This essay, on the opioid crisis in America, its roots and its lessons, was published in the Observer on 1 September 2019 under the headline ‘America’s opioid catastrophe has lessons for us all, about greed and racial division’. (I have restored a couple of paragraphs that I had to remove for reasons of space in the Observer.)
‘We’ll build a wall to keep the damn drugs out.’ So insisted Donald Trump at a rally last year to launch the White House’s initiative to stop opioid abuse. For Trump, at the heart of America’s opioid crisis lie open borders, illegal immigrants and foreign drug cartels.
Brad Beckworth, an Oklahoma state attorney, takes a different view. The drugs to which so many in the state are addicted, he told a court in July, ‘didn’t get here from drug cartels. They got here from one cartel: the pharmaceutical industry cartel.’
The court agreed. Last week, it ordered the pharmaceutical giant Johnson & Johnson to pay $572m in compensation for running a ‘false and dangerous’ sales campaign that had created an unprecedented epidemic of addiction in Oklahoma.
America’s opioid crisis is stark. Both the use and abuse of prescription opioids – painkillers such as OxyContin and Vicodin – have, since the 1990s, rocketed. Last year, 211m opioid prescriptions were handed out in the US. At its peak in 2012, that figure stood at 255m – 81 prescriptions for every 100 residents. In 2016, a fifth of all deaths among Americans aged 24 to 35 were due to opioids. Opioid-caused deaths have been a major factor in life expectancy falling for three years in a row.
Foreign drug cartels have certainly exploited the epidemic, smuggling in heroin and Chinese-made opioids such as fentanyl. But they are relatively minor players in comparison with the US drug companies that, between 2006 and 2012, saturated America with 76bn oxycodone and hydrocodone pills alone. It resulted in nearly 100,000 deaths. In 2016, one million Americans were using heroin. Eleven times as many misused prescription opioids, more than 2 million of whom had become addicted; 80% of new heroin users started out misusing prescription painkillers. Insofar as drug cartels are playing a role in the opioid crisis, it is because pharmaceutical companies created a market for them.
Big Pharma relentlessly pushed the sales of opioids, even when they knew of its harm. A series of court cases against drug companies have revealed their cynicism. ‘Keep ’em comin!’, a sales executive at a drug wholesaler emailed a national account manager for Mallinckrodt, America’s largest manufacturer of opioid pills. ‘Flyin’ out of there. It’s like people are addicted to these things or something. Oh, wait, people are. . .’
The highest death rates from opioids have been in rural communities in West Virginia, Kentucky and Virginia. In Norton, Virginia, an old coal-mining town of about 4,000 people, drug companies shipped in 306 pain pills for every man, woman and child every year between 2006 and 2012. The town’s Walmart alone received more than 3.5 million opioids. The death rate from prescription opioid overdoses in Norton was 18 times the national level.
The relationship between Big Pharma and US doctors can only be described as corrupt. Official figures show that last year 627,000 doctors received between them more than $2.1bn in what are called ‘general payments’ – payments unrelated to research. The total paid to doctors and hospitals by drug companies was more than $9bn. Unsurprisingly, the greater the payments, the more willing doctors were to prescribe opioids.
Big Pharma’s relationship with lawmakers is equally rotten. Between 2006 and 2015, drug companies and their advocate organisations spent more than $880m on lobbying. They contributed to the campaigns of more than 7,000 candidates for state-level offices. And they secretly funded ‘independent’ patient groups to advocate on their behalf.
There is, however, more to the story of the opioid crisis than venal drug companies. It is an indictment of a health system built on profit, a political perspective that encourages the medicalisation of social problems and a racialised ‘war on drugs’.
The roots of the crisis lie in the 1980s and Ronald Reagan’s policy of corporate deregulation. Drug companies, led by Purdue Pharma, the corporation owned by the Mortimer and Raymond branches of the Sackler family, took advantage with aggressive marketing campaigns to convince doctors and regulators of the need for, and the safety of, a new class of opioid analgesics. Drugs previously used primarily for patients with cancer or a terminal illness became a routine prescription.
It wasn’t just marketing skills that drove this shift. This was an era of deindustrialisation, mass job losses and the breakdown of communities, particularly in white rural areas such as West Virginia, and in the rust belt of the midwest, many of the areas that later became ‘Trump country’. These communities were targeted by drug companies. The answer to poverty, social dislocation and political disillusionment became opioid pills. Between 1991 and 2011, painkiller prescriptions in the US tripled.
The problem was exacerbated by America’s insurance-based healthcare system. Insurance companies insist on the cheapest solution to any problem. And pills are cheap. In Japan, doctors treat acute pain with opioids in 47% of cases; in America, the figure is 97%.
Then there is the question of race. It’s no coincidence that the opioid epidemic has devastated largely white, working-class and rural communities. It was a conscious strategy by pharmaceutical companies to avoid the taint of being associated with inner cities, black communities and illicit drug use.
Deregulation took place at the same time as the launch of the ‘war on drugs’, a war waged against foreign drug dealers and within African American urban communities. The consequence was more intensive and repressive policing, greater social inequality, mass incarceration of black men – and a social narrative about ‘drug-infested ghettos’.
David Herzberg, author of Happy Pills in America, a cultural history of America’s relationship to drugs, observes that for more than a century there have been two parallel discussions about drug use. Psychoactive drugs used largely by middle-class whites are classified as ‘therapeutic’ and ‘medicines’ and subject to light-touch regulation. Those used by non-whites and the poor are deemed ‘illegal’ and sanctions are enforced through harsh policing. Trump’s rhetoric about foreign drug cartels and illegal immigrants is merely the latest expression of the historic tendency to view the problem of drugs through a racial lens. And while blacks have been the main victims of this, the opioid crisis shows how a racist perspective can affect poor whites, too.
It is tempting to see the opioid crisis as a peculiarly American issue. There are features of the story that are unique to America. But many aspects, from the tendency to treat social issues as medical problems to the racialisation of the ‘war on drugs’, have wider relevance too, not least to Britain.
Perhaps the most important lesson to learn is that turning health into a money-making machine inevitably has tragic consequences. Supporters of the free market, and of its extension into areas such as health, suggest that privatised services are more efficient. The reality is that when the primary goal is profit, not social need, corruption gets built into the system. The actions of companies such as Purdue and Johnson & Johnson are contemptible. They also follow the logic of the market.