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[ Opinion ]

Creating an Epidemic — Part 1

Written By Val Everett

HEROIN. It’s an epidemic. In my neck of the woods, southwestern Ohio, nary a day goes by without a story on how heroin is destroying lives and neighborhoods, and what local communities are doing to fight it.

The media has covered the heroin epidemic like they cover a massive flood. First a trickle, then a torrent, the waters rising, now topping the riverbanks, then covering some low lying neighborhoods, fought by valiant members of the community banding together to lay sandbags. Some days they report daring rescues; others, foul crimes.

Floods happen in days or weeks. The heroin epidemic is happening over months and years.Both drug epidemics and floods are treated as natural disasters. Neither are. Floods rarely have one cause. They are the culmination of centuries of self-interested human actions, like mining and burning coal and oil; cutting down forests; draining swamps. The people doing the mining, draining, and logging get profit; those living on or near floodplains (and elsewhere) pay the price when dams inevitably break , and levees breach.

This is happening now, but with heroin. The heroin epidemic has a root cause — the prescription drug abuse “craze” of the past decade or so. But this “craze” is like the floodwaters — no one cause, but rather the devastating confluence of decades of self-interested actions. People made money creating the heroin epidemic. Lots of people. Lots of money.

And others paid, and are paying, the price.

The roots of the heroin epidemic have been reported elsewhere. Most explanations cite the same elements:

First, in the 1990s a growing recognition that pain is under-treated (it still is) led to increased efforts to identify and treat pain. This is the now-notorious “pain is the fifth vital sign” campaign, adopted in 1998 by the Department of Veterans’ Affairs, whereby in addition to measuring the usual four vital signs (temperature, heart rate, breathing rate, blood pressure) they would measure pain, and when it was present, treat it. They chose to measure pain on a numeric scale from 0–10, where 0 means no pain, and 10 means the worst possible pain.

Second, around the same time, OxyContin showed up. OxyContin is, without any doubt, the ur-drug of the current heroin epidemic. In the mid-1990s, Purdue Pharma came out with Oxycontin. Purdue took an opiate, well known at the time, called Oxycodone. Oxycodone was developed in 1917 by German chemists. Oxycodone is what is known as a “semi-synthetic” drug, in that it is derived from natural sources. Here, the natural source is the Opium poppy. Drug manufacturers, in the course of processing the raw opium, make changes to the chemical form, and voila — oxycodone.

Oxycodone is an old chemical, and not protected by a patent. As such, under U.S. law, it is a generic drug, and anyone who can get the proper credentials (including state and federal licensing) can manufacture and sell it.There are some exceptions to this rule, however. One is this: extended release. New to the market extended release versions of an old drug can be patent-protected.

Ever wonder why there’s so many Mucinex commercials these days? Mucinex managed to take guaifenisn, a mucus-abating drug that’s so old it has never been protected by patent, and developed an extended release version. What’s really funny about this is that they weren’t the first to do so — plenty of other companies had developed and were selling extended release guaifenesin. Mucinex’s only difference was that they actually got their version FDA-approved. Once they did that, they could (and did) force their competition out of business. The FDA even helped. Now extended-release guaifenesin can make a lot of money. Hence all the commercials.

Purdue Pharma did the same thing, but with narcotics. Purdue took a substance that was cheap and common, made an extended release version, got patent protection (read: monopoly power) and sold the shit out of it. They went across the country and sold this drug, approved for only major, chronic pain, and sold it for everything. They told people you could take it for arthritis, headaches, cramps, whatever. Sales skyrocketed.

I agree that these factors were important, but on their own they are incomplete. First, the ‘pain as the fifth vital sign” campaign initiated by the VA suggests that the VA did a lot of the overprescribing of narcotics. By and large, they didn’t. Moreover, since the VA is a national organization, distributed across the country, you might think that the overprescribing would be evenly distributed nationwide. It wasn’t.

Second, the OxyContin boom is long over. Purdue Pharma was fined for its aggressive marketing of the drug in 2007. As part of that settlement, they took a number of aggressive steps to monitor and restrict the supply of OxyContin. In 2010 they won approval for a new formulation of OxyContin that made the pills very hard to crush, snort, dissolve, or inject, making them much less attractive to addicts. Yet the heroin epidemic only started to rage in the last year or two. What happened in the meantime?

Explanations like these fail to take into account how prescription drugs generally, and narcotics specifically, physically get from their manufacturers in the U.S. and abroad and into patients’ hands. The movement of these medications, involving gigantic, well-known companies, tiny startups, and everything in between, was a key factor in getting so many people addicted to narcotics. When these companies, largely due to regulatory action, stopped supplying medications in such large quantities, desperate patients naturally turned to other, suddenly cheaper and more available narcotics. Like heroin.

Over the course of several posts I’m going to try and add a bit to the conventional wisdom on the causes of the heroin epidemic. Where all of those pills came from, how they got to their patients, and why they stopped coming. Stay tuned.