Out on a Limb

by Andrew Sullivan

  The poppy’s paradox is a profoundly human one: If you want to bring heaven to Earth, you must also bring hell. In the words of Lenny Bruce, “I’ll die young, but it’s like kissing God.”

  No other developed country is as devoted to the poppy as America. We consume 99 percent of the world’s hydrocodone and 81 percent of its oxycodone. We use an estimated thirty times more opioids than is medically necessary for a population our size. And this love affair has been with us from the start. The drug was ubiquitous among both the British and American forces in the War of Independence as an indispensable medicine for the pain of battlefield injuries. Thomas Jefferson planted poppies at Monticello, and they became part of the place’s legend (until the DEA raided his garden in 1987 and tore them out of the ground). Benjamin Franklin was reputed to be an addict in later life, as many were at the time. William Wilberforce, the evangelical who abolished the British slave trade, was a daily enthusiast. As Martin Booth explains in his classic history of the drug, Opium: A History, poppies proliferated in America, and the use of opioids in over-the-counter drugs was commonplace. A wide range of household remedies were based on the poppy’s fruit; among the most popular was an elixir called laudanum—the word literally means “praiseworthy”—which took off in England as early as the seventeenth century.

  Mixed with wine or licorice, or anything else to disguise the bitter taste, opiates were for much of the nineteenth century the primary treatment for diarrhea or any physical pain. Mothers gave them to squalling infants as a “soothing syrup.” A huge boom was kick-started by the Civil War, when many states cultivated poppies in order to treat not only the excruciating pain of horrific injuries but endemic dysentery. Booth notes that 10 million opium pills and 2 million ounces of opiates in powder or tinctures were distributed by Union forces. Subsequently, vast numbers of veterans became addicted—the condition became known as “Soldier’s Disease”—and their high became more intense with the developments of morphine and the hypodermic needle. They were joined by millions of wives, sisters, and mothers who, consumed by postwar grief, sought refuge in the obliviating joy that opiates offered.

  Based on contemporary accounts, it appears that the epidemic of the late 1860s and 1870s was probably more widespread, if far less intense, than today’s—a response to the way in which the war tore up settled ways of life, as industrialization transformed the landscape, and as huge social change generated acute emotional distress. This aspect of the epidemic—as a response to mass social and cultural dislocation—was also clear among the working classes in the earlier part of the nineteenth century in Britain. As small armies of human beings were lured from their accustomed rural environments, with traditions and seasons and community, and thrown into vast new industrialized cities, the psychic stress gave opium an allure not even alcohol could match. Some historians estimate that as much as 10 percent of a working family’s income in industrializing Britain was spent on opium. By 1870, opium was more available in the United States than tobacco was in 1970. It was as if the shift toward modernity and a wholly different kind of life for humanity necessitated for most working people some kind of relief—some way of getting out of the train while it was still moving.

  It is tempting to wonder if, in the future, today’s crisis will be seen as generated from the same kind of trauma, this time in reverse.

  If industrialization caused an opium epidemic, deindustrialization is no small part of what’s fueling our opioid surge. It’s telling that the drug has not taken off as intensely among all Americans—especially not among the engaged, multiethnic, urban-dwelling, financially successful inhabitants of the coasts. The poppy has instead found a home in those places left behind—towns and small cities that owed their success to a particular industry, whose civic life was built around a factory or a mine. Unlike in Europe, where cities and towns existed long before industrialization, much of America’s heartland has no remaining preindustrial history, given the destruction of Native American societies. The gutting of that industrial backbone—especially as globalization intensified in a country where market forces are least restrained—has been not just an economic fact but a cultural, even spiritual devastation. The pain was exacerbated by the Great Recession and has barely receded in the years since. And to meet that pain, America’s uniquely market-driven health-care system was more than ready.

  The great dream of the medical profession, which has been fascinated by opioids over the centuries, was to create an experience that captured the drug’s miraculous pain relief but somehow managed to eliminate its intoxicating hook. The attempt to refine opium into a pain reliever without addictive properties produced morphine and later heroin—each generated by perfectly legal pharmaceutical and medical specialists for the most enlightened of reasons. (The word “heroin” was coined from the German word heroisch, meaning “heroic,” by the drug company Bayer.) In the mid-1990s, OxyContin emerged as the latest innovation: a slow-timed release would prevent sudden highs or lows, which, researchers hoped, would remove craving and thereby addiction. Relying on a single study based on a mere thirty-eight subjects, scientists concluded that the vast majority of hospital inpatients who underwent pain treatment with strong opioids did not go on to develop an addiction, spurring the drug to be administered more widely.

  This reassuring research coincided with a social and cultural revolution in medicine: in the wake of the AIDS epidemic, patients were becoming much more assertive in managing their own treatment—and those suffering from debilitating pain began to demand the relief that the new opioids promised. The industry moved quickly to cash in on the opportunity: aggressively marketing the new drugs to doctors via sales reps, coupons, and countless luxurious conferences, while waging innovative video campaigns designed to be played in doctors’ waiting rooms. As Sam Quinones explains in his indispensable account of the epidemic, Dreamland, all this happened at the same time that doctors were being pressured to become much more efficient under the new regime of “managed care.” It was a fateful combination: patients began to come into doctors’ offices demanding pain relief, and doctors needed to process patients faster. A “pain” diagnosis was often the most difficult and time-consuming to resolve, so it became far easier just to write a quick prescription to abolish the discomfort rather than attempt to isolate its cause. The more expensive and laborious methods for treating pain—physical and psychological therapy—were abandoned almost overnight in favor of the magic pills.

  A huge new supply and a burgeoning demand thereby created a massive new population of opioid users. Getting your opioid fix no longer meant a visit to a terrifying shooting alley in a ravaged city; now it just required a legitimate prescription and a bottle of pills that looked as bland as a statin or an SSRI. But as time went on, doctors and scientists began to realize that they were indeed creating addicts. Much of the initial, hopeful research had been taken from patients who had undergone opioid treatment as inpatients, under strict supervision. No one had examined the addictive potential of opioids for outpatients, handed bottles and bottles of pills, in doses that could be easily abused. Doctors and scientists also missed something only recently revealed about OxyContin itself: its effects actually declined after a few hours, not twelve—thus subjecting most patients to daily highs and lows and the increased craving this created. Patients whose pain hadn’t gone away entirely were kept on opioids for longer periods of time and at higher dosages. And OxyContin had not removed the agonies of withdrawal: someone on painkillers for three months would often find, as her prescription ran out, that she started vomiting or was convulsed with fever. The quickest and simplest solution was a return to the doctor.

  Add to this the federal government’s move in the mid-1980s to replace welfare payments for the poor with disability benefits—which covered opioids for pain—and unscrupulous doctors, often in poorer areas, found a way to make a literal killing from shady pill mills. So did many patients. A Medicaid co-pay of $3 for a bottle of pills, as Quinones disc
overed, could yield $10,000 on the streets—an economic arbitrage that enticed countless middle-class Americans to become drug dealers. One study has found that 75 percent of those addicted to opioids in the United States began with prescription painkillers given to them by a friend, family member, or dealer. As a result, the social and cultural profile of opioid users shifted as well: the old stereotype of a heroin junkie—a dropout or a hippie or a Vietnam vet—disappeared in the younger generation, especially in high schools. Football players were given opioids to mask injuries and keep them on the field, they shared them with cheerleaders and other popular peers, and their elevated social status rebranded the addiction. Now opiates came wrapped in the bodies and minds of some of the most promising, physically fit, and capable young men and women of their generation. Courtesy of their doctors and coaches.

  It’s hard to convey the sheer magnitude of what happened. Between 2007 and 2012, for example, 780 million hydrocodone and oxycodone pills were delivered to West Virginia, a state with a mere 1.8 million residents. In one town, population twenty-nine hundred, more than 20 million opioid prescriptions were processed in the past decade. Nationwide, between 1999 and 2011, oxycodone prescriptions increased sixfold. National per capita consumption of oxycodone went from around 10 milligrams in 1995 to almost 250 milligrams by 2012.

  The quantum leap in opioid use arrived by stealth. Most previous drug epidemics were accompanied by waves of crime and violence, which prompted others, outside the drug circles, to take notice and action. But the opioid scourge was accompanied, during its first decade, by a record drop in both. Drug users were not out on the streets causing mayhem or havoc. They were inside, mostly alone, and deadly quiet. There were no crack houses to raid or gangs to monitor. Overdose deaths began to climb, but they were often obscured by a variety of dry terms used in coroners’ reports to hide what was really happening. When the cause of death was inescapable—young corpses discovered in bedrooms or fast-food restrooms—it was also, frequently, too shameful to share. Parents of dead teenagers were unlikely to advertise their agony.

  In time, of course, doctors realized the scale of their error. Between 2010 and 2015, opioid prescriptions declined by 18 percent. But if it was a huge, well-intended mistake to create this army of addicts, it was an even bigger one to cut them off from their supply. That is when the addicted were forced to turn to black-market pills and street heroin. Here again, the illegal supply channel broke with previous patterns. It was no longer controlled by the established cartels in the big cities that had historically been the main source of narcotics. This time, the heroin—particularly cheap, black-tar heroin from Mexico—came from small drug-dealing operations that avoided major urban areas, instead following the trail of methadone clinics and pill mills into the American heartland.

  Their innovation, Quinones discovered, was to pay the dealers a flat salary, rather than a cut from the heroin itself. This removed the incentives to weaken the product, by cutting it with baking soda or other additives, and so made the new drug much more predictable in its power and reliable in its dosage. And rather than setting up a central location to sell the drugs—like a conventional shooting gallery or crack house—the new heroin marketers delivered it by car. Outside methadone clinics or pill mills, they handed out cards bearing only a telephone number. Call them and they would arrange to meet you near your house, in a suburban parking lot. They were routinely polite and punctual.

  Buying heroin became as easy in the suburbs and rural areas as buying weed in the cities. No violence, low risk, familiar surroundings: an entire system specifically designed to provide a clean-cut, friendly, middle-class high. America was returning to the norm of the nineteenth century, when opiates were a routine medicine, but it was consuming compounds far more potent, addictive, and deadly than any nineteenth-century tincture enthusiast could have imagined. The country resembled someone who had once been accustomed to opium, who had spent a long time in recovery, whose tolerance for the drug had collapsed, and who was then offered a hit of the most powerful new variety.

  * * *

  The iron law of prohibition, as first stipulated by activist Richard Cowan in 1986, is that the more intense the crackdown, “the more potent the drugs will become.” In other words, the harder the enforcement, the harder the drugs. The legal risks associated with manufacturing and transporting a drug increase exponentially under prohibition, which pushes the cost of supplying the drug higher, which incentivizes traffickers to minimize the size of the product, which leads to innovations in higher potency. That’s why during the prohibition of alcohol much of the production and trafficking was in hard liquor, not beer or wine; why amphetamines evolved into crystal meth; why today’s cannabis is much more potent than in the late-twentieth century. Heroin, rather than old-fashioned opium, became the opioid of the streets.

  Then came fentanyl, a massively concentrated opioid that delivers up to fifty times the strength of heroin. Developed in 1959, it is now one of the most widely used opioids in global medicine, its miraculous pain relief delivered through transdermal patches, or lozenges, that have revolutionized surgery and recovery and helped save countless lives. But in its raw form, it is one of the most dangerous drugs ever created by human beings. A recent shipment of fentanyl seized in New Jersey fit into the trunk of a single car yet contained enough poison to wipe out the entire population of New Jersey and New York City combined. That’s more potential death than a dirty bomb or a small nuke. That’s also what makes it a dream for traffickers. A kilo of heroin can yield $500,000; a kilo of fentanyl is worth as much as $1.2 million.

  The problem with fentanyl, as it pertains to traffickers, is that it is close to impossible to dose correctly. To be injected at all, fentanyl’s microscopic form requires it to be cut with various other substances, and that cutting is playing with fire. Just the equivalent of a few grains of salt can send you into sudden paroxysms of heaven; a few more grains will kill you. It is obviously not in the interests of drug dealers to kill their entire customer base, but keeping most of their clients alive appears beyond their skill. The way heroin kills you is simple: the drug dramatically slows the respiratory system, suffocating users as they drift to sleep. Increase the potency by a factor of fifty and it is no surprise that you can die from ingesting just a half a milligram of the stuff.

  Fentanyl comes from labs in China; you can find it, if you try, on the dark web. It’s so small in size and so valuable that it’s close to impossible to prevent it coming into the country. Last year, 500 million packages of all kinds entered the United States through the regular mail—making them virtually impossible to monitor with the Postal Service’s current technology. And so, over the past few years, the impact of opioids has gone from mass intoxication to mass death. In the last heroin epidemic, as Vietnam vets brought the addiction back home, the overdose rate was 1.5 per 10,000 Americans. Now, it’s 10.5. Three years ago in New Jersey, 2 percent of all seized heroin contained fentanyl. Today, it’s a third. Since 2013, overdose deaths from fentanyl and other synthetic opioids have increased sixfold, outstripping those from every other drug.

  If the war on drugs is seen as a century-long game of chess between the law and the drugs, it seems pretty obvious that fentanyl, by massively concentrating the most pleasurable substance ever known to mankind, is checkmate.

  * * *

  Watching as this catastrophe unfolded these past few years, I began to notice how closely it resembles the last epidemic that dramatically reduced life spans in America: AIDS. It took a while for anyone to really notice what was happening there too. AIDS occurred in a population that was often hidden and therefore distant from the cultural elite (or closeted within it). To everyone else, the deaths were abstract, and relatively tolerable, especially as they were associated with an activity most people disapproved of. By the time the epidemic was exposed and understood, so much damage had been done that tens of thousands of deaths were already inevitable.

  Today, once more, the
cultural and political elites find it possible to ignore the scale of the crisis because it is so often invisible in their—our—own lives. The polarized nature of our society only makes this worse: a plague that is killing the other tribe is easier to look away from. Occasionally, members of the elite discover their own children with the disease, and it suddenly becomes more urgent. A celebrity death—Rock Hudson in 1985, Prince in 2016—begins to break down some of the denial. Those within the vortex of death get radicalized by the failure of government to tackle the problem. The dying gay men who joined ACT UP in the 1980s share one thing with the opioid-ridden communities who voted for Donald Trump in unexpected numbers: a desperate sense of powerlessness, of living through a plague that others are choosing not to see.

  At some point, the sheer numbers of the dead become unmissable. With AIDS, the government, along with pharmaceutical companies, eventually developed a plan of action: prevention, education, and research for a viable treatment and cure. Some of this is happening with opioids. The widespread distribution of Narcan sprays—which contain the antidote naloxone—has already saved countless lives. The use of alternative, less dangerous opioid drugs such as methadone and buprenorphine to wean people off heroin or cushion them through withdrawal has helped. Some harm-reduction centers have established needle-exchange programs. But none of this comes close to stopping the current onslaught. With HIV and AIDS, after all, there was a clear scientific goal: to find drugs that would prevent HIV from replicating. With opioid addiction, there is no such potential cure in the foreseeable future. When we see the toll from opioids exceed that of peak AIDS deaths, it’s important to remember that after that peak came a sudden decline. After the latest fentanyl peak, no such decline looks probable. On the contrary, the deaths continue to mount.