Book Review: “American Overdose: The Opioid Tragedy in Three Acts”

 

 

 

 

This last year, publishers churned out books about the U.S. opioid use disorder epidemic with some regularity. I’ve already reviewed some of the more well-known, such as “Fentanyl, Inc.;” “American Pain;” Dopesick;” and “Dreamland.” Published in 2010 and far ahead of its time, “Painkiller,” by Barry Meier, had an updated second edition released in 2018. All these books are worth reading.

“American Overdose,” written by Chris McGreal, is a little different. Instead of long stories about particular people who became addicted to opioids, this author dug into the history of factors that set up this tragedy and how it evolved. He describes how prominent people and agencies that should have protected us either ignored the problem or had weak and inadequate responses.

He divided his book into three parts: “Dealing” was about the factors that contributed to the opioid epidemic and the people who tried to warn of impending problems; “Hooked” was about the failures to act after the epidemic was well underway; “Withdrawal” describes how changes finally were made to the opioid prescribing landscape, and the heroin epidemic that followed as an unintended consequence of tighter controls on prescription opioids. This section also talks about our task of trying to repair the damage done by a few decades of opioid epidemic.

The author gives the names of individual people who left their mark, for good and for bad, on the opioid epidemic. He also names specific organizations that lit the match and fanned the flames of the opioid disaster. Other people who have written or talked about the opioid epidemic have refrained from blame, saying that though people were wrong, they had good intentions and it isn’t helpful to blame. If that’s your outlook… this book probably isn’t for you. He names and blames people, often individuals who are leaders of organizations.

He specifically focused on Purdue Pharma’s drug OxyContin as the “most powerful narcotic painkiller ever released for routine prescribing.” He’s right about his claims, and prescribing data tells the story. OxyContin was heavily promoted to rural areas, and specifically to rural Appalachian areas. These places have the highest prescribing rates, the highest opioid use disorder rates, and the highest opioid overdose death rates.

I remember attending ASAM’s (American Society of Addiction Medicine) “Pain and Addiction: Common Threads” course in 2004 or 2005.  Purdue Pharma was still a major sponsor of that conference. (Later, due to the objections of ASAM’s members, drug companies were no longer allowed to sponsor whole conferences, but were allowed to have small informational booths at the conference, should attendees wish to talk to them). I remember how a physician was chided for mentioning OxyContin by name as a factor in our region’s burgeoning opioid addiction problem. He was told that people weren’t misusing only OxyContin, and that other brands like Percocet and Lortab were also involved, so we shouldn’t point the finger at one drug company.

Those of us working in the field knew bullshit when we smelled it. Maybe there were more combination oxycodone/acetaminophen pills sold, but they didn’t have the opioid firepower of an OxyContin 40mg, let alone an Oxy 80, and – for a brief time – an Oxy 160mg. From 2001 when I started at an OTP until around 2010, the drug my patients mentioned, nearly without fail, was OxyContin. I was working in rural and small-town Western North Carolina at that time: Hickory, Concord, Statesville, Gastonia, and Marion. What I saw every day did NOT match what the drug company shills were saying.

Books like McGreal’s and earlier sources have since examined the facts behind how Purdue Pharma operated, how they made misleading statements about the addiction potential for patients prescribed their drug, and how they blamed people who got addicted as causing their own troubles.

In 2007, relatively early in the epidemic, a U.S. attorney in Virginia, John Brownlee, was able with much difficulty and resistance to get Purdue to admit to felony misbranding of OxyContin. The three top executives pled guilty to misdemeanors and the company paid $600 million in a settlement.

If you think this slowed Purdue and caused them to re-think what they were doing…nope. There’s a great deal of evidence to show you would be wrong. In 2003, representatives of Purdue told Congress that they were working on an abuse-deterrent formulation of their OxyContin, but they didn’t re-formulate until 2010. The patent on OxyContin was due to expire in 2013, so re-formulating meant the new patent would last until 2030.

The Sackler family, owners of Purdue Pharma, is mentioned only briefly near the end of the book.

The book took great pains to point out how Big Pharma paid to influence decisions made by the government at all levels, and how Big Pharma sought to silence well-intentioned people who worked a government regulatory bodies about what was happening in the beginning of the epidemic.

The book spends much ink dwelling on the failings of the FDA (Food and Drug Administration). The author traces the FDAs weakening status from the days of HIV. After the FDA was criticized for its slow pace for approval of new medications, the FDA created pathways for drugs to get approved more quickly. Big Pharma took notice and took advantage. In 1992, a deal was struck between pharmaceutical companies and the FDA that said the drug companies would pay fees to fund the approval of their drugs. As time passed, the FDA became more dependent on these fees. However, the FDA continues to insist that the fees did not buy influence.

The author says that this money, combined with the money pharmaceutical companies spent lobbying members of Congress, changed the atmosphere at the FDA from that of a watch dog to that of a business partner, eager to please the drug company partners. This attitude weakened their response to the opioid epidemic.

The FDA’s response to the approval of two new opioids, Opana and Zohydro, underlined this new attitude. For Opana, the FDA agreed to let the pharmaceutical company do drug safety trials with “enriched enrollment,” which means the drug company had permission to exclude any trial subjects that appeared to develop signs of addiction or misuse from the final data presented to the FDA. This meant that the very people who might overdose and die from the drug were excluded from studies, which will skew safety data, making a drug look safer than it is. After Opana was approved by the FDA in 2006, it became popular with people who sought to crush and inject or snort the drug. More than a million prescriptions per year were written for this drug before it was ultimately taken off the market in its easily abusable form.

Injected Opana was associated with an outbreak of patients in Eastern Tennessee with a specific blood disorder called thrombotic thrombocytopenic purpura (TTP), and an outbreak of HIV infections in a small town in Indiana.

Zohydro ER sought FDA approval in 2012. This medication contained hydrocodone at up to ten times the dose found in hydrocodone pills already being sold. Like OxyContin and Opana, it could be crushed to be snorted or injected. But the drug company making Zohydro, Zogenix, promised it would watch for any sign their medication was being abused, and wouldn’t allow it to be abused like OxyContin had been. The FDA’s advisory committee wasn’t convinced and voted against approval of Zohydro. However, the FDA unexpectedly went against the recommendations of its own advisory committee and approved the drug.

The book gives a quote from a physician who was on the FDA’s advisory committee, and who was in a position to know: “…The FDA puts pharma’s interests first.”

The deeds of Doctors Acting Badly are described in detail in the book. Prescribers of pain pills, claiming they are trying to alleviate pain while “seeing” and prescribing to more than a hundred people per day, acted as essential links in the chain. Without them, the streets couldn’t have been flooded with prescription opioids. I feel the most disappointment and distain towards these providers.  I think they knew they were doing wrong but didn’t care.

Don’t get me wrong. Plenty of good doctors work at pain clinics. But those are not the ones described in this book.

The doctors in McGreal’s book did things like prescribe “more than 2 million pills to 4,000 patients in over 101 days…” (p 102). It’s impossible to give good care seeing that many patients per day. In fact, in some cases the prescriptions were pre-signed and other staff members filled them out, so patients weren’t even seen by the physician.

Many of these physicians went to jail and/or lost their medical licenses.

But these weren’t the only doctors who contributed to the opioid epidemic. There were others, experts in pain management, who fueled the opioid prescribing frenzy by touting benefits of opioids for chronic pain, though safety data was lacking at that time. Some of these physicians also had financial connections with the drug companies manufacturing prescription opioids.

These experts talked at medical conferences sponsored by drug companies. With the mantle of authority that the podium gives, they taught other medical professionals that the risk of developing opioid use disorder was negligible for patients prescribed opioids for chronic pain. Even after it was apparent these patients often did develop addiction, these experts claimed prescribers needed to maintain a balanced approach and chose patients more wisely. The “bad” patients who were prone to misuse the opioids should be separated from the “good” patients who could take them as prescribed.

I think the doctors who jumped on the crowded bandwagon to prescribe opioids for chronic pain did what they thought was right, but their thinking was clouded by the benefits they gained personally. The science wasn’t strong enough to support the claims made by the pain medicine experts and the drug companies who sometimes funded them.

The role of the Centers for Disease Control and Prevention’s (CDC) is mentioned briefly. While individual physicians collected data about opioid overdose deaths and tried to sound an alarm, weak leadership at the CDC did not encourage the FDA to act upon the science the CDC had collected. It wasn’t until 2009, when Dr. Tom Frieden took over as CDC director, that he focused national attention on our escalating opioid situation. He was perhaps the first head of a governmental agency to take the opioid epidemic seriously, and to call it an epidemic. Even though the CDC joined the fight against opioid epidemic late, at least they did begin to participate.

The book helped me understand the role of the major drug distributors in our nation’s opioid epidemic. I the past, I thought the big companies like McKesson, AmerisourceBergen, and Cardinal were merely supplying pills to pharmacies who asked for them. I wasn’t sure why they were wrong to merely supply pills where there’s a demand. But the author says the law requires that drug distributors of controlled substances must report suspicious orders of controlled substances and cease deliveries until the DEA investigates. It’s part of the job if you want to distribute potentially addicting medications.

In chapter 15, titled “A Free Pass,” I read how distributors blatantly disregarded their legal obligations to report unusual orders of opioids. As early as 2008, the big three distributors were warned they must comply with the law and were fined millions of dollars. And even after that, some of the companies continued to provide large shipments of opioids to suspicious customers with little legal repercussions.

In fact, in West Virginia, these drug distributors delivered 780 million doses of prescription opioids over a six-year period. That was enough for 433 pills for every person living in the state. And during those six years, overdose deaths rose dramatically. In the small town of Kermit, West Virginia, population of 406 in 2010, 9 million pain pills were delivered and sold over two years. That area had several well-known pill mills, shuttered long ago, and an unethical pharmacy that would fill any prescription for the right price. Looking at those kinds of numbers, the distributors had to be willfully blind instead of purely unaware.

If you want recommendations about treatment, don’t look in this book. Treatment isn’t covered in the book.

Compared to our present COVID19 pandemic, one might be tempted to dismiss the problem of the opioid use disorder epidemic. But remember this: the U.S. saw 350,000 overdose deaths from 1999 to 2016 from opioids and opioids in combination with other drugs. By 2018, around 200 people per day were dying from drug overdoses, and overdoses were the most frequent cause of death for Americans under fifty.

This is the best book around if you want to understand factors that caused the opioid epidemic and factors that allowed it to continue for so long. It’s far more comprehensive that I can describe in a review, so get a copy and read for yourself.

 

Book Review: “Dopesick: Dealers, Doctors, and the Drug Company that Addicted America,” by Beth Macy

Dopesick, by Beth Macy

This well-written book has it all: compact information about how the opioid epidemic started, how our nation failed to act early to mitigate the damage of the epidemic, and how the epidemic shifted into our present predicament. The author did a great deal of research and talked to experts with vital information, but she humanized this data with personal stories about people affected by the opioid epidemic. She told this story not only from the view of the person with opioid use disorder, but also illustrated the grief of families who lost loved ones. The prolonged grief of families who have lost loved ones to opioid overdose deaths is rarely examined as well as it is in this book.

This is a book that will be staying on my shelf for a re-read.

The author is a journalist who works for the Roanoke Times newspaper, so this book focuses mostly on events in the western part of Virginia.

Avid readers on this topic will recall the book “Painkiller,” by Barry Meier, who also covered rural Western Virginia. Ms. Macy’s book picks up where Mr. Meier’s left off. They talk about many of the same communities and the same treatment providers, fifteen years later.

Mr. Meier’s book, published in 2003, could have been an early warning to the U.S. healthcare system. Unfortunately, the book wasn’t widely read, so few people took any note of what was going on, other than those of us already working in the field. I understand Mr. Meier wrote a second edition of “Painkiller” this year, and I plan to read and review it.

The most remarkable theme of Ms. Macy’s book is how the opioid use disorder epidemic grew worse over the past fifteen years. After physicians finally stopped prescribing so many opioid pain pills, these pills were less available on the black market. Many people with opioid use disorder switched to cheap and potent heroin.

In Ms. Macy’s book, she tells the experience of a rural physician, Dr. Art Van Zee, who was also interviewed for Barry Meier’s book. He was one of the brave people who stood up at conferences and raised the question about the ethics of Purdue Pharma, manufacturer of OxyContin, when it wasn’t easy to question anything about that drug company. He’s the first physician I can recall who actively sought answers about his perceived over-prescribing and mis-marketing of OxyContin.

This isn’t in the book: I remember Dr. Van Zee at an Addiction Medicine conference called “Pain and Addiction: Common Threads,” that I attended in 2003 o4 2004. I bought the recordings of the conference, because I was so excited to learn more about Addiction Medicine. I remember a recorded session where Dr. Van Zee asked a question after a lecture, asking – as I remember it many years later – why Purdue Pharma was still peddling their OxyContin as a relatively harmless opioid for chronic pain, while he was seeing patients with lives destroyed by this drug.

It was one of those moments where all you hear are crickets. His question wasn’t answered, but rather he was reprimanded by the speaker. He was cautioned to remember our conferences were sponsored in part by Purdue money, and that appropriate prescribing of OxyContin was a huge benefit to patients. He was told it wasn’t the drug, it was the prescribing that needed to be fixed.

Fast forward to 2007. As described in “Dopesick,” Purdue Pharma pled guilty to fraudulent marketing of OxyContin, which was a felony misbranding charge. Purdue paid $600 million in fines. Its top three executives pled guilty to misdemeanor versions of the same crime, and ordered to pay a total of $34.5 million.

So yes, inappropriate prescribing was a big part of the problem, but Purdue deliberately misinformed physicians about potential dangers of the drug, which contributed to inappropriate prescribing. From a 2018 perspective, that speaker’s answer to Dr. Van Zee seems disingenuous at best.

Dr. Van Zee’s perceptions, based on his clinical experiences, were correct. Around that same time, I was seeing the same thing in rural Western North Carolina. I remember having twenty to thirty new patients show up on admission day, all of them were using OxyContin, almost exclusively. This drug was easy to crush to snort and inject, and Purdue knew it.

Purdue Pharma testified before congress in 2003 that they were nearly ready to release a new formulation of their OxyContin pill that was more abuse resistant. As it turns out, that new formulation wasn’t released until 2010. With that change, people with opioid use disorder changed to other opioids, easier to misuse, such as Roxicodone and Opana. Eventually Opana underwent reformulation to a less abused form.

But I digress; back to the book. The author’s first few chapters summarize the history of opioid use disorder and the factors that lead up to the release and promotion of OxyContin. It related how this drug crept into the social fabric of Southwestern Virginia, and how early attempts to sound an alarm about its abuse were met with contempt from drug company representatives.

Chapter Three tells of the “unwinnable” case brought against Purdue Pharma by Virginia attorney general John Brownlee. He went up against the famous Rudy Giuliani, who was one of the lawyers who represented the drug company, and successfully negotiated the eleventh-largest fine against a pharmaceutical company. This chapter contrasts this legal victory with the devastating grief of parents who lost their children to overdose death with OxyContin. The book describes the creation of the “OxyKills.com” message board, which became a sort of a database for overdose deaths. The chapter after that contains depressing descriptions of how Purdue Pharma’s corporation executives and the owners, the Sackler family, distanced themselves from the profound harm caused by their medication and criminal mis- marketing.

The next several chapters contain the tragic stories of people who became addicted to opioids, and their journeys through the criminal justice system, the addiction treatment system, and the pain their families felt, every step of the way. The author illustrates the ridiculousness of our patchwork system of care for people with opioid use disorder, and how ineffective treatments are often pushed as first-line options.

Then the book details efforts to pursue the heroin ring that sprang up in Virginia, and how the ringleader, a man named Ronnie Jones, was eventually arrested, charged and convicted of trafficking heroin from Baltimore to the Roanoke suburbs. Many of Jones’ drug runners were addicted young adults, many female, from Roanoke’s suburbs. Families were shocked when they found out their children were involved with the drug trade. Heroin used to be an inner-city drug, but times have changed. Heroin is now plentiful in suburban and rural areas, as this book illustrates repeatedly.

I was most interested in the author’s description of available treatments. Usually I dread reading writers’ summaries of treatment for opioid use disorder. If they describe medication-assisted treatment at all, it’s often couched in negative terms. However, this author did her homework.

She describes the accurate reasons why medication-assisted treatment with buprenorphine and methadone is the gold standard of treatment, and even writes about some of the success stories. However, she also writes about the more common public perception of buprenorphine: “shoddy” prescribers located in strip malls who don’t mandate counseling or do drug testing patients. She writes about the poor opinion of Virginia law enforcement officials, who criticize doctors for not weaning people off the drug, and for allowing patients to inject the drug & sell it on the street.

However, it’s clear the author was able to grasp harm reduction principles, and latest research findings, since she said (on page 219) the unyielding opposition to MAT was the single biggest barrier to reducing overdose deaths.

I felt gratified to read this in print. I underlined it.

She also pointed out how some states’ refusal to expand Medicaid when given the opportunity kept many people with opioid use disorder from being able to access treatment. That’s more perceptive than I expect from a writer who isn’t trained in public health or substance use disorder treatment.

But my favorite part of the book was on page 221, where an addiction counselor named Anne Giles said of the opioid overdose death epidemic: “We should be sending helicopters!”

I underlined this too.

She pointed out that if the same number of people dying from opioid overdoses were dying of Ebola, the government would be sending helicopters of medical help to rescue people and contain the epidemic, and she’s right. We ought to be sending helicopters….helicopters loaded with emergency medical personnel and treatment medication. (By the way, per most recent data from NIDA, over 49,000 people in the U.S. died from opioid overdose in 2017. That’s one-hundred and thirty-four people per day. If they were dying from Ebola…helicopters for sure.)

So I heartily recommend this book to anyone interested in this topic. Even if you aren’t interested, it’s so well-written that it will entertain you. I particularly appreciate the author’s talent at describing so many facets of this opioid epidemic and the obvious scope of her research.

The Recovering: Intoxication and Its Aftermath, by Leslie Jamison

This book will stay on my bookshelf to read again; that’s the highest praise I can give any book. Any person interested in substance use disorders and recovery from substance use disorders will find the book interesting and informative.

This is a memoir of the author’s drinking days and her forays into recovery, but it’s more than that too. Intertwined with her story, she divagates down some interesting roads.

She talks about artists, and the relationship between intoxication and the artistic temperament. Since she is an author, most of the examples she gives are of other authors, like David Foster Wallace, who wrote Infinite Jest, or Charles Jackson, who wrote The Lost Weekend. She does talk about the singer Billie Holiday, and about the misery her heroin use brought into her life, and about many other artists.

By page 352 (out of a hefty 448 total pages), the author reveals that her PhD dissertation was about authors who got sober, and how their sobriety affected subsequent work. No wonder she had interesting details about these writers and their struggles. In some cases, she could point out their best works were in sobriety.

I appreciate this idea. I’m bored to death of the cliché of intoxication as artistic muse. Sure, some works of art, be they literature, paintings, music, or other forms, were inspired by intoxicants. Yet how many renowned artists’ lives have been cut short by substance use disorders? The main examples that spring to my mind are musicians, like Janis Joplin, Kurt Cobain, Michael Jackson, Prince…how much enjoyment has the world be cheated out of from the early demise of these artists?

Dead artists don’t create. I hate to hear people imply that great talents must have substance use problems, as proof of how much they suffer for their art. That’s a tired, inaccurate lie.

In her narrative segments, she gives a window into the mind of an alcoholic, or anyone with an obsession that causes harm. She describes the usual justifications and rationalizations she used while drinking, and the same thoughts that came to her while sober.

In other segments, she talks about how race, class, and sex impact how society regards people afflicted with substance use disorders. She points out the inequities of the legal system, and how the percentages of blacks in prison is higher than of whites. She uses the cocaine laws of the 1980’s to make her point. Then, crack cocaine, which was more often used by blacks, carried the same penalty as ten times that amount of powder cocaine, more often used by whites. This meant blacks received much stiffer sentences of incarceration than whites for the same amount of drug. That’s one example of many of how minorities face more consequences for drug and alcohol use disorders.

She gives some history of the Lexington, Kentucky, Narcotic Farm, where people with opioid use disorders went voluntarily or were sentenced for recovery.

She gives a little history of how Alcoholics Anonymous was formed, and how the 12 steps and recovery community work together. She describes what scientists found years later – that peer support and contingency management treatments work, and AA has offered a version of them since the 1930s.

She also writes about the negative aspects of AA. She writes about how simplistic it is, how it’s too reductionist for complex people, and how some people may feel too smart for AA. It’s obvious that she is highly intelligent, and she admits, throughout the book, to her struggles with AA’s basic concepts.

She didn’t have an easy recovery. During her first try at sobriety, she tells how her primary relationship suffered, how depressed she felt much of the time, and how she didn’t feel as creative. She planned her relapse ahead of time at her seventh month of sobriety, with predictable results. She initially enjoyed her return to drinking but it didn’t take long to become more miserable than ever.

Her second try at sobriety went better. She was more enthusiastic about AA, and she eventually sponsored other people. She stopped focusing on herself and saw the importance of being part of a bigger community. She saw the value of people’s stories, even when they were so similar. Indeed, she saw value in the similarity of the stories, because people in AA could relate to one another even though their life experiences were different.

The emotions behind the events of drug and alcohol use connected people seeking recovery. People from different lives and lifestyles bond over shared emotional experiences common to during substance use disorder and their recovery. That’s why it’s not unusual to see a tattooed biker dude hugging a nun at a 12-step meeting

Though much of the book is about her struggles with alcohol, she describes traveling to and working in some exotic places, all of which became dreary under the influence of alcohol. She describes similar drabness in her relationships while drinking, coloring her world gray.

I have few criticisms about the book. I got bored with her constant relationship problems before, during, and after sobriety, but then I tend to have little patience with that sort of thing. If the relationship isn’t working, then end the relationship instead of bemoaning the dysfunction. I understand that sometimes relationships, even the best ones, need work. But she described mostly the work and rarely the rewards of these relationships.

I thought she should have ended her relationship with her long-term boyfriend Dave when she suspected he was cheating on her. While I read about her painful moments when she was at home and he was out doing who knows what, I kept muttering, “Dump him! Dump him!” But who among us hasn’t held on to a relationship longer than we should? So, I do understand. I won’t spoil the book by telling you whether they stay together or not.

Best of all, I like how the author ultimately embraced Alcoholics Anonymous in all its imperfections, while acknowledging other recovery paths are valid. At the end of her book in the section “Author’s Note,” I was happy to read her clear statements that one treatment doesn’t work for everyone, and that medications should be made available to help people. She specifically mentions buprenorphine, which of course warmed my heart.

She also talks about the War on Drugs, and about countries who have found a better way to deal with substance use disorders, without the moral disapproval that is so common in the U.S.

In short, it’s an interesting book with information tucked into an entertaining narrative about one woman’s alcohol use disorder and recovery. It’s the best book I’ve read on this subject since Caroline Knapp’s “Drinking: A Love Story.”

I highly recommend this book.

 

Book Review: “American Pain,” by John Temple

 

This nonfiction book, published in 2016, describes in amazing detail the rise and fall of one of the biggest of South Florida’s pill mills, named American Pain. The book reads as easily as a novel. It describes the casual criminality and greed that fueled one of our nation’s biggest drug overdose epidemics.

The book starts by describing how a felon, his twin brother, and a body-building buddy decide to open a pain clinic. They hire doctors to work there, but still manage clinic, in appallingly unprofessional ways. These owners and managers show a shocking lack of concern for human life and the suffering they saw daily. For example, they talk derisively of their customers as “druggies” and “zombies,” yet the owners were also drug users. Bribes were taken for all sorts of unethical activities, from advancing a patient through the line more quickly, falsifying drug screen results, or getting the patient seen by a doctor with a reputation for being a generous prescriber.

This pill mill saw mostly people from Appalachia – as the book points out, 43% of the clinic patients lived in Kentucky, 20% in Florida, 18% from Tennessee, and 11% from Ohio.

The methods developed by the addicted patients and their handlers were astounding. Appalachian families who in the past may have distribute moonshine, marijuana, or methamphetamine used the same organizations to distribute these pain pills transported out of Florida. People called “sponsors” would arrange for a group of people to come to American Pain, located in Broward County, Florida, sometimes traveling hundreds in buses or vans or just carloads of people. Each of these people would be given money by the sponsor to be seen by the physician and to buy the pain pills and benzodiazepines dispensed on site. They gave a portion of these pills to their sponsor to be sold through the networks of drug dealers already established, or they could give all the pills to the sponsor in return for a tidy profit.

Some airlines offered cheap flights from the Appalachians to Florida. So many pain patients flew on one flight that it was called the “Oxy Express.”

MRI owners and operators profited because the pain clinic made every patient get an MRI, to maintain a veneer of medical respectability. Patients could bribe their way to the head of this long line, too. Pharmacies profited, as long as they didn’t ask too many questions. Many times, the pain clinics had their own pharmacies and dispensed on site, to make yet more money and to keep legitimate pharmacies from asking uncomfortable questions.

Flea markets in Kentucky sold urine in Mason jars to pain clinic patients who were required to pass a drug test. Dive motels in Florida rented rooms to “oxy-tourists,” and some overdosed and died in these places.

Between 2007 and 2009, Broward County went from having four pain clinics to having one hundred and fifteen. In one area, there were eighteen pain clinics within a two mile radius.

Everyone was happy; the people with addiction got more pain pills to inject or snort, the sponsors made money, the doctors made money, and the clinic owners made staggering amounts of money.

Of course, in the long run, irreparable harm was done. Patients of the clinics died, people who bought pills from American Pain patients died, and families suffered from the deaths of their loved ones. Many people were incarcerated, children were put into foster care, and medical costs of complications from addictions soared. The cost to taxpayers and U.S. social fabric can never be calculated.

Police routinely pulled over cars traveling north on the interstates if they had Kentucky, Tennessee, or West Virginia license plates and were filled with people. Usually, some crime could be detected. If one person had pill bottles from multiple doctors, this was the crime known as doctor shopping. If a pill bottle had too few pills remaining, the owner could be arrested for drug dealing. Many times, there would be drug paraphernalia in the vehicles. The driver could be impaired.

The book is painfully funny in places; the manager of the pain clinic describes what he calls “addict stunts,” like when an RV filled with three generations of a family from Appalachia rolled into their parking lot, spread an outdoor carpet on the asphalt, and set up folding chairs and a grill, planning to make a day of it at the pain clinic. It was a family outing, going to a Florida pain clinic to get pills to fuel one’s addiction.

Pain clinic patients would pee in the hedges, fornicate near other businesses, and shoot up in the parking lot, all of which appalled the owners, who were trying not to attract attention.

The owners even asked themselves, “How could this be legal?” But it was.

Apparently Florida didn’t have any corporate practice of medicine laws, which prevents non-physicians from owning any medical facility. I’ve derided these types of laws in the past, but here’s one situation which cried out for this kind of law.

Florida also had no prescription monitoring program, as I pointed out in my blog of March 8, 2011. Long after Florida’s pain clinic problem exploded, their governor inexplicably blocked development of a PMP. They have one now, but only after Purdue Pharma (manufacturer of OxyContin) offered money to the state to start one.

Florida also allowed physicians to sell pain pills and other medication directly, without involving a pharmacy. This allowed much of the mis-prescribing to go unnoticed.

Of course, things finally ended badly. The FBI got involved, and did investigations, undercover work, and eventually got wire taps to prove RICO indictments of all the main people. After they were arrested, the owners and operators, who talked big about how they would never turn on each other, all ratted on each other to get favorable plea deals.

The main owner got 14 years in prison for his part in the scheme that earned him 40 million dollars, and his twin was sentenced to 17 years in prison. Their friend, the manager of American Pain, was sentenced to 14 years.

All but two of the physicians took plea deals, and most lost their medical licenses and had various criminal penalties.

The two doctors who refused to take plea deals were both charged in the deaths of patients who had overdosed on medications these doctors prescribed. Both doctors said they had no idea they were working for a pill mill, and the juries acquitted both of them

However, they were both convicted of money laundering, under the premise that they would have to be willfully blind not to know the operations of this place weren’t legitimate medical care. Prosecutors said the doctors had to have known they were prescribing to people with addiction or people who intended to sell their pills. In one doctor’s case, she would see in excess of sixty patients per day, and was the largest prescriber in the nation for certain drugs.

She also made 1.2 million dollars in just the sixteen months she worked there. That last fact alone is so far out of line for what legitimate physicians make in that same time period that she had to have known she was committing crimes. She was sentenced to 6.5 years in prison.

The only other physician not to take a plea deal made around $160,000 for working at the pill mill, and was sentenced to 18 months in prison.

This is a fascinating book, about an incredible time in Florida’s history. Of course, as the book illustrates, Florida’s problem bled into other states, and poured gasoline of the raging fire of opioid use disorder that already existed in Appalachia.

The book illustrated the mindset of people who operate such pill mills, their derision towards the people who are making them all this money, and their disregard to the human misery caused by addiction.

One of the most poignant scenes in the book is when the mother of a young man who dies of an opioid and benzodiazepine overdose goes to talk to the doctor who prescribed him the pills. This mother left the hills of Kentucky and drove to Florida for the confrontation. But the doctor said nothing, only looked downward to the floor. For what could she say? Under the best light, she was guilty of willful blindness, and under the worst, something much more sinister.

The events in this book took place not even ten years ago, and we were about ten years into the opioid epidemic when American Pain opened its first clinic. The owners and operators and doctors weren’t the only ones at fault. Why did it take Florida so long to get an operational prescription monitoring program? Why did their governor, Rick Scott, block efforts to establish this important program? Where was the state’s medical board, and why didn’t they investigate the doctors’ actions at American Pain?

I highly recommend this book to anyone interested in the opioid use disorder situation in the U.S., to get better insight into how it started and how it was perpetuated

 

Book Review: “Dreamland: The True Tale of America’s Opiate Epidemic,” by Sam Quinones

I’m happy to tell my readers of a great new book. Published in 2015, this book is about the pain pill epidemic in the U.S., and how black tar heroin from Mexico quietly filled the void when pain pills became less plentiful.

The story of how this nation found itself in the middle of an opioid addiction epidemic isn’t a new tale, but the scope of the story has rarely been told with the completeness found in this book. The author talked to, or attempted to talk to, key people in all the realms affected by addiction: pain management experts, drug company leaders, addicts, parents whose children died from opioid addiction, doctors who prescribed OxyContin, everyday members of drug rings, prominent leaders of drug rings, law enforcement personnel, and addiction treatment personnel.

This book covered the pain management movement of the late 20th century, and how pain management experts grossly underestimated the risks of prescribing opioids long-term for chronic pain. Those experts taught other doctors that the risk of triggering addiction was almost zero, and that physicians had an obligation to relieve pain in their patients. Pain was described as the “fifth vital sign,” with the implication that a patient’s reported pain level was as objective as their pulse, blood pressure, body temperature, and heart rate.

All of these recommendations were based on thin evidence. Some of the pain management experts were also employed by drug companies marketing powerful opioid pain relievers, creating at the least the appearance of a conflict of interest.

The author described the inappropriate marketing of pain medications in general, and then focused on Purdue Pharma’s criminally inaccurate promotion of OxyContin. Purdue taught its young and attractive drug representatives to say things about OxyContin that were not true. These drug reps pushed their product with fervor, using falsified material provided to them by their company (p. 265). Purdue wasn’t the only drug company to oversell its products, but they did the best job of it. Ultimately, their marketing strategy lead to a criminal case brought in Southwest Virginia, and resulted in Purdue Pharma, along with their three top executives, pleading guilty to a felony count of misbranding. They were ordered to pay a fine of $634.5 million…but the company’s profits have been estimate to exceed three billion dollars thus far.

For me, the most interesting part of the book described the Mexican drug dealers. In a relatively small, agricultural area of Mexico, sugar cane farmers switched to growing opium poppies. The crop was easier to harvest, and much more profitable. Then young men from the area were recruited to travel north to the U.S. to sell the semi-processed heroin known as black tar. This was not a centralized drug unit, but rather multiple small organizations of growers, transporters, and driver-salesmen. Many of these groups were from Xalisco, a city in the Mexico state of Nayarit.

Each group had a handful of drivers located in smaller U.S. cities, ready to deliver black tar heroin to young addicts who called them on the phone. By delivering the product, middle and upper class addicts didn’t have to travel to bad neighborhoods for their drug. The drivers carried only small amounts of black tar heroin with them, in balloons which they carried in their mouth. If stopped by the police, they could swallow the evidence. Even if they were caught, the amount of heroin was so small that they were only deported, not jailed.

The drivers-dealers didn’t use the product, so they weren’t tempted to dilute the product for personal use. Drivers were paid by the hour, so that also gave no financial incentive to dilute the product. These young Mexican men were polite, and taught to give the best possible customer service, to keep the business of the addicts. In fact, they frequently ran sales on their product, as an incentive for customer loyalty.

This heroin was cheap and potent. Opioid pain pill addicts who were desperate to avoid opioid withdrawal switched to heroin because they could get high with less money. Because the tar could be snorted, the stigma of IV use was avoided – at first. Ultimately as the addiction progressed, addicts who started using intranasally eventually switched to IV use.

Groups of heroin sellers competed with each other to sell the most heroin, but they didn’t engage in violence. Since they were all from the same relatively small area of Mexico, and violence in the U.S. would bring repercussions from relatives back home. The drivers delivering the product were cautioned to stay away from blacks, since the Mexicans believed blacks to be more violent.

Because these heroin-selling groups avoided all violence, they were able to concentrate of profits. They didn’t call attention to themselves, making it easier to pass under the radar of law enforcement.

Groups of heroin dealers from Nayarit settled in mid-sized cities. They avoided cities where established drug cartels controlled the sale of heroin, such as New York City, Los Angeles, Philadelphia, Baltimore, or Detroit, fearing there would be violence from the cartels. Instead, they settled into cities like Salt Lake City, Portland, Oregon; Columbus, Ohio; and Charlotte, NC. They needed cities where other Mexicans worked in order to blend in with the populace. The book tells of opioid addiction in Huntington, WVA; Denver, Colorado; Boise, Idaho; Santé Fe, New Mexico; Nashville, TN; and Myrtle Beach, South Carolina.

These Mexican farm boys returned home with money and spent ostentatiously in order to impress their neighbors and friends. They hired bands, threw parties, and built houses with the money they earned from selling heroin. In a relatively poor area, young men saw there was a way to make their fortunes, so recruiting new drivers wasn’t difficult. In fact, the supply appeared to be inexhaustible.

The author makes the point that all of this happened slowly and without much publicity, but I question this conclusion. He says that it was only when Phillip Seymour Hoffman died that the U.S. sat up and took notice.

Maybe I have a different view since I’ve been treating opioid addicts since 2001, and saw a rapid rise of opioid addiction in my state since then. At conferences we seem to talk little about anything else – but then, I go to Addiction Medicine conferences.

The book has its flaws. It was a little repetitive, and many chapters were short, giving the book a choppy feel, but this was because the author described events chronologically, and described what was happening in multiple areas to multiple people.

He described drug abuse in Portsmouth, Ohio, which he called the birthplace of the pill mill. I don’t agree with this. Ever since doctors could prescribe medications that caused euphoria, there have been pill mills. Sadly there are always a handful of unscrupulous doctors who prescribe freely to patients willing to pay. I don’t think Portsmouth was the location of the first pill mill, and sadly it won’t be the last.

The most distressing thing that I read was how the Mexican drug families would move into a new city and go to the methadone clinics to recruit its first customers. From there, word of mouth via the addict grapevine resulted in plentiful business for the Mexicans.

That’s appalling. I’m sure it seems like no big deal to people wanted to make money off of addicts, but to target people who are in treatment to get well, and then tempt them into a relapse…that is low down. The book also describes how drug rings would pay more attention to an addict if he said things about quitting heroin. The dealers would offer this person an exceptional deal to remain a customer.

I know this is good business. But this business breeds death and misery.

I struggle with how to provide security at opioid treatment programs. I don’t like it when an armed guard in the parking lot makes it feel like a police state, but then I want our facility to be safe, and free from interlopers such as these described in the book.

I was also disappointed about the lack of information about treatment. Granted, the title implies only coverage of how the opioid epidemic emerged and evolved, but it would have been nice to add even a small section to readers who are addicted themselves, or who have relatives who are addicted.

Aside from the few nit-picky flaws, this book is great – it’s well-written, informative, and entertaining. It’s one of the best books I’ve read about this country’s story of opioid addiction. It picks up where “Pain Killers,” by Barry Meier left off.

This book should be read by anyone interested in our pain pill epidemic. Addicts should read it so they can realize where their money goes. Families of addicts should read it to better understand the compulsion of addiction. Law enforcement personnel should read it to hear the stories of the addicts, and come to see them as people with a disease, not just as criminals. Every doctor should read it, to better understand risks to patients who are prescribed heavy opioids. Treatment center personnel should read it to get a better idea of the milieu of addiction in the U.S.

Book Review: “Her Best Kept Secret: Why Women Drink-and How they can Regain Control,” by Gabrielle Glaser

This book disappointed me. The title suggests a book of interesting research and conjecture about the reasons women drink. I was hoping for new insights that I could use in my practice with patients who drink alcohol. As it turned out, most of the book wasn’t about what the title implied. That topic was lightly touched on in the beginning, and there was a bit of summary at the end, but way too much of the book was about why AA sucks and why women don’t get the right treatment.

I liked the first third of the book, as it was basically history of alcohol and history of addiction treatment. She wrote about the shame women feel about having alcohol addiction, but that was brief. Overall, that portion of the book was mildly interesting, if a little tedious.

Then the next third of the book felt like an attack on AA. I admit I’m sensitive to AA bashing. I know AA works for many people, and I also know AA has never claimed to be the answer for every problem drinker. Given AA’s stance of “we will help you if you want help,” I don’t think it’s productive to berate the organization if you don’t want to go to their meetings.

My own opinion is that if you don’t like AA or don’t think it works for you, then fine. Take your ass on out of the meetings and go find another way that helps you. After all, AA members are under no obligation to help anyone; they help only because they want to, because it helps keep them sober. They don’t recruit new members, and they don’t ask for any money.

The author’s logic isn’t consistent. First she says AA isn’t helpful for women because it tells them they have to admit powerlessness and that interferes with women’s recovery process, rather than helping it. She says it’s insulting for women to be told that “your best thinking got you here,” and the slogans are too trite or hackneyed to help intelligent female problem drinkers who have problems with alcohol. She says women should be told they do have the power to make changes and stop drinking.

But then the next section, she says women are often victimized by men in meetings who have more time in sobriety, and thus more able to take sexual advantage of the fragile newcomer women. So which is it? Are the newcomer women tender blossoms with have no idea how to thwart a creepy man’s advances? Or are these women so powerful and capable that the simplicity of AA is insulting to their intelligence and capabilities?

Alcoholic Anonymous is made up of humans. Humans with drinking problems. It seems disingenuous to expect these humans to behave better than people in other human organizations (Catholic Church, for example). Also, I suspect some alcoholic women may have encountered creepy male advances in bars.

What kind of treatment does this author say works best? She correctly champions cognitive behavioral therapy and Motivational Enhancement therapy.

As an example, she describes an excellent treatment program that consists of treatment sessions from two therapists, with the addition of other services as needed (primary care consult, mental health provider). This treatment is done as an outpatient, where the person stays in a nice hotel close to the therapists’ office.

It costs ten grand. Ten thousand dollars.

This author gushes about how these therapists are so caring and dedicated that they even eat lunch with the patient. I would hope so. If I were paying ten thousand dollars for a few weeks of therapy, I’d expect my therapists not only to eat lunch with me, but also tuck me in at night and tell me a bedtime story!

So overall, I don’t think the ideas in this book extend to any new territory. Twelve step bashing has been done by many authors, so that’s dull. I found much of the book to be derivative, containing ideas from earlier books about women and addiction. Plus, I was surprised by how little time this author spent describing real barriers many women face when they are seeking help for alcohol addiction. For example, women are the primary caregivers for their children. Male partners may not want to take over childcare responsibilities while the woman gets treatment. Many times the woman’s partner is also in active addiction, and seeks to deter or undermine her efforts to get help and to stay in recovery. Transportation is a big problem, especially in rural areas with no public transportation. She may not have a car she can drive to treatment each day.

These issues were not addressed at any depth.

If you want to read a book about women and addiction, I highly recommend you read, “Substance and Shadow,” by Stephen Kandall, or “Women Under the Influence,” by the CASA program. Both are better written and with more information.

Addiction Fiction: “All Fall Down” by Jennifer Weiner

Sometimes the greatest facts can be transmitted by fictional stories.

My bookshelves at home are groaning under the weight of all sorts of written material about addiction. I have textbooks, journals, and SAMHSA publications about addiction and treatment. I also have numerous autobiographical memoirs written by people with addiction issues, which seems to be a whole new exploding genre, with more books coming out each month. I’ve read The End of My Addiction; More, Now, Again: A Memoir of Addiction; Pill Head; Rolling Away; Drinking: A Love Story; Dry: A Memoir; Beautiful Boy: A Father’s Journey Through His Son’s Addiction; Tweak; Leaving Jersey Dirty; Broken: My Story of Addiction and Redemption; Lit: A Memoir; Parched: A Memoir; Hit Hard; The Adderall Diaries; Junky; and probably many others that don’t come to mind at present.

But I can’t think of any fiction I’ve read about addiction, probably because I tend towards non-fiction in my reading life. So this new book I recently read was unusual for me, and I enjoyed it. I also found many truths contained within the fictional story.

In this novel, All Fall Down,” the protagonist, Allison, narrates the arc of addiction from occasional pain pill use to compulsive and uncontrolled use, and then through the bad consequences that follow. The book gives a fresh and accurate account of the protagonist’s stay in an inpatient rehab, and ends by describing her life in early recovery.

I am particularly impressed by the way the author describes the thoughts of Allison, the protagonist. The author has great insight into the mind of someone in active addiction. Allison lies to herself about how many she takes, about the reasons she takes the pills, and that she functions better with the pills than without. I found the author’s description of Allison’s thought process and self-deception to be accurate and believable. I hear the same self-deceptions in my work. Allison tells herself she deserves a few extra pain pills because she’s under emotional stress dealing with a difficult family situation. She tells herself everyone uses something to get through the day. She resolves again and again to cut back on her pill use, and then has moments of clarity when she realizes she’s using more than ever.

When Allison has these moments of clarity, the author accurately describes her confusion and self- blame. Allison realizes she’s doing things that are against her personal beliefs, resolves to stop, and yet can’t. The author truthfully describes the self-reproach and shame an addict feels when she can’t control her drug use.

Eventually, she admits she needs help, but still has to be forced into treatment by her family.

Buprenorphine makes a brief appearance, and I’m not too happy about how it was portrayed. In desperation because her pill stash was gone, Allison goes to an urgent care to get a prescription for pain pills, so a made-up reason. She surprises herself by being honest to the doctor about how much oxycodone she’s using. Even more surprising, the doctor is knowledgeable about opioid addiction and prescribes Suboxone. But in the book, the doctor doesn’t set her up in an addiction treatment program. Then Allison goes into precipitated opioid withdrawal after she takes the Suboxone, and has to go to the hospital. The hospital talks to her family and Allison is eventually admitted to an abstinence-only treatment center called Meadowcrest.

Meadowcrest gets harsh treatment from the author, but the details are amusingly accurate. Allison is dismayed that most of the treatment center staff have few counseling credentials, other than being past graduates of the treatment center themselves. She also illustrates the petty meanness some people are capable of when given power over other people. She describes Michelle, an overweight recovering addict who delights in thwarting Allison’s plans to use the phone or go to her daughter’s birthday party. She describes how some of the treatment center staff talk down to patients they are supposed to be helping, by calling them selfish and lazy.

This author does such a great job of describing all of the facets of early addiction and treatment that I can’t help but think she must either have personal experience or has a close friend or family member who went through opioid addiction and recovery.

I appreciate the honesty of the Allison character. She thinks the slogans of 12-step recovery are dumb and trite, and that she’s different from all the other patients because she never injected opioids or was homeless. She feels out of place around patients who have obviously gone much farther down in their addiction. She resents the twelve step program and finds some of the steps to be shaming. She has a difficult time with the idea of a higher power.

Then gradually, as Allison slowly starts bonding with other patients, she acknowledges she has the same feelings as they do, underneath the addiction circumstances. She comes to see that when she was stopped from driving by a teacher at her daughter’s school when she was impaired, that was her bottom. For other people, stealing or prostitution constituted the low of their addiction, but the feelings of shame and self-reproach were the same.

Allison starts to focus on her similarities to other addicts, rather than her differences. She starts to feel empathy for other addicts and wants to help them recover. Her own healing begins.

By the end of the book, Allison is going to 12-step meetings and she feels connected to the other people there. She sees that the slogans do have value, even though she finds them trite. She still struggles with any concept of a Higher Power, and is honest about that. She often doesn’t want to go to meetings but still goes, if only to see how the other addicts are doing. She develops a focus outside of herself, and begins to do things that are helpful for her and her recovery. Her marriage may be over, but she’s able to tolerate not knowing what will happen, allowing things to play out on their own.

This book will resonate with all people who have addiction, but especially with the relatively well-to-do opioid addicts who didn’t experience the low-bottom consequences of jails and institutions. I think the author accurately described the inner experience of the opioid addict. She certainly illustrated the failings of the Meadowcrests of the world while still showing how they can help people.

After I read the book and wrote this blog entry, I went to Amazon and read the book’s reviews. The people who liked it and gave the book five stars seemed to be either life-long fans of the author, Jennifer Weiner, or to have had some previous encounter with addiction. The readers who didn’t like it, and gave it one star, said the book was boring and depressing, or that it wasn’t like the author’s other books and they were disappointed. A few of the one-star readers said they were in recovery themselves, or worked in a treatment center, and they didn’t feel the book gave a realistic portrayal of addiction.

It’s always fascinating to me how two people can read the same book and come away with such opposite views.

I recommend this book for people with opioid addiction, in recovery or out, and for those who love them. It’s a great book for anyone who has been puzzled by the weird behavior of the addicts in the world.

I’d like to see more addiction fiction like this…