AMERICAN PAIN (9 page)

Inside, Golbom entered a beige studio, just four walls and a desk, a few computer monitors and microphones. No personal items adorned the studio, no workspace toys or ornaments. The studio was nobody’s permanent home, just space rented by the hour.

Tonight, Golbom pulled on bulky headphones and kicked off the show by playing a few lines of a 2002 rap song that described the pleasures of OxyContin, Lortabs, and Percocets. Then the sound engineer faded the song away, and Golbom spoke close into the microphone, his insistent nasal drone in distinct contrast with the Memphis rapper’s drawl.

“Again, folks, in case you missed it, that’s the lyrics of the song, ‘Oxy-Cotton’ by Lil Wyte. That song’s actually been around for a little while. There’s no question that since the introduction of OxyContin, our country’s been experiencing what I refer to as the new opium epidemic of the twenty-first century. The active ingredient of oxycodone is interchangeable with heroin, and I think more and more people are beginning to understand that we have a huge medical hoax going on.”

Golbom believed he’d been an unwitting part of the hoax until the day, five years earlier, when he’d discovered that his teenage son had bought oxycodone pills from a local woman. Golbom had reported the woman’s doctor to the Florida Board of Medicine. The subsequent investigation revealed that the patient was a textbook drug seeker. She’d altered prescriptions. She’d been charged with possession of a controlled substance. She’d claimed more than once that her medications had been stolen. She’d claimed to need drugs early so she could go on trips. Despite all these red flags, the doctor had continued to prescribe the woman high doses of opioids.

In 2006, the doctor settled his case. He was fined $12,500, plus administrative costs, and was ordered to do seventy-five hours of community service and complete two courses. He retained his medical license, continued practicing.

To Golbom, it felt like nothing had been accomplished.

But in the meantime, he’d educated himself about opioids. In fact, the drugs had become his obsession. He’d founded the radio show and talked on-air to hundreds of people about the resurgence of opium in America—public officials, experts, addicts and their relatives. He’d read medical texts and histories of past temperance movements. He’d delved deep into obscure corners of the Federal Register to find statistics about oxycodone production. He’d searched newspaper archives for information about pharmaceutical companies.

He couldn’t believe he hadn’t figured out sooner what was going on. He’d spent more than twenty-five years as a pharmacist, meaning he had lived through an entire sea change in narcotics prescribing practices and never questioned it. Or even realized it.

It embarrassed Golbom, and it made him angry. If he’d been fooled, along with most other pharmacists and doctors, what chance did the average person have?

Through his research, Golbom discovered that humans have known about the wondrous substance inside opium poppies since before the dawn of recorded time. It’s not hard to extract. Just before the plant’s seed pod ripens, scratch its smooth, blue-green skin and catch the tears of whitish milk that leak out. Dried until it’s a sticky yellow residue, opium contains the elemental ingredients for the vast array of illegal and legal opioid narcotics made today, from heroin to oxycodone.

Opioids subdue pain. They work beautifully, blocking electrical and chemical signals before they can leap the synapse from one nerve cell to the next. In six thousand years, we’ve never found another painkiller that works as well. They don’t cure anything; they simply mute sensations. They also change the way the brain perceives the nerve signals. Suddenly, pain doesn’t cause as much panic or stress. It becomes tolerable.

But opioids produce a number of additional effects. They slow the pump of heart and lungs. Bowels grow sluggish too, causing constipation. They galvanize the brain’s pleasure centers, causing joy.

Another thing about opioids: Nerve cells become desensitized to them more quickly than any other group of drugs. Higher and higher doses are necessary to produce the same impact.

They’re also addictive. Severely. Profoundly. And quickly. Withdrawal symptoms can be detected at the cellular level after a single dose of morphine. Administer opioids long enough, and the patient will become physically and psychologically dependent, terrified that the supply will be cut off, willing to go great lengths to forestall the nibbling panic of early withdrawal. That dread is felt more frequently as the body builds a tolerance to the drug, always needing more. Long-term users become physically dependent. Addicts go a step further and crave the drug psychologically, love the euphoria and seek more of it.

American doctors have known about the dark side of opioids for a long time, at least since hundreds of thousands of Civil War veterans became morphine addicts after that drug was administered liberally to wounded soldiers. Around the turn of the previous century, opium and other narcotics were available in a number of snake-oil elixirs, including baby-soothing formulas. Over time, the medical establishment came to the firm conclusion that heavy-duty narcotics were best prescribed sparingly, to patients in such bad shape that the risk of addiction seemed a laughably minor menace, such as cancer patients with tumors gnawing at their bones, or to someone in agony in a controlled, hospital environment. Almost by definition, opioids were not considered to be acceptable treatments for long-term chronic pain, because long-term use meant dependence. Doctors generally agreed you didn’t simply send people home with a big supply of the stuff and hope for the best.

It was often hard to tell who was in pain. Pain is personal, subjective. It is influenced by mood, psychology, upbringing. It’s cultural too. The Irish were less likely to voice pain than the Italians, according to a 1950s study at a veterans hospital in San Francisco. Pain had a randomness, an arbitrary nature that didn’t sit well with doctors, who were, after all, scientists looking for something to measure.

Over the decades, pharmaceutical companies developed and released an ever-expanding lineup of narcotics of different strains and mixtures and strengths. Vicodin, a mix of hydrocodone and acetaminophen. Percocet, oxycodone and acetaminophen. Fentanyl, usually administered through a skin patch. MS Contin, a long-acting morphine formulation. Sometimes researchers thought they’d found one that didn’t get you high, but there was an army of junkie scientists out there who would burn and dissolve and combine until they unlocked the narcotic trove. Then word would get around. Mix pentazocine with this drugstore antihistamine and you’ve got yourself a nice speedball. Or take a time-release morphine tablet, painstakingly peel off the outer coating, then crush, dissolve, and inject. There was always a way.

So the pharmaceutical companies kept the dosages small and typically cut their products with acetaminophen or aspirin, which discouraged addicts from ingesting massive doses. And doctors were trained to regard painkillers as a last resort. Which meant that many patients lived in pain. Too many, according to a new generation of doctors that began to emerge in the 1980s. Pain management specialists saw patients in agony, desperate for a cure and often unable to get medicine that would give them relief. Pain was real, they said, and it was destroying lives. These specialists began to wonder if physicians had become
too
reluctant to use the painkilling power of opioids.

By the early 1990s, as some doctors were reconsidering their approach to pain, a smallish, family-owned pharmaceutical company called Purdue Pharma was looking for ways to grow its customer base. Purdue was best known for an extended-release morphine drug called MS Contin. Unlike traditional morphine, which wore off within a few hours, these pills dissolved slowly and allowed cancer patients to sleep through the night. But Purdue’s patent on the formulation would expire soon, which meant that cheaper generic versions would soon be eating into its market share. The company was developing a new drug, an oxycodone pill it would call OxyContin.

Like MS Contin, OxyContin was a controlled-release pill. Swallowed, the dose broke down slowly in the digestive system, doling itself out over twelve hours. This meant Purdue could pack much more oxyco-done into each pill. Percocets contained doses of 5 or 10 milligrams of oxycodone. By contrast, OxyContin came in doses of 10 milligrams, 15 milligrams, 20 milligrams, 30 milligrams, 40 milligrams, 80 milligrams, and even the whopping 160-milligram horse pill, a midnight-blue oblong pebble nearly an inch long. The other thing was that OxyContin was pure. It wasn’t cut with acetaminophen or aspirin. The only active ingredient in the pill was oxycodone.

Purdue didn’t want simply to provide an alternative to MS Contin. That drug was used primarily to ease the suffering of cancer patients, a limited pool of consumers who typically either died or got better. Purdue wanted OxyContin to be prescribed to a much broader array of patients and for a longer period of time. The untapped marketplace was chronic pain, which could mean anything from backaches to arthritis to the crippling agony of trigeminal neuralgia. If Purdue could persuade a portion of that vast and varied market to take OxyContin, the drug would be a blockbuster.

To accomplish this, Purdue had to do no less than undertake a massive, multi-pronged hearts-and-minds campaign to change the way American doctors and the public felt about prescription narcotics. The company needed to train people to think of opioids as benign liberators, as long as they came in pill form and with a prescription.

Purdue leaders borrowed a page from the advertising industry: problem-solution marketing. They would market and publicize the problem of untreated pain. Then they’d promote the solution: OxyContin.

Over the following decade, Purdue Pharma created or funded a vast network of mouthpieces to promote and justify the use of heavy-duty narcotics to ease all kinds of pain. The company’s primary hurdle was to convince prescribers that their pain patients would not become addicted to OxyContin, even if they took heavy doses of it for a long period of time. This was no easy task, since it directly contradicted thousands of years of human experience with opiates.

The company found and cultivated “key opinion leaders,” usually doctors who were already promoting the idea that pain was undertreated and that narcotics should be more liberally prescribed. Researchers like Dr. J. David Haddox, who helped coin the term “pseudoaddiction.” Pseudoaddicts, Haddox said, were pain patients who displayed common drug-seeking behaviors: demanding specific drugs, hoarding drugs, seeking early refills, taking higher doses than prescribed. Pseudoaddiction
looked
a lot like addiction, Haddox said, but it wasn’t addiction. Those patients simply needed more pills. The counterintuitive concept was based on a case study of a single cancer patient, and it hadn’t been backed up by rigorous studies. Nevertheless, Purdue seized upon the new word—pseudoaddiction—and liberally sprinkled it throughout educational materials. The company also hired Haddox and made him a top executive.

Purdue poured millions of dollars into organizations like the American Academy of Pain Medicine, the American Pain Society, and the American Pain Foundation, and those organizations backed or promoted the work of pro-opioid researchers. Some researchers dug up obscure and largely inapplicable nuggets of scientific data that seemed to support a pro-opioid hypothesis, then published and republished that data. One Purdue-funded study claimed that “psychological dependence or addiction is low” for chronic pain patients on narcotics. The Purdue study cited a single article from the prestigious
New England Journal of Medicine
. It didn’t mention that the “article” was a letter to the editor, published in 1980, and that its conclusions were based on a simple review of the charts of hospitalized patients, not a scientific study of long-term narcotic use.

But the idea was out there, published in a scientific journal: Fewer than 1 percent of pain patients would develop addictions.

Armed with this seemingly legitimate number, Purdue got to work.