The story of the OxyContin epidemic doesn’t reach national media until a New York Times article published on February 9, 2001. By the summer, it is clear that the opioid abuse epidemic is spreading out from areas like Virginia and Maine, into the rest of Appalachia, into major East Coast cities, into the Deep South, and even into parts of the Southwest. The parents of those who die from overdoses are some of the first to organize a response. Ed Bisch, from Philadelphia, first learns about OxyContin on the day that his son Eddie dies of an overdose.
Macy begins looking in more detail at the next phase of the epidemic when it was branching out from rural communities to more suburban and urban ones. As with before, Macy often follows the stories of the families (particularly parents) of opioid victims. This is both a narrative choice (since the grief of these families eloquently shows the impact of the epidemic) as well as a practical one (since the families are often the only ones alive who know what happened).
The new movement of OxyContin from rural areas into the cities and suburbs resembles the wave of iatrogenic morphine and opium addiction that swept through the nation about a century earlier. Eventually, opioid addiction died out in most places except big cities (where heroin was part of the jazz scene). When, after the Vietnam War, 20 percent of American soldiers came back with signs of heroin dependence, it didn’t lead to an epidemic, largely because there was no heroin network outside of major cities. By the mid-1990s, however, OxyContin changed this by expanding the supply.
While Macy often looks to draw comparisons between the current opioid epidemic and historical issues with opioids, she also acknowledges how the current epidemic is unique. In this case, the lack of widespread, long-term addiction after the Vietnam War highlights how in the 1970s, the rural and urban parts of United States were not as closely connected. She suggests that perhaps if an event like the Vietnam war had happened in the mid-1990s, it would have led to a similar epidemic, fueled by greater connections between urban and rural communities.
Ed Bisch learns that his son Eddie wasn’t alone—that Eddie’s death was in fact the 30th overdose in the region in just the past three months. He starts a message board called OxyKills.com. In 2001, the same year OxyKills.com is founded, OxyContin hits $1 billion in sales for the first time.
Macy’s history of the opioid epidemic is also in some ways a history of media. Here, she looks at how awareness about the epidemic was affected by the media that was available at the time and how message boards helped create a community in a way that differs from how the Internet creates communities today (when individual message boards are less common and social media is generally run by large tech companies rather than individuals).
Lee Nuss is another parent with a story similar to Bisch. She lost an 18-year-old son named Randy to the opioid epidemic. Though she initially hesitates to reach out because of grief, she eventually connects with Bisch and discovers that they’re from similar areas of Philadelphia. The two of them eventually align with Van Zee and Sister Beth after they read Barry Meier’s 2003 book Pain Killer. Nuss and Bisch launch a grassroots nonprofit to oppose the opioid epidemic, called Relatives Against Purdue Pharma (RAPP).
Though Van Zee and Sister Beth are some of the most visible activists during the opioid epidemic, Macy presents the story of others like Bisch and Nuss to show that in fact, activism came in many forms and emerged from different places. The story of Bisch and Nuss is in many ways a hopeful counterpoint to the stories of addiction covered in the book—while ordinary people can suddenly find themselves struggling with addiction, there’s also the possibility for ordinary people to achieve great things as activists.
More memorials flood the OxyKills.com message board. Barbara Van Rooyan’s 24-year-old son Patrick is another victim. Van Rooyan asks Van Zee how OxyContin ever got approved for sale by the FDA. As it turns out, Van Zee receives some documents from Sue Ella about Purdue Pharma, including their application to the FDA for OxyContin’s approval. It turns out that, although Purdue was claiming they had no knowledge of the drug’s potential for abuse until February 2000, the drug’s 1995 FDA application contradicts this.
The FDA papers are the most damning evidence so far to suggest that Purdue Pharma deliberately covered up negative side-effects of OxyContin during the marketing campaign. They also show that the FDA failed to regulate OxyContin even when presented with information about its addictive qualities. Macy further explores how competing interests can cause companies and regulatory agencies to ignore science when it turns up inconvenient information.
The FDA’s top examiner noted in 1995 that the drug could be crushed up for a more immediate high and that the company should be cautious in its marketing. Two years later, however, the same examiner was hired as a consultant by Purdue.
With the example of the FDA examiner, Macy shows how people can be bought and sacrifice their principles. While many aspects of the opioid crisis are complicated, sometimes it is as simple as following the money.
Armed with this knowledge, in January 2002, Van Zee goes to testify before an FDA advisory committee. At the meeting, he is outnumbered 19-to-1 by Purdue people, and they try to portray him as a kook. Purdue also falls back on the fact that no clinical studies have been done to look at the long-term risks of opioid abuse. The FDA ends the forum promising to monitor the abuse situation more closely, but many, like Van Rooyan, feel that it’s too little too late. It takes several more years, until 2013, before it comes to light that FDA regulators had been meeting in expensive hotels with Big Pharma executives, who were using a strategy called “enriched enrollment” (weeding out people from studies who don’t respond well to drugs) in order to get approval of their drugs.
The fact that Van Zee is outnumbered 19-to-1 shows that the odds are stacked against him and highlights how exceptional his viewpoint was in 2002. As with previous cases (like with the black label on OxyContin), the FDA promises action but makes largely symbolic gestures. Strategies like “enriched enrollment” show how pharmaceutical companies use the appearance of science to get approval for drugs, but the expensive hotel meetings make it clear that for pharmaceutical companies and for many FDA regulators, money was the biggest motivator.
Staffers at the FDA get to know Barbara Van Rooyan whether they want to or not. She picks up where Van Zee left off, formally submitting a recall petition for OxyContin to the FDA in 2005.
Despite being outnumbered, activists like Barbara Van Rooyan show persistence and instead of being discourage by the lack of results, they continue to organize.
RAPP gets involved with civil lawsuits against Purdue. Though Purdue wins the cases, the legal bills are adding up. To help rehabilitate its reputation, Purdue hires the consulting firm of former New York City mayor Rudy Giuliani (who was recently popular because of his response to the 9/11 terrorist attacks).
The involvement of Rudy Giuliani (who was influential at the time) sets up a David and Goliath battle in the courtroom, with Purdue having far more money and resources than the activist groups bringing civil cases against them.
One of the early civil lawsuits that RAPP gets involved with is a wrongful termination case about a former Purdue sales representative. The representative believes she was fired because she refused to sell OxyContin to doctors who were illegally overprescribing it. White has a single lawyer with no staff, in contrast to Purdue’s high-powered team and their consultancy with Rudy Giuliani. Ultimately, the judge rules in favor of Purdue, saying that the former sales rep’s lawyer had not sufficiently proved that Purdue’s tactics were illegal.
This court case shows that Purdue’s strategy of using power and prestige in the courtroom is effective. The judge’s ruling leaves things open-ended, however, suggesting the possibility that maybe some future court case could provide enough evidence to show that Purdue’s conduct is illegal. This case illustrates how the progress of activists like RAPP was slow.
Back in western Virginia, John L. Brownlee is a 36-year-old former paratrooper, now an attorney who likes to make a splash in the press. He likes to take risky cases and wants a big win so that he can run for office, and he sees an opportunity with OxyContin lawsuits.
Macy mentions Brownlee’s history as a paratrooper to highlight his daredevil personality. He gets involved with opioid court cases partly for selfish reasons (to improve his own political reputation), but Macy has shown that activist groups can work together even when they are made up of people with different motivations.
In 2005, Purdue lawyer Howard Udell goes after Barry Meier (author of Pain Killer and a New York Times journalist). Udell gets Meier taken off the opioid beat at the newspaper because, as the author of a book about OxyContin, he has a financial conflict of interest. For the most part, Meier doesn’t write about Purdue in the paper for four years.
When a newspaper reporter is assigned to a beat, they cover once specific issue in depth. This helps them become experts on reporting the topic. As the reporter on the opioid beat, Meier was well-qualified to report on it—which was dangerous for Purdue, since they were trying to cover up the addictive nature of OxyContin. The fact that Udell gets Meier reassigned suggests that even the free press wasn’t immune to Purdue’s influence.
Brownlee (along with his office’s fraud investigator, Gregg Wood), keep in communication with Van Zee and RAPP about the latest OxyContin news. Wood in particular is passionate about collecting dirt on Purdue.
One of the things that all anti-opioid activists have in common is passion. The fact that Wood is interested in collecting information contrasts with how Udell got Meier removed from the opioid beat of the New York Times. It sets up the activists as people looking to bring the truth to light, while Purdue is trying to stifle it.
Fayne McCauley is a miner in Lee County, Virginia, who injured his shoulder in the 1990s and got prescribed OxyContin. Though McCauley is not the ideal client for a lawsuit against Purdue (since he has admitted to taking other drugs), his case seems promising to an ambitious lawyer from Abingdon who agrees to take up the case. Again, however, a judge rules that there is not enough evidence to rule in McCauley’s favor, suggesting that the risk of addiction was not proven to be high enough to outweigh the benefits of eliminating pain.
As a coal miner, Fayne McCauley is connected to the old traditional way of life in western Virginia. He is a victim first of the exploitative coal industry (which gave him the injured shoulder), then of the economic changes that made coal mining increasingly obsolete. This all makes him particularly vulnerable to OxyContin. The judge rules against McCauley, showing how high the burden of proof is and how difficult it is to find a perfect plaintiff to make the case against opioids.
Lisa Green, the daughter of McCauley, remembers sending her father to rehab multiple times before he died. Despite her efforts, however, on October 22, 2009, she gets the news that he has died. Though a state trooper tells her that her father died of a heart attack, his head is blown apart, suggesting murder over a bad drug deal.
As is often the case with family members of opioid victims, Lisa Green doesn’t know the exact circumstances of her father’s death. While problems with OxyContin were beginning to be more widely recognized in 2009, there were still significant gaps in information (either because people didn’t talk about the issue or because companies like Purdue were deliberately suppressing information). Green’s uncertainty about her father’s death helps portray this.
Despite the 2005 loss in McCauley’s court case, Brownlee continues to stock ammunition against Purdue. Later in 2005, news breaks that a federal grand jury is investigating Purdue, which gets the attention of Van Rooyan, Bisch, and the other RAPP parents. Leading the investigation are the assistant U.S. attorneys Randy Ramseyer and Rick Mountcastle, who are both much less interested in the spotlight than Brownlee but who have a record of sending overprescribing doctors to jail.
The involvement of the federal government suggests that Purdue will face a higher level of scrutiny than ever before. It raises the question of to what extent the previous cases against Purdue were actually failures versus to what extent they were the building blocks for a federal case. Macy again shows how activism that may seem ineffective is sometimes gradually building towards larger change. The introduction of Ramseyer and Mountcastle (who are more cautious than Brownlee) reinforces the gradual nature of anti-opioid activism.
By fall 2006, Purdue’s lawyers sense that things may be beginning to change. A memo from federal prosecutors to Brownlee suggests there may be enough evidence to prosecute Purdue with felony charges. But Purdue is able to use its influence to water down the charges, using Giuliani’s influence as well as pressuring the current deputy attorney general, James Comey, to question Brownlee about his tactics. Brownlee personally drives to Washington to lay out his tactics, however, and Comey ultimately lets him go ahead.
While Macy showed earlier the power Purdue was able to wield with its expensive legal team, now she shows the limits of what money can achieve in a courtroom. When there’s enough evidence, even a consultancy from Rudy Giuliani isn’t enough to secure a ruling.
Purdue’s boldest move comes in October 2006: they get a senior Justice Department officer to call Brownlee at home and pressure him to give Purdue more time for a plea agreement. Brownlee doesn’t budge, and the company accepts the plea deal. Eight days later, Brownlee and several other attorneys find themselves on a list to be fired (although Brownlee is not ultimately fired)—this seems to be yet another case of Purdue meddling with U.S. attorneys’ offices.
Macy depicts how Purdue attempted to influence the Justice Department itself. She presents the facts and lets the audience draw conclusions. For example, do Purdue’s actions suggest that even the government is vulnerable to the influence of big corporations or does the fact that Purdue failed suggest that some traditional institutions can’t be corrupted? Macy seems to suggest that both of these things can be true.
The charges are not as large as what Ramseyer and Mountcastle initially threatened against Purdue, but they represent a mixed success against the company, particularly compared to earlier lawsuit outcomes. The Sacklers realize that a plea deal is preferable to holding a trial in southwest Virginia, which could lead to much harsher penalties.
While this court case is a big win compared to previous cases, it also falls far short of the goals of many activists. The fact that the Sacklers want to avoid southwest Virginia suggests that even all their wealth isn’t enough to protect them from everything.
In May 2007, Brownlee unveils news of the settlement: Purdue has pleaded guilty to falsely advertising the benefits of OxyContin while concealing its potential for abuse. As a result, Purdue will pay $600 million in fines, and top executives will admit to misdemeanor crimes (although without jail time). A sentencing hearing in mid-July will also force these executives to meet the parents of opioid abuse victims. At the press conference, Brownlee’s team shows evidence from their vast collection of Purdue’s wrongdoings—they have so much evidence that they have to rent extra space in a strip mall to store it.
While both the activists and Purdue hoped for a decisive victory in the court battle, Macy depicts how some cases are more complicated. From one perspective, this is a major win for the activists, who, with the involvement of the federal government, have achieved a historic win over Purdue’s mighty legal team. On the other hand, however, this victory does little to address the underlying causes of the opioid epidemic or even to punish Purdue as a company, suggesting that the activists still have plenty more work to do.