The Problem of Pain

The Problem of Pain

It’s easier to blame individuals for the opioid crisis than to attempt to diagnose and cure the ills of a society.

White Market Drugs: Big Pharma and the Hidden History of Addiction in America
by David Herzberg
University of Chicago Press, 2020, 400 pp.

Reams have been written about the misdeeds of Purdue Pharma, the manufacturer of OxyContin, and Purdue’s majority owners, the Sackler family. After years of litigation prompted by spiking overdose rates, in November 2020 Purdue pleaded guilty to conspiracy to aid and abet doctors in dispensing OxyContin without a legitimate medical purpose. The company was ordered to pay $8.3 billion in penalties, damage, and forfeiture. This sum is less impressive than it looked in headlines: Purdue’s bankruptcy in 2019 means that the money is unlikely to be collected. Though they were branded as villains in the eyes of the public, the Sacklers escaped criminal charges and had to pay only $225 million of their family money—small potatoes for a family that took some $10 billion out of Purdue between 2007 and 2017.

Mostly overlooked was the fact that OxyContin was only the latest in America’s long history of pharmaceutical disasters. David Herzberg’s White Market Drugs: Big Pharma and the Hidden History of Addiction in America seeks to correct this “radical act of forgetting” by examining the troubled history of psychoactive drugs in America. He considers licit and illicit drugs together, arguing that the marketing of medicine relies on the stigmatization and criminalization of those who consume drugs outside the medical system; the development of America’s gargantuan pharmaceutical markets must be understood alongside the growth of the illicit drug market. His choice of the phrase “white market” to describe pharmaceuticals reflects the racial bias that has been baked into this system from the start.

The distinction between licit and illicit drugs hinges on binaries: healing versus harm, relief of suffering versus desire for pleasure, medication versus recreation, obedience versus rebellion. These oppositions crumble under the slightest pressure. There are countless examples of harm caused by medical interventions. In the case of psychoactive medications, the most severe unwanted effects include addiction, psychosis, overdose, and suicide. Illicit psychoactive drugs, meanwhile, can heal. Ibogaine can help those addicted to heroin; psychedelics and MDMA can help relieve PTSD, depression, and anxiety in some people; opiates, stimulants, and sedatives can help people survive the aftermath of trauma or the suffering of unhappy everyday life. Relief is a kind of pleasure, engendering desire. Recreation relieves pain, and obedience can be a form of self-harm.

Drugs often move from one category to the other. Cocaine was first marketed to Americans as a pharmaceutical. Bayer’s Heroin (diacetylmorphine), named for its heroic powers, was introduced in 1898. Today, cannabis, MDMA, psilocybin, and ketamine are all in the process of moving from the illicit to the white market. They’re the same as they ever were; we’re the ones who have changed. A bottle of Adderall prescribed for a student struggling with term papers or a banker exhausted by long working hours can have a new existence at an all-night party. A drug becomes illicit when it’s used for fun.

Medical diagnoses legitimize the need for relief in the eyes of the law, but diagnosis is subjective, shaped by a doctor’s preconceptions about a patient on the basis of race, class, gender, age, sexual orientation, and self-presentation. A diagnosis and prescription can be a reward for conformity or a blunt instrument used to enforce it. In the 1970s, feminists protested the widespread prescription of Valium, which they viewed as a tool to suppress female rebellion. If, on the other hand, you’re looking to be prescribed a particular drug, be sure to dress neatly—imagine you’re going to court—and tell the doctor you need the pills for your office job.

The story of America’s love affair with pharmaceuticals starts in the late nineteenth century, during a period of rapid industrialization and rising consumerism. Among the cornucopia of new commodities were products derived from the poppy and coca plants. (Imperialism, colonialism, and global trade are important parts of this story, though they’re beyond the scope of Herzberg’s book.) Scientific advances in extracting psychoactive elements and the invention of the hypodermic syringe offered potency that would have been unthinkable a few decades earlier. Amid widespread suffering due to lingering Civil War injuries as well as everyday disease, and with very few effective medicines or medical treatments available, Americans embraced the new drugs. Opiate use rose threefold between 1870 and the mid-1890s, and cocaine use increased by a factor of ten between 1883 and 1893. Opiates were used to treat not only pain but “respiratory disorders, diarrhea, syphilis . . . insomnia, anxiety, overwork, masturbation, photophobia, nymphomania, and violent hiccough,” Herzberg writes. Cocaine started off as an anesthetic, but it was soon prescribed for various “nervous diseases” and for hay fever. Traditional societies had long used poppy and coca to treat a range of maladies, but they had never used it in such strong formulations or via injection or insufflation. A pattern of disturbing, compulsive use of morphine, cocaine, and related drugs soon emerged, and was eventually named “addiction.” Markets still operated on the principle of caveat emptor, without significant state regulation.

Legal morphine and cocaine were available, Herzberg explains, to the “doctor-visiting class,” who were characteristically “white, native born, Protestant, middle aged, and middle class.” But all kinds of people wanted the new drugs, and those who did not fall into the doctor-visiting class acquired them through informal channels. Some Chinese laborers, who were mostly segregated into disreputable urban areas, frequented “opium dens,” where drugs were used not by medical prescription but on a social model analogous to the consumption of alcohol in bars. (Chinese opium consumption had dramatically increased after Britain coerced China into importing opium from the Indian colonies, but Americans viewed opium smoking as an “Oriental” vice.) White women opium smokers and their potential sexual relations with Chinese men became the focal point of racist and xenophobic crusades—a moral panic trope that would recur in anti-drug campaigns over the following decades. Meanwhile, reformers advocated for protection of white-market consumers through greater regulation of morphine and cocaine.

The campaign to control opiates and cocaine was an early example, Herzberg argues, of an artificial and explicitly racist distinction between “respectable” white consumers, who were portrayed as innocents in need of protection, and stigmatized, largely nonwhite consumers, who became the target of punitive, prohibitionist tactics that endure today. In 1877, the New York Times wrote that morphine “habitués” were rare among “the laboring classes,” “the negro and Indian races,” or “tramps.” In fact, morphine users were “the highest, worthiest, and best educated people in the country—those whose social and intellectual status gives them a certain pre-eminence over the masses.” Morphine was dangerous but chic, used by cultured intellectuals to relieve the pain of a highly refined existence. Chinese opium smokers, on the other hand, had “corrupt and effeminate manners, and . . . decided tastes for negative enjoyments and a dreamy and contemplative life,” per an 1866 newspaper article. Opium dens were banned around the time of the Chinese Exclusion Act. Chinese opium smoking was a vice; white opium use was a disease. The moral distinction drawn between morphine users and opium smokers would be echoed a century later in the racist legal distinction between powder and crack cocaine.

From the perspective of white, “respectable” consumers, efforts to regulate opiates were quite successful. Stronger medical licensing laws, the introduction of a system of prescription-only requirements for opiates and cocaine, control of “patent” medicines, and restrictions on advertising and publicity helped dramatically decrease the rate of morphine prescription and consumption. The prohibition side, by contrast, was a disaster. Opium was bulky and smelly, making it hard to smuggle after the United States banned the import of smoking opium in 1909. The informal market moved to a lighter, scentless, more potent product: heroin, which was often injected rather than smoked, maximizing addictive potential and the risk of overdose. Herzberg argues that the dual processes of regulatory reform in the medical sector and heightened criminalization in the informal market hardened the distinction between “good” patients who had accidentally become dependent and “bad” addicts, who had succumbed to vice. “White markets became both safer and less publicly visible,” he writes, “while informal markets became both more dangerous and more visible.”

In response to the heavy state scrutiny of opioids, the pharmaceutical industry turned to other psychoactive drugs: barbiturates, benzodiazepines, and amphetamines. The first commercial barbiturate was Bayer’s Veronal, introduced in 1903. Pharmaceutical companies scrambled to patent their own barbiturate brands and to promote diagnoses that would call for barbiturate prescriptions: according to Herzberg, these included sleeplessness, “nervousness and restlessness,” “hysteria, bronchitis, hypertension, dysmenorrhea, ‘sexual irritability,’ and ‘nocturnal pollutions.’”  These campaigns took place at a time when increasing creativity in marketing, technological advances, and changes in manufacturing and transportation “brought an unprecedented array of new devices to solve a dizzying array of problems that advertisers taught Americans that they should no longer have to endure,” he notes. It was easy to die from a barbiturate overdose, and soon death rates—by accident, suicide, or homicide—began to rise.

Efforts to put tighter controls on barbiturates went nowhere in the 1920s, when the government was strongly pro-business, but gained a foothold in the 1930s, a period of expanded government regulation and intervention. (This was also the decade when cannabis was classified as an addictive narcotic, in a campaign that associated the drug with insanity, violence, and racial minorities.) But attempts at regulation encountered resistance from pharmaceutical companies, pharmacists, and physicians worried about lost profits, burdensome paperwork, and diminished authority. A coalition of opponents of reform adopted the time-tested strategy of blaming barbiturate addiction and overdose on criminals who were diverting pills. The answer, they said, was to crack down on criminals, not pharmaceutical companies and doctors.

In the 1950s, white Americans were awash in legal barbiturates even as law enforcement cracked down on illicit drug use in urban areas with nonwhite populations, introducing mandatory minimum sentences for drug infractions. Billie Holiday died in 1959, handcuffed in a hospital bed, after twenty years of harassment by the Federal Bureau of Narcotics. Marilyn Monroe overdosed on doctor-prescribed barbiturates alone in her Brentwood home in 1962; her erstwhile lover, President John F. Kennedy, convened an Advisory Commission on Narcotic and Drug Abuse that endorsed federal control of barbiturates and stimulants. In the 1950s, the rate of fatalities from pharmaceutical sedatives was four times higher than that caused by opioids. Even during a period of increased heroin use in the 1960s and 1970s, more Americans died from legal sedative overdoses than from illegal opiates.

Barbiturates were joined in the white market by amphetamines—fuel for the Second World War, the postwar economic boom, the Beats, and Andy Warhol’s Factory—and by less potent tranquilizers like benzodiazepines. Mother’s little helpers allowed housewives to vacuum with record speed, pick-me-up pills helped businessmen work long hours, and tranquilizers helped salesmen overcome their social anxiety. The psychiatrist brothers Arthur, Raymond, and Mortimer Sackler helped market benzodiazepines, which were presented as a safer alternative to barbiturates, through advertisements, “education” campaigns, and the expansion of diagnoses for which benzodiazepine treatment was indicated.

In the 1960s, during a rise in countercultural drug use, the consumer advocacy, civil rights, and feminist movements challenged the artificial divide between medicines and drugs. Their reform efforts focused on the rapaciousness of pharmaceutical companies and on racial and gender discrimination in medical treatment and drug policy. They pushed for tighter regulations of commercial actors, which resulted in a sharp decline in the use of stimulants and sedatives. Herzberg sees this as a brief bright spot in American drug policy. Still, the reform efforts were rooted in the “distinction between sellers and consumers,” which Herzberg argues “made practical sense only in white markets, where sellers were easily identifiable corporations, physicians, and pharmacists. In informal markets the line was far harder to draw because people with addiction so often also sold drugs to support their habits.” The crackdown on prescriptions prompted the rise of a gray market of “scrip doctors” and “pill mills.”

This relatively progressive period in drug policy was short-lived. The Reagan era loosened regulation on the pharmaceutical industry and introduced much harsher punishments for illicit drug use. Meanwhile, a new wave of stimulants and sedatives was rebranded for a new era of drug consumption. As Food and Drug Administration (FDA) restrictions relaxed, direct-to-consumer pharmaceutical advertising skyrocketed. Spending on pharmaceutical ads rose from $12 million in 1989 to $2.24 billion in 1999.

These trends were accelerated by the American Psychiatric Association’s 1980 diagnostic guide, the DSM-III, which defined illnesses not according to etiology but on the basis of a checklist of symptoms. Such reporting was highly subjective, but it supported the increasingly complex system of insurance reimbursements and the testing of new pharmaceuticals through double-blind, placebo-controlled trials. (These trials were often funded by pharmaceutical companies, which routinely manipulated the resulting publications to increase evidence of effectiveness and hide evidence of negative side effects.) By ignoring the causes behind psychiatric disorders, the DSM-III turned natural human responses to difficult circumstances—grief, despair, boredom, worry, distraction, anger—into reasons for medical intervention. The 1980 manual listed 265 mental illnesses; by the time the DSM-IV was released in 1994, there were almost 400. Antidepressants became new blockbusters. An old stimulant from the 1950s, methylphenidate, was dusted off, rebranded as Ritalin, and marketed for attention deficit disorder, which had first been codified in the DSM-III. Amphetamine roared back as Adderall, which soon became ubiquitous in high schools and colleges. America was returning to the Gilded Age of barely regulated, heavily advertised wonder drugs. Let the buyer beware.

The most striking throwback, according to Herzberg’s account, was Big Pharma’s success in launching an unprecedented boom in opioid use. The use of opioids to treat acute pain was nothing new; the change was in their use to treat chronic pain. Opioids were rehabilitated with the help of a small group of doctors who advocated for expanded access to these drugs, not only in acute cases or at the end of life but for chronic conditions. These “radical reformers,” as Herzberg calls them, put forth a theory that distinguished addiction from dependence. If opioids were used as prescribed for pain, they argued, physical dependence might result, but this was distinct from the destructive, rapidly escalating effects of “psychological dependence.” In a landmark paper, Kathleen Foley and Russell Portenoy argued that addiction should be understood not as physical dependence but as “a set of aberrant behaviors marked by drug craving, efforts to secure its supply, interference with physical health or psychosocial function, and recidivism after detoxification.” Other reformers argued that when pain patients desired larger doses of opioids, this was only “pseudoaddiction”—the result of inadequate dosage from their physicians. These new definitions helped legitimate the use of opioids for longer periods and in a wider range of cases. Herzberg points out that they also served to reinforce the stigma of any informal-market drug use, affirming the obvious fact that white-market drug dependence is far safer and easier than dependence on drugs that have been illegally obtained. Patients receiving drugs from a doctor are less likely to experience cravings and the “aberrant behaviors” that follow them because their drug supply is stable.

Purdue Pharma embraced this turn in pain management with the launch of their new slow-release oxycodone formulation, OxyContin, which was designed for chronic pain. They gave extensive support to the small group of radical pain reformers, funding medical societies, journals, chairs, and studies. In keeping with the larger pattern of corporate capture of government during this period, the FDA medical officer who oversaw OxyContin’s successful application went on to become Purdue’s executive director of medical affairs. Purdue promoted the use of OxyContin not only for pain associated with terminal illness but, Herzberg tells us, for “back pain, osteoarthritis, neuropathic pain, postoperative pain, rheumatology, dentistry, [and] sports/rehabilitation.” As insurance companies grew less likely to cover cognitive behavioral treatments or physical therapy for chronic pain, pills offered an attractive alternative for both patients and doctors.

To protect the sales potential of this potent opioid, it was imperative that it be perceived as a respectable white-market medicine. Purdue therefore focused its marketing efforts on white consumers and white areas like northern New England, Kentucky, and West Virginia. Physicians prescribing unusually large volumes of opioids had once been the targets of investigation. Now Purdue sales representatives were instructed to train their sights on this same category of doctors. Meanwhile, other companies were developing competing opioids; the Johnson & Johnson subsidiary Janssen threw its hat in the ring with fentanyl patches and lollipops.

It quickly became apparent that use of pharmaceutical opioids was turning into a public health crisis. Learning nothing from the past, authorities cracked down in the most counterproductive way possible. They targeted drug diversion, cut off “abusers” of legal pills, and aggressively pursued and punished informal market suppliers—even people who had merely given a single dose to a friend—while doing virtually nothing to rein in pharmaceutical companies or to improve access to drug treatment, overdose prevention, or alternative pain treatment. People who had become dependent on OxyContin were pushed into the informal market, buying diverted pills or, even more dangerous, counterfeit pills or heroin, whose potency could never be guaranteed and which were increasingly contaminated with the far more potent fentanyl and carfentanil. The result was an unprecedented increase in overdose rates.

After college, I worked for some of the “radical pain reformers” Herzberg describes. I was an administrative assistant in the Open Society Institute’s International Palliative Care Initiative, whose medical director was Dr. Kathleen Foley. While reading Herzberg’s book, I recognized the names of people I’d known as kindly doctors who had devoted their careers to the care of the dying. Back then, sitting in my cubicle, I was moved to tears by reports about Mongolian cancer patients forced to travel long distances over rocky roads in horse-drawn carts if they wanted pain relief. I learned that people around the world were dying in unnecessary agony because their governments were afraid of “drug abuse,” and that black Americans had dramatically less access to pain relief than white patients did. I had gotten my position with the help of a former nurse turned palliative care specialist who had lived through the 1980s in San Francisco. Before there was effective HIV treatment, she had wanted to help the gay men who were dying all around her. If they couldn’t be saved, at least they could die without pain. These are the kinds of stories that can make a person radical.

Like others who have written about OxyContin’s fatal trajectory through the American market, Herzberg sees the pain reformers’ advocacy for broader opioid prescription as an important contributor to the overdose crisis. In his view, pharma legitimized its predatory practices by purchasing authority for a small coterie of doctors with extreme, misguided views. He does not delve into the ways in which good intentions can yield bad results in a dysfunctional system, and he does not address pain reform’s roots in palliative care. (His is already a rich and complicated book, and perhaps this was simply beyond its scope.) But Foley and her colleagues weren’t wrong about everything. If the reaction to the opioid crisis causes pain to go untreated or to be unequally treated based on race or class or drug use history, we’ve made another mistake. Overprescription is a risk—but underprescription (including of methadone or buprenorphine treatment) can be harmful, too.

To blame the opioid crisis on pharma and doctors risks missing the larger picture of the system that created them. As with #MeToo, the justified rage over the overdose disaster has focused on individual villains, while mostly neglecting larger structural problems. Our poorly regulated, profit-hungry pharmaceutical industry, with its deep pockets and friends in Washington, is a machine for producing Sacklers, just as extreme economic inequality and a lack of worker protections will inevitably produce more Harvey Weinsteins. Whether or not the Sacklers apologize is beside the point, and while it’s useful to confiscate assets from the Sacklers and from Purdue, that’s not enough. The Sacklers and Purdue are the symptom, not the disease. It’s easier to denounce individuals than to attempt to diagnose and cure the ills of a society. This kind of one-off court case is like our broken medical system: it privileges symptoms over causes, the individual over the collective, and quick fixes over deep reform, while making no provisions for preventive care. Transformative change will have to be structural and long-term.

“Free markets and prohibition,” Herzberg observes, “are usually thought of as opposite policies, but in practice they lead to the same end result: poorly regulated markets designed to serve sellers’ profits rather than consumers’ interests.” He concludes that the best drug policy in an imperfect world is one that “charts a narrow path between the Scylla of prohibition and the Charybdis of the ‘free market,’” and whose priority is the protection of consumers in white, gray, and informal markets alike. Rather than taking as its central distinction medical and nonmedical use, drug policy should be organized around safe and unsafe use, balancing benefits—which include pleasure—against harm. Ultimately, Herzberg argues, we need to eliminate the profit motive from the market for addictive drugs and explore possibilities like state monopolies and public utility models.

These are essential reforms. But like the stricter regulatory approach of the 1930s and the consumer advocacy and civil rights–inspired reforms of the 1960s, they don’t go far enough. Why should any medicine be sold for private profit? Rather than our overpriced, byzantine, grossly unequal and inefficient patchwork of medical coverage, we need a comprehensive social safety net that allows all sick and injured people to receive truly effective treatment, including long-term physical and cognitive behavioral therapy, and to take time off work without losing their healthcare, their homes, or their livelihoods. We need a national pension system that allows people to retire in comfort from jobs that have become too taxing for their aging bodies. A second New Deal with an emphasis on racial and gender equality would function as society-wide pain relief, with no risk of overdose. Finally, we need to ask why so many Americans desire psychoactive drugs, looking at socioeconomic as well as physiological causes. Why are we so depressed? Why are we so anxious? Why are we in so much pain? And what are we going to do about it?

Sophie Pinkham is the author of Black Square: Adventures in Post-Soviet Ukraine. She previously worked in international drug policy and harm reduction, and produced the documentary Balka: Women, Drugs, and HIV in Ukraine.