is taking me on a driving tour of Man, the tiny West Virginia town where
she has spent her entire life. Because I don't know my way around the
hollows and gullies and creeks that carve through these hills, Paula is at
the wheel. And because Paula isn't a morning person, we've set out on our
tour at midnight. It's dark; the only illumination comes from our
headlights cutting through the mist that rolls down from the hills.
The tour Paula is leading isn't sanctioned by the local chamber of
commerce; there are no stops at Civil War plaques or scenic vistas. It's a
pillhead tour: an addict's-eye view of the radical changes that a single
prescription drug, called OxyContin, has brought to the town of Man.
OxyContin abuse started in remote communities like this one more than two
years ago; more recently, it has spread beyond its origins in Appalachia
and rural Maine to affect cities and suburbs across the eastern United
States. I came to Man to try to understand how America's latest drug
problem started, to see its roots and trace how it has spread.
"That's my best friend's trailer right there," Paula says,
pointing out a comfortable-looking single-wide across the creek.
"She's somebody that you couldn't look at and know she was an oxy
addict. She was a cheerleader in junior high. She's married. You can't
just look at somebody and tell."
A few years ago, Paula says, Man was like any small town in America:
you could buy a variety of illegal drugs, as long as you knew the right
person to talk to. Pot was big; there was occasionally some cocaine around
and a few pills for recreational use. Fads would come and go. But these
days, she says, the only drug for sale in Man is OxyContin, a narcotic
painkiller that users crush -- to disable its patented time-release
mechanism -- and then snort or inject for a powerful and immediate opiate
high. Legally, it's sold only by prescription for the treatment of chronic
pain. In practice it's available just about everywhere around here,
immediately, for cash. The going rate is a dollar a milligram, or $40 for
a 40-milligram pill.
Paula is a thoughtful, good-natured 24-year-old with wispy blond hair,
serious eyes and faded jeans. She's fidgety; as she drives with one hand,
she's rummaging through her handbag with the other, looking for her pack
of Marlboro Lights. She finds them, removes one and stabs the dashboard
lighter. "I'll show you some places over here," she says, as she
turns her car off the main road, over a short bridge and down into a rough
indentation that holds a couple dozen trailers and prefab homes.
"This is Green Valley. We just call it the valley. It's a pretty good
neighborhood," she says, then interrupts herself. "Well, except
that's a dealer there."
She points to a trailer with a Chevy pickup out front and a light
burning inside. I crane my neck to get a look at a real-life drug den, but
the tour has already moved on. Paula is pointing out a trailer on the
other side of the road: "That's a small-time dealer there, nothing
big," she says. Then she points to another one, and then another:
"That's a dealer. . . . That's a small-time dealer. . . . That's a
dealer. . . . Her son's a dealer, but I don't know if he lives there. . .
. He uses, that boy in there. . . . They use really, really big."
We're driving slowly around the circular dirt road that is the only
path through Green Valley. The neighborhood doesn't feel dangerous -- no
graffiti, no pit bulls, no broken bottles lying around. Still, Paula is
pointing out criminal activity in every second home, peering through the
front windshield and gesturing left and right: "They used to deal,
too, but they don't no more. . . . They deal. . . . There's some dealers
up through there, one or two, nothing big. . . . This boy that lives here
deals. . . . They deal, in that trailer there."
The first time Paula did an oxy (as she calls the pills), in the summer
of 1999, it didn't do much for her. "That first 10-milligram pill, I
didn't really feel nothing off it," she says. "But the second
time I did it, I did two 20's, and I was high." She liked the effect.
"When you get that oxy buzz," she says, "it's a great
feeling. You're happy. Your body don't hurt. Nothing can bring you down.
It's a high to where you don't have to think about nothing. All your
troubles go away. You just feel like everything is lifted off your
What Paula calls "that oxy buzz" comes
from OxyContin's only active ingredient: oxycodone, an opioid, or
synthetic opiate, developed in a German laboratory in 1916. Chemically, it
is a close relative of every other opium derivative and synthetic: heroin,
morphine, codeine, fentanyl, methadone. The narcotic effects that Paula is
describing are the exact same ones that have drawn people to opiates for
centuries. And just as every opiate does, oxycodone creates a physical
dependence in most of its users and a powerful addiction in some of them.
"At first you do them to get high," Paula says, "and then
after you're addicted to them you don't do them to get high; you do them
to survive. You do them to feel normal." At her peak, she says, she
was snorting four or five 80-milligram pills a day.
earliest reported cases of Oxycontin abuse were in rural Maine, rust-belt
counties in western Pennsylvania and eastern Ohio and the Appalachian
areas of Virginia, West Virginia and Kentucky. The problem traveled
through these regions, as friends told friends and the word spread from
town to town, county to county, up and down the Appalachians. There are a
few defining characteristics that the first affected regions share:
they're home to large populations of disabled and chronically ill people
who are in need of pain relief; they're marked by high unemployment and a
lack of economic opportunity; they're remote, far from the network of
Interstates and metropolises through which heroin and cocaine travel; and
they're areas where prescription drugs have been abused -- though in much
smaller numbers -- in the past. "There's always been a certain degree
of prescription drug abuse in this area," says Art Van Zee, a
physician in Lee County, Va., "but there's never been anything like
this. This is something that is very different and very new, and we don't
understand all the reasons why. This is not just people who have long-term
substance-abuse problems. In our region this is young teenagers, 13- and
14-year-olds, experimenting with recreational drug use and rapidly
becoming addicted. Tens of thousands of opioid addicts are being created
In Man, Paula said, it was like OxyContin came out of nowhere. One day
no one had heard of oxys, and a month later, the pills had become a way of
life for hundreds of locals. It became so easy to buy OxyContin in and
around Man, Paula said, that until recently, she never really thought
about the fact that everyone involved was breaking the law. "Buying
pills never seemed illegal," she said. "It just didn't feel like
it was wrong." There aren't lookouts involved, or secret passwords or
elaborate drop sites: when Paula wants to buy an OxyContin pill, she
simply drives to a dealer's house and knocks on the front door in broad
daylight. If she knows the dealer well enough, she'll go on in and snort
the pill there, just to be neighborly. If not, she'll hand over the cash,
put the pill in her pocket and drive away. Sometimes she'll be the only
person there; other times, there will be a dozen cars lined up out front.
The dealers have the benefit of a captive market: OxyContin,
like any opioid, is very difficult to quit abusing. And given the
pill's ubiquity here in Man, and the fact that the
nearest rehab clinic is two hours away, this is an unusually hard
place to quit using it. Nonetheless, Paula is trying. Six months ago, she
and her best friend decided they were going to quit cold turkey. They took
a couple of days off work, locked themselves in her friend's trailer and
started to detox. "That was the worst three days of my life,"
Paula said. "Honestly, I prayed to God to let me die. That's how bad
it is. Your stomach hurts, you get really bad headaches, you get diarrhea.
You want to throw up. You get really depressed. If you can get past the
third day or the fourth day, you're pretty much fine, but most people
don't make it." Paula and her friend didn't make it: at the end of
the third day, they went out and got a pill.
A few months ago, OxyContin abuse was considered a regional problem,
labeled "hillbilly heroin" and confined to areas far from the
nation's population centers. This year, though, abuse of OxyContin has
started to move away from its backwoods origins and into metropolitan
areas on the East Coast, into the Deep South and parts of the Southwest
and into suburban communities throughout the Eastern United States. In
Miami-Dade County, there have been 11 overdose deaths so far this year in
which oxycodone was the probable cause, according to the county medical
examiner. There have been 11 more in Philadelphia, according to the
medical examiner there. Police in Bridgeport, Conn., arrested a local
doctor in July for prescribing tens of thousands of OxyContin tablets to
patients, often, they say, without any medical examination at all. And in
the suburbs of Boston, police say more than a dozen pharmacies have been
held up by a gang of young men wearing baseball caps and bandannas,
looking for OxyContin.
many ways, the spread of Oxycontin abuse closely resembles another recent
drug epidemic. In the early 1990's, the Medellin and Cali cartels
controlled cocaine and heroin distribution in the United States. Cocaine
was selling well, but there was a marketing problem with heroin: it could
only be injected, and many people, even frequent drug abusers, are
reluctant to stick needles in their arms.
The Colombians' solution to this problem was to increase the purity of
the heroin they were bringing into the United States until it was potent
enough to snort. They were then able to use their existing
cocaine-trafficking network in the Eastern United States to get heroin
onto the street in powder form. Cocaine users, who were used to the idea
of buying and snorting a white powder, experimented and became addicted.
As their tolerance increased, these new heroin snorters overcame their
aversion to needles and soon turned into heroin injectors.
Similarly, there were plenty of oxycodone users in Appalachia before
OxyContin came along. Many of the OxyContin addicts I spoke to in Kentucky
and West Virginia used to snort or chew a mild oxycodone-based painkiller
called Tylox. They said they found the pills somewhat euphoric and not
very addictive -- each Tylox contains just 5 milligrams of oxycodone,
along with 500 milligrams of acetaminophen. When OxyContin arrived on the
scene, in pills containing 20, 40 and 80 milligrams of oxycodone, it
marked a jump in purity similar to that of early-90's heroin -- and again,
casual users started snorting, and then shooting, a powerful opioid.
Although heroin and OxyContin have a similar unhappy effect on the
lives of people addicted to them, there is a critical and simple
difference between the two: heroin is illegal; OxyContin, when used as
directed, is legal. More than that: the pill is government-approved. It is
made by Purdue Pharma, a successful and well-regarded pharmaceutical
company headquartered in Stamford, Conn. It is prescribed to a million
patients for the treatment of chronic pain, and it is closely regulated at
every stage of its manufacture and distribution by the Food and Drug
Administration and the Drug Enforcement Administration.
This fact has meant a major conceptual shift for law-enforcement
officials, who are used to combating narcotics produced by international
drug lords, not international corporations. Terry Woodworth, the deputy
director of the D.E.A.'s office of diversion control, says the spread of
OxyContin has posed a challenge to the D.E.A.'s traditional methods:
"Instead of using the normal law-enforcement techniques -- like going
to the source and attempting to eradicate or destroy the criminal
organization producing the drug and immobilize its distribution networks
and seize all its assets -- you have a very different situation in a
legitimate industry, in that your manufacture and distribution is
Scott Walker, the director of Layne House, a drug treatment facility in
Prestonsburg, Ky., puts it more concisely: "You don't have the Coast
Guard chasing OxyContin ships," he says. "This isn't something
you can stop at the border. It's growing from within."
Part of what makes the spread of OxyContin abuse so difficult to track,
let alone to stop, is that the drug moves not physically but conceptually.
When crack cocaine spread from the big cities on either coast toward the
center of the country, it traveled gradually, along Interstates, city by
city. OxyContin abuse pops up suddenly, in unexpected locations: Kenai,
Alaska; Tucson; West Palm Beach, Fla. At the Gateway Rehabilitation Center
in Aliquippa, Pa., a suburb of Pittsburgh, Jay, a recovering OxyContin
addict and a former small-time dealer, offered an explanation for
OxyContin's sudden geographical shifts. "It's the idea that passes
on," he told me. "That's how it spreads. There aren't mules
running the drug across the country. It's dealt by word of mouth. I call a
friend in Colorado and explain it to him: 'Hey, I've got this crazy pill,
an OC 80, an OC 40. You've got to go to the doctor and get it. Tell him
your back hurts."'
Jay is 26, a college graduate and former nurse. He started doing oxys
in 1999, and his consumption quickly rose to 240 milligrams a day. He was
clean when we met and trying to stay that way. But when he talked about
the drug's potential as a small business, he couldn't help getting
excited. "I could go to California or Las Vegas and say, 'Hey, I was
getting OC's prescribed to me in Pennsylvania; I'm going to get them in
Las Vegas,"' he said. "And then if I wanted to sell them, I
could sell them there. I'd start out and sell them for 10 bucks apiece.
Get people hooked on them, then sell them for 50 bucks apiece. It's
experienced word of mouth. I've experienced the drug, therefore I know how
to describe it to you."
Unlike heroin, Jay explained, OxyContin doesn't require investment or
muscle or manpower to move across the country. OxyContin
abuse is a a contagious idea -- a meme, if you will. Because
OxyContin, the medicine, is readily available in pharmacies everywhere,
all it takes to bring OxyContin, the drug, to a new place is a persuasive
talker like Jay. A powerful recreational narcotic can now travel halfway
across the country in the course of a phone call.
order to understand the particular dilemma of OxyContin, you need to
understand the long-fought war among doctors over pain and addiction. For
centuries, opium and its derivatives have been considered a double-edged
sword -- the most effective painkiller on earth and also the most
addictive substance. For most of the 20th century, opiates were
considered too dangerous to use in all but the most critical pain
treatments. The assumption was that their medical use would inevitably
lead to addiction. In the late 1980's, for the first time, public and
medical opinion began to swing decisively in the other direction.
Patient advocates and pharmaceutical companies, bolstered by studies
showing that there were vast numbers of cancer patients whose pain was
being under treated, encouraged the medical community to rethink its
approach to opioids, especially in the management of cancer pain. Their
campaign was persuasive. Between 1990 and 1994, morphine consumption in
the United States rose by 75 percent, and in 1994, the Department of
Health and Human Services issued new clinical guidelines encouraging the
use of opioids in the treatment of cancer pain.
Purdue Pharma was a leading player in the pro-opioid campaign. The
company contributed generously to patient-advocacy organizations,
including the American Pain Foundation, the National Foundation for the
Treatment of Pain and the American Chronic Pain Association, and
underwrote dozens of scientific studies on the effectiveness of opioids in
the treatment of pain. In 1985, the company began marketing MS Contin, a
time-release morphine pill that was used to treat cancer pain. As
attitudes on opioids shifted, Purdue began to promote MS Contin for
noncancer pain as well.
Dr. Russell Portenoy is chairman of pain medicine and palliative care
at Beth Israel Medical Center in New York City, and the co-author of a
groundbreaking 1986 study that supported the long-term use of opioids to
treat noncancer pain. "Between 1986 and 1997, within the community of
pain specialists, there was increasing attention on the role of
opioids," Portenoy says, "but there was relatively little
diffusion of that idea to family doctors and other nonspecialists."
That began to change, Portenoy says, with the F.D.A.'s approval of
OxyContin in 1995. "There was a sea change that occurred with the
release of this drug," Portenoy says. For the first time, general
practitioners began to prescribe strong, long-acting opioids to treat
chronic noncancer pain.
Portenoy says the change was due to four factors that came together at
about the same time. "The reasons were partly cultural -- the
attitudes of the medical and regulatory communities had been gradually
shifting for a decade. They were partly medical
-- studies had been coming out showing that patients with low back pain,
chronic headaches and neuropathic pain might benefit from long-term opioid
therapy. They were partly pharmacological --
OxyContin made it easier and more convenient for patients to receive
long-term opioid therapy. And they were finally related to marketing,
because Purdue Pharma was the first company to advertise an opioid pill to
general practitioners in mainstream medical journals."
In addition to those doctor-directed ads in magazines like The Journal
of the American Medical Association, the company began an innovative
indirect-marketing campaign just before OxyContin's release. Because of
F.D.A. regulations on the marketing of narcotics, the company was unable
to use direct-to-consumer advertising, as other pharmaceutical companies
were beginning to do for antidepressants and prescription allergy
medications. So Purdue decided to concentrate on what they call "nonbranded
education." Just as Nike advertises the concept of sports
instead of shoes, so Purdue would market the concept
of pain relief to consumers, but not OxyContin.
In 1994, the company launched Partners Against Pain, a public-education
program that at first concentrated on cancer pain and later expanded to
include other forms of long-term pain. Through videos, patient pain
journals and an elaborate Web site, Purdue promoted
three ideas to doctors and patients: that pain was much more widespread
than had previously been thought; that it was treatable; and that in many
cases it could, and should, be treated with opioids. Partners
Against Pain didn't promote OxyContin specifically; the company's
marketers knew that simply expanding the total market would also increase
their bottom line.
OxyContin was seen by many doctors as the
solution to the long rift between pain specialists and addiction
specialists. Purdue Pharma believed that OxyContin's time-release
function would mean a much lower risk of addiction than other opioid
medications. According to a principle known as the
"rate hypothesis," the rate at which an opioid enters the
brain determines its euphoric effect, and also its addiction potential.
This is why injecting a narcotic produces a more powerful high, and
addiction risk, than snorting it or swallowing it. Because
OxyContin, taken whole, provides a steady flow of oxycodone over an
extended period, the high it produces is diminished, as is the risk of
Before OxyContin, narcotic painkillers were prescribed mostly by
oncologists and pain specialists. Purdue believed
that OxyContin's time-release safeguards made it appropriate for use by a
much broader array of medical professionals. The company began
promoting OxyContin to family doctors and local pharmacists nationwide
through a network of hundreds of field reps who emphasized, in their
office visits, the idea that OxyContin presented a lower addiction risk
than other opioid medicines.
Over the next few years, sales of OxyContin exploded. OxyContin
prescriptions have more or less doubled in number each year since its
release; the company's revenues from the pill jumped to $1.14 billion in
2000 from $55 million in 1996. Last year, doctors
wrote more than six and a half million OxyContin prescriptions, and
OxyContin ranked as the 18th best-selling
prescription drug in the country (as measured by retail sales) and
the No. 1 opioid painkiller. The company grew along with its main
product's sales; between 1998 and 2000, the Purdue work force expanded to
nearly 3,000 employees from 1,600.
Purdue's attempt to expand the opioid marketplace beyond cancer
patients was also remarkably successful. Five years ago, cancer patients
were still the main market for long-acting opioids, but oncologists
accounted for only 3 percent of the OxyContin prescribed last year. The
largest single group of OxyContin prescribers is now family physicians,
who account for 21 percent of the total.
According to Portenoy, this change in the number and kinds of doctors
prescribing OxyContin is fundamentally linked to the spread of OxyContin
abuse. "It's not the drug, per se," Portenoy says. "It's
rapidly expanding access, plus the reality of doctors prescribing it who
may not have the skill set required to prescribe it responsibly."
Purdue's field reps were the first wave of OxyContin apostles,
spreading word of the pill's effectiveness door to door -- doctor by
doctor, pharmacist by pharmacist. But Purdue's officially sanctioned
word-of-mouth marketing campaign was followed by another, unsanctioned
one. This time the news was that the miracle pill had an Achilles' heel,
that its time-release matrix could be eliminated
completely in a matter of seconds by the simple act of crushing the pill
with a spoon, a lighter, even a thumbnail, and that the resulting powder,
when snorted or mixed with water and injected, produced a very potent
high. The apostles this time were not Purdue's field reps but
casual drug abusers throughout the Eastern United States. And just like
Purdue's, their marketing campaign was enormously successful.
a steel-mill suburb northwest of Pittsburgh, the leader of the second wave
of OxyContin apostles was Curt, a young man who in 1998, at the age of 23,
found himself kicked out of the Air Force and living back in his hometown.
He worked the midnight shift running cranes at the mill, and he dealt a
little marijuana during the day. He was part of a "drug
community," as he calls it, 20 or so people who worked together, hung
out together, went to parties and concerts and smoked a lot of pot. Every
couple of months someone would land a prescription for Percocet or Vicodin,
and they'd sell the pills to friends for $5 apiece, a cheap and mild high.
In April 1999, someone in his circle was prescribed OxyContin. Curt
assumed that it was just like any other pain pill. "Everybody thought
at first that they were like a Percocet," Curt says. "Nobody
understood how many milligrams were really in these things. People were
selling them like an expensive Percocet" -- for $10, in other words,
instead of $5 -- and swallowing them whole. At a party, Curt figured out
the trick of crushing the pill and snorting the powder, and he quickly
spread the word. "I showed a lot of people," Curt says. "At
first they were like, 'You're crazy.' But then they'd do it, and that
would be it. People tell me now, Yeah, you're the one who showed me how to
snort this thing."
Oxys quickly became very popular in Curt's circle of friends, and Curt
found a comfortable niche for himself between supply and demand. "I
knew people all over the county that were getting prescriptions," he
says. "They'd call me and say, I'm getting OC's now and I want to get
rid of them. They knew there was money there, but they didn't know who to
sell to. They usually gave me a heck of a deal. I'd get them all for maybe
$10" per 40-milligram pill. "I'd sell them for $20, so for every
one I sold, I made one. And then I'd give them their money and the next
month I'd get their scrip again." At that rate, he could make $900
off a 90-pill bottle. But he wasn't in it for the
profit; he was in it for the pills. "I didn't need
money," he explains. "I worked at the mill. I was always doing
it just for the free drugs."
Before long, he had 10 people giving him their pills to sell, mostly
women in their 30's and 40's on welfare or disability. (Patients on
Medicaid pay just a dollar for a $250 OxyContin prescription.) "It's
so weird the people that got into this," Curt says. "Some of
them were innocent mothers. I had one that was in her 60's. She never did
drugs. She'd sell every last one of her pills, and it would pay for all
her other medication." Curt would keep careful track of which day of
the month each of his suppliers filled her prescription. "A lot of
times I would drive them to the pharmacy," he says. "I'd always
get a couple of pills for that."
One of the most valuable -and closely guarded -- resources in the local
OxyContin economy was a doctor who was willing to write an OxyContin
prescription without asking too many questions. "It's a slow process,
breaking a doctor in," Curt explains. "You've got to know how to
work him. I'd say: 'I can't take the Vicodins and the Percocets because
they're hurting my stomach. Do they have anything that's, like, time
released?' The doctor goes, 'Oh, you know what, they've got this new stuff
called OxyContin.' And I'd say: 'Oh, yeah? Wow, how's that work?"'
Some local doctors, Curt says, knew exactly what was going on, but they
needed the business. One started handing out monthlong OxyContin
prescriptions every two weeks.
On the demand end, Curt had between 25 and 50 steady customers. "I
had a cell phone at that time, so I was doing a lot of driving," he
says. "People would gather at their houses, and they'd bring all
their friends over, 10 of them that'd use it. They'd all gather when they
knew I was coming, because they wanted the pill immediately."
Curt has been in recovery for a few months now; since he got out of
rehab, he's been cut off from almost all his old friends, and he fills his
spare time fixing up his sister's house, fishing and reading up on
psychology, which he plans to begin studying this fall. He's a man of
boundless energy and focus, and he has taken to the 12-step process with
an unusual intensity; in his first 60 days clean, he told me, he attended
138 Narcotics Anonymous meetings. That same energy served him well back in
his oxy days, when he was cutting steel at the mill all night and driving
around making pickups and deliveries all day. The pills themselves, he
says, helped him keep going. "I could go get two hours of sleep, wake
up, do a pill and continue on from there," he says.
It was only a couple of months after OxyContin arrived in town that
Curt and most of his customers realized they were addicted. At
first, they were happy just to take a pill whenever one was around, for
fun, but soon they found themselves experiencing severe withdrawal
symptoms if they didn't have a pill every day. Everyone's tolerance built
up quickly -- one week they were able to get by on a 20 a day, the next
week they'd need a 40, and a couple of weeks later, it had to be an 80. "No
one knew what was going on," Curt says. "These are a bunch of
pot smokers, drinkers, just mellow people. This drug just took us by
storm. A whole community, at least a hundred people I know around here.
They're all into the addiction. These are guys I used to smoke pot with
and drink beer with in the woods. I grew up with them all, having parties
and that. And now there's not one of them -- not one of them -- that don't
Pharma wasn't aware of significant problems with OxyContin abuse until
April 2000, when a front-page article in The Bangor Daily News, claiming
that OxyContin "is quickly becoming the recreational drug of choice
in Maine," landed on the desk of Purdue's senior medical director,
Dr. J. David Haddox. In the summer of 2000, the company formed a response
team, made up of medical personnel, public relations specialists and two
of the company's top executives, which has guided the company's OxyContin
campaign ever since.
It's fair to say that in public relations terms, Purdue's reaction to
the OxyContin problem has been less than successful. As recently as six
months ago, the company had a considerable supply of good will in the
media, the government and the affected communities; it is now facing 12
separate potential class-action suits from former patients, as well as one
from the attorney general of West Virginia; formerly sympathetic community
leaders in Appalachia and Maine have grown increasingly skeptical of the
company's approach; and in separate Congressional testimony, Attorney
General John Ashcroft called OxyContin a "very, very dangerous
drug," and Donnie Marshall, then head of the D.E.A., said in May that
unless he received "more cooperation" from Purdue, he was
"seriously considering rolling back the quotas that D.E.A. sets . . .
to the 1996 level," which would have meant a 95 percent cut in
Purdue's P.R. problems seem rooted in the
company's deep-seated belief in the inherent safety of and public need for
its product. It is an article of faith for the company that illegal
traffic in its drug is the work of "bad guys" and
"professionals," in Haddox's words. In fact, Purdue says that
its internal data indicate that the levels of OxyContin abuse in the
country are no greater than expected. "We have had increased numbers
in the last year or so," I was told by Robert Reder, Purdue's vice
president of medical affairs and worldwide drug safety, "but our
estimation is that they're commensurate with the distribution of the
drug." The abuse situation, according to Reder's numbers, is normal. (Government
statistics indicate that as of 1999, 221,000 Americans had abused
OxyContin.) The real victims, the company says, are their
"legitimate patients," who would be denied OxyContin if its
distribution were restricted.
In March, Purdue announced a 10-point plan to combat OxyContin abuse.
The plan includes tamper-resistant prescription pads for doctors,
antidiversion brochures and educational seminars for doctors and
pharmacists in affected areas, an initiative to combat smuggling of
OxyContin from Mexico and Canada and a donation of $100,000 to a Virginia
group for a study of prescription-monitoring programs. To Purdue, the plan
is generous and well focused; to people in the communities where abuse is
widespread, it seems like a way for the company to avoid the real problem.
I spoke several times this spring and summer to Debbie Trent, a
professional counselor in Gilbert, W. Va., who runs the local antidrug
community group called STOP (Strong Through Our Plan). In our first
conversation, she was scrupulously cautious and polite when she spoke
about Purdue Pharma, saying, "I don't want STOP to be seen as
fighting OxyContin." During STOP's first few months, Haddox addressed
her group twice.
When we spoke in April, though, Trent told me that she had come to
believe that the company's 10-point plan was
addressing the wrong problems -- prescription fraud and international
smuggling, for example, when what Gilbert
really needed was a way to get immediate treatment for its many addicts. "I
read about the tamper-proof prescription pads and I think, Give me a
break!" she said. "That seems like such a little thing. It seems
so minute in comparison to the scope of the problem. It's almost
intentionally missing the point. Rather than prescription pads, I would
like to see something done in rehab, something where they're making an
effort to help these folks get better."
Similar sentiments were expressed in Maine in July, when Purdue
announced its latest solution to the OxyContin problem: a $100,000 grant
to start a "mini-M.B.A." program in high schools. This fall,
Purdue will send 20 teachers from some of the most affected counties in
Appalachia and Maine to New York for training by the National Foundation
for Teaching Entrepreneurship. When they return to their schools, they
will teach students how to formulate a business plan and invest in the
stock market. The idea is to "provide these kids with a sense of
hope," according to a Purdue spokesperson. A Maine school
administrator was quoted in The Boston Globe asking why the company
"wouldn't have come up here and asked us what we want"; if
anyone had, she said, she would have asked for money for the treatment of
addicts rather than entrepreneurial training.
Again and again, Purdue has apparently been blindsided by criticism. At
a news conference in Alabama attended by parents whose teenage children
had died from OxyContin overdoses, Gov. Don Siegelman interrupted a Purdue
doctor who was going point by point through Purdue's 10-point plan.
"I find this very offensive, and I want you to stop," he said as
the doctor stood open-mouthed in front of the television cameras.
"We've had enough public relations and enough sugar-coating of this
issue and quite frankly, as governor, I am fed up." In March, Haddox
had what he thought was a cordial and cooperative meeting with Attorney
General Darrell V. McGraw of West Virginia to discuss the company's plan
to combat drug abuse. Less than three months later, McGraw filed a lawsuit
against Purdue, charging the company with "highly coercive and
inappropriate tactics to attempt to get physicians and pharmacists to
prescribe OxyContin and to fill prescriptions for OxyContin, often when it
was not called for," and seeking millions of dollars in compensation
for state medical costs.
In the meantime, the lack of co-ordination between Purdue and the
government agencies that regulate it has had serious repercussions in
affected communities, as local police, small-town mayors and individual
doctors and pharmacies have been forced to make up their own policies on
the fly. Six states -- Florida, Maine, Vermont, West
Virginia, Ohio and South Carolina -- have introduced regulations making it
harder for Medicaid recipients to receive OxyContin. After the
recent spate of pharmacy robberies near Boston, dozens of drug stores in
Massachusetts pulled OxyContin from their shelves -- only to be ordered by
the state pharmacy board to begin carrying the drug again. In
the small town of Pulaski, Va., the police have instituted a program in
which patients picking up OxyContin prescriptions from local pharmacies
must give their fingerprints, a development that has alarmed civil
liberties advocates. Doctors in many states,
sometimes fearing reprisals from the D.E.A., have refused to prescribe
OxyContin even to patients clearly in need.
Purdue's executives see the company as an unwitting victim of criminal
activity -- not unlike Johnson & Johnson in 1982, when seven people
were killed by Extra-Strength Tylenol tablets that had been laced with
cyanide. The company's critics prefer to compare Purdue to tobacco
companies and handgun manufacturers, who are increasingly likely to be
found liable for deaths caused by their products. Clearly, the company
failed to anticipate the growing chorus of public sentiment against it.
And as OxyContin incidents move closer to Washington and New York,
pressure may increase on the D.E.A. and the F.D.A. to take regulatory
action against Purdue.
I returned to the Gateway rehabilitation Center outside Pittsburgh earlier
this month, I got a clearer sense of the way in which OxyContin is taking
hold in urban and suburban America. I also learned about an unexpected
secondary effect of OxyContin abuse: in cities like
Pittsburgh, the crackdown on OxyContin is resulting in a sharp rise in
I sat for an afternoon in a glassed-in conference room, looking out on
Gateway's parking lot and groomed grounds, and talked with Andy and B.,
two addicts and former low-level dealers. Before trying OxyContin, they
had used their share of recreational drugs, but they didn't consider
themselves part of a hard-core drug community. Aside from the track marks
on his arms, B., 21, looked like every disaffected college kid in America.
He was a professional sloucher, dressed in an orange T-shirt, Army shorts
and sneakers, with a mop of brown hair. Andy wore a sparse goatee, a
hooded Ecko sweatshirt and a baseball cap with a Japanese character on it.
I asked him what it meant, and he said he didn't know.
B. began using OxyContin in 1998, when a friend told him about the
pills. He soon started dealing to support his habit, buying pills from a
dozen or so people and then selling them from his apartment to friends and
friends of friends. His sources were all legitimate
pain patients, sick with cancer, carpal tunnel syndrome, lupus or chronic
back problems. But, as B. explained, they would often supplement
their OxyContin prescriptions with something weaker and cheaper, like
Vicodin, then sell the OxyContin and struggle through the month on Vicodin.
"Some of them were old sick ladies who've never done drugs," B.
said. "They didn't understand what oxy can do to people. They just
knew they were getting $20 for each pill -- $1,800 a month off something
they can do without. They just wanted that money."
Andy laughed. "Old people are supposed to keep young people off
drugs," he said.
B. described for me the casual feel of his drug deals. For the first
several months that he was selling OxyContin, he said, everything was
friendly when he'd go to pick up pills from his suppliers. "Most of
them would say, 'Hi, honey, come on in.' You go into their house and sit
down and have something to drink and talk for a while and see how their
family's doing, and they see how mine's doing. They were nice people. I
don't think they think of themselves as drug dealers." Nonetheless,
B. said, his suppliers kept most of the profits; he'd generally buy their
pills for $20 apiece and then sell them for $25.
About six months ago, B. said, as the police and
news media began to sound the alarm about OxyContin abuse, local doctors
grew anxious. Many switched their patients to harder-to-abuse fentanyl
patches and morphine, and B. lost most of his connections. The supply
dried up, prices rose and people started ripping each other off.
A friend told him that shooting heroin was just like shooting
OxyContin, only cheaper. He'd never imagined that he might take heroin,
but the expense of OxyContin was killing him. "I was spending a
hundred bucks a day on oxy," B. said. "That's why I switched to
heroin. You get really high off two bags, which is 30 bucks a day. That's
a big savings."
Andy agreed. It took him only a month and a half to go from using
OxyContin for the first time to shooting heroin, he said. "I've
always said that I'd never ever touch heroin. But then oxys came along and
that's the same thing, just cleaner. And that got me into shooting dope.
If I'd never touched OxyContin, I wouldn't have done heroin."
In Pittsburgh and its suburbs, Andy and B.'s stories aren't unique. Gateway's
doctors report a sharp increase in admissions of young heroin addicts who
started out on OxyContin. "Ninety percent of my friends that
were addicted to oxys are now addicted to heroin," B. said. "I
know probably 30 or 40 heroin IV drug users now because of
OxyContin entered the lives of casual drug users as a Trojan horse,
disguised as something it is not. It has never become a popular drug among
existing heroin or crack addicts, who already have a cheaper and at least
as intoxicating mechanism for getting high. OxyContin
does the most damage when it enters a community of casual drug users --
Curt's pot smokers and beer drinkers -- who think of pain pills as just
another interesting diversion for a Saturday night. In networks like
Curt's or Paula's, before OxyContin, no one ever did heroin or crack;
those were seen as an entirely different category of drug: something that
will take over your life.
When you hold it in your hand, an OxyContin pill doesn't seem any
different than a Tylox or a Percocet or any of the mild narcotic
preparations that have for years seeped out of the pharmaceutical pipeline
and into the lives of casual drug users. What B. and Andy and Paula and
Curt failed to realize is that despite appearances, OxyContin actually
belongs on the other side of the drug divide; it might look like a casual
Saturday-night drug, but it's a take-over-your-life drug. Rehab centers
across the country are filling up with young people who discovered that
fact too late.
To Art Van Zee, the doctor who has seen his small community in western
Virginia "devastated" by OxyContin abuse, the answer to the
crisis is to take OxyContin off the market. Van Zee is circulating a
petition asking the F.D.A. and Purdue to withdraw the pill until a safer
formulation can be found. "The bottom line is, there's much more harm
being created by this drug being available than good," he says.
"There are very good medicines available that are equally effective.
We can certainly meet people's pain needs without OxyContin."
But for many people, "drug communities" like Curt's are not
worthy of a whole lot of official sympathy or regulatory concern --
especially not when their interests are considered next to those of patients
in pain, who are using OxyContin the way it is meant to be used and whose
lives have been improved as a result. For doctors who have seen
their patients transformed by OxyContin, there is something mystifying,
even infuriating, about the suggestion that it should be withdrawn or even
restricted, just because a bunch of kids in Kentucky didn't know what they
"There is no question that increasing opioid
consumption for legitimate medical purposes is going to lead to some
increase in the rates of addiction," Portenoy of Beth Israel
says. "But the fact is, the trade-off is worth
it. At the moment, the attitude is that if one housewife in Alabama
becomes addicted, then the drug must be pulled and the company shut down.
But we're talking about millions of people whose
lives can be brought back from total disability by the proper use of
opioids. Any actions taken by law enforcement or the regulatory
community that increase the stigma associated with these drugs, or
increase the fear of physicians in prescribing these drugs, is going to
exacerbate an already terrible condition and hurt patients."
The 10th point in Purdue Pharma's 10-point plan to reduce OxyContin
abuse is reformulation. The company says that it is spending millions of
dollars to create a new version of OxyContin, or perhaps a whole new
medication, that would have all the benefits of OxyContin and none of its
dangers. Of all the initiatives under way, this is the one that has
received the most attention and created the most hope in Appalachia and
other affected areas.
In some interviews, Purdue's representatives sound downright
enthusiastic about this idea. Earlier this month, they put a price tag --
$50 million -- on the project for the first time. But when pressed, Haddox
admits that what Purdue's scientists are looking for is a "holy
grail," a drug that will activate the receptors in the brain that
control pain relief and leave alone those that control euphoria. And this
isn't a new initiative, it turns out, but one that the company has been
working on for many years. Scientists and doctors as far back as
Hippocrates have tried to find a way to separate the benefits of opiates
from their dangers.
There are often suggestions from Purdue that this reformulation may
take "a few years"; it's also entirely possible that it will
never happen. Opioids, including OxyContin, may remain the double-edged
sword they have always been. And regulators may simply decide to accept a
certain amount of unintentional damage in the treatment of pain, and leave
local police chiefs and drug counselors -- as well as individual addicts
-- to find solutions to the OxyContin problem on their own.