Van Zee attended a nearby meeting of the Appalachian Pain Foundation, a Purdue-funded professional association whose job was to capitalize on the growing pain-management movement of the 1990s and to amplify its organizing principle—that pain remained vastly undertreated. The invitation to the meeting featured a quote from a seventeenth-century English apothecary: “Among the remedies which it has pleased Almighty God to give man to relieve his suffering, none is so universal or efficacious as opium.”
Van Zee presented the company with two major requests: stop the aggressive marketing of OxyContin for the treatment of noncancer pain, and reformulate the drug to make it less prone to abuse. As an example, he touted the makers of the painkiller Talwin, who in a 1982 reformulation had added a narcotic blocker, or antagonist, called naloxone, to the mix—and immediately reduced the drug’s diversion and misuse.
In the fall of 2000, a newspaper story had run in nearby Tazewell County, Virginia, about an uptick in crime—between August 1999 and August 2000, 150 people had been charged with OxyContin-related felonies. In a county of just 44,000 people, there had been ten armed robberies of drugstores in the past eighteen months. Unemployed Tazewell miners like Doug Clark, who’d once made thirty-five dollars an hour, were now in legal trouble for ripping copper from an abandoned mining-equipment shop—to resell on the black market and fund his next OxyContin buy. Clark had gotten hooked after surgery to repair an injured neck and broken jaw; a rock had fallen on him inside a nearby Russell County mine, since closed.
Purdue’s medical director, Haddox, called the reporter, Theresa M. Clemons, to complain about her crime coverage, and he seemed intimidating.
Now, at the meeting that followed Clemons’s reporting, Haddox met with Van Zee, the county prosecutor, and other county officials, who told him about Oxy-related property crimes and check forgeries, and addicts who were doctor-shopping multiple physicians to feed their habit and to make a buck. Hypodermic needles were turning up at routine traffic stops.
While Purdue was concerned about the problem in the coalfields, Haddox said, he believed the worries were overblown. At the meeting, when Haddox and his colleagues steered the conversation toward the underprescribing of narcotics, prosecutor Dennis Lee was gobsmacked.
“We have never seen anything like this before,” Lee interrupted. “There’s just no comparison. Not just pill counting, but the human [tragedies].”
On the way out of the meeting, Van Zee pulled Haddox aside to reiterate his concerns about the promotional gimmicks the company was lavishing on doctors. The physician freebies needed to stop, Van Zee said.
“How is that any different from what every other drug company does?” Haddox fired back.
“People aren’t stealing from their families or breaking into their neighbors’ homes over blood-pressure pills,” Van Zee said.
Van Zee didn’t yet grasp what was truly driving the furious rate of overprescription. Sales-rep bonuses were growing exponentially, from $1 million in 1996, the year OxyContin hit the market, to $40 million in 2001. New patients were given OxyContin “starter coupons” for free prescriptions—redeemable for a thirty-day supply—and Purdue conducted more than forty national pain management and speaker-training conferences, luring doctors to resorts from Boca Raton, Florida, to Scottsdale, Arizona. The trips were free, including beach hats with the royal-blue OxyContin logo. More than five thousand doctors, nurses, and pharmacists attended the conferences during the drug’s first five years—all expenses paid.
“The doctors started prostituting themselves for a few free trips to Florida,” recalled lawyer Emmitt Yeary from nearby Abingdon, Virginia. As Van Zee delivered his message in meetings and letters, some desperate families hired Yeary to represent their loved ones for Oxy-related crimes. “The irony of it was, the victims were getting jail time instead of the people who caused it,” Yeary recalled.
He remembered a dislocated coal miner from Grundy, Virginia, confessing that OxyContin had become more important to him than his family, his church, and his children. “It became my god,” the man said.
*
By the end of 2000, Purdue had passed out fifteen thousand copies of an OxyContin video called “I Got My Life Back: Patients in Pain Tell Their Story,” without submitting it to the FDA for review, as required by the agency.
The video, available for checkout from doctors’ offices, lauded OxyContin’s effect on patients’ quality of life and minimized its risks. The doctor-narrator heralded the new term “pseudo addiction,” wherein opioid-seeking patients “look like a drug addict because they’re pursuing pain relief…[when in reality] it’s relief-seeking behavior mistaken as drug addiction.” He then repeated Haddox’s favorite sound bite: that opioid analgesics caused addiction in less than 1 percent of patients.
The source of this claim was a one-paragraph letter to the editor of the New England Journal of Medicine written in 1980. The letter was never intended as a conclusion on the risks of long-term opiate use, one of the authors would much later explain, yet it was trotted out repeatedly during OxyContin’s first decade.
At Dine ’n’ Dash gatherings and in doctors’ offices from the coalfields to the California coast, this letter about an unrelated initiative was repeated and tweaked until its contents no longer resembled anything close to the authors’ intention, like an old-fashioned game of telephone gone terribly awry.
A year after starring in the Purdue Pharma video, that same doctor, South Carolina pain specialist Dr. Alan Spanos, gave a lecture insisting that patients with chronic noncancer pain should be trusted to decide for themselves how many painkillers they could take without overdosing—just as the morphine-dispensing doctors had said of wounded Civil War veterans a century before. He reasoned that the patients would simply “go to sleep” before they stopped breathing.
*
By March 2001, Van Zee was as fed up with letter writing as the alarmed Richmond doctor had been in 1884, precisely two decades before his peers took up the cause and three decades before the government began regulating the drugs: I have heard them, with tears in their eyes, say that they wished it had never been prescribed for them.
Van Zee’s neighbors were dying. The region had now buried forty-three people, dead of oxycodone overdose, since Purdue launched its drug. Addicted users had gone from snorting to routinely injecting the liquefied crushed-up powder with livestock syringes they bought (or stole) from local feed stores. At the Lee County jail, seventy-nine people were crammed into cells designed to hold thirty-four. “We were so overwhelmed, we were just stacking ’em on the floor,” the sheriff, Gary Parsons, told me; one of the prisoners had bought four OxyContin tablets by trading away his family’s mule.
While attempting to make a night deposit at the bank next door, the manager of Payless Supermarket in nearby Coeburn was gunned down by a masked robber trying to fund his next Oxy fix.
A half hour away in Clintwood, a man made the bold move of throwing a cement block through the front door of a pharmacy, even though it was across the street from the courthouse and the sheriff’s department. “A deputy heard the alarm go off, and here’s this guy running away and dropping pill bottles along the way, he’s so high,” Richard Stallard, the lieutenant, recalled.