The American Heroin Epidemic, Volume I: The Pharmaceutical Industry

Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. Last month, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

I had originally intended to have Addiction Professional publish this, but they said it was too long (just under 10,000 words) and too steeped in policy. I offered it to Hazelden, but they said it conflicts with their own publishing house. After some thought, I have decided to publish it as a series on my site throughout the winter of 2016. This is the first of eight articles from that interview. We discussed the role of the pharmaceutical industry in the current American opiate epidemic.

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Frank Greenagel: The history of pharmaceutical marketing and the work of Dr. Sackler was fascinating. It’s astonishing that he was able to use the money he made from marketing to buy a drug company. Years after his death, his company released Oxycontin in 1996. When I present on opiates, I talk about how Purdue Pharma, which clearly overstated the benefits and understated the side effects of Oxycontin, had to pay a $600B+ fine in 2007 but did not really change their behavior. I also mention that Purdue makes Subutex strips and I leave it up to the audience to form their own opinion about that. How much blame, and I know you can’t put a percentage here, but how much blame should be placed on Purdue and Big Pharma for the current opiate epidemic in America?

Sam Quinones: If it was only one company doing this, we would not have the problem we have today. Let’s put it that way. They were greatly helped by pain specialists who appeared to be independent, who were saying that we were a country in pain, an epidemic pain. They stated that these pills were now virtually non-addictive when used to treat pain. I really believe had it not been for that message being broadcast by pain specialists, Purdue would never have been able to convince doctors that these pills were virtually non-addictive. That said, it’s also very clear to me without the money, essentially the megaphone of Purdue Pharma, without use of techniques that are probably far better suited to over-the-counter medication, that the message of the pain specialists would also never have gone anywhere. Let me just say this also, though. I believe they happen to hit at a time when Americans really, really wanted to hear the message, which was that we were entitled to a life without pain. Americans, health consumers, patients, really wanted to hear that. It sounds great when a doctor says “now we know that these are non-addictive, so don’t worry. You can take these for any pain that ails you.” Americans also did not feel the need to be accountable for our own health decisions. A doctor might say part of your pain comes from the fact that you’re obese and you don’t get enough exercise and you eat poorly and you smoke. It was easier not to hear that and hear that “now we have a pill that will take care of your problem and we know now that it’s virtually nonaddictive.”

Frank Greenagel: The marketing of the pill, do you think that the benefits were pushed so much that the doctors were encouraged to not even look at the behavioral issues? Or do you think that ignoring the behavioral issues was just a fallout of the fact that they were overworked and didn’t have enough time to work with the patients and patients didn’t want to hear that anyway?

Sam Quinones: I think all of that is correct. I hate to be skimping or shrinking from the question, but it’s true. All of that is correct. There were patients with pain problems that were taking huge amount of time from doctors, time that doctors didn’t have. There was a feeling that this was a way of getting them out of the office, it was what the patients wanted to hear. I’ve got a solution for pain. Thank God, finally, I’ve got a solution for my pain. Let me put it this way. This is a nationwide thing. It goes from Maine, to southern California, to Alaska, to Atlanta. The only way you’re going to be able to create that kind of blanket response and therefore blanket problem that we’re now facing today is when a whole lot of factors come to play. It’s not one boogeyman. What I set out to say in my book was that there are a lot of factors in this. Hollywood is used to showing us one bad guy who is very easily identified. That’s not the way, I think, a lot of social problems work, particularly not one that goes all across the country and effects millions, if not tens of millions. That doesn’t mean that individuals don’t play an extraordinarily important role, and I tried to find that as well, but I’m also not believing that a problem of this magnitude, this widespread, is caused by one small factor. It’s a combination of factors, all of them working together to produce what we’ve got here.

Frank Greenagel: One follow-up on the Purdue question is that I’m sure you’re aware of the law suits that were filed by Santa Clara and Orange County and then the City of Chicago last year. Basically, they sued the biggest five pharmaceutical companies, of which Purdue Pharma is one of, for exaggerating the benefits and understating the harms of these drugs. It seems like the government’s come out at least with a boogeyman and I think part of it’s that city and county and state budgets are all suffering and they’re saying our workman’s comp costs are really over the top and our healthcare costs are over the top, so we’re going to go after you. Do you have an opinion on those law suits or do you have any thoughts about what’s going to happen with them?

Sam Quinones: I don’t. I was waiting to see what would happen, if they proceed. At that point, I was going to find out more about them basically. To me, it felt like I’d seen this before and they’d all been stymied. Frequently, they’ve been stymied, these law suits, and so I was just going to wait and see. Here’s the issue. This is a classic example of corporate welfare, where the profits accrue to a small number of private companies and the costs are borne by the public sector, coroners, jails, courts, public health offices, county hospitals, etc, etc. You can go on and on. Therefore, I would imagine that they will see more of those kinds of law suits I would think.

Frank Greenagel: Now, when someone says corporate welfare, conservatives get very upset about that notion and they’re not able to hear it, so is there another way that we can phrase this so that members of that party would be able to hear it and address it better or do you think it only gets addressed when…

Sam Quinones: No I don’t care. I really don’t care how they want to hear it. Really. This is a classic example of capitalism twisted, where the real price … Here’s the issue. If you’re a true conservative, you want truth in pricing. The real price of those drugs is astronomical if you consider the cost of what’s happened because of their marketing in this way. These are not cheap drugs. They may be cheap … Their price looks cheap, but their real cost, if we were to really factor in all the costs that have been borne by people who had to pay in a variety of ways, taxpayers and other folks, who had to pay for what this has created. It’s a classic example of the risks being pushed onto the public sector and benefits being accruing almost entirely to a few companies in the private sector.

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Part two will be published next week and is entirely on the topic of race and drug policies. Mr. Quinones talks at great length about how the current heroin epidemic is very different from the crack epidemic of the 1980’s.

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