Dreamland (48 page)

Fast-food restaurants developed a heroin problem. Across the country, people were using their convenient bathrooms as places to shoot up. There, locked in isolation, many overdosed and died. In Boston, the problem got so bad that the city’s public health commission asked fast-food workers to do periodic bathroom checks, and began training workers to notice the signs of overdose: a person’s slowed breathing, or lips turning blue.

Alabama now had heroin. Mississippi and southern Louisiana did, too. Rural towns in Indiana and Oregon were bad. Eastern Idaho, North Dakota, and Wyoming were, too. West Virginia saw fatal heroin overdoses triple in five years; Cabell County, where Huntington is located, had the highest number in 2012, with twenty-six people dying from too much heroin. Local media from Upstate New York and Minneapolis ran large and continuing stories about heroin. The
Albuquerque Journal
reported an 80 percent increase in heroin use in New Mexico. The Ohio River valley and Salt Lake City were swimming in it. Heroin was all over New Hampshire and Vermont, and Vermont governor Peter Shumlin dedicated his entire 2014 state of the state speech to the new plague.

Heroin had spread to most corners of the country because the rising sea level of opiates flowed there first. The story resembled the heroin scourge a century before, ushered in on the prescription pads of physicians, the vast majority of whom were sincere in intent. Drug traffickers only arrived later, and took far less profit than did the companies that made the legitimate drugs that started it all. “What started as an OxyContin and prescription drug addiction problem in Vermont has now grown into a full-blown heroin crisis,” Governor Shumlin said.

What made New York City the dominant heroin market for so much of the twentieth century—its vast number of addicts, its immigrants, and its proximity to poppy-growing countries—was now true of most of America. Most of the country’s heroin was coming from Mexico, and thus through the Southwest, trucked into New York, not arriving on ships from Asia. New York functioned now as more of a regional hub than the nation’s central heroin distribution point it once was.

The pharmaceutical industry’s sales force arms race ended. Pfizer, Merck, Lilly, and others laid off thousands. One U.S. trade publication suggested that 2014—with sales rep employment down from 110,000 people to 60,000 nationwide—might be the year when the “pharma salesperson really begins his slow walk to extinction.” Patents on blockbuster drugs had expired. The image of sales reps walking the halls of hospitals and medical offices, cornering doctors with “the opportunity to ‘present, respond and close the deal’ is very likely going to be limited,” the article lamented.

The arms race left behind massive lawsuits and criminal cases for misbranding and false advertising. Purdue was hardly the only company to have been sued. Its $634.5 million fine was soon dwarfed. Pfizer alone paid more than $3 billion in fines and legal penalties to settle lawsuits alleging, among other things, the misbranding and false advertising of several drugs. That included $2.3 billion to settle a criminal suit in 2009 alleging the company illegally marketed its blockbuster painkiller Bextra. The sum was the largest criminal fine of any kind, though it amounted to less than three weeks of the company’s sales, the
New York Times
observed.

Various agencies had tempered their initial enthusiasm where opiate pain treatment was concerned.

The JCAHO was now promoting multidisciplinary approaches to pain, including more healthy behavior, psychological support, and non-opiate medications, along with the education of patients on the addiction risks of opiates. So presumably Vicodin and similar drugs would no longer be prescribed without a word as to what they contained. The FDA was now requiring drug companies to provide patients and doctors with education on addiction risks from timed-release opiate painkillers—a common-sense extension of the patients rights movement, though one that came inexplicably late.

The FDA, meanwhile, reclassified Vicodin from a Schedule III drug to a more restrictive Schedule II. It also denied approval of a generic timed-release form of oxycodone—a no-name OxyContin. But then it approved Zohydro, a timed-release pill similar to OxyContin, containing as much as 50 mg of hydrocodone per pill, though without acetaminophen or anything else to deter abuse. The agency’s own advisory committee of pain specialists recommended against Zohydro, and was overruled.

Purdue followed that with an announcement that the company would soon seek FDA approval for its own timed-release hydrocodone pill—though this one would include an abuse deterrent. The FDA approved another Purdue drug, Targiniq ER, which combines timed-release oxycodone with naloxone, the opiate-overdose antidote. OxyContin sales, meanwhile, kept rising. Within a few years of the criminal case brought against the company by John Brownlee’s prosecutors in Abingdon, Virginia,
Fortune
reported, Purdue was selling $3.1 billion worth of the drug a year.

At the same time, though, many doctors now seemed to eschew opiate painkillers as energetically as they had embraced them a few years before. Patients who truly needed low-dose opiate treatment for their pain were having difficulty finding anyone to prescribe it.

Primary care docs still didn’t have the time, and many hadn’t the preparation, to effectively treat chronic-pain patients. That wasn’t about to change. In fact, fewer medical students were going into primary care—repelled by long hours, the modest money, and the lack of respect. One study estimated the country would need fifty-two thousand more primary care docs by 2025.

A commentary by four doctors and researchers in the American Journal of Public Health in September 2014 insisted that “It is difficult to believe that the parallel rise in prescriptions and associated harms is mere correlation without causation. [Also] it is difficult to believe that the problem is solely attributable to patients with already existing substance use disorders.” They went on, “Appropriate medical use of prescription opioidscan, in some unknown proportion of cases, initiate a progression toward misuse and ultimately addiction . . . Even if an initial exposure is insufficient to cause addiction directly, perhaps it is sufficient to trigger initial misuse that could ultimately lead to addiction.”

Pain may well help lessen the euphoria of opiates, as the pain crusaders had contended. Yet the authors noted how little was known about pain and addiction—both enormously complicated topics. Medicine still lacked the tools, they wrote, to identify who was at risk of addiction from properly prescribed opiate painkillers. Nor was there much knowledge of how, in treating pain, to balance that risk with the benefit of relief in patients showing signs of sliding into abuse of these drugs. What little knowledge existed, moreover, had not made it into medical-school training; certainly not to the degree that the pain crusaders, aided by drug companies, had changed medical-school curriculum with “selected evidence” of the benefits of opiate painkillers, the authors wrote.

After more than a decade in which chronic pain was treated with highly addictive medicine, there still was no attempt to bring the studies of pain and addiction together. Specialists in pain and in addiction operated in different worlds. They appeared not to know each other socially. They saw the same patients; a pain patient now might soon be an addict, after all. But there were no conferences where they shared ideas. No journal combined both specialties. Nor could I find any study that attempted to measure this crucial question: How many people grew addicted to pills they were prescribed?

I felt for doctors. Prescribe and they risked a patient growing addicted. Don’t prescribe and a patient may have to live with crushing pain. Patient evaluations nipped at their heels. It was a minefield. No wonder so few young doctors were going into primary care.

Multidisciplinary pain clinics were seeing a rebirth, however. Their menu of services had been shown to help many chronic-pain patients over time. Agencies with a financial interest in their patients’ long-term improvement were turning to it. Above all, the Veterans Health Administration, once a promoter of opiate therapy for chronic pain, had been turning around. Pain as the fifth vital sign was no longer gospel.

“Opioids are effective pain medication. They do work. But a pill is just not always the answer,” said Dr. Gavin West, a top VHA clinician.

After years of watching too many vets with chronic pain become bedeviled by addiction as well, the VHA was opening multidisciplinary pain clinics. The clinics included physical therapy, acupuncture, massage, and swimming-pool therapy, as well as social workers and psychological counselors to help vets suffering chronic pain also find work and housing and resolve marital problems. The VHA has seventy of these clinics around the country, as I write. The numbers of their high-dose opiate patients have fallen dramatically. The goal was to get patients back on their feet, going to work and their kids’ soccer games.

“To do those things, you have to approach the patients holistically. We not only have a financial stake, but an ethical stake in this, too,” West said. “We’re lucky, though. We have the advantage of taking the long view. A lot of [insurance] medical systems don’t have that. They’ll pay for what helps a person over a couple years. What happens in ten years is probably the next insurance company’s problem. If your economic driver is ‘I’m going to see a patient for ten minutes and bill them’—that’s a bad driver. People who can take a long view are at an advantage to treating a patient holistically.”

Insurance companies, notably, have not found the same virtue in multidisciplinary care. But the VHA has figured a more balanced approach to pain will improve patient function while lowering treatment costs in the long run. Their clients, after all, will be with them forever.

I never was able to speak with Russell Portenoy. In an e-mail, he politely declined my interview request. However, weeks before that, a remarkably frank interview with him was included in a video released by PROP—Physicians for Responsible Opioid Prescribing.

In the interview, Portenoy acknowledged that as he urged the more liberal use of opiates for chronic pain, he gave many lectures to primary care doctors citing Porter and Jick and several other papers.

None of the papers, he said, “represented real evidence, and yet what I was trying to do was to create a narrative so that the primary care audience would look at this information
in toto
and feel more comfort about opioids in a way they hadn’t before. In essence this was education to destigmatize [opioids] and because the primary goal was to destigmatize, we often left evidence behind.

“Clearly, if I had an inkling of what I know now then, I wouldn’t have spoken in the way that I spoke. It was clearly the wrong thing to do and to the extent that some of the adverse outcomes now are as bad as they have become in terms of endemic occurrences of addiction and unintentional overdose deaths, it’s quite scary to think about how the growth in that prescribing driven by people like me led, in part, to that occurring.”

The Treatment Is You

Washington State

Out in Washington State, Jaymie Mai and Gary Franklin continued chronicling the effects of what Franklin called “the worst man-made epidemic in history, made by organized medicine.”

Washington addicts in treatment for opiates had skyrocketed through the 2000s from about six hundred to a conservatively estimated eighty-six hundred by 2010. Most were young, suburban, and white. Overdose deaths in the state rose to 512 in 2008.

In 2008, L&I issued its guidelines to doctors aimed to limit opiate prescribing. Overdose deaths had declined since then and by 2012 they stood at 388. The numbers of injured workers dying from overdoses—which had so startled Jaymie Mai years before when she was new to her job—had kept rising, up to thirty-two in 2009; but since the prescribing guidelines came out, the number had been cut in half. So, too, had the numbers of injured workers who ended up as chronic opiate users.

I went up to Seattle, where the Multidisciplinary Pain Center traced its lineage back to John Bonica, the former pro wrestler and pain pioneer. Dr. David Tauben was now its director. Years ago, Tauben was an eager opiate prescriber. He taught the purported message of Porter and Jick. He cheered the introduction of higher-dose OxyContin. Then he watched patients fail to improve. They became disgruntled, demanding ever-higher doses.

During these years, he remembered an applicant to the center’s pain fellowship program who was asked why he wanted the post. I want a Bentley, the applicant replied.

“That to me is a metaphor for where pain management is,” Tauben told me.

Having changed his mind about opiates, Tauben came to work at the clinic when Alex Cahana took over. Cahana’s new approach was to try to get back to the old approach: treat the social and psychological roots of pain, along with the biological. The center staff now included two psychiatrists, three psychologists, a vocational counselor, as well as doctors in family, internal, and rehab medicine.

A generation of doctors had been urged to consider pain the fifth vital sign. “It’s just wrong,” Tauben said. “I’d say fifteen percent of my patients are probably much better off by being on opiates, but at low or moderate doses.”

Tauben took over for Cahana in 2013. Cahana’s five years at the center immersed him in America’s pain culture wars. The experience had made him something of a philosopher of pain and happiness. Cahana believed that what insurance companies reimbursed for distilled many unfortunate values of the country.