PURDUE PHARMA & THE SUPPLY-SIDE OF ADDICTION

The opioid crisis is rarely out of the headlines. This week – w/c 19th October 2020 – The Times reported on a University of Manchester study which demonstrates a massive increase in Codeine use in the UK over the past decade, fuelling fears of a US-style opioid addiction crisis on British soil. Across the Atlantic, US drug overdose deaths are on track to hit an historic high, the Covid-19 pandemic disrupting treatment services and increasing demand for illicit opioids. It also emerged that Purdue Pharma will pay a settlement of $8billion and plead guilty to enabling the supply of drugs “without legitimate medical purpose” in relation to the role played by its product, OxyContin, in the advent of the opioid crisis. In that context, it seemed like a timely to share this post on the supply-side of addiction.

I

The team that tends the lawns of Huntington’s Spring Hill Cemetery know better than to mow the grass around Adam Johnson’s grave, just a few meters away from the Marshall Memorial. “They know I want to be the one to take care of it”, says Adam’s father, Teddy.[1] An aspiring musician, radio broadcaster, and Marshall freshman, Adam was 22 when a heroin overdose took his life one weekend in September of 2007. 

In the previous six-and-a-half years, Huntington had suffered just four fatal overdoses. On that fall weekend in 2007, three men died: Patrick Byars, 42, a Papa John’s employee, and George Shore, 54, an artist who made his living selling antiques, and Adam Johnson.[2] By the end of the year, another nine would overdose and die.[3] Huntington’s opioid addiction problem would not come to international attention until 2016. It was, however, that weekend – nearly a decade earlier – that Heroin’s infiltration of the community came to light. It came, as it already had to so much of the US, in the form of Mexican black tar heroin. 

In his 2015 book, Dreamland, journalist Sam Quinones narrates the story of that sticky black substance’s journey from rural poppy farms on Mexico’s Pacific coast to the San Fernando Valley of Los Angeles, and across the Western United States to places as diverse as Portland, Salt Lake City, Maui, Anchorage, Denver, and Oklahoma. The trafficking of black tar heroin onto US soil began in the 1980s but it was only in the late 90s that it would finally make its way across theMississippi River to Columbus, Ohio, and, from there, into the cities, suburbs, and small towns of the eastern United States.

Black tar heroin’s journey into the bloodstream of America was predicated on its purity and price. It gained market share because it gave you more bang for your buck than the South American white powder heroin which, historically, dominated east of the Mississippi.[4] Its journey was expedited by the innovative approach of its Mexican traffickers, who all hailedfrom Xalisco county, Nayarit – the Mexican backwater where the product was grown and processed – and operated “like a fast-food franchise… like a pizza delivery service.”[5]

“I called the DEA in Columbus”, writes Quinones, “and spoke with an especially loquacious agent. ‘We got dozens of Mexican heroin traffickers. They all drive around selling their dope in small balloons, delivering it to the addicts. They’re like teams, or cells. We arrest the drivers all the time and they send new ones up from Mexico,’ he said. ‘They never go away.’ He discoursed at some length on the frustration of arduous investigations ending with the arrest of young men who were replaced so quickly. They hide among Columbus’s large Mexican population, he said. The drivers all know each other and never talk. They’re never armed. They come, give false names, rent apartments, and are gone six months later. This was not the kind of heroin mafia Ohio and the eastern United States was used to.’”[6]

To fully understand the success of black tar heroin you must look beyond the product itself, and the creativity of its traffickers, to another psychoactive import, this one entirely legal: opioids from Johnson & Johnson’s poppy production on the Australian island state of Tasmania,[7] imported to manufacture hydrocodone (Vicodin) and oxycodone (Percocet, OxyContin). Mexican drug-traffickers weren’t the first to bring opioids to the masses. Pharmaceutical companies – most notably Purdue Pharma – supplying the population through a vast network of misinformed and – in some cases –unscrupulous physicians, got there before them. The market for black tar heroin existed because communities the length and breadth of the country had an opioid habit to feed.[8]

It would be hard to overstate the impact of prescription of opioid painkillers on the US since the turn of the century – or the extent to which the ubiquity of opioid painkillers is a distinctly American phenomenon. Approximately 80% of the global opioid supply is consumed on US soil by a little over 4% of the world’s population.[9] A third of all US adults were prescribed opioids in 2015.[10] Of the 70,237 drug overdose deaths recorded in 2017, a quarter were from physician-prescribed opioids.[11] Between 2007 and 2012, according to Congress’s Energy and Commerce Committee, 780 million hydrocodone and oxycodone pills were shipped to West Virginia alone, population 1.8 million.[12] In one 2-year period close to 9 million pills were legally distributed to a pharmacy in Kermit, West Virginia, population 406. These opioids were no doubt diverted to ‘pill mills’, where prescriptions were sold in bulk, for cash, entirely within the bounds of the law. 

Black tar heroin didn’t precipitate a rush of new opioid addictions. It simply provided addicts with a replacement drug at a time when the state-sponsored supply was running out. “The overuse of prescription opioids”, write economists Anne Case and Angus Deaton, “triggered the secondary epidemic of illegal drugs when Purdue introduced an abuse-resistant form of OxyContin and as physicians became more aware of the dangers and held back, or at least reduced the growth of the legal supply… By 2011 it was too late to put the genie back in the bottle. Illegal heroin, an almost perfect substitute for oxycodone, quickly picked up the slack; deaths from prescription drugs were replaced by deaths from heroin, and the total of overdose deaths continued its climb. Drug dealers waited outside pain clinics for patients whose doctors had denied them refills. Some bought (diverted) OxyContin on the street until discovering that heroin was both cheaper and more potent.”[13]

II

The tragic story of America’s de facto legalization of opioids illustrates the critical role played by the supply-side in the formation of an addiction. It’s not the only thing that matters. Far from it. However, the supply-tap of psychoactive chemicals and activities – whether cheap booze, online games, pornography, illegal drugs, or narcotics prescribed by a physician – has to be open for addiction to flourish. 

In his 2019 book, The Age of Addiction, the historian David Courtwright explores the growth and diversification of addiction through the ages, arguing that we find ourselves not simply in an age of addiction, but an age of “addiction by design”. Addiction flourishes in the modern world because – actively and passively – we have allowed it to be shaped by limbic capitalism. Courtwright describes limbic capitalism as the “evil twin” and “cancerous outgrowth” of productive capitalism.[14] It is the domain of industries – legal and illicit – that actively design and market products that give rise to excessive consumption and the formation of addictions by targeting the limbic system, the brain pathways responsible for feeling, learning, motivation, memory, and quick reaction. 

“Civilized inventiveness weaponized pleasurable products and pastimes”, writes Courtwright. “The more rapid and intense the brain reward they imparted, the likelier they were to foster pathological learning and craving, particularly among socially and genetically vulnerable consumers. Meanwhile, globalization, industrialization, and urbanization made these seductive commodities and services more accessible and affordable, often in anonymous environments conducive to anomie and saturated with advertising. Accessibility, affordability, advertising, anonymity, and anomie, the five cylinders of the engine of mass addiction, ultimately have found their most radical technological expression in the floating world of the internet.”[15]

Limbic capitalists invented the ’happy hour’ to get us drinking more and drinking more quickly. They removed windows and clocks – anything that might signal the passing of time – from casinos. They invest huge sums of time and money marketing opioids to physicians across the United States. Limbic capitalists ensure that, whilst 10% of 15-24s have tried a Juul e-cigarette, most are unaware they contain nicotine.[16] The goal of those who create and supply these products is excessive consumption and addiction. By ensuring the five cylinders of mass addiction fire in concert, they keep our supply of these products – and the brain rewards they offer – flowing like an artesian well. 

What is true of the producers of physical products is true also of the purveyors of virtual goods. Adam Alter, author of Irresistible: Why We Can’t Stop Checking, Scrolling, Clicking and Watching, writes: “Instagram, like so many other social media platforms, is bottomless. Facebook has an endless feed; Netflix automatically moves on to the next episode in a series; Tinder encourages users to keep swiping in search of a better option. Users benefit from these apps and websites, but also struggle to use them in moderation.”[17] In the form of the ubiquitous smartphone, we are now physically connected – 24/7 in many cases – to the suppliers of these objects of digital addiction. In some cases, it may take a few minutes for the dealer to deliver, but likely no longer than your local pizza delivery service. In others, the product is just a click or two away, often – as in the case of online gambling platforms and clothing retailers – with powerful inducements one offer, designed to make it easier for you to dive-in than walk away. 

III

Heroin use by American military personnel deployed in Vietnam in the late 60s and early 70s is a source of ongoing interest to those wanting to understand the social causes of addiction. As the withdrawal of US troops drew closer – and marijuana use by soldiers was stamped-out – heroin use surged. Politicians stateside became increasingly concerned the streets of American would be overwhelmed by junky veterans, leading President Nixon to declare heroin addiction the nation’s leading public health concern.[18] Their alarm was understandable. Ninety enlisted men died from heroin overdoses in 1970.[19] As the war in Vietnam drew to a close there were more heroin addicts enlisted in the ranks of the military than in the civilian population.[20]

The result of was a program – nicknamed ‘Operation Golden Flow’ – which compelled returning soldiers who had tested positive for opiates to detox, and prove they were clean with a urine-sample before they were permitted to return home.[21] Once home, these same soldiers were followed-up, the authorities anxious to do everything in their power to prevent the kind of public health crisis we face with opioid addiction today. A study published in the Archives of General Psychiatry in 1975 drew together the data gathered from Operation Golden Flow in Vietnam, and through interviews with 898 soldiers who returned from Vietnam in September 1971.[22] The study showed that “before arrival, hard drug use was largely casual, and less than 1% had ever been addicted to narcotics.” Whilst deployed in Vietnam, “almost half of the general sample tried narcotics and 20% reported opiate addiction”, yet on returning to the US, “usage and addiction essentially decreased to pre-Vietnam levels.”[23]

Why did heroin use amongst service personnel reach such levels during their deployments in Vietnam? How were so many of them then able to leave their addictions behind when they settled back home? 

David Courtwright’s five-cylinders of mass addiction shed light on the matter. Detached from family and wider community structures, deployed military personnel operate within a distinct subculture, which provides a form of anonymity and anomie. In Vietnam, soldiers had ready access to highly affordable heroin and little else on which to spend their money. Time magazine reported that heroin was “as a common as chewing gum” – an exaggeration, but one that reinforces a truth.[24] Heroin was advertised and promoted to soldiers, as Adam Alter vividly describes: “Teenage girls sold vials from roadside stands along the highway between Saigon and the Long Binh US army base. In Saigon, street merchants crammed sample vials into the pockets of passing GIs, hoping they would return later for a second dose. The maids who cleaned the army barracks sold vials as they worked. In interviews, 85% of the returning GIs said they had been offered heroin. One soldier was offered heroin as he disembarked from the plane that brought him to Vietnam. The salesman, a heroin-addled soldier returning home from the war, asked only for a sample of urine so he could convince the U.S. authorities that he was clean.”[25]

But is this the whole story? Or was there something about deployment, about the life of a soldier far from home, about the nature of warfare itself, that created a hunger for heroin? 

How did the soldiers explain their heroin use? According to Professor Lee Robins, lead author of that 1975 study, when asked, the answer was that they used heroin because “it was enjoyable and made life in the service bearable.”[26] It met a need. It provided a way to escape the harsh realities of a tour of Vietnam. Heroin satisfied desires created – or at least heightened – by the experience of a violent war. Once home those desires diminished. As Dan Baum puts it, “Take a man out of a pestilential jungle where people he can’t see are trying to kill him for reasons he doesn’t understand, and – surprise! – his need to shoot smack goes away.”[27]

IV

Without access to cheap heroin – and the liberty to enjoy it – heroin use and addiction amongst service personnel in Vietnam would not have reached the levels it did. The supply-side does not, however, tell the whole story. A robust and plentiful supply is a necessary condition for the development of that addiction, it is not sufficient on its own. The supply-side alone fails to explain why few some did what common sense would expect them to, and continue using heroin back in the US, not least to navigate the trials associated with returning from the frontlines, including PTSD.

The rest of the answer – perhaps the lion’s share – is found on the demand-side. 


[1] https://huntingtonquarterly.com/2018/09/28/issue-94-remembering-adam-johnson/ 

[2] https://www.herald-dispatch.com/news/the-victims/article_7c565cae-8a98-53f6-b12b-73226544da45.html

[3] https://huntingtonquarterly.com/2018/09/28/issue-94-remembering-adam-johnson/

[4] https://fas.org/sgp/crs/misc/R44599.pdf, p.2 

[5] Quinones, Dreamland, 43.

[6] Quinones, Dreamland, p. 20.

[7] “Johnson & Johnson, one of the best-known American pharmaceutical companies, supplied most of the raw material for opioid painkillers in the US from a subsidiary, Tasmanian Alkaloids, which grew poppies on farms in Tasmania… At a time when the American military was bombing the opium supply in Helmand province in Afghanistan, Johnson & Johnson was legally growing the raw material for the nation’s opioid supply in Tasmania.”

Case & Deaton, Deaths of Despair and the Future of Capitalism, p. 125.

[8] See Macy, Lembke, Quinones, and Case……….

[9] https://www.health.state.mn.us/communities/opioids/prevention/painperception.html

[10] Case & Deaton, Deaths of Despair and the Future of Capitalism, 113

[11] Case & Deaton, Deaths of Despair and the Future of Capitalism, 112

[12] Case & Deaton, Deaths of Despair and the Future of Capitalism, 124

[13] Case & Deaton, Deaths of Despair and the Future of Capitalism, 113, 119.

[14] https://www.vox.com/science-and-health/2019/10/17/18647521/capitalism-age-of-addiction-phone-david-courtwright

[15] David Courtwright, The Age of Addiction, location 185.

[16] https://tobaccocontrol.bmj.com/content/28/1/115, https://www.vox.com/science-and-health/2018/5/1/17286638/juul-vaping-e-cigarette

[17] Adam Atler, Irresistible, p. 3

[18] Anne Case, Deaths of Despair, p.122

[19] Alter, Adam. Irresistible, p. 48

[20] Johann Hari, Chasing the Scream, location 3397.

[21] Case, Anne. Deaths of Despair and the Future of Capitalism (p. 122). Princeton University Press. Kindle Edition

[22] https://jamanetwork.com/journals/jamapsychiatry/article-abstract/491395

[23] Case, Anne. Deaths of Despair and the Future of Capitalism, p. 122

[24] Hari, Johann. Chasing the Scream, location 3397.

[25] Alter, Adam. Irresistible, p. 47

[26] Lee Robins, ‘Vietnam veterans’ rapid recovery from heroin addiction: a fluke or a normal expectation?’, Addiction, 88, 1041–54, 1049.

[27] Dan Baum, Smoke and Mirrors, 62.

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