The Genesis of the Opioid Epidemic

In 1986, Russell Portenoy and Kathy Foley published a study of 38 cancer patients who used opiate painkillers. Only two grew addicted, and they had previous histories of drug abuse. The rest remained addiction-free. To support this study, Foley and Portenoy cited, in a footnote, a 1980 letter to the editor of NEJM by one Dr. Hershel Jick titled “Addiction Rare in Patients Treated with Narcotics.” Portenoy and Foley never meant their study to be taken as an endorsement of prescribing opioids for any pain to any patient. They believed – and this is currently considered not controversial – that some brains are more addiction-prone than others. While some people can smoke 1-2 cigarettes a week for years and never get addicted, others get hooked and have to suck down two packs a day or they have no peace. Only after spending a serious amount of time with a patient, argued Portenoy, can a doctor know if there’s a likelihood of addiction. When you are working over a period of time with a cancer patient, this is feasible. But without asking these questions and studying the whole history of the patient, you can’t decide that opioids will not be addictive.

Of course, the pharma companies that wanted to make money disregarded these nuances and decided to use Portenoy’s, Foley’s and even Jick’s statements – without their knowledge or endorsement – to make an argument that opioid painkillers were not addictive, period. Of course, it was a complete misreading of what Jick actually said in his letter. One single number was extracted, ripped out of all context, and used carelessly and irresponsibly. Plus, it wasn’t even an actual study. It was just a letter to an editor cited in a footnote! But it became the central part of every Purdue Pharma pitch for prescribing more opioids. Most people who cited it thought it was a study, an actual scientific paper. In scientific papers, actual scientists referred to it as “an extensive study” and “a landmark report.” But it was not. It was in the “somebody said something to somebody in some context” kind of thing. Jick himself is adamant that he never said or intended to say that opioids are not addictive when prescribed as outpatient medication for chronic pain. He’s not happy at all about being misrepresented and used for nefarious purposes like he was.

If you are not shocked at this point, then you must be very jaded. And yes, we’ve seen all the same tactics in the COVID era.

At first, Portenoy and Foley thought they were doing important work, standing up for patients’ rights. But then gradually a consensus started to form (egged on by regulatory institutions, politicians and their pharma donors) that pain was being severely undertreated, unnoticed and unaddressed in America. Curiously, this wasn’t happening anywhere else on the planet, even though prohibitions on prescribing opioids casually and for daily little infirmities exist everywhere. This was, by the way, the time when this utterly ludicrous practice was instituted in the US healthcare of asking patients to rate their pain at a scale of 1 to 10. It’s moronic because, of course, a self-involved drama queen will screech “eleven!” whenever she has a minor scratch while a more stoic individual will say 2, even when there is real pain. What people SAY they feel means exactly that, it’s what they say. As a gauge of reality, feeling is not a great indicator. “I feel that I’m a man” is not a description of existing reality, no matter how much I might want it to be.

Between 1998 and 2005, over 900 pain clinics that studied non-medicalized treatment of pain went out of existence. Their patients were now on opioids. Insurance companies reimbursed for pills because “pain” was no considered a vital sign (no matter how subjective it is). They were not reimbursing any non-drug-based therapies. It became generally accepted in the medical profession that if a patient kept coming back for larger doses of painkillers, he wasn’t addicted. He was simply not getting prescribed enough.

OxyContin came out in 1996. The FDA allowed Purdue Pharma to claim that Oxy was less addictive because its timed-release formula supposedly allowed for a delay in absorbing the drug. This “time-release formula” became the centerpiece of the company’s aggressive marketing strategy. There’s a time-release mechanism, so you don’t get a rapid high, so it’s not as addictive. Should I list the problems with this claim or are they easy to figure out?

Purdue aggressively targeted doctors to convince, bribe and bully them to prescribe Oxy for moderate and minor pain. It also put a cute warning sticker on the packaging of Oxy, telling patients that crushing the pills will make them more potent. Not to give anybody any ideas that might get them hooked, eh? Just a fair warning from the goodness of their hearts.

Purdue sales manager for West Virginia, William Gergely, described in South Florida Sun Sentinel the sales pitch as follows: “They told us to say things like it is ‘virtually’ non-addicting. That’s what we were instructed to do. It’s not right, but that’s what they told us to say . . . You’d tell the doctor there is a study, but you wouldn’t show it to him.”

The “study” was, of course, the same old footnote based on a letter that said something completely different.

OK, this is already the size of a master’s thesis. I can go on if people want, but do they? There are other places where this story was told a lot better than I’m telling it.

23 thoughts on “The Genesis of the Opioid Epidemic

  1. I did not know any of this, so it’s extremely helpful.

    “Between 1998 and 2005, over 900 pain clinics that studied non-medicalized treatment of pain went out of existence.” This fact alone is startling.

    A friend who practices homeopathic medicine recently said she wants it to stay “under the radar” because if the government tries to get involved in regulating anything, it will draw the attention (and the attacks) from big pharma. She said this in response to Aaron Rodgers claim that he had been “inoculated” against the virus by a homeopath.

    We have been so lazy. Instead of pursuing health and vitality, we have asked for a pill. We want the easy way. Comfort has made us apathetic. The saddest thing to me in reading this article is that there are chronic pain patients who need pain management. I have read the history about soldier’s enduring amputations and surgeries during wars who would have benefitted from pain medications. I don’t think opioids by themselves are horrible medicines – but we were exploited by big pharma. And it will continue as long as we allow it.

    Those of us who are recovering addicts have learned coping mechanisms and behaviors to stay sober. It’s hard work. And we rightfully hate companies who exploit us. All of that to say, none of this surprised me so yes, I am explicitly jaded.

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  2. There have certainly been times when pain was seriously undertreated. Half a century ago when I needed my wisdom teeth removed, it was a brutally violent procedure that left the victim in severe, unrelenting pain, often for many days, and they advised us to take two aspirin. (Which I couldn’t do, as I’m allergic to aspirin.) The general consensus at the time was that pain wouldn’t kill you, so quit your whining. Decades later, when my kids needed their wisdom teeth removed, the surgical process had been improved dramatically, such that they experienced only minor soreness afterwards — yet their oral surgeons gave them prescriptions for opioids, which they didn’t need (or use). I would have sold my birthright for those pills back when I was recovering from having my teeth yanked, but back then no one cared.

    Another example: When I was in my late teens I developed a persistent case of gastroenteritis which resulted in my being hospitalized for severe dehydration, since I couldn’t keep anything down, not even water. I was in an insane amount of pain, but no one cared, because “pain won’t kill you” was still their operating philosophy. I was still alive, I had my intravenous drip to get me rehydrated, so what was I complaining about? Doctors and nurses have gone to the opposite extreme now, constantly asking patients to rate their pain on a scale of one to ten, but I’d rather have it that way than the way it used to be, when you could beg for pain relief until you were blue in the face and have it fall on deaf ears.

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    1. Yep. I highly recommend it to everybody. It’s so well-written. He has recently published a sequel which I’m meaning to read but not finding the time.

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  3. I read “Dreamland” when it first came out – and have read no fewer than 28 other scholarly works on the subject since then – so I really need to review it again before putting in my 2 cents about it (I have it on hold but both copies are currently checked out, so it could be a bit).

    Assuming I’m recalling it correctly and not confusing it with another narrative exposé, I found Quinones likely to be fairly accurately describing one very isolated situation, yet doing so in a way that led the reader to assume it was 100% fact about what was happening all over the nation, when in fact there were very real and isolated situational and very specific inter-generational contributing factors that he disregarded or minimized. I would not rely on that book as the authoritative truth on everything regarding opioids. At best, it is one point of view on a recent-current situation including opioids that is not applicable to most other situations.

    “the pharma companies that wanted to make money disregarded these nuances and decided to use Portenoy’s, Foley’s and even Jick’s statements – without their knowledge or endorsement – to make an argument that opioid painkillers were not addictive, period.”

    So I asked this before and never saw an answer – where are you getting your evidence that “the pharma companies” specifically argued “that opioid painkillers were not addictive, period.” If there is evidence, why has that super-smoking-hot gun not been introduced in ANY of the myriad court cases against these companies?

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    1. The whole pitch was that the slow-release formula made it non-addictive. Without that argument, no doctor would prescribe. As they never had before the Portenoy-Jick narrative.

      As for the lawsuits, I’m completely uninterested in them, don’t follow, and have no idea what legal strategy was used and why.

      You are confusing the Quinones book with something else.

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      1. No, it wasn’t. The pharmacy companies specifically claimed (officially) was that it made it LESS addictive (and even the less specific claims made by individual reps that were admitted in court never get anywhere close to the standard of “not addictive, period”). That wasn’t true, though there still is no evidence that it was actual patients being prescribed either short-acting opioids or OxyContin that are even a significant minority of the “victims” in the “Opioid Crisis,” much less the majority. The only thing the massive increase in prescribing did was move a lot of already-addicts from street drugs to easier-to-acquire opioids and get a new generation of people who purposely chose to abuse drugs started on them.

        Part of the problem here is that you’re hyper-focusing on the past 30 years as though anything that came before that is irrelevant. (The other part is that you seem to be buying the narrative that the person who “was given pills after having their wisdom teeth out, got addicted, died of a heroin overdose” is the norm, not the incredibly rare exception.

        If you do actually research this subject, here’s something important to include: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369835/pdf/jpr-12-617.pdf

        “In a September 2018 analysis of CDC data going back to the 1970s, Jalal et al found that “death rates from drug overdoses in the U.S. have been on an exponential growth curve that began at least 15 years before the mid-1990s surge in opioid prescribing, suggesting that overdose death rates may con- tinue along this same historical growth trajectory for years to come”.”

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        1. I absolutely do not believe that everybody, or most, or a large percentage of people who got Oxy for wisdom teeth, etc got addicted. Just like I don’t think everybody, or most people or a large percentage of those who take COVID vaccines suffer serious adverse effects.

          What I think is that enough people suffered adverse effects in both cases (even though they are absolutely a small minority) and the benefits were small enough to make cost-benefit in both cases not worth it.

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          1. And yes, it’s well-known that before the opioid epidemic there was crack cocaine. Completely different demographics, though, which makes any attempt to conflate them into a single phenomenon dishonest and meaningless. The horror of the opioid epidemic is precisely that all of a sudden these were completely non-at-risk people getting addicted. Moms, grandmas, good kids from well-to-do families.

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            1. “…before the opioid epidemic there was crack cocaine. Completely different demographics…”

              Do you have some secret treasure trove of statistics that no one else has access to?

              “The horror of the opioid epidemic is precisely that all of a sudden these were completely non-at-risk people getting addicted. Moms, grandmas, good kids from well-to-do families.”

              This makes zero sense. People who are “completely non-at-risk” do not get addicted.

              There are other types of addictions (alcoholism, gambling, sex addiction, etc) showing the same kinds of increases in those demographic groups. The problem isn’t the substance, it’s an increase in psychological, mental, spiritual, and external situational issues in those who are already addiction-susceptible.

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  4. “Between 1998 and 2005, over 900 pain clinics that studied non-medicalized treatment of pain went out of existence. Their patients were now on opioids.”

    Actually, due to the pendulum swinging to a severe crackdown on all opioid prescribing, the majority of their patients are living 24/7 in excruciating pain with no options, or are now dead (many committed suicide after CDC guidance and 33 states passed laws severely limiting opioid prescriptions, including many which screwed patients dealing with long-term, life-altering pain conditions).

    Yes, non-pharmaceutical interventions for pain need to be researched and offered, not shut down by pharma-captured government agencies. Just as non-chemo options for cancer, and non-vaccine options for Covid. The parallels are uncanny, no?

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    1. I wonder how all of the people in the rest of the world where opioids were never legalized are surviving this “excruciating life-altering pain.”

      As for this supposed crackdown, I just explained how less than 2 months ago I was pestered with endless offers of prescriptions that I never asked for. Maybe Illinois isn’t one of these 33 states. I hope it becomes one soon.

      As for these long-term pain conditions (that only exist in highly consumerist societies), how about actually treating them instead of briefly numbing them? It’s the same problem as these life-long “chemical imbalance” depressions. Why not just treat them? There’s a whole world out there that sees all these endless-medication life strategies as insane. And very American.

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      1. “I wonder how all of the people in the rest of the world where opioids were never legalized are surviving this “excruciating life-altering pain.””

        You seem to be suggesting they don’t exist? On the contrary, they certainly do. The fact that you aren’t aware of chronic pain in other industrialized countries, and extensive amounts of chronic pain in the developing world is deeply concerning! In some developing countries, chronic pain conditions are so widespread that they are considered the norm, not the exception. And how do they survive? You should know – with significantly lower quality of life, earlier death, liberal use of any substance that dulls pain, and greater dependence on government subsidy (industrialized countries) or extended family (developing countries).

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        1. One thing is missing from this list: non-medicalized treatments. Why dull the symptom with something very addictive when you can get cured, once and for all?

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          1. Non-medicalized treatments for pain are missing for the same reason that Ivermectin and Hydrozychloroquine, and vitamin regimens and real health advice are “missing” from Covid treatments. The inexpensive things that work are stomped out and eliminated by the elites – pharma, government, media. You yourself mentioned non-pharmaceutical options being shut down, so you aren’t unaware of this happening.

            Did you know there have been non-pharmaceutical treatments for all kinds of medical problems that were developed where buyers (posing as enthusiastic entrepreneurs, but really lawyers or bureaucrats representing pharma interests) offered to “help” by providing funding, patent help, etc, only to structure deals that gave them the ability to hold the patent on those treatments and never let them see the light of day? Yes, pharma is absolutely complicit in trying to make it so that narcotic medications are the only option to get relief from many types of unfixable pain.

            Believe it or not, there is no such thing as a “Dr. House, MD” (referring to the Tv show with Hugh Laurie), the specialist who deeply understands the normal function of the body, has multi-disciplinary expertise, and who will not rest until they find the solution and fix the actual issue that’s causing the problem. Most patients who end up using opioids for pain long-term did not start out with that solution – it became their only option after 20, 30, 50, 200+ different doctors, specialists, alternative therapists, and non-medical options were all tried and exhausted, after bank accounts were ravaged and life savings decimated by investing in alternatives that insurance wouldn’t cover, and all hope of any semblance of “normal” living was nearly gone.

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  5. As a rule, I don’t like to use first-hand accounts, because I find they’re almost always too narrowly focused and never show the whole picture, but in this case I’m going to break this rule. You seem to have a very narrow view already – based on several of your comments, it appears this may be somewhat based on personal experiences – and at the very least, you need to be able to understand another part of the picture.

    The first ten years of my life were spent with a very engaged father. He would come home from work and play outside with my brother and I. He would read aloud to us every night before bed. He took us to ball games, bowling, or swimming most Friday nights, and from March through October, he would take us camping, hiking, and fishing at least one weekend a month. He frequently talked to us about important, grown-up things like politics, morality, faith, and truth. He was incredibly active. We lived up in the mountains, 30 minutes from the nearest town, and he would ride his bike to and from work – 22 miles each way (and the ride home was almost all uphill) – at least 3 times a week when the weather was nice (desert southwest with 300+ days of sunshine, so it nearly always was). He ran four miles every day on his lunch break, and swam laps 3-4 times a week after work. He directed the church choir, played the organ at our church, and every Christmas directed a community performance of Handel’s Messiah.
    He was incredibly handy, and did all of the home maintenance by himself. If the dishwasher broke, he would take it apart and figure out the problem, go to town to buy the necessary part, install it and put the entire thing back together. Same with the water heater, the washing machine, and any other mechanical, electrical, plumbing, or structural thing in the house that needed fixing. He maintained our family’s vehicles, and not just the oil changes. He did his own tire rotations, spark plugs, belts, hoses, ignition coils, brake pads, etc. He built furniture, manually mowed 2 of our 10 acres (I don’t mean push mower; our “lawn mower” was literally sharpened blades on a spindle with wheels and a handle), cleared our 1/4-mile driveway with a hand shovel when it snowed. He also maintained all of the structures for our chickens, ducks, rabbits, and dogs, maintained an orchard and garden, and much, much more, all while holding down a regular 40+-hour/week job as a chemical engineer at a national lab.

    Things began to change when I was 10. Something happened to cause an ongoing, vicious pain in his shoulder, and he and my mom spent 4 years and hundreds of thousands of dollars trying to figure out what the problem was. No doctor could diagnose it, nor could they recommend anything to relieve the constant, agonizing pain he was in. They tried everyone – from general practitioners, specialists, alternative docs, chiropractors, to a bunch of “quacks” (especially considered so at that point in time) like hypnotists, homeopaths, eastern practitioners, and more.
    I spent those same 4 years watching the father I had known disappear. He still got up and went to work every day, but the pain wore him out, and living with no relief made him short-tempered. Any use of that shoulder exacerbated his pain, to the point where even trying to help my 4yo little sister learn to ride her bike by holding it up left him white as a sheet, drenched in sweat, shaking in pain. The pain broke him. The day he had to tell my mom to call someone to come fix the broken water heater, I stumbled across him laying on the ground in our orchard, sobbing. Terrified, I ran to get my mom, then had my heart wrenched out to hear him tell her she (and we) would be better off if he was dead, that he was “useless” to us in that condition. In the time it took me to complete middle school, he had gone from an active, engaged, strong, resourceful man who was deeply involved with his family and community, to an empty, thoroughly demoralized, self-loathing shell of his former self, with absolutely no hope of cure, healing, or help. I was terrified he was going to die, and just as terrified that he’d have to live like that for the rest of his life.

    The first time a doctor even suggested the possibility of using an opioid was my senior year of high school. My dad – who had been an Army medic in Vietnam and a nurse in a hospital burn unit afterward – refused. He did not deem his pain “severe” enough to warrant a narcotic, and he did not want to risk adding addiction to his life. I agonized about leaving for college, because my older brother had gone wild and been nothing but grief to my parents since my dad’s pain began, and my mom still had four younger kids (and my dad) that I had been largely helping her manage through those years. But they urged me to go, told me they’d figure it out, so I left. I hadn’t been gone long, when a man who had been a mentor to my dad through high school and college went to visit my folks. Mr. S had been fighting a recurring cancer for nearly 2 decades, and his doctor had given him 6 months. He spent a lot of time talking to my parents, and urged my dad to reconsider trying pain medication. Mr. S had researched it thoroughly before agreeing to try it to deal with the permanent injuries caused by his first cancer treatments, and it had literally given him back the ability to live his life normally again.

    My dad began taking opioid medication for his pain the year I got married. My younger siblings and my mom all got to experience the rest of their childhoods with the same dad I spent the first 10 years of my life with. He seemed to have more patience and energy for his grandkids (my very young kids) than even I remember him having when I was growing up. When my sister bought her first house, my dad helped her gut and renovate the entire place – floors, walls, new bathrooms, new kitchen, everything. He began going to help my brother with big construction jobs on the weekends, He went back to playing the organ, and directing not just the church choir, but starting a handbell choir too. He self-taught himself how to fix and maintain vehicles that are more computer than moving parts. He tackled long-neglected home maintenance projects, and spent years writing thank you notes to the people my mom had hired to do all the things he’d lost the ability to do (I have the feeling they were more like “Thanks for your help, but I’m overjoyed to inform you we don’t need you anymore.” He sold the tractor and snowblower, and went back to hand-sharpening the blades for his manual mower (“not because I don’t appreciate those things, I just prefer the joy it gives me to do those things by hand”).

    We got our dad back for 11 years. In 2012, his doctor told him that he had to taper his medication over the next 12 months, at the end of which he would no longer be prescribing any opioids for any reason. The doctor literally said to my face “a patient’s quality of life isn’t worth the risk to my license.” When I pointed out that he likely had dozens of patients just like my dad, he agreed, but told me “that doesn’t change the equation.” No other doctor was willing to take him on, even when we began looking around the entire state, and even at the possibility of other states. The tapering allowed my dad to come off the opioids without experiencing excessive withdrawal discomfort. But – as well all feared would happen – his pain was still there, and went right back into taking everything away from my dad, starting with his ability to be active and capable, and ending with his hope and his dignity.

    It wasn’t opioids that devastated my family – it was the demonization of them. The day my dad’s doctor told him he’d be tapering my dad off the opioids was the day I began researching this issue. Not just reading books, research papers, and court transcripts, but talking to and interviewing hundreds of people – doctors, patients, families, and addicts. I can tell you that the informal results of MY polls have shown a lot more people like my dad – people without answers, without hope, living in excruciating pain every day for months or years on end – who were given the ability to go back to “normal” life with no changes from their “pre-pain” lives, except for now they’re taking a pill 2-3 times a day. Except for the ones that the demonization of opioids has effected. Most of them are back to their “pain lives” now, living severely restricted, agonizing days with virtually no hope. They are ashamed to admit it, but they envy the rest – the ones whose lives have ended, and the “lucky” ones who managed to escape the ever-tightening opioid restrictions. And those lucky ones live in fear that their last prescription was their final one, and their final month to live normally.

    You know who I almost never find, even among the scores of former and current addicts I’ve interviewed? Anyone who had no history of addiction or medication abuse, who went to a doctor in pain, got a prescription for an opioid and liked how it made them feel, and went on to abuse it.

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    1. I’m very, very sorry this happened to you. My heart bleeds for you, for real.

      I don’t remember if you read my passworded posts but I posted this morning an almost identical story. And it really sucks.

      Again, I’m very sorry.

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      1. “I don’t remember if you read my passworded posts but I posted this morning an almost identical story.”

        Yes, I do read them. I’m struggling to wrap my brain around what you view about the item you shared to be “almost identical” to what I’m attempting to convey here. Feel free to reply on the passworded post if that’s easier.

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