How did opioids become killers?

Addiction’s grip traps thousands, often fatally

Editor’s note: More Americans die each year now from drug overdoses than from car crashes, gun homicides and AIDS-related deaths combined. Most of the overdoses come from opioids, which since ancient days have been relieving pain, providing pleasure and killing people.

Dr. Bill Fannin found his son unconscious in his bedroom. Medical training and a father’s love told him what to do.

The Pikeville, Kentucky, physician cupped his son’s face and tried to resuscitate him on this October evening in 2011. He pushed down on his son’s chest.

Sean Fannin lay there, still unmoving.

“It was,” Fannin recalled, his voice fading as he spoke, “too late.”

He soon learned Sean had overdosed on a drug derived from the opium poppy.It was a drug the doctor knew all too well, one he had prescribed to many patients to ease their pain.

A native of Prestonsburg, Kentucky, Fannin attended the University of Ken-

tucky’s medical school and trained under a pain specialist.

He learned that pain fell into three categories: acute, cancer-related and chronic. Doctors typically treated patients who suffered acute pain (for instance, after surgery or an accident) with a short-term prescription of opioids mixed with less powerful painkillers, such as aspirin or acetaminophen (under brand names such as Percodan, Vicodin, Percocet and Lortab).

Doctors typically treated patients with cancer-related pain with opioids such as morphine. For patients with serious or terminal diseases, addiction was much less a concern.

But doctors hesitated to prescribe these powerful opioids for chronic pain because they feared patients might become addicted.

Fannin understood pain didn’t always need pills.

‘New class of addicts’

German scientists worked with the morphine molecule and came up with oxycodone. It seemed to have fewer side effects but was no less addictive.

In 1950, the FDA approved Percodan, which combined oxycodone with aspirin. Nearly a quarter-century later, Percocet — a combination of oxycodone and acetaminophen — followed.

By 1962, doctors had prescribed nearly 36 million Percodan in California. The state’s attorney general concluded the drug was creating a “new class of addicts composed of otherwise honest, not criminally inclined persons.”

Addicts eventually included singer Elvis Presley, who died of a drug overdose in 1977, and comedian Jerry Lewis, who received the opioid after a spinal injury and became addicted for 13 years.

In the 1980s, some doctors, including pain specialist Dr. Russell Portenoy, offered the solution to millions of Americans suffering from “untreated pain.” He became the first president of the American Pain Society, which drugmakers helped fund.

The society campaigned for health care providers to make pain the “fifth vital sign,” joining blood pressure, temperature, heartbeat and breathing.

The Federation of State Medical Boards, which received up to $2 million from drugmakers, recommended doctors not face punishment for prescribing large amounts of opioids and called on those boards to punish doctors who “undertreated” pain.

By the 1990s, juries awarded more than $16 million to patients and families whose loved ones suffered from pain, concluding the nursing homes, nurses and doctors that failed to give opioids were guilty of negligence.

‘The fifth vital sign’

By the mid-1990s, Fannin, who served in the Army in Vietnam, was working part time at a Veterans Affairs clinic in Prestonsburg.

That was where he first heard doctors call pain “the fifth vital sign.”

It seemed odd to equate pain with something like breathing, but he understood the need to “dignify” and take care of pain.

He noticed doctors seemed too willing to prescribe these opioid pills for chronic pain, patients too willing to take them and insurers too willing to pay.

“Pain as the fifth vital sign” became policy at the VA clinic and VA hospitals across the U.S.

The Joint Commission began requiring hospitals to assess all patients for pain on a scale of 1 to 10. Purdue Pharma gave the commission a grant to produce a pain assessment and management manual.

Officials from the commission and Purdue denied the company had anything to do with the content of the manual, although it was co-written by Dr. June Dahl, who served on the speakers bureau for Purdue.

The manual told health care facilities: “There is no evidence that addiction is a significant issue when persons are given opioids for pain control.”

The painkiller market

Since 1987, Purdue Pharma had been selling a timed-release drug named MS Contin, the company’s version of morphine. Seven years later, it became Perdue’s best-performing painkiller with annual sales topping $88 million.

But the company faced problems.

Doctors knew how addictive morphine could be, and most were reluctant to prescribe MS Contin to patients suffering from chronic pain.

The even bigger problem? MS Contin’s patent would expire soon, which would allow generic drug manufacturers to create their own versions of MS Contin and eat into Purdue’s share of the painkiller market.

A generation earlier, Arthur Sackler, the brother of Purdue’s owners, had marketed Valium and other tranquilizers to women experiencing anxiety, tension or countless other symptoms. The drug broke all sales records, turning many women into addicts and Sackler into a multimillionaire.

The Sackler family planned to repeat that success with a timed-release version of OxyContin, the company’s version of oxycodone.

In internal Purdue documents obtained by the USA TODAY NETWORK, company officials gushed that OxyContin could become a hit in “the $462 million Class II opioid marketplace.”

These documents detail their strategy: They would first market OxyContin strictly for cancer pain, where doctors were familiar with oxycodone, then pivot to the lucrative market of chronic pain, which afflicted at least 25 million Americans.

Purdue’s plan included targeting primary care physicians, surgeons, obstetricians and dentists

The plan also included targeting patients and caregivers through Purdue’s “Partners Against Pain” program. “You are the expert on your own pain,” the website reassured patients.

The website reassured patients that the risk of addiction to opioids “very rarely occurs when under medical supervision to relieve pain.”

Purdue sponsored more than 20,000 educational programs to encourage health care providers to prescribe the new drug and sent videos to 15,000 doctors.

It also hosted dozens of all-expenses-paid national pain management conferences, where more than 5,000 physicians, pharmacists and nurses were trained for the company’s national speakers bureau.

By 2001, Purdue was spending $200 million on marketing and promotion and had doubled its sales force to 671. Before the year ended, sales bonuses reached $40 million.

Addiction knowledge: ‘zip’

Fannin remembers sales reps from Purdue flooding doctors’ offices in Appalachia, where poverty and pain are constant realities. They gave away fishing hats, stuffed toys and music CDs titled “Get in the Swing with OxyContin.”

“We had a population of doctors with very little grounding in pain, and I think Purdue took advantage of that,” Fannin said.

Many doctors knew about oxycodone from Percocet. What many of them didn’t realize was it was nearly twice as powerful as morphine, delivering a powerful high to those who use the drug.

“It’s more like heroin,” explained Dr. Andrew Kolodny, co-director of the Opioid Policy Research Collaborative at Brandeis University. “It crosses the blood-brain barrier more quickly.”

But the sales reps never mentioned that.

They talked of studies, citing one that found only four of 11,882 became addicted after using opioids. Portenoy and others repeatedly cited what some called this “landmark study.”

The truth is it wasn’t a study. It was a five-sentence letter to the editor a doctor wrote the New England Journal of Medicine.

For the most part, Fannin and other doctors believed what the sales reps were telling him. So did other doctors in the region.

“Our knowledge about addiction,” he said, “was about zip.”

So they spread the opioid with their prescription pads, and it settled into the Appalachian mountains like the ever-present morning fog.

OxyContin became the blockbuster in 2001 that Purdue officials dreamed of, with more than 7 million in prescriptions and nearly $3 billion in revenue. By 2015, the Sackler family had made $14 billion, joining Forbes’ 2015 list of America’s richest families, edging out the Rockefellers.

A nation addicted

In five years, OxyContin prescriptions for chronic, non-cancer pain shot up almost tenfold from about 670,000 in 1997 to 6.2 million in 2002.

Admitted abusers of OxyContin jumped from 400,000 in 1999 to nearly 3 million in 2003. By 2009, abuse of prescription painkillers had played a role in the nation’s record 1.2 million emergency room visits.

Former Mississippi Attorney General Mike Moore, who led the litigation against tobacco companies and is now involved in the litigation against opioids makers, said a Purdue salesman told him that each morning he would look at reports detailing doctors in his territory who had prescribed OxyContin or other opioids.

Moore said the salesman told these doctors that OxyContin lasted 12 hours and it was OK to increase the dosage to 40 milligrams to ensure that pain was controlled.

“Sales skyrocketed,” Moore said, “and a nation became addicted.”

In 2007, Purdue’s holding company pleaded guilty to “misbranding” OxyContin, admitting that sales reps “with intent to defraud or mislead” had promoted the drug as less addictive and less likely to be abused than other opioid painkillers.

Purdue, a privately held company in Stamford, Connecticut, paid a $600 million fine. Three executives pleaded guilty to misbranding, paying nearly $35 million in fines. Still, Purdue insisted the executives had not been guilty of misleading anybody.

At the sentencings, the judge gave the executives probation and community service.

Some present praised OxyContin for killing their pain. Others said the drug had killed their teenage children. One mother held up a jar that contained the ashes of her deceased son.

Treatment, sobriety, relapse

Pills were everywhere — and easy for Fannin’s son to find.

Sean Fannin, the younger of two boys, was a smart kid who preferred skilled trades to medicine, telling his dad he wanted to be a welder. He would grow up to work in the coal mines for a time, like his grandfather.

As he came of age, Fannin later learned, Sean was smoking pot, drinking and eventually abusing pills. Fannin and his wife thought he had attention deficit hyperactivity disorder or a mood problem until a University of Kentucky doctor diagnosed his addiction.

“It made me angry that I missed it,” Fannin said, “especially being a doctor.”

On the long drive to a teen recovery center in the Tennessee woods, Sean confessed his drug use to his parents. He was around 14 at the time, and this stint in recovery was the first of many.

The family filled the next several years with periods of treatment, sobriety and relapses.

While supporting Sean’s recovery, Fannin began helping others trapped by addiction. Eventually, he became one of the few board-certified addiction specialists in eastern Kentucky.

In his family practice, Fannin prescribed far less OxyContin and required patients on opioids to undergo urine screens and pill counts. He checked their prescription history through the state’s electronic prescription drug monitoring system.

He was determined not to fuel more addiction in his community, but he was unable to pry his son from addiction’s grip.

‘Healers become dealers’

Opioids kill first by slowing down breathing, then by depriving the brain and body of oxygen, the very stuff of life.

By 2009, drug overdose deaths had become the leading cause of accidental deaths in the U.S., surpassing traffic fatalities.

Overprescribing has fueled much of this epidemic, said Dr. Anna Lembke, an associate professor of psychiatry, behavioral sciences and anesthesiology at the Stanford University School of Medicine.

“So how did healers become dealers?” she asked. It happened as medicine became an industry, she said, with doctors practicing “assembly-line medicine” in “health care factories.”

With millions of Americans abusing prescription opioids, Mexican cartels found a new market for their cheap heroin. In 2001, fewer than 1,800 Americans died of a heroin overdose. By 2016, those deaths had topped 15,000.

And that heroin has often been laced with synthetic opioids such as fentanyl, which is 50 times more powerful than morphine, and carfentanil, which is 10,000 times more powerful than morphine.

Fentanyl is used to treat breakthrough cancer pain. Carfentanil is an elephant tranquilizer, and just a few grains can kill humans. In 2016, overdoses from these synthetic opioids surpassed 20,000 deaths.

‘It honors him’

Sean Fannin’s Pikeville funeral was standing room only.

Fannin finds it tough to talk about the overdose of OxyContin and the anti-anxiety medicine Xanax that killed him at just 28.

But he’ll share his experiences with addicted patients and their families.

Sometimes, Fannin, who turns 70 in February, gets a glimpse of the difference he’s making. At a local Walmart last year, a former patient walked up to him with her baby, asking if he remembered her. He did.

She pointed to her husband, another former patient. She told the doctor they were both staying clean and doing great. She’d been pregnant when he treated her, and now had two healthy kids.

Tears flowed as she spoke. “I just wanted to thank you.”

Fannin knew that couple was among the lucky ones. Studies show only 1 in 10 Americans are able to get treatment for addiction.

He stared out the window, aching, as he always does, for his own loss. But the memory of Sean infuses his work.

“The way I figure,” Fannin said, “it honors him.”