Revenge of the Tipping Point: Chapter 9 Summary & Analysis

The opium poppy has served a variety of uses for humans over thousands of years. In the early 1800s, it became the basis for morphine, later followed by codeine, heroin, and oxycodone. When two German chemists discovered oxycodone in 1916, few saw it as being as dangerous or addictive as heroin. But 80 years later, the Sackler family-owned Purdue Pharma harnessed oxycodone to create OxyContin, the drug at the center of the opioid epidemic.

Gladwell writes that over the course of this book, many of the anecdotes he’s shared involve people in a state of denial who either refuse to take responsibility for their actions or refuse to acknowledge cause and effect during periods of change in an overstory. He believes it’s important to take examples like Miami or Poplar Grove and understand why things changed.

In the United States, from the mid-1990s through 2015, drug overdose deaths soared. The data shows that, while other countries did struggle with overdoses, the high recent rate in the United States was an American phenomenon. On a more granular state-by-state level, opioid abuse statistics can vary wildly, even in neighboring states. Although poverty and factors like unemployment do play a role in opioid use, other nations that with higher rates of these issues don’t have the same problem that the United States does.

Paul E. Madden isn’t well-known to history, but Gladwell believes that he played a surprisingly large role in the current pattern of opioid devastation. In 1939, Madden became director of the California Bureau of Narcotic Enforcement. He often spoke in grandiose terms about the evils of drugs. He conducted raids, even going so far as to confiscate poppy seeds supposedly meant for kaiser rolls. Under his direction, a law passed that each opioid prescription had to be written in triplicate, with one copy sent to the Bureau of Narcotic Enforcement.

The triplicate system led Madden to prosecute a San Francisco doctor named Nathan Housman, who provided several morphine prescriptions that had not been properly filed with the Bureau of Narcotic Enforcement. Madden sent Housman to San Quentin Prison, which sent the message that he was serious about enforcing his drug laws. Madden’s elaborate prescription records might not seem significant, but they played a role in changing how prescriptions worked. Prescriptions used to be a private matter between doctors and patients, but Madden helped to change them into a public health issue.

Decades later, Russell Portenoy grew up in Yonkers outside New York City. After medical school, he did a residency where his mentor was a doctor named Ron Kanner. Kanner specialized in studying pain, an idea that was still novel at the time. Portenoy came to see how focusing on pain could be useful for patients with conditions like cancer, and by 1993, he was an enthusiastic supporter of opioids as a way to treat pain, believing they carried little risk of abuse or addiction.

Portenoy had a different overstory from Madden. While Madden wanted to make an example of over-prescribing doctors to keep all doctors in line, Portenoy wanted to empower doctors to make their own decisions when it came to treating pain with medication. His ideas became popular, and he developed a reputation as the “King of Pain.” In the 1990s, there were a few states that had a triplicate system like California, but most followed recommendations more like Portenoy in giving doctor’s free reign over what to prescribe.

Against this backdrop, a company called Purdue Pharma that had been making painkillers for a while suddenly had a massively popular new drug called OxyContin. The Sackler brothers, who ran the company, believed that the drug was their “ticket to the moon.” But while use of OxyContin expanded rapidly, the drug faced trouble in states like Texas that had a triplicate system—in these states, OxyContin use generally remained limited to treating cancer patients. Purdue noticed this trend and pushed its advertising most aggressively in states with friendlier regulations. Gladwell believes that OxyContin’s rapid expansion—and the tragic impact of the addiction it caused—was a result of people following a Portenoy-style overstory. Had Madden’s overstory prevailed, the negative effects of opioids might have been much more limited.

Parallel to this story of the rise of opioids is a related story about increasingly sophisticated pharmaceutical marketing to doctors. Initially, pharmaceutical sales forces were haphazard, canvassing widely to sell to doctors. But as hospitals started to crack down on access to doctors by sales teams, pharma companies eventually became more sophisticated, with Purdue calling the consulting firm McKinsey to target specific drugs to specific doctors.

By 2013, the problems with OxyContin were well-known, and Purdue had faced significant backlash. McKinsey helped them rethink their strategy on OxyContin by focusing on the highest-prescribing doctors, which it labeled “core” and “super core” prescribers. McKinsey then advised specializing even further, focusing on the “core” and “super core” prescribers who were most susceptible to marketing. Certain doctors essentially became superspreaders in the opioid epidemic due to how rapidly their prescriptions rose under this plan. One doctor earned the nickname “the candyman” for how freely he prescribed opioids.

Gladwell believes the opioid crisis can be divided into three acts, with the first act being the decision by Purdue to target non-triplicate states and the second being Purdue’s decision to target “core” prescribers. The third phase began after Purdue was forced to reformulate OxyContin to be less potent and less subject to abuse. These measures didn’t reduce the number of prescription drug deaths and instead led to a new increase in people dying due to heroin and synthetic opioids like fentanyl, which people addicted to prescription drugs increasingly turned to after OxyContin no longer suited their needs.

While any opioid crisis is bad, this third phase was particularly dangerous because people addicted to painkillers were now dealing with criminals selling on the black market instead of doctors who, at least ostensibly, had to follow laws and regulations. The researchers Pacula and Powell looked at research to hypothesize what might have happened if OxyContin hadn’t changed its formula. They reached the surprising conclusion that before this reformulation, regulators were winning the war on opioids. Making OxyContin less dangerous might have had the paradoxical effect of creating more overdose deaths by disrupting progress and leading people to seek other painkiller solutions.

Gladwell summarizes the opioid crisis thus far, agreeing with the sentiment that OxyContin’s reformulation had the unintended side effect of giving the epidemic new life. By the early 2020s, this meant almost 80,000 Americans were dying annually from opioid overdoses, with no relief in sight. Gladwell believes that epidemics have “rules” and work in predictable ways. He believes that we have tools to guide the course of epidemics like the opioid crisis, and that rather than abdicating responsibility to the “unscrupulous,” we need to use these tools ourselves to build a better world.