Stoned

American Overdose. The Opioid Tragedy in Three Acts, Chris MacGreal, Faber & Faber, 2018, £12.99.

The doctor at the Wellness Center in West Virginia was receiving $6,800 a day in cash payments alone in return for prescribing a heavy opioid painkiller called OxyContin (generic name oxycodone). The drug’s street name was ‘hillbilly heroin,’ an accurate description of its effect on people to whom the doctors had prescribed it. It wasn’t very effective for chronic pain, but it was very effective in addicting users. And it was very, very profitable.

American Overdose is the story of how a high-minded search for better pain relief became a way of addicting tens of thousands of people and how legal prescription drugs became the gateway not just to financial catastrophe and overdose but also a gateway to the use of illegal heroin. The Food and Drug Administration, responsible for protecting US public health, did nothing to stop the unfolding catastrophe.

The author interweaves the stories of bereaved parents, desperate addicts and corrupt doctors with stories of regulatory apathy. By 2009 drug overdoses outnumbered deaths from traffic accidents and in the following year the death toll from legal prescription opioids rose to 16,651. Last year it was calculated that about 350,000 Americans had died from opioids since l999, roughly eight times the number of Americans killed in the last Iraq war.

In the USA pharmaceutical companies are allowed to run TV ads promoting their drugs to ordinary people. And to help with this marketing, as well as their paid salesmen, there is an unpaid but highly qualified sales force of doctors who will profit by selling to patients. To influence these doctors, the makers of OxyContin ran 40 all-expenses-paid ‘pain management’ conferences over a five-year period, distributed 34,000 coupons for free ‘starter supplies’, and gave away goodies such as soft toys, ‘pain management’ videos, and even a music CD titled ‘Get in the Swing with OxyContin’.

OxyContin wasn’t the first opioid painkiller on the market, but it was stronger than the previous ones. If it had been marketed as a painkiller for the severe pain of cancer patients, sales would have been limited. To sell large quantities it had to be marketed as a safe painkiller for moderate pain. Therefore, it claimed to be safer and less likely to cause addiction than the previous drugs. The evidence for this was a brief letter, not a peer-reviewed paper, in the New England Journal of Medicine, and a study based on just 38 cancer patients using opioid painkillers. The FDA official who oversaw these claims was not overly impressed, but he approved the drug for wide use anyway. Two years later he got a job at the drug’s manufacturers.

When the full scale of the resulting addiction started to be noticed, the Federation of State Medical Boards, which had received about 2m dollars from the drugs industry, came up with a way of explaining it. This wasn’t real addiction: this was pseudo-addiction. ‘Physicians should recognise that tolerance and physical dependence are normal consequences of sustained use of opioid analgesic and are not synonymous with addiction,’ it reported.

In one sense there was a difference between normal narcotic addiction and this new addiction. In this new addiction the drug dealers were not criminals, they were doctors; and these new addicts were not the usual addicts looking for illegal highs. These were people who would never have even sought out illegal drugs but were happy to take drugs prescribed by their doctor.

The money that could be made from repeat prescriptions corrupted several doctors. One Kentucky doctor prescribed more than two million pills for 4,000 patients over 101 days, while another saw 133 patients a day. The money corrupted elderly patients who became drug mules, selling their prescribed drugs to drug dealers. It ‘influenced’ politicians, who took generous donations from the pharmaceutical firms. Congress even passed a law, with the backing of the FDA, that made it easier for drug distributors to keep their licence even if they were caught breaking regulations.

Nothing seemed to stop the wave of dangerous painkillers. A new and even more powerful drug, fentanyl, 50 times more powerful than heroin, came on to the market and by 2013 caused its first overdose deaths. As late as 2014 the FDA approved yet another powerful opioid drug, Zohydro, despite its own expert committee voting against it.

Slowly the tide began to turn thanks to a few brave campaigning doctors, parents and the Center for Disease Control and Prevention who raised the alarm that the FDA should have done. President Trump tried to appoint as the ‘drug czar’ (who can remember the sheer pointlessness of Tony Blair’s drugs czar?) a man who had opposed any curb on opiate prescriptions, but after outrage, finally gave the job to a White House lawyer. He also declared the opioid crisis a National Emergency. As ever, talk was the easiest response to the crisis.

Meanwhile the consequences of this medical-made wave of addiction continues to take its toll of Americans. Oxycontin was brought under control, but as their prescriptions dried up, the addicts looked elsewhere. (When addicts cannot get their drug of choice, they make do with others.) The Oxycontin addicts turned to illegal heroin and illegally manufactured fentanyl. About 30,000 Americans have now died from fentanyl overdoses in the last recorded figures. The toll of addiction is not just deaths: addiction results in babies being born addicted, children taken into care, street crimes, homelessness, and suffering parents who have lost their children to drugs.

Could what happens in the USA happen here? Overprescribing doctors have always existed in the UK, even without the financial incentives that US doctors have. In the l980s a London doctor privately prescribed recreational heroin to city high fliers and as late as 2006 a doctor who ran an ‘addiction centre’ was struck off for reckless over-prescribing. Addicts are also expert at getting pills out of hurried or careless doctors. An addict friend of mine persuaded her GP to give her copious supplies of painkilling opiates and antiepileptics although the doctor knew she was already on a daily prescription of a heroin substitute. I was sad, but not surprised, that she died of an overdose last year.

Could over-prescription set off addiction in thousands here? I believe it could, if we persist in believing pills are the only answer for moderate pain. Prescription figures for opioids have risen by ten percent already in this country and fentanyl deaths are rising fast. OxyContin in the USA claimed to be non-addictive and the same claim was made in the UK about tranquillizers in the l980s. When the next ‘nonaddictive’ and ‘safe’ painkiller or tranquilliser comes on the market (as it will), shall we remember to be careful? Maybe if the UK regulatory authorities read this book, there is a chance they will require proper proof. I am not optimistic.

This book review appeared in the spring edition of the Salisbury Review. The next edition will be on June 1st 2019 .  Subscribe