Mar­cia An­gell

The New York Review of Books - - Contents - Mar­cia An­gell

Pain Killer:

An Em­pire of De­ceit and the Ori­gin of Amer­ica’s Opi­oid Epi­demic (Ex­panded and Up­dated Edi­tion) by Barry Meier.

Ran­dom House, 223 pp., $27.00

Dopesick:

Deal­ers, Doc­tors, and the Drug Com­pany That Ad­dicted Amer­ica by Beth Macy.

Lit­tle, Brown, 376 pp., $28.00

Amer­i­can Over­dose:

The Opi­oid Tragedy in Three Acts by Chris McGreal.

PublicAf­fairs, 316 pp., $27.00

Amer­i­can Fix:

In­side the Opi­oid Ad­dic­tion Cri­sis—and How to End It by Ryan Hamp­ton, with Claire Rudy Fos­ter.

All Points, 290 pp., $27.99

The Na­tional In­sti­tute on Drug Abuse es­ti­mates that 72,000 Amer­i­cans died from drug over­doses in 2017, up from some 64,000 the pre­vi­ous year and 52,000 the year be­fore that—a stag­ger­ing in­crease with no end in sight. Most in­volved opi­oids.

A few def­i­ni­tions are in or­der.

The term opi­oid is now used to in­clude opi­ates, which are de­riv­a­tives of the opium poppy, and opi­oids, which orig­i­nally re­ferred only to syn­the­sized drugs that act in the same way as opi­ates do. Opium, the sap from the poppy, has been used through­out the world for thou­sands of years to treat pain and short­ness of breath, sup­press cough and di­ar­rhea, and, maybe most of­ten, sim­ply for its tran­quil­iz­ing ef­fect. The ac­tive con­stituent of opium, mor­phine, was not iden­ti­fied un­til 1806. Soon a va­ri­ety of mor­phine tinc­tures be­came read­ily avail­able with­out any so­cial op­pro­brium, used, in some ac­counts, to com­bat the tra­vails and bore­dom of Vic­to­rian women. (Thomas Jef­fer­son was also an en­thu­si­ast of lau­danum, one of the mor­phine tinc­tures.) Heroin, a stronger opi­ate made from mor­phine, en­tered the mar­ket later in the nine­teenth cen­tury. It wasn’t un­til the twen­ti­eth cen­tury that syn­thetic or par­tially syn­thetic opi­oids, in­clud­ing fen­tanyl, methadone, oxy­codone (Per­co­cet), hy­drocodone (Vi­codin), and hy­dro­mor­phone (Di­lau­did), were de­vel­oped. In 1996 a new form of oxy­codone called OxyCon­tin came on the mar­ket, and three re­cent books—Beth Macy’s Dopesick, Chris McGreal’s Amer­i­can Over­dose, and Barry Meier’s Pain Killer—blame the opi­oid epi­demic al­most en­tirely on its maker, Pur­due Pharma. OxyCon­tin is for­mu­lated to be re­leased more slowly and there­fore lasts longer. The com­pany claimed that the drug’s slow re­lease would make it less ad­dic­tive than or­di­nary oxy­codone, since the ini­tial eu­pho­ria—the high—would be muted. Based on this the­ory and lit­tle else, the FDA per­mit­ted OxyCon­tin to con­tain twice the usual dose of oxy­codone and carry on the la­bel this state­ment: “De­layed ab­sorp­tion, as pro­vided by OxyCon­tin tablets, is be­lieved to re­duce the abuse li­a­bil­ity of a drug.” (The FDA of­fi­cial who over­saw OxyCon­tin’s ap­proval later got a plum job at Pur­due Pharma.) The com­pany launched an ex­traor­di­nar­ily ag­gres­sive and suc­cess­ful mar­ket­ing cam­paign to con­vince physi­cians that they had the holy grail of a non­ad­dic­tive opi­oid. It sent hun­dreds of sales rep­re­sen­ta­tives to doc­tors’ of­fices to tout OxyCon­tin, and of­fered doc­tors din­ners and trips to meet­ings at lux­ury re­sorts. And it paid more than five thou­sand doc­tors, phar­ma­cists, and nurses to train as speak­ers to tour the coun­try pro­mot­ing OxyCon­tin. But like all opi­oids, OxyCon­tin is ad­dic­tive. And soon enough, users found that they could crush the pills or dis­solve the coat­ing, then snort the drug like co­caine or in­ject it like heroin. Each pill would then be­come es­sen­tially an in­stan­ta­neous dou­ble dose of oxy­codone.

OxyCon­tin al­most im­me­di­ately be­came a block­buster—that is, a pre­scrip­tion drug with an­nual sales of more than $1 bil­lion. It was widely used not just by those for whom the pre­scrip­tions were writ­ten, but by their rel­a­tives and friends. The pills were also sold or stolen or oth­er­wise di­verted to street use. In ad­di­tion, “pill mills” sprang up, where un­eth­i­cal physi­cians wrote in­nu­mer­able pre­scrip­tions for OxyCon­tin and re­filled them au­to­mat­i­cally with­out ever see­ing the pa­tient. McGreal de­scribes “one of the most pro­duc­tive pill mills in the coun­try,” which op­er­ated in the small town of Wil­liamson, West Vir­ginia—known lo­cally as “Pil­liamson.” The town, he says, “was awash in pills,” and peo­ple came by car and bus to line up at the clinic and co­op­er­at­ing drug­stores. “In­ves­ti­ga­tors cal­cu­lated that in 2009 alone, the clinic pulled in $4.6 mil­lion in a town with a pop­u­la­tion of lit­tle more than three thou­sand peo­ple.”

It’s im­pos­si­ble to know how many new pre­scrip­tions were ob­tained in each of these ways, but one way or an­other, OxyCon­tin ad­dic­tion grew into an epi­demic. The epi­cen­ter was cen­tral Ap­palachia, and its vic­tims were mainly white peo­ple in small, eco­nom­i­cally de­pressed coal-min­ing com­mu­ni­ties in south­ern West Vir­ginia and parts of Ken­tucky, Ten­nessee, and south­west­ern Vir­ginia.1

The three books that fo­cus on Pur­due Pharma are in a sense the same book. Barry Meier first pub­lished Pain Killer in 2003. The new edi­tion (re­leased by a dif­fer­ent pub­lisher) is much the same, with some up­dat­ing and re­arrange­ments. The two new books, Dopesick and Amer­i­can Over­dose, cover the same story as it un­folded in the same re­gion of the coun­try. Both Macy and McGreal re­fer to the 2003 edi­tion of Meier’s book (but not the new edi­tion, prob­a­bly be­cause they could not have known of it at the time their books were writ­ten). All three books are grip­ping and well writ­ten, with de­tailed ac­counts, one after an­other (per­haps too many), of fam­i­lies dec­i­mated by the epi­demic. And they all tell the story of Art Van Zee, a physi­cian in south­west­ern Vir­ginia, who in 2000 be­came aware of the grow­ing epi­demic of OxyCon­tin there and tried hero­ically to get Pur­due Pharma and the FDA to take re­spon­si­bil­ity for it. Pur­due Pharma and the Sack­ler fam­ily that founded it are very hard to de­fend. By ag­gres­sively mar­ket­ing OxyCon­tin, even after they knew it was be­ing widely abused, the fam­ily be­came enor­mously wealthy. But the FDA was also guilty. It per­mit­ted OxyCon­tin to be sold as a rel­a­tively non­ad­dic­tive opi­oid with­out good ev­i­dence to sup­port that claim, and it should have been ob­vi­ous that the pills

1The books by Macy and McGreal pro­vide full ac­counts of the de­vel­op­ment and pro­mo­tion of OxyCon­tin, the on­set of the epi­demic in Ap­palachia, the fail­ure of Pur­due to re­spond, and the com­pany’s even­tual ad­mis­sion to fraud­u­lent mar­ket­ing. might be crushed or dis­solved to make them even more ad­dic­tive. Van Zee, along with Beth Davies, a nun who ran the lo­cal sub­stance abuse clinic, saw Lee County, Vir­ginia, blan­keted with OxyCon­tin pre­scrip­tions and watched the deaths mount, par­tic­u­larly among young peo­ple. They in­formed Pur­due, which sim­ply stonewalled. Over the fol­low­ing year, Van Zee de­voted him­self com­pletely to the cause, meet­ing with com­pany and FDA of­fi­cials and tes­ti­fy­ing be­fore a Se­nate com­mit­tee, try­ing to get Pur­due to re­for­mu­late the drug or even with­draw it from the mar­ket. In 2007 Pur­due pled guilty to crim­i­nal charges of fraud­u­lently mar­ket­ing OxyCon­tin and set­tled for $600 mil­lion in fines and penal­ties. Three ex­ec­u­tives pled guilty to mis­de­meanor charges and were sen­tenced to four hun­dred hours of com­mu­nity ser­vice and lesser fines. The com­pany’s fine was triv­ial in com­par­i­son with its prof­its from OxyCon­tin. In fact, al­most ev­ery other ma­jor phar­ma­ceu­ti­cal com­pany has had to set­tle both civil and crim­i­nal charges of fraud­u­lent mar­ket­ing for much more (the record set­tle­ment is now Glax­oSmithK­line’s $3 bil­lion, for a va­ri­ety of vi­o­la­tions, in­clud­ing falsely pro­mot­ing drugs and fail­ing to re­port safety data). These kinds of fines are just the cost of do­ing busi­ness. And so it was for Pur­due Pharma, although the fraud­u­lent mar­ket­ing stopped and a warn­ing was added to the la­bel. The prob­lem with these three books, and it’s a big one, is that they treat the Pur­due story as though it were the whole story of the opi­oid epi­demic. But OxyCon­tin did not give rise to opi­oid ad­dic­tion, although it jump-started the cur­rent epi­demic. Heroin has been a com­mon street drug ever since it was banned in 1924. Mor­phine has also been widely abused.

Nor would tak­ing OxyCon­tin off the mar­ket end the epi­demic. The over­whelm­ing ma­jor­ity of opi­oid deaths are caused not by OxyCon­tin but by com­bi­na­tions of fen­tanyl, heroin, and co­caine, of­ten brought in from China via Mex­i­can car­tels, and fre­quently taken along with ben­zo­di­azepines (such as Val­ium or Xanax) and al­co­hol. These drugs are cheaper and stronger, par­tic­u­larly fen­tanyl. Fen­tanyl was first syn­the­sized in 1960, and soon be­came widely used as an anes­thetic and pow­er­ful painkiller. It is legally man­u­fac­tured and highly ef­fec­tive when used ap­pro­pri­ately, of­ten for short med­i­cal pro­ce­dures such as colono­scopies. The il­licit pro­duc­tion and street use is rel­a­tively new, but it is now the main cause of most opi­oid-re­lated deaths (nearly 90 per­cent in Mas­sachusetts).

The steady in­crease in opi­oid deaths after OxyCon­tin came on the mar­ket has been sup­planted by a much faster in­crease start­ing around 2013, when heroin and fen­tanyl use in­creased dra­mat­i­cally. We now have two epi­demics—the overuse of pre­scrip­tion drugs and the much more deadly and now largely un­re­lated epi­demic of street drugs. By con­cen­trat­ing on the first,

we are clos­ing the barn door after the horse is long gone.

Ef­forts to deal with the epi­demic have been all over the map—lit­er­ally. Pos­ses­sion of il­le­gal drugs (and le­gal drugs il­lic­itly used) is still a fed­eral crime, and pris­ons are still full of peo­ple whose only crime was that. But many states, coun­ties, and cities have be­gun to re­gard opi­oid ad­dic­tion as a pub­lic health is­sue, not a po­lice is­sue. They are open­ing cen­ters in which peo­ple who seek help are shifted to less pow­er­ful opi­oids like methadone and buprenor­phine (Subu­tex)—a method known as “med­i­ca­tion-as­sisted treat­ment,” or MAT. Nalox­one (Nar­can), the an­ti­dote for an opi­oid over­dose, is now sold over the counter in al­most all states. If used im­me­di­ately, it can pre­vent an oth­er­wise in­evitable death from a drug over­dose. And drug courts, which may drop crim­i­nal charges in re­turn for an agree­ment to sub­mit to treat­ment and mon­i­tor­ing, are be­com­ing more com­mon.

Most con­tro­ver­sial are fa­cil­i­ties called “safe in­jec­tion sites,” or SIFs, where drug users can come to use drugs with­out fear of ar­rest. The staff pro­vides clean nee­dles to re­duce the risk of HIV and hepati­tis C in­fec­tions, and is pre­pared to re­sus­ci­tate ad­dicts who over­dose. This ap­proach is called “harm re­duc­tion.” The prob­lem is that ad­dicts must still buy drugs il­le­gally, and it’s al­most im­pos­si­ble to know ex­actly what is in them.

In a re­cent New York Times OpEd, the deputy at­tor­ney gen­eral, Rod Rosen­stein, came down hard on SIFs. He warned that “it is a fed­eral felony to main­tain any lo­ca­tion for the pur­pose of fa­cil­i­tat­ing il­licit drug use,” and that “cities and coun­ties should ex­pect the Depart­ment of Jus­tice to meet the open­ing of any in­jec­tion site with swift and ag­gres­sive ac­tion.” He was re­fer­ring to plans to op­er­ate SIFs in San Fran­cisco, New York City, and Seat­tle, and sim­i­lar op­tions now be­ing con­sid­ered by Colorado, Maine, Mas­sachusetts, and Ver­mont. Later in the same ar­ti­cle, how­ever, he soft­ened, say­ing we should “help drug users get treat­ment and ag­gres­sively pros­e­cute crim­i­nals who sup­ply the deadly poi­son,” sug­gest­ing that per­haps he doesn’t be­lieve sim­ple pos­ses­sion is so bad, after all. But the pro­posed so­lu­tions to this epi­demic range from the ex­treme of “lock ’em up” to “drug abuse is no less a dis­ease than can­cer or di­a­betes” and should there­fore be met with the same so­lic­i­tude. Ryan Hamp­ton ex­em­pli­fies the lat­ter view in his an­gry book, Amer­i­can Fix. A for­mer drug user him­self and now an im­pas­sioned ad­vo­cate and ac­tivist, he in­sists that drug abuse should be re­garded like other dis­eases. He doesn’t ac­knowl­edge that for most users there was a mo­ment of choice in be­com­ing ad­dicted that is not the case for peo­ple with can­cer or di­a­betes. After re­ceiv­ing Di­lau­did for a painful an­kle, Hamp­ton de­cided to ask for more, and then more. I think one can make the ar­gu­ment for sym­pa­thy with drug users and for un­der­stand­ing how the quest for drugs ceases to be un­der their con­trol with­out claim­ing an anal­ogy to dis­eases like can­cer or di­a­betes. Hamp­ton paints a vivid pic­ture of the down­ward spi­ral of ad­dic­tion. When he “lev­eled up to IV heroin,” he ex­plains, “it was cheaper than pills, eas­ier to get hold of, and a quar­ter the cost. More im­por­tant, no­body was track­ing us in a database.”

Where Hamp­ton is at his best is in his ex­po­sure of the prof­i­teer­ing and cor­rup­tion in the bur­geon­ing ad­dic­tion in­dus­try—what he calls “the treat­ment in­dus­try swamp.” In the swamp, he found

lack of ef­fec­tive treat­ment, ex­or­bi­tant costs, and ridicu­lous twen­tyeight-day va­ca­tions dis­guised as med­i­cal help, fed by pa­tient bro­kers who run a com­pletely le­gal, high-end hu­man traf­fick­ing car­tel to push tens of thou­sands of pa­tients through the bro­ken sys­tem.

He was re­fer­ring to the panoply of treat­ment cen­ters, both res­i­den­tial and out­pa­tient, and detox fa­cil­i­ties, where users are sup­posed to be weaned from drugs be­fore en­ter­ing “sober liv­ing houses.” As in so much of Amer­i­can

medicine, even non­profit in­sur­ers like Med­ic­aid out­source the ac­tual de­liv­ery of care to for-profit com­pa­nies that charge what­ever the mar­ket will bear. Ac­cord­ing to Hamp­ton, “one of the most ex­pen­sive treat­ment cen­ters in Amer­ica, Pas­sages Mal­ibu, costs more than $60,000 per month.” Costs are set­tled by a crazy quilt of pay­ers, in­clud­ing state and lo­cal gov­ern­ments, Med­ic­aid, other fed­eral pro­grams, pri­vate in­sur­ers, and of­ten by des­per­ate fam­i­lies. Not sur­pris­ingly, only a mi­nor­ity of users are ever treated.

In

2017 the Aspen In­sti­tute’s Health Strat­egy Group, led by two for­mer sec­re­taries of health and hu­man ser­vices, Tommy Thomp­son and Kath­leen Se­be­lius, and con­sist­ing of twenty-four mem­bers from var­i­ous health-re­lated fields (I am among them), met for three days to ex­am­ine the opi­oid epi­demic. The de­lib­er­a­tions were pre­ceded by four pre­sen­ta­tions by ex­perts in the field. In the fi­nal broad and com­pre­hen­sive re­port, the group made a strong case for de­crim­i­nal­iz­ing drug ad­dic­tion and in­stead re­gard­ing it as a pub­lic health is­sue. Among the five ma­jor rec­om­men­da­tions was a call for more re­search into nearly all as­pects of the epi­demic. It’s star­tling how lit­tle we know, given the im­men­sity of the prob­lem and the me­dia at­ten­tion it re­ceives.2

We need to know, for in­stance, how ef­fec­tive opi­oids are for dif­fer­ent kinds

2This re­port is avail­able at www.aspen in­sti­tute.org/pub­li­ca­tions/con­frontin­gour-na­tions-opi­oid-cri­sis. of pain, in­clud­ing long-term treat­ment for chronic pain. We need to know how opi­oids com­pare in ef­fec­tive­ness and side ef­fects with ac­etaminophen (which can cause liver fail­ure) and non­s­teroidal anti-in­flam­ma­tory drugs (NSAIDs) like ibupro­fen (which can cause gas­troin­testi­nal bleed­ing). We need to know how the death rate in the opi­oid epi­demic com­pares with the rate of use. We know the death rate is soar­ing, but does that mean the rate of use is, too, or is it sim­ply a re­sult of the lethal­ity of the drug mix­tures ob­tained on the street? We need to know how much di­ver­sion there is now from le­git­i­mate treat­ment to abuse. That in­cludes di­ver­sion of methadone and buprenor­phine, which are also opi­oids and can be sold on the street or added to the user’s il­licit in­take. Ac­cord­ing to Macy, “Buprenor­phine is the third-most-di­verted opi­oid in the coun­try, after oxy­codone and hy­drocodone.”

We need to know how many ad­dicts want to quit, since most don’t seek treat­ment. Why don’t they? And fi­nally, we need to know the best ap­proach to treat­ment. There is con­cern, for ex­am­ple, that detox might be dan­ger­ous, be­cause the first dose after a re­lapse can be deadly if the user is no longer tol­er­ant to the drug’s ef­fects. Is pro­vid­ing methadone or buprenor­phine in­def­i­nitely, even for life, the best treat­ment among bad choices? There is plenty of spec­u­la­tion about all of these ques­tions, and sug­ges­tive find­ings about some of them, but lit­tle solid ev­i­dence.

We also need to re­mem­ber an es­sen­tial and cru­cial fact: opi­oids do have a le­git­i­mate pur­pose, and it’s an enor­mously im­por­tant one. They treat se­vere pain, of­ten when no other treat­ment is ef­fec­tive. Pa­tients suf­fer­ing from can­cer are some­times com­pletely de­pen­dent on opi­oids for re­lief, as are some pa­tients with other forms of se­vere pain. As the au­thors of the books ac­knowl­edge, pain was sys­tem­at­i­cally un­der­treated through­out most of the twen­ti­eth cen­tury. After cen­turies of free and easy use of opi­oids, there was a sud­den re­ac­tion in the United States at the start of the twen­ti­eth cen­tury, which had much to do with anti-im­mi­grant sen­ti­ment, par­tic­u­larly an­imus to­ward Chi­nese im­mi­grants who were widely as­sumed to be opium ad­dicts. (It also par­al­leled the grow­ing re­ac­tion against al­co­hol that re­sulted in Pro­hi­bi­tion.) The 1914 Har­ri­son Nar­cotics Tax Act im­posed strict reg­u­la­tions on the use of opi­oids; they had to be pre­scribed by physi­cians, and then only for pa­tients not al­ready tak­ing them. Pro­hi­bi­tion lasted for only thir­teen years, but the dread of opi­oid ad­dic­tion stayed with us un­til the 1980s and caused cruel suf­fer­ing for gen­er­a­tions of pa­tients.

Even in hos­pi­tals where can­cer pa­tients lay dy­ing in agony, opi­oids were ad­min­is­tered re­luc­tantly, in small doses, and at in­fre­quent in­ter­vals. When I was in train­ing in a teach­ing hos­pi­tal in the 1960s, there was an aw­ful rit­ual to it. The drugs were ad­min­is­tered ac­cord­ing to a pro re nata (prn) reg­i­men (os­ten­si­bly “as needed”) that re­quired the pa­tient to wait out a four-hour in­ter­val, no mat­ter how se­vere the pain, and then re­quest the next dose. Those who badly wanted the drug had to keep track of the time and have the strength and en­durance to sum­mon a nurse if one was nearby. Pa­tients were some­times in­hib­ited in ask­ing for the next dose by a de­sire to please the med­i­cal staff and not be a nui­sance, or by their own be­lief that tak­ing mor­phine was some­how wrong or re­flected weak­ness. The ex­tent to which nurses and physi­cians shared the com­mon fears of ad­dic­tion in­flu­enced their readi­ness to re­spond. Des­per­ate pa­tients would count the min­utes to­ward the end of the in­ter­val, hop­ing they could flag down a nurse. Many doc­tors and nurses in­ter­preted the anx­i­ety and clock-watch­ing as a sign of grow­ing ad­dic­tion, not in­ad­e­quate pain re­lief. These pa­tients were la­beled “drug-seek­ing” and of­ten pun­ished for it by be­ing de­nied the very help they needed.

Dur­ing the 1980s there was a wel­come change in that at­ti­tude, partly due to the hospice move­ment that had be­gun in the United King­dom. The prn sys­tem be­came more flex­i­ble, or was elim­i­nated al­to­gether. There was a re­al­iza­tion that be­cause pain is en­tirely sub­jec­tive, there is no way to mea­sure or ver­ify it, and even pa­tients with the same con­di­tion could dif­fer in their ex­pe­ri­ence of pain. In­stead of hav­ing to flag down nurses, pa­tients were asked at shorter in­ter­vals whether they needed pain re­lief, and how much. In 2001 the Joint Com­mis­sion on the Ac­cred­i­ta­tion of Health­care Or­ga­ni­za­tions pro­claimed pain the fifth vi­tal sign, to be as­sessed in ev­ery pa­tient, along with heart rate, res­pi­ra­tory rate, tem­per­a­ture, and blood pres­sure. Although the mo­ti­va­tion for this move was laud­able, it pre­sented prob­lems, since, un­like the other four vi­tal signs, pain can’t be ob­jec­tively quan­ti­fied.

The au­thors of the books un­der re­view rec­og­nize the his­tory of in­ad­e­quate treat­ment of pain through­out most of the twen­ti­eth cen­tury, but they don’t give it its due. They con­cen­trate in­stead on the re­ac­tion of the 1980s, which they con­sider ex­ces­sive and an un­der­ly­ing cause of the opi­oid epi­demic. In 1982 I wrote an ed­i­to­rial in The New Eng­land Jour­nal of Medicine, which be­gan, “Few things a doc­tor does are more im­por­tant than re­liev­ing pain.” I still be­lieve that. I ended with these words: “Pain is soul-de­stroy­ing. No pa­tients should have to en­dure in­tense pain un­nec­es­sar­ily. The qual­ity of mercy is es­sen­tial to the prac­tice of medicine; here, of all places, it should not be strained.”

The opi­oid epi­demic, while hor­ri­fy­ing, is still out­weighed by al­co­hol deaths, which are also in­creas­ing, ac­cord­ing to the Cen­ters for Dis­ease Con­trol. Hamp­ton writes, “If my first drug of choice came with a pre­scrip­tion, the sec­ond one, al­co­hol, was cul­tur­ally em­bed­ded and used to cel­e­brate at ev­ery turn of events.” In 2016, when there were 64,000 deaths in the US from the drug epi­demic, there were 90,000 from al­co­hol (in­clud­ing ac­ci­dents and homi­cides caused by ine­bri­ated peo­ple, as well as di­rect ef­fects, mainly cir­rho­sis of the liver). Cig­a­rette smok­ing is es­ti­mated to cause 480,000 deaths a year. I do not in­tend to min­i­mize the opi­oid epi­demic. Far from it. What I want to un­der­score is the dif­fer­ences in these three epi­demics. Al­co­hol and cig­a­rettes have no med­i­cal or prac­ti­cal uses of any kind. Yet we per­mit their use if reg­u­lated. In con­trast, opi­oids do have med­i­cal uses, and they are im­por­tant. The opi­oid epi­demic is usu­ally seen as a sup­ply prob­lem. If we can

A man who has just taken heroin, Philadel­phia, April 2018

Nan Goldin: With­drawal/Quick­sand, Ber­lin/NY, Fe­bru­ary 2016, 2016

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