March 2022

Reviewed by Brian Durrans

In January 2022 actor Michael Keaton won a Golden Globe award for his leading role in Dopesick, a dramatised TV miniseries on the Disney+ subscription channel, about the opioid epidemic which has plagued the US since the late 1990s. Based on a book of the same name by journalist Beth Macy, Dopesick exposes how the Sacklers, the family owning the Purdue Pharma company but hitherto best known as art-world philanthropists, played a leading role in the epidemic itself. The Sacklers lied about the addictiveness of the prescription pain relief, OxyContin, which they aggressively marketed to physicians serving millions of mainly working class Americans. (1) OxyContin sales accounted for the greater part of their accumulated wealth officially estimated in spring 2021 at $11bn, much of it legally transferred from the company to their private bank accounts. Three months later, the total economic cost of the epidemic, including crime, healthcare and lost productivity, was calculated as running year-on-year at nearly $124bn. (2)

The death rate (the ultimate lost productivity) was even more striking. Between 2014-2016 average life expectancy in the US fell for the first time in a century, caused by drug-related suicides and overdoses, which tripled from 1999 to 2017 while opioid overdoses rose sixfold. (3) The epidemic claimed half a million Americans from 2000 to 2018 and even now kills about 100,000 more every year. (4) Whilst overshadowed by the dramatically higher US death rate from Covid (about 847,000 in 2020 and 2021), the causes of the opioid epidemic and how it is being resisted, reported and interpreted, hold lessons at least as pressing as those from the more widespread Covid pandemic for achieving a healthy, sustainable future. In the meantime, both AstraZeneca and Pfizer, the leading and massively state-aided companies producing Covid vaccines, have both publicly declared that making profits was the last thing on their minds (5): perhaps a sign, whatever its sincerity, that Big Pharma is at least for now feeling the heat of public revulsion against Purdue as well respect for the dedication of health workers. 

INDIVIDUALS AND THE SYSTEM

The activities of particular capitalist enterprises rarely attract a TV mini-series, so what is it about the spectacular rise and fall of Purdue Pharma that caught the eye of the Disney Corporation, of Home Box Office (HBO) whose excellent two-part documentary Crime of the Century was screened in 2021, of Netflix who are bringing out their own mini-series in 2022, and of a small legion of writers whose output of books and articles exposing and analysing the epidemic shows no signs of drying up? The obvious answer is human interest and a story with no end in sight, though there is a little more to it than that.

Capitalist media are also pro-capitalist media, experienced in making a profit out of stories with strong public interest while keeping capitalism itself out of the spotlight or the dock. The opportunities and risks are high, not least because widespread outrage against those who most obviously fuelled the epidemic is likely to continue, given frequent updates on the legal wrangling over the Sackler fortune and culpability, or on the latest effects of the epidemic itself, both still ongoing. In the spotlight are: one family (the Sacklers), one company (Purdue), one industry (pharmaceuticals), and one aspect of declining capitalism’s collateral damage (domestic drug-dependency) rather than its even more devastating impact in death, destruction, impoverishment, malnutrition and injustice through ‘business as usual’, war, and looming environmental catastrophe. Under capitalist rules, exposing the back-story of the first drop in life expectancy for a century in the world’s richest nation is co-opted into a damage-limitation exercise.

Although occasionally mentioned in other analyses of the crisis, several additional pharmaceutical companies have also been illegally involved in making and supplying opioids, including some already penalised for breaking the law or likely to be, among them Allergan, AmerisourceBergen, Cardinal Health, CVS, Endo International, Johnson & Johnson, McKesson, Mallinckrodt, Teva, Walgreens and Walmart. (6) Only a comprehensive view of the context in which the crisis evolved can best help prevent it from happening again, but perhaps it is already too late to enlarge the rogues’ gallery beyond the Sackers and their Purdue entourage.

If neither Purdue nor even their voracious appetite for profits deserve all the blame, two candidates to share it with emerged in the first two decades of post-war America.  In the early years of the Cold War, in reaction against both the socialised medicine of the socialist countries and temporary improvements under Roosevelt, private healthcare reached a dominance unchallenged until the advent of over-hyped Obamacare. Then, in the early 1960s, mildly-addictive sedatives were developed for over-the-counter access and marketed for self-managing a wide range of conditions, moods and anxieties, which, even if only imagined, advertisers could persuade people were real.  Individualising medication and expanding its scope was deliberately planned in the 1960s by the Swiss company Roche Pharma with the help of Arthur Sackler, then working for the advertising company McAdams, which came up with the term “broad spectrum” for Librium and Valium to give them an aura of scientific legitimacy. (7)

Profitably splashing the crimes of Purdue Pharma across the broadcasting, print and social media comes at a price, however, and capitalism doesn’t hold all the aces. Dopesick and similar accounts tell a story which poses questions for their audiences. Drugs-based crime has long been popular staple of fictionalised films and TV series, but one of these, the Netflix series Ozark, now uses a thinly-veiled version of Purdue and the Sacklers to make its plot-line more convincing, and even has a member of a Mexican drugs cartel family reminding the Sackler-like owner of the Purdue-like pharmaceutical company that her family had killed more people than his. The reality of the opioid pandemic which Dopesick reveals, and even Ozark refers to, is getting into people’s living rooms even when it might not make today’s news: the terrible consequences of the Sacklers’ profiteering for those they lured into addiction in run-down mining villages in West Virginia; the duplicity of self-serving corporate publicists, lawyers and accountants; the dedication of those seeking justice and compensation; and, occasionally, even the vision of those beginning to realise the need for radical change. Because it has such an obvious connection with real and ongoing experience, the drama that plays out on the page or screen is unlikely to stay there.

MANUFACTURING ADDICTION

Launching OxyContin in 1995, Purdue argued that it offered twelve hours of pain relief by means of a special coating designed to release its contents slowly, and that this made the tablet safe to prescribe since the coating made it hard to crush then snort or inject for an immediate and dangerous high. Knowing the tablets were easy to crush, the company focused instead on the need to take them as prescribed. It was able (with inside help from an official who later joined the company as a much higher salary) to persuade the Federal Drug Administration (FDA) to approve OxyContin on the basis that an addiction risk of less than one percent had been proved in a clinical trial when in fact no such trial had been conducted. The Sacklers’ philanthropic reputation was an asset here, but they were not going to take any chances, so they wrote the terms of the FDA’s approval and unprecedentedly steered the whole approval process.

FDA approval gave Purdue the green light to develop a hyper-profitable marketing strategy knowing that eventually some users would become abusers by crushing the tablets or non-users would get hold of them if they became widely prescribed, and that people would (or could be encouraged by their doctors to) start taking more - or more concentrated - tablets more often and become addicted in that way even if each protective coating continued working as claimed.  Demand, sales and profits were boosted in several ways: by targeting working class communities especially liable to past occupational pain and its chronic legacy; by winning support (and raising the profile) of medical pain specialists with the argument that pain of whatever cause deserves the status of a “fifth vital sign”, for the patient to measure using a simplified scale, giving a spurious objectivity without regard to wider factors; inventing the idea that when withdrawal from OxyContin produces symptoms resembling those of an addict, then the addiction must be “false” and treated by increasing the dosage; by incentivising marketing reps with unlimited bonuses; and by bribing unprincipled or avaricious doctors to get more OxyContin into far more patients than could be medically justified. 

With all these measures in place, OxyContin prescriptions, addictions, drug-related crime, family breakdowns and drug-related deaths skyrocketed. But neither the epidemic nor public concern about it could be brushed aside. By 2018, the Sacklers faced fraud charges and worse. The crisis which OxyContin did most to generate began to move onto cartel-sourced opioids like heroin and the more powerful Fentanyl and related products.

WILL JUSTICE BE DONE?

The medical assessment of opioid addiction increasingly recognises Opioid Use Disorder as a chronic brain disease, not a character defect. Rehabilitation, with dedicated support, social therapy and controlled medication, is therefore critical if more are to survive the epidemic, which is why fully funded provision matters to campaigners. The origins of the epidemic and where its devastation is greatest make an overwhelming case for tackling the poverty and austerity, and their capitalist roots, to which drugs are no answer.

In July 2021, a legal settlement was reached that would have protected the Sacklers from prosecution themselves, in exchange for Purdue declaring bankruptcy and releasing both $4.5bn to pay opioid claims and some 33 million company records potentially revealing the full extent of its collusion with public and professional institutions and individuals. Those who sought to hold the Sacklers individually liable for their crimes were outraged by this decision until it was overturned by another judge in December. At the time of writing (late January 2022), the Sackler lawyers are seeking to rescue the July 2021 bankruptcy deal by overturning the December ruling against it. (8)

Notes

1. In this article, Dopesick refers to the TV series rather than the book.
2. https://oversight.house.gov/news/press-releases/committee-releases-documents-showing-sackler-family-wealth-totals-11-billion; https://www.pewtrusts.org/en/research-and-analysis/data-visualizations/2021/the-high-price-of-the-opioid-crisis-2021
3. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm Dopesick and this review are only about the US where the media coverage is greatest and the political stakes highest, but opioid over-prescription or misuse may also be a (potential) problem elsewhere. In 2018, for example, the UK recorded the highest level of opioid use in Europe, increasing fourfold during the previous decade: https://www.bjanaesthesia.org/article/S0007-0912(17)54182-3/fulltext
4. https://www.nature.com/articles/d41586-019-02686-2
5. The Race for a Vaccine (14 December 2020), BBC Panorama, about Oxford University and AstraZeneca; and Mission Possible: The Race for a Vaccine (6 April 2021), produced by Pfizer; both available on YouTube.
6. https://www.washingtonpost.com/investigations/76-billion-opioid-pills-newly-released-federal-data-unmasks-the-epidemic/2019/07/16/5f29fd62-a73e-11e9-86dd-d7f0e60391e9_story.html
7. Patrick Radden Keefe, Empire of Pain: The Secret History of the Sackler Dynasty. London, Pan Macmillan, 2021.
8. The current security and future fate of those 33 million documents, and whether any have already been shredded, and by whom, is also unclear at the time of writing.