Dopesick: Dealers, Doctors, and the Drug Company that Addicted America by Beth Macy

A sweeping, painstaking journey into the heart of the opioid epidemic — where it started, how it got to this point, the people, places, and communities that are being torn apart at the seams — and everything in between. This is one of my favorite styles of non-fiction books because it weaves in and out between the stories of those that are personally impacted and also offers a host of facts, data, science, and opinion on how we can potentially turn the tide. As always, this is a complex, multi-layered issue that involves politics, doctors, community advocates, average, everyday Americans, and a multi-billion dollar industry that can’t and won’t stop what they are doing because there is too much money to be made. Macy makes a compelling argument that Medication-Assisted Treatment is the gold standard of care for those that are addicted, but depending on where you live, how many resources you have, who your connections are, and the support systems you have in place, most folks do not have access to the specific type of treatment they need to get better. Macy also busts the common misperception that drug addiction is an inner-city (read: minority) problem — these drugs are available anywhere and everywhere, no matter where you live, what your socioeconomic status is, and what you do for a living. The stories that she shares are deeply moving, compelling, and heartbreaking, and some of these situations quite literally tear families and communities apart to the point where, one by one, everybody is effected in some way — and there is no way out. Macy shows that we can do better — and if we can’t, people are going to continue die for no reason at all.

• drug overdose has taken the lives of 300K Americans over 15 years
• leading cause of death for Americans under the age of 50
• opioid epidemic started in isolated Appalachia, Midwestern rust best communities, rural Maine
• until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment
• the goal for those addicted is to not experience the crushing physical and psychological pain of withdrawal: to avoid dopesickness at any cost
• post civil war there was a morphine epidemic, “morphinism” — soldier’s disease
• heroin is derived from the german word for “heroic”, bracketed by the swirling ribbon frame — heroin
• sold widely from drugstore counters, no prescription necessary, not only for veterans but also fro women with menstrual cramps and babies with hiccups
• mid 90’s is when the pills first hit, ensnaring coal miners, loggers, furniture makers, and their kids
• “disease of despair”
• in Appalachia, overdose mortality rates 65 percent higher than in the rest of the nation — white American’s dying in their prime
• OxyContin — euphoria was immediate and intense, purity similar to that of heroin
• supposed to provide a steady relief three times as long, giving people in serious pain the miracle of sleep; slow release delivery mechanism
• Purdue Frederick, based in Stamford, CT — made initial fortunes specializing in random over the counter products; acquired drug companies in the 80’s, most prominent drug was MS Contin (“continuous”)
• new drug was supposed to be a reformulation of the painkiller oxycodone, beyond hospice and end of life care; form of oxycodone synthesized from thebaine, an ingredient in the Persian poppy
• company’s marketing arm was Purdue Pharma — convinced others that addiction was “extremely rare”
• in the 1820’s on of Boston’s leading merchants had an opium smuggling operation which spawned millions — Cabot, Delano (FDR), Forbes — money would go on to build many of the nation’s first railroads, mines, and factories
• German Friedrich Serturner isolated a main ingredient inside the poppy of opium, an alkaloid he named morphium — side effects often progressed from euphoria to depression and nausea
• Civil War addiction became rampant
• in the 1870’s, upper classes in Europe and the U.S. injected it all the time, so did doctors to treat all sorts of stuff
• Bayer chemist Heinrich Dieser discovered archives of a British chemist who was researching nonaddictive alternatives for morphine — heroin
• more than twice as powerful as morphine, which was already ten times stronger than opium
• Bayer convinced people that heroin wasn’t addictive, even adding it to cough drops and baby soothing syrups
• by 1900 more than 250K Americans were addicted to opium derived painkillers
• for eight years, you could buy heroin at any American drugstore or by mail order
• Harrison Narcotics Act of 1914 restricted sale and possession — addicted were now termed “junkies”, inner-city users who supported their habit by collecting and selling scrap metal — remaining addicted were reclassified as criminals
• OxyContin was prescribed for pain — moral, responsible, compassionate thing to do — pain was the “fifth vital sign”, 1996
• Purdue incentivized nurses and docs to treat pain liberally or risk losing reimbursements
• reliance on pain scales did not correlate with improved patient outcomes, also had effect of increasing opioid prescribing and opioid abuse
• insurance companies were more likely to cover opioid pills — cheaper and quicker fix
• 2017: 1T financial toll, when taken all together — social services, education, law enforcement, health care
• drug advertising ballooned from 360M in 1995 to 1.3B in 1998
• Purdue made a million calls annually to doctors, promoting the notion that Oxygen was safe for non cancer patients with low back pain, osteoarthritis, injury, trauma pain
• side effects included constipation, sleepiness, unsteadiness on feet
• in Appalachia, many of the factories and furniture plants were gravitating to other countries — post NAFTA
• Oxy turned people almost totally nonfunctioning
• “sentinel areas”, like San Fran and NYC in the early years of HIV — Appalachia
• opioid addiction is a lifelong and typically relapse-filled disease
• more than 5K docs and nurses and pharmacists attended conferences (all expenses paid) by Purdue in the early years
• victims were getting jail time instead of the people who caused it
• suburban teenage parties, “pharm parties” or “farming”, practice of passing random pills around in hats
• “hipster” drew from a Chinese opium smoker of the 1800’s who spent much of his time smoking while reclining on one hip — inspiration from Charlie Parker, John Coltrane
• many soldiers detoxed in Vietnam before they came home
• when docs started prescribing Oxy for non cancer pain, it effectively nationalized the supply, making opioids no longer only a big city story
• crushing the tablets would lead to immediate, rather than controlled, release of the drug
• was discovered that FDA regulators and Big Pharma execs had been holding private meetings for years at expensive hotels
• “enriched enrollment”: allowed drug companies to weed out people from their studies who didn’t respond well to their drugs, tipping the balance towards FDA approval of new drugs — away from science
• American Pain Society and American Academy of Pain Medicine pushed for expanded use of opioids for long term chronic pain while taking millions from the companies that made them
• Purdue used Giuliani and his form for their defense
• They paid 600M in fines and admit that for six years it had fraudulently marketed Oxy as being less prone to abuse and having fewer narcotic side effects than instant release versions of the drug — felony misbranding charge
• 11th largest fine paid by a pharma firm in Justice Department history
• Purdue refused to take responsibility for the death and destruction caused by the drug — kept repeating that the benefits outweighed the risks, even taking into account the grief and death
• because Purdue was privately held, they only answered to the Sacklers — net worth of 14B in 2014
• Arthur Sackler was the Don Draper of American pharma marketing — showered doctors with favors and funding experts to back drugmakers claims in the 60's
• inevitably flawed studies were first used to buttress drugs
• “The corporation feels no pain.”
• 635M fine levied was divided amongst law enforcement, state, and federal Medicaid programs — the hardest hit counties got nothing
• once the drug hooks you in, nothing else matters to the person
• legal and medical structures meant to combat America’s heroin epidemic were woefully disconnected, often at odds with one another, full of unintended consequences
• no one was paying attention to heroin arrests when they only concerned the children of inner-city Black families
• once a person is addicted, he loses his power of choice; free will becomes hijacked along with the opioid receptors in his brain
• when a person’s natural opioids are shut down by the deluge of synthetic ones, creates a growing tolerance to the drug, making the brain crave ever-larger quantities of opioids just to keep from being violently ill
• best prevention advice — rid cabinets of anything that has codone, indicative of morphine components, in the name
• NAFTA, 1994 — tons of jobs went away in rural America
• Chinese peasants would better their lot by making chairs in factories, while dislocated American workers would retrain for more fulfilling, advanced jobs — this according to economists at the time
• global economy created winners and losers
• invisible hand manifested in soaring crime, food insecurity, disability claims
• federal disability program was becoming a de facto safety net for the formerly employed, a well-intentioned but ultimately disastrous way of incentivizing poor people to stay sick, with mental illness and chronic pain — majority of disability awards
• disability claims nearly doubled from 1996 to 2015
• poorer and sicker and work starved the already struggling parts of the nation truly were — media didn’t follow the story
• there is no less urgency and desperation in America’s middle and upper classes today when it comes to drug use
• genetics account for 50 to 60 percent of the risk
• other risk factors include poverty, unemployment, multigenerational trauma, access to drugs
• big enough for users to easily forge drug connections and yet small enough for drug dealers to hide out — Roanoke, VA
• suburbs the epidemic spread because of access to money
• early suburban wave stayed mostly hidden — parents there could afford to put their kids in a thirty or sixty day program
• broad American narrative promotes pills as a quick fix — between 1998–2005, abuse of prescription drugs increased 76 percent
• teenagers are dangerously comfortable with the notion of taking pills
• Adderall — studies show that over the long term those kids don’t do any better in school than people who don’t receive stimulants
• fewer than one quarter of heroin addicts who receive abstinence-only counseling and support remain clean two or more years
• recovery rate is higher, 40 to 60 percent, among those who get counseling, support group, and medication assisted treatment (MAT) such as methadone, buprenorphine, or naltrexone
• drug users are arrested four times more often than those who sell the drugs
• places with lowest overdose mortality rates tend to be in farming dependent counties with a more diversified economy
• perfect storm — collapse of work, rise in disability, flood of painkillers pushed by pharma, and regulators who approved one opioid pill after another
• Baltimore — highest per capita rate of heroin use in the country, residents 6X more likely to die from an opioid overdoes than the national average
• most authorities agree that indefinite, and maybe lifelong, maintenance treatment is superior to abstinence based rehab for opioid use disorder — Medication Assisted Treatment
• 8 years on average to get one year of sobriety … and four to five different episodes of treatment for that sobriety to stick
• FDA — inherent conflicts of an agency that both approves drugs and is then supposed to function as a watchdog over those drugs
• Americans, representing roughly 4.4 percent of the world’s population, consume roughly 30 percent of the opioids
• mail order Fentanyl — synthetic opioid considered 25 to 50 times stronger than heroin
• once a popularly diverted opioid prescribed in patch form for advanced cancer patients that was now being illicitly imported from china and mixed with heroin or manufactured into pills
• Gloucester MA — Campanello: turn in your drugs, I’ll hook you up with treatment instead of handcuffs — Gloucester Model, Police Assisted Addiction and Recovery Initiative, by 2017 had been adopted by 200 police agencies in 28 states
• public/private partnership where “angels” helped funnel addicts into treatment
• VA legislature repeatedly turned down attempts to pass Medicaid expansion in the wake of the ACA, sacrificing 6.6M a day in federal funds and insurance coverage for 400K low income Virginians
• in states where medicaid expansions were passed, the safety-net program had become the most important epidemic-fighting tool, paying for treatment, counseling, and addiction medications, and filling other long-standing gaps in care
• Oxy epidemic became Heroin, which itself would lead to more deaths from HIV and Hep C
• among public health officials, buprenorphine is considered the gold standard for opioid use disorder because it reduces the risk of overdose death by half compared with behavioral therapy alone
• critics compared the British makers of Suboxone with Purdue Pharma because of their zest for market saturation and noted that clinic operators have a financial incentive not to wean someone off the drug
• “No one wants to tell Prince he has an opioid problem.”
• methadone quelled narcotic withdrawal, but the Fed Bureau of Narcotics (precursor to DEA) was rabidly against using drugs to treat drug addiction (WWII period)
• Vivitrol — no abuse potential or street value, would therefore later become the favored MAT of law enforcement
• when complicated lives need repair, medication can only do so much
• as liberally as doctors could prescribe opioid painkillers up through 2016, they remained regulated as hell when it came to treating opioid addiction with methadone and buprenorphine
• battle lines over MAT and unyielding viewpoints lead the author to believe that that is the single biggest barrier to turning back overdose deaths
• drug courts remain among the country’s models for preventing recidivism and relapse
• graduates less likely to return to crime or drugs — singular place where prosecutors, defense attorneys, judges, and mental health advocates get together around a table to coordinate care and punishment, and discuss the daily challenges of the addicted
• best treatment for opioid addiction combines MAT with psychosocial support, although some benefit is seen even with low does and minimum support
• MAT should be predominantly expanded in the nonprofit realm of health departments, community service boards, federally qualified health centers, where salaried doctors are less motivated to overprescribe
• MAT opponents failed to see the distinction between people who abused buprenorphine and those who took it responsibly
• superiors outcomes with maintenance medications
• users can’t bet sober if they’re dead, and it’s cheaper and more humane to give them clean syringes, then it is to pay for HIV and/or Hep c treatment
• Vancouver officials launched supervised injection sites where nurses stood by to revive overdosed users, fostered the free exchange of used needles for clean ones, and distributed naloxone
• still only one treatment bed available for every five people trying to get into rehab, and at a cost far beyond the financial reach of most heroin users
• rehab isn’t standardized — gold standard is MAT
• 8 years, 4 to 5 attempts at rehab, to achieve remission for just a year
• only 10 percent of addicted population manages to get access to care and treatment for a disease that has roughly the same incidence rate as diabetes
• sober for a year = 50 percent chance of relapsing; sober for 5 years, chance of relapse was less than 15 percent
• drug involved offenders, who represent half the incarcerated population, had a recidivism rate of 75 percent
• statistically less likely to use or deal — Black and Brown people
• doctors didn’t trust people of color not to abuse opioids, so they prescribed them painkillers at a far lower rate (theory)
• “The whole thing is designed for you to come back.” (prison)
• felon friendly city like Seattle — jobs and harm reduction measures are more plentiful and police divert low level drug and prostitution offenders who are addicted from prosecution before they’re booked, assisting with housing, case management and employment services
• works to dry up demand for drug dealing
• Portugal — decriminalized all drugs, lowest drug rate in the EU, resources that were once devoted to prosecuting and imprisoning drug addicts were funneled into treatment instead
• jurisdictions across the country increasingly inhibit ex offenders ability to reenter society by assessing hefty court fines and fees, requiring them to pay thousands or face more jail time
• long term opioids in fact created more pain in many patients, condition known as opioid induced hyperalgesia
• Narcotics Farm — National Institute on Drug Abuse and the scientific notion that addiction is a chronic, relapse-ridden disease
• more than half of all patients taking Oxy are still on dosages higher than the CDC suggests
• Big Pharma will keep churning these drugs out
• crime has not historically risen in communities with access to clean needles
• rewarding activities — work, play, relationships to build lives around
• biggest barriers to treatment remain cultural
• Opioids now on pace to kill as many Americans in a decade as HIV/AIDS since it began, with some leveling off
• studies showed kids were more likely to use drugs after DARE
• the more we chose to talk about the epidemic as an individual disease phenomenon or moral failing, easier it is to obfuscate and ignore the social and economic conditions that predispose certain individuals to addiction
• reinvigorated democracy that provides a pathway for meaningful work, with a living wage, for everybody
• “the answer is always community”
• denying opioid addicted participants medicine they have legitimately been prescribed is akin to denying diabetics their insulin on the grounds they’re fat
• media cutbacks aren’t helping the issue
• sprawling heroin ring prosecutions that receive zero media attention
• americans now more likely to die of an accidental opioid overdose than they are from a car crash
• opioid overdose rates have risen among Blacks
• adopters of expanded Medicaid, the number one tool for helping the addicted access MAT
• if you’re addicted, where you live in the US can determine whether you live or die
• how we as a community of human beings can provide the environment for each other to thrive as well as recover from sometimes unspeakable hurt
• how many times should a person with opioid use disorder be given another chance? as many times as it takes
• fundamental philosophical difference between providing treatment for the addicted and punishing them via a War on Drubs that costs American taxpayers 47B a year
• expand harm reduction measures, Medicaid, easy access MAT
• expand our circle of compassion and empathy