Dopesick - Beth Macy Page 0,10

to do. It was pushed on us big time, the idea that they can’t become addicted if you’re using opioids to treat legitimate pain. The advent of the pain score, we now think, got patients used to the idea that zero pain was the goal, whereas now doctors focus more on function if the pain score is three or four.”

Compared with the New Zealand hospitals where Davis worked earlier in his career—often prescribing physical therapy, anti-inflammatories, biofeedback, or acupuncture as a first-line measure—American insurance companies in the age of managed care were more likely to cover opioid pills, which were not only cheaper but also considered a much quicker fix.

Little did Davis or the other ER docs understand that the routine practice of sending patients home with a two-week supply of oxycodone or hydrocodone would culminate by the year 2017 in a financial toll of $1 trillion as measured in lost productivity and increased health care, social services, education, and law enforcement costs.

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Throughout OxyContin’s earliest years, only a few voices of dissent rose to remind doctors that, historically, there had been risks associated with prescribing narcotics, and even those warnings were timid. Dartmouth medical school substance abuse researcher Dr. Seddon R. Savage argued that addiction risks for pain patients on narcotics tended to increase the longer the patients used the drugs. “It is tempting to dismiss all concerns regarding therapeutic opioid use as irrelevant,” she wrote in a physician journal in 1996. “That would clearly be a mistake.” A colleague argued in the same paper that there simply wasn’t enough good data available to make a case for or against liberal opiate prescribing.

The first real dissent would come soon, though, in the unlikely form of a country doctor and one thoroughly pissed-off Catholic-nun-turned-drug counselor. Though Dr. Art Van Zee and his colleague Sister Beth Davies would sound the epidemic’s first sentinel alarm from Appalachia, they were greeted with the same indifference as the Richmond doctor who demanded prompt action to curb the rampant use of opioids in 1884, and the inventor of morphine, who strongly urged caution in 1810. Their outsider status disguised both the depth and the relevance of their knowledge.

Evidence room, Lee County Sheriff’s Office

Chapter Two

Swag ’n’ Dash

Around the time the Big Stone Gap informant was leaning into the police officer’s cruiser, the FDA loosened rules on pharmaceutical ads, allowing drugmakers to air detailed television ads touting specific medical claims for nonnarcotic drugs. Drug advertising ballooned from $360 million in 1995 to $1.3 billion in 1998, and nearly all pharmaceutical companies spent more plying doctors with freebies. At a time when there were scant industry or federal guidelines regulating the promotion of prescription drugs, the new sales strategies pushed the narrative of curing every ill with a pill and emboldened many patients to seek medicines unnecessarily.

From a sales perspective, OxyContin had its greatest early success in rural, small-town America—already full of shuttered factories and Dollar General stores, along with burgeoning disability claims. Purdue handpicked the physicians who were most susceptible to their marketing, using information it bought from a data-mining network, IMS Health, to determine which doctors in which towns prescribed the most competing painkillers. If a doctor was already prescribing lots of Percocet and Vicodin, a rep was sent out to deliver a pitch about OxyContin’s potency and longer-lasting action. The higher the decile—a term reps use as a predictor of a doctor’s potential for prescribing whatever drug they’re hawking—the more visits that doctor received from a rep, who often brought along “reminders” such as OxyContin-branded clocks for the exam-room walls.

The reminders were as steady as an alarm clock permanently set to snooze. Purdue’s growing legion of OxyContin apostles was now expected to make more than a million calls annually on doctors in hospitals and offices, targeting the top prescriber deciles and family doctors, and aggressively promoting the notion that OxyContin was safe for noncancer patients with low back pain, osteoarthritis, and injury and trauma pain.

The practice became standard in rural Virginia towns like Big Stone Gap, Lebanon, and St. Charles—places that already claimed higher numbers, per capita, of dislocated workers and work-related disability claims. Now Purdue reps were navigating the winding roads and hilly towns in company-rented Ford Explorers, some pulling down annual bonuses of $70,000—the higher the milligrams a doctor prescribed, the larger the bonus. And they were remarkably adept. Five years earlier, cancer doctors had been by far the biggest prescribers of long-acting opioids, but by 2000 the company’s positioning goals had been nailed,