Last night, I watched the new Netflix documentary Heroin(e). This documentary was of special interest to me, as it revolved around the opioid epidemic in Huntington, West Virginia. Huntington happens to be home to my alma mater, Marshall University, as well as my entire immediate family. Huntington also has the highest per capita rate of heroin overdose in the country.
The documentary covered the crises in an emotional way, but it utterly failed to inform the viewer about the causes and history of the problem. For the long history of heroin, which is more than can be documented in a short article such as this, you can listen to the episode of Historical Controversies devoted to opium. But what was not covered in that episode is the more recent history of opioid addiction as it applies to the tri-state region surrounding Huntington.
The Fifth Vital Sign
In 1986, a paper co-authored by Russell Portenoy and Kathy Foley was published in the medical journal Pain, in which they looked at the use of opiates to treat pain in 38 patients. In the paper, the authors cited in a footnote an obscure 1980 letter to the editor of the New England Journal of Medicine titled “Addiction Rare in Patients Treated with Narcotics.”
The paper was modest in its prescription of opioid painkillers, acknowledging that addiction was a possibility, and in later interviews, Portenoy would stress the need for doctors to prescribe opiates judiciously, only after spending sufficient time with a patient. But regardless of Portenoy’s warnings, new approaches to treating pain were being sought after by a medical community increasingly pressured to supply quick fixes for pain rather than real treatment for the underlying problem.
The pressure to treat pain is hardly the fault of the doctors prescribing the opioids. In the 1990s, the American Pain Society began to push the idea of getting pain added as the fifth vital sign (the four primary vital signs are body temperature, pulse, blood pressure, and respiration). The APS even adopted the slogan “Pain: The Fifth Vital Sign” in 1996. Two years later, the Veterans Health Administration added pain as a fifth vital sign, and the Joint Commission for Accreditation of Healthcare Organizations followed suit.
Although the Joint Commission for Accreditation is a private non-profit organization, several states use their accreditation as a condition for licensure, Medicaid, and Medicare. What this meant is that to maintain accreditation, hospitals were now judged on how they assessed and treated a patient’s pain. Several state legislatures started to require hospitals and nursing homes to screen for pain, and the Board of Pharmacy in California, as one example, pushed opiates as having “extremely low potential for abuse.”1
By the 2000s, the country was starting to view pain as an undertreated epidemic. But doctors were concerned about prescribing opiates, so many states passed laws protecting them from lawsuits based on the prescription of opiates. By now, the incentives were clear. If doctors didn’t aggressively treat pain, they were putting their licenses or their employers’ accreditation at risk. If they irresponsibly overprescribed addictive painkillers, they were protected from legal consequences. State laws were rapidly piling on the incentives for doctors to quickly prescribe opiates, and to ease their minds, Pharmaceutical Boards like the one in California were pointing to the Portenoy-Foley article as evidence that there needn’t be much worry about the development of addiction in their patients (Portenoy himself has warned of the possibility of addiction with opiate prescriptions since the article was published).
Enter OxyContin
About the same time that this movement against the “pain epidemic” was taking place, Purdue Pharmaceutical released a new painkiller to the market: OxyContin. This new pill was a time-released version of oxycodone.
Purdue started a major marketing campaign to push their new product. They misleadingly advertised it as non-addictive, using Dr. Herschel Jick’s 1980 letter-to-the-editor as their justification. Historically, this tactic is not new, of course, and most likely, the company genuinely believed the claim that the drug was non-addictive (at least, at first). When Bayer first patented heroin in 1898, they marketed it as a non-addictive treatment for morphine addiction. Purdue was repeating this folly a century later, and in 2007, it would cost them $634 million in fines from the federal government.
But it was government policy that, at least in part, created the environment that allowed for OxyContin to create an epidemic, though it was often state-level policy. Doctors were being given increasing incentive to recklessly prescribe painkillers, and healthcare reforms were constantly eating away their time with patients. So when Purdue offered them a supposedly non-addictive option for meeting the new standards of pain treatment, it seemed like an obvious path to take.
But as is now well-known, OxyContin was actually extremely addictive. Furthermore, patients-turned-addicts learned how to break open the capsule to receive the entire 12-hour dose in one shot. Thus, as they were being treated for pain, their addiction developed. Eventually, the doctor would have to cut them off (after all, roughly 20,000 doctors were thrown in prison in the 1920s after the Supreme Court ruled that it was an irresponsible practice to treat addicts by giving them access to pharmacy-grade versions of their drugs). So addicts had to turn to the black market.
This led to the rise of so-called “pill mills,” the largest of which for the entire country was located in Proctorville, Ohio, which is just across the border from Huntington. Here, doctors such as David Proctor (who was probably less well-meaning than many of the other doctors prescribing OxyContin), set up clinics that existed entirely off of writing prescriptions for opiates. Drug seekers and drug dealers would frequent these clinics, and the pills were pushed into the black market to feed the habit of addicts, most of whom got their start from legitimate prescriptions.
But Oxy is pricey, and eventually, an addict would be offered an alternative. They could pay the exorbitant price for a single Oxy pill, or they could pay significantly less for a dose of injectable heroin. Thus the heroin market exploded. Because of the level of poverty West Virginia faces, Huntington and surrounding areas effectively acted like a petri dish for opiate addiction.
The economic devastation in Detroit didn’t help matters. Heroin was transported from there down the “Hillbilly Highway” into Appalachia. To make their heroin more powerful, distributers started cutting it with fentanyl. As I mentioned in a previous article, this is one of the dangers of pushing drugs to the black market through prohibitions. The majority of the deaths by heroin overdose in recent years have been due to the fentanyl, rather than the heroin itself. Other sources of heroin came from the Municipality of Xalisco, in Mexico, where distributers sold low-purity, but uncut, Class 4 heroin – also known as “black tar” heroin because of the dark color it has from its impurities. When addicts were cut off from OxyContin, these suppliers filled the void.
- 1Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic (New York: Bloomsbury Press, 2015), 95.
