Eight years after the 2007 sentencing of the company and three top executives for criminal misbranding, more lawsuits were being filed against Purdue and/or other opioid makers and distributors by the month, and they would grow to include such plaintiffs as the city of Everett, Washington; the state of Ohio; Cabell County, West Virginia; and Virginia’s tiny Dickenson County, not far from Lee. Purdue had followed Big Tobacco’s playbook when it downplayed the risks of its drug, and now some of America’s best legal minds were trying to make it and other pharmaceutical companies pay for the “public nuisance” burdening their communities. The states of West Virginia and Kentucky had already garnered modest settlement payments from Purdue, to the tune of $10 million and $24 million, respectively, victories that brought to mind the civil litigation brought by forty-six states and six other jurisdictions against the tobacco industry in 1998. Cigarette companies then agreed to pay billions to the states, in perpetuity, for the funding of prevention and public health programs.
But painkillers aren’t tobacco, and the cases differ partly because opioids have legitimate medical benefits when prescribed and used correctly, and the companies who make them use as fall guys the out-of-work coal miners and furniture makers and underchallenged youth who have illegally abused and diverted their drugs. “The cigarette companies finally caved, but only because the litigation costs were eating them alive,” said legal scholar Richard Ausness at the University of Kentucky. He foresaw the possibility of such a settlement being forged with opioid makers, but to a much smaller degree. “It’s a tough call because you want to punish them, but you may not want to put them out of business, because then you’re largely forgoing the right to any future claims,” he said. Tightening new opioid prescriptions through physician monitoring programs, then shifting the government’s focus to treatment and prevention, were more effective strategies than litigation, Ausness believed.
*
Haddox punctuated his talk with slides touting the work Purdue was undertaking to create new, “safer” painkillers. When his thirty-minute speech was over, the general practitioners in the audience grumbled a bit. Despite Haddox’s great slides and optimistic plans for new and improved opioids, the doctors were still slogging it out in the trenches. They knew they’d be the ones left holding the prescription pads when it came time to juggle their patients’ pleas for pain relief and addiction treatment with their patient satisfaction ratings, still used by many insurers to gauge reimbursements.
But Haddox remained firmly on point. “What’s getting lost here is the prevalence of chronic pain in this country,” he said. The optics of the opioid epidemic had clearly been bad for business. While Ronnie turned gray in prison and Kristi prepared the next seasonal decorations for Jesse’s grave, the Sacklers’ rank among “America’s Richest Families” slid from sixteenth to nineteenth on the Forbes list.
Powell Valley Overlook, Wise County, Virginia
Chapter Thirteen
Outcasts and Inroads
“If you want to treat an illness that has no easy cure, first of all treat it with hope.”
—Psychiatrist George Vaillant, Harvard Medical School
In 1925, the psychiatrist Lawrence Kolb Sr. published a set of groundbreaking articles arguing that addiction afflicted only people who were born with personality defects. He distinguished between “normal” users, who had been prescribed opiates by their doctors, and users who were “vicious” (a word deriving from “vice”), who had become addicted via illicit channels. The latter were much worse than the former, he initially believed, and this notion led him to categorize the addicted person as a criminal rather than a patient deserving of treatment and care.
In the mid to late 1930s, Kolb oversaw the opening of two U.S. Narcotics Farms, in Lexington, Kentucky, and Fort Worth, Texas, part of the federal government’s so-called New Deal for the Drug Addict. In bucolic rural settings, the government provided treatment both to the addicted who had arrived by court mandate and those who had volunteered, along with job training and medical care. Meanwhile, the government scientists were allowed to conduct research on the farms’ captive populations.
Kolb changed his beliefs about addiction after his colleagues proved to him that “normal” people, including the 10 to 15 percent of patients who were health care professionals, could become addicted, too, if they were opioid-exposed.
The work at the Narcotics Farm labs led to the field of addiction medicine. Both farms closed in the mid-1970s—due to an ethics scandal over experimentation on the addicted who were improperly exploited as research subjects. But their legacy includes the establishment of the National Institute on Drug Abuse and the scientific notion that addiction is a chronic, relapse-ridden disease.
Today, courts largely continue to send the addicted to prisons when reliable treatment is difficult to secure, and many drug courts controlled by elected prosecutors still refuse to allow MAT, even though every significant scientific study supports its use.
Not every patient wants or needs maintenance drugs, because every human experiences addiction differently, and what works for one might not work for another. Still, it is crucial to preserve treatments for people with addiction and help them obtain the means needed to get off drugs, rather than simply treat them as criminals who have no right to health care.
If my own child were turning tricks on the streets, enslaved not only by the drug but also criminal dealers and pimps, I would want her to have the benefit of maintenance drugs, even if she sometimes misused them or otherwise figured out how to glean a subtle high from the experience. If my child’s fear of dopesickness was so outsized that she refused even MAT, I would want her to have access to clean needles that prevented her from getting HIV and/or hepatitis C and potentially spreading them to others.
As the science historian Nancy D. Campbell, who documented Kolb’s work, has written: “Perhaps the day will come when more sensible views prevail—that relapse is the norm; that drug addiction should be treated as a chronic, relapsing problem that affects the public health; and that meeting people’s basic needs will dampen their enthusiasm for drugs.”
But there is so much more work to be done.
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Why, in less than two decades, had the epidemic been allowed to fester and to gain such force? Why would it take until 2016 for the CDC to announce voluntary prescribing guidelines, strongly suggesting that doctors severely limit the use of opioids for chronic pain—recommendations that echoed, almost to the word, what Barbara Van Rooyan begged the FDA to enact a decade before? Why did the American Medical Association wait two decades before endorsing the removal of “pain as the fifth vital sign” from its standards of care? If three-fourths of all opioid prescriptions still go unused, becoming targets for medicine-chest thievery, why do surgeons still prescribe so many of the things?
While it is true that doctor junkets funded by Big Pharma are no longer the norm, and physicians no longer ask reps to sponsor their kids’ birthday parties, more than half of all patients taking OxyContin are still on dosages higher than the CDC suggests—and many patients in legitimate pain stabilized by the drugs believe the pendulum has swung too far the other way.