The Opioid Crisis Through the Lens of Government, Medicine, and the Personal

Book review: American Overdose, by Chris McGreal
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A former head of the Food and Drug Adminsitration has called America’s opioid epidemic, “one of the greatest mistakes of modern medicine.” It is neither a mistake nor the kind of catastrophe born of some ghastly accident. It is a tragedy forged by the capture of medical policy by corporations and the failure of institutions in their duty to protect Americans.

Guardian journalist Chris McGreal’s American Overdose is the latest narrative look at the opioid epidemic overwhelming the US, and it’s a well researched, emotionally intense one that combines personal perspectives from users and families with medical industry background and lawmakers’ inaction to give a timeline of the crisis progression and where its responsibility lies, at least in part. It shows how frighteningly easy it is for addiction to take hold and how politicians and government have been lobbied and financially influenced by drug companies, allowing addiction to burgeon unchecked.

In comparison to an excellent previous book on the epidemic, Dreamland, this focused more on the culpability of pharmaceutical companies, Purdue with its deceptive, selective statistics and aggressive marketing of OxyContin in particular; the unscrupulous doctors running pill mills; and the politicians, especially in Congress, willing to look the other way when supporting drug companies benefited them financially. We see some of the extreme lobbying on behalf of the pharma industry that goes into this as well, which is horrifying. Especially when juxtaposed with the voices of the people affected – sometimes of users and former users, and very affectingly, from families when loved ones didn’t survive.

In contrast, Dreamland focuses more on the Mexican cartels who moved in when they saw opportunity multiplying in the opiate market. American Overdose better explores how the problem exploded in the first place. It also covers territory like the drug companies’ continued development of prescription opioids, including stronger ones despite knowledge of abuse. McGreal also covers the dangerously skewed research that was cited claiming the drugs’ safety.

They homed in on the statistic showing that only two of the patients became addicted and probably because they had previously abused drugs.

[ArtVan Zee] was among the first doctors to raise the alarm, but he struggled to be taken seriously against the arrayed forces of the opioid makers’ money, a Congress unwilling to challenge the industry, and a federal medical establishment that showed little interest in addressing its wider responsibilities to the public health.

The book reads somewhat like a magazine article. A well written and extensively researched one, but not as cohesive or consistently compelling as I’d prefer. The sections detailing maneuverings in Congress and other government bureaucratic measures and missteps were tough to slog through, as important as these failures of policy were, and there are a plethora of figures that make it a bit disorienting.

Some stories stuck out though, like this one:

After sporadic legislation to tax and limit opium imports, the US Congress passed the Harrison Act in 1914 to restrict distribution to prescribing physicians. Because the law involved taxation, the Treasury Department was left to enforce it. Drawing on its absolute lack of medical expertise, the Treasury made a moral judgment that addiction was not a disease but a human failing. It ruled that doctors would not be permitted to prescribe narcotics to people who were hooked even if it was to help them shake their addiction. The Supreme Court upheld that position, and it prevailed for half a century.

It explains so much.

But the policy stories also left me with questions. There are several mentions of the Obama administration, and Obama himself, being uninterested in addressing the opioid crisis. But not enough explanation of why; I wanted to understand more of that.

When breakthroughs are made, such as strides in recognizing addiction as disease, it’s often tangled with other thorny issues like the crack epidemic, which was criminalized and disproportionately affected African American communities. Now that a drug problem is affecting white people, it’s labeled a public health crisis and beginning to receive political attention instead of criminalization.

I thought the reporting was strongest when the people affected spoke for themselves, because the impact of their stories and the trajectory of how they occurred is what really unmasks the ugliness and horror of this pharmaceutical-sponsored epidemic. It exists because of a perfect storm of drug companies pushing their product through aggressive, persuasive pharmaceutical reps, doctors and insurance companies more willing to treat symptoms than root causes (not to mention unscrupulous doctors who saw profit opportunity and ran with it), and legislation unwilling to address medical regulation or insurance issues. It is, in one word, infuriating.

A story that gets central attention here is the bizarre one of Henry Vinson, a former mortician arrested in a prostitution scandal in Washington, D.C. He eventually made his way to Williamson, West Virginia and opened a clinic, employing doctors Diane Shafer and Katherine Hoover, who would make thousands of dollars a day, cash, writing opioid prescriptions. Patients were encouraged to not even see the doctors during appointments. These two illustrate a sadly not uncommon story of extreme greed and absence of ethics, which is heartbreaking (and eyebrow-raising as Shafer’s case spirals into the soap operatic) but also a deep-dive look at how pill mills function and affect the towns where they take root.

McGreal also does excellent work in showing that addiction knows no socioeconomic boundaries, period. That should go without saying at this point and yet there are those who persist in believing it’s a choice, not to mention gut-wrenching stories from parents who, thanks to long-entrenched prejudices, understood too late the depth and seriousness of what their children were suffering. He interviews people across the spectrum who suffered opiate addiction, including doctors themselves. The slippery slope from trying to manage pain enough to live normal, everyday life into full-fledged, all-consuming addiction is not nearly as lengthy or rare as many still believe.

The stories from grieving parents are the hardest. To know the story behind why this is happening – how many legislators and medical professionals who were supposed to have human best interest at the core of their work and who instead have created, allowed, and added gasoline to the flames of this epidemic is tragic. American Overdose covers the details but it doesn’t offer much hope – only the reality that there is no easy or quick solution.

American Overdose:
The Opioid Tragedy in Three Acts
by Chris McGreal
published November 13, 2018 by PublicAffairs (Perseus)

I received an advance copy courtesy of the publisher for unbiased review.

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