The Opioid Crisis and America’s Homegrown Cartels
The “crisis” of drugs in United States, dating at least to the “war” that Richard Nixon declared on “public enemy number one” in 1971, has seemingly become a permanent frame of our political life. After trillions of dollars spent and decades of chaos produced in Latin America, we have reached a point where the language of “crisis,” largely directed outside to other “sources,” seems to have moved home. But to what? Since 2016, drug overdoses have become the leading cause of death in America, 2/3 of which are related to opioids (a larger class that includes both plant-derived substances like heroin and semi-synthetics like oxycodone). For many, statistics like this are not necessary to recognize that, no matter which way you put it, the opiate crisis is our crisis. But how far are we willing to go in recognizing our complicity in it? Many will have to continue to deal with overdoses, withdrawal, relapse, and an unfortunate number of deaths. Socially, we should be questioning the corporate, marketing, and governmental practices that have reaped billions of dollars from an epidemic that is largely homegrown.
A recent CBS 60 Minutes exclusive documents one side of a process in which the U.S. Drug Enforcement Agency (DEA), responsible in principle for curtailing drug abuse, has systematically diverted itself away from the source of its largest and most pressing epidemic. CBS’s subject is Joe Rannazzisi, a former administrator of the DEA’s “Diversion Control” taskforce cum whistleblower. The subject of his DEA work was the “diversion” of pharmaceutical painkillers from “legitimate” medical use to addictive and illegal purposes. Along with former colleagues and DEA legal counsel, Rannazzisi claims that his division’s investigations were deliberately obstructed by superiors in the agency, their political higher-ups in Congress, and the pharmaceutical lobby that funds them.
The original target of Rannazzisi’s team was the rampant operations of opioid “pill mills,” facilities (“off an entrance [or] exit ramp on an interstate”) where unscrupulous doctors prescribe painkillers in excessive quantity for profit. Witnessing that their crack-down on doctors and pharmacists was not making a dent in the street supply, they expanded their eye from “rogue doctors” to their prescription records. Rannazzisi’s team found that particular pharmacies had succeeded for years in ordering shockingly disproportionate quantities of drugs from “Fortune 500” distributors. Particular cases started to show a trend: a pharmacy in Kermit, West Virginia, for instance, ordered nine million hydrocodone pills over two years for a town of only 392 people.
A bigger fish appeared behind all the bad apple doctors and pharmacists: corporate drug distributors that were systematically turning a blind eye to “suspicious orders” which the DEA mandated them to report. “Greed always trumped compliance,” noted Jim Geldhof, a 40-year DEA agent under Rannazzisi’s command. And yet the efforts of Rannazzisi’s team to pursue action against these companies, they claim, was thwarted from above. Members of Congress eventually intervened, leading to the uncontested, bi-partisan “Marino Bill” signed into Congress that stripped the DEA of any power to limit the supply of opioids between distributors and consumers.
Had their work not been blocked, the next logical objective for Rannazzisi was the “choke point” of the corporate distributors where the supply of drugs could potentially be mitigated. What is mentioned only in passing is that pharmaceutical distributors like Cardinal Health merely facilitate the bulk of drug distribution for larger corporations who have ultimately been responsible for designing, manufacturing, patenting, marketing, and politically lobbying them for decades. Rannazzisi’s tactical insight about the “choke point” of distribution would logically extend to the sources in which these pharmaceuticals were introduced into American life. This would mean looking at companies like Purdue Pharma whose flagship product OxyContin — a pure oxycodone pill with a patented “time-release” design — was approved by the FDA in 1995. These companies not only had access to, but also regularly consulted for marketing purposes, the same distribution and sales data between distributors and pharmacies in places like Kermit, West Virginia, or throughout states like Ohio where 500,000 years of life expectancy have been lost due to overdoses between 2010 and 2016.
An important 2017 exposé in The New Yorker traces the legacy of Purdue Pharma and its causative role in our opioid crisis. Following the immense wealth of the Sackler family (whose name philanthropically adorns cultural buildings across the country), we see how Purdue built an empire for OxyContin by – as Arthur Sackler was once praised in all seriousness by an awards committee – “bringing the full power of advertising and promotion to pharmaceutical marketing.” As Patrick Radden Keefe catalogues, this meant Purdue running its own medical journal, widely disseminating flashy and deceptive ads for its drug, promoting the product directly to doctors not specialized in pain management, encouraging them to prescribe the drug for a wide rather than narrow spectrum of pain, recruiting an army of paid doctors to vouch for the product’s safety, underwriting scientific studies attesting to its medical value, failing to conduct studies on its addictive potential prior to or after its FDA approval, ignoring internal studies that indicated withdrawal symptoms and abuse, and “grossly overstating” its safety even as the reality of abuse and over-prescription reached epidemic proportions in the 2000s.
As Keefe notes, the “marketing of OxyContin relied on an empirical circularity: the company convinced doctors of the drug’s safety with literature that had been produced by doctors who were paid, or funded, by the company.” OxyContin has since made Purdue approximately $35 billion in revenue. Since 1999, three years after the FDA approval of OxyContin, over 200,000 Americans have died from overdoses “related to OxyContin and other prescription opioids.” This is the vicious cycle produced by Purdue’s marketing brilliance.
Citing Arthur Sackler’s claim that “all health problems devolve upon the individual,” Keefe notes that “it was Purdue’s position that OxyContin overdoses were a matter of individual responsibility, rather than the drug’s addictive properties.” The commodity is a source of value, the argument goes, and the problem is rooted solely in the addict’s misuse of the product. (It is worth noting the formal similarity here to the anecdotal argument that “guns don’t kill people, people kill people.”) Much of Purdue’s marketing strategy was geared toward reassuring skeptical doctors and public critics that their time-release mechanism — the novelty in what is an otherwise unadulterated opioid up to twice as strong as morphine — was a sufficient deterrent against addiction. It was not until 2010 that Purdue augmented the design of its pills (strategically months before its patent needed to be renewed) to inhibit the inhalation and injection of crushed pills for immediate high. Ironically, the rough instructions for this method appeared as a “toxicity” warning in OxyContin packaging without any public acknowledgment of the drug’s addictive potential. Between 1999 and 2009, opioid addiction skyrocketed to epidemic proportions. The introduction of the non-crushable design significantly reduced the black market availability of OxyContin. And at that same moment, heroin overdoses increased dramatically as already dependent users transitioned to cheaper opiates in the wake of the drought. The American Society of Addiction Medicine estimates that four of five new heroin users today began with prescription painkillers.
At stake is the question of accountability. Drawing from its sizable profit-margins, Purdue has paid out hundreds of millions of dollars in class action settlements in suits alleging the company’s culpability in an epidemic that has devastated communities across the continent. However, Purdue’s successful legal strategy means that they have been able to settle out of court and avoid a public trial regarding their practices, as well as the public-disclosure of documents and evidence. Any comprehensive approach to the problem of companies like Purdue would have to take into account not only the ethics of their marketing strategies, but also the role of political representatives in enabling these cartel-grade enterprises. Philosophically, we should go even further to appraise the very logic of profit that makes possible a system of lucrative corporate benefit from massive public harm.
At the beginning of his analysis of the generation of profit in capitalist economies, Karl Marx points out an important distinction — between something’s “use-value” and its “exchange-value” — at the core of the commodity itself, that thing we produce, desire, buy, and sell (Capital, Pt. I, Ch. 1). In short, the “use-value” of something is the value it has by virtue of contributing to the human life (or lives) that produced it. The hammer, for instance, is made so that it might replace the rusted nails of a collapsing frame. Its use-value cannot be separated from what it can and does accomplish materially and socially: if the hammer’s grip constantly slips out of the hand, the potential harm of its use quickly outweighs any other quantitative worth. Something’s “exchange-value,” on the other hand, is the value it has by virtue of its being sellable or exchangeable: an equivalence, quantity, or price which accompanies and claims to represent the worth of the thing. Marx argues, however, that a defining feature of a capitalist economy (as opposed to something like a barter economy) is the tendency for the exchange-value (its monetary price) to “disguise,” “abstract” from, and become entirely independent of the use-value of the thing – that is, all the “social relations” that make it meaningful. What this means is that the form of money – with its power of producing profit – takes over as the sole source of value. Money becomes a “fetish” that “modern society greets … as its Holy Grail, as the glittering incarnation of its innermost principles of life” (Ch. 3).
To see the possible disparity between the social use-value of commodities and their profitability, one need only remember the logic that has led to entrepreneurial price-hikes in private pharmaceuticals, like the notorious 5,500% inflation of Daraprim in 2015, an internationally recognized “essential medicine” for AIDS patients. Marx’s insight has a particular importance for how we might understand the corporate-pharmaceutical exceptionalism that has, in the United States, formed an unbridgeable moat around companies like Purdue. In the case of OxyContin and other opioids (distinguished from the manufacture of opiates like heroin from the poppy plant), we see a concerted effort to hide and misinform the public about the social costs and risks of products in order to guarantee their profitability. The exchange-value of pharmaceutical opioids in the United States, in short, trumped their use-value; profit-motives overran the social and health realities that should, in principle, govern what we produce and consume. Given the U.S. Government’s longstanding (and largely failed) policy of deterring drug manufacturing and distribution at their sources, this phenomenon can only be explained by a system of profit making at the expense of the public itself.
One argument we need to consider as a society is whether commodities related to public health should be part of a private, profit-driven market in the way a computer or a car is (and further, as Marx argued, whether profit-based economies can justify the exploitation of the labor that sustains them). Companies like Purdue and Turing Pharmaceuticals will argue that cutting the profit-margins of commodities like pharmaceuticals will disincentivize innovation. The reality, as Purdue’s success has made clear, is that “innovation” often serves patent and monopoly interests rather than public health. Complicity has many forms. Sometimes the things we say and believe echo and reinforce the principles and logics that perpetuate the problems of our world. When we defend the right of profit-making at the cost of our own lives, then perhaps we have misjudged what should be valued. It was not merely the supply and prohibition against drugs that made both their prices and our crisis, but also our commitment to profit and pharmaceutical exceptionalism.