Ten months into his “listening” tour of America, the Facebook CEO, Mark Zuckerberg, better understands the big issues that have divided the country. Some he anticipated, such as the lost jobs and economic uncertainty resulting from technological advances and free trade. But there was one that he did not.
Speaking in Kansas on 10 November, Zuckerberg said his “biggest surprise by far” was the extent of the opioid crisis – fuelled by the overprescription of pain management drugs – and its effect on the American psyche. Around 64,000 people died from drug overdoses in the US last year – more people than died from Aids at the height of that epidemic, Zuckerberg noted. “It’s more people than die of car accidents and gun violence, I think, combined, and it’s growing quickly.”
Opioids are drugs derived from the juice of the opium poppy, including heroin and prescription painkillers, or their synthetic equivalents, such as fentanyl. The best-known painkiller and the one attracting the most criticism for its part in America’s opioid crisis is OxyContin.
For many years, doctors were wary of prescribing strong opioids, except in cases of extreme pain or palliative care, because of their well-known addictive properties. But Purdue Pharma, which was acquired by the doctors Raymond and Mortimer Sackler in the mid-20th century, sought to change this.
Their breakthrough product was a slow-release morphine pill, MS Contin. The drug dissolved gradually over several hours in a patient’s bloodstream, allowing cancer patients to sleep through the night. When MS Contin’s patent was due to expire, Purdue decided to develop a new drug that could be used much more widely for chronic pain. Instead of morphine, which carried a stigma among patients who weren’t terminally ill, Purdue designed a new slow-release pill made of pure oxycodone, another, more powerful, chemical derived from opium.
Purdue launched OxyContin in 1996, making a bold claim: one dose relieved pain for 12 hours, twice as long as generic alternatives. The company paid doctors and funded research to support the case that the addiction risk was exaggerated and that the drug was effective for a wide range of ailments, including less severe, long-term complaints such as back pain. As the New Yorker reported in October, Purdue marketed OxyContin as a remedy to “start with and to stay with”.
The pill was effective in helping many people with chronic pain who until then had received inadequate treatment and, by 2001, annual sales exceeded $1bn. But controversy was mounting. For some people, the drug only lasted for six or eight hours, resulting in withdrawal symptoms. This created “a cycle of crash and euphoria that one academic called ‘a perfect recipe for addiction’”, Esquire noted in a investigative report last month. Sales reps told doctors, many of whom mistakenly believed that oxycodone was weaker than morphine, to prescribe stronger doses rather than more frequent ones, increasing the risk of overdose. And addicts had worked out that the pills could be crushed and snorted for a quick, intense high.
Purdue settled a number of class action suits before they came to trial. But in 2007 it was charged by the US federal government with “misbranding a drug with intent to defraud or mislead”. The company paid $635m in fines, one of the largest pharmaceutical settlements in US history, and three executives pleaded guilty to misdemeanour charges. But sales continued to soar. OxyContin sales now total $35bn, and have made the Sacklers one of the richest – and most controversial – families in the US.
Since 1999, 200,000 Americans have died from overdoses connected to OxyContin and similar prescription opioids. Addicts who can no longer source or afford prescription drugs often turn to heroin. The American Society of Addiction Medicine says four in five people who try heroin today started with prescription painkillers.
Though many of the opioid-related deaths are linked to drugs other than OxyContin, many experts blame Purdue’s marketing tactics for the significant rise in prescriptions of opioids. For every million Americans, nearly 50,000 doses of opioids are taken daily – four times the rate in the UK.
In Kansas, Zuckerberg said that the crisis has influenced people’s attitude to policy issues. Seeing family and friends succumb to addiction has made people more fearful of crime and eager for border controls that could stop the flow of drugs, he said.
White, working-class, middle-aged people have been especially affected. The Princeton economists Anne Case and Angus Deaton have noted the rise in the number of “deaths of despair” – from suicide, overdoses and drug- and alcohol-related diseases – among that demographic. Decades of wage stagnation and the decline of well-paying jobs were the main underlying causes, they wrote in the Washington Post. But: “Opioids are like guns handed out in a suicide ward; they have certainly made the total epidemic much worse.”
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This article appears in the 15 Nov 2017 issue of the New Statesman, The plot to stop Brexit