American Overdose: An Interview with Chris McGreal

By John McMillian 12/11/18

In American Overdose, McGreal lays bare the shady behavior of greedy pharmaceutical executives, duplicitous lobbyists, and crooked doctors who helped to perpetuate the worst drug epidemic in American history.

Book cover for American Overdose and author Chris McGreal
McGreal writes with admiration for those who recognized what was brewing – and who tried to ward off the crisis – but this is a story with far more villains than heroes.

Shortly after I woke yesterday morning [on November 29, 2018] I went to the New York Times website, where I saw a report indicating that drug overdose deaths in the United States set a new record last year. There were over 70,000 of them, mostly due to opioids, especially strong synthetics like fentanyl (which often gets mixed with heroin to provide a more potent high). That is far more than the number of Americans who died from car accidents last year (40,200), or guns (38,440). Opioid abuse is also a big part of the reason that life expectancy in the United States has actually diminished over the past three years. This phenomenon, the Times says, is unprecedented since World War II.

Later in the afternoon, I had the chance to discuss the crisis with the British-born journalist Chris McGreal, a Guardian reporter who is the author of American Overdose: The Opioid Tragedy in Three Acts (Public Affairs, 2018). It is a sharply-etched and tenaciously reported book that exposes the massive corruption that allowed the epidemic to reach such staggering proportions. He shows how Purdue Pharma continued to profit mightily from opioids, even after it became widely known that the narcotics they pushed were destroying lives and killing people. And he breaks new ground in showing the degree to which the FDA allowed that to happen. McGreal writes with admiration for those who recognized what was brewing – and who tried to ward off the crisis – but this is a story with far more villains than heroes. He lays bare the shady behavior of greedy pharmaceutical executives, duplicitous lobbyists, and crooked doctors who helped to perpetuate the worst drug epidemic in American history. We spoke at length; the following interview is significantly edited for brevity, and lightly edited for clarity.

You and I both saw the same New York Times report this morning. If you look at the statistics, you see that most of the 70,000 overdose deaths last year are concentrated in a few regions. In American Overdose, you focus largely on southern West Virginia. Why are some places, and not others, having the hardest time with the addiction crisis?

Well, if you look at those areas where the epidemic began, they became the crucible because they were targeted for the selling of opioids, and particularly high-strength opioids, like Oxycontin. And that is because these are regions where you have a lot of manual labor, a large number of people who work in jobs that take a real physical toll. And they’ve often used some form of “painkiller” (for lack of a better word), whether it was moonshine or marijuana, or different forms of pills, or lower levels of opioids. But when Oxycontin came along, and they looked where to market it, these were logical places. Drug companies simply buy up data from pharmacies about what drugs are being prescribed. So, they know where to go.

By the late 1990s, it was becoming clear that the mass prescribing of opioids was causing tremendous harm. Oxycontin acquired significant value as a street drug, and people were getting addicted and dying. How did the drug industry respond?

One of the reasons I wanted to write this book is because I was hit by the question: “Why has [the opioid epidemic] gone on so long?” You mentioned the 1990s, but it’s really only now that we’re having a proper national discussion about this epidemic. How did it drag on for twenty years? Where were the institutions that were supposed to protect Americans from this kind of thing?

When you go back and look to the early 2000s, you learn that in fact there were warning signals, and they were made very loud and clear, particularly by some people who emerge as heroes in this story. One of them, for instance, is Dr. Jane Ballantyne. (She was the head of pain management at Harvard University and its associated hospital, Massachusetts General.) Initially, she buys into the idea that opiates are a magic bullet for pain treatment. But she starts to see, in her own patients, that this wasn’t true. She sees that in fact, once a person has been on opioids for a long time, their pain isn’t diminishing – it’s actually getting worse. Plus, they’re becoming dependent and addicted. So, she gathers data, and eventually in 2003 she publishes a paper in the New England Journal of Medicine saying, “We need to pause, we need to rethink this strategy of mass prescribing opioids.” And she said to me, “I thought that would be a wakeup call.”

She thought the drug industry – and if not the industry, then at least federal institutions that regulate the drug industry, such as the FDA – would sit up and take notice and say, “Wait a minute, is this the right thing to do?”

Instead, the industry decides it wants to change the conversation, and make people look in the other direction. So, they start a campaign that says the people who become addicted to these drugs are abusers. They are misusing the drugs, so they are to be blamed for their condition. They begin blaming the victim. And they say, “Meanwhile, look over here: There are tens of millions of Americans who live with chronic pain. They’re the real victims in all of this, and what we mustn’t allow is to let the abusers take [analgesic] drugs away from the people who really need them.”

Of course, what that claim failed to recognize is that many of those that became addicted to those drugs – and who did go on to abuse them – began by following prescriptions for chronic pain! They were one and the same people. And where were the federal institutions that were supposed to protect Americans? Like the FDA, or the National Institute for Drug Abuse, or any one of a number of institutions? What happens is, they get coopted into that narrative. Instead of standing up and regulating as they’re supposed to do, they buy into it, and help perpetuate [the growing crisis].

You also spoke to some ordinary people who have been affected by the crisis. One person who piqued my curiosity was Bre McUlty, who got hooked on drugs as a teenager. Will you tell us what she went through, and how she’s doing now?

Bre’s an interesting character. There are lots of ways to be drawn into drug addiction, and Bre really got it through her family. Her father used a lot of drugs, and she grew up with her father (her mother wasn’t on the scene at that point). She lived at a house where drug dealers were coming by all the time, and people were doing drugs in front of her. (Actually, her first drug was alcohol. She was drinking as a teenager.) One day, somebody comes to her and says, “Hey, do you want to sell some drugs for us?” And she starts to sell drugs, makes a bit of money on the side. Eventually she ends up, by her late teens, dealing in heroin. And she was one of those people – there was an inevitability about it, I think. She grew up in that world, and she never saw anything outside of that world. She ends up pregnant as a teenager. She tries to break out from all of this, but can’t. And eventually she gets arrested. She winds up in prison, ironically, not for drug dealing but for threatening someone else who was dealing drugs and saying if she talks, she’ll burn her house down!

I felt sympathetic to her, but when I got to that part in your book I thought, “Oh no. She should not have written those letters!”

But she came out of prison. One of the things that’s really striking about Bre, is she’s a really a strong young woman. She has now settled elsewhere in the country. She left West Virginia, essentially because she felt there was no escaping drugs there. And she moved on to try and rebuild her life with her children. What is quite interesting about her is there’s a parallel story with a doctor in the same town [Rajan Masih] who also went to prison, only he went for mass prescribing opioids. Eventually he lost his license.

They both came out of prison at about the same time, a couple of years ago, and I would say she is much more honest about her part in this crisis than he is. He’s still in denial. Although he’s got death on his hands – prosecutors said he prescribed to anybody and everybody – he blames that on his own addiction, rather than taking responsibility for his actions. (And this a man who had every chance; he’s a doctor, and quite a privileged person.) Bre – who never really had a chance in the beginning – is, I think, much more honest about taking responsibility for what she’s done in her life.

You know, I’ve never taken heroin, mostly because I’ve always been so scared of it. And in light of what we now know about how pernicious opioid addiction is, I’m surprised that the crisis is still building. I agree with you about the culpability of companies and institutions. But is there any conceptual room for also talking about the behavior and responsibility of addicts who are keeping this crisis going?

Yeah. “Do people have responsibility for the decisions they make?” Absolutely. What I would add is that while they have responsibility, once they get dragged into addiction – and not everybody does – but for those that do, it gets beyond their control. Addiction is a disease, and it’s a really, really hard thing to get out of. So, whatever the original causes of that, I don’t think it diminishes the need for some sincere understanding.

The other thing I would say about some people who go down that path – and again, I don’t want to necessarily excuse – but if you come from certain backgrounds, if you live in certain communities, I think you’re far more likely to go down that path. There are some very interesting studies of this. One is by a pair of academics, Princeton professors Anne Case and Angus Deaton. And they look at who is most affected by this crisis. And by a long way, it is people who have no more than a high school education. And you can’t diminish those economic and social factors. Other studies that show that if your parents were using, or were addicted, then there’s a good chance that you are going to go down that path – like with Bre McUlty. And so, yes, perhaps younger people who do this – they [should know better]. But at the same time, if the drugs are widely available, and they’re living in difficult circumstances, I’m not without sympathy for them. People take up smoking in this day and age, and we all know what that does!

Do you have a sense of where this is heading? Among the range of options that are being used to solve the problem, what do you think is most encouraging?

Well I think there are different plusses and minuses. On the plus side, there’s been a huge change in attitudes, and a breakdown of stigma. A lot of that has got to do with people who have become addicted themselves, or are the relatives of people who died (particularly parents of children). They’ve gone out there, and they’ve tried to break down the stigma toward opioids and heroin addiction. I think that has had a huge impact, because it means people can talk about it, and go and seek help, without feeling judged. That is really important.

There’s a view that access to medication-assisted treatment – which essentially involves low levels of opioids to help you stave off the worst effects of withdrawal – are probably the most effective for most people. Although the 12 steps work for some people, that involves total abstinence, which can be much harder. One of the things to recognize is that when most people try to end their addiction, they don’t do it on the first try. It takes repeated attempts. So, you need the resources, particularly in the poor parts of the country. When someone comes in and says “I want to do something [about my addiction],” you have to have the resources there for them. It’s no good saying, “Come back in six months.” So, there are more resources available, there is more awareness.

But there are plenty of downsides. I think the rising death toll that you mentioned tells us something. I also think, when we look at how this began, with mass prescribing, [it’s troubling] that overall, prescribing hasn’t fallen like it needs to. At the height in 2012, there were 255 million prescriptions for opioids written that year. Last year, it was 192 million. That’s still incredibly high! And that mass prescribing, it puts the drugs out there. And so, if you’re not going to have a second wave [of addiction], you need to reduce the mass prescribing. Now there are people trying to do that, like the Centers for Disease Control. But there’s still a lot of resistance, particularly from the medical profession. Everybody I talk to about this, who has expert knowledge – they all say this has a very long tail. This is the worst drug epidemic in American history and it is not going to be over in five or possibly even ten years. It’s going to go on for quite a long time.

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John McMillian is an associate professor of history at Georgia State University, in Atlanta. His most recent book is Beatles Vs. Stones (Simon & Schuster, 2013).