rows of cubicles and sold fentanyl ingredients to American dealers and Mexican cartels.
The latter company didn’t even bother operating clandestinely, instead doing its business out in the open. That’s because, as I soon learned, the Chinese government offers subsidies and tax rebates to chemical companies that are making these drugs. It’s a case of financial incentives gone horribly wrong—one that seems likely to drive a further wedge between two powerful countries that are already extremely wary of each other.
“We need to make very clear to the Chinese, that this is an act of war. You are sending this into our country to kill our people,” said former New Jersey governor Chris Christie, who headed President Trump’s opioid epidemic commission, in the fall of 2017, speaking about fentanyl. China is “sending that garbage and killing our people,” added President Trump, at an August 2018 cabinet meeting. “It’s almost a form of warfare.”
The former director of the DEA’s Special Operations Division, Derek Maltz, used stark terms to describe the fentanyl-driven opioid epidemic. “Where it becomes a national security emergency is the connectivity between the drug traffickers and the terrorists that are out there that are trying to destroy our way of life,” he said in November 2018.
Such rhetoric aside, America’s problem with fentanyl and other new drugs undermines its national security as much as—perhaps more than—any other issue in the headlines, with the wrecking of families and relationships, the massive casualty toll, the billions in lost productivity, and the billions more needed to fight the scourge. Many American political and thought leaders have castigated China’s negligence; some even believe it is purposeful.
Addressing the problem is extremely complicated, however, because this is a story that goes well beyond drugs. It’s a political story about the clashing of the world’s biggest superpowers. It’s an economics story about the deception of giant pharmaceutical companies. It’s a higher-education story about how university science can go horribly wrong. It’s a tech story about incredible innovation happening in real time, a business story about marketing genius. It’s a physiological and philosophical story about the human body in conflict with the human mind.
And it’s forcing us to rethink our assumptions. The drug economy no longer just benefits the producers and dealers. Nowadays it involves the otherwise innocent people who deliver our mail, who program Internet algorithms, who design medicine in chemistry labs, who scrub toilets at drug companies.
More than anything, this is a story of global capitalism run amok. The new-drugs trade is growing for the same reasons the world economy is growing—increasing speed of communications, Internet technology, and shipping; relaxed barriers to trade; and, of course, the ever-present pressure for higher profit margins. And if global capitalism is hard to control, the new-drugs trade is nearly impossible, given that it is peopled by local actors in jurisdictions with no overlap interacting with far-flung markets and supply chains.
The New Drugs
Americans have used and abused opiates* for as long as America has existed. Opium was administered to Revolutionary War soldiers, and for much of our history it was one of the only medicines available, given to colicky babies, the dying elderly, and everyone in between. Misuse may even have been more common in previous centuries than now, and the problem grew particularly acute after the Civil War, during which morphine was used to soothe the injured. In fact, the term soldier’s disease was coined to describe opiate addiction. At the dawn of the twentieth century, one could buy opium from the Sears, Roebuck catalog, yet addiction was so widespread that President Theodore Roosevelt appointed an opium commissioner in 1908. During the industrial revolution the problem ravaged the United Kingdom as well, and the country sought to balance its trade deficit by using its British East India Company to ply opium in tremendous quantities to the Chinese, causing a pair of wars.
Never, however, has an opiate—or any other drug, for that matter—killed so many annually as the fentanyl epidemic. It is the next phase in the opioid crisis that began with the overprescription of opioid painkillers, which was catalyzed by a short letter published in a 1980 issue of the New England Journal of Medicine. Written by a doctor named Hershel Jick and his graduate student, Jane Porter, the letter discussed the thousands of cases they had examined in which patients received opioid narcotics. In only four cases had anyone become addicted, they claimed, and only one of those was troubling. “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”
The above sentence was one of only five in Jick and Porter’s letter, which was far from comprehensive. It referenced only patients who received small doses and were closely monitored by their doctors, not outpatients taking home bottles of ultra-strong prescription drugs. Nonetheless, the letter had great influence; academics cited it in more than six hundred studies, and doctors and pharmaceutical companies pitching their products deferred to it as well.
During the 1990s another sea change swept American medicine: the desire to treat patients more humanely. Traditionally, doctors focused on four “vital signs” when caring for patients: their temperature, breathing rate, blood pressure, and pulse rate. But in the mid-1990s the American Pain Society called for pain to be considered a new “fifth vital sign.” Whereas doctors were previously hesitant to prescribe opioids because they considered them addictive, the ramifications of the Jick-Porter letter caused their thinking to shift: if opioids were, in fact, safe, patients should not be consigned to agony. “It was not only okay, but it was our holy mission, to cure the world of its pain by waking people up to the fact that opiates were safe,” Boston pain specialist Dr. Nathaniel Katz told journalist Sam Quinones for his book Dreamland: The True Tale Of America’s Opiate Epidemic, describing the new conventional wisdom that took hold. “All those rumors of addiction were misguided. . . . My fellowship director even told me, ‘If you have pain, you can’t get addicted to opiates because the pain soaks up the euphoria.’ ”
The Sackler family, the owners of the company responsible for OxyContin, became billionaires many times over thanks to this new perspective. Long before the drug’s creation, Arthur Sackler, a physician by training, had been a pioneer in the field of pharmaceutical advertising. In 1952, Arthur and his brothers, Raymond and Mortimer, purchased the company that became Purdue Pharma. With the inherent conflict of advertising and pharmaceuticals in its DNA, Purdue brought OxyContin to market in 1996, touting its benefits as a slow-release pill that contained high doses of the opioid oxycodone—contin means “continuous.” Since the pills lasted twelve hours, the company claimed, patients would need only two per day, fewer than comparable medicines. Addiction, it promised, was extremely rare.
Purdue launched a huge marketing blitz, deploying hundreds of salespeople to sway doctors and dispense free promotional items, including pedometers, headgear, and even an OxyContin-branded music CD, Swing Is Alive, with a pair of dancing geriatrics on the cover. Purdue sent doctors to tropical locations for “pain management seminars;” those who attended these events in 1996 were more than twice as likely to write OxyContin prescriptions as doctors who did not. Although originally OxyContin was promoted for use by cancer patients, according to internal reports, the company saw that market as too small. Annual sales might top out around $260 million, whereas if Purdue was able to sell to patients with a host of chronic conditions, the annual market was closer to $1.3 billion. Sales rose from just under $50 million in 1996 to more than $1 billion by 2000. Oxycodone became the most prescribed drug in the United States.
Yet for many patients, the dosages didn’t last an entire half day, and they began experiencing withdrawal symptoms when the pills wore off hours
