by John Temple
Nevertheless, Purdue had inflated the market for opioids, and other pharmaceutical companies rushed to meet the demand. They copied Purdue’s OxyContin marketing techniques. They re-educated doctors about narcotics, hired “key opinion leaders” to promote the drugs, funded pro-opioid medical education courses, funneled money to seemingly independent patient advocacy groups, and professional societies. And the companies developed one new opioid narcotic after another, hailing each as a breakthrough.
Cephalon promoted its berry-flavored narcotic lollipop Actiq for migraines, sickle-cell pain, and injuries, despite the fact that the FDA had approved its use only for cancer pain.
Janssen Pharmaceuticals, Inc. promoted the narcotic Ultracet for everyday chronic pain, distributing posters to doctor’s offices that showed people in active professions with the breezy tagline “Pain doesn’t fit into their schedules.”
Endo, maker of Opana, Percocet, and Percodan, distributed a patient education publication that said withdrawal symptoms and increased tolerance to narcotics are not the same as addiction. “Addicts take opioids for other reasons, such as unbearable emotional problems.”*
The overall impact of the lollipops and posters and authoritative assurances was to create the impression that prescription opioids were like any other class of drugs—a life-enhancer like the erectile dysfunction pills or acid reflux tablets advertised on TV.
The tactic of distinguishing between addiction and physical dependence was key to many of the feel-good campaigns. On their drug labels, the companies were required by the FDA to acknowledge that opioids are addictive narcotics that could kill. But the companies often left that information out of patient education materials. Brochures and websites often mentioned only the least scary side effects of the drugs, usually leading with constipation, which no doubt seemed a small price to pay for pain relief. The drug companies also highlighted drowsiness, confusion, nausea, and dizziness, among other mild complaints. And the side effects would probably go away in a couple of days, they assured.
Janssen sponsored a multimedia patient education campaign called “Let’s Talk Pain,” which warned that strict regulatory control had made doctors fearful to prescribe opioids, leaving patients to suffer in pain: “This prescribing environment is one of many barriers that may contribute to the under treatment of pain, a serious problem in the United States.”
Despite the competition, Purdue continued to be the face of the opioid gold rush because it had introduced the first blockbuster narcotic. In response to the bad press, Purdue eventually did make a number of concessions. The company put additional warnings about addiction in its information about OxyContin. It stopped making the much-sought-after 160-milligram mega-pill. It began reporting physicians it believed might be diverting drugs.
Hundreds of lawsuits were filed against Purdue, mostly personal-injury claims from small-town plaintiffs claiming they’d been hurt by the drug, and the drugmaker was committed to winning them all. No trials, few settlements. Purdue hired big-gun corporate defense law firms in Atlanta and New York and spent $3 million a month in legal bills. The company beat back almost every lawsuit, including a number of class-action cases.
When Purdue finally lost a big one in 2007, it was a criminal case, not civil. The charge was led by a US attorney named John Brownlee, whose district in Roanoke, Virginia, had been devastated by pharmaceutical painkillers. Brownlee had prosecuted street dealers and doctors and finally decided to investigate the top of the narcotics chain. The company pleaded guilty to federal criminal charges that it had lied about the drug’s risk of addiction. Three top executives paid $34.5 million in fines and the company paid $600 million, one of the largest such fines ever paid by a pharmaceutical company.
Golbom and a group of activists traveled to Virginia for the sentencing, and Golbom spoke at a rally outside the courthouse. Golbom let loose. A photographer snapped a picture of him mid-cry, his face contorted in anger, chopping a hand through the air. The anger was real, but his outbursts on the radio and at the rally were not quite genuine. His natural state was quieter, more analytical. But he was experimenting, willing to do anything to strike a chord.
Golbom didn’t want to do away with opioids. Morphine was a godsend for someone with pancreatic cancer, someone hospitalized for trauma. But over the long run, he increasingly believed, few people seemed to get better on the stuff. He didn’t even want new laws; he just wanted people to better understand what they were taking.
And to Golbom, the federal government’s approach to the opioid crisis was contradictory.
On one hand, there was plenty of concern and action. The feds had gone after Purdue, and the Centers for Disease Control and Prevention had published report after report on painkiller deaths. Lawmakers held hearings and railed about oxycodone crime and addiction in their districts. The DEA stepped up its investigations of doctors whose patients had died after receiving huge prescriptions.
On the other hand, the government was ultimately responsible for the flood of narcotics. The FDA signed off on one new opioid formulation after another—patches, lollipops, and pills, pills, pills. Many observers questioned why the FDA was so compliant with the pain industry. What escaped most people’s attention was that the pharmaceutical companies had an even more dependable ally in, ironically, the Drug Enforcement Administration.
One of the DEA’s most important and least recognized duties is to decide how much of each controlled substance can be manufactured. If the DEA decides that the amount of oxycodone being made exceeds the “medical, scientific, research, and industrial needs of the United States,” it can reduce the drug’s production, simply cut it down by denying pharmaceutical companies’ annual requests to manufacture more of the drugs.
Instead, year after year, the DEA had signed off on hikes in the manufacturing quotas of all popular prescription narcotics. Golbom dug up the numbers. And they were stunning.
In 1993, three years before OxyContin came out, the DEA allowed pharmaceutical companies to manufacture 3,520 kilograms of oxycodone.
In 2007, the DEA signed off on the production of seventy thousand kilograms of oxycodone.
Almost twenty times the amount manufactured just fourteen years earlier.
Twenty times.
Less than four tons compared to seventy-seven tons.
And it wasn’t just oxycodone. Between 1996 and 2007, the DEA had nearly quadrupled the production of hydrocodone, allowed manufacturers to produce almost ten times the amount of fentanyl, and hiked the quota of hydromorphone by four and a half times.
Despite its impact on public health, the quota-setting process was conducted in secret. Each pharmaceutical company applied to make a certain amount of a given controlled substance each year, but the DEA wouldn’t reveal how many pills each wanted to produce. That was considered to be a trade secret. Then, the companies and the DEA had negotiation meetings, the content of which was restricted from the public record. The DEA then set quotas based on “expected need.” Essentially, the only information the DEA revealed each year was the total amounts of each drug requested by the entire industry and the total amounts the DEA allowed them to produce. The DEA said it would be unfair to the pharmaceutical companies to reveal how many pills the individual companies wanted to manufacture.
Amid the uproar over painkillers and all the strategies invoked to curb abuse and overprescription, few officials or politicians seemed to consider simply reducing the supply. The idea had been brought up seriously only one time, in 2001, when the country was first becoming aware of Oxy-Contin abuse. The DEA had asked Purdue to restrict OxyContin prescribing to physicians trained in pain management, and Purdue balked. In response, during a congressional subcommittee hearing, DEA administrator Donnie R. Marshall said he was considering “rolling back those quotas to 1996 levels.” The pain industry said this would be a disaster, that prices would skyrocket and pain patients would suffer. Purdue didn’t budge, and the quota-cut idea vanished when new administrato
rs came in.
Cutting back the quotas wasn’t a radical idea. In fact, the DEA had combated drug waves by reducing quotas before. In the 1970s, when speed pills were popular, the DEA cut the quota of amphetamines by 90 percent, and the illicit market dried up. A decade later, sedative-hypnotics like Quaa- ludes swept across the country, and the DEA cut the quota of the ingredient methaqualone by 74 percent, which effectively erased the problem.
Now, prescription narcotics were killing far more people than speed or sedatives, but the government was signing off on large increases in the supply each year. It baffled previous DEA administrators like Gene Haislip, former head of the DEA’s Office of Diversion Control. Haislip had been in charge during the methaqualone quota reduction. It hadn’t been easy to buck the pharmaceutical industry, but, as he told a reporter shortly before his death: “You’ve got to have some kind of principles.”
Golbom had come to the conclusion that a $7 billion industry had been built on marketing and bad science.
By 2008, the United States was awash in prescription narcotics, enough for every American adult to pop a 5-milligram Vicodin every four hours for nearly a month. According to the International Narcotics Control Board, the US had consumed 83 percent of the global supply of oxyco-done in 2007. And 99 percent of the world’s hydrocodone. No one believed that the US was in that much more pain than the rest of the world.
Golbom could see how it had happened. It wasn’t the 1970s or the 1980s any more. Pharmaceuticals were the most profitable industry in the country, and the pharmaceutical lobby was by far the biggest in Washington.*
He’d never considered himself prone to conspiracy theories. But now he had his own pet belief that he couldn’t stop thinking about. He’d been an unwitting tool of the conspiracy for years, until it had infiltrated his home. When he came across an advertisement for radio time—“You, too, can be on the radio!”—he decided to take the leap. To Golbom, prescription narcotics seemed like a natural topic for a talk radio show. By now, just about everyone knew someone who had a problem with pain pills.
Golbom spent three weeks writing his first hour of radio. He wrote out every word of the early shows. His stomach churned every week when he walked into the station. To protect his job and his son, he called himself “Larry G” on air. And he never explained in any depth why he’d begun investigating controlled substances. His personal story didn’t matter. He also wouldn’t reveal his employer. He needed his pharmacy job.
Each week he interviewed different drug experts, legislators, recovering addicts. There were always fresh topics to discuss—a suspicious new pain clinic in town, a new narcotic coming out, new legislation. His network of listeners kept track of trends and reported back to him.
On the July 6, 2008, show, Golbom reported a strange new phenomenon. A pain clinic in Pinellas Park seemed to be serving customers primarily from out of state. Golbom told his listeners what his source had seen.
“One car had a Louisiana license plate. Another car had a New Jersey license plate. This individual saw cash going back and forth, and they saw the deal get done. And here’s what so frightening, folks: We are now becoming the suppliers for people around the country.”
Golbom wasn’t the only one who’d noticed this trend. That same summer, in Fort Lauderdale, a television news reporter named Carmel Cafiero got a tip about pain clinics that serviced out-of-state patients.
Cafiero was an anomaly in the South Florida TV news scene, a pixie-cut redheaded grandmother among younger blown-out blondes and brunettes. She was in her early sixties and had worked for WSVNTV Channel 7 since 1973, producing a weekly investigative segment called “Carmel on the Case.” She specialized in “jump-outs”—on-camera ambushes of pimps, bad cops, crooked businessmen—after she’d gotten the goods on them. She found joy in her job at the family-owned Fox affiliate, and it showed in her big blue eyes and her hee-hee-hee chortle.
Cafiero’s source said the biggest pain clinic around was located on Oakland Park Boulevard, so she and a cameraman, Anthony Pineda, drove out to take a look. The clinic was in a small bungalow, lots of people loitering outside. Cafiero and Pineda parked across the street and settled in to watch. The patients waited in a ragged line. Many went shirtless. They all seemed to drink Mountain Dew and smoke cigarettes. There was a guy riding an old bike around the parking lot. He appeared to be the security guard. He also looked like a street bum.
Carmel thought: Whoa, what is this place?
She could have put together a story right away, collected some interviews with neighboring businesses and plugged the package into the weekly “Carmel on the Case” lineup. But she didn’t want to do that. She had a feeling about this strange little clinic. Something big was going on here. She was going to sit on this one for a while, do some digging.
For the next three months, every time Cafiero and Pineda were between assignments in Broward, they’d go to South Florida Pain and shoot video. They used the station’s unmarked silver Dodge Caravan. Pineda had an uncanny ability to pick which pain clinic patient was most likely to do something interesting on camera. The cameraman would park next to the target’s car, and he and Cafiero would move to the rear of the van and draw the curtains behind the front seat. Pineda would shoot through the van’s dark-tinted windows. They got video of patients shooting up, trading cash for pills, leaving children in their cars.
Cafiero also dug into state corporate records and identified the clinic manager as a Christopher P. George of Wellington, Florida. She interviewed local police and the Broward sheriff’s office. She found statistics about drug-dispensing doctors in the state of Florida. The picture began to come together.
Pretty soon, Cafiero would be ready for her jump-out on this Christopher P. George character.
Footnotes
* Both the American Pain Foundation and the Appalachian Pain Foundation have since shut down.
* The promotional efforts of Endo, Janssen, and Cephalon are alleged in the pending lawsuit, The People of the State of California v. Purdue Pharma L.P. et al.
* In her 2004 book, The Truth About the Drug Companies, former New England Journal of Medicine editor Marcia Angell reported that in 2001, the top ten American pharmaceutical companies took in an average net return on sales of 18.5 percent. In 2002 alone, 675 pharma lobbyists spent more than $91 million.
3
To Derik Nolan, the whole thing felt like the biggest practical joke ever. Two assholes like Chris and himself could just open a pain clinic, and nobody could do anything about it. Derik figured they were getting away with it because the basic transaction that was taking place—a patient getting a prescription from a licensed doctor—was legal. Whatever the patients did with the pills after leaving the clinic, that was on them.
Same with the doctors. They might be violating the law inside their offices, not following diagnostic guidelines or something. But Chris and Derik weren’t doctors—neither of them even had a college degree—so what they didn’t know couldn’t hurt them. How could they be held responsible for the way people with medical degrees prescribed medicine?
Besides, they weren’t going to quit just as they were starting to make real money. Chris had grown up rich, and Derik had enjoyed some flush years. When Derik was nineteen, making good money as a plumber, he’d bought a $60,000 Mustang Cobra convertible and had his own house. Later, he’d owned his own companies, pulled down six figures in the good years. But this was different. They’d tapped into something big and rich and desperate here, something that made people line up around the block at 6:00 a.m. every morning. The clinic accepted credit cards, but almost nobody paid that way. Cash poured into the clinic so fast that they’d given up on using their register. No cash register could take in $20,000 to $30,000 a day. It took too long to push all those buttons and ring someone up, and the cash drawer was too small. They had to empty it too often, and it was taking time away from processing the patients. So Derik had just grabbed a couple of nine-gallon garbage cans, the
kind you see in bathrooms, and stuck one under the customer window. When it filled up, he’d cart it back to Chris’s office to be counted and stick the empty one under the window.
Every day seemed like a miracle. Every day they were amazed by the things they saw. Every day they realized that this thing was bigger than what they’d thought it was just the day before. Oxycodone was growing out of control, like black mold in a Florida bathroom, and they’d suddenly become a major supplier for a half-dozen states.
By summer 2008, they were seeing one hundred patients a day. The little bungalow couldn’t handle that amount of traffic. As the days had grown hotter, they discovered that the two old air-conditioning units cut into the waiting-room walls were completely inadequate for the job. The waiting room had about thirty chairs, and there were sometimes another dozen people standing. At regular intervals, a row of automatic-spray air fresheners on the wall spritzed the lukewarm stench. It didn’t help much. The bathroom was always a mess, so Derik took out the paper towel dispenser and installed an air dryer. The cleaning lady started coming in early to get a head start on the daily cleanup. She found hypodermic needles in the garbage cans, in the parking lot, rattling inside empty soda cans.
Derik and Chris didn’t talk much about what was really going on at South Florida Pain. They talked business, sure, but they only rarely referred to the fact that they’d suddenly become a strange brand of drug dealer. It wasn’t something they wanted to talk about much. Not with each other, and definitely not with the doctors or anyone else. It was partly a precaution, in case anybody was listening, and partly because they were afraid of jinxing their business luck. Derik believed Chris was feeling the same as he was: like a pitcher throwing a perfect game. It was the seventh inning, and they couldn’t talk up what was happening, so they kept their excitement to themselves, maybe shaking their heads or raising an eyebrow at each other when they saw an especially long line of zombies lined up in the morning. Derik wanted to laugh when he remembered how they’d talked about the pain clinic when it was first starting, Chris saying that Jeff might be able to hire Derik for $12 an hour.