Dreamland (21 page)

OxyContin riffed off an earlier Purdue product: MS Contin. MS Contin was Purdue’s first foray into pain management using the Continus timed-release formula invented by Napp in England. MS Contin sent morphine into a patient’s bloodstream continuously—hence Contin—over several hours. To accomplish this, MS Contin came in large doses of morphine: 15, 30, 60, 100, and 200 mg. Purdue marketed it to cancer patients and people just out of surgery, and MS Contin apparently served them well.

Likewise, OxyContin contains large doses of oxycodone—40 and 80 mg typically—wrapped in a timed-release formula that slowly sends the drug into the body over several hours. It has legitimate medical uses, and has assuaged the pain of many Americans, for whom life would otherwise be torture.

But OxyContin came out in 1996, which was a very different time in American medicine than 1984, when MS Contin appeared, or its story might have been similarly pedestrian. In the 1980s, few people in medicine accepted prescribing a strong opiate for chronic pain. By 1996, however, the opiate revolution wrought by the pain crusaders had been changing minds in American medicine for a decade. More insurance companies were reimbursing for pills, but not for therapy that was not strictly medical. Pain was now considered a vital sign, measured by a subjective scale between 1 and 10, and treated aggressively.

Later, Purdue officials would say that what happened with OxyContin surprised them because MS Contin hadn’t been abused. That wasn’t entirely accurate. Detectives in Ohio I spoke to remembered that MS Contin was stolen and abused. Doctors were conned into prescribing it to drug addicts in some cities, but not others—in Cincinnati but not in Columbus, for example. But certainly abuse of MS Contin was sporadic and never hit the levels that its cousin, OxyContin, would attain.

To promote OxyContin, Purdue hired William Douglas McAdams for the first time. While Arthur Sackler was alive, he didn’t allow the firm to work for Purdue, said Win Gerson, then the president of the firm. But Sackler had died in 1987 and the ad firm now got the Purdue contract. In preparing OxyContin for sale, Purdue thought it was just an extension of MS Contin, Gerson said. “There was nothing that suggested in reading the data that five minutes after you marketed it the kids would learn how to break it down,” Gerson told me. “[Purdue] followed the model of the drug they had, which was MS Contin. They absolutely thought that OxyContin would not be addictive.”

But MS Contin wasn’t sold as a virtually risk-free panacea for chronic pain. Other opiate painkillers had been confined to small doses and combined with acetaminophen or Tylenol to make them hard to liquefy and inject. These drugs were Vicodin, Lorcet, Lortab, Percocet, and others. Yet even those were abused. Moreover, no one had imagined that a pill containing a drug similar to heroin would be marketed almost like an over-the-counter drug. But by 1996 American physicians were tenderized to accepting opiates for chronic pain. Undertreated pain was an epidemic and physicians now had the duty, the calling, to relieve it using the new tools and drugs the pharmaceutical companies were inventing.

Indeed, some pain crusaders saw Purdue’s continuous release mechanism as the Holy Grail that the Rockefeller Committee had sought, and that had eluded researchers, testing drugs at the Narcotic Farm, for decades. If a nonaddictive drug couldn’t be found, perhaps a new method for administering opiates would lead to less addiction. OxyContin theoretically parsed out oxycodone in a way that did not cause the intense highs and lows that caused addiction. This was an exciting possibility. All that testing at the Narcotic Farm in Lexington might not have been in vain after all. Science might finally have come up with a way to provide merciful pain relief without the torment of addiction—albeit not in the way that researchers originally imagined.

“We went from not having very potent drugs . . . to an oral morphine form and to a pharmaceutical industry that wanted to promote it,” Kathy Foley said in an oral history interview in 1996, the year OxyContin was released. “So we, for the first time, then, had a marketer and a distributor for a drug that we had, and an educator. We knew then that oral morphine was effective. We can get away from these silly elixirs and cocktails into tablets that people take once or twice a day, and we’re into a revolutionary field of pain management . . . It was the drug-delivery device that changed, not the drug, and with that the whole mentality, ‘Well, now that we have this drug, we can treat pain.’ Really extraordinary.”

This possibility was indeed extraordinary. Up to then, pain patients spent most of their day thinking about pain, or the pills they needed every two to four hours to keep it at bay. Clock watching, it was called. Two OxyContin a day was better. That became a main selling point. The advantage was hardly trivial. Two pills a day allowed a pain patient’s life to recommence.

FDA examiner Dr. Curtis Wright, supervisor of the agency’s team that examined Purdue’s application, thought OxyContin might well possess addictive side effects and thought its only benefit was to reduce the number of pills a patient had to take every day. “Care should be taken to limit competitive promotion,” Wright is quoted as writing in an FDA report by the
New York Times
’s Barry Meier in his 2003 book on OxyContin,
Pain Killer
. Wright later left the FDA to work for Purdue.

In 1995, the FDA approved OxyContin for 10, 20, and 40 mg pills. Later, it added 80 and 160 mg pills. Despite the high doses of oxycodone loaded into each pill, the FDA bought the idea that by creating fewer surges of euphoria and depression OxyContin would be less addictive—the Holy Grail, at last.

The FDA approved a unique warning label for OxyContin. It allowed Purdue to claim that OxyContin had a lower potential for abuse than other oxycodone products because its timed-release formula allowed for a delay in absorbing the drug. “No other manufacturer of a Schedule II narcotic ever got the go-ahead from the FDA to make such a claim,” Meier wrote. “It was a claim that soon became a cornerstone of the marketing of OxyContin.”

The warning label also inadvertently told addicts how to abuse the pill, warning patients not to crush the tablets because that would release “a potentially toxic amount of the drug.” That was like an invitation to a junkie. A 2003 U.S. GAO report on the company’s OxyContin marketing efforts, requested by members of Congress, found that the FDA didn’t realize that “the drug could be dissolved in water and injected.”

From the start, Purdue promoted OxyContin far beyond the cancer and postsurgical patients to whom it marketed MS Contin. Purdue positioned OxyContin as the opiate of choice in the World Health Organization’s Ladder of pain management. The company aimed to convince doctors to aggressively treat noncancer pain, and prescribe OxyContin for moderate pain lasting more than a few days. OxyContin ought to be used for bad backs, knee pain, tooth extraction, headaches, fibromyalgia, as well as football, hockey, and dirt-bike injuries, broken bones, and, of course, after surgery. This was a vast new market for an opiate painkiller. U.S. back pain patients alone numbered some thirty-five million people; the total number of cancer patients were a fifth of that.

To get there, Purdue had to answer doctors’ first doubt: Isn’t this stuff addictive?

As Arthur Sackler had done with Valium in the 1960s, Purdue set about promoting OxyContin as virtually risk-free and a solution to the problems patients presented doctors with every day. The company urged salespeople, meanwhile, to “attach an emotional aspect to non-cancer pain so physicians treat it more seriously and aggressively.” Many pain patients suffered badly. Purdue urged doctors to believe that Oxy was the drug to “start with and stay with.” The doctors needn’t worry because the oxycodone was released slowly over many hours. Thus, OxyContin did not create the steep highs and lows that created cravings.

This message went out mostly to primary care doctors, whose sole pain-management training was usually at medical conferences, listening to the pain crusaders, who bore the news that opiates had been “shown” to be addictive in less than 1 percent of pain patients.

A former Purdue sales manager for West Virginia, William Gergely, said that the company urged its salespeople to emphasize the safety of OxyContin. Gergely declined my request for an interview. But in 2003, he told the
South
Florida Sun Sentinel
: “They told us to say things like it is ‘virtually’ non-addicting. That’s what we were instructed to do. It’s not right, but that’s what they told us to say . . . You’d tell the doctor there is a study, but you wouldn’t show it to him.”

In
Pain Killer
, Barry Meier describes at length Purdue’s sales techniques and training. The company put its sales reps through several weeks of training. One question they addressed concerned the risk of addiction to pain patients when treated with narcotics. “The correct answer was ‘less than one percent,’” Meier wrote.

The Man and the Nayarit

Northern Nevada

By the early 1990s, the Man was doing time at the Northern Nevada Correctional Center, a medium-security prison in Carson City.

White inmates ran the yard; blacks were also a force. But the prison’s Mexican population was small and vulnerable. They were mostly illegal immigrants and first-time inmates, wary and quiet, and spoke no English. The Man, bilingual all his life, became their spokesman.

Blacks and whites had their own large gardens, watered by underground pipes, where they could grow vegetables, melons, and other food. Mexicans had nothing. He lobbied for a plot where Mexicans could grow their food. Prison officials gave them a piece of land, but it had no water.

He met with the warden. “What’s the point of having land with no water?” he told her. “You’re mistreating my people.”

The warden let them extend a water pipe out to the garden. From then on, the Man got a cut of whatever the Mexicans harvested from the garden.

He kept on. On the Fourth of July, the whites fired up large grills where they barbecued ribs and roasted corn on the cob. There was nothing for Cinco de Mayo. The Man lobbied the warden and the Mexican inmates soon had the kitchen for a half day on May 5, and the gym after that for a party. They invited the guards and their wives, and the inmates taught the wives to dance
la quebradita
, with banda music blasting from the boom boxes they set up. The Man gave a speech, thanking the warden for acknowledging the Mexican inmates and their holiday.

He organized soccer games with teams from outside. He played on the inmates’ baseball team. The prison was made of barracks and he had a corner in one where he lived, and a table on which he played dominos and cards. There, he began to hang out with a guy from the small Pacific coast state of Nayarit in Mexico who was doing time for transporting cocaine.

Turned out, the Nayarit
had come to the United States illegally at eighteen to work derecho—the right way. An uncle had taken him and his brothers to Yakima to pick apples for a time. He then made his way down to the San Fernando Valley, which had the largest community of people from his town in the United States.

One of them, a cousin, was by then selling heroin from an apartment in Panorama City, a district of Los Angeles in the San Fernando Valley. From the cousin, the Nayarit learned the trade on the street. Then he fell in with some guys sending cocaine to Nevada and was arrested and went to prison.

In prison,
the Nayarit had no money. The Man cooked and shared his food with him. The Nayarit,
meanwhile, told him an intriguing tale.

He was, he said, from a town called Xalisco, near the Nayarit capital city of Tepic. In the mountains above Xalisco, he said, opium poppies grew abundantly. Cora Indians sold the flowers’ goo to people in his town. Cooking the opium goo into black tar heroin was a folkcraft that a few families in this town had mastered. They supplied relatives in the San Fernando Valley. Since he’d been locked up, the Nayarit said, his cousins had expanded to Honolulu, Phoenix, and Portland, too.

Problem was, the Nayarit said, his family spoke no English, and didn’t understand the addict world. So they missed markets and opportunities. You’re bilingual. You’re American, he said. You’ve been on methadone and know the clinics where they congregate. Right now you’re just an addict, the Nayarit told him. You’ve had to depend for supply on wherever you can find a source. I can supply all the dope you need. We could get rich like you wouldn’t believe. You, me, my family, my brothers. Reno, Denver, Salt Lake, and Hawaii. These are big markets.

“He had a broad vision of what this could mean for his town,” the Man told me years later. “I grasped it, took a hold of it, and took off with it. I give him credit for having the vision in seeing that I could help out, that I could do a lot for them. I knew about the addict in the United States. With what I knew here, we could combine and scratch each other’s back. We were just talking about the western states then.”

And not even all the western states, for he would not go to Texas and Arizona. The Man had spent years in California prisons, where Latino inmates had long feuded with those from Texas and Arizona. He considered those states backwaters of ignorance, and though heroin was big there, he never considered them potential markets.

He paroled to Reno in 1993. A few months later, the Nayarit appeared at his door. He had been deported, but had returned. He walked in bursting with ideas. Back home, he saw his cousin and others who said they had a system. It was 1993, and pagers were the rage. The Nayarit described his cousin’s system. It worked like this: Addicts called a number. The operator would then page a runner with a code for where to deliver the addict his dope. His cousin hired Xalisco kids to come up and run the dope around to the junkies. Most of these drivers were relatives, from poor families that farmed sugarcane, work that was hot, hard, and led nowhere. Hundreds of these young kids back home—poor, whose fathers owned a few acres and never got ahead—burned to move beyond sugar, and up the social ladder.