“I have been living with survivor’s guilt for years now.”
We were lingering after dinner in an upscale restaurant in a small New England city, discussing the heroin epidemic that has ravaged the region for 15 years and the impact it has had on his life and tragically, that of his son.
“I can’t walk into the hardware store, or the local diner back home, without running into parents who have lost children to heroin. And my son is still alive. After 12 years of using, and quitting, and using again, he is still alive. It is hard facing those other parents, many of whom blame my son for their child’s death and blame me for his survival.”
A dozen years earlier, his son was involved in a serious traffic accident that left him with traumatic brain injury (TBI) and an addiction to opioid pain medication that eventually led him to heroin. Since then, of the 10 friends his teenaged son hung out with, only five remain. The rest have died of overdoses.
Mac has spent tens of thousands of dollars seeking out rehab clinics to help his son, going as far as Minnesota to find one that specialized in treating addicts with TBI. But the bigger toll has been on the marriage that dissolved, and on Mac’s own well-being after years of dealing with an addicted son. It is a burden that you can’t just put down. As he described it, “For the last 12 years we have been constantly circling the drain of his addiction.” As he twirled his finger in the air, the pull that kept him tied to his son was almost tangible.
The opioid addiction story actually begins much earlier. In the early 1990s, faced with the expiration of its patent on MS Contin, an extended-release morphine drug, Purdue Pharma, until then a relatively small manufacturer of drugs, did what many pharmaceutical manufacturers do: They designed a new version of MS Contin for which it would be granted the protection of a new patent. Named OxyContin, it was another time-released opioid intended to provide long-term pain relief to patients experiencing severe pain—mostly cancer patients.
Recognizing that cancer patients provided only a limited market, Purdue decided to use modern marketing techniques to expand sales. According to John Temple’s book American Pain: How a Young Felon and His Ring of Doctors Unleashed America's Deadliest Drug Epidemic, Purdue first sponsored non-profit foundations and studies that purportedly “exposed” the problem of patients with untreated chronic pain.
Soon, articles were appearing in newspapers and magazines suggesting that the problem of untreated chronic pain was epidemic. Then Purdue introduced OxyContin as a safe narcotic that would not be addictive when used as directed. The machinations that were used to convince the public, and physicians, that this opioid was non-addictive and safe were complex and successful. Soon, Oxycontin was being freely prescribed as a painkiller for all kinds of pain, including chronic back pain. Pain clinics sprang up overnight in places like Florida, which supplied OxyContin to people as far away as Kentucky. And by 2002, Purdue Pharmaceuticals was selling $1.5 billion worth of the pills annually.
Inevitably, other manufacturers jumped on the opioid marketing bandwagon, including Janssen Pharmaceutical which promoted its narcotic, Ultracet, for chronic pain. Cephalon promoted its narcotic lollipop, Actiq (fentanyl) for migraine pain instead of the cancer pain for which it had received FDA approval, and Endo claimed that “withdrawal symptoms and increased tolerance to narcotics are not the same as addiction” in its promotional materials for Opana, Percocet, and Percodan.
The problem with all of these narcotic pain relievers was that they were all highly addictive. And they were all easily abused by crushing and inhaling or injecting them. Opioid analgesic-related deaths began to increase:
In 2007, Purdue Pharma, which had been mostly successful at fending off civil suits based on the harm that its product caused, finally lost a major criminal case in Virginia that was brought by the local U.S. Attorney.
The company pleaded guilty to federal criminal charges that it had lied about the drug’s risk of addiction. Three top executives paid $34.5 million in fines and the company paid $600 million, one of the largest such fines ever paid by a pharmaceutical company.
In 2010 Purdue quietly introduced an abuse-resistant form of OxyContin that was so successful that the name brand drug soon disappeared from the streets. Prior to that, however, Mexican drug cartels had already been moving heroin into the communities that had high prescription opioid use. Although the Colombians have provided the eastern half of the country with heroin for the past two decades, the Mexicans are moving into that market as well, and now control the majority of heroin trafficking in the United States. While the Xalisco Boys have even set up retail operations in America’s suburbs and rural areas, most Mexican wholesalers work through already established criminal gangs.
They made their move into the States at just the right time. Peddling heroin which today can be inhaled or smoked as well as injected, they were ready to provide a cheaper high to those who could no longer obtain or afford the price of prescription narcotics as their tolerance and dependence grew. When the newer, abuse-resistant OxyContin was introduced, the heroin suppliers were already on the ground and ready to provide an alternative. (While Afghanistan accounts for 80 percent of the world’s opium, most of the heroin that makes it to the States comes from Mexico.)
And while correlation does not indicate causation, it is very hard to look at the above chart, which shows the skyrocketing increase in heroin deaths that began in 2010—the same year that Purdue introduced its revised OxyContin—and not suspect that there is some connection between the two. At the same time, states were implementing drug databases that made it easier to detect patients who were doctor shopping and receiving multiple prescriptions for narcotic pain medication, and some states were also closing down some of the most notorious pain clinics that served as pill mills.
(By the way, last year Forbes estimated that OxyContin sales have earned Purdue Pharma $35 billion—annual sales are around $3 billion. The Sackler family, which owns Purdue, was included in Forbes 2015 richest list, coming in at No. 16 with an estimated wealth of $14 billion dollars.)
Heroin has changed a lot over the years, both in purity and in price. In 1981, the street heroin was 10 percent pure. By 1999 that percentage had increased to 40 percent, and with some fluctuations, it remains high today. The price for a gram of heroin in 1981 was $3,260 (in 2012 U.S. dollars) and by 1999 it was down to $622 (again, in 2012 dollars) and has remained low ever since, according to the latest Drug Enforcement Agency (DEA) Threat Assessment Update.
Not only has the heroin changed, the users have as well:
In the second major wave of American opiate addiction, heroin was integrated into the new cultural identity of the "hipster," first through the Harlem jazz scene in the 1930s and 1940s and then through the Beatnik subculture of the 1950s. During this period the major supply of heroin entering the U.S. came through the "French Connection"--a collaboration between Corsican gangsters in Marseille and the Sicilian Mafia. In April 1971, Congressman Robert Steele (R-CT) investigated reports of rampant heroin abuse among U.S. servicemen in Vietnam.
Today’s users tend to be rural and suburban whites, mostly in the 18 to 34-year-old age group. And most of them started with controlled prescription drugs (CPD) before moving on to heroin, unlike the earlier users who had had no exposure to prescription pain relievers.
Most CPD abusers will not become heroin addicts: According to the DEA, only about 3.6 percent will move onto heroin. However, of the heroin users, 79.5 percent were CPD abusers. The problem with heroin is that its use, and the accompanying death rate from overdoses, are both increasing dramatically.
Adding to the concern over the climbing figures is fentanyl and its analogues. Fentanyl is a synthetic opioid that is 50 to 100 times stronger than morphine and 30 to 40 times more potent than heroin. Designed for the severe pain of advanced cancer, it is administered through skin patches or lozenges. Potentially lethal in even small quantities, fentanyl and its analogues are now being laced with heroin and cocaine and processed into pills and sold on the street.
Mac is aware of the risk that fentanyl presents to his son, but finds some hope in the fact that he has been clean for the past seven months. He recognizes how hard it is to battle this addiction, and how much like a rollercoaster his life has become. He’s clearly frustrated that he has not been able to get his son the help he needs to live a life free from heroin. Called MacGyver by his girlfriend for his unfailing ability to solve problems at home or at work, this is one that appears to be beyond his ability to handle alone.
Next week we will look at some of the possible steps that could be taken by our government to help families like Mac’s—and what the two main presidential candidates have had to say about the issue.