Mind Wondering

Curating Curiosity

A Brief History of The Opioid Epidemic

“Perhaps all pleasure is only relief.” – William Burroughs (Junkie)

Our lives are marred by pain. It can take many forms: physical, mental, spiritual, and emotional among them. As a highly sensitive kid struggling with depression who excelled at football and constantly questioned the spiritual beliefs my fellow Oklahomans seemed to accept unconditionally, I suffered from all of them.

Early on, I realized that you could sometimes exchange one form of pain for another. When my emotional suffering became too much to deal with I turned to self-harm. Watching the blood trickle down my arm after cutting myself with whatever sharp object happened to be near me at the time eradicated the emotional anguish in my body and brain.

At least for a moment.

But it wasn’t long before I needed to cut again, and I eventually tried to make the final cut at 16 years old, slicing my wrist open with a boxed razor blade in an attempt to end the pain once and for all. As soon as I did this, I realized I didn’t actually want to die. I just didn’t want life to hurt so much. I decided I wouldn’t cut myself again and went looking for other ways to ease the pain.

Around this time, my friends and I started using prescription painkillers recreationally. Though they were only meant for physical pain, I realized that if I took enough of them, they’d get rid of all the other forms too. The best part was I didn’t even feel like I was doing anything wrong. After all, doctors were prescribing these to their patients. And, as a football player, my body was in a constant state of physical pain.

Over the next four years, I spent thousands of dollars maintaining what would eventually become a seemingly impossible habit to break. The details of my story may be unique, but the overarching theme isn’t. Americans are increasingly turning to prescription and illicit opioids to ease their suffering and both legitimate and criminal organizations are only too willing to prey on the nation’s vulnerability.

What follows is my attempt to discern why we’re experiencing an opioid epidemic using what I’ve learned from my own experience and the many books and articles I’ve read on the subject.

America First

When it comes to our health, America is flourishing. Not in life expectancy or infant mortality, where we rank 26th and 29th out of 35 industrialized countries according to the OECD Health Statistics. But in terms of health-related spending, we are in a league all our own. The United States spends over $10,000 per person every year on healthcare (double what most other wealthy countries spend) while having worse outcomes for its citizens. One of the things we spend money on is medication. In our constant quest to become the biggest, strongest, and fastest nation in the world, we’ve turned pill-popping into a sport as American as football.

Over 175,000,000 Americans take prescription pills on a regular basis. And not just one, but an average of four. These are often necessary and life-saving. At the very least, one would hope they’re life-enhancing. But there’s a reason almost every single one comes with a warning label.

Prescription Medication Warning Labels

Medications have side effects, some of which can be life-threatening.

One class of drugs that Americans are consuming at an alarming rate are opioids. You’ve likely heard the term in the news recently as physicians, politicians, and statisticians talk about the Opioid Epidemic. But what is an opioid?

noun: opioid; plural noun: opioids
An opium-like compound that binds to one or more of the three opioid receptors of the body.
noun: opium
A reddish-brown heavy-scented addictive drug prepared from the juice of the opium poppy, used as a narcotic and in medicine as an analgesic.

The same poppy that my mom uses for her delicious Lemon Poppy Seed Cake? Yep. In fact, very low levels of opiates are found in those seeds and, though it’s unlikely, can cause you to fail a drug test. But the Opioid Epidemic wasn’t started by a chubby 10-year-old lathering butter onto his fourth muffin of the morning. And, though it could be argued that they’re impossible to resist, the opioids we’ll focus on are far more perilous than a handful of poppy seeds or a few extra pounds.

Consider this: In 2016, more Americans died of drug overdoses than died in the 20-year-long Vietnam War. Of these deaths, 66% involved opioids (including illicit drugs like heroin) and 40% of those involved a prescription opioid such as OxyContin or Vicodin. In less than two decades, prescription painkillers have grown to kill as many people as all drugs had previously.

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CDC National Center for Health Statistics

I could include more statistics and graphs, but you get the idea. This shit is real. So how exactly did a flowering plant fuel the worst man-made health crisis in US history?

Papaver somniferum (“the opium poppy”)

A Brief History of Opioids

The opium poppy, from which our modern opiates all derive, was discovered in 3400 BC in Mesopotamia. Referred to by the Sumerians as the “joy plant”, it has a rich history of use and abuse spanning thousands of years, but really got out of control once modern science started playing around with things.

London’s Bill’s of Mortality.
December 19, 1665.

Fast forward a few centuries to the 1600s, a grim time compared to today’s standards. Consider London’s bills of mortality, a weekly death list compiled by John Graunt in the mid-1600s. Among other notable things, this was a time when a third of London’s children died before age seven and some of the highest rates of death were due to plague, tuberculosis, and “teeth and worms.” So little did they know about what was killing their countrymen that “frighted,” “lunatick,” and “lethargy” each received multiple entries.

Knowing how tenuous life was back then, it’s easy to see how a mixture of opium and alcohol called laudanum could become one of the most widely used medications of the time. To get your hands on a tincture of the stuff, you didn’t even need a prescription. All you had to do was head to the pub to pick up a bottle or grab some while you were waiting for a chair at the barbershop. Among other things, physicians recommended laudanum for: insomnia, menstrual cramps, diarrhea, headaches, cough, melancholy, and fussy children.

Even presidents got in on the action. Thomas Jefferson began treatment with laudanum in his twilight years, and in a letter to a friend, espoused its benefits. “The day before yesterday I rode about my garden in a walk half an hour, without any inconvenience at that time or since,” wrote the author of the Declaration of Independence. “I suppose therefore that with care and laudanum I may consider myself in what is to be my habitual state.”

Yes, our founding fathers were indeed sippin’ on some Sizzurp.

But the fun wasn’t finished yet. 150 years into laudanum’s tenure as a drug for all illnesses, science would find a way to kick it up a notch when German pharmacist Friedrich Sertürner first isolated morphine. Much stronger than the opium used at the time, he originally gave it the name Morpheus after the Greek god of sleep and dreams.

One of the original uses of morphine was as a cure for alcohol and opium addiction.

This wonder drug chugged along throughout the early 1800s, being added to laudanum and packed into rectal suppositories. However, it really picked up steam when a doctor named Alexander Wood invented the hypodermic needle. The invention of the needle allowed for more precise dosing and, I imagine, a much-preferred method of delivery when compared to its anal analogue.

Commercial Heroin

But science wasn’t done yet. Chemists, always looking to top previous achievements, eventually isolated a new compound from the opium poppy that was even more potent than morphine and believed to be non-habit forming. Just before the turn of the century, Bayer, who you might know better as the manufacturer of Aspirin, began marketing this compound for medical use under the name “heroin.”

At this point you may be wondering how doctors could make such egregious errors in determining whether or not a drug derived from opium was addictive. But consider the time; people were still traveling on horse and buggy and the telephone was in its infancy. Even if they had that hot new tech, doctors would have had a hell of a time finding enough of their counterparts’ numbers to spread the information wide enough to make a difference.

Still, some knew, and as the telephone became more ubiquitous and information more easily shared, heroin was eventually made illegal in 1924. While all this was happening, another opiate-based medicine was being used to get children to Go The Fuck To Sleep.

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Mrs. Winslow’s Soothing Syrup

To the right is an actual label for Mrs. Winslow’s Soothing Syrup, a laudanum-like cocktail marketed for children whose primary ingredients were morphine and alcohol.

Unfortunately for Mrs. Winslow, her “soothing syrup” would soon earn another nickname, “the baby killer.” As Alysha Strongman points out in her blog post for the Museum of Health Care, “A teaspoonful of the syrup would have contained enough morphine to kill the average child, so it isn’t hard to understand why so many babies who were given Mrs. Winslow’s Soothing Syrup went to sleep only to never wake back up again… Thousands of children are believed to have died from overdoses or from morphine addiction and withdrawal.

Hey, everyone makes mistakes, even Mrs. Winslow, and this deadly concoction was eventually made illegal in 1930… 19 years after its morbid moniker told everyone the “wind” it was relieving was a child’s ability to breathe.

But this was a different time, and deducing what was actually killing these kids was much more difficult than it would be today. After all, diarrhea, one of the conditions the syrup was meant to treat was, and still is, extremely deadly to babies. How could they have known it was from the Soothing Syrup and not the ailment it was meant for?

Luckily for us, this could never happen today.

OxyContin Takes Control

Purdue Pharma began developing OxyContin because of the fear that generic medications might overtake the opioid market when their patent on MS Contin, a painkiller designed for cancer patients and the biggest seller in the company’s history, eventually ran out.

In an internal memo from 1990 under the heading, “Rationale for Another Controlled-Release Opioid Analgesic”, Purdue’s vice president of clinical research wrote, “MS Contin may eventually face such serious generic competition that other controlled-release opioids must be considered… While we are ‘going laterally’ with MS Contin to non-cancer pain indications, it would be unwise to ‘put all of our eggs into the MS Contin basket’ in face of the prospect of generic MS Contin competition that would ‘crush all of the analgesic eggs.’”

Fortunately for Purdue Pharma, it wouldn’t take long to create another basket for their analgesic eggs. OxyContin was approved by the FDA in 1995, five years after that internal memo was sent and before any trials measuring its potential for abuse had been done. But, as Patrick Radden Keefe points out in his New Yorker article “The Family That Built An Empire of Pain“, that didn’t prevent our government from allowing Purdue to market the drug as “safer” than alternatives saying that its patented 12-hour formula reduced its potential for abuse.

Yes, the drug that would soon be referred to as “Hillbilly Heroin” and provide the spark that lit the fire of our current epidemic was allowed to be marketed as safer than alternative pain treatments by the Food & Drug Administration despite any evidence of it actually being safer.

You’ll be happy to know that the FDA agent overseeing this process left the department shortly after…

Thank god!

…and in less than two years was working for Purdue Pharma.

What the fuck?!

Well, the government doesn’t pay for shit, so it makes sense that he would go to a company willing to offer a higher salary to its employees. And, if there’s one thing Big Pharma has, it’s a shitload of dough.

In 2001 alone, Purdue Pharma spent 200 million dollars to promote OxyContin. That’s over 5,000 times the average starting salary for teachers in the U.S. and enough to feed 2,000,000 hungry kids every weekend for an entire year.

Dr. Art Van Zee’s article, The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy, goes into depth on the promotion and misrepresentation of OxyContin. The crux of this campaign focused on the “fact” that OxyContin was a sustained-release (“Contin” for “continuous”) version of oxycodone (“Oxy”) that patients only needed to take twice per day, and thus, it was less addictive than alternative pain medications taken at more frequent intervals. As early as 1997, internal memos show that Purdue knew its highest-selling drug was being abused, yet it continued to train its sales reps to push the claim that “less than 1%” of patients were at risk for addiction.

Here’s a video they used to market the drug to doctors…

  • “Much less than 1%.”
  • “They don’t wear out.”
  • “They go on working.”
  • “They do not have serious medical side effects.”
  • “…should be used much more than they are for patients in pain.”

So, basically, you can just say whatever you want in a campaign marketed at doctors. Why didn’t the FDA do something this time?

Well, Purdue sent this video to over 15,000 doctors without submitting it to the FDA first, which is, in fact, illegal.

Oops.

This aggressive marketing of OxyContin didn’t stop at commercials. Here’s a list of some of other tactics Purdue Pharma used…

  • All-expenses paid conferences at resorts in Florida, California, and Arizona, aimed at getting physicians to become part of Purdue’s national speaker bureau. This practice has been shown to affect prescribing habits.
  • Exorbitant bonuses for reps that increased sales in their territories. All told, Purdue paid $40 million in bonuses tied to OxyContin in 2001, up from $1 million in 1996, the year it was released.
  • A coupon starter program that allowed patients to try a limited-time prescription of OxyContin for free.
  • Internal pressure from sales managers who urged reps to spend a majority of their time selling OxyContin with such overly expressive sales strategy memos as this – “Dedicate 70% of your time selling Oxycontin!!!!!!!!!!!

My favorite of all the tactics was the creativity behind the OxyContin swag. Among other things, sales reps distributed hats, coffee mugs with heat-activated messages, pens with a pullout chart to help physicians convert a patient from another pain-reliever to OxyContin, luggage tags, plush toys, and the chart-topping CD, “Swing is Alive.”

What kid wouldn’t want to cuddle up with this…

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OxyContin 80mg Plush Toy

Let’s be honest, the little guy’s cute… until you realize that 80mg of OxyContin is a lethal dose for new users of the drug.

As much as we hate to concede marketing’s immense influence on our decisions, it works.

Purdue Pharma’s prescriptions for OxyContin skyrocketed from under one million in 1997 to 6 million+ in 2002, while sales grew from $48 million in 1996 to over $1 billion in 2001.

Imagine how much more money they could have made had they released this classic on Vinyl…

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OxyContin CD “Swing is Alive”

It wasn’t all glory for Big Pharma though. In 2007, a decade after OxyContin’s release, Purdue was sued for making the false claims that the medication was less addictive and less likely to be abused than other painkillers. Eventually, it was ordered to pay $634.5 million dollars.

While that amount of money is almost unheard of for most people and companies, it represented less than 2% of the $35 billion the company had made from its sales of OxyContin, and no one went to jail.

If you were a drug dealer, you’d kill for a plea like that. Imagine if you made a million dollars and all you had to do was pay an $18,000 fine with no jail time. Cha-ching!

Still, a guilty plea and $600 million dollar settlement is a goldmine for journalists and because of the bad press, Purdue could no longer ignore its OxyContin problem. And so, three years after forking over the dough, Purdue took a big step in decreasing OxyContin’s risk for addiction by introducing an abuse-deterrent formulation (ADF) of the drug. Now when you tried to crush up a pill or boil it into a liquid, it would turn into a gummy substance instead of a fine powder that could easily be snorted or injected.

The FDA approved the reformulation in April 2010 and allowed Purdue to market the new version of OxyContin as having “abuse-deterrent properties” on the label. Four months later, Purdue ceased shipping the abuse-able formulation entirely and shifted exclusively to the new ADF.

They gave no public notice that this was happening.

Needless to say, addicts were in for a big surprise. But perhaps forcing them to stop by abruptly cutting off their supply would be the kickstart they needed to turn their lives around.

Hooked on Heroin

The graph below shows the dramatic rise in heroin deaths over the past seven years…

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Source: CDC Wonder

In a thoroughly researched paper titled, “How the Reformulation of OxyContin Ignited the Heroin Epidemic”, the authors attempt to draw a parallel between the reformulation and rise in heroin use. Their conclusion states that “the switch to the ADF of OxyContin in August of 2010 led to the increase in the heroin death rate and we find that in states that were at a high-risk of substitution from opioids to heroin, the reformulation did not reduce the combined heroin and opioid death rate at all.”

In his book, Dreamland: The True Tale of America’s Opiate Epidemic, author Sam Quinones offers another perspective. Here’s what three heroin dealers had to say about getting addicts to make the switch from OxyContin…

“At first, addicts crushed the pills and snorted the powder. As their tolerance built, they used more. To get a bigger bang from the pill, they liquefied it and injected it. But their tolerance never stopped climbing. OxyContin sold on the street for a dollar a milligram and addicts very quickly were using well over 100 mg a day. As they reached their financial limits, many switched to heroin, since they were already shooting up Oxy and had lost any fear of the needle.”

“It was part of the marketing strategy. Chiva (heroin) is the same as OxyContin; just OxyContin is legal. OxyContin users change to chiva. They can get our stuff more easily than going to a doctor for the pills.”

“I’ve yet to find one who didn’t start with OxyContin. They wouldn’t be selling this quantity of heroin on the street right now if they hadn’t made these decisions in the boardroom.”

Dreamland – Sam Quinones (2015)

There’s certainly an argument to be made here that correlation does not equal causation. People who abuse prescription opioids have always been at a greater risk to progress to heroin use and the reformulation may have just sped up this process instead of actually creating an increase in overall users. What is clear is that Big Pharma’s push to get doctors to prescribe more painkillers to more people for longer periods of time has increased the risk that individuals will become dependent on them. And addiction to a prescription opioid is the number one risk factor for heroin addiction, one of the toughest addictions to break with one study reporting relapse rates as high as 91%.

If all this sounds scary, keep in mind that heroin isn’t even the scariest opioid out there…

Synthetic Opioids Hit the Streets

Fentanyl Patch

If you’ve been paying attention to the news and know even a little bit about the Opioid Crisis, you’ve probably heard of Fentanyl. It’s gained press in pop culture news over the past few years as the drug that killed Prince and Tom Petty.

But Fentanyl has actually been around for quite some time. Developed by Janssen Pharmaceutica in 1959, Fentanyl was initially used to anesthetize patients and/or provide pain relief in a medical setting. It wasn’t until the mid-90s that the Fentanyl patch was developed as a treatment for chronic pain and the opioid made its way out of the hospital and into the streets.

Neither endogenous nor exogenous, Fentanyl is a synthetic opioid. What this means is that, like Frankenstein’s monster, it was developed in a lab and is much stronger than anything a poppy plant could produce.

Fentanyl is 100 times more potent than morphine and up to 50 times stronger than heroin.

Lethal Dose of Fentanyl

Needless to say, it doesn’t take much to kill you. To the left is an image showing a fatal amount of Fentanyl for most people.

If being hooked on heroin is like playing Russian Roulette, then illicit use of synthetic opioids is like aiming a loaded gun at your temple and hoping to god it backfires.

Considering how big a punch is packed into a tiny amount of Fentanyl, you can imagine how difficult it is to stop it from being smuggled into the states. An article from the The Economist detailing the near impossibility of keeping Fentanyl out of the country breaks down the monetary value of a kilo of Fentanyl compared to a kilo of heroin, saying the DEA recently estimated a kilo of heroin would fetch $80,000 on the streets, whereas a kilo of fentanyl could get you as much as $1.9 million.

Not only does its size make it easier to smuggle, but since it can be made in a lab with simple and inexpensive materials in about a week, it’s cheap. $1,000 worth of heroin, chopped up and sold on the streets, could fetch the dealer a profit of $4,000. The same thousand dollars worth of fentanyl bought from China could bring in $7,800,000 (Bloomberg).

If you’re a drug dealer, switching users from OxyContin and heroin to fentanyl is a no brainer. And if you’re like me and thinking that something a strong as fentanyl being in the hands of people that aren’t trained professionals sounds like a recipe for death and disaster, you’d be right as well. The graph below shows the contribution synthetic opioids have made to overdoses over the past 20 years.

Source: CDC Wonder

At this point, you might be wondering how something 50 times stronger than heroin, a drug the DEA has labeled Schedule 1 for having no accepted medical use and a high potential for abuse, can be legal while heroin is not. But Fentanyl isn’t even the strongest opioid on the market.

Sufentanil, a synthetic opioid 10 times more potent than Fentanyl and over 200 times as potent as heroin, was approved at the end of 2018 for management of acute pain in adults despite warnings from many in the medical community, including chairman of the FDA’s Anesthetic and Analgesic Drug Products Advisory Committee Roster, Dr. Raeford Brown, that it would only make our current opioid epidemic worse. In a letter to the FDA opposing the approval, Dr. Brown urges the FDA to “reject this needless and dangerous addition to the FDA-approved opioid armamentarium. It has no truly unique benefits and will only add to the worsening, not the mitigation, of the opioid epidemic in this country.”

For those of you searching for the line drawn by the FDA, you’ll need to head down the synthetic opioid path until you hit Carfentanil. Known as The Elephant Tranquilizer because it’s only accepted use is as a tranquilizer for large animals, Carfentanil is 100 times stronger than Fentanyl and 10,000 times more powerful than morphine. This compound is so deadly that the US and other countries have prepared for its use as a deadly chemical agent in war (Vox).

Being as strong as it is, a single dose of Naloxone or Narcan, medications used by first responders to rapidly reverse opioid overdose, are often insufficient to save the lives of people who’ve unwittingly taken Carfentanil.

Maybe that will be enough to stop Big Pharma lobbyists from espousing Carfentanil’s benefits to greedy politicians when they realize how much money can be made from this stuff in the future. For now, to get your fix you’ll have to settle for getting it from your drug dealer. Of course, they won’t tell you this is what you’re getting. Carfentanil sounds more like designer battery acid than a fun night out. It certainly doesn’t have quite the same ring to it as heroin or OxyContin, which is how dealers will be selling it.

If we’re hopeless against the legitimate and illegal drug dealers of the world, what are we supposed to do?

We could blame the addicts. After all, no one forced them to take their medications and it’s their fault for not being able to stop when they realized they had a problem. Deep down they’re all just junkies who like getting high, right?

Let’s explore that theory by taking a look at what opioids do to our brains.

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The Brain on Opioids

2 Comments

  1. Larry Lewyn

    Awesome read. Very well written, with the perfect mix of wit and fact.

    • jjnaylor

      Thanks so much for your reply, Larry! My goal was to make it entertaining enough to convey some information on the current state of opioids in America without it being all doom and gloom. Glad you enjoyed it!

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