[It’s easier to blame individuals for the opioid crisis than to
attempt to diagnose and cure the ills of a society.]
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PORTSIDE CULTURE

THE PROBLEM OF PAIN   [[link removed]]


 

Sophie Pinkham
April 1, 2021
Dissent [[link removed]]

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_ It’s easier to blame individuals for the opioid crisis than to
attempt to diagnose and cure the ills of a society. _

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_White Market Drugs: Big Pharma and the Hidden History of Addiction in
America_
David Herzberg
University of Chicago Press 
ISBN:
978-022-673-1919                                                                                                                                                         

Reams have been written about the misdeeds of Purdue Pharma, the
manufacturer of OxyContin, and Purdue’s majority owners, the Sackler
family. After years of litigation prompted by spiking overdose rates,
in November 2020 Purdue pleaded guilty to conspiracy to aid and abet
doctors in dispensing OxyContin without a legitimate medical purpose.
The company was ordered to pay $8.3 billion in penalties, damage, and
forfeiture. This sum is less impressive than it looked in headlines:
Purdue’s bankruptcy in 2019 means that the money is unlikely to be
collected. Though they were branded as villains in the eyes of the
public, the Sacklers escaped criminal charges and had to pay only $225
million of their family money—small potatoes for a family that took
some $10 billion out of Purdue between 2007 and 2017.

Mostly overlooked was the fact that OxyContin was only the latest in
America’s long history of pharmaceutical disasters. David
Herzberg’s _White Market Drugs: Big Pharma and the Hidden History of
Addiction in America _seeks to correct this “radical act of
forgetting” by examining the troubled history of psychoactive drugs
in America. He considers licit and illicit drugs together, arguing
that the marketing of medicine relies on the stigmatization and
criminalization of those who consume drugs outside the medical system;
the development of America’s gargantuan pharmaceutical markets must
be understood alongside the growth of the illicit drug market. His
choice of the phrase “white market” to describe pharmaceuticals
reflects the racial bias that has been baked into this system from the
start.

The distinction between licit and illicit drugs hinges on binaries:
healing versus harm, relief of suffering versus desire for pleasure,
medication versus recreation, obedience versus rebellion. These
oppositions crumble under the slightest pressure. There are countless
examples of harm caused by medical interventions. In the case of
psychoactive medications, the most severe unwanted effects include
addiction, psychosis, overdose, and suicide. Illicit psychoactive
drugs, meanwhile, can heal. Ibogaine can help those addicted to
heroin; psychedelics and MDMA can help relieve PTSD, depression, and
anxiety in some people; opiates, stimulants, and sedatives can help
people survive the aftermath of trauma or the suffering of unhappy
everyday life. Relief is a kind of pleasure, engendering desire.
Recreation relieves pain, and obedience can be a form of self-harm.

Drugs often move from one category to the other. Cocaine was first
marketed to Americans as a pharmaceutical. Bayer’s Heroin
(diacetylmorphine), named for its heroic powers, was introduced in
1898. Today, cannabis, MDMA, psilocybin, and ketamine are all in the
process of moving from the illicit to the white market. They’re the
same as they ever were; we’re the ones who have changed. A bottle of
Adderall prescribed for a student struggling with term papers or a
banker exhausted by long working hours can have a new existence at an
all-night party. A drug becomes illicit when it’s used for fun.

Medical diagnoses legitimize the need for relief in the eyes of the
law, but diagnosis is subjective, shaped by a doctor’s
preconceptions about a patient on the basis of race, class, gender,
age, sexual orientation, and self-presentation. A diagnosis and
prescription can be a reward for conformity or a blunt instrument used
to enforce it. In the 1970s, feminists protested the widespread
prescription of Valium, which they viewed as a tool to suppress female
rebellion. If, on the other hand, you’re looking to be prescribed a
particular drug, be sure to dress neatly—imagine you’re going to
court—and tell the doctor you need the pills for your office job.

The story of America’s love affair with pharmaceuticals starts in
the late nineteenth century, during a period of rapid
industrialization and rising consumerism. Among the cornucopia of new
commodities were products derived from the poppy and coca plants.
(Imperialism, colonialism, and global trade are important parts of
this story, though they’re beyond the scope of Herzberg’s book.)
Scientific advances in extracting psychoactive elements and the
invention of the hypodermic syringe offered potency that would have
been unthinkable a few decades earlier. Amid widespread suffering due
to lingering Civil War injuries as well as everyday disease, and with
very few effective medicines or medical treatments available,
Americans embraced the new drugs. Opiate use rose threefold between
1870 and the mid-1890s, and cocaine use increased by a factor of ten
between 1883 and 1893. Opiates were used to treat not only pain but
“respiratory disorders, diarrhea, syphilis . . . insomnia, anxiety,
overwork, masturbation, photophobia, nymphomania, and violent
hiccough,” Herzberg writes. Cocaine started off as an anesthetic,
but it was soon prescribed for various “nervous diseases” and for
hay fever. Traditional societies had long used poppy and coca to treat
a range of maladies, but they had never used it in such strong
formulations or via injection or insufflation. A pattern of
disturbing, compulsive use of morphine, cocaine, and related drugs
soon emerged, and was eventually named “addiction.” Markets still
operated on the principle of caveat emptor, without significant state
regulation_._

Legal morphine and cocaine were available, Herzberg explains, to the
“doctor-visiting class,” who were characteristically “white,
native born, Protestant, middle aged, and middle class.” But all
kinds of people wanted the new drugs, and those who did not fall into
the doctor-visiting class acquired them through informal channels.
Some Chinese laborers, who were mostly segregated into disreputable
urban areas, frequented “opium dens,” where drugs were used not by
medical prescription but on a social model analogous to the
consumption of alcohol in bars. (Chinese opium consumption had
dramatically increased after Britain coerced China into importing
opium from the Indian colonies, but Americans viewed opium smoking as
an “Oriental” vice.) White women opium smokers and their potential
sexual relations with Chinese men became the focal point of racist and
xenophobic crusades—a moral panic trope that would recur in
anti-drug campaigns over the following decades. Meanwhile, reformers
advocated for protection of white-market consumers through greater
regulation of morphine and cocaine.

The campaign to control opiates and cocaine was an early example,
Herzberg argues, of an artificial and explicitly racist distinction
between “respectable” white consumers, who were portrayed as
innocents in need of protection, and stigmatized, largely nonwhite
consumers, who became the target of punitive, prohibitionist tactics
that endure today. In 1877, the _New York Times _wrote that morphine
“habitués” were rare among “the laboring classes,” “the
negro and Indian races,” or “tramps.” In fact, morphine users
were “the highest, worthiest, and best educated people in the
country—those whose social and intellectual status gives them a
certain pre-eminence over the masses.” Morphine was dangerous but
chic, used by cultured intellectuals to relieve the pain of a highly
refined existence. Chinese opium smokers, on the other hand, had
“corrupt and effeminate manners, and . . . decided tastes for
negative enjoyments and a dreamy and contemplative life,” per an
1866 newspaper article. Opium dens were banned around the time of the
Chinese Exclusion Act. Chinese opium smoking was a vice; white opium
use was a disease. The moral distinction drawn between morphine users
and opium smokers would be echoed a century later in the racist legal
distinction between powder and crack cocaine.

From the perspective of white, “respectable” consumers, efforts to
regulate opiates were quite successful. Stronger medical licensing
laws, the introduction of a system of prescription-only requirements
for opiates and cocaine, control of “patent” medicines, and
restrictions on advertising and publicity helped dramatically decrease
the rate of morphine prescription and consumption. The prohibition
side, by contrast, was a disaster. Opium was bulky and smelly, making
it hard to smuggle after the United States banned the import of
smoking opium in 1909. The informal market moved to a lighter,
scentless, more potent product: heroin, which was often injected
rather than smoked, maximizing addictive potential and the risk of
overdose. Herzberg argues that the dual processes of regulatory reform
in the medical sector and heightened criminalization in the informal
market hardened the distinction between “good” patients who had
accidentally become dependent and “bad” addicts, who had succumbed
to vice. “White markets became both safer and less publicly
visible,” he writes, “while informal markets became both more
dangerous and more visible.”

In response to the heavy state scrutiny of opioids, the pharmaceutical
industry turned to other psychoactive drugs: barbiturates,
benzodiazepines, and amphetamines. The first commercial barbiturate
was Bayer’s Veronal, introduced in 1903. Pharmaceutical companies
scrambled to patent their own barbiturate brands and to promote
diagnoses that would call for barbiturate prescriptions: according to
Herzberg, these included sleeplessness, “nervousness and
restlessness,” “hysteria, bronchitis, hypertension, dysmenorrhea,
‘sexual irritability,’ and ‘nocturnal pollutions.’”  These
campaigns took place at a time when increasing creativity in
marketing, technological advances, and changes in manufacturing and
transportation “brought an unprecedented array of new devices to
solve a dizzying array of problems that advertisers taught Americans
that they should no longer have to endure,” he notes. It was easy to
die from a barbiturate overdose, and soon death rates—by accident,
suicide, or homicide—began to rise.

Efforts to put tighter controls on barbiturates went nowhere in the
1920s, when the government was strongly pro-business, but gained a
foothold in the 1930s, a period of expanded government regulation and
intervention. (This was also the decade when cannabis was classified
as an addictive narcotic, in a campaign that associated the drug with
insanity, violence, and racial minorities.) But attempts at regulation
encountered resistance from pharmaceutical companies, pharmacists, and
physicians worried about lost profits, burdensome paperwork, and
diminished authority. A coalition of opponents of reform adopted the
time-tested strategy of blaming barbiturate addiction and overdose on
criminals who were diverting pills. The answer, they said, was to
crack down on criminals, not pharmaceutical companies and doctors.

In the 1950s, white Americans were awash in legal barbiturates even as
law enforcement cracked down on illicit drug use in urban areas with
nonwhite populations, introducing mandatory minimum sentences for drug
infractions. Billie Holiday died in 1959, handcuffed in a hospital
bed, after twenty years of harassment by the Federal Bureau of
Narcotics. Marilyn Monroe overdosed on doctor-prescribed barbiturates
alone in her Brentwood home in 1962; her erstwhile lover, President
John F. Kennedy, convened an Advisory Commission on Narcotic and Drug
Abuse that endorsed federal control of barbiturates and stimulants. In
the 1950s, the rate of fatalities from pharmaceutical sedatives was
four times higher than that caused by opioids. Even during a period of
increased heroin use in the 1960s and 1970s, more Americans died from
legal sedative overdoses than from illegal opiates.

Barbiturates were joined in the white market by amphetamines—fuel
for the Second World War, the postwar economic boom, the Beats, and
Andy Warhol’s Factory—and by less potent tranquilizers like
benzodiazepines. Mother’s little helpers allowed housewives to
vacuum with record speed, pick-me-up pills helped businessmen work
long hours, and tranquilizers helped salesmen overcome their social
anxiety. The psychiatrist brothers Arthur, Raymond, and Mortimer
Sackler helped market benzodiazepines, which were presented as a safer
alternative to barbiturates, through advertisements, “education”
campaigns, and the expansion of diagnoses for which benzodiazepine
treatment was indicated.

In the 1960s, during a rise in countercultural drug use, the consumer
advocacy, civil rights, and feminist movements challenged the
artificial divide between medicines and drugs. Their reform efforts
focused on the rapaciousness of pharmaceutical companies and on racial
and gender discrimination in medical treatment and drug policy. They
pushed for tighter regulations of commercial actors, which resulted in
a sharp decline in the use of stimulants and sedatives. Herzberg sees
this as a brief bright spot in American drug policy. Still, the reform
efforts were rooted in the “distinction between sellers and
consumers,” which Herzberg argues “made practical sense only in
white markets, where sellers were easily identifiable corporations,
physicians, and pharmacists. In informal markets the line was far
harder to draw because people with addiction so often also sold drugs
to support their habits.” The crackdown on prescriptions prompted
the rise of a gray market of “scrip doctors” and “pill mills.”

This relatively progressive period in drug policy was short-lived. The
Reagan era loosened regulation on the pharmaceutical industry and
introduced much harsher punishments for illicit drug use. Meanwhile, a
new wave of stimulants and sedatives was rebranded for a new era of
drug consumption. As Food and Drug Administration (FDA) restrictions
relaxed, direct-to-consumer pharmaceutical advertising skyrocketed.
Spending on pharmaceutical ads rose from $12 million in 1989 to $2.24
billion in 1999.

These trends were accelerated by the American Psychiatric
Association’s 1980 diagnostic guide, the _DSM-III_, which defined
illnesses not according to etiology but on the basis of a checklist of
symptoms. Such reporting was highly subjective, but it supported the
increasingly complex system of insurance reimbursements and the
testing of new pharmaceuticals through double-blind,
placebo-controlled trials. (These trials were often funded by
pharmaceutical companies, which routinely manipulated the resulting
publications to increase evidence of effectiveness and hide evidence
of negative side effects.) By ignoring the causes behind psychiatric
disorders, the _DSM-III_ turned natural human responses to difficult
circumstances—grief, despair, boredom, worry, distraction,
anger—into reasons for medical intervention. The 1980 manual listed
265 mental illnesses; by the time the _DSM-IV _was released in 1994,
there were almost 400. Antidepressants became new blockbusters. An old
stimulant from the 1950s, methylphenidate, was dusted off, rebranded
as Ritalin, and marketed for attention deficit disorder, which had
first been codified in the _DSM-III_. Amphetamine roared back as
Adderall, which soon became ubiquitous in high schools and colleges.
America was returning to the Gilded Age of barely regulated, heavily
advertised wonder drugs. Let the buyer beware.

The most striking throwback, according to Herzberg’s account, was
Big Pharma’s success in launching an unprecedented boom in opioid
use. The use of opioids to treat acute pain was nothing new; the
change was in their use to treat chronic pain. Opioids were
rehabilitated with the help of a small group of doctors who advocated
for expanded access to these drugs, not only in acute cases or at the
end of life but for chronic conditions. These “radical reformers,”
as Herzberg calls them, put forth a theory that distinguished
addiction from dependence. If opioids were used as prescribed for
pain, they argued, physical dependence might result, but this was
distinct from the destructive, rapidly escalating effects of
“psychological dependence.” In a landmark paper, Kathleen Foley
and Russell Portenoy argued that addiction should be understood not as
physical dependence but as “a set of aberrant behaviors marked by
drug craving, efforts to secure its supply, interference with physical
health or psychosocial function, and recidivism after
detoxification.” Other reformers argued that when pain patients
desired larger doses of opioids, this was only
“pseudoaddiction”—the result of inadequate dosage from their
physicians. These new definitions helped legitimate the use of opioids
for longer periods and in a wider range of cases. Herzberg points out
that they also served to reinforce the stigma of any informal-market
drug use, affirming the obvious fact that white-market drug dependence
is far safer and easier than dependence on drugs that have been
illegally obtained. Patients receiving drugs from a doctor are less
likely to experience cravings and the “aberrant behaviors” that
follow them because their drug supply is stable.

Purdue Pharma embraced this turn in pain management with the launch of
their new slow-release oxycodone formulation, OxyContin, which was
designed for chronic pain. They gave extensive support to the small
group of radical pain reformers, funding medical societies, journals,
chairs, and studies. In keeping with the larger pattern of corporate
capture of government during this period, the FDA medical officer who
oversaw OxyContin’s successful application went on to become
Purdue’s executive director of medical affairs. Purdue promoted the
use of OxyContin not only for pain associated with terminal illness
but, Herzberg tells us, for “back pain, osteoarthritis, neuropathic
pain, postoperative pain, rheumatology, dentistry, [and]
sports/rehabilitation.” As insurance companies grew less likely to
cover cognitive behavioral treatments or physical therapy for chronic
pain, pills offered an attractive alternative for both patients and
doctors.

To protect the sales potential of this potent opioid, it was
imperative that it be perceived as a respectable white-market
medicine. Purdue therefore focused its marketing efforts on white
consumers and white areas like northern New England, Kentucky, and
West Virginia. Physicians prescribing unusually large volumes of
opioids had once been the targets of investigation. Now Purdue sales
representatives were instructed to train their sights on this same
category of doctors. Meanwhile, other companies were developing
competing opioids; the Johnson & Johnson subsidiary Janssen threw its
hat in the ring with fentanyl patches and lollipops.

It quickly became apparent that use of pharmaceutical opioids was
turning into a public health crisis. Learning nothing from the past,
authorities cracked down in the most counterproductive way possible.
They targeted drug diversion, cut off “abusers” of legal pills,
and aggressively pursued and punished informal market suppliers—even
people who had merely given a single dose to a friend—while doing
virtually nothing to rein in pharmaceutical companies or to improve
access to drug treatment, overdose prevention, or alternative pain
treatment. People who had become dependent on OxyContin were pushed
into the informal market, buying diverted pills or, even more
dangerous, counterfeit pills or heroin, whose potency could never be
guaranteed and which were increasingly contaminated with the far more
potent fentanyl and carfentanil. The result was an unprecedented
increase in overdose rates.

After college, I worked for some of the “radical pain reformers”
Herzberg describes. I was an administrative assistant in the Open
Society Institute’s International Palliative Care Initiative, whose
medical director was Dr. Kathleen Foley. While reading Herzberg’s
book, I recognized the names of people I’d known as kindly doctors
who had devoted their careers to the care of the dying. Back then,
sitting in my cubicle, I was moved to tears by reports about Mongolian
cancer patients forced to travel long distances over rocky roads in
horse-drawn carts if they wanted pain relief. I learned that people
around the world were dying in unnecessary agony because their
governments were afraid of “drug abuse,” and that black Americans
had dramatically less access to pain relief than white patients did. I
had gotten my position with the help of a former nurse turned
palliative care specialist who had lived through the 1980s in San
Francisco. Before there was effective HIV treatment, she had wanted to
help the gay men who were dying all around her. If they couldn’t be
saved, at least they could die without pain. These are the kinds of
stories that can make a person radical.

Like others who have written about OxyContin’s fatal trajectory
through the American market, Herzberg sees the pain reformers’
advocacy for broader opioid prescription as an important contributor
to the overdose crisis. In his view, pharma legitimized its predatory
practices by purchasing authority for a small coterie of doctors with
extreme, misguided views. He does not delve into the ways in which
good intentions can yield bad results in a dysfunctional system, and
he does not address pain reform’s roots in palliative care. (His is
already a rich and complicated book, and perhaps this was simply
beyond its scope.) But Foley and her colleagues weren’t wrong about
everything. If the reaction to the opioid crisis causes pain to go
untreated or to be unequally treated based on race or class or drug
use history, we’ve made another mistake. Overprescription is a
risk—but underprescription (including of methadone or buprenorphine
treatment) can be harmful, too.

To blame the opioid crisis on pharma and doctors risks missing the
larger picture of the system that created them. As with #MeToo, the
justified rage over the overdose disaster has focused on individual
villains, while mostly neglecting larger structural problems. Our
poorly regulated, profit-hungry pharmaceutical industry, with its deep
pockets and friends in Washington, is a machine for producing
Sacklers, just as extreme economic inequality and a lack of worker
protections will inevitably produce more Harvey Weinsteins. Whether or
not the Sacklers apologize is beside the point, and while it’s
useful to confiscate assets from the Sacklers and from Purdue,
that’s not enough. The Sacklers and Purdue are the symptom, not the
disease. It’s easier to denounce individuals than to attempt to
diagnose and cure the ills of a society. This kind of one-off court
case is like our broken medical system: it privileges symptoms over
causes, the individual over the collective, and quick fixes over deep
reform, while making no provisions for preventive care. Transformative
change will have to be structural and long-term.

“Free markets and prohibition,” Herzberg observes, “are usually
thought of as opposite policies, but in practice they lead to the same
end result: poorly regulated markets designed to serve sellers’
profits rather than consumers’ interests.” He concludes that the
best drug policy in an imperfect world is one that “charts a narrow
path between the Scylla of prohibition and the Charybdis of the
‘free market,’” and whose priority is the protection of
consumers in white, gray, and informal markets alike. Rather than
taking as its central distinction medical and nonmedical use, drug
policy should be organized around safe and unsafe use, balancing
benefits—which include pleasure—against harm. Ultimately, Herzberg
argues, we need to eliminate the profit motive from the market for
addictive drugs and explore possibilities like state monopolies and
public utility models.

These are essential reforms. But like the stricter regulatory approach
of the 1930s and the consumer advocacy and civil rights–inspired
reforms of the 1960s, they don’t go far enough. Why should any
medicine be sold for private profit? Rather than our overpriced,
byzantine, grossly unequal and inefficient patchwork of medical
coverage, we need a comprehensive social safety net that allows all
sick and injured people to receive truly effective treatment,
including long-term physical and cognitive behavioral therapy, and to
take time off work without losing their healthcare, their homes, or
their livelihoods. We need a national pension system that allows
people to retire in comfort from jobs that have become too taxing for
their aging bodies. A second New Deal with an emphasis on racial and
gender equality would function as society-wide pain relief, with no
risk of overdose. Finally, we need to ask why so many Americans desire
psychoactive drugs, looking at socioeconomic as well as physiological
causes. Why are we so depressed? Why are we so anxious? Why are we in
so much pain? And what are we going to do about it?

SOPHIE PINKHAM is the author of _Black Square: Adventures in
Post-Soviet Ukraine_. She previously worked in international drug
policy and harm reduction, and produced the documentary _Balka: Women,
Drugs, and HIV in Ukraine_.

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