Opioids in the US
Hello! Welcome to Overdosed a weekly newsletter on drug policy and people who use drugs by me, Diane Roznowski.
Before we get into today’s newsletter I wanted to take a second to address a piece of feedback I got through my feedback/ questions form. I really appreciated it and didn’t want to wait longer to address it.
The feedback was about me not talking enough about race in my first newsletter on the war on drugs. I hear that completely, and hope that part two better addressed the issues of race and racism in the creation of these policies.
As a white person, I will never personally know the harms these policies created for people of color. But I also know white people need to be talking about racism.
I will do better moving forward and hope you all feel comfortable expressing feedback either through my form or by replying to these newsletters.
Today it’s hard to find someone who doesn’t know something about the opioid epidemic. Since the late 1990s over 700,000 American deaths were caused by opioids. That’s more than the number of people who live in Washington, DC.
While this scale of deaths is shocking and demands a comprehensive response, opioid overdose deaths aren’t a new phenomenon in this country. Opioids and opioid addiction have been a problem in the US for much longer than the last 20-ish years.
In the early 1800s, Friedrich Serturner, a German pharmacist, extracted the part of the opium poppy plant that causes you to feel high and provides pain relief. He named this alkaloid morphine. While completing further experiments with the drug, he worried about how it would be used in the future.
The United States first started really using the power of this pain reliever during the Civil War and they imported a lot of morphine to treat injured soldiers. Many of these soldiers became addicted, so much so that people commonly called morphine addiction “the soldiers' disease.” Many who became addicted to morphine during the war continued using it once they returned home.
Despite the number of people being addicted to morphine, it was still prescribed for many types of pain. Doctors commonly prescribed the drugs to women for almost anything, whether it was a cough or menstrual cramps. Many of these women became addicted and almost all of them were white women who could afford to go to the doctor and their prescriptions.
By the 1880s, doctors started worrying about the effects of morphine, but there weren’t any good alternatives. Aspirin, for example, wouldn’t be invented until the 1890s.
Tens of thousands of people were addicted to morphine by the early 20th century. Overdose deaths weren’t uncommon and many mostly white communities were devastated by opioid addiction. The government struggled to find a solution.
Sound familiar?
Pharmacists and researchers developed what they thought would be the solution, a new drug called heroin. At the time, they didn’t know that heroin was more potent and that it was more likely someone would become addicted to it. It was seen as safer and many thought it would end the morphine crisis. Pharmaceutical marketing was a huge reason people thought heroin was safe and this was only the beginning of pharmaceutical marketing.
Researchers and the American Medical Association quickly realized heroin was extremely addictive, but the damage was already done. Eventually, the government stepped in and passed The Harrison Act (covered here). The passage of this act led to fewer doctors prescribing heroin and morphine. It’s what we call a supply-side drug policy since it aims at controlling the supply of drugs and not the underlying issues that cause people to use drugs or to make drug use safer. Supply-side policies often push drug users away from medical care and into the black markets to avoid withdrawal.
When alcohol prohibition began, international alcohol smuggling operations popped up all over. These alcohol smuggling operations made it easier to smuggle in other drugs like heroin. In 1924, the US completely outlawed heroin.
During World War II, many underground drug markets had run out of drugs. When the war ended, they became flooded with opioids. Most of these markets were in large cities and this caused a shift in what the average drug user looked like. This is the first time the average drug user is younger and most likely a man of color.
When the average drug user switched from a white person to a person of color it caused attitudes towards drug users to shift greatly. Addiction was now seen as a moral failing and a crime. Throughout history, we have consistently changed how we view addiction based on who is addicted.
The shift in what a drug user looked like also caused a shift in drug policy. The US government chose to use a punitive approach against drug users and started trying to arrest their way out of the first heroin epidemic (1950s-1970s). Mandatory minimums and harsh sentences disproportionally affected men of color and these effects can still be seen today.
Opioids remained out of most people’s minds until OxyContin was patented in 1996 by Purdue Pharma. Before that, the Sackler family was busy creating a name for themselves and the conditions that arguably created the modern opioid crisis.
In the 1950s, the three Sackler brothers (Arthur, Mortimer, and Raymond) were all doctors. Arthur, the oldest, did a lot of pathbreaking research and the three brothers authored over 100 studies on the biological aspects of psychiatric disorders. Despite their success, Arthur wanted more. He joined and then purchased an ad agency that specialized in medical ads.
He quickly became the father of modern pharmaceutical marketing. He would market the drugs first to doctors because when they believed in it, they would prescribe it. At this time, doctors were highly skeptical of opioids so most of these ads were for barbiturates and benzodiazepines.
Arthur Sackler made his first real fortune by marketing drugs like Valium. The brothers used that money to buy a pharmaceutical company, Purdue Frederick. They started developing many drugs and marketed them well. The Sackler family started making millions and millions of dollars.
The rapid growth of the pharmaceutical industry worried policymakers so in the 1960s a Senate subcommittee had a hearing. Arthur testified at the hearing and one staffer noted in his memo:
“The Sackler empire is a completely integrated operation in that it can devise a new drug in its drug development enterprise, have the drug clinically tested and secure favorable reports on the drug from the various hospitals with which they have connections, conceive the advertising approach and prepare the actual advertising copy with which to promote the drug, have the clinical articles as well as advertising copy published in their own medical journals, [and] prepare and plant articles in newspapers and magazines.”
The hearing didn’t change anything. Arthur left unscathed and continued selling many pharmaceuticals and the idea that there was a pill for any problem you could have. At this time opioids still weren’t part of this mix.
Then in the 1990s groups, many of which were financially supported by the pharmaceutical companies, came together and said the US wasn’t taking pain seriously and that there was an epidemic of untreated pain. They got pain reclassified as the fifth vital sign. Around the same time, a short letter in a medical journal stated that addiction was rare. The pharmaceutical companies shared this letter broadly and many stated believing that opioids were safe and underused.
At the time they were pushing this letter, the Sacklers were also developing a new drug using the opioid oxycodone. Arthur had passed away and his nephew Richard had taken over the company and renamed it Purdue Pharma.
In 1996, Purdue released OxyContin. To market the drug, they went straight to the FDA and persuaded them to include the claim that it was safer than other drugs on the market when they approved it. Purdue claimed that the time-release coating made it less likely to cause addiction, but there were no studies backing this claim up.
Once approved by the FDA, Purdue started marketing the drug to doctors and patients directly. They said the drug was safe and that untreated pain was dangerous. They created countless ads, hired tons of sales reps, flew doctors to tropical destinations to teach them about the drug, and they targeted rural and poorer communities. They targeted white communities because they had higher access to the healthcare system and because doctors were less likely to prescribe potentially addictive drugs to people of color because of addiction stereotypes.
Within a few years, doctors and patients quickly realized that OxyContin was addictive, but it was too late. Many communities were already devastated by it. When patients ran out of the drug and couldn’t get more they would often turn to the black market. If they couldn’t afford the pills, many would switch to heroin since is was astronomically cheaper.
In recent years, doctors have cut down on prescribing opioids but they haven’t been doing so in ways that protect chronic pain patients and many still default to prescribing opioids instead of other pain relievers and treatments. Additionally, cutting down on the supply of these pills has only made the drug supply more dangerous.
With more people turning to the streets and heroin, the drug supply has become more deadly and caused significant increases in overdose deaths. Over the last couple of years, super-potent synthetic opioids like fentanyl have caused the majority of these deaths.
Recently politicians have implemented many policies attempting to solve this crisis, but it keeps getting worse. My sister Emily was one of over 63,600 people to die from an overdose in 2016. One of my best friend’s older brothers was one of the nearly 72,000 people to die from an overdose in 2017. My neighbor who was like an older brother to me was one of the people to die from an overdose in 2018, but we still don’t know how many people died from this last year. Preliminary numbers show that they may have been a tiny decrease, but we may not have the final number until next year.
Too many people are dying because our solutions haven’t been bold enough. The US life expectancy has declined because of this crisis. 192 people will die today in the United States because of drug overdoses, we need to do something to stop this and we need to do it now.
Further Reading
There’s no shortage of further readings for this week. In addition to the articles themselves, I wanted to recommend a few journalists who write a lot of good articles on opioids and substance use.
Abraham Gutman of The Philadelphia Inquirer
German Lopez of Vox News
Zachary Siegel co-host of Narcotica Podcast and a fellow at Health in Justice Action Lab
Maia Szalavitz a neuroscience journalist and author
Articles
National Institute on Drug Abuse - Opioid Overdose Crisis
CNN - Opioid Crisis Fast Facts
Current Readings
I recently realized that because I have been basing this newsletter on different topics, I have been missing out on sharing current relative pieces. This new section is where I will be sharing them. I hope you enjoy them!
ESPN - Why Megan Rapinoe's brother Brian is her greatest heartbreak, and hope: After winning the World Cup, Megan Rapinoe, winner of Golden Ball for the tournament’s best player and the Golden Boot for its top scorer, gave her older brother Brian a birthday shoutout on international TV. He couldn’t make it to the game because he is currently serving the remainder of his most recent drug-related prison sentence in a rehabilitation program.
CNN - Delta's on-board emergency medical kits will now include a powerful overdose-reversal drug: After reports of a passenger experiencing a fatal overdose on-board, Delta announced they will start stocking naloxone in their emergency kits. They are the first airline to do so.
The Washington Post - 76 billion opioid pills: Newly released federal data unmasks the epidemic: "In a country of 306 million, the companies distributed enough pills to supply every adult and child with 36 each year."
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Until next time,