Fentanyl, Inc.

How Rogue Chemists Are Creating the Deadliest Wave of the Opioid Epidemic

Ben Westhoff

• Publisher: Atlantic Monthly Press
• Year: 2019
• ISBN:
  9780802147950
• Topic: Business
• Subtopic: Pharmaceutical, Biotechnology & Healthcare Industry
• Index: Business

A four-year investigation into the world of synthetic drugs—from black market factories to users & dealers to harm reduction activists—and what it revealed. A deeply human story, Fentanyl, Inc. is the first deep-dive investigation of a hazardous and illicit industry that has created a worldwide epidemic, ravaging communities and overwhelming and confounding government agencies that are challenged to combat it. "A whole new crop of chemicals is radically changing the recreational drug landscape, " writes Ben Westhoff. "These are known as Novel Psychoactive Substances (NPS) and they include replacements for known drugs like heroin, cocaine, ecstasy, and marijuana. They are synthetic, made in a laboratory, and are much more potent than traditional drugs" —and all-too-often tragically lethal. Drugs like fentanyl, K2, and Spice—and those with arcane acronyms like 25i-NBOMe—were all originally conceived in legitimate laboratories for proper scientific and medicinal purposes. Their formulas were then hijacked and manufactured by rogue chemists, largely in China, who change their molecular structures to stay ahead of the law, making the drugs' effects impossible to predict. Westhoff has infiltrated this shadowy world. He tracks down the little-known scientists who invented these drugs and inadvertently killed thousands, as well as a mysterious drug baron who turned the law upside down in his home country of New Zealand. Westhoff visits the shady factories in China from which these drugs emanate, providing startling and original reporting on how China's vast chemical industry operates, and how the Chinese government subsidizes it. Poignantly, he chronicles the lives of addicted users and dealers, families of victims, law enforcement officers, and underground drug awareness organizers in the United States and Europe. Together they represent the shocking and riveting full anatomy of a calamity we are just beginning to understand. From its depths, as Westhoff relates, are emerging new strategies that may provide essential long-term solutions to the drug crisis that has affected so many. "Timely and agonizing.... An impressive work of investigative journalism." — USA Today "Westhoff explores the many-tentacled world of illicit opioids, from the streets of East St. Louis to Chinese pharmaceutical companies, from music festivals deep in the Michigan woods to sanctioned 'shooting up rooms' in Barcelona, in this frank, insightful, and occasionally searing exposé.... Westhoff's well-reported and researched work will likely open eyes, slow knee-jerk responses, and start much needed conversations." — Publishers Weekly "Our 25 Favorite Books of 2019" — St. Louis Post-Dispatch "Best Books of 2019" — Buzzfeed "Best Nonfiction of 2019" — Kirkus Reviews "50 Best Books of 2019" — Daily Telegraph "Best Nonfiction Books of 2019" —Tyler Cowen "Best Books of 2019" — Yahoo Finance

Part I:

The New Drugs

One

Americans have used and abused opiates* for as long as America has existed. Opium was administered to Revolutionary War soldiers, and for much of our history it was one of the only medicines available, given to colicky babies, the dying elderly, and everyone in between. Misuse may even have been more common in previous centuries than now, and the problem grew particularly acute after the Civil War, during which morphine was used to soothe the injured. In fact, the term soldier’s disease was coined to describe opiate addiction. At the dawn of the twentieth century, one could buy opium from the Sears, Roebuck catalog, yet addiction was so widespread that President Theodore Roosevelt appointed an opium commissioner in 1908. During the industrial revolution the problem ravaged the United Kingdom as well, and the country sought to balance its trade deficit by using its British East India Company to ply opium in tremendous quantities to the Chinese, causing a pair of wars.

Never, however, has an opiate—or any other drug, for that ­matter—killed so many annually as the fentanyl epidemic. It is the next phase in the opioid crisis that began with the overprescription of opioid painkillers, which was catalyzed by a short letter published in a 1980 issue of the New England Journal of Medicine. Written by a doctor named Hershel Jick and his graduate student, Jane Porter, the letter discussed the thousands of cases they had examined in which patients received opioid narcotics. In only four cases had anyone become addicted, they claimed, and only one of those was troubling. “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

The above sentence was one of only five in Jick and Porter’s letter, which was far from comprehensive. It referenced only patients who received small doses and were closely monitored by their doctors, not outpatients taking home bottles of ultra-strong prescription drugs. Nonetheless, the letter had great influence; academics cited it in more than six hundred studies, and doctors and pharmaceutical companies pitching their products deferred to it as well.

During the 1990s another sea change swept American medicine: the desire to treat patients more humanely. Traditionally, doctors focused on four “vital signs” when caring for patients: their temperature, breathing rate, blood pressure, and pulse rate. But in the mid-1990s the American Pain Society called for pain to be considered a new “fifth vital sign.” Whereas doctors were previously hesitant to prescribe opioids because they considered them addictive, the ramifications of the Jick-Porter letter caused their thinking to shift: if opioids were, in fact, safe, patients should not be consigned to agony. “It was not only okay, but it was our holy mission, to cure the world of its pain by waking people up to the fact that opiates were safe,” Boston pain specialist Dr. Nathaniel Katz told journalist Sam Quinones for his book Dreamland: The True Tale Of America’s Opiate Epidemic, describing the new conventional wisdom that took hold. “All those rumors of addiction were misguided. . . . My fellowship director even told me, ‘If you have pain, you can’t get addicted to opiates because the pain soaks up the euphoria.’ ”

The Sackler family, the owners of the company responsible for OxyContin, became billionaires many times over thanks to this new perspective. Long before the drug’s creation, Arthur Sackler, a physician by training, had been a pioneer in the field of pharmaceutical advertising. In 1952, Arthur and his brothers, Raymond and Mortimer, purchased the company that became Purdue Pharma. With the inherent conflict of advertising and pharmaceuticals in its DNA, Purdue brought OxyContin to market in 1996, touting its benefits as a slow-release pill that contained high doses of the opioid oxycodone—contin means “continuous.” Since the pills lasted twelve hours, the company claimed, patients would need only two per day, fewer than comparable medicines. Addiction, it promised, was extremely rare.

Purdue launched a huge marketing blitz, deploying hundreds of salespeople to sway doctors and dispense free promotional items, including pedometers, headgear, and even an OxyContin-branded music CD, Swing Is Alive, with a pair of dancing geriatrics on the cover. Purdue sent doctors to tropical locations for “pain management seminars;” those who attended these events in 1996 were more than twice as likely to write OxyContin prescriptions as doctors who did not. Although originally OxyContin was promoted for use by cancer patients, according to internal reports, the company saw that market as too small. Annual sales might top out around $260 million, whereas if Purdue was able to sell to patients with a host of chronic conditions, the annual market was closer to $1.3 billion. Sales rose from just under $50 million in 1996 to more than $1 billion by 2000. Oxycodone became the most prescribed drug in the United States.

Yet for many patients, the dosages didn’t last an entire half day, and they began experiencing withdrawal symptoms when the pills wore off hours early. And while Purdue salespeople told doctors that less than 1 percent of OxyContin patients would become addicted, Purdue’s own study from 1999 found the rate to be 13 percent.

Misuse became rampant. Many users crushed the pills, known by some as “hillbilly heroin,” into powder form to snort or make into an injectable solution, so they could get high faster. Others fashioned themselves into drug dealers and sold them; the going rate on the street for OxyContin was one dollar per milligram, meaning that an eighty-milligram pill sold for eighty dollars.

For some, using OxyContin as directed caused anguish. Patients recovering from knee surgery or a root canal, or experiencing chronic pain from a condition like rheumatoid arthritis, gained temporary relief but soon confronted a new problem: when their prescription ran out, they were addicted. Many tried to “doctor shop” for more pills, but some who couldn’t do that, or couldn’t afford the pills, turned to heroin, which is cheaper—as low as five dollars a dose in some places—and satisfied their opioid cravings. Before they knew it, they were regularly visiting dangerous parts of town to meet heroin dealers.

This is a complex problem. The vast majority of legitimate users of OxyContin and other opioid medicines receive the intended benefit. For the most part, people dying from oxycodone overdoses tend to get the pills on the black market, not their doctors. Nonetheless, Purdue bears “the lion’s share” of the blame for America’s opioid crisis, according to Andrew Kolodny, the codirector of the Opioid Policy Research Collaborative at Brandeis University. “If you look at the prescribing trends for all the different opioids, it’s in 1996 that prescribing really takes off,” Kolodny said, referencing the year OxyContin debuted. “It’s not a coincidence. That was the year Purdue launched a multifaceted campaign that misinformed the medical community about the risks.” The company, found guilty of playing down OxyContin’s abuse potential, paid $600 million in fines in 2007. Considering the billions it had earned, and would continue to earn, this seemed a pittance. No one from the company received jail time, causing then US senator Arlen Specter, from Pennsylvania, to take issue with the sentence. “I see fines with some frequency and think that they are expensive licenses for criminal misconduct,” he said at a Senate hearing. “I do not know whether that applies in this case, but a jail sentence is a deterrent and a fine is not.”

In 2010 Purdue released a new version of OxyContin that couldn’t be crushed up and injected, which the company believed would help stymie abuse. The FDA agreed. However, this new pill may have worsened the opioid crisis. In a 2015 study, psychiatrists at Washington University in St. Louis interviewed 244 people who had sought treatment for addiction to the new version of OxyContin. The study showed that while many were able to kick their OxyContin habit, about one-third of the subjects migrated to other drugs. Seven out of ten in this group started taking heroin. Further, in the early 2010s, prescription narcotics became harder to obtain. This, along with heroin shortages, likely accelerated fentanyl use in the United States, concluded a 2018 study at the University of California, San Francisco. (Fentanyl is an odd case, the UC San Francisco researchers noted, since its rise wasn’t driven because people wanted it—they just feared withdrawal and didn’t have access to other opioids. As one indication of this, unlike most drugs, which develop street names—smack, weed, Molly—fentanyl doesn’t have much in the way of nicknames.)

Purdue got most of the bad publicity, but the DEA found that a less-known pharmaceutical company called Mallinckrodt manufactured 36 billion opioid pills between 2006 and 2014, more than anyone else. The Washington Post spotlighted a national sales director for the company named Victor Borelli, who told a distribution client that the pills were “Just like Doritos.”

“[K]eep eating, we’ll make more,” he added.

Charges have also mounted against Insys Therapeutics, makers of the prescription fentanyl spray Subsys. The company has been sued by many parties, including state governments and individual patients, and its executives have been indicted (and in some cases pled guilty) of bribing doctors to prescribe Subsys. The spray is approved only for cancer patients, but individual doctors have been accused of prescribing it for lesser ailments and accepting gratuitous kickbacks. A former Insys sales rep named Maria Guzman detailed in her 2013 whistleblower lawsuit that the company provided doctors with stock options, trips to a gun range, fancy dinners, and even hired a woman specifically “to have sexual relations with doctors in exchange for Subsys prescriptions.” The FDA had information about doctors prescribing Subsys and other fentanyl medications for noncancer patients but did little to stop it, according to documents obtained by Johns Hopkins public-health researchers.

Operating under the public radar as the crisis ramped up were drug distributors like Cardinal Health, AmerisourceBergen, and McKesson, which filled gigantic opioid prescription orders from corrupt doctors operating pill mills. For example, a drugstore in the small West Virginia town of Kermit (population: four hundred) received nine million hydrocodone pills in only two years. A 2017 investigation by television news program 60 Minutes and the Washington Post outlined this practice and helped expose how Congress allowed it—and even encouraged it. As laid out by whistleblower Joe Rannazzisi, the former head of the DEA’s Office of Diversion Control, a 2016 law called the Ensuring Patient Access and Effective Drug Enforcement Act, signed by President Barack Obama, made it harder for the DEA to freeze suspicious opioid shipments by these drug distributors. The law had been sponsored by Pennsylvania representative Tom Marino, who, at the time of the investigation’s publication, was President Trump’s nominee for drug czar. He was forced to withdraw.

Did Obama realize the law—which Congress quickly green-lighted, without debate—would have such devastating consequences? No, concluded an October 2017 Washington Post story: “Few lawmakers knew the true impact the law would have,” it reads, adding that the White House was also unaware. Nonetheless, according to a 2019 Washington Post analysis, the Obama administration did n...