Gone and buried were the doctor-addicted opioid users once common, especially in small towns—think of Harper Lee’s morphine-addicted eccentric, Mrs. Dubose, from To Kill a Mockingbird, or the morphine-addicted mother who inspired Eugene O’Neill’s Long Day’s Journey into Night. Think of the “Des Moines woman [who] gave her husband morphine to cure him of chewing tobacco,” as one newspaper chortled. “It cured him, but she is doing her own spring planting.”
Think of the time in 1914, decades before the term “neonatal abstinence syndrome” was coined (to describe the withdrawal of a baby born drug-dependent), when a Washington official wrote that it was “almost unbelievable that anyone for the sake of a few dollars would concoct for infant use a pernicious mixture containing…morphine, codeine, opium, cannabis indica, and heroin, which are widely advertised and which are accompanied by the assertion that they ‘contain nothing injurious to the youngest babe.’”
Below the story, on the same newspaper page, appeared an ad for an opium “sanitorium,” a sprawling Victorian home in Richmond in which Dr. H. L. Devine promised that he could cure opium addiction in ten days to three weeks.
But the yellowed newspaper warnings would become moot, like so many historical footnotes—destined to repeat themselves as soon as they receded from living memory.
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Despite all the technical, medical, and political sophistication developed over the past century, despite the regulatory initiatives and the so-called War on Drugs, few people batted an eye in the late 1990s as a new wave of opioid addiction crept onto the prescription pads of America’s doctors, then morphed into an all-out epidemic of OxyContin’s chemical cousin: Heinrich Dreser’s drug.
No one saw the train wreck coming—not the epidemiologists, not the criminologists, not even the scholars who for decades had dissected the historical arc of Papaver somniferum, the opium poppy.
Like Alexander Wood promoting his syringes, and Dreser with his sleepy frogs, Purdue Pharma’s David Haddox touted OxyContin for all kinds of chronic pain, not just cancer, and claimed it was safe and reliable, with addiction rates of less than 1 percent. Haddox heralded that statistic to the new army of pharmaceutical sales reps Purdue Pharma hired. They fanned out to evangelize to doctors and dentists in all fifty states with this message: Prescribing OxyContin for pain was the moral, responsible, and compassionate thing to do—and not just for dying people with stage-four cancer but also for folks with moderate back injuries, wisdom-tooth surgery, bronchitis, and temporomandibular joint disorder, or TMJ.
The 1996 introduction of OxyContin coincided with the moment in medical history when doctors, hospitals, and accreditation boards were adopting the notion of pain as “the fifth vital sign,” developing new standards for pain assessment and treatment that gave pain equal status with blood pressure, heart rate, respiratory rate, and temperature. The seismic shift toward thinking of patients as health care consumers was already under way, as patients now rated their health care experiences in formal surveys, Press Ganey the largest among them, and doctors and hospitals alike competed to see who could engender the highest scores, incentivizing nurses and doctors to treat pain liberally or risk losing reimbursements. In 1999, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nonprofit health care and hospital accreditation body, took the idea a step further, approving new mandatory standards for the assessment and treatment of pain.
The next year, Purdue’s bean counters gushed about the prospects: “This presents Purdue with the opportunity to provide true value-added services as the ‘pain experts’ in this key area,” read the company’s budget plan. “We have an opportunity to be seen as a leader in helping hospitals meet the JCAHO requirements in this area through the development of pain assessment and pain management materials geared to the hospital setting.”
To underscore such opportunities, the company planned to pass out $300,000 worth of OxyContin-branded scroll pens, $225,000 worth of OxyContin resource binders, and $290,000 worth of “Pain: The Fifth Vital Sign” wall charts and clipboards. With any luck, every nurse and doctor would soon be wandering the hospital halls, their name badges dangling from a Purdue-branded lanyard.
A 2000 New York Times article reflected the new and widespread view among the vast majority of health care experts that pain had been grossly undertreated for too long. It featured the story of an older woman in a nursing home who’d been left to writhe in pain, given only Tylenol for the relief of her severe osteoporosis and pulmonary disease. The story demonstrated the growing concern that pain was woefully mismanaged due to outdated notions about addiction: “Many health care workers still erroneously believe that adequate pain relief can leave patients addicted to the drugs.”
But what exactly was adequate pain relief? That point was unaddressed. Nor could anyone define it. No one questioned whether the notion of pain, invisible to the human eye, could actually be measured simply by asking the patient for his or her subjective opinion. Quantifying pain made it easy to standardize procedures, but experts would later concede that it was objective only in appearance—transition labor and a stubbed toe could both measure as a ten, depending on a person’s tolerance. And not only did reliance on pain scales not correlate with improved patient outcomes, it also had the effect of increasing opioid prescribing and opioid abuse.
“Every single physician I knew at the time was told to be much more serious about making pain a priority,” said Dr. John Burton, the head of emergency medicine for Carilion Clinic, the largest medical provider in western Virginia. “All it did was drive up our opioid prescribing without really understanding the consequences of what we were doing.
“I can remember telling my residents, ‘A patient can’t get hooked on fourteen days’ worth of [opioid] pills.’ And I was absolutely wrong.”
The Press Ganey survey upped the pressure, recalled an emergency-room doctor who practiced in St. Louis. “We quickly found that drug-seeking patients or others sending off vibes we didn’t like would give us bad reviews,” remembered Dr. David Davis. “When you’re really busy and interrupted all the time with seriously sick patients, it’s so easy to give them an IV dose of Dilaudid or morphine, and kinda kick the can down the road.
“I did it myself, though I knew it was not the right thing to do. It was pushed on us big time, the idea that they can’t become addicted if you’re using opioids to treat legitimate pain. The advent of the pain score, we now think, got patients used to the idea that zero pain was the goal, whereas now doctors focus more on function if the pain score is three or four.”
Compared with the New Zealand hospitals where Davis worked earlier in his career—often prescribing physical therapy, anti-inflammatories, biofeedback, or acupuncture as a first-line measure—American insurance companies in the age of managed care were more likely to cover opioid pills, which were not only cheaper but also considered a much quicker fix.
Little did Davis or the other ER docs understand that the routine practice of sending patients home with a two-week supply of oxycodone or hydrocodone would culminate by the year 2017 in a financial toll of $1 trillion as measured in lost productivity and increased health care, social services, education, and law enforcement costs.