A Crisis of Demand: An Insider Account of the Opioid Crisis
Pharmaceutical companies reached a settlement with Oklahoma for 270 million dollars for deceptive marketing that the state claims is responsible for the opioid crisis. The idea the “opioid crisis” is due to over prescribing caused by a deceptive marketing campaign by the manufacturer is not rooted in reality. Yet in the minds of many Americans the media has attempted to reduce the cause of widespread opioid addiction over the last decade to Purdue Pharma’s deceptive marketing campaign, whereby doctors unknowingly over prescribed the medication to patients who took the medication as directed and became addicts. This is not how it went down.
First, about 10 years ago the company added a filler to OxyContin which eliminated its value to substance abusers. The filler prevented the pills from being snorted or injected.
I bought OxyContin in bulk from a few different people who were prescribed them. My best supplier sold me 80mg tablets for $25 each and I would sell them for $40 to $55 depending on the quantity purchased. Typical resale market value was about $60 per 80mg tablet, (.75per mg) but depending on availability and area, people were charging as much as a dollar per mg. Prior to the filler being added the pills were stamped OC. After the filler, pills were stamped OP.
I received a call from a customer who told me about the change. He said “there’s new OCs going around but they say OP on the pill, don’t pick em up because no ones gona buy em. You can’t “bang em” (inject) or snort em”.
People were calling me about OPs, they were trying to sell them to me for less than 15 cents a mg, 80mg OPs for $10. Eventually I picked up 60mg OPs for $5 each, feeling like I could at least get $10 per pill if someone was sick (withdrawing). They did not sell, which isn’t to say I didn’t sell any but it was few and far apart. Even for a person who only has $10 who is sick, they would rather spend that $10 on a small bag of heroin which will give them a fleeting high and will eliminate their symptoms, rather than an OP that when orally ingested will only provide them partial relief from the symptoms of their sickness. The opioid crisis did not end in 2008 or 2009 when the change took place.
After the change, instant release oxycodone was still being prescribed at a maximum strength of 30mg. These pills were not flooding the market because doctors were fooled by the manufacturer into believing they were safe. Among people I knew, nearly everyone had a prescription. A freind told me about a doctor I could see and we agreed on an amount of pills I would give him if the doctor worked out. It was customary to provide gratuity to a person who “plugged” you with a doctor.
I went to the doctor, paid him $150 cash and told him I had back pain. I told him I was prescribed 30mg oxycodone that I took 4 times per day. The reason for the interruption in use was because I was out of work and couldn’t afford the doctor visits. I was coping with the pain since the cessation of use. Now I needed the medication so I could return to work. He didn’t really care about the explanation. Offering a plausible story was more for my comfort than for his.
He had me perform a few tests associated with pain and movement. I was given a two week supply of 15mg oxycodone (60 tablets), and I was scheduled to return in two weeks. This was the general process to ensure a patient wouldn’t overdose on 30mg tabs. When I returned in two weeks I told him I had to double up on dosages while working and then I would be in pain in the evening. I was given a prescription for 120 30mg oxycodone’s.
This doctor was shut down before I could return for my next months appointment but I had what I needed which was the prescription. Most “pill mill” doctors were not as loose as this particular doctor but they were still loose, especially with cash customers. I went to another doctor, I told him my doctor relocated his practice and I needed a new pain management doctor. I gave him my prescription from the previous month. He performed a few in office tests similar to the other doctor and wrote my prescription. I went to this doctor monthly for probably close to a year give or take a few months.
This doctor as all these doctors do required a urinalysis. I usually didn’t take the pills but I did smoke marijuana which the doctors typically didn’t have a problem with. I would pee in the cup and then take the powder residue from inside an empty pill bottle with my finger and mix the residue with the urine which would cause the urine to test positive for oxycodone. This is called peppering and it created the illusion I was taking my medication.
A lot of people went to this doctor, and among people in this life style (drug sales and drug dependence), when people had issues with one another they will maliciously call people’s doctors. They’ll tell the doctor the patient was using drugs, has someone else’s urine, is peppering and so on and so forth. Allegations that may bring the patient under additional scrutiny and cause him to lose his or her doctor(s). (many people had more than one doctor). I don’t know for sure, but I surmise this may have been the case with this particular doctor because he changed his method of drug testing.
I remember walking into the doctors office and seeing people sitting in chairs with what looked like a home pregnancy test hanging out of their mouth. The doctor switched to a saliva test. I had no oxycodone in my system. He wrote me my prescription and later in the week I received an email stating I had been discharged for not taking my medication.
Before the next month I had another doctor. After a few months at this doctor I made a mistake. I ingested a hydromorphone which is a morphine pill about 4 days before my appointment. Usually these substances are out of your system in 48 hours but it came up in my urinalysis.
By the time I was due for my next month prescription I had another doctor which I kept until I left the state and changed my lifestyle. I obtained prescriptions from 4 different doctors without furnishing an X-ray, an MRI, or any referral diagnosis from a primary care physician.
The point is, doctors didn’t prescribe OxyContin and oxycodone because the manufacturer caused them to believe it wasn’t a highly addictive and dangerous substance. Doctors prescribed these drugs because of market demand from the public. The demand already existed and the percentage of people in the United States who will develop a dependency is determined by factors unrelated to supply.
There was a greater ease of procurement of these drugs, but it was caused by the willingness of doctors to prescribe it FOR PROFIT. If you are a doctor with a private practice you can conservatively see up to 4 patients an hour. That’s $600 an hour which reflects the market rate of the referenced period, based on 4 different doctors who all charged $150 per visit. Working an 8 hour day, 4 patients per hour, at $150 per patient, is nearly $5000 per day in sales. 100,000 a month on a 5 day work week. 1.2 million per year.
When someone comes to see you about pain management and they’re asking for specific medication by telling you it is what they were prescribed and it worked for their pain; are you going to prescribe hydrocodone and muscle relaxers or are you going to give them what they what? If you choose the conservative course of action that patient will never return. There is going to be no referral from that patient and chances are your practice is going to struggle and may fail. Option two. You give the patient what they want. This patient tells everyone they found a new doctor and refers people to your practice. Within a month or two you have to stop accepting new patients because your schedule is full and in a year you’ve made close to a million dollars. What would you do?
The second reason for the shift in the market deals with understanding how drug habits are adopted. Obviously drugs are spread socially. If someone you know does cocaine, at some point a person is going to become interested in trying it, or eventually out of courtesy, the user is going to offer you cocaine. Of course if a highly addictive pill finds them before cocaine, now the person you know who does cocaine isn’t doing cocaine they’re sniffing pills. In both cases there is the risk of spreading substance abuse, the only difference is the substance.
Some may argue because pills are socially more acceptable, there is a greater likelihood that people who may not have become addicts due to the stigma of cocaine or heroin, became addicts due to the socially acceptable medium of a pill. This isn’t a point that can be measured because there is no way to determine if a person would not have developed any dependency had they not exposed themselves to opioids.
Still, the manufacturer can hardly be blamed for social norms. Even the argument the manufacturer infiltrated the market through a less stigmatized medium (pills) with an addictive substance they minimized the danger of is of no merit, because it is the doctors who prescribed it. Doctors who prescribe opioids were not ignorant of the effects and neither were the patients. In fact some doctors who prescribed oxycodone also treated substance abuse with suboxone.
An increase in the over all percentage of the population who has substance abuse issues can be attributed to the recession. People use drugs to cope with stress and the number one cause of stress in the United States is money.
Addiction or dependency if you prefer, has everything to do with Perceived Achievable Purpose and to what extent drugs interfere with your Perceived Achievable Purpose. I mentioned previously I went to a doctor and I peppered my urine because I didn’t have the medication in my system, which was true during that time, but I also binged on the substance from time to time and dealt with the symptoms of an opioid withdrawal.
My binge was managed, I may crush up a total of 30 to 60mg a day for a week or two weeks. I recognized use was interfering with the purposes I wanted to serve in life and I would stop. Sometimes I’d use marijuana as a crutch for the symptoms and play video games to hold my attention and pass the time. Your stomach is in knots, you can’t sleep, your body aches, anxiety is almost palpable, there is the feeling of an agitating vibration all over your body, you get hot and then cold, and you become extremely depressed, but as long as you acknowledge the source of your depression is the withdrawal, you move past it, and eventually get a good nights sleep and you’re fine.
Prior to my perceived achievable purpose being the transformation of the human species, my PAP was to be successful as a recording artist. Drugs usually were not in conflict with that purpose and at times aided the creative and technical process of recording and engineering music. I didn’t become dependent on substances during this period for two different reasons. First is money.
The amount of sacrifice required for me to elevate my mood was usually unperceivable. If I purchased 100 30mg oxycodone tabs for $1200, if I sell 99 at 17 dollars each I’m still making 483 dollars. If I’m using 2 a day for a week I start thinking about the cost. Even though it was an aid to my PAP musically, dependency would have nullified that aid if it interfered with my ability to make money which was central to my PAP. Dependency itself was detrimental to the PAP from an image stand point which I was conscious of.
Some peoples PAP is working a dead end job that barely pays their bills, and with no real prospects for improvement they cope with these circumstances using drugs, and sometimes this use becomes dependency. Sometimes dependency, doesn’t interfere with their PAP. Some people’s substance use is maintained responsibly, they go to work, they pay their bills, and they use drugs on a daily basis. There are a lot of people who go to work high everyday.
Purpose is the key to recovery from dependency. This is why 12 step programs which are the most common roads to recovery require belief in a higher power. Individual’s Perceived Achievable Purpose becomes pleasing this higher power who disapproves of their drug use, but who also is more powerful than the drug. Of course the circumstances that caused the dependency to begin with remain unchanged, which is why everyone who was an addict and prescribes to this recovery line of reasoning, doesn’t recover but is always recovering. They assign an addictive personality label to the individual, but their recovery through the program hinges almost entirely on their loyalty to the higher power.
Bear in mind I have no problem with whatever a person does to improve their life or to make their life more of what they want it to be (so long as what they do is unimposing), but I do have a problem with how these programs brainwash people. The substance is more powerful than the user, only through service to a higher power can they avoid the substance, and the existence of the substance coupled with their impotence to manage use is the source of their problem.
Absent is the acknowledgement of the economic circumstances including a lack of opportunity to be productive, to have purpose, or to be adequately compensated for work performed. Circumstances which likely still exist but may be more manageable due to the PAP of fighting drug addiction which they are taught develops in a vacuum: due to the power of the drug and the user being powerless over it. Lasting recovery is usually the result of purpose derived from the crusade against drugs, and relapse should be associated with circumstances existing that made the user susceptible to dependency to begin with.
The “opioid crisis” is also promoted more than other substance abuse based on the industry that has grown up around it. The recovery industry. On any given day, in nearly any given area, at nearly any given time a person can turn on broadcast TV and see commercials for opioid treatment. Many of these treatment centers are in the same general business as the doctors were, which is long term prescription sales. Some doctors are still in this business having changed their focus from opioid distribution through the pretext of pain management, to opioid addiction recovery. Probably the same rate, same demand, but a different substance and less scrutiny.
Substance abuse treatment is usually covered by insurance, and most people with substance dependency have state insurance. This treatment option which sometimes attaches counseling to it, is primarily an indefinite term treatment where heroin or prescription opiate dependency is substituted for another substance, methadone or suboxone. There are people who are taking this medication for years. The facilities profit by billing insurance companies for prescribing the substituted substance. Marketing the opioid crisis is central to their business.
The idea that doctors unknowingly prescribed medication because the manufacturer hid the dangers of the medication is an effort to bring something to blame other than the failings of American society. It is the economic, political, and social order that produces circumstances of dissatisfaction that lead to drug dependency. But the American myth must be preserved. The American myth consists of the intents of liberty, justice, and opportunity with which this country was founded on and operates under, inclusive of the idea that the US represents these values in foreign policy. The problems have to compartmentalized. Drugs are the problem, suppliers of drugs are the problem, Purdue Pharma and the Sackler’s caused an opioid crisis, not the circumstances that created a demand for drugs, and not the doctors who knowingly prescribed the drugs for their own financial gain. Critique of “the American way” is outside the spectrum of the acceptable limits of controversy.
People didn’t become drug addicts by taking their prescription as directed in the frequency and in manner it was prescribed: orally not nasally or intravenously, and every 6 hours AS NEEDED for pain. People knew what they were doing and the deceptive efforts by the manufacturer to promote their product had no bearing on the demand or the supply. But someone had to take the blame. America cannot be responsible for the circumstances it produces that cause people to want to use and abuse drugs. Demand for drugs existed before OxyContin, as well as after OxyContin.
Overdose deaths have increased significantly, but the greatest recent catalyst for overdose deaths isn’t abuse of prescription medication but the use of fentanyl to increase the potency of heroin. Fentanyl is as I understand it the strongest pain killer on the market.
Adding Fentanyl to heroin allows for the distributor to step on it (add to it) without diluting the potency of the product. Imagine you have a kilo of heroin. If you add a kilo of filler you have twice as much product but with half the potency. Fentanyl is up to 100 times more potent than heroin. Which means you can double up a kilogram and maintain the same potency by adding 10 grams of Fentanyl.
The heroin market is driven by quality. In Milwaukee, you can walk down the street in certain areas and people will ask you if you’re looking for a sample. (Milwaukee is also one of the most segregated cities in the United States. You have large portions of the city’s northside that are near exclusively black meaning if you’re in that area and you’re white, you’re probably in that area looking for drugs.) It is a buyers market, and once an addict finds a person with a quality product, they will buy from that person when ever that person is “good” (has drugs). Even if the bags are smaller and it is more of a hassle to go through said individual, quality is king when it comes to heroin users.
Beyond adding Fentanyl for the purpose of streching product, Fentanyl may be added to enhance potency, and I have heard of batches of what users were calling synthetic heroin. Synthetic herion being basically “dummy bags” (all cut no drugs) mixed with Fentanyl.
When the heroin is cut with a drug that is 100 times more potent, the product isn’t assembled to guarantee an even distribution of heroin, filler, and fentanyl. As a result some people are going to be distributing weak batches, and others or going to be distributing heavy batches containing more fentanyl per parts than heroin or filler. A person who usually shoots up a 3/10th of a gram to get high, (roughly 3 20 dollar bags), if they shoot up a 3/10ths of a gram that is heavy in fentanyl, they die.
The other side of opioid death occurs when users are either released from jail or they relapse. They don’t consider how their tolerance to the drug has decreased and they use a dose of the same quantity they were using when they were getting high on a regular basis, and they die.
My motivation for this article is not to create a defense for Purdue Pharma; although injustice is still injustice when it is perpetrated against the advantaged as it is against the disadvantaged, especially when there is no true benefit to the disadvantaged. I do not consider the proposed purpose of the settlement (a treatment facility) as constituting a great act of balance for disadvantaged people. I am primarily motivated by bringing to light that the cause of drug abuse does not stem from a single entity or a group. It is not true that in the absence of the manufacture of a single substance, and in the absence of deceptive marketing of that product, that a drug epidemic would have been averted. A drug epidemic exists because of political, economic, and social systems that create the circumstances that produce demand for drugs.