addiction that began when doctors began over-prescribing OxyContin and Purdue began concealing its risk.

That risk was even greater when it was tampered with—e.g., by crushing and snorting or dissolving and injecting. Both techniques brought a sense of deep relaxation and euphoria similar to heroin—at least the first time. Increasingly, patients who had begun taking OxyContin legitimately for pain relief found themselves chasing this high.

Regardless of their path to addiction, when a patient could no longer get any by prescription—or simply wanted more than they were prescribed—they would buy some from friends and then strangers on the street. And when that supply dried up, many turned to more readily available and less expensive heroin.

Doctors and patients wanted OxyContin. The FDA approved it. The government’s efforts to mandate data monitoring and sharing technologies that would expose prescription drug fraud were woefully inadequate. Was it really Purdue Pharma’s fault it was so widely used and abused? After all, what they did was simply the continuation of a long tradition of poorly tested medical miracles and shameless overmarketing. Were they really so much worse than “Mrs. Winslow,” who in the 1800s claimed right on the label of Mrs. Winslow’s Soothing Syrup that it was The Mother’s Friend for Children Teething? (Unbeknownst to many mothers—and the person on the label who looks suspiciously like a nanny—the bottle had 65 mg of morphine in it.) Similarly, when Bayer introduced heroin, it claimed the new drug was the “Cheapest Specific for the Relief of Coughs (bronchitis, phthisis whooping cough etc.).”

Actually, it was Purdue’s fault. If they had just been self-deceiving hucksters like those patent remedy marketers of the 1800s, they—as well as the FDA and the doctors who trusted them—would “simply” be guilty of sloppy science and wishful thinking. Their crime was ignoring and concealing indisputable reports from the field that the pills were being overprescribed, sold on the street, and adulterated. By the time the company came out with an “abuse-deterrent formulation” (which, ultimately, didn’t completely deter abuse), and states slowly began to pressure doctors (and pharmacies) to decrease prescriptions, many users had already turned to heroin.

In 2007, the president, top lawyer, and former chief medical officer of Purdue Pharma were ordered to pay $634.5 million in fines. The company itself agreed to pay $19.5 million to twenty-six states and the District of Columbia (Purdue earned over $1 billion in OxyContin sales that year). Ten years later, in September 2018, as part of negotiations to settle 1,000 lawsuits, Purdue reportedly offered to give away buprenorphine—one of the main drugs used in medication-assisted treatment for addiction. The patent for buprenorphine is owned by a company known as Rhodes Pharmaceuticals, which is owned by the Sackler family.

Estimates are that 200,000 Americans have died directly from OxyContin-related overdoses since 1999. Countless other addicts have been given long, if not lifetime, sentences for opioid sales and use.

By the end of 2017, Purdue had sold approximately $35 billion worth of OxyContin.

No one from Purdue has ever served time in prison.

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While people were just becoming aware of how dangerous OxyContin was, George W. Bush became president. At first, it appeared his drug policy would be more compassionate than Clinton’s. While there was $2.3 billion for border control in his first budget, it also included $3.8 billion for treatment and research as well as $650 million for youth education programs at schools and in the community.

Yet, however sincere his attempt to deal with the drug problem in a more enlightened way, his response to 9/11 would end up exacerbating it significantly, as once again, America made opium a foreign policy tool.

Afghanistan’s opium production had increased by twenty times between the 1970s and the early 1990s, thanks in part to the CIA using the drug to fund Afghanistan’s resistance to Soviet occupation. Once the Soviets left Afghanistan, the country plunged into civil war until the Taliban, backed by al-Qaeda, formed a tenuous central government—one whose gross national product depended heavily on raw opium and heroin. While the West officially frowned on this, it was too busy in the Middle East by then to address it.

By 2000, the Taliban controlled about 75 percent of the country, with the rest controlled by the Northern Alliance, which was supported by Russia and other neighboring countries. When a severe drought destroyed the poppy crop, the Taliban government needed money badly and looked to the United Nations for foreign aid, offering in exchange to crack down on future opium production. As far as the international community was concerned, Afghanistan had to stop supporting terrorism and violating human rights before they would be given any assistance. Bush, seeing the opportunity to expand American influence in the region, agreed to give them $43 million in foreign aid—a decision he soon regretted when Osama bin Laden (whom the Taliban had been protecting on behalf of his Islamic terrorist group al-Qaeda) choreographed the most successful terrorist attack on US soil in history.

After 9/11, when the Taliban refused to turn over bin Laden, the United States and Great Britain attacked alongside their former enemies, the Northern Alliance. The Taliban government crumbled and a new government was formally elected. The Taliban started a counterinsurgency movement, which they financed by getting back in the opium business. So, in turn, President George Bush decided to get back into the opium-fighting business and authorized major crop-eradication efforts. He also turned a blind eye to certain factional warlords of the Northern Alliance who were allied with the United States versus the Taliban, despite abundant evidence that they, too, were involved in heroin trafficking.

Crop eradication is a zero-sum game. There are 10,000 seeds in a single opium poppy pod. A farmer whose crop has been destroyed (or who has been driven off his or her land) can easily walk away with enough seeds to start over. Not only do new crops and other sources of supply seem to pop up overnight, eradication turns farmers who are just trying to feed and shelter their families into willing recruits for governments, terrorist organizations, and revolutionary groups. As one Afghan woman shouted, “They will have to roll over me and kill me before they can kill my poppy.”

If farmers could make as much money (or at least a reasonable living) growing legal crops and raising flocks of sheep, goats, and cows, most would be happy to do so. It would certainly be far less dangerous than being in the middle of warring factions in the drug trade. Instead, after years of warfare, Afghanistan’s irrigation systems have been ruined, orchards devastated, animal flocks decimated, and seed supplies destroyed. The United States has spent billions of dollars on military solutions, money that would be far better spent “winning the hearts and minds of the people” by rebuilding the country’s economic infrastructure.

This is obvious to some of those who have witnessed the problem firsthand. It is the reason that a group of US military veterans started a nonprofit called Rumi Spice to help farmers in Wardak Province grow and market premium saffron, one of the world’s most expensive spices. At approximately $200 per kilogram, it doesn’t quite match the $300 per kilogram they could make from poppies but it’s much more reliable, sustainable, and safe to grow; and since, like poppy cultivation, it’s labor intensive, it employs a similar number of people. The country’s agricultural ministry has embarked on a similar initiative in the province of Herat, where there are now 400 farmers in the saffron business.

In the long run, crop replacement might do no more than crop eradication to reduce overall worldwide supply, since other countries can increase their crops within a season to compensate. However, it is certainly a more effective and honorable—and potentially even more strategically successful—way to work with countries that have been ravaged by drugs, in part due to America’s nation-building efforts.

When Barack Obama came into office, he renewed America’s commitment to defeat the Taliban and, by the end of 2009, he had raised the number of US forces to 100,000 as part of what he called a “surge” to make it possible to begin withdrawing troops. After the assassination of Osama bin Laden, Congress began to push for more rapid troop withdrawal. By the end of 2015, there were only about 10,000 American troops still in the country.

Some foreign policy experts continue to insist that destroying poppy crops is essential to accomplish our goals in Afghanistan. They also say troop levels will have to go up again to 100,000 or more to do that job. They point out that, when the number of soldiers tripled (from 30,000 to more than 90,000) between 2007 and 2012, the area under cultivation went down 25 percent (200,000 hectares to 150,000 hectares). Whereas after Obama’s troop reductions the hectares under production more than doubled.

If only the math were so simple. If only more troops = fewer poppies = 0 Taliban = America wins. However, other experts argue that, no matter how much nation-building and investing the West does to support Afghanistan’s economy, it won’t have a major impact on production because, for most of its people, drugs remain the most reliable source of income.

One writer, after enumerating the total number of troops deployed, soldiers killed, and stunning amount of money spent in Afghanistan from 2001 to 2017, concluded, “In the American failure lies a paradox: Washington’s massive military juggernaut has been stopped in its steel tracks by a small pink flower—the opium poppy.”

Even if America “succeeded” in Afghanistan there’s one very inconvenient truth that changes all these equations. Less than 10 percent of the heroin smuggled into America originates there. Most of the heroin entering the country is instead processed from poppies grown in Southeast Asia and increasingly Mexico and other Latin American countries. In other words, even if there weren’t a single poppy growing in Afghanistan, America would still be awash in opiates.

The even more inconvenient truth is that heroin’s long reign as the primary addictive “hard” street opiate is coming to an end, regardless where it’s being grown. Free from the ingredients within the opium flower, opiate analogs are synthesized rather than grown and are designed to be hundreds of times stronger than heroin.

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Excerpted from the book Opium: How an Ancient Flower Shaped and Poisoned Our World by John Halpern and David Blistein, to be published on August 13, 2019 by Hachette Books, a division of Hachette Book Group. Copyright 2019 John Halpern and David Blistein.