New documents show that Big Pharma isn’t the only culprit when it comes to getting people hooked on addictive drugs.
By ZACHARY SIEGEL
July 30, 2019
“Just like Doritos keep eating. We’ll make more.”
“It’s like people are addicted to these things or something. Oh, wait, people are…”
These lines are from emails sent between opioid manufacturers and distributors, recently pried loose by attorneys general suing Big Pharma for its role in fueling a massive wave of overdose deaths. Similar to the damning internal memos revealing that Big Tobacco knew that cigarettes indeed caused cancer, these emails appear to show that Big Pharma knew that a significant share of their product was landing in the street, feeding addiction. And yet they kept shipping out obscene quantities to rural towns across America, creating even more demand.
Nearly every step of the pharmaceutical supply chain is implicated in the soaring death rate. According to the Centers for Disease Control and Prevention, prescription opioids killed 218,000 people from 1999 to 2017. Many of the companies—from Johnson & Johnson to obscure distributors like Cardinal Health—are listed as defendants in hundreds of lawsuits filed by nearly every state in the country. The government thinks these corporations should pay up and treat the addiction their products caused. But the companies claim to have been acting legally and in compliance with federal regulators like the Drug Enforcement Administration (DEA). Was it all, technically, legal?
What the opioid crisis illustrates is not that there are a few bad apples in the pharmaceutical industry, but that the country’s entire health care system is driven by profit at the expense of public health and safety. Drug manufacturers, pharmacy chains, drug distributors, and insurance companiesgot rich while people, especially people lower down the income ladder, suffered—and the DEA, through neglect or incompetence or a mix of both, watched it all happen.
While there are significant similarities between Big Pharma and Big Tobacco, there is also a key difference that makes today’s story of corporate malfeasance even worse: namely, that the supply chain for tobacco is much simpler than opioids, which are, theoretically, tightly controlled substances that pass through a dizzying array of actors and regulators.
First, a doctor must write a prescription, which must be filled at a pharmacy, and is likely paid for by an insurance company. Depending on the needs of their customers, pharmacies place orders for these drugs (customers, it turns out, need a lot of them). Shipping companies then go between the pharmacy and the drug manufacturers. Overseeing this entire system is the DEA, which sets the quota for how many opioids a company is allowed to manufacture, and tracks where those pills go.
While politicians are making hay out of Big Pharma’s wanton greed and recklessness, far less attention has been paid to the DEA. Attorneys general suing Big Pharma recently unearthed a database that both the corporations and the government—each for their own self-interested reasons—fought to keep sealed, called the Automation of Reports and Consolidated Orders System (ARCOS). Mammoth in size and granular in detail, ARCOS tracks the shipments of every single controlled substance, from the company that manufactured it, to the company that shipped it, to the pharmacy that received it. It is the world atlas for how the opioid crisis began.
All told, from 2006 to 2012, roughly 76 billion oxycodone and hydrocodone pills criss-crossed America, according to a Washington Post analysis. While many of these pills went to legitimate patients, millions more were showered on troubled communities with a voracious thirst for pain relief. While drug manufacturers produced more and more opioids (approved by the DEA), and distributors shipped those pills to pharmacies all over the country (tracked by the DEA), drug companies saw record profits—and America’s overdose death rate soared off the charts.
“I think this [database] brings home what we all knew,” says Corey Davis, an attorney and public health expert at the Network for Public Health Law. “This wasn’t just incompetence on the part of the DEA and the Department of Justice, it was knowing and intentional failure to do what most people think is their jobs.”
What is the DEA’s job, exactly? Its first task, and the one most associated with the agency, is the Sicario-esque disruption of illicit flows of drugs coming into the U.S. from abroad, like intercepting speedboats filled with cocaine. Its other major responsibility is controlling licit pharmaceuticals. “The whole goal of the prescription system is to make sure that patients are getting their medications, and that medications are not going to those who aren’t patients,” which is called “diversion,” says Bryce Pardo, a drug policy researcher at the RAND Corporation. “That’s the whole point of the system, which was invented a hundred years ago. Clearly, the system broke. The system failed.”
Pardo points out, in the DEA’s defense, the story of a so-called DEA whistle-blower blaming a pharma-backed piece of legislation passed by Congress in 2016, which prevented agents from stopping suspicious shipments of opioids, and stunted investigations into the very corporations that are now being villainized and sued. Just as DEA agents were working their way up the pharmaceutical supply chain, much as they would in a case against any transnational crime organization, Congress hamstrung their enforcement efforts.
Or so the story goes—but that’s not the whole of it. “These companies, often times acting legally, were asking for preclearance from the DEA to go about their business,” says Leo Beletsky, a professor of law and health sciences at Northeastern University (where I’m currently a journalism fellow). “Now, the DEA is saying their hands were tied when, in fact, their hands were not tied. They were completely asleep at the wheel. And by the time the DEA began constricting the [prescription] supply and targeting certain doctors and distributors, it was too late.”
In drug policy scholarship, there is a concept called the “balloon hypothesis.” When one end of a balloon gets squeezed, the air inside, rather than disappearing, rushes to fill the other end of the balloon. The balloon hypothesis is used to describe, often critically, America’s drug enforcement strategy. If cocaine production in Colombia is stamped out, production will shift to, say, Peru. If the Dark Web’s Silk Road gets shut down, a new Dark Web market pops up. The air has to go somewhere.
The balloon hypothesis also applies to the ever-shifting demand for drugs. “Over a period of 20 years, the DEA provided the green light to a 39-fold increase in the oxycodone quota and a 12-fold increase in the hydrocodone quota, even as our opioid epidemic unfolded,” Senator Dick Durbin wrote in a letter to the editor to The Washington Post.
In other words, the prescription balloon expanded, under the DEA’s watch, big time. But starting in 2011, the prescription market finally began to shrink after Purdue Pharma reformulated its blockbuster drug OxyContin with so-called abuse deterrent technology, and pill mills serving the black market were shut down. The supply was squeezed. The air still had to go somewhere, and it rushed to deadlier opioids like heroin spiked with illicit fentanyl. With enforcement focused on prescription opioids, the overdose crisis got worse.
Dan Ciccarone, a physician-researcher at the University of California, San Francisco who studies heroin use, says the crisis unfolded in three waves: Prescription painkillers gave way to old-fashioned heroin, which gave way to illicit fentanyl. “Big Pharma has egg on its face,” Ciccarone says. “It obviously could have played a more responsible role here. But at the same time, I don’t want the buck to stop there.”
“The only solution to the puzzle is to focus on demand,” he adds. “And we’ve been avoiding this for years. We need to structurally reduce demand through a healthier society.”
That means asking why 200 pills per person per year went to places like Mingo County, West Virginia. Mingo County, deep in coal country, ranks first out of 55 West Virginia counties for rates of obesity, binge drinking, and teen births. And West Virginia ranks first in the nation for poor health outcomes. In a town of 24,000 residents, 42 percent of the children live below the poverty line and 35 percent of adults over 25 did not graduate high school.
The Big Pharma lawsuits and the ARCOS database show how these pills landed in Mingo County. But they do not answer why. To researchers like Ciccarone, it’s no mystery. “Disenfranchisement, loneliness, lack of purpose, multigenerational job loss, lack of hope, and the lack of future,” he said, listing off the “social determinants of health” that determine why some people get addicted and not others.
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