In one New York county, doctors are struggling to keep up with the constant autopsies from overdoses. We speak with families whose children's addictions began with prescription drugs. Is Big Pharma the cause of the epidemic?
BUFFALO, New York — Kaitlyn Haines preferred being called Kate. On May 6, 2016, she died of opioid drug overdose, 11 days before her 24th birthday. She had been battling addiction for seven years. Kate is now part of the much-talked about statistics of death that are being used to describe a nationwide scourge, a deadly epidemic ripping through America, leaving behind landscapes of grief. "I grieved mostly when she was alive. I feel better now, because I don't have to see her the way she was," Kate's mother, Amy Haller, told me.
On May 30, 2017, I met Amy at a church in Buffalo city, seat of New York's Erie County. She was there to speak before a gathering of parents.
The parents had gathered to mourn collectively. Some had children who had died, like Kate, and some had living children who were addicted to the drugs but who they feared could die anytime of an overdose. They shared their stories. The sharing served as an act of finding fortitude, of healing, a way of dealing with the loss and with the sense of impending loss. Amy read out a speech to the group, a little biography of her daughter. While she was reading out from the podium, I saw an old woman in one of the rows struggling to hold her tears back. Later I found out that her addicted daughter had been missing for six days — she feared the news of her death might arrive anytime.
In and around the city of Buffalo, groups of such parents, mostly white and from the suburbs, gather once or twice a month to share their grief. They also ponder over what they can and should do to save their community from the crisis that has gripped it. Amy gave me a list of 16 Facebook groups she is a part of. Each group meets once a month. The list had names like Bereaved Parents, Caring for Opioid Addicted Loved Ones, End of the Struggle, Heroin Memorial, Heroin Support, Mothers Who Have Lost a Child, Parents of Addicted Adult Children, Save the Michaels of the World, The Addict's Mom, and so on. I could only attend a few.
Erie County — the largest metropolitan county in upstate New York, about 80 percent white, and with nearly 15 percent living below the poverty line — is battling an epidemic of opioid overdose deaths. Over the first quarter of 2017, on average, it recorded seven overdose deaths each week, according to the latest data made available by county's health department. In March, when in less than 24 hours seven people died from heroin overdoses, the county's executive, Mark C. Poloncarz, described the situation as a public health crisis. At the time of my reporting, the county's Medical Examiner's office, which is part of the health department and generates death certificates, was struggling to keep up with the constant autopsies.
"We are dealing with a huge public health crisis. The number of people dying from drug overdose is alarming and going further up," Dr. Gale Burstein, the county's Commissioner of Health, told me.
The county's crisis is part of the national tragedy that has long been in the making. It has surged like an invisible inferno, sweeping up tens of thousands of young American lives as it burns its way across the country. From 2010 to 2015, opioid drugs killed 153,824 Americans. Out of these, 45,178 died of heroin overdoses. The annual number of heroin overdose deaths has more than quadrupled since 2010, peaking at 13,000 in 2015.
At the heart of the statistics of death is a new reality—the white face of addiction. Across the United States, young whites are increasingly making up the largest percentages of annual heroin overdose deaths, according to the government agency the Center for Disease Control (CDC). Heroin addiction is no more merely an African-American problem, the way it has largely existed within the national imagination. Its symbols, both real and imaginary, are not the alienated young black men any more; they are no longer like Sonny, hero of one of James Baldwin's iconic essays — Sonny's Blues — that gives a reader access to the psychological world of urban African-American life and to the frustrations that inhabit it.
In Erie County, according to the data, out of the 295 overdose deaths recorded in 2016, 241 were white. In 2015, 221 were white out of the total 256 deaths.
There is a feeling that the changing face of the addiction is also changing the US response to it. The (white) addicts are now perceived more as "victims", in need of treatment and rehabilitation, rather than (black) "criminals" to be locked away in the country's overflowing prisons. There is also a change happening at the highest levels of politics. In a recent cabinet-level meeting with Mexican officials, US Secretary of State Rex Tillerson made a rare and bold admission, much to the welcome surprise of his Mexican counterpart — "We Americans must own this problem. It is ours," he said.
Opioids are a class of drugs used for reducing pain, particularly chronic pain. All of them contain heroin. While they produce analgesia, they also produce euphoria — feelings of pleasure and well-being. It is the effect of euphoria that causes addiction, a mental state when the patient starts craving for the drugs whether or not pain is there. The longer the prescription, the higher the likelihood of addiction. A person can obtain an opioid drug either legally through a doctor's prescription or consume it in an illicit form like pure heroin. Once the addiction happens, the patients either resort to taking large doses of prescription opioids, or turn to heroin, or do both. The overdose causes instant death. The drugs suppress the urge to breathe.
Even though medical research claims that only a small percentage of those on opioid therapy become addicts, the extent of smallness is relative. In 2014 alone, US retail pharmacies dispensed 245 million prescriptions for opioid pain relievers. Of these, three to four percent of the adult population — 9.6 million to 11.5 million people — were prescribed longer-term opioid therapy.
But how did the addiction get so bad?
More than 50 years ago, in The Affluent Society, John Galbraith made a path breaking observation about the behavior of consumption in societies. Galbraith disputed the centuries-old central idea of microeconomic theory, according to which production in a society is a response to its needs and wants that exist independently of the system seeking to satisfy them.
Put more technically, he rejected as a "myth" the idea that a society's demand curve can be plotted independently of its supply curve. He argued that consumer wants are created by the very process by which they are satisfied; that what people are able and willing to consume is influenced by producers.
Galbraith was writing about US society, and his thesis was driven as much by moral anxiety as it was by something he saw as being economically illogical. He feared that the system of relentless production favoured by the old logic of capitalism, one that he had disputed and that seeks to satisfy invented needs, can prove disastrous for a society.
It is hard to think of Galbraith's observations in the context of pain and production of painkillers in America. Hard, because one is likely to think how can the physical pain of individuals be invented or influenced by those who seek to cure it. But pain is a complex biological condition. Medically, all pain, regardless of its source, is both physical and psychological at the same time. It is not the prevalence of chronic physical pain that the producers of painkillers have influenced, or invented, in Galbraith's sense. It is the euphoria that they have.
The story of the epidemic's creation is a story of the management of pain in the US and the political economy that it has spawned.
A large number of Americans have some form of acute or chronic pain, about 100 million according to a 2011 report by the Institute of Medicine.
In the mid-1990s, after decades of public and medical debate, state legislatures began passing laws to relax a host of license and disciplinary regulations that for much of the 20th century had prevented doctors from freely prescribing narcotic painkillers. The debate had been driven as much by ethical concerns as it had been by medical and legal ones. The leaders argued they have a moral responsibility to act and reduce the suffering of those in chronic pain. The new laws were intended to shield doctors from being prosecuted for freely prescribing powerful painkillers.
But, to borrow from Charles E. Lindblom, in market oriented societies there are two forces behind all great organising and coordinating tasks: politics and markets. While the politicians were putting new institutions in place to lessen America's pain, the market, driven by the cult of profit-making, was readying for its own role. Pharmaceutical companies were soon going to flood America with deadly painkillers.
One of the major companies to do so was Purdue Pharma, established in 1991 by Richard S. Sackler, a scion of one of the wealthiest families in the world. In 1995, Purdue unleashed one of the most aggressive campaigns in the history of US medicine to promote and market OxyContin, an opioid painkiller that is also highly addictive. The campaign, fueled by millions of dollars, meant to influence doctors to flexibly prescribe the drug. Within a period of four years, from 1996 to 2000, sales of the drug grew from $48 million to almost $1.1 billion.
In 2007, the US justice department prosecuted the company. It paid $635 million in fines, but no one from the Sackler family faced charges. In 2016, Forbes estimated the family's worth at $13 billion.
Even as Purdue's drug was treating Americans' pain, it was also turning millions into addicts. By 2004, OxyContin had become a leading drug of abuse in the United States.
When the realisation finally hit home around 2006 and states begun to tighten the prescription regulations, it was too late. By 2010, as the Prescription Monitoring Programs (PMP) started to take effect, a vast population of addicts was turning to streets to obtain the illicit opioid — heroin. The PMPs allowed prescribers to monitor all the controlled drugs that their patients were getting from all the prescribers. However, "when doctors stopped prescribing licit drugs to these patients, they turned to the illicit market where diverted prescription drugs and highly potent illegal drugs were becoming more available at lower costs," Dr. Richard Blondell, Professor and Vice-Chair for Addiction Medicine at the University at Buffalo's Jacobs School of Medicine, told me. The system had created a new demand for cartels to step in.
By now, the cartels had also figured how to manufacture fentanyl — a synthetic opioid painkiller that has been particularly behind the recent scourge of overdose deaths. It is 100 times more powerful than morphine and about 50 times more powerful than heroin. It is cheap.
"It is so potent that quantities equivalent to five or six grains of salt can kill a person," Dr. Blondell told me. The cartels knew the magnitude and intensity of America's new addiction. It was only a matter of time before heroin laced with fentanyl was going to appear on the American streets.
It was fentanyl from the street that had killed Kate, Amy's daughter. She had started taking OxyContin at the age of 17. Soon after, the medicine had given her the addiction. "She would then take anything to get high," Amy told me. In the end she turned to heroin, and then fentanyl.
All the dead children I came to know about from the parents in Buffalo had followed the same sequence: prescription opioids—addiction—more prescription drugs—heroin—death from overdose.
Dr. Blondell, who for decades has cared for patients of drug addiction, has twice received the Best Doctors in America award, and has an active research programme on addiction medicine, had no hesitation in saying that the current epidemic is a creation of the US healthcare system. I asked him if in the entire story of this disaster doctors are somewhere complicit; when they prescribed long term opioid therapies, did they not know what it can do to the patients, did they not warn them?
"Greed can leave some individuals empty of all moral considerations," he said while looking at two newspaper clippings pinned to his wall.
The clippings featured stories about Dr. Eugene J. Gosy and Dr. Pravin V. Mehta. Dr. Gosy, a local neurologist, had been accused last April by Federal prosecutors of criminal conspiracy for issuing more than 300,000 illegal opioid prescriptions in four years. In September 2015, the authorities had seized two of Gosy's cars—a $126,000 Ferrari and a $103,000 Ford GT coupe. Dr. Mehta, who practiced in the adjacent Niagara County and had an estimated net worth of $13 million, had been sentenced to two years in prison in January 2016 for issuing tens of thousands of opioid prescription over a five year period. Among the locals, Mehta is known by the name of Dr. Feel Good.
When I stepped out of Dr. Blondell's office, I googled "Dr. Gosy, Buffalo NY" on my phone. The first result that popped up was "Gosy & Associates: the Pain Management Associates of Western New York". The page directed me to a new website, flashing a message: "New name, same great care!"
In June 2016, the US Magistrate Judge Kenneth Schroeder issued an order allowing Dr. Gosy to resume ‘limited' practice. Dr. Gosy's defence argued that the community faced a greater danger if he was not allowed to continue practice; that his patients would find no treatment. I thought how the system, perhaps, had become its own iron cage.
Shannon Veiders, a recovering addict I met in Buffalo, embodies how the institutional arrangements for treating America's pain translated into the addiction of individuals.
In 2005, at the age of 22, Shannon had her second child delivered through a cesarean section. For the pain, the doctor gave her Vicodin, the market name for hydrocodone, an opioid painkiller. Shannon also had a gastric bypass surgery.
"The doctor gave me big bottles of liquid hydrocodone." Within a period of five months, Shannon got hooked to the drug.
"There was no pain now, but I craved for the drugs. It was so easy to obtain them. I wouldn't even need to see my doctor. I would just call him and he would call the pharmacy for me. I kept getting the drugs as much as I wanted." Between 2005 and 2010, Shannon lived a life of chronic addiction. "There were days when I would consume as many as 80 pills."
Shannon also entered the trade. Because it was so easy to obtain the prescriptions, she would stockpile them and sell them to other addicts. "This is a common practice among the patients," she told me. She would use the money to buy crack and heroin.
In 2008, Shannon ended up in prison. A friend, pretending to buy drugs from her, tipped off the police. Sometime in 2010, largely because of the fear of prison, she decided to return to the life she had lost. She took help and rehab and slowly recovered.
She is now a team leader at Addict 2 Addict, a group of recovering addicts in Buffalo city that helps those who want to come out of their addiction. "I wish the doctor had at least once told me what the drugs would do. Maybe I would have been careful," she said.
Because she had been in the trade, I asked her about fentanyl and how people end up taking something that kills them. Her answer was unsettling. "If a local dealer packs ten bags of heroin, he would deliberately make one that has deadly proportions of fentanyl. They call them kill-packs. It is a way to shore up the business. When the customers know something kills, they know it is the best stuff. They start seeking out the dealer."
Mark Nettleton is another recovering addict who works at the Addict to Addict. In 1997, at the age of 14, Mark had an accident while racing his dirt bike. He was operated on and prescribed oxycodone for the pain.
"Within a month of operation my pain was gone, but the feeling the drug had given me was irresistible now. Everything went downhill from here. I lost everything and the drugs became my only love." From 1997 to 2010, Mark lived the life of a chronic addict.
For years, Mark would obtain the prescriptions through "doctor shopping," a practice that allowed patients to obtain multiple opioid prescriptions for nonmedical use from different unknowing physicians. Doctor shopping would allow Mark to stockpile the drugs like Shannon did. He would sell them and use the money to buy illicit drugs like heroin and cocaine. "I did this for years," he told me.
One of the mothers I met in Buffalo was Debra Smith. Her son, Nathaniel Smith, died on September 15, 2015 from an overdose. He was 26. After Nathaniel died, Debra told me she went to meet the doctor who had prescribed him the painkillers.
"I wasn't angry. I was looking for things to heal myself. I still am." She told me she asked the doctor whether or not he knew what was in those pills and what they could do to her son. "The doctor said yes. I said, ‘don't you have a Plan B?'" The doctor replied, "I am sorry, Ma'am. We don't even have a Plan A."
In my meeting with Dr. Blondell, I also asked him why no one tried to change things for a long time. He said, "If you want to know why, follow the money." He meant the lobbying power of the pharmaceutical companies.
But, in a system that thrives on partisan politics, when issues acquire political mileage for the actors, there is always a danger of denials and inappropriate responses from those who have the responsibility of dealing with them. Last week, the Washington Post published a transcript of a call that President Donald Trump had with his Mexican counterpart, Enrique Pena Nieto, on January 27. In the call, Mr. Trump, in his quintessential manner, lashed out at Mr. Nieto: "we have the drug lords in Mexico that are knocking the hell out of our country… Up in New Hampshire — I won New Hampshire because New Hampshire is a drug-infested den — [it] is coming from the southern border," he added.
The state's lawmakers were quick to reject and condemn Trump's comments as insensitive. Senator Maggie Hassan, former governor of the state, called Trump's remarks "disgusting". She added, "As he knows, NH and states across America have [a] substance misuse crisis."
There is hardly any doubt that the current epidemic is largely the country's own creation. Its solution needs a comprehensive reassessment of the system that has been silently creating a mass craving for drugs.
As Dr. Blondell told me, "We are looking at a vast river in which our kids are drowning, and all we have done so far is try to pull them out. But we can't save all of them because there are too many of them. We have to go upstream and change what is making them fall in the first place."
One hopes that back in January, Trump made the comments because he was still in the heat of the bitter campaign he had just left behind. One hopes that since then his views have changed, and that may indeed be the case. On Thursday, at his golf club in Bedminster, New Jersey, the president announced that he is preparing to declare the epidemic a national health emergency.