Pain (31 page)

Between 1996 and 2000, OxyContin prescriptions climbed from less than three hundred thousand to nearly six million, with annual sales skyrocketing from under $50 million to over $1 billion in 2000. Florida ranked fourth in the nation for per capita OxyContin consumption, behind West Virginia, Maine, and Alaska. As some physicians saw it, the rising focus on end-of-life care drove the trend—one Fairfax, Virginia, physician commented, “If Grandma is placed on morphine, it's like ‘Oh, my God.' But if Grandma comes home placed on OxyContin—that's OK.” By 2001, the drug's sales accounted for 80 percent of the company's revenue. As one reviewer noted in 2003, “If the drug had remained limited to patients with the most severe pain, the story would probably be different, but advocates for pain treatment minimized the danger of addiction and recommended prescribing OxyContin for milder and chronic pains.”
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A controlled release pill had strong consumer appeal—it lasted longer, called for fewer repeat doses, and depended less on the user's remembering to take their medicine. The time-release mechanism claimed to be
a near-perfect safeguard against addiction. One study argued that “around-the-clock controlled-release oxycodone therapy seemed to be effective and safe” and was accompanied with few side effects—reducing “the interference of pain with mood, sleep, and enjoyment of life.”
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The theory that controlled release inevitably reduced addiction was flawed in many ways, not least because physicians, drug promoters, and drug enforcers failed to take into account the inventiveness of consumers who, in time, would discover that crushing the pill, rather than swallowing it whole, released the full dose of the drug immediately. For drug companies, this argument served a broader goal—feeding their argument that conniving consumers, not the drug itself or improper marketing, were to blame for abuse.

Within a few years of OxyContin's appearance, problems with diversion and abuse appeared; and although OxyContin's abusers were diverse, a caricature of the drug as “hillbilly heroin,” came to life. Thus while in 2002, “a rash of armed robberies in suburban Boston” prompted one pharmacy to discontinue OxyContin sales, many stories followed abuse in Appalachia, where the drug was portrayed as a symptom of a broader economic and social problem. The
Cincinnati Inquirer
, for example, characterized the poor region as “ground zero for abuse of a revolutionary narcotic pain medicine” and noted in a headline: “OxyContin Abuse Said Likely to Spread—Appalachian Economy Tied to Painkiller Abuse.” In such accounts, the desire for excessive relief was explained by the declining mining industry, the rural economic depression, men's desires for relief amid economic and social turmoil, and doctors blurring the line between compassionate care and drug dealing. The media profile meshed neatly with another emerging rural epidemic—the rise of methamphetamine as a symbol of economic and social decline across rural America. As for OxyContin, arrests in 2001 and poignant stories of addiction attracted the interest of regional and national legislatures.
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In Florida, as one commentator later put it, the anti-OxyContin story took a new turn. The state was battling the economic declines characteristic of northern states, but it also had a large elderly population where the goals of killing pain for chronic illness and at the end of life had pressing immediacy.

Trying to avoid the stigma of pushing an abused drug, Purdue Pharma characterized the OxyContin fears of 2001 as a “media frenzy”
and shrewdly sought to rebrand its product—not as an abused drug but as a remedy for America's undertreated sufferers of pain. Politicians sought the middle ground. Late that year, for example, a congressional committee called the main players to testify on OxyContin. The committee's chair praised Purdue Pharma for a drug that had “brought relief to many Americans” but also blamed the drug for producing “hooked” teenagers, murder, suicide, pharmacy robberies, “big spikes in crime … and entire neighborhoods being overtaken either by users or drug dealers.” In a Congress prone to drug panics, the chair of the committee speculated that this could well be “the next crack cocaine.” In its response, Purdue Pharma sat squarely in the corner of liberalizing relief—calling attention to its advocacy for the undertreated. Writing at the dawn of the OxyContin controversy, J. David Haddox, the senior medical director of Purdue Pharma, defended the company, noting “as an academician, I can say no other company has done more to increase the understanding of pain … The media frenzy about OxyContin abuse is interfering with good pain management. In fighting drug abuse, we must not limit patients' access to strong analgesics to … preserve quality of life.” The company bemoaned the rising barriers for effective pain relief made worse by media hysteria and lack of medical education. “Thirty two percent of anesthesiology residents felt unprepared to manage chronic pain,” and only one of the 125 accredited U.S. medical schools offered pain management as a separate course. Physicians, in short, were still woefully undereducated in how to treat pain. Yet they often believed that their patients were poor judges of their own experience—prone to exaggerate the scope and severity of their pain. These exaggerated clinical fears were, a company document argued, one of the main barriers to effective relief.
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But claims of OxyContin's dangers went well beyond addiction and the black market; the drug was increasingly gaining a lethal reputation. As one source noted, “In 2001 and 2002, more people died from overdoses of prescription pain medications oxycodone and hydrocodone, such as the brand drugs Vicodin and Lortab, than die from heroin.” But with OxyContin producing revenues for Purdue Pharma on the scale of $1.5 billion in 2002 alone, the company decided that the best strategy for its bottom line was to litigate every claim of product liability. It also effectively pointed to others (doctors, patients) as the cause of any problems
with OxyContin. In Florida, where Rush Limbaugh would be charged in 2003, 328 deaths were attributed to heroin, but three times as many, 957, were blamed on oxycodone/hydrocodone. In the years leading up to the Limbaugh story, then, Americans were already engaged in an extensive reassessment of OxyContin and its promoters. A new regulatory dilemma emerged. The question was whether regulators would focus on untreated pain and uneducated doctors as many pain relief advocates (and the company) wished or on inflated marketing claims, excessive consumption, and physicians duped by unscrupulous drug companies (as industry critics hoped).
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As cases of OxyContin abuse mounted, Purdue Pharma's marketing practices worried liberals and conservatives alike—producing strange political bedfellows who slowly embraced the goal of enhanced market surveillance. Physicians who advocated liberal relief aligned with the profit-seeking industry and relief-seeking patients on one side, and conservatives who were usually steady allies of the drug industry and skeptics of government oversight aligned with liberal regulators on the other. Physician-assisted suicide had already begun to split conservatives; for many on the religious right, painkillers unacceptably blurred the lines between pain relief and covert euthanasia (see
chapter 4
). In this context, state legislatures had written pain statutes to define a clear and sharp line between standards of acceptable compassionate care and illegal “mercy killings.” Florida's Republican-controlled legislature passed just such a measure in 1994. With the arrival of OxyContin as an alternative to morphine, legislators on the right were already primed to move toward aggressive oversight and surveillance.

While surveillance took several forms, physicians were frequently targeted first. Florida, Virginia, and other states became the sites of high-profile convictions of doctors involved in running so-called pill mills that offered excessive pain prescriptions. In 2001, Florida doctor James Graves was sentenced to sixty-three years in federal prison—convicted of manslaughter for overdosing patients on OxyContin. As one libertarian critic of the Graves case saw it, OxyContin had ushered in the surveillance
society—it was “the first time in U.S. history that a physician was found guilty of manslaughter for prescribing self-administered medication that led to a patient's death.” As Ronald Libby (writing in coordination with the libertarian Cato Institute) saw it, the atmosphere in Florida was particularly ominous—with “media-induced hysteria” driven by a series of articles in the
Orlando Sentinel
by reporter Doris Bloodsworth.
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Purdue Pharma executives agreed.

But, with Limbaugh's case, the media narrative pivoted to a more diverse array of users, constructing stories of pain and relief among the middle class. The
New York Post
characterized Limbaugh as one among a new class of “upscale junkies” who were able to shop for drugs more widely, whether by hiring others to do the purchasing or by using the new phenomenon of online pharmacies to satisfy their needs. Other reports focused on the “college-age kids” and individuals once “comfortably middle class” who, in the grip of OxyContin, had crossed the line “from party guy to junkie low life.” One Vermont newspaper presented oxycodone usage as “migrating out of Appalachia to areas such as Columbus, Ohio and Fort Lauderdale, Fla.”—a rural plague upon “suburban neighborhoods.” Seen in this light, the suburbs and those who lived in them could be seen as victims (rather than as perpetrators) of crime. Limbaugh himself emphasized his virtues even as he confessed to his loyal listeners that “over the past several years, I have tried to break my dependence on pain pills and, in fact, twice checked myself into medical facilities in an attempt to do so.” On the right, there was praise for his “refreshing honesty”; the Left responded with scorn for his hypocrisy mixed with hope that he might become less self-righteous and critical of others. But, as one author noted in Florida's
St. Petersburg Times
, “Beyond the damage Limbaugh has done to his highly burnished conservative credentials, his sensational fall has added to the woes of another group: those in chronic pain who rely on OxyContin to relieve their torment. This kind of adverse publicity will only make it harder for patients to get access to the pain medication they need.”
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Other observers on the left, meanwhile, had been blaming Reagan-era policies for almost a decade for causing these new epidemics; Limbaugh's case did little to change their rhetoric. To Democratic representative Henry Waxman, the rise of OxyContin addiction gave liberal, proregulation Democrats an opening to highlight just how unaware Republican
administrations had been about drug marketing, diversion, and industry malfeasance. Waxman, the powerful member on the House Committee on Government Reform, insisted that the George W. Bush administration had been purposefully lax in its oversight of the pharmaceutical industry. As a report prepared by House Democrats for Waxman observed, “In 1999 and 2000, the last two years of the Clinton administration, FDA sent an average of ninety-five enforcement letters per year to drug manufacturers for false and misleading advertisements. The number of enforcement letters sent by the Bush Administration in 2003 is 75 percent below the average level of the last two years of the Clinton Administration.”
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To Waxman, the problems with OxyContin illustrated how right-wing policies had harmed public health, and its rise revealed the life-and-death difference between the Clinton and George W. Bush administrations' approaches to private sector drug surveillance. The Bush administration DEA had waited three months after Purdue Pharma launched its OxyContin ads to issue weak warnings to the company about its fraudulent claims. A Democratic committee reporting to Waxman observed that “the OxyContin delay stands in stark contrast to the actions of the Clinton Administration. In May 2000, the Clinton Administration cited Purdue Pharma for advertisements that overstated the effectiveness of the drug and presented a misleading safety profile. This citation came only one week after the ads initially ran.”
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The irony of “reform” in an era when Republicans controlled so many branches of government at both federal and state levels—the White House, both houses of Congress (from 2000 to 2006), many governorships and state legislatures, while making inroads with judicial appointments as well—was that legislation tilted not toward keeping drugs off the market but toward various kinds of market monitoring and postmarket surveillance. The industry's answer to market excesses leaned toward more monitoring of consumption rather than stronger safety or marketing regulations. In 2004, the FDA announced industry-approved initiatives, such as putting “tiny radio antennas on the labels of millions of medicine bottles to combat counterfeiting and fraud.” “It's basically a bar code that barks,” one industry researcher told the
New York Times
—one that could “make supply chains more efficient and more secure.” As the chief security officer for Purdue Pharma commented, “We get calls once a
week from state troopers saying they got a guy with one of our bottles.” Indeed, Purdue itself played a role in focusing attention on users rather than on the company. In Florida, facing an investigation of its sales practices by the state's Democratic attorney general Bob Butterworth, the company struck a compromise with the term-limited Butterworth in late 2001. As one commentator noted, “Purdue pledged $2-million for software to run a drug prescription tracking system for the state. In turn, Butterworth agreed to end his inquiry.”
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Other critics, meanwhile, pointed out that tracing pill bottles back through the supply chain would not be enough to stop the OxyContin epidemic. The pain relief economy was far more extensive than this; many players in this pain relief economy (consumers, physicians, drug companies, and pharmacists) had powerful incentives to promote consumption regardless of the social costs. In 2013, the Walgreen's pharmacy chain confirmed that, at the height of public concerns about OxyContin, its officials created a bonus program (a perverse incentive plan) to reward pharmacists who sold more, not less, oxycodone. They were encouraged to look the other way even if customers were “red flagged” as possible abusers. How effective could surveillance be when the perverse incentive to promote OxyContin stretched throughout, and to some extent defined, the political economy from manufacturers, prescribers, regulators, dispensers, and users?
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