First Do No Harm

Dream Land – The True Tale of America’s Opiate Epidemic by Sam Quinones is an outstanding book.  It should be required reading for every politician, doctor, and government bureaucrat in the country.  It tells a sad maddening tale of a drug crisis that kills tens of thousands of Americans each year, a crisis that didn’t have to happen.

The topic is engaging, the writing direct and compelling, and the lessons to be drawn significant and applicable to fields far beyond drug abuse.  The story flits between Mexico and the United States, between drug runners and medical doctors, from California to Ohio and places in between.  The book is exceptional.  Read it.

Humans are inherently selfish and, in moderation, that’s not a bad thing.  Adam Smith’s “invisible hand” guides economic activity as people (and countries) gravitate toward their competitive advantage.  But the invisible hand also applies to illegal markets.  In a small province in Mexico, that competitive advantage is a surplus of opium and labor.  It turns out that among the competitive advantages of the United States is an abundance of money and greed.  (Who knew?)  A basic theme of the book is that our doctors and pharmaceutical companies primed the pump, creating many addicts who were ripe for a cheap fix, providing perfect entre for the Xalisco Boys.

The tale begins, almost fictionally, with a short letter to the editor of the New England Journal of Medicine, published on January 10, 1980.  Graduate student Jane Porter and Doctor Hershel Jick submitted a one-paragraph letter which concluded “despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”  And then the law of unintended consequences took over.

The letter was referenced again and again – over 900 times in scholarly papers.   http://www.businessinsider.com/porter-and-jick-letter-launched-the-opioid-epidemic-2016-5 It became de rigueur for doctors, pharmacists, and nurses, although there is no evidence that any of them ever read it.  To wit, it was referred to as “an extensive study,” “a landmark study,” and “a landmark report.”  It never purported to be any of those things and it wasn’t.  It was a simple letter based on observations in a controlled setting.  Still the letter helped spawn an entire industry: pain.

Doctors began treating pain, the so-called fifth vital sign, aggressively, and increasingly with opiates, despite residual reservations (held over from medical school) about the addictive power of opium-based products.  Even the best and most cautious doctors were worn down by colleagues and pharmaceutical companies who continually touted the Jink letter.  Despite strong reasons to believe otherwise, the gospel that “opiates are not addictive” spread throughout the medical community.

And the law of unintended consequences kicked in again.  Lesser doctors, unscrupulous even, opened pain centers, liberally dispensing OxyContin and similar drugs.  These doctors regularly failed to conduct true medical evaluations.  Among the worst of the breed, one doctor routinely saw patients for as little as 90 seconds, once prescribing 46,000 controlled substance prescriptions in nine months.  It boggles the mind, as does the money generated.  Most of the prescriptions required a doctor’s visit at $250, cash only please.  Often the drugs were then dispensed at the doctor’s office for $200 or so, again cash only.

The ready availability of the prescription drugs, primarily OxyContin, attracted drug addicts, not just those in pain.  Pain can be properly and appropriately treated with opiates, but the pill mill doctors were anything but proper and appropriate.  And addicts never are.  Because they could get more pills prescribed than they needed for their fix, they began using the pills as currency.  The street value was roughly $1 per milligram.  A single 80 milligram pill of OxyContin had street value of $80, making the prescription’s costs seem reasonable.

People drove addicts to and from doctor’s appointments, fronting the money for the visit and the drugs in return for half of the pills.  That was a good economic investment, if a moral catastrophe.  $450 invested per visit (see above) garnered $1,200 worth of pills (15 pills times $80 each).  And the drivers were not limiting themselves to one prescription run per day.  People able to procure a medicaid card received a bonus windfall as the cost of the drugs dropped to $3 for the co-pay.  With profit margins like that, it’s not surprising that many poor and desperate people succumbed to temptation — or that given the abundance of Oxy available, more people began using.

People also began dying from Oxy overdoses, enough deaths to attract the attention of police and others.  As pressure was brought to bear, Oxy prescriptions started to decline and become harder to get.  This chagrined Purdue Pharma, which continued to espouse the non-addictive nature of OxyContin right up until they paid a fine in excess of $600 million for misbranding.  And then, amazingly, things got even worse.

With so many long-time heroin addicts and newly-minted Oxy addicts searching for a fix, the path had been paved for the Xalisco Boys.  They sold black tar heroin.  They sold cheap, under $15 a fix; they sold conveniently, basically by delivering it to the addict; they sold without violence, none of them carried weapons; they sold honestly, all of them were on salary and subject to be returned to Mexico for any insubordination; they sold pure unadulterated heroin, which was much more potent and deadly than the powder more conventionally available.  And overdose deaths skyrocketed.  Approximately 47,000 people died in the United States from drug overdoses in 2014.  https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

The trajectory from a one-paragraph letter to 47,000 annual deaths is a true trail of tears, one that I hope we never repeat.  As I read the book, I was screaming (on the inside) “read the letter, don’t just refer to it.”  We (all humans) have a tendency to accept what we hear or read from an expert at face value.  We shouldn’t, unless they have proven reliable in the past.  Just because somebody, however expert, once said something, doesn’t mean it was true then.  And it most certainly doesn’t mean it is true now given how rapidly circumstances change.

I can’t help wondering what other solitary paragraphs are out there lurking as virtual time bombs waiting to cause another explosive crisis.  Who knows?  But we must all be more skeptical of everything we read – not just when the other (political) team is doing the writing.

It dismays me that so many doctors were not careful enough to double check what they were being told.  It infuriates me that some doctors went out of their way to “create a narrative so [primary care doctors] would feel more comfort about opioids in a way they hadn’t before.”  Dr. Russell Portenoy, Dream Land, p. 309.  Portenoy had financial ties to several drug companies at the time he was encouraging the use of more opiates.  He has conditionally recanted, stating that based on current standards, he had provided misinformation.  https://www.minnpost.com/second-opinion/2012/12/doctor-who-encouraged-wider-use-opioid-painkillers-having-second-thoughts   Based on what I read in the book, Portenoy provided misinformation according to any standard you might choose to impose.

Why didn’t more doctors question the extensive use of opioids sooner?  We might never know.  I hope they are more distrustful the next time a time-honored and proven precept is so egregiously flouted.  I hope we all are.

One final reminder – read Dream Land.  It’s well worth the money and the time.