These highlights are from the Kindle version of Opioids for the Masses by Trey Garrison.

The story we’ve come for began just two decades ago, when a new generation of “safer” opium-based painkillers triggered an onslaught of prescriptions in America. Tragically and inevitably, these prescriptions were followed by dependence and abuse. In the decades since, opioid overdoses have killed well over 400,000 Americans, closing in on half a million.

More Americans have died from opiates since the 1990s than died in the entirety of World War II.

Today, 54 percent of Americans know someone who died from a drug overdose. One in three will have a friend who dies from a drug overdose in their lifetime. And drug overdose is now the leading cause of death for Americans under fifty.

the Vietnam War lasted nineteen years and saw 58,000 Americans die, but in 2017, nearly as many Americans perished from opioid overdoses as in twenty years of war in Southeast Asia.

The pills that caused this crisis were flooded into parts of the country—rural, working-class communities—where drug use was largely frowned upon and marginalized.

Morphine, which is derived from opium but is ten times stronger, was widely used as a painkiller in the Civil War, and historians estimate that about 400,000 American soldiers on both sides became addicted by the war’s end.

In the 1870s scientists tried to develop a less addictive form of morphine, and the result, ironically, was heroin. A cautionary tale, if ever there was one.

The fact that “flyover America” is most affected by the crisis explains the relative paucity of coverage in the news. Rural White Americans are those least likely to receive sympathy from coastal media and politicians. Both the leadership of the left and right often take rural and working-class Americans for granted. But these Americans are part of the backbone of this country. They comprise a surprising percentage of our armed forces. They contribute a disproportionate amount to the Federal tax coffers. And historically, they have provided the labor that made America the industrial superpower of the modern world. Without them, America simply won’t be the same.

Coal mining is back-breaking labor and eventually, miners with a sore back or a bad tooth became eager for the twelve-hour, non-addictive pain relief that was being marketed to them by drug companies. Doctors were encouraged and often rewarded by manufacturers to treat every single pain complaint with pain pills.

Records and congressional testimony from 2018 show that from 2007 to 2012, distributors sent more than 780 million hydrocodone and oxycodone pills into West Virginia: 433 pills for every man, woman and child. One town of 400 residents was sent 9 million opioid pills in two years. Another, with less than 1,800 citizens, received 16.5 million in ten years. Another, population 2,900, received almost 21 million pills during that decade.

in 2013 alone, there were twelve billion opioid tablets prescribed. That’s enough for every single adult American to take opioids daily for five weeks.

In very large measure, this blizzard of opioid prescriptions really started with Purdue Pharma. “Blizzard” here is not a capriciously chosen word, by the way. According to court filings, a member of the Sackler family, owners of Purdue Pharma the maker of OxyContin, told attendees of the drug’s 1996 launch party that the drug’s takeoff would be “followed by a blizzard of prescriptions that will bury the competition,” according to filings and records produced in Massachusetts v Pursue Pharma et al. And he was right. OxyContin was the most successful pharmaceutical product launch in American history.

Around 68 percent of the more than 70,200 drug overdose deaths in 2017 involved an opioid.

Right now, there are 130 deaths a day from opioids alone.

Their first taste came from a person they trusted most—their doctor. Some might sneer at “pill poppers” for a moral failing, but the number one way Americans are introduced to prescription opioids is when they get them for acute pain for minor or major surgeries. The second most common way is wisdom tooth removal. The average age of the recipients of opioids for wisdom tooth removal is around seventeen years old.

Consider the American Pain Foundation. While also official sounding and apparently reasonable, they were anything but. Valuck describes the American Pain Foundation as “a money laundering organization for the pharmaceutical industry.” Funding records bear this out. According to an investigation by ProPublica, fully 90 percent of its funding came from Big Pharma. It was the chief advocate for the proliferation of opioid pain relievers and expanded pain management as part of the medical practice for decades. That is, it was the chief advocate until it abruptly closed its doors in 2012, just as it came under intense Congressional scrutiny.

Mortimer Sackler was the patriarch of the Sackler dynasty until his death in 2010. The second son of Jewish immigrants from Ukraine and Poland, Sackler and his three brothers became the leaders of a small pharmaceutical company in the 1950s. By the mid-1980s, Purdue Pharma was still a small concern, but Mortimer Sackler had big ideas on how to grow its product line.

Purdue Pharma was a pioneer in campaigns geared towards patients directly, such as the “Get Your Life Back” campaign that was basically preparing the market for Purdue and the Sackler’s greatest achievement—the launch of OxyContin in 1996.

“OxyContin was the most successful launch in the history of modern medicine,” Valuck says. By 2001, something like 80 percent of Purdue’s gross revenue of $3 billion came from OxyContin sales. And according to the New Yorker, OxyContin had generated for Purdue “some $35 billion in revenue” by 2017. The Sackler family had gone from owners of a relatively modest pharmaceutical company in the mid-1980s to the nineteenth wealthiest family in America in 2016, according to Forbes.

The addictive nature of opioids has been known for over a century. Today, it isn’t simply anecdotal. We can almost measure the likelihood of addiction to the tablet. According to Valuck, there is a 6 percent chance a person given just 6 tablets will be taking opioids a year later. This comes from a survey of over half a million patients, not a letter to the editor of a medical journal. “And if you give a patient three weeks or more of tablets, say 60-90, there is a 20 percent chance they’ll be taking opioids a year later. Give them forty days—it’s a 40 percent chance. We know how this works,” he said. The calculus of opiate addiction is as consistent as it is depressing.

Jasper, Alabama is a rural town of just 14,000 residents located in the northwest part of the state. It has the sort of tree-lined, shady streets that characterize so much of small town America. It’s also a hotspot for prescription opiate abuse.

Government subsidies helped fuel Jasper’s addiction. As coal jobs started disappearing, Medicare and Medicaid ensured that retired or unemployed patients would still be able to get their medications. Moreover, the price of opioid tablets on the street was high enough in recent decades that many could sell pills to others while still having enough left to satisfy their dependence, perversely replacing some of the income lost to globalization. Ironically, patient health may have been at greater risk by having health insurance, Medicare, or Medicaid than not having it, due to the lack of interest the government showed in how it was being used and affecting people’s lives.

She tells us of the pills and the heroin and the crime that have followed, and the people who got rich off of it. She tells of the rot opioids have brought. “There’s basically a war against my people here. Not a war, a slaughter. They’re destroying entire generations to make their blood money,” she says. “People are dying and killing themselves. They’re not having children. These are the people who are always first to volunteer when their country calls them to war.”

If the cost in terms of crime in this area is staggering, then the cost in terms of overdose deaths is even more so. In a nation overcome with a widespread crisis of opiate addiction, West Virginia, which is ranked thirty-eighth in population and forty-eighth in income, is number one in overdose fatalities per capita. The rate there is 57.8 per 100,000, according to data from the US Centers for Disease Control and Prevention. It’s held the top spot for years. Ohio is ranked second at 46.3 deaths by overdose per 100,000. Kentucky’s rate was 37.2.

“Law enforcement saw this opioid crisis coming. We saw it with the prescription pills ten to fifteen years ago. You asked why it so predominantly hit Caucasians instead of African-Americans. This may have been the one time in history it was unhealthier to have health insurance than not have it,” he says.

After she leaves us, Martin makes a point that leaves us thunderstruck. “We lost what, 50,000 people last year to drug overdoses,” he says. “If you changed the name of what killed them to something else—say, terrorism—do you think a year later we’d still be hoping to get funding to fight terrorism?”

Street price for meth just three years ago was about $300 for an eight ball (an eighth of an ounce or 3-3.5 grams). Cartels, not local cooks, have been upping their imports, so now the price is down to $100 for an eight ball, Martin tells.

Here’s a thumbnail of how the drug traffic into Lexington works today. Detroit remains the primary source for heroin and fentanyl. A typical dealer is a “D Boy” who comes into town with about $6,000 worth of product on him. He’ll inform his network of buyers that he’s in town and where. He’ll stay a week, make his sales, and head back north with about $10,000—clearing $4,000 for a week’s work.

From the Blue Ridge Mountains to the Shenandoah River, this is gorgeous country. The ancient forests of sycamore and Norway maples, the winding streams and flowing waters, the dramatic rises and rock formations are all breathtaking.

Entire towns now seem populated almost entirely by drug-addicted zombies. In West Huntington, population 48,000, opioid-addicted prostitutes hit the streets on a weekday before the sun is even down, plying their trade on the streets within sight of children playing ball in a parking lot. But that’s why we’re here.

Logan is coal country through and through. The entire economy is built on it. Logan County holds a special place in coal mining lore and the hearts of generations of coal miners. In 1921, it was the epicenter of the Battle of Blair Mountain, the largest armed uprising in American history since the Civil War. It was part of the Coal Wars. This part of American history isn’t taught much outside of this part of the country.

The Coal Wars were a series of early twentieth century labor disputes that culminated in armed confrontation in Logan County. For five days in the late summer of 1921, about ten thousand armed coal miners confronted three thousand strikebreaker lawmen and “gun thugs” backed by the coal companies, who were fighting attempts by the miners to unionize their part of the state. More than a million rounds were fired, according to accounts, and as many as one hundred people died in the confrontation. The miners lost, but saw some concessions later on in working conditions.

“With the benefit of hindsight, I wish we had moved faster and asked a different set of questions. I am deeply sorry we did not,” Barrett told the committee back in May 2018. The drug wholesaler admitted it supplied Family Discount Pharmacy, in Mount Gay, with 6.5 million doses of hydrocodone and oxycodone between 2008 and 2012. That’s 3,561 painkillers a day to a single pharmacy in rural Logan County.

What locals call “town critters” wander aimlessly about, searching for their next high. What locals call “fashion girls” make driving a little dangerous, because they’re walking into the street trying to get the attention of potential customers.

Everyone points the finger at everyone else for why this is. One group says it’s Big Pharma. Pharmacists say it’s doctors who are irresponsible. Doctors blame bad information and/or patient abuse. Everyone involved finds a way to absolve themselves, mostly by pointing the finger at addicts. It’s a classic display of victim blaming. And while for decades Big Pharma’s lawyers and lobbyists in Congress, AMA and the FDA, paved a superhighway for their flood of prescriptions, the matter has only gotten more complicated and ugly, with state lawmakers and trial lawyers in the last decade dog piling after seeing blood money in the water in the form of class action lawsuits—the goals of which often are far less based on justice or restoration and more on opportunism and avarice.

Officially, per capita prescribing grew exponentially around the turn of the century, so that by early 2010s more than 259 million prescriptions were written in the United States. That was the peak in 2013. According to the CDC, it’s about 190 million now.

Getting good data about the distribution of opiates is impossible, but one fact stands out. Drug companies aren’t less profitable today than they were in 2013.

In 2018, Huntington saw a roughly 40 percent decline in opioid overdoses. Some quickly seized on that statistic as proof of a marked decline in opioid use. But it wasn’t. It turns out that it was almost entirely the result of expanded training in the use of naloxone, or Narcan, by first responders in the Huntington Fire Department, teachers, police, EMTs, and others. So there were more lives saved by Narcan, meaning fewer deaths, but that doesn’t mean there’s been any reduction in actual opioid use or opioid overdoses.

The following is not comprehensive, but they are the worst of the worst, and it reads more like something out of a bonus content side story from Nip and Tuck than something you might title Dr. Innocent Bad Judgment. Easily the most brazen in the last decade was Katherine Hoover. From December 2002 to January 2010, she “wrote” more than 335,130 prescriptions for painkillers. That’s about 130 per day, seven days a week, 365 days a year.

Hoover worked with another doctor named William Ryckman in a clinic in Williamson. He was eventually charged with selling prescriptions to patients he never saw and did six months and more than $413,000 in fines. Hoover, now sixty-eight, simply closed the clinic and moved to the Bahamas, where she bought an island.

Suicidal people deal with a struggle that part of them wants to die but part of them wants to live. The survival instinct is hard-wired into human beings. Sometimes people make a half-hearted attempt at suicide for attention, but more often they only go halfway through on an attempt because they’re fighting their better nature. Remember, all twenty-nine people who have survived a suicide attempt by jumping off San Francisco’s Golden Gate Bridge said they regretted their decision as soon as they jumped.

The first thing that happens when you take an opioid by whatever delivery means is that it spreads throughout your body via the bloodstream. That opioid-rich blood plugs into the system of opioid receptors all over your body. That feeling of euphoria users describe comes when it hits the brain receptors. That happens once those opioid molecules cross the blood-brain barrier, where they enter a section of the brain at the center of your reward circuitry called the nucleus accumbens. That’s where dopamine is produced. There, the drug latches onto cells called GABAergic neurons. Normally the GABA serves as a block to make sure dopamine doesn’t overflow, but opioid molecules knock that barrier down and let dopamine spill over into the bloodstream, creating the euphoria users crave.

Overdose deaths are declining, but overdoses are on the rise. The easy and widespread availability of Narcan saves lives but it masks the toll of use, and gives.

Opioid prescribing guidelines and recommendations, as well as provider resources, vary by state. But basically, if you go to your doctor for acute pain like a pulled muscle, if he does prescribe some kind of Schedule II narcotic, you’ll only get a three to five-day supply, and you’ll have to visit them again for a refill. It can’t be just called into the pharmacy.

According to the press release form the Justice Department, the operation by the Appalachian Regional Prescription Strike Force included more than three hundred investigators from jurisdictions in Kentucky, Ohio, Tennessee, Alabama, and West Virginia. The operation was revealing for just how blatantly and overtly some prescribers and pharmacists operate, even in light of the supposed crackdown. Accusations included, among other things, that doctors were trading drugs for sex, or giving prescriptions to Facebook friends without conducting even a rudimentary exam (much less that which is prescribed by state regulations). Astonishingly, some dentists were accused of pulling patients’ teeth unnecessarily to justify writing prescriptions for pain pills.

In a written statement to the press, Assistant US Attorney General Brian Benczkowski said that “if so-called medical professionals are going to behave like drug dealers, we’re going to treat them like drug dealers.” J. Douglas Overbey, U.S. Attorney in the Eastern District of Tennessee, went further in his statement, saying the doctors arrested “are simply white-coated drug dealers.”

In practice, investigators tell us, there are many unscrupulous operators who set up pain management clinics and operate similarly to the pill mills of previous years. They meet the letter of the law, perhaps, but not the spirit. They check the boxes, but the primary purpose is to provide narcotic prescriptions, not genuine alternative pain management.

Dr. Richard is listed as the number one prescriber of hydrocodone-acetaminophen in the state of Kentucky, as ranked by Medicare claims, according to ProPublica. Note that the ranking by Medicare claims is the best measure for tracking prescription rates, because Medicare pays for one in four prescriptions nationally and there is no other national public record available to track prescriptions.

Between 2013 and 2015, Richard wrote 28,099 opioid prescriptions for his 3,318 patients. Each year, his volume of prescriptions increased noticeably even though the number of patients he treated with opioid drugs only rose slightly.

In mid-2019, Purdue Pharma settled with Oklahoma to pay $270 million rather than face trial on charges of illegal marketing practices and misrepresentation regarding the drug OxyContin, according to company and state press releases.

The Oklahoma settlement was announced in 2019 about two months before the state trial against Purdue Pharma and three other pharmaceutical companies was slated to begin, according to the Oklahoma Attorney General’s office.

At that time, David L. Noll, associate professor of law at Rutgers Law School, was interviewed by the healthcare website Healio, where he said the decision to settle was likely driven by the fear the Sackler family members themselves would be called to testify. Being a civil trial where Fifth Amendment protections aren’t guaranteed, Sackler family members could have been compelled to give self-incriminating testimony, which could open them up to criminal and further civil liability.

The New Yorker reported in 2017 that OxyContin had generated Purdue Pharma more than $35 billion in sales in the twenty years since its release in 1995. The company’s annual revenues at the time were about $3 billion, largely from OxyContin. The Sackler family was, according to varying estimates, worth between $13 and $14 billion in terms of their personal fortune.

According to the U.S. National Institutes of Health, the aggregate cost of all these factors—deaths, overdose, treatment, criminal justice—was $78.5 billion a year as of 2013, and it only grew from there as overdoses, use, abuse and treatment costs rose.

Purdue received FDA approval to sell OxyContin in 1995. The following year it has gross sales of $45 million for the product. By 2002, Purdue was moving $1.5 billion in pills. 

In the five years after OxyContin was brought to market, Purdue held more than forty national pain management conferences at swanky resorts in California and Florida, where Purdue hosted more than 5,000 doctors, nurses and pharmacists, generously covering all expenses at these luxury getaways. NIH notes that while medical professionals claim they are not influenced in their standards of care or medical treatments, it is well-documented that indeed they are.

Not only was Purdue and its contemporaries aware of their actions, but so was the U.S. National Institutes for Health, the DEA, Health and Human Services, and the CDC. They’ve been running this game for a long time, and those who were supposed to be the watchmen did just that—sat back and watched.

Few believe these lawsuits will harm Big Pharma, even if the settlement amounts were ten or one hundred times larger. Decades after the Big Tobacco settlements, those companies are still in business. The executives behind those companies are still in business. Most of all, the settlements reached included agreements that the executives, those who told the lies and whose addictive products killed millions, would be immune from criminal prosecution or personal liability.

By spreading their tentacles around Washington, DC and state capitols across the country, Big Pharma has made it well-nigh impossible for any actual regulatory crackdown, or even oversight with any teeth.

“Purdue Pharma Is Dissolved and Sacklers Pay $4.5 Billion to Settle Opioid Claims” reads The New York Times headline of September 1st, 2021. “The ruling in bankruptcy court caps a long legal battle over the fate of a company accused of fueling the opioid epidemic and the family that owns it,” declares the secondary headline.

Under the terms of the deal reached in U.S. Bankruptcy Court in White Plains, New York, Judge Robert Drain ruled that Purdue Pharma was dissolved as a corporate entity, and that the owners and the Sackler family would pay more than $4.5 billion in fines, fees and restitution. That money is supposed to be paid out throughout this decade, with the lion’s share coming from the former Purdue entity and from projected profits of the “public interest” drug company that will emerge from Purdue’s corpse.

The penalties under the deal include a $3.5 billion criminal fine and $2 billion in criminal forfeiture, the former of which is to be paid out in installments through 2030.

As for the Sackler family? They are separately on the hook for—wait for it—just $225 million. This for a family with a current estimated net worth of between $11 billion and $13 billion, which during these suits revealed they had personally moved $1.36 billion into offshore—and therefore untouchable—accounts, according to court records from this very same bankruptcy court, which Judge Drain specifically addressed in his ruling, according to The New York Times coverage of the judge’s decision. In fact, it’s suspected that the Sacklers transferred more than $10 billion out of the company between 2008 and 2017, as scrutiny of the company increased.

The Sacklers, according to the judge’s order, are absolved from Purdue’s liability. That’s why they are only on the hook for $225 million and why they will get to maintain their elite status as one of the richest families in the United States.

While some states that are party to the settlement said they would fight this agreement in appellate court, most accepted the terms, even though the ruling with its fines and fees and penalties doesn’t even begin to cover the monetary cost of the opioid crisis, to say nothing of addressing the concept of justice for the hundreds of thousands who died.

This was a murder. But it’s also a chemical weapons attack. Not by a hostile foreign nation, but by those most entrusted to protect, serve and heal America.

Pharmaceutical companies manufactured phony reports that claimed their products were safe and non-addictive, much like Big Tobacco did decades ago, and just as dishonestly. They created products they knew would have patients—customers—coming back and literally begging for more. They manufactured and distributed these products—this poison—in insane amounts that no one, at any level, could have thought made sense.

Regulators at the FDA green-lit these products and hand-waved any concerns raised by the blatantly obvious fact that opiates, opioids, and synthetic opioid derivatives are highly addictive. They accepted as research what were overtly dishonest marketing materials. Deregulation became their highest totem.

The medical field as a whole bought into the pain management and “pain as a fifth vital sign” malarkey that was bought and paid for by Big Pharma. The industry took as read the propaganda that Purdue and others manufactured. Doctors at every level failed in their due diligence and their duty to their patients. They accepted almost blindly the marketing of these drugs. Individually, they were, at best, derelict in their duty to their patients and, at worst, complicit in the money-making scheme hatched by the manufacturers. Pharmacists and pharmacies filling prescriptions for tens of millions of pills in towns with populations that number in the thousands were also culpable. While many may hide behind the idea of “duty to fill,” they couldn’t help but see what was really happening. Those that weren’t actively in on this crime could have done something to bring it to the attention of state or federal regulators or authorities. Government’s first role is to protect the people of the nation. Legislators were either ignorant or indifferent to the suffering of their constituents for decades. The executive branch’s regulatory and law enforcement apparatus either rubber-stamped manufacturers and doctors, or made it such a low priority that this cancer grew unabated. State licensing boards were more interested in protecting their members—doctors or pharmacists—than they were in protecting the public or upholding professional standards.

the majority of this crime was perpetrated on and aimed at one specific group of Americans: rural and working-class Whites, primarily in Appalachia and the South, the people no one in power has time for or wants to represent, the people it’s most politically frowned upon to speak for or identify with. It’s not a coincidence that they suffered for so long unheard.