This summer, a sculptor built a steel, 11-foot, 800-pound bent heroin spoon. With the help of an gallery owner, he put it on a trailer and drove it to the headquarters of Purdue Pharma, the manufacturer of OxyContin.
The bent-spoon protest of the country’s opiate epidemic by Massachusetts sculptor Domenic Esposito and Fernando Alvarez, owner of a Connecticut art gallery, stayed in front of the company’s Stamford, CT offices for only two hours before police impounded the sculpture, but it gained worldwide attention.
Alvarez was arrested and eventually convicted of a misdemeanor charge of blocking free passage.
I was in Boston recently and had a chance to meet and talk with Esposito about the episode and what brought it on.
Our conversation ended up including his brother’s addiction, drug marketing, Americans’ pain, and #thespoon movement they hope to ignite.
Great story. Take a listen. Share it if you like it:
In Louisville the other day, I wanted to see how jail was changing in America.
This epidemic of opiate addictions calling on us to reexamine a lot about how we live, our values, culture, ideas and institutions we’ve taken for granted.
One of them is jail. Jail has always been a crippling liability in our fight against drug abuse. Jails are usually places where humans vegetate, sit around, argue, learn better criminal techniques, then get out weary and stressed and, if they’re addicted to drugs, they head straight to the dealer’s house.
This epidemic is forcing new ideas. One of them is jail turned into an asset, a place of nurturing, of communion as addicts learn to help each other.
That’s a bizarre concept. I never thought I’d write “nurturing” and “jail” in the same sentence, but it’s happening.
The state of Kentucky seems furthest along in all this. I wrote an Op-Ed column for the NY Times about a visit I paid to the jail in Kenton County, Kentucky. Yet what’s being tried in Kenton County – and a couple dozen other county jails in Kentucky — began in Louisville – in Metro Jail.
Well, if “we can’t arrest our way out of this,” as is so often said, then we need more drug-addiction treatment. Yet this epidemic has swamped our treatment-center infrastructure. New centers are costly to build, politically difficult to site, and entering them is beyond the means of most uninsured street addicts, anyway.
I know that jailing addicts is anathema to treatment advocates. But opiates are mind-controlling beasts. Waiting for an addict to reach rock bottom and make a rational choice to seek treatment sounds nice in theory. But it ignores the nature of the drugs in question, while also assuming a private treatment bed is miraculously available at the moment the street addict is willing to occupy it. With opiates rock bottom is often death.
Jail can be a necessary, maybe the only, lever with which to encourage or force an addict to seek treatment before it’s too late. In jail, addicts first interface with the criminal-justice system, long before they commit crimes that warrant a prison sentence. Once detoxed of the dope that has controlled their decisions, jail is where addicts more clearly behold the wreckage of their lives. The problem has been that it’s at this very moment of contrition when they have been plunged into a jail world of extortion, violence, and tedium. It’s a horrible waste of an opportunity, and almost guarantees recidivism.
With this epidemic, though, we’re seeing new approaches – jail as a place of rehabilitation, a place where recovery can begin.
Several years ago, as heroin began to grip the area, the Louisville jail saw inmates dying from overdoses.
Mark Bolton, the jail’s director, said the spate of deaths forced new ideas.
“We modeled a pod on outside treatment (centers),” he said. “It became a matter of taking the resources we had and repurposing them. We sent people [to drug rehabilitation centers on the outside] and found out how they run their peer detox program. We learned from them.”
Louisville Metro began with female inmates. Those who were just off the street and detoxing, and who normally were spread across the jail, were placed together in one pod, christened Enough is Enough. This allowed more focus on their needs, and got them away from other inmates who were angered by their withdrawal symptoms, which included vomiting, diarrhea, screaming, insomnia and more.
Jail officials began allowing people in recovery into the detox pod as well. These recovering addicts mentored the new arrivals – washing and soothing them. Officers preferred it, as they no longer had to clean up vomit and diarrhea.
In addition to bathing and caring for those in withdrawal, inmates take classes in relapse prevention, understanding criminal thinking, accountability, parenting, and more; they run their own 12-step groups.
As the Enough is Enough pod began to function, there were fewer fights, less contraband. “Inmates into their recovery and into their sobriety are self-policing. The wear and tear is less,” Bolton said. “After we worked out the bugs, we began to see some of these people show progress. The inmates into their treatment appreciated the fact that they were caring for a human being that was at a place where they had been once.”
When they leave jail, they’re given a Vivitrol shot, which blocks opiates, and they were connected with housing and follow-up Vivitrol shots.
The jail now has the one women’s pod and three pods for men: 56 detox beds and 64 recovery beds, total.
I visited the pod – with about 30 women, four of whom were detoxing. The walls were covered with art work.
(Click here to hear the end of the pod’s afternoon meeting that day.)
It seemed, finally, a nurturing place in jail – far more about recovery than its connecting pod, where fights and loud noise were common until the early morning.
I spoke at length with a woman named Kara, whose addiction was more than 20 years old. This was her 17th time in jail. She had come from washing the vomit off another woman who had just arrived in the pod.
Here’s our interview:
The Louisville jail experiment isn’t a cure-all – no one thing is for this opiate-addiction epidemic. And the jail has difficulty tracking inmates who leave, so it’s unclear how well they do on the outside. What’s more, inmates by this time face a daunting uphill trudge to sobriety, hampered by family dysfunction on the outside, shredded personal relationships, a private sector wary of hiring them, and on and on.
And of course, there isn’t nearly enough in available treatment options.
“I would love to shut some of these programs down,” Bolton said. “This shouldn’t be the jail’s responsibility. [Addiction] is a public health issue. Our job is detention, protection of the public, to get people to court. When we have to become the quasi mental health facility for people who are poor and don’t have access to services, or for people who are drug addicts and who’ve created these chaotic lifestyles for themselves and can’t get treatment in the community — then we become this de facto fallback place for everybody. That’s not what jails are designed to do, nor should they be.”
Yet until a massive investment in community drug rehab and medically assisted treatment takes place, it’s likely that pods like Enough is Enough will be necessary.
It also occurs to me that with jail rethought and remade — a nurturing place — we have the chance that it will be an asset in the next drug scourge that comes along.
Either way, as with Kenton County, it seems like a better bet of public money than the way jail has been done up to now.
Portsmouth, a small town I wrote about in Dreamland, has been slowly rebounding from years of economic decline and drug addiction.
That’s a remarkable thing. For it was Portsmouth – on the Ohio River — that led the way into our national opiate-addiction epidemic. The town was where the Pill Mill – sleazy pain clinics prescribing massive amounts of pills to almost anyone for cash – was born.
With the town blasted by this huge supply, and the sense of community shredded by job loss and more, widespread pain-pill addiction was a fact of life in Portsmouth by the end of the 1990s.
But a lot has happened since then. The town, each time I return, seems slightly more energetic, more invigorated, more about positivity and less about dope’s inertia and fatalism. A recovery culture has taken hold there that’s exciting to watch.
Not that all the problems are behind Portsmouth, Ohio. But there’s another story now competing with the “let’s get high” culture that gripped the town for so long. I wrote about the beginnings of this at the end of my book – the small clues of rebirth: new gyms, a coffee shop, lofts, refurbished buildings and more.
Along that line, the folks of Portsmouth – 500+ volunteers – get together this Saturday to wash, repaint, redo their downtown in something they’re calling Plant Portsmouth.
They’ll be painting light poles, scraping and painting all the curbs, replacing 120 streetlights, and more. “None of this has been done in 20 years,” said Jeremy Burnside, an attorney in town who got the idea started.
They’ll also be planting plants as a way of signaling the town’s rebirth.
Burnside’s hoping to set a Guinness World Record for the most people planting plants simultaneously.
(Folks — please send me photos from the day and I’ll post them here and on social media. #plantportsmouth)
Organizers have raised $75,000 from local businesses to pay for supplies. That itself is a sign of how locally owned businesses are now growing in Portsmouth. None of that money came from the chain stores and corporate fast-food restaurants that have dominated the town’s economy since things began to go bad in the early 1980s and the shops on its main street closed. (Btw, I bought a couple t-shirts, inspired by Dreamland and the community pool that was the source of my book’s title, from a company called 3rdand Court that began in downtown Portsmouth. Check them out.)
The antidote to opiates is not naloxone. It is community. I say this often in my speeches when I’m traveling around the country. We Americans have isolated and fragmented ourselves in a million ways – this in poor areas and in wealthy areas. That left us vulnerable; it left us dangerously separate and disconnected from each other – strange to say in this time of technological hyper-connectivity.
The final expression of all that is our national epidemic of addiction to opiates – the most isolating class of drugs we know.
Rebuilding community (in a million different ways) is crucial to fighting it, I believe.
I’m glad to see Portsmouth leading the way on that, too.
Our national opiate-addiction epidemic is different from other American drug scourges for many reasons.
It’s the deadliest and the most widespread. It didn’t begin with drug mafias, but through the promotion of narcotic painkillers by pharmaceutical companies to doctors, who were pressured by we Americans, demanding an easy solution
to our pain.
But the epidemic is also remarkable for whom it has forced to its frontlines.
Librarians make up one such group.
I’m in Ohio this week, speaking at four regional conferences of librarians around the state. Today was Gallipolis — pop. 3500, in rural Gallia County, along the quiet, majestic Ohio River.
I stayed after my talk to listen to a panel made up of a university librarian, an elementary school librarian, and a public librarian talking about their experiences with this epidemic.
We heard about needles in the bushes, about how a child who lives in a drug house smells, about calling 911 because a customer had overdosed in a bathroom, about the look of some people who come into the library high. The epidemic has made danger zones of innocuous public places.
One school librarian, I was told, suspects two girls at her school are being abused. They come to school smelling badly. She takes their clothes home and washes them.
I was also struck by the stories many in the audience (80 people or so) had to tell about addiction in their families. Several librarians were raising their addicted relatives’ children.
Librarians are also perfectly poised, though, to be great catalysts for change – community organizers in the fight against this plague. That’s what I believe. They have the spaces, the local trust and credibility, and often small towns need folks like librarians to bring them together — and this is happening.
As I said to the group I spoke to, who better than purveyors of the book to be the leaders in this fight.
Plus, librarians are looking for new roles to play – rebranding libraries as community centers, places where people can come together. This catastrophe is offering libraries and librarians that moment to reinvent themselves towns and counties.
In the afternoon, I drove through the pristine southern Ohio farmland – white houses, white churches, silver siloes, blue sky, and acres of green corn.
I stopped at the Dairy Queen in Washington Court House, another small town with a bunch of opiate addiction problems.
Tomorrow Dayton – then Findlay and, finally, Twinsburg.
Next week I speak in Weber County, Utah, and after that Brunswick County, North Carolina.
All frontlines in America’s epidemic of opiate addiction.
From 2006 to 2015, Dr. Michael Rhodes was one of the top prescribers of OxyContin in the state of Tennessee.
His practice had many of the signs of what had come to be called a “pill mill.” Lines of people outside. A knife fight in front of his office. Investigators found he often prescribed without proper physical examinations or knowing the medical histories of his patients. Over those years, Rhodes, of Springfield TN, prescribed 319,000 OxyContin tablets. In May, 2013 had his license placed on restrictive probation by the Tennessee Board of Medical Examiners.
Still, representatives from drug-maker Purdue Pharma continued to call on him urging him to prescribe more OxyContin, their signature drug, according to a lawsuit filed by Tennessee Attorney General Herbert Slatery.
“In spite of this disciplinary action by the board (of medical examiners) and direct knowledge of his patient’s death from OxyContin, Purdue continued to call on Dr. Rhodes,” the Tennessee complaint states. They continued to “pressure Dr. Rhodes to prescribe more and more opioids, even when he expressed concerns regarding his own ability to competently do so.”
According to the lawsuit, Purdue reps called on Dr. Rhodes 126 times, include 31 times after his license was restricted.
They did so during the years after the company signed an agreement in 2007 with the federal government to be vigilant for abuse and diversion of the pills and look out for doctors prescribing in unscrupulous ways.
Part of the Tennessee complaint against Purdue catalogues alleged attempts by the company to get high-prescribing doctors and nurses to prescribe even more of their product, despite signs that those medical professionals were behaving in unethical ways and that their prescribing habits were out of control. Cultivating high-volume prescribers, the complaint alleges, was seen as crucial to the company’s business. The complaint alleges the company called on several such nurse practitioners, three now-shuttered pain clinics, and 13 doctors, who’ve retired or had their licenses revoked or placed on probation.
Among them was Dr. James Pogue, of Brentwood, TN, who prescribed 562,000 OxyContin 80mg pills between 2006 and 2013, making him one of the largest prescribers in Tennessee even three years after he stopped practicing medicine. He generated $655,000 in revenue for the company during one six-month period in 2009, according to the complaint.
Company sales reps called on him 53 times between 2005 and 2012, “more than half of those occasion coming after his license was reprimanded in 2009.”
The Breakthrough Pain Therapy Center, in Maryville TN, was known to have none of the typical diagnostic tools associated with pain clinics: examination tables, gloves, urine screens “or providers who performed independent pain diagnoses.” It also included “scant” office records and pre-written prescriptions often dispensed “without a physician present.”
While placing some staff on no-call lists, the complaint claims Purdue continued to call on other staff members at Breakthrough Pain Therapy, whose owners were federally indicted in December 2010. This included Buffy Kirkland, a nurse practitioner who worked there for several years. Between 1998 and 2017 as a nurse practioner in Tennessee, she prescribed 68,000 OxyContin tablets, of which two-thirds were of 40mg or stronger, according to the complaint.
The Tennessee complaint is one of numerous lawsuits filed in the last year or so against Purdue and several other drug companies that make opioid painkillers. The plaintiffs include Native-American tribes, small towns like Everett, WA and large cities like Los Angeles and Chicago. Most state attorneys general have filed lawsuits, as have at least 300 counties in a suit that alleges a “public nuisance” by these companies. That suit is consolidated in a federal court in Cleveland.
When I was writing Dreamland in 2013-14, I remember only three such lawsuits against makers of opioid painkillers. This was a time when the issue was largely hidden, those affected largely silent. Families were ashamed and wanted to obscure the truth of the addiction and manner of death of their loved ones. Thus the media paid scant attention and elected officials, outside those in a few states, paid less.
But the awareness has expanded in the last three years. One result is that many more lawyers across the country have turned to examining legal theories that might prosper in court.
Public agencies have been hammered by the cost of the epidemic. Indeed the epidemic’s costs have largely been borne by the public — by coroners and public health offices, police and sheriffs departments, jails, county hospitals, foster children agencies and more. Meanwhile profits have largely accrued to the private sector, mostly to pharmaceutical companies.
Thus, today, most state and county officials have to be seen by their constituencies as doing something dramatic about this epidemic, and a lawsuit has become an option to recoup some of those costs. None of the new lawsuits has yet gone to court.
“Always Be Closing” is the motto that salesmen live by in the movie/play Glengarry Glen Ross.
If you haven’t seen the movie, do so. It’s great: Al Pacino, Jack Lemmon, Alex Baldwin, Kevin Spacey. It’s about an office of desperate sales guys hawking shady real estate investments. ABC — “Always Be Closing” — is the way each is supposed to approach every sales call.
The suit was filed in May by the office of Tennessee Attorney General Herbert Slatery. It alleges a lot of things, but in general that Purdue used deceptive marketing practices to push its signature drug, OxyContin. This took place, the suit alleges, between 2009 and 2012, well after the company and three of its executives pleaded guilty (in 2007) to a federal misdemeanor of false branding and paid a $634 million fine, while also committing to a series of measures to ensure they were not marketing to doctors who were prescribing unscrupulously.
The company moved to seal the lawsuit, but a judge in Knoxville recently decided against that idea, allowing the office to send me, and others, a copy.
In general terms, what I find interesting the lawsuit is how it displays the changes in pharmaceutical sales in this country, much of that coming during the life of OxyContin, though not due to it.
Up to the mid-1990s, drug salesmen in the United States were usually older men, often with backgrounds in pharmacy or medicine. They were often from the communities they sold to, knew the doctors they sold to, and became credible sources of information for those same doctors as medicine began to change rapidly.
Then the industry went another route. Those older folks were shown the door. In what can be called a sales force arms race, drug companies hired more and more reps. These reps were usually much younger, very good looking. They didn’t know much about they were selling but they have backgrounds in sales. They inundated doctors with visits and giveaways, of pens, calendars, lunch, sometimes trips for continuing medical education seminars. The companies were aware that by massaging a doctor’s staff, the doctor would soon be an easier mark.
Many companies did this. The numbers of sales rep rose through the 1990s from 35,000 nationwide to over 100,000 by the end of the decade. But other companies were selling blockbuster drugs to deal with cholesterol, hypertension and others. Purdue was among the few that used these techniques, and this enhanced salesforce (numbering eventually 1,000), to sell a narcotic painkiller.
“Always Be Closing” was, apparently, part of that push at Purdue. So, allegedly, was mention of the movie. All of this coming after the 2007 criminal lawsuit.
In Tennessee, (pop. 6.6 million people), the company made 300,000 sales calls to health care providers in the 2007-17 decade, during which time doctors prescribed more than 104,000,000 OxyContin tablets; more than half of those tablets were at the strongest doses the company made: 40mg and above.
Those of you who’ve read my book Dreamland know that, to me, supply is the crucial factor in this, and really in any drug scourge. What the lawsuit describes is a company hard at work at creating a vast new supply of opioids.
Company instructional materials pushed sales folks to “expand the physician’s definition of the appropriate patient” to which opioids might be prescribed; to “never give someone more info than they need to act”; and to develop a “specific plan for systematically moving physicians to move to the next level of prescribing.”
“We sell hope in a bottle,” said one guide for incoming salespeople, who were also instructed to encourage doctors to increase patients’ daily doses.
The lawsuit goes on to claim that Purdue sales reps in Tennessee were urged to make frequent sales calls, as evidence showed that that increased the number of prescriptions. According to the lawsuit, the company urged its salespeople to “focus on doctors who had more patients, less likely to have pain management expertise, and have less time to appropriately monitor patients on opioids.”
During these years, Purdue sales reps, according to the lawsuit, focused their efforts on primary care doctors, nurse practitioners and physicians assistants, whom the company “knew or should have known … had limited resources or time to scrutinize the company’s claims.” Together, people in those three profession prescribed 65 percent of all OxyContin tablets in Tennessee during these years. By 2015, Tennessee had the third highest prescription rate of opioids in the country.
A major part of the lawsuit goes on to discuss specific examples of Tennessee doctors who were leading the state in opioid prescribing, often with signs that their practice was out of control or they were incompetent or unscrupulous, yet who were nonetheless aggressively marketed to by Purdue salespeople.
Couple weeks ago, I spent a morning in federal court in Los Angeles to learn a little more about drug underworld ingenuity.
Federal agents had busted an enterprise known as Manny’s Delivery Service, an organization that they alleged distributed heroin across the San Fernando Valley to customers who’d call in and place their orders.
Manny was the street name of the lead defendant, Sigifrido Gurrola Barrientos (see photo).
These guys reportedly used Uber to transport the proceeds – $129,000 in one instance, according to the indictment. (Read the press release here.)
They seemed to replicate the system that was perfected and taken nationwide by the folks from Xalisco, Nayarit, which I wrote about in my book, Dreamland.
As it turns out, according to defense attorneys, Manny’s was allegedly run by fellows from the Mexican states of Puebla and Guanajuato, which are not states I’ve associated with drug trafficking. Not sure where Mr. Gurrola Barrientos is from. But it’s not surprising the business model would be used by others. There’s no trademark or copyright in the underworld.
I was intrigued by the case as well because I’m fascinated by all the ingenuity displayed in that vast, profit-motivated culture of drug trafficking, particularly from Mexico.
In the 1990s, American medicine began to claim that opiate painkillers could be prescribed virtually indiscriminately, with little risk of addiction to patients. The result over the next two decades was a huge increase in our national supply of painkillers.
That happened without anyone realizing that our heroin market had also shifted during those years. Most of our heroin now came not from the Far East (Turkey, Burma, Afghanistan) but from Latin America – Colombia and, today especially, from Mexico. It got here cheaper and more potent than the Far East stuff.
Truth is, though, most Mexican traffickers for years cared little for heroin, which they viewed as decidedly scuzzy and back-alley and with a relatively small market of tapped-out users in the United States. So they focused more on cocaine and meth, and pot, of course.
Then we began creating scads of new opiate addicts with this expansion of indiscriminate prescribing of narcotic painkillers.
That, in turn, awoke an underworld version of Fedex, and unleashed the powerful and ingeniously creative forces of the Mexican drug-trafficking culture, then largely dormant when it came to heroin. By the way, that’s not to say, necessarily, cartels. Just a widespread culture of drug trafficking, particularly in certain regions of Mexico.
There’s a reason why heroin exists. It’s not because it has much medicinal use. Or, better put, the painkilling benefits it does possess can be provided by other drugs at far less risk of addiction. Heroin exists because it’s a great drug if you’re a trafficker. It’s easy to make and is very condensed. It’s easy to cut – making it profitable to traffic even in small quantities. So small-scale heroin trafficking is a big part of the story of how it gets here from Mexico.
Also, heroin is one of the few drugs that makes sense to sell retail – as it creates customers who must buy your product every day, Christmas included, and usually several times a day.
Thus applying basic business-school principles to heroin vending – principles of marketing, customer service, etc – just naturally occurs to folks.
Hence Manny’s Delivery Service. And a bunch more like them.
I meet a lot of great folks as I talk about Dreamland across America – and hear amazing stories, too.
In Richmond, Virginia recently, where Virginia Commonwealth University had chosen Dreamland as the Common Read for their incoming freshmen, I happened to meet Sheriff Karl Leonard, of nearby Chesterfield County.
We got to talking about a recovery pod – which he calls the Heroin Addiction Recovery Program (HARP) – he instituted in his jail. HARP allows inmates to begin their recovery from addiction, with a nurturing, inmate-led environment. This replaces the stress and tedium of traditionally run jail.
Traditional jail has always been a prod to crime and drug addiction. But sheriffs like Karl Leonard are rethinking how it’s done. I find this transformation of jail, which is growing as a response to our opiate-addiction epidemic, to be one of the most radical and positive ideas happening in America today.
Later, Sheriff Leonard sent me an email with the following story. Please read:
I work very hard with our Heroin Addiction Recovery program (HARP) to educate the public and to break down the stigma that is attached to not only being an addict but a criminal as well. I take recovered addicts from our program out into the community all the time so they can put a face with this disease. And once I do that I have personalized this crisis with them and they can no longer look away. I have these addicts tell their stories which are always compelling and gut wrenching. But just when I think I have heard it all, I get educated myself.
Just a few weeks ago after one such public engagement in the community with two of the HARP members, one male and one female, I decided to take them to lunch at a local Burger King as a reward, which I do often. (They are placed in civilian clothes when we take them out of the jail).
When we pulled into the Burger King parking lot, the male asked me what this was. I was dumfounded by the question and told him it was Burger King. I then asked him if he’d ever been in a Burger King before, thinking he was messing with me. But he said no. I then asked him if he was ever in a McDonald’s before; he again said no.
I shrugged it off and took him inside. He spent several minutes looking at the menu above his head like a child on Christmas morning. He turned to me and asked me if he could get whatever he wanted. I said yes. He then asked me if he could get the biggest thing on the menu and I again said yes, knowing that jail food probably didn’t satisfy this 6’4”, strapping 26-year-old. He then ordered the mushroom Swiss triple burger and a large Coke and fries.
I watched him devour his meal. I asked him if he liked it and he replied he did very much, especially the Coke. I asked him if he had Coke before and he told me he had not. This kid who never had a Burger King or McDonald’s hamburger or a Coke is a heroin addict.
He told me he grew up in a very rural county in Virginia and his father was very strict with him about eating junk food, sugars, sodas, etc. His father made sure they only ate good fresh food without sugars. It is also why he led a life that was drug free – not even marijuana.
His father also helped him with his athletic skills, which helped him become a very good football player in high school. So good he was given a scholarship to play football at a prominent four-year university in our state. I was intrigued by how this seemingly innocent guy became a heroin addict.
Then the common thread to almost all of our heroin addicts revealed itself.
While at the university, he said, he was involved in a bad car crash and suffered a broken femur, shoulder, and other bones. Eventually his doctor gave him Oxycontin and Dilantin pills. He was directed to take four Oxycontin pills a day for 30 days in addition to the Dilantin.
Once the prescriptions ran out he said he started to become very sick but he didn’t know why. He spoke to a friend who told him he was in withdrawal from the painkillers, which was causing his sickness. So he went back to his doctor, who refused to prescribe him any more. He was very sick and tried to get pills on the street but they were hard to get and expensive so he turned to heroin. And that was all it took.
He eventually had bad drug screens at school and was kicked out of the university and lost his full scholarship. When his father found out he was using drugs he disowned him. So now, without a dorm room or family to take him in, he turned to criminal activity to sustain his life.
These stories go on and on. They are all heartbreaking but also examples of how these are not bad people trying to be good but sick people trying to get well. And we are making a difference here with our very unconventional approach to recovery.
Thank you for enlightening a Nation with your book!
When the Senate’s health-care bill died this week, it was worth noting the few who led the revolt.
Most were senators from states hardest hit by our epidemic of opiate addiction:
Maine (Susan Collins), West Virginia (Shelly Moore Capito), Utah (Mike Lee), Ohio (Rob Portman).
“I didn’t come to Washington to hurt people,” Shelly Moore Capito said.
Let’s leave aside how the bill would have done away with basic health care for millions of working folks and provided a tax cut for wealthy people.
One of the biggest problems with it, I think, was that it would have reversed Medicaid expansion and that meant taking away coverage for drug rehabilitation from hundreds of thousands of people, maybe millions of them.
I could not understand how that was a good idea.
It was also interesting to see how, as the debate progressed through the spring to now, a lot of people began to realize what they were losing.
In so many areas where Donald Trump did best in November’s election, areas he promised to make great again, there is a documented need for massive investment in more drug rehabilitation capacity, not less. That is not an opinion. What exists is saturated. Getting into rehab takes weeks, months. Many addicts have no resources of their own with which to seek treatment.
I wrote in another post that opiate addiction was the crucial element in Trump’s victories in several states that were in turn essential to his capturing the presidency.
Eight months later, the Senate’s health-care carnival emphasized my belief that this issue is one of the most potent political forces of our time.
In the spring of 2015, shortly after Dreamland was released, I received a call from Hillary Clinton’s campaign advisor for health issues. Hillary was feeling the ferocity of parents in Iowa and New Hampshire from all walks of life, horrified at their children’s addiction and not knowing where to turn. This surprised the candidate, her advisor told me.
I spoke with her for about ninety minutes. I told her that I thought this was the great silent issue in America today and whoever truly owned it, embraced it, treated it as a thing of the heart, would have a good chance of getting votes from unexpected places, but that this probably would not be felt in opinion polls ahead of time. Mrs. Clinton did some of that, but never enough, and in the end she wrote a position paper and that amounted to most of her campaign’s attention to opiate addiction. I might be wrong, but she didn’t seem to understand the latent power of the issue. Least she didn’t act on it. That was a huge mistake.
Politicians would do well to better understand the deep well of pain and anxiety surrounding, and thus the political power within, this issue. It’s not something expressed easily in polls. People aren’t likely to admit to a pollster on a phone that a loved one is an addict.
But it’s there and dims the view of the future of so many people, the prospects of so many towns and counties, the economies of so many regions, and thus is of paramount importance to them. Right up there with jobs – connected inextricably with jobs, in fact. In so many depressed areas, huge numbers of folks can’t pass an employer’s drug test.
Nor does it take many addicts for that foreboding to spread. A few cases in a small town, I think, are all that’s needed. People see it hit almost anyone and seemingly at random – like a plague – including families who before had no connection to the drug world or the criminal justice system. Soon everyone’s view of the future turns negative.
On top of that, today we have the increasing nationwide notoriety of the issue as compared with just two years ago. An awakening has taken place in those short years – a reckoning and a truth-telling when before there was subterfuge and fabrication.
Overall, this is healthy – for the families now telling the truth and for the country, I think.
But one effect is that the knowledge, and thus dread, has spread to even families untouched by addiction.
In that room where 13 of them put that bill together, Senate Republicans didn’t seem to understand that.
That was a huge mistake.
Because in the small towns or suburbs where folks live, they now know the high school’s quarterback has landed in jail again, and that their pastor’s daughter died from an overdose and that it wasn’t a heart attack after all.
Today a startup in the small town of Portsmouth, Ohio comes out with a line of t-shirts called DREAMLAND LIFEGUARD.
The shirts, designed by a company called 3rd and Court, also feature the words “Time to Turn So You Don’t Burn,” which was a jingle a local radio station broadcast every half hour, knowing that most of its listeners were at the legendary pool.
I’m proud that the designers say they were inspired by my book about our national opiate epidemic, which as many of you know has a lot to say about Portsmouth, and which took its title from the town’s Dreamland pool, which was razed in 1993.
But more than that, I’m impressed with the entrepreneurial DIY energy and imagination that 3rd and Court represents in a town that for years wallowed in a plague of narcotic negativity.
When the fog of dope lifts, creativity and passion have room to blossom. Something like that feels like it’s happening in Portsmouth. A lot of abandoned buildings are under renovation. Downtown has a lot of artists staking their claim.
I spoke with Connor Sherman, 23, who designed the shirts. Connor was partly raised in the Portsmouth area, then went to Shawnee State in town, and graduated with a degree in visual design.
“I see a lot of people, their mindset has changed to entrepreneurship and moving forward,” he said. “Not that I’m going to get out of school and somebody’s going to hand me something, like a job 9-to-5. It’s more about creating something out of nothing.”
The building at 3rd and Court streets in downtown Portsmouth has become a hive for small startups. Years ago, it was an auto shop. Then like so much of Portsmouth it stood vacant for a good while. Finally, it was renovated and PSKC Crossfit occupied the space. (This is part of Portsmouth’s recovery from opiates. Several workout gyms have opened in town. “A lot of people take pride in restoring themselves and restoring others,” Connor told me.)
The crossfit was a place for people to commune.
They began to share ideas and, in time, to discuss business possibilities. That had been lacking for many years in Portsmouth. Really ever since the pool closed in 1993. For years, with the town in decline, buildings abandoned, and half the population leaving, the only place people really saw each other was Walmart.
The new incarnation of the building at 3rd and Court emerged as part of some new alternatives to that isolation.
Soon, Doc Spartan, a maker of natural lotions and hand creams for workout aficionados, started in the building. They advertise their “Combat Ready Ointment” as made from coconut oil, beeswax, eucalyptus oil, vitamin E and more, and good for “cuts scrapes knicks rips rashes razor burn blistered feet rope burn diaper rash chapped skin and calluses.” (Check them out here.)
That was followed by 3rd and Court apparel, making “small town” summer clothes. “Apparel dedicated to the lovely Portsmouth, Ohio and other small towns like ours,” – reads their website.
“My desire to do design instead of something else that someone tells me to do all day is what made me want to start looking for opportunity,” Connor told me.
So the town where for years noxious pill mills were the only locally owned businesses to open is displaying capitalist effervescence of a more wholesome kind.
I get asked by people all over the country what the solution is to this nationwide pill-and-heroin epidemic. Honestly, I don’t always know what to say. But I do believe in harnessing the creativity of folks who are in recovery, or, like Connor, never did dope to begin with.
So here it is:
3rd and Court is offering DREAMLAND LIFEGUARD t-shirts in men’s and women’s sizes, plus a unisex tank top – each for $24.99.
The New England Journal of Medicine startled everyone this week by a posting a one-sentence warning over the so-called Porter & Jick letter to the editor that the journal published in January of 1980.
The warning note reads: “For reasons of public health, readers should be aware that this letter has been `heavily and uncritically cited’ as evidence that addiction is rare with opioid therapy.”
I find it remarkable that the NEJM did this, particularly so long after the letter itself was published in the journal. Apparently this kind of note is very rare.
But I think it confirms what I wrote in Dreamland – in which I interviewed the main author of the letter, Dr. Herschel Jick.
I think it’s important to reiterate the impact, as well as the intent, of the letter.
As written, it is entirely correct. That a data base of hospital patient records, that Dr. Jick ran, and still runs, found the following: of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.
Remember this was data taken from the 1960s and 1970s, a time when narcotic painkillers were rigorously controlled, and never given to patients to take home with them. So it stands to reason that patients, under such strict controls and administered the drugs only in hospital, would rarely develop addictions – as the letter’s headline in the journal read when it was published: Addiction Rare in Patients Treated With Narcotics.
They simply didn’t have access to large supplies of narcotics, and especially drugs to take home with them, as patients routinely do today. Hence they didn’t run much risk of addiction. (The whole thing, btw, helped change my mind about what ignites a scourge of addiction, which I now believe is not demand, but supply. Supply first sparks demand.)
The problem came not with how the letter was written, but how it was interpreted, then used, by others. Through the late 1980s and 1990s, it was widely cited, quoted, footnoted – as my research in Dreamland made clear and as a recent letter to the NEJM from the Canadian doctors confirmed. It was deemed to be proof that somehow science now knew that addiction was rare when opiates were used to treat pain. Through the years, it became known, through a process similar to a game of telephone, as some kind of “landmark study” that presumably refuted much about what we know about narcotic painkillers and addiction.
The Porter & Jick letter – 101 words – neither did, nor intended, anything of the kind.
It was also used, of course, by pharmaceutical companies – especially Purdue Pharma, manufacturer of OxyContin – as proof that their drugs no longer caused addiction when they were used to treat pain. The company used the statistic that “less than 1 percent” of all patients administered opiate painkillers drugs – especially OxyContin – grew addicted to it. This was not true nor supported by any science. It was not supported by Porter & Jick, which was making an entirely different observation. Yet the letter was used to convince a generation of doctors that science now knew new things about narcotic painkillers and one was that they were “virtually nonaddictive” when used to treat pain. A claim that, again, has no basis in science or the letter.
All this I wrote in Dreamland, which came out two years ago. I found the whole story to be an unsettling episode in how scientific thinking changes based on no evidence at all, but due instead to deft and relentless marketing.
I’ll add one more thing. The NEJM’s warning note was prompted, as I said, by a review of the letter and its influence in scholarly studies that was published by some Canadian doctors in the journal this week.
I read the letter these doctors wrote and I don’t see Dreamland credited or footnoted.
I’m trying to take it all in with equanimity. Yet I’ll admit to some frustration to have done so much research and storytelling that brought this to light as part of Dreamland’s larger story of how this opiate-addiction epidemic spread, and which others have read and learned from, and then not have it reflected in the work those people do. On the contrary, the Canadian doctors’ letter is presented as some new revelation, which it is not.
So I’ll just say that it would have been nice to see my work credited in the recent NEJM report by those Canadian doctors, as well as media coverage of that letter. I’ll leave it at that.
Two weeks ago I had a heart attack at a high-rise hotel in Atlanta on the morning I was supposed to deliver a speech at a large conference on prescription-painkiller and heroin abuse.
Turned out one of my major arteries was completely blocked. I’ve written elsewhere about what happened that day and you can read it here.
I rebounded quickly because I was near help, and also because of an outpouring of prayers and good wishes sent from many you, which I greatly appreciated.
My wife and I were teary-eyed for days reading your posts and comments.
I went to visit my new cardiologist when I got home. I had never thought of what was happening during a heart attack.
“What you were feeling is the pain of the heart dying,” she told me.
This hit me much harder than anything else I’d heard from a doctor. I began to understand more deeply the enormous good fortune I’d had in being where I was when this happened. Another two or three hours without help, “and you’d have been in serious trouble,” she said.
I’ve spoken a lot about personal accountability in my talks about Dreamland. I believe it’s one of the lessons we ought to learn from our opiate-addiction epidemic: that as a culture, we almost demanded doctors cure our pain quickly and completely and we weren’t going to do much to help them do that – like eat better, exercise more, avoid processed foods. Opiate painkillers were quick, cheap and those were the tools doctors turned to.
So midway through writing the book, I stopped drinking sugary drinks; lots of junk food I’d already eliminated from my diet. I don’t buy food that’s advertised on TV. I’ve always walked a lot, but I added swimming. I had no clue that I had a blocked artery, or ought to believe I had one, because I thought I was doing a lot right. (My cardio rehab nurse said she thought the swimming had saved me, because through it my blood had found new ways of circulating around the blocked artery and used those when the attack came.)
Still, I’ve come to believe that our heroin/pill epidemic has a lot to say about who we are as Americans, how we do live and how we should live. I think I felt that a bit more deeply following my heart attack.
As part of that, I came across a discussion of the work of Viktor Frankl, a great philosopher and Holocaust survivor. It reads in part that what gave him the ability to survive Nazi concentration camps (four of them) was the search for meaning. That life is more than the pursuit of happiness; it’s the pursuit of meaning and with that comes fulfillment.
“We all said to each other in camp,” he writes, “that there could be no earthly happiness which could compensate for all we had suffered.” But it was not the hope of happiness that “gave us courage,” he writes. It was the “will to meaning” that looked to the future, not to the past. In Frankl’s existentialist view, we ourselves create that meaning, for ourselves, and not for others. … We must acknowledge the need to make sense of our lives and fill what Frankl called the “existential vacuum.” And we alone are responsible for writing better stories for ourselves.
That last sentence is the most important one.
Frankl’s work, I think, is hugely relevant amid this opiate-addiction epidemic.
I’m just beginning this new life – renewed approach to exercise, avoiding stress, and thinking of food differently than even I had. Feeling very fortunate to be alive and be around people who care – like many of you.
Hoping to continue writing a better story for myself, and wishing the same for you.
Her obituary doesn’t provide a lot of detail, but it does provide some. It sounded as if she spent a lot of time in rehab, then relapsed each time. Finally, when she looked to be putting the worst behind her, she relapsed again and overdosed and died.
It’s an extraordinarily sad story – and it must have been very difficult for her parents to write the obituary.
It made me think of what her death can tell us. First, all addiction seems to involve relapse. I quit smoking (and started again) nine times before I finally quit for good – at 37.
But I lived through my cigarette relapses. With opiates, particularly given the amount of supply of dope on the street, getting out of treatment is like Russian Roulette. People go in, detox, get clean. Their tolerance to narcotics drops. They leave rehab and do well, then they relapse. With these drugs, and their prevalence and potency on the street, relapse too often means death.
It feels good to say, `We can’t arrest our way out of this.’ I agree. We do need expanded treatment. But, frankly, that also feels too easy.
My feeling is, when it comes to opiates, we have to arrest our way out of this before we can treat our way out of it. That’s a bit discombobulated, I know. What I mean is that we need to address supply on the street. That comes only with arrests. It seems to me dangerous to assume that in modern America people can get out of rehab and go home to areas awash in dope and be expected to stay alive, given the likelihood of relapse and the potency and controlling nature of opiates. It’s not cigarettes people are relapsing on. It’s pain pills and, especially now, heroin and fentanyl.
This is a supply story and has been from the beginning. Huge amounts of very potent opiates were unleashed on the country – first in the form of prescription opiate painkillers. When millions of people grew addicted to these pills, a lot of them looked for cheaper alternatives. Heroin traffickers, mostly from Mexico, slowly realized that these folks were a growing market and expanded their offering.
But it all has to do with supply. No treatment has much chance against a cheap and plentiful supply of potent dope.
It’s why doctors and the medical establishment need to continue reassessing how they prescribe opiate painkillers.
It’s also why we need to make Mexico a sustained priority. I’ve written elsewhere that I don’t think building a wall — or rather, more walls — at the U.S.-Mexico border is likely to do much to slow heroin trafficking. That doesn’t mean we shouldn’t seriously address Mexico’s continued production and exporting of this drug. Ninety percent of our heroin comes from Mexico, according to the U.S. State Department. It’s unconscionable that one country should export so much of this junk. China fought a war with England in the 1800s, twice, over this issue. We don’t need wars with Mexico, but it does seem to me that we need to make this the priority it deserves to be – and walls are a distraction from the real work that needs doing.
This young woman’s death also shows why we probably need to make much greater use of what’s known as medically assisted treatment – the use of drugs as replacements, as shields. These include methadone, Vivitrol and Suboxone – they either take away the craving for heroin or block overdoses.
It’s unreasonable, I think, to assume that addicts can go back to these same neighborhoods, where opiate supply is plentiful, without some sort of protection, some kind of shield.
The last couple years have shown how dangerous that is.
It’s real world. It’s working the program. Accepting blame and accountability, breaking with fantasy. It’s hanging out with people who don’t think like you. It’s reminding yourself that life is full of constraints and you can’t just do whatever occurs to you. It’s realizing that you are not perfect and there are others whose opinions matter in this world.
That said, the recent health-care fiasco displayed House Republicans behaving like heroin addicts.
It’s easy to go on Fox News for years, blame someone else for everything when you don’t have to be accountable for finding solutions. It’s easy to rant about the endless failures of those people who do. Ranting is a narcotic; so is outrage; so is complaining and destroying. It gives us a big blast of dopamine to the brain. As does spending a lot of time insisting on all the nifty ways you’d do things better when you are king of the world. Feels so luxurious. Feels a lot like heroin, I suspect.
Being an opposition party means never having to put an idea to a constituent smell test. You get used to it – your tolerance for fantasy rises like an addict’s tolerance for a narcotic. Like addicts, you hang out with folks who think like you, talk like you, and never force you to face anything resembling reality, or the necessity of compromise.
Living without compromise is a nice idea in theory, but it’s possible only when you’re high on, and surrounded by, ideology — or dope.
A heroin addict brooks no compromise. He wants a world his way only. No messy complications, no one telling him no. Ask any parent of an addict.
What I think we saw was people addicted to a warm, euphoric ideological fantasy world in which they’ve lived for the last several years. Addicted to the idea that they could do it alone, didn’t need anybody, didn’t need to compromise. This Freedom Caucus seemed dead-set on depriving anyone but the wealthiest of what most would deem civilized health care: maternity care, ER visits, not to mention addiction-treatment coverage.
It was bizarre to watch them line up to take away benefits needed by so many who had just elected them and their president, and give them to our aristocracy.
How do you come to the conclusion that thinking like the upper classes of pre-revolution France is okay?
Well, perhaps because House Republicans lived in a bubble for seven years, voting to repeatedly repeal Obamacare knowing it would be vetoed. Then the fantasy ended and they finally had the power to do it. They had nothing to replace it with. (John Boehner is, I’m sure, happy to be away from all that.) What they came up with would have savaged the very people who put them in office.
The word `compromise’ gets a bad rap these days, but it’s actually another way of saying something else. It’s saying, we’re behaving like adults. We’re not going to act like petulant children who want a world run according to their whims alone, which is, in turn, another way of describing how a heroin addict thinks.
Something like this, I suspect, is what Ryan was referring to when he spoke of House Republican “growing pains.” Getting off the dope of viewing compromise as a dirty word.
A big part of addiction recovery is relating to others again, accepting that your views are not the only ones that matter, that you have to modify your behavior, answer to others who may not think like you.
It’s like governing.
It’s messy and ragged; it’s hard and far from perfect. It’s adult, in other words, and it’s the opposite of dope.
Here’s a letter from doctor with a long exposure to the problem of addiction and pain pills. I get lots of email letters about Dreamland. I’ve put a few up on this blog – always with names and identifying details removed.
I have recognized for many years, at least since the late 1980s, that the chronic use of opioid medications was typically a barrier to recovery. I am a physiatrist, a physician specializing in physical medicine and rehabilitation, since 1986. We manage patients who have catastrophic injuries: spinal cord injury, traumatic brain injury, amputations and those with multiple and severe trauma. I also treated many patients who had less severe injuries including strains, sprains and other soft tissue trauma. We often manage patients over many years. When the use of opioids became more frequent, in the late 1980s, I was perplexed. I did my best to manage pain, if at all possible, without the use of chronic opioid therapy. I was perplexed even more so in the mid to late 1990s when Oxycontin came on the scene. Physicians no longer were afraid to prescribe opioids for non-cancer pain and did so seemingly without caution. They were duped. Drug companies and their physician spokesmen duped them.
I grew up and later practiced medicine for many years in New Mexico. New Mexico, as you may know, has always had one of the highest drug overdose rates in the nation. Heroin had been the drug of choice, at least until opioid medications came on the scene. I worked as a house painter’s apprentice in the late 1960s while in college. I worked on one crew that every journeyman painter was an ex-con related to heroin use. I had plenty of opportunity to use heroin but it scared me. My co-workers told me how great it was. One guy, much older than me, made it sound so appealing. “Come over and we will shoot up and listen to jazz.” I never tried it though I had lots of opportunity.
I knew quite well how dangerous heroin was and never believed that opioid medications were any less dangerous. When I started practicing in the late 1980s many of the patients I saw were on opioid medications when I assumed their care. Most of the more seriously injured patients I saw were successfully weaned off opioids. Many of the less seriously injured, especially those with work related injuries, were much more difficult to wean. Some patients of both categories ended up on long term opioids but were closely monitored to determine if they were benefitting from opioids and whether they were abusing them. Escalating doses were typically not allowed.
The work related injury group of patients who generally had much less severe injuries, were routinely on opioid medications when I took over their care. My job as a rehabilitation physician was to get them back to their usual activities including return to work. I found that opioid medications were a barrier to their recovery. Some of my referring physicians believed the standard of care was to treat pain with opioids as long as patients complained of pain. Some patients were never going to stop complaining of pain and the reasons were frequently psychosocial in nature. I never believed the hype from drug companies regarding the safety of opioids. I saw from up close as a young man and as a doctor that they were dangerous and in general not appropriate for long term use in non-cancer pain.
I knew little about Dr. Russell Portenoy at the time of the opioid prescription explosion but I knew plenty about what drug companies were saying about the safety of opioid medications and the unlikelihood for addiction. I now understand Dr. Portenoy’s role in this public health catastrophe. I don’t believe Dr. Portenoy and other drug company marketer’s claims that they are now surprised about the addiction potential and danger of opioids. Intuitively it did not make sense. Oxycodone and hydrocodone are so similar to morphine and heroin both chemically and by their mechanism of action. Why would you believe they are so much safer? Those guys were either just plain dumb and so drunk with drug company money and self promotion that they refused to pay attention to what was happening to patients. I am sure they are not dumb. Dr. Portenoy is a brilliant and charming guy. Just view his video presentations and interviews. He is also a successful academic physician. That is what made him so dangerous. I am just an average doc who has never had a higher academic position than a clinical assistant professor. I have never authored a paper that made it to a medical journal. How could I know more than them and have been so right about the proper role of opioid medications? Why didn’t they? Certainly not because I am smarter.
I think your book was very even handed, maybe a little too much, with Portenoy and the other opioid selling/promoting physicians. I’m telling you they knew better. Their response of “If I knew then what I know now….” just doesn’t cut it. They are responsible for the hundreds of thousands of deaths and ruined lives. They should not get off the hook. I suspect their narcissism will prevent even one sleepless night for the damage they have done. But they and their benefactors, the drug companies, have created a horrible health crisis that was largely preventable in the United States. It is almost strictly a U.S. problem caused by U.S. physician “thought leaders”, drug companies and misguided bureaucrats.
I applaud your book. Bringing the black tar heroin story into your narrative was great. You connected the dots. I wasn’t aware of that part of the story. Thanks again for your book. It may just impact our legislators and government officials even more so, to focus on rehabilitation not punishment for those young kids who got caught up in a drug problem often caused by misguided or crooked doctors.
The punishment of “pill mill” docs and drug company marketers including their corrupt physician lackeys could never be equal to the suffering they have created. Glad you spotlighted the problem and did it in such a well-researched, entertaining and cogent way. Thank you.