by Joshua Lyon
“What are these?” Emily asked.
The dealer repeated almost the same words as the nurse: “You’re going to need them.”
She took the pills inside, reached into the baggie, and swallowed the first one that touched her fingers. Her brothers and her mother were back at the hospital. She sat down on the couch. Her dad’s ashtray was on the coffee table, one and a half cigarettes ground inside a pool of ashes. As her mind settled and a warm comfortable haze enveloped her, she had a burst of practical insight and checked her father’s computer. As Emily had suspected, there was enough porn on the hard drive to keep an entire fraternity occupied for a whole semester. She erased the files and canceled his accounts. She sat down in front of the answering machine and retrieved condolences from people who weren’t even sure who they were leaving their messages for, knowing that the recorded voice they’d just heard was no longer there.
Emily doesn’t remember what she did with the rest of the pills. The dealer who gave them to her later became addicted to whatever it was she had been distributing and soon turned to heroin. What Emily does remember is the connection between mind-shattering emotional pain and the temporary solace the pills provided. And that’s why, a few years later, in the midst of a brutal breakup with her musician boyfriend, Emily showed up at my apartment with tears streaming down her face and quoted our favorite line from Ab Fab: “I want total sensory deprivation and backup drugs.”
Luckily, I had just the thing for her. I gave her two Vicodins and a cup of tea. We sat on opposite ends of the sofa. She hugged a pillow to her chest and didn’t have to say anything. Instead of consoling her for her broken heart, I turned on a marathon of America’s Next Top Model and let the pills do their work. We spent the next four hours in silence, in the dark, with only the light from the television to wash over our glazed eyes. We didn’t need anyone, not even each other. I woke up the next morning, still on the couch. There was no hangover, no cocaine depression creeping around the corners of my brain like the Nothing from The NeverEnding Story. There was just a bottle of pills on the coffee table and Emily, stirring awake across from me.
“Hey, Em,” I said, yawning and stretching. “Let’s take pills and go look at art.”
At first, the refills were easy. I’d already established a relationship with my original online pharmacy, so I never needed to re-fax my fake papers or talk to another doctor-for-hire. In fact, they called me to schedule refills (to this day, I still get calls from online pharmacies). I was making an associate editor’s salary at the time, which meant I could barely afford food after I paid my rent and bills. Luckily the pharmacy took credit cards. It also helped that the pills kept me indoors on most nights, so I didn’t spend money at bars.
The pharmacies that still call me these days are mostly offering mild sedatives or muscle relaxers. It’s much harder to get anything stronger now, because of the Drug Enforcement Agency’s crackdown. In 2003, as I was becoming more and more addicted to my FedEx’d Vicodin, the DEA established a special pharmaceutical Internet coordination section. They had formally recognized online pharmacies as an epidemic as early as 2000, but prior to 2003, different DEA divisions handled the cases independently.
The DEA’s Office of Diversion Control (“diversion” meaning controlled substances being illegally distributed, i.e., pharmaceuticals) was initially established as a regulatory arm of the agency. Its classification system for illegal drugs and legal controlled substances regulated by the federal government came about in 1970, when Congress passed the Controlled Substances Act. (The DEA wasn’t actually created until 1973; prior to its formation, drug scheduling was over-seen by the Bureau of Narcotics and Dangerous Drugs.)
This system assigns federally regulated substances to one of five categories, depending on how relatively safe or dangerous they are, how great a potential for abuse or likelihood of addiction they pose, and whether they have any medical value. Schedule I drugs are those that have high abuse potential and no currently accepted medical use; for example, heroin, Ecstasy, and psilocybin, a component of psychotropic mushrooms. Cocaine isn’t on this list, because it still has a limited medical use as a local anesthetic for some eye, ear, and throat surgeries, so it falls under Schedule II drugs, which are legally available only by prescription. These drugs have a high level of abuse potential and users run the risk of physical dependency. Drugs in the Schedule II category also include narcotic painkillers like morphine, oxycodone, and codeine, and drugs used for attention deficit disorder (ADD), like the amphetamines found in Adderall. Vicodin and hydrocodone are classified as Schedule III controlled substances, meaning that they have been determined to have less potential for abuse relative to Schedule II drugs, but still may have the potential to be abused and to cause addiction or dependence.
The Office of Diversion Control initially started out inspecting large-scale drug manufacturers and distributors. But around the mid-1980s, the DEA began to see evidence of new kinds of pharmaceutical diversions, and the ODC began to change accordingly. It started to get more involved in criminal investigations and investigations of pharmacies and doctors who were illegally selling drugs they had access to. About ten years later, in the mid-1990s, the ODC started to see an even larger scale of diversion going on. Once Internet shopping became the norm, the volume of drugs being pumped out to consumers online exploded.
There are two main types of Internet pharmacies. The first is a legitimate, registered pharmacy that decides to make extra money by selling its wares nationwide. The pills originate from the usual supply medical chain: drugs manufactured in the United States that have been made available to the pharmacy through a distributor and have been accounted for. The pharmacy will align itself with a doctor or doctors who are willing to write bogus prescriptions for anyone with a credit card. Following a typical pattern, in 2004, a pharmacy in Fort Worth, Texas, that had been illegally employing doctors in the Caribbean to authorize its Internet orders was taken down by the DEA.
The other type relies on drugs that are manufactured in other countries and then smuggled into the United States. The DEA took down a major operation in 2003 whose supply source was in India. The leaders of the drug ring set up a receiving warehouse in Philadelphia, then moved the operation to New York to set up an order fulfillment center. They hired dozens of people to count pills, place them in packages, and send them to buyers via UPS.
My pharmacy fit the former model. The pharmacy address was featured prominently on my pill bottle, and the fact that I had to talk to a “doctor” meant the pharmacy was at least trying to put up a legitimate front. But suddenly my online pharmacy disappeared and its number was disconnected. The afternoon it happened I had noticed that my current bottle was getting low; I only had about ten pills left. My pharmacy was usually pretty good about sending products overnight, but sometimes there would be a delay of a few days, so I liked to reorder before I completely ran out. At this point I was up to about four or five pills a day. I’d take my first two Vicodin toward the end of the day at work, then keep popping extras as the night went on. There was no way I was going to let my last ten pills disappear before I had a supply lined up. So I simply made another Internet search for “buy Vicodin” and found another source. From then on, whenever I started to run low on my pills, I’d just call the pharmacy and reorder. If the pharmacy had been shut down, I’d do another Google search and start the whole cycle over again, with ever-increasing frequency.
Caleb likes to claim that his OxyContin addiction started with MTV.
When I first got to know him, he was twenty-five and living above his parents’ garage in the suburbs of Los Angeles. He’s your typical LA native—tall, blond, a splash of beach bum freckles across the center of his face. As a teenager he did tons of drugs—acid, pot, speed, coke. He doesn’t even remember the first time he took Vicodin, but he knows that was the first pill he ever tried. It was just after he graduated high school, and he was bored with pot and how tired it made him feel. Someone g
ave him two Vicodins that he washed down with a beer. “I just got that sort of tired-wired buzz that I really like,” he remembers.
After that night, he started asking around, bugging people who he had heard through the grapevine had their own prescriptions from dental work, broken limbs, minor surgeries. “The great thing about it was that I could do anything on Vicodin,” he remembers. “Work on music or drive or whatever. But the problem was that I could never get it steadily. The pills would come and they’d go. At one point I got a bottle of a hundred that was prescribed to my sister, and when that bottle ran out it was the first time I felt withdrawal. I didn’t even realize that’s what it was, I just thought I had gotten the flu.”
After about two years of taking all the Vicodin he could get his hands on, Caleb saw a show called MTV True Life—OxyContin. “I saw all these testimonials of people saying that Oxy was better than Vicodin,” he remembers. “They called it hillbilly heroin. They explained that it was all the opiates of Vicodin without all the acetaminophen added.”
Acetaminophen, the active ingredient in over-the-counter painkillers like Tylenol, is also found in prescription narcotics like Vicodin (hydrocodone and acetaminophen) and Percocet (oxycodone and acetaminophen). Yet acetaminophen is a much less powerful pain-killer than the narcotic drugs with which it’s combined. Eliminating it as an ingredient in these stronger painkillers lessens the damaging effects the pills can have on your liver and gives you a pure rush of the really powerful goods.
“I was like, ‘Oooh, I want to try that,’” Caleb says. “Which is embarrassing because the show was about all these people who were having problems with it. They weren’t making it appealing, but I already knew what it felt like to do pills, and I knew that if I could get a hold of this one, it would feel really good. The problem was, I couldn’t find them anywhere.”
Caleb went on a mission. He asked everyone he knew, specifically targeting people he’d gotten Vicodin from in the past and his regular pot dealers. Finally, a friend of a friend got a steady OxyContin supply because he knew a crew of people who were robbing trucks that delivered the pills to pharmacies. Hillbilly heroin was officially all over the California suburbs.
I take offense to the phrase “hillbilly heroin.” Not just because I’m originally from Tennessee and have a strong sense of state pride, but because it’s a contradiction. In most major cities, the current street value for pills usually follows the $1 per milligram rule, so an 80 mg pill of OxyContin usually goes for $80 if you’re a first-time buyer (regular customers can usually work out discounts). The street value of a bag of heroin is around $10 to $20. If you go by the rules of the hillbilly stereotype, you’d assume that their version of heroin would be less expensive than the original. Like buying generic toothpaste instead of Crest. I understand that the media needed a cute, buzz-worthy phrase to document the rise of OxyContin abuse in rural areas, but in terms of street value for a similar high, OxyContin is more like sucker’s smack.
I tried for weeks to land an interview with Dr. J. David Haddox, who is Purdue Pharma’s (the makers of OxyContin) senior medical director and official spokesman. But Purdue’s media relations department wouldn’t let me near him. I imagine it was because I made the dumb mistake of telling them the title of this book. I was told curtly that there were enough third-party medical experts out there for me to talk to, but I think the main reason Purdue didn’t want me to talk to Haddox is because the company got in a ton of trouble for the way it initially marketed OxyContin to doctors. Not to mention all the lawsuits that came a few years later.
In order to market the drug, Purdue targeted thousands of private-practice doctors and invited them to all-expenses-paid seminar weekends in warm locations like Florida and California to talk about pain management. The seminars stressed treating pain with their product, unfortunately a standard practice among some drug companies.
When the FDA approved OxyContin, Purdue’s biggest painkiller was MS Contin, a controlled-release form of morphine. But there was resistance to treating chronic pain with morphine. It’s a very strong narcotic derived from opium with a lot of stigma attached to it, and it wasn’t too popular with doctors because of its potential for abuse. But OxyContin was a synthetic (man-made) form of morphine called oxycodone, and that somehow made it all right.
Like MS Contin, OxyContin is a controlled-released formula, so it lasts for twelve hours. Another advantage was that doctors could increase the patient’s dosage over time because the drug didn’t contain acetaminophen, which in larger doses can damage the liver and cause gastrointestinal bleeding. The FDA approved OxyContin for people with moderate to severe pain that went on for more than a few days. It’s most often prescribed to people with severe pain brought on by cancer, a prolonged surgical recovery, or chronic pain syndromes, such as back pain.
What was quickly discovered was that if you chewed the tablets or crushed them and either snorted the powder or injected the dissolved product, the time-release aspect of the pill was destroyed and what you got was the full effect, all at once. Meaning you could get a giant rush similar to the effect of heroin, rather than the longer-lasting, gentle rolling waves of pain relief. No one is exactly sure how people got the idea to crush the tablets. But it’s standard practice that if there is a way to abuse a drug, drug addicts will find it.
The U.S. Department of Health and Human Services has admitted as much:
At the time of OxyContin’s approval the FDA was aware that crushing the controlled-release tablet followed by intravenous injection of the tablet’s contents could result in a lethal overdose. A warning against such practice was included in the approved labeling. The FDA did not anticipate, however, nor did anyone suggest, that crushing the controlled-release capsule followed by intravenous injection or snorting would become widespread and lead to a high level of abuse.
It’s debatable whether painkiller junkies got the idea to shoot the drug just by reading the label.
Caleb’s first steady OxyContin supply—those friends of friends who were robbing the trucks that delivered the drugs from the manufacturer to a supply center—came from another fairly common form of diversion. The DEA recently handled a case where a group of thieves stalked the driver of an eighteen-wheeler as he left a drug manufacturer. They followed the truck, and then waited until the driver pulled into a truck stop. There is no official requirement for pharmaceutical companies to use GPS systems in their trucks, but many do so anyway because of the high value of their product. Sometimes they will place it with the truck, sometimes they will place it with the drug load. In this particular case, the thieves were smart enough to know about the truck’s GPS device and disabled it. But they weren’t sure if there was another one in the load, so they separated the trailer from the cab and parked it a few miles away in a vacant lot and left it there. The plan was to wait a few days to see if the cab was collected, and if not, make off with the haul. But before this happened, another trucker noticed the cab just sitting in the lot and called the police. Too bad for the thieves—the load was 16.6 million hydrocodone pills. The DEA believes the robbers had no idea just how large their haul would have been.
Caleb’s friend who knew the guys who were robbing OxyContin delivery trucks kept up a successful diversion business for about eight months before it all came crashing down, though not through a typical bust. The man who was in charge of distributing the pills to buyers overdosed on methadone in Caleb’s friend’s house. Someone called an ambulance, but in his panic stupidly warned 911, “don’t bring any cops.” So of course the police showed up, searched the house, and found guns, $14,000 worth of marijuana, a hundred methadone pills, and tons of drug residue.
“He got locked up in the harshest of prisons,” Caleb says. “He was the only white kid there, he went through withdrawal there, and I know he got fucked with. I don’t know what eventually happened to him. But all I could think at the time, was, ‘Damn, that was our hookup!’”
After the bust, Caleb got
sick from Oxy withdrawal too. Since opiates stimulate the endorphin receptors in your brain and curb the release of the neurotransmitter norepinephrine, withdrawal symptoms are brought on by a surge of norepinephrine in the brain. (Most attention deficit disorder drugs, like Ritalin, are designed to boost norepinephrine and dopamine in a person’s system.) But in an opiate user going through withdrawal, this norepinephrine surge can cause agitation, nausea or vomiting, abdominal pain, diarrhea, insomnia, increased blood pressure, and sweating. The first time I went through withdrawal it just felt like a bad cold. I was able to drink it away with hot toddies. By the time I was several years into my use, withdrawal became a full-on muscle spasm on the floor situation. But most people report feeling like they have the flu mixed with a crippling depression, muscle spasms, and, at least for me, the sensation that a razor blade is scraping away at your bones.
“But the withdrawal only lasted for a few days,” Caleb says. He didn’t consider himself to be addicted. Neither did I, in the beginning.
These days, pain specialists continue to feud over the distinction between dependence and addiction. Some experts believe the word addiction has negative connotations and should not be used. Others point out that a person who is physically dependent on a medication may not necessarily exhibit addictive behaviors. Having two terms allows clinicians to differentiate one kind of patient from the other.
The current edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV, does not recognize this distinction, however. Unfortunately, this blurring of the line has actually ended up stigmatizing patients with legitimate pain by encouraging physicians to view drug-dependent patients and addicts through the same lens. The definitions are being reconsidered and may be revised for the next addition of the DSM, which will come out in 2012.