Around the same time that Stallard is meeting with his informant, the FDA changes the rules for drug ads, giving pharmaceutical companies more leeway. The industry more than triples in size in just three years, with drug companies aggressively trying to win influence with doctors.
While Macy hinted in the previous chapter at how Purdue Pharma made OxyContin a best-selling drug, this chapter goes into greater detail, showing how the company overcame safeguards that should have theoretically prevented a dangerous opioid like OxyContin from entering mainstream medicine. One of Macy’s biggest targets of criticism is the FDA, which approved OxyContin’s use and allowed it to be widely advertised.
OxyContin becomes a huge marketing success in rural America, where disability claims are already high. Purdue targets doctors who already prescribe lots of rival painkillers, hoping to convert them to OxyContin by handing out OxyContin-branded freebies. The campaign is wildly successful, and by 2000, family doctors are the largest group of OxyContin prescribers. In that same year, pharma companies spend over four billion dollars directly marketing to doctors, often providing additional freebies to receptionists, nurses, and anyone else who might stand between them and the doctor.
While there was a genuine need for pain medications in rural parts of the United States (as evidenced by all the disability claims), Macy shows that the spread of OxyContin was only possible due to the massive amounts of money that Purdue spent on advertising (which itself was only allowed because of loosened FDA regulations). The fact that Purdue Pharma spent over four billion dollars on advertising suggests that profits from OxyContin must have been even greater. Macy presents these shockingly high figures to explore how money influences the pharmaceutical industry (and not in a good way).
The main technique these sales reps use is called the “Dine ‘n’ Dash.” Reps start by taking doctors to fancy restaurants but soon progress to just giving the doctors food to take home, then progress to giving the doctors other things, like gas or even shrubberies.
Normally, dining and dashing is eating a restaurant, then leaving before paying. In this case, however, sales representatives are giving doctors fancy meals or other perks before taking off. The implication is that because the doctors received these gifts, they will be more likely to consider prescribing the drugs that the sales reps are selling.
Steve Huff first encounters pharmaceutical swag as a medical resident in the mid-1990s. It’s not just stickers and branded merch, but even golfing outings and free lunch most days of the week. Later, as a family doctor, Huff decides that the ethical thing to do is turn down these free meals, and he tries to convince the others at his practice to do the same.
Steve Huff is just one doctor, but his experiences are typical of what many doctors experienced in the mid-1990s. He is a bit unusual in that he refuses the “free” gifts from sales representatives rather than accepting them. The fact that this was seen as unusual at his practice highlights how widespread this gifting culture was.
When in 2003, Huff moves to a new practice in Laurel Fork, Virginia, he finds himself overwhelmed by the volume of patients who had been prescribed large amounts of opioids by his predecessors. He cuts back severely on narcotics prescriptions and finds the whole experience very stressful—two patients even threaten his life.
As the new member at his practice, Huff is able to see things from an outside perspective. To him, it is obvious that his predecessors have been prescribing too many opioids, but because the culture of overprescribing is so ingrained at his practice, other doctors and patients resist Huff’s changes. Macy develops the theme of how sometimes an outsider’s perspective is necessary to effect change.
Dr. Sue Cantrell, a former pharmacist who has been a longtime health-department director in Virginia, sees the arrival of OxyContin as particularly ill-timed. The decent-paying mining jobs and lower-paying production jobs have all been steadily drying up, due to factory closings and increased automation. Cantrell gets her first call about OxyContin from a doctor based out of one of the smallest, poorest areas in the state: Dr. Art Van Zee.
Cantrell, as a health administration official, represents another side of the opioid epidemic. She views the situation from a broader perspective than people like Stallard or Huff (who are largely focusing on their own communities), but she faces similar challenges, feeling isolated and lacking in information when the crisis begins.
Van Zee is a Vanderbilt-educated doctor originally from Nevada who moved to tiny St. Charles, in Lee County, Virginia, at age 29 in order to help out a medically underserved community. There, at an NAACP rally to stop a planned KKK event, he met his wife, Sue Ella Kobak, who is a lawyer and an activist. When they got married, the flower girl was a three-legged goat, and Sue Ella didn’t change her name. Some locals compare Van Zee to Abe Lincoln, because he is lanky and bearded.
Van Zee’s background establishes that he is an intelligent and passionate (if sometimes unconventional) doctor. His wife, Sue Ella, shares similar convictions and balances out his work. While Van Zee’s resemblance to Abraham Lincoln is physical, Macy perhaps brings the comparison up to suggest how Van Zee’s ideas about fairness and justice owe something to historical figures like Lincoln.
Macy first learns about Van Zee from a 2003 book by Barry Meier called Pain Killer, which was one of the first books to explore the harmful effects of OxyContin. Van Zee was ahead of his time in recognizing the dangers of OxyContin, and he ends up spending much of his career dealing with the fallout of the opioid crisis.
Macy gives credit to one of her sources for recognizing the significance of the opioid crisis and Van Zee’s activism before she did. She acknowledges how her own work builds on the work of those who came before her.
In the 1990s when OxyContin first arrives in Virginia, however, Van Zee is still confused about what’s happening. He calls Sue Cantrell with some concerns about what he’s seen experienced users do with the new pill, OxyContin. He hears horror stories about how the drug is causing people to spend vast amounts of money and basically stop functioning as normal humans.
Rather than trusting the marketing hype around OxyContin, Van Zee looks around with his own eyes to see what OxyContin is doing in his local community. Macy suggests that if more doctors had taken this approach—of paying attention to what’s actually happening in communities—the opioid crisis may not have been as severe.
Cantrell, as the region’s top public health official, begins in the late 1990s to call other officials to look into the burgeoning opioid crisis. They don’t listen and mostly pass the blame elsewhere.
Cantrell’s experience illustrates one of the major challenges faced by activists trying to fight the opioid crisis—getting people in power to listen. Because the crisis is so widespread, it is easy for officials to pass the blame elsewhere.
In the early 2000s, Debbie Honaker is a 27-year-old woman who lives a couple counties east of Van Zee. She is prescribed OxyContin and Percocet after routine gall bladder surgery that continues to leave her in pain. When this isn’t enough for the pain, a neighbor advises her to snort the pills instead. Within three months, Honaker has become a regular user, learning how to fake kidney injuries to get more pills. Honaker begins stealing money from her husband and pills from her husband’s grandmother.
Macy uses the specific example of Debbie Honaker to show how even people who don’t seem like likely drug users can become addicted to OxyContin. Nothing in Honaker’s previous history suggests that she would become addicted to pills, but within just a few months she is faking injuries and stealing pills, using sophisticated techniques to keep up her addiction.
Crystal Street is a patient in the same addiction clinic where Honaker is currently being treated. Street’s father got addicted to morphine and Dilaudid in his 80s and was arrested for selling prescription pills from his nursing home bed. Honaker and Street have both themselves spent time in jail after going through near-death experiences to get more pills.
Crystal Street and her father provide further evidence that Honaker’s story isn’t unique, that in fact addiction clinics are full of people like Honaker. Macy tries to show that no one is simply an “addict”—that all of the people affected by the epidemic had their own lives and stories before the drug hijacked everything.
In the early days of the opioid epidemic, Van Zee watches as 24 percent of juniors at a local high school report having tried OxyContin, as well as nine percent of seventh graders. Many of his friends from the community begin showing up at the ER.
If even many high school juniors can get their hands on opioids, this suggests that the drugs are already circulating wildly in the region. The appearance of Van Zee’s friends in the clinic confirms this. The fact that there is so much evidence of the epidemic but so few people in the community acknowledge it suggests that there is still a stigma about discussing the issue in the open.
In the spring of 2000, before small-town newspapers were widely online, Van Zee doesn’t yet know that the opioid epidemic is also affecting other communities. He first gets the news from a copy of the Boston Globe that a young doctor from his clinic brings back. The article details a remote area of Maine where addiction is on the rise, and as a result, crime is, too. Van Zee realizes that he and his community aren’t alone and that it’s time to organize.
Macy reminds readers how the news worked very differently back near the turn of the millennium and how it’s important to understand this when considering the opioid crisis. As a journalist, Macy is particularly interested in how the news media covered (or ignored) the opioid epidemic and how this affected its spread.
Van Zee begins holding public meetings. At one, an undercover Purdue Pharma rep raises sharp objections. Sue Ella begins to worry that her husband’s heavy caseload is getting the better of him. He begins contacting Purdue directly, writing increasingly pointed letters. Purdue remains resistant. At one point, Purdue's medical director, Haddox, calls a local Virginia reporter to complain about her crime coverage (which mentions connections to OxyContin).
Van Zee displays extraordinary dedication to his activism. The fact that he achieves so little at first highlights how large the challenges facing him were. Macy looks at how Purdue Pharma and its employees intervened to try to control the media narrative around OxyContin. Though Macy supports independent journalism, she also explores how it can be influenced and manipulated by money and power.
At a meeting about crimes related to the opioid epidemic, Van Zee has a chance to speak with Haddox. Despite Van Zee’s concerns and accusations, Haddox defends Purdue’s behavior and says it’s no different from what other pharma companies do.
Even after securing a meeting with Haddox, Van Zee is not able to get meaningful change from the company. Macy shows how profit motivated companies like Purdue far more than concerns from activists like Van Zee.
By late 2000, Purdue is giving doctors a promotional video about how OxyContin is helping patients with pain get their lives back. They push back against claims that OxyContin is addictive, citing a one-paragraph letter to the editor from a 1980 edition of the New England Journal of Medicine.
While Macy champions the value of science in Dopesick, she also shows how the appearance of scientific legitimacy can be cynically exploited. In this case, the evidence for OxyContin’s lack of addictive properties is very weak, but this weak evidence becomes the cornerstone of a whole marketing campaign for Purdue. It’s obvious the evidence is insufficient; Macy is making the argument that, for Purdue, this wasn’t a case of good intentions gone wrong but in fact, a deliberate attempt at deception.
By March 2001, Van Zee is frustrated that his letters are doing nothing while the harmful effects of OxyContin in his community only get worse, with people resorting to increasingly bold crimes to get more pills. Van Zee and the Lee County Coalition for Health launch a petition asking the FDA to recall OxyContin, receiving over 10,000 signatures.
Van Zee’s pivot from contacting Purdue to contacting the FDA represents an acknowledgment that companies like Purdue can’t be shamed into doing the right thing—they have to be forced into it by a regulatory board.
The next month, the DEA begins a “national action plan” to observe Purdue’s distribution and marketing. In response to the pressure, Purdue puts out its own plan to reduce abuse. The FDA announces in July 2001 that it will add a black-box warning (the highest kind for prescription drugs) to the label for OxyContin. Purdue tries to downplay the black box, suggesting that “legitimate patients” are being hurt by the decision. They maintain that the issue is abuse, not the drug, and that Purdue shouldn’t be blamed for any of the crimes committed by OxyContin users.
The DEA clearly has more sway with Purdue than activists like Van Zee. When the FDA gets involved, its new regulation seems to be largely symbolic—Purdue is able to spin the issue in their favor. Macy shows here that enforcement agencies like the DEA and FDA do have real power to influence companies like Purdue but that their actions often fall far short of what’s required. She further develops the theme of skepticism toward establishment solutions to the opioid crisis.
One of Purdue’s other tactics to silence opponents is a $100,000 “grant” that they offer to community leaders in Appalachia like Stallard, with the money to be put toward drug treatment and law enforcement. During a meeting where several locals discuss the issue as a coalition, many—including Van Zee and Sue Ella—are initially leaning toward accepting the money. But a five-foot-tall nun named Sister Beth is adamantly opposed to the idea.
The $100,000 grant presents an interesting moral question for the activists. On the one hand, they want Purdue to have to pay for the damage its drug has caused, but they are also wary about the strings that might come attached if they accept the money. Macy shows that Van Zee and Sue Ella are willing to accept the money, suggesting that sometimes activism involves making difficult, pragmatic decisions.
Sister Beth is a Staten Island native with a masters from Columbia. She has a history of activism in the coal industry, helping miners demand reparations. She threatens to quit the coalition if they accept the grant, calling it “blood money.” Eventually, the whole group agrees with her.
Ultimately, however, the activists decide not to accept the money. The back-and-forth discussions of the activists provide a stark contrast with the communications with Purdue Pharma, where representatives like Haddox dogmatically repeat the same claims over and over.