How to Create a Crisis

Edmund was such a bratty kid the first time I read The Lion, the Witch and the Wardrobe.  I loved Lucy, since I was a girl her age, but his relentless effort to embarrass her only made him half villain.  What was really repulsive was his ignorance to temptation. He didn’t even try to defend himself against White Witch! How could a person so shamelessly seek after evil, trudging through snow with no coat, just to sell out his siblings for some nasty candy?  I understood that he represented me as a sinner, but I couldn’t bear being lumped in with someone so oblivious to an evil plot.

People feel kind of the same way about opioids in the Appalachians. People’s resentment builds as heroin abuse bashes away at the infrastructure of rural life. It’s not that they’re unfamiliar with addiction, or the depression that leads people to it. They’re just tired of the unrelenting pain that heroin brings, and of lacking the resources to fight back.  People wonder, why can’t addicts just say ‘no’? They did DARE in school like everyone else, so how could they be so helpless against such an obvious evil?  Maybe if addicts just thought about their choices, money wouldn’t be wasted on Narcan, social services and jail.  A town in Ohio went as far as suggesting a 3 strike policy for people who overdose, coming to revive them three times, but not the fourth.  It’s callous and simplistic, but people are so annoyed that heroin is even an issue.

The applicable moral of that first Narnia book for the fed up population of Appalachia, though, is that every life is precious, no matter how many idiotic mistakes have been made.  What was funny to me was that when I read the book to my boys, thirty years after I read it for myself, they saw him as a victim, not as a dimwitted bully. Through their eyes I could see he was just an emotional little boy, frightened by the war and annoyed by his seemingly perfect siblings.  He was nursing wounds caused by circumstance, being separated from his parents and scared for their safety.  Adding to Edmund’s plight, he’s sacrificing joys he’s been entitled to since birth- sugar, chocolate, tin cans, rubber… even new shoes and socks.  He wasn’t wandering Narnia looking for a one up on his siblings, the chance just found him, cold and lonely in the woods with an unsettled heart.  All it took was a small promise of some nice treats, and suddenly his greed was insatiable. 

The enchanted treats perverted Edmund’s character similar to the way heroin would.  The more of the treat he ate, the less remained of his virtue.  Reality became distorted to the point he could no longer decipher the good from evil, or truth from lie. His disposition became increasingly combative, even when he was obviously wrong.  Of the Turkish Delight, Lewis says, “…anyone who had tasted it would want more and more of it, and would even, if they were allowed to, go on eating it until they killed themselves.” His greed for it left Edmund with an empty container, making promises he couldn’t keep, to a woman he couldn’t trust, all to dominate his siblings and live in a fantasy.   We scoff at people who fall prey to addiction, the same way we do at Edmund, but truthfully we know more about this scenario than we’d care to admit.  

The creation of today’s Heroin crisis is rooted in the same oblivion as Edmund’s.  He didn’t know that the Witch’s treats were enchanted.  He’d probably eaten Turkish Delight before without feeling the urge to sell his soul, so why would he suspect danger? The Witch may have been exuding evil, but it was just candy.  Similarly, the increase in heroin use today is attributed to the mass abuse of OxyContin, which originally no one thought would be habit forming.   For a decade doctors were encouraged to prescribe it to anyone with chronic pain, which opioids had never been used for before, and then even for smaller things like tooth extractions.  The lie was so pervasive even primary care doctors started prescribing it.  Finally, and FDA approved solution for all the pain.  Maybe we should have been more wary, but doctors prescribe all kinds of drugs that heal and help, so why should this be different? Even after 1000’s of years of experience with opium and its derivatives, we never stopped to question if these claims were true.

In the time that it has taken OxyContin to rise and level off in popularity, our culture has seen an abundance of fraudulent schemes fail. Our economy imploded as the housing market crashed.  Record breaking athletes almost all turned out to be bogus, and our olive oil was fake.  We wanted so much, we even ruined kindergarten in our quest to have the smartest kids.  Ignoring fraud and then being horrified at the consequences is our national pastime.  The American Dream is one of consumption. It sounds decent and non habit forming at its inception, and sure most people handle it well, but what starts as a little piece of land to call your own becomes a desire for a bigger piece of land.  After that its a nicer car, and then maybe some fancier clothes, a few dogs, and a pool, too. People who would otherwise be satisfied are suddenly not when they walk in to Target and see how cute the Magnolia line is.  The dream is habit forming, and the danger comes when the lack of fulfillment festers so deep, it becomes impossible to maintain a moral code and satiate the desire.  In this way we know Edmund and the addicts on the street, universally we suffer from blinding greed.  

The story of how we legalized drug dealing reveals this greed as the root of the  epidemic, and the drug abuse as a symptom of it.  The easiest villains to target in this story are people struggling with addiction, but a pill prescription doesn’t magically appear. As the opioid story unfolds, it reveals layers of villainy, shared between doctors, crooks, marketing departments and a struggling pharmaceutical company.

*  *  *

The first people to absorb blame are usually doctors, since they introduced many unwitting patients to opioids without any warning about the possibility of addiction. Dr. William Hurwitz was one of the first to be penalized.  The star of the documentary “Dr. Feelgood: Dealer or Healer”, has an impressive resume.  He was educated at Columbia and Stanford, and then volunteered with the Peace Corp in Brazil. When he came back to the States, he specialized in chronic pain, became an expert in the field, and opened his own clinic in an affluent D.C. suburb.  His patients were people whose pain was so crippling they were unable to do basic things, like walk or work. They were grateful for his support, but traditional treatment involved multiple types of surgeries and therapies in addition to some meager medication.  It was a long, expensive road, lined with tiresome insurance battles, and no promise of relief.  Everyone was desperate for an easier answer to the problem of chronic pain.

In 1996, sales reps from a company called Purdue Pharma showed up in doctor offices across the country, and the problem was solved.  They promised their new pill, OxyContin,  was the first ever non-addictive opioid, thanks to its fancy new time release capsule. They wooed doctors during special conferences at fancy resorts, and cited a few loosely applied studies to substantiate their claims.  At these conferences they promised even a primary care physician could prescribe it safely.  It’s so harmless, people could use it after a tooth extraction.  Purdue trained its sales team to ingrain the message that the risk of addiction was “less than one percent.” They even made up a term to describe skeptics: ‘opiophobic.’

Hurwitz was  enamored with the pill. After years of repeated appointments with little progress, his patients were finally happy, and he was overjoyed. “It’s a miracle from heaven,” they’d tell their friends.  They can go back to work, walk without a cane, and play with their grandchildren again.  But soon they would become tolerant and ask for a higher dose, and Hurwitz would oblige.  He started to ignore signs that his patients were abusing the drug.  When a nurse would point out a patient with track marks, or an unclean urine sample, he would argue didn’t an addict also need pain relief?  If a patient ran out of pills before their prescription ended ( a sign of pill abuse), Hurwitz would assume the patient was developing more severez pain, and increased their dosage.  After two of his patients overdosed and died, the DEA opened an investigation. His abundance of patients taking abnormally large doses led them to shut his practice down.  Soon after the medical board revoked his license, and eventually he went to jail.

Even after losing everything, including his marriage and career, he still thinks OxyContin is the answer for chronic pain.  When they interviewed his ex-patients, ones who were lucky enough to have recovered from their habit, they all regretted their addiction and understood how the pills had made them suffer more.  Hurwitz showed remorse for the people who had died, but was unwilling to assume any blame. He was sad that people had taken the drug incorrectly, mostly because it ruined the chance for others to use it for relief.  In his post jail interviews, he still did not feel that large doses, extended use, or increasing tolerance had anything to do with creating epidemic addiction. He shows we can be greedy with excellent motives, and what’s scary is that will blind us all the same.

*  *  *

Well meaning doctors have absorbed a lot of the initial blame, but once people realized  the draw of OxyContin and its generic oxycodone, anyone with a prescription pad had the ability to get rich quick.  In fact, you didn’t even have to be a doctor to profit, you just had to employ one. Jeff and Chris George owned and operated the U.S.’s  largest chain of pill mills, profiting $40 million in just two and a half years.  Twin brothers from Florida, who had no medical experience and had only ever worked as housing contractors, opened shop in 2008. They hired desperate doctors who were bankrupt, literally and/or morally, and told them if they wrote a lot of prescriptions they could make $2 million a year.  At this point many people were relying on the black market for pills, but once patients realized how easy it was to obtain drugs without getting arrested, American Pain exploded.   People drove down by the van full from as far away as West Virginia and Kentucky.  All a patient needed was an MRI (done for $50 in a trailer behind a nearby strip club) and a clean cup of urine (didn’t have to be yours). A visit would require one to act civil in the waiting room, and 15mn with the doctor to make up a story about what hurt, but as long as someone followed the procedure they could go home with a month’s worth of pills.

Since pain is relative and mostly invisible, you can’t prove someone is lying about their pain, making it difficult for the DEA to build a case against pill mills such as American Pain. It wasn’t until the brothers violently threatened people that agents were allowed to wiretap their phones and prove the clinic was a sham.  At any point before that, the George’s certainly could have walked away with a fortune, but when recounting the story they said their love for profits and power became insatiable. They wanted to stop, but they couldn’t give up the excitement of large stacks of cash.  By the time the clinics were shut down and everyone was arrested, the DEA estimated that 20 million doses of opioids had been prescribed, an average of about 10,000 per day.

In the end, the George brothers regretted what they had done, but from jail they asked the question, why were they the only ones in trouble? The drug distributors all knew what was happening, because the clinics demand for meds was so much higher than the average doctors office, but they all turned a blind eye.  And what about the people who made the drug? For every pill the George’s sold, a portion of their profit went to them too, so why weren’t they in trouble?

*  *  *

 

That company the George’s were talking about is called Purdue Pharma.  In the early 90’s they were still a small company, whose primary product was a painkiller called MS Contin given mainly to dying cancer patients. It was profitable, but the patent was about to expire, and with it’s limited market it wouldn’t be able to compete with its generic versions. The company needed something new to keep them afloat, preferably something with a bigger market so they wouldn’t be in the same position ten years later. OxyContin, was their answer, a new opioid drug that would release its potency slowly into the bloodstream, to prevent the bodies dependence on it.  In clinical tests they decided it would be mellow enough for chonic pain, which happened to be a very large, untapped market.  Soon enough, its popularity turned them into superstars, and opioids became a billion dollar a year industry in just a few years.  Today their reach is global, and the Sackler family, who owns the brand, is the 16th richest in the nation according to Forbes.

It’s unclear what their original intention was other than trying to stay in business. Did they create their product to help people or did they know they had found a way to legalize and profit off of heroin? By 2000, people began to realize that OxyContin actually was addictive, and started filing lawsuits.  In 2007 The U.S. Attorney General’s office in Virginia took up the case, against the advice of superiors, and Purdue Pharma pleaded guilty to criminal ‘misbranding’, which included mislabeling the drug, fraudulently promoting it, and marketing it for an unapproved use.  They paid $635 million dollars in fines to stay out of jail, which was the biggest penalty at the time, but has lost its meaning compared to the $35 billion in revenue that Purdue Pharma earned from OxyContin to date.  Several other affected places have successfully filed for damages since, including Kentucky, New York, Ohio, West Virginia and Canada.  Most recently the town of Everett, Washington has filed a new lawsuit, this time claiming the company purposely fueled the black market in order to increase profits.  

Why did it take almost two decades for Purdue to admit their guilt or do anything about it? Could they really not see that their product was destructive?  It’s difficult to judge where the distinction between evil intention and ignorance lies.  The CEO’s themselves were so caught up in the success of their product, it’s possible they didn’t understand the long term consequences of their actions.  Even once the effects became undeniable, the profits were too blinding to ever admit the pill was causing problems.  29 claims for damages were fought off before a single case was settled.  With bank accounts growing into the billions, morals became subject to the desires of stockholders.  The company’s  polluted motives became a classier version of those addicted to the drug they were selling.  For some reason though, there aren’t any CEO’s behind bars yet like there are street dealers, pill mill operators, or unscrupulous doctors.  Maybe we’re more comfortable with their sin, all they wanted was there company to stay afloat. and then just a little more money after that. 

 

After Purdue Pharma was convicted, their profits and the rates of pill abuse continued to increase for 3 more years.  I think the most frightening part of this story is how little we care.  Even with the landmark court case, opioids were not a top news story in 2007, or listed in the top 10 headlines for any year before or after.  Most headlines were about elections and their related issues, the war on terrorism, sports or celebrity gossip.  The housing crisis and the ensuing recession have been a top story almost every year since 2008 because of the mayhem it caused, but opioids have devastated almost as many.  It’s estimated that 7 million have struggled with dependency since the release of OxyContin, many cases resulting in death.  On the surface this seems about equal to recession unemployment or foreclosures, but the statistic grows exponentially when we realize that addiction is a family problem.  For every dependent person counted, there are several more suffering the consequences, like kids in foster care, babies in withdrawal, and/or relatives spending a fortune on their loved ones in rehab.

After such a traumatic experience, you would think we would make an elaborate effort to keep history from repeating.  Some progress has been made; OxyContin now has a tamper resistant coating, and databases have been formed to track prescriptions and prevent abuse.  Doctors now have strict guidelines for prescribing opioids for chronic pain. Rates of abuse have leveled off, but at the same time so have profits.  Instead of being satisfied with the money that’s been made, there is now a global campaign for OxyContin, using the same misleading and aggressive marketing techniques that proved so successful in the U.S. In a terrifying quote from a promotional video, the company claims, “We’re only just getting started.” 

At the end of The Lion, The Witch and the Wardrobe, when Peter confesses that he was partially to blame for Edmund’s actions, and Aslan doesn’t deny it.  The uniting sin behind every facet of the opioid epidemic is as much in my soul as it is that of addicts, over-prescribing doctors and Purdue Pharma’s.  Like Peter, we all have a part in contributing to a culture that values material gain with low tolerance for pain or misfortune. The most terrifying part of raising four little boys is to see how deeply embedded in our human nature greed is, because it feels so impossible to teach them to see others needs before their own, and to be content with what they already have.  Everything else, from their friends to our junk mail, teaches them they need more: more activities, brains, ambition, muscles, toys, fun, food, gifts and then also more money…to pay for it all.

In the aftermath of OxyContin we find ourselves like Edmund, standing alone in a frigid wasteland, desperate for hope and lamenting the greed of our actions.  Heroin addicts may receive the worst of our scorn, but those that can find recovery are the most blessed, for they’ll have seen their problem clearly enough to be freed from it.  Unfortunately, greed pushes us to live in denial. Maybe we suffer the consequences for a while, but in the end we learn nothing.  The opioid disaster probably won’t be a catalyst for lasting change.  Historically speaking there is not much precedent, since this same exact problem happened when heroin was released by Bayer Pharmaceutical in the early 1900’s.  But it might, and we could be louder and more emphatic in our prayers that it will.  Celestially there may be hope, but individually, our power against is in choice as individuals to be satisfied, and our ability to teach our kids, friends, and neighbors to do the same.  Many of us know the serenity prayer, recited in almost all group recovery meetings. God grant us serenity…courage…wisdom…, but the heart of this prayer is contentment, a plea for peace with and about the world as it is, and freedom from the desire to control or escape it. It is fitting, since contentment is also the antidote to greed. The true fight against addiction epidemics begins with this. I pray above all else that contentment will become our heritage we cherish above all, not chasing illusive, unfulfilling dreams.

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