Lethal Relief: The Irony and Destruction of America’s Opioid Crisis

A look at how our nation’s attempt to treat pain only made things worse

While the world has been fixated on COVID-19 over the last three years, America has been battling a long-standing health crisis at home: its population’s addiction to painkillers. Some blame the medical professionals who normalized the alarmingly liberal prescription culture of today, where anything from coughing to back aches are enough to warrant access to pain pills. Others point fingers at Big Pharma for employing misleading marketing tactics for substances with high addiction potential. The reality, as we’ll find, is a combination of both. 

When we talk about painkillers, what we’re really talking about are opioids, a class of drugs derived from the opium poppy plant. The primary use case of opioids, as you may have guessed, is to provide pain relief, but when consumed in unregulated amounts users face the risk of developing a long-term dependency on and addiction to its renowned euphoric high. I recall my mother being hyper aware of these risks when I had my wisdom teeth removed or was in the midst of recovering from a knee injury. “Take them as a last resort, and don’t take more than you need,” was her attitude.

To put our nation’s pill use habits into perspective, Americans consume 80% of the world’s prescription opioids while making up only 5% of the global population, where patients are regularly prescribed higher doses than needed. It’s no wonder, then, that the U.S. is in the midst of a worsening substance abuse problem, where in 2021, there were 107,622 deaths in the U.S. from drug overdoses, up 15% from the year prior and an all-time high. 

What’s more is that nowadays, prescription painkillers aren’t even the main issue: They were simply the catalysts. People originally hooked to prescribed medicine have since found illegal and cheaper substances with significantly stronger highs to satiate their addiction, such as heroin and fentanyl. 

As we’ll find, America’s journey with opioids is a tale of greed, unethical marketing tactics, business-savvy drug lords and an ironic case of how a ‘breakthrough medical innovation’ became a driving force behind one of our nation’s worst health crises to date. While many parties were at fault, a few major factors can be pinpointed as significant drivers of the crisis today. They are as follows:

1. The Rise of Purdue Pharmaceutical 

2. The Business-Savvy Xalisco Boys

3. The Unsuspecting Ubiquity of Fentanyl 

The Rise of Purdue Pharmaceutical  

American healthcare’s liberal approach to prescribing medication wasn’t always a thing, at least when it came to opioids. In fact, for most of the 1900s, there was a pervasive ‘opioid-phobia’ among doctors who feared the drug’s addictive potential and avoided prescribing them for even the most dire of patient cases. But at the turn of the century, a new wave of change was brewing within the community; there was an emerging attitude that chronic, non-cancer pain was undertreated, that opioids were being underutilized and that the risks for getting hooked to the drug were overblown.

Many of these conclusions were based on unverifiable claims and misinformation. Nonetheless, this culminated into changes being made at the institutional level, including the introduction of new pain management standards and an overall more outspoken attitude within the medical community around a patient’s right to pain relief. As institutional changes coaxed the industry towards embracing a more liberal prescription culture, a similar campaign was already occurring among other stakeholders in the field, where pharmaceutical companies aggressively lobbied for opioid prescription reform.

The eventual massive boom in the popularity of painkillers, however, can largely be drawn back to the efforts of one pharmaceutical company in particular: Purdue Pharma, the producers of OxyContin. 

Purdue’s origins can be traced back to 1952 when it was purchased by Brooklyn-born brothers Arthur, Mortimer and Raymond Sackler, all of whom had some form of a medical background, with Arthur notably rising to prominence as a ‘gifted’ medical advertiser. Back then, Purdue was an unassuming patent-medicine company based in Greenwich Village, but under its new ownership it relocated to Connecticut, underwent a rebrand and by 1996 released its breakthrough medical innovation: OxyContin.

Now, OxyContin marked a new kind of painkiller for the times and was especially notable for its patented time-release formula and availability in doses more potent than any other painkiller in the market. And while the pro-opioid movement was already underway at the time of its release, the medical community still needed to be convinced it was safe to prescribe.

To tackle this, Purdue launched an aggressive marketing campaign to snuff any existing doubts around Oxycontin’s efficacy and addictive potential—spending as much as $200M on marketing alone in 2001. As reporter Patrick Radden Keefe found in his investigation into the Sackler family and Purdue, this took the form of several tactics, those primarily being:

1. Militarizing an aggressive sales team: Purdue sales representatives attended extensive training sessions that equipped them with data and responses specifically catered to combat clinician questions about the drug. Some of the representatives’ go-to talking points, such as that less than 1% of patients who took OxyContin were at risk of addiction, were found to be outright false; the reality was closer to 13%. Representatives were also instructed to reform the idea that painkillers could only be used for severe, short-term injuries, and instead insist that the medication was safe for more acute, long-term cases, like back and joint pain.

2. Sponsored speaker bureaus: Purdue sent doctors on free trips to speaker bureaus and pain management seminars in tropical locations to hear paid clinicians promote and celebrate OxyContin—and it worked: Those who attended these seminars were twice as likely to write prescriptions for the drug than those who didn’t.

3. Peer-to-Peer marketing: Knowing that reshaping a set of long-standing beliefs on such a high stakes matter would not be easy, Purdue heavily leaned on peer-to-peer marketing to break into the physician circle. By sending paid clinicians to speak at industry events and paying doctors to promote the drug in medical journals, they knew that the most effective way to get buy-in would be for the medication to be championed from the inside. 

4. Targeting the highest prescribers: Perhaps a more sinister part of Purdue’s marketing strategy was the methods with which they identified their physician targets. Through leveraging I.M.S., a data company that provided insights into the prescription habits of doctors, sales representatives were able to target physicians who were the most frequent opioid prescribers and thus most likely to have the largest client bases with chronic-pain (or who were simply those over-prescribing). Many of the targeted areas were found to be in lower-income, higher-poverty regions.

While deceptive in nature, these tactics were effective and, in tandem to the broader industry changes afoot, ultimately successful in their goal of rebranding the drug in the minds of physicians. Eventually, the floodgates for new prescribers finally opened, and in 1997-2002 prescriptions for OxyContin increased 10X for non-cancer related pain alone.

Early Signs of Abuse

One of the key characteristics of OxyContin was its time-release formula, which gradually released the medication into the user’s bloodstream. As prescriptions shot up, users figured out ways to deliver stronger highs by crushing and snorting or dissolving and injecting the pill instead. Between these new means of drug consumption and the false narratives being circulated about the drug’s addiction potential, abuse quickly began to run rampant. 

Initially, the hardest hit areas were lower income states, including West Virginia, Kentucky and Alabama, but the problem gradually escalated to a national scale, where in 2004, OxyContin became the most abused prescription opioid in the U.S., marking the first of three waves of mass deaths on the opioid crisis timeline.

Purdue’s lies eventually caught up to them in 2007, when they pled guilty for misbranding the addictive properties of OxyContin and were forced to cough up $634 in fines. But the drug had already done its damage, and the ramifications were only just beginning. 

The Business-Savvy Xalisco Boys

In 2010, with a clear opioid crisis on their hands and a drug patent that was about to expire, Purdue released a reformulation of Oxycontin made from an ‘abuse deterrent’ substance that essentially made it impossible to crush and ingest the pill. Though well-intended, plenty of alternatives to the drug were already available on the black market, and one of the cheapest, most accessible among them was heroin.

Down south, Mexican drug traffickers were already cooking up their own version of this drug: Black tar heroin, aptly-named for its dark and sticky-like appearance, was a cheaper, less-processed but more potent form of heroin that could be injected or smoked by users. 

Undoubtedly the most prolific of these traffickers was a group of savvy entrepreneurs called The Xalisco Boys. Originally immigrants from a small county in the Mexican State of Nayarit, the group created a brilliant, end-to-end system for heroin distribution within the U.S. rooted in convenience, customer service and non-violence. Their operations were made up of small, independent crews, each with a leader and set of drivers. The way it worked was a number would be passed around town for buyers to dial in, and once the number was called, an operator would direct both the driver and caller to a meeting point where the hand-off would occur. Drivers would carry the heroin in tiny balloons stored in their mouth, ready to be conveniently swallowed in the event of a drug bust. 

The genius behind this system, as journalist Sam Quinones articulated in “Serving All Your Heroin Needs” was how ‘anti-Scarface’ and covert the whole operation was. Whereas most drug cartels at the time typically ran as large-scale operations spearheaded by a main ‘Jeffe’ and often heavily relied on violence, these traffickers were hanging out in normal-looking cars without any need for weapons and employing the typical marketing tactics of any customer-centric business. In fact, it was common practice for crews to collect customer feedback on the quality of their services, offer discounts and reward existing clients for referrals. 

In short, the addicts didn’t have to venture far to get their high, while the drivers hung tight in their cars racking up as much as $80,000 on a weekly basis. Many of The Xalisco Boys had modest, blue collar jobs back home, but through trafficking, they were micro-entrepreneurs, able to build their own mini empire and make significantly more money than they could ever back home. It was their version of the American Dream. 

This of course came at the devastating cost of addicts in the areas they targeted, which were primarily mid-sized cities and suburbs in the Midwest. It was typically in these regions that there was already a growing population of addicts, primed from being hooked on prescription painkillers but without any established heroin lines or distributors to turn to. As a result, in most of these areas it was The Xalisco Boys who introduced the addicts to this new form of opioids. 

As the trafficking network tore through the most vulnerable population of America’s addicts, 2010 marked the start of the second wave in mass opioid deaths and an opening of the gateway into illicit opioid consumption. 

The Unsuspecting Ubiquity of Fentanyl 

As heroin became the new drug of choice, the use of other illicit opioids followed not too long after. In fact, the third wave of the opioid saga, which we are still in the midst of today, took off just a few years later in 2013. In this phase, deaths are primarily driven by fentanyl—a synthetically produced drug that is 50x more potent than heroin. Just two milligrams of fentanyl, which is about the size of a mosquito, is enough to deliver a lethal dose. 

While fentanyl does have legitimate use cases under medical supervision, such as in treatment for cancer or post-surgery relief, it’s more often illegally made and sold as a street drug and is becoming an increasingly ubiquitous contaminant to other drugs, often in lethal doses and unbeknownst to users. In fact, in 2021, almost ⅔ of overdose deaths were fentanyl-related, where victims were often unaware that their drugs were laced in the first place.

In 2022, the DEA had seized 50.6 million fentanyl-based products and over 10,000 pounds of fentanyl powder, equating to around 380 million lethal doses. Sustained efforts have been made to snuff the flow of fentanyl into the country, but the drug’s supply chain has only grown increasingly more complex as new trafficking nodes continue to emerge globally. China is primarily responsible for most of the fentanyl and fentanyl chemicals that come into the U.S. today, which are often first funneled into Mexico for manufacturing. From there, the Sinaloa Cartel and the Jalisco New Generation Cartel act as the primary traffickers and distributors who transport the drugs into the U.S. 

The ubiquity of fentanyl remains a top of mind issue as traffickers continue to lace other street drugs to unsuspecting buyers or sell fentanyl disguised as anything from candy to different branded prescription painkillers. It’s also a particularly urgent issue among young adults and teens, as dealers have leveraged everything from the dark web to social media platforms to reach new customers.

Steps to Proper Recovery

Overdose deaths have been on the rise since 1999, notably jumping 30% during the pandemic year-over-year. And while recent data shows that they aren’t quite increasing at the exponential rate they once were, they’re still at an all-time high in comparison to the last decade.

So what’s being done? Unfortunately, research shows that battling opioid addiction is a long and complicated process, and not a simple matter of cutting off access to the medication; for instance, a study on a group of Medicaid patients who had been taking high doses of opioids for a sustained period of time were found to be 3.5-4.5x as likely to die by suicide than their peers when their medication supply ended. Thus, working directly with addicts to develop a more balanced, nuanced approach to rehabilitation, including using medically-assisted detoxes as needed, will be a key component for effectively addressing the crisis and getting users clean.

Treatment affordability, a lack of state resources and negative stigmas around addicts present headwinds to our nation’s fight for recovery, but recent steps by the government indicate that changes are underway to grant greater access to care: In May of 2022, Biden Admin announced $1.5B in funding to support opioid use treatments, and with Big Pharma lawsuits finally being settled, more funds are expected to be distributed to state and local parties to support local relief programs and resources.

The Sacklers Today

As for the Sacklers, on March 3rd, 2022, a national settlement was reached for them to pay $6 billion in damages for the role they and their company played in America’s opioid crisis. But while Purdue Pharma has pled guilty to criminal wrongdoing, the Sacklers themselves never faced criminal charges and have persistently denied personal liability. In fact, as part of this new settlement, the Sacklers would be immune from current and future civil lawsuits related to Purdue and OxyContin. As Slate reporter Brian Mann characterized it, Purdue is ultimately the sinking ship of the Sacklers’ legacy that they’re attempting to pay off in order to keep the rest of their estate afloat.

To be clear, as we’ve seen The Sacklers were far from being the only players responsible for the opioid crisis today. It was a clear failure across multiple levels, from the institutions that pushed for a reform of pain management in the first place, to the regulators that allowed Purdue get away with their questionable tactics, to the black market cartels that brought illicit alternatives to addicts’ doorsteps. 

But as the suppliers of what was the ‘Goliath’ painkiller at the time, The Sacklers and Purdue rightfully maintain a bulk of the responsibility. The family has made at least $10 billion from OxyContin and remain billionaires to this day. And as their settlement becomes finalized, looming questions around pharmaceutical regulation, the ethics of medical marketing and holding higher corporations accountable remain. 

In the meantime, local governments and families nationwide are left to deal with the destruction of a pill that, while originally meant to kill pain, ended up simply killing millions of Americans in the process.