American Overdose: The Opioid Tragedy in Three Acts by Chris Mcgreal Kate Womersley
American Overdose: The Opioid Tragedy in Three Acts By Chris Mcgreal Faber & Faber £12.99
When it comes to pain, I’m a nervous prescriber as a doctor. Pain is not a condition in itself, but a clue to something else going on: acute, chronic, physical or psychological. There’s no blood test to say which or how much analgesia to give; no precise algorithm to predict who will crave more.
The first step on the World Health Organisation’s ‘analgesic ladder’ is paracetamol and ibuprofen, followed by weak narcotics such as codeine, then up to stronger ones, including poppyderived opiates such as morphine, and the newer synthetic opioids of oxycodone and fentanyl. Mostly, the drugs bring some relief. Patients are grateful. The exchange feels physicianly.
A drug is maximally profitable when lots of people can be persuaded to take it every day, while their underlying state is unchanged or worsened, and they need ever-larger doses to feel the same effect. Medically, this is disastrous, which is partly why doctors have tended to be wary of narcotics.
Only when Cicely Saunders started the hospice movement in the 1970s was the opprobrium over morphine rightly questioned, and opiates became an established part of palliative care and cancer treatment. By the 1990s, against this backdrop of compassionate use, doctors were primed to reconsider opioids for other purposes too.
Chris Mcgreal’s American Overdose tells the story of Oxycontin, an old drug dressed in new clothes. Its active ingredient, oxycodone, has been around since 1917, but it took two brothers, both doctors with a flair for advertising, to make it a blockbuster. Mortimer and Raymond Sackler – their surname synonymous with philanthropy, chiselled into stone facades on university campuses and art galleries on both sides of the Atlantic – were the owners of Purdue Pharma, which in 1996 launched Oxycontin and its ‘slow-release technology’. For moderate or severe pain, Oxycontin promised 12-hour relief without an addictive kick. The Food and Drug Administration (FDA) rubberstamped these claims, despite weak evidence to support them.
When safety was questioned, Purdue retorted that 50 million Americans were suffering from untreated chronic pain. Mcgreal is evasive about the idea that pain needed, and still needs, more medical attention. It certainly does, even in the UK, where free access to healthcare is a human right. This kernel of truth in Purdue’s opportunistic campaign explains why well-meaning doctors took their bait. In hospitals, pain became known as the fifth vital sign. But unlike temperature, pulse, blood pressure and respiration rate, no objective scale exists to distinguish discomfort from agony. Meanwhile, patients believed that drugs from clinics must be safe. The epidemic of pain bred an epidemic of reckless prescribing and ‘accidental addiction’.
Rural Appalachia was the epidemic’s ground zero. Mcgreal tells the tragedies of locals in Williamson – or Pilliamson as it was known – where corrupt doctors became drug dealers, pre-signing prescriptions for hundreds of hooked customers who waited in line to hand over cash each morning. Independent pharmacies, some with a drive-through window, prospered in deprived West Virginian towns. Firemen were more often called out for overdoses than conflagrations.
The warning label on Oxycontin was actually a recipe for getting high: tablets ‘are not to be broken, chewed or crushed’ as this ‘could lead to rapid release and absorption of a potentially toxic dose’. Purdue said that inappropriate use was not the fault of the drug, but rather that of patients prone to addiction. It took until 2007 for Purdue to be found guilty of fraudulent marketing, and fined £475 million. This was a tax more than a deterrent. By 2015, the Sacklers had made £11 billion from Oxycontin, emboldened by ‘a medical system run not as a service for the public good but as a business for corporate profit’. When regulation was eventually stepped up, the crisis was not resolved. Since 2016, illegally imported fentanyl and street opioids have replaced prescriptions to increase the death toll further.
What American Overdose masterfully demonstrates is how the privacy of pain has become a public health concern. To call opiate abuse an ‘epidemic’ is not mere metaphor. This ‘modern-day plague’ has been more destructive than the infectious spread of AIDS at its height. Pain, and the drugs to treat it, are traded by human actors, contaminating areas of social deprivation where opportunities are few and permanent injuries the routine cost of physically demanding labour.
Unlike their counterparts in the US, British doctors are more willing to
accept national guidelines telling them how to do their job. This surveillance is hugely valuable. It makes pain relief more democratic and ensures that society as a whole participates in both its risks and its rewards.