We live in a broken country. Our citizens are gunned down on the street for trying to protect the vulnerable from overzealous agents instructed to disregard all prior concepts of law and justice, and labeled "domestic terrorists." Our President routinely targets judges that issue orders in any kind of opposition to his edicts--even the Supreme Court, even after appointing 3 of the 9 on it. Officials in the administration are swiftly fired when public outcry over their party-fueled machinations becomes politically inconvenient. Charlatans abound throughout the halls of government, and anti-intellectualism continues to stretch towards a more complete apotheosis, as A.I. deep-fakes and bot accounts trigger the online ecosystem, dividing people with black & white thinking, an imbecilic riposte for every thoughtful rebuttal, couched in righteousness. They claim to be People of God and are granted audiences with the Pope, only to later insult and accuse him of not understanding theology when he opposes warmongering and the military industrial complex, pleading for dialogue and diplomacy and decency--three D's they have determined to be ineffectual, after performative attempts at such have maintained the status quo. Our leaders in power are not serious people and do not appear to know what they are doing.
They wanted to make this country great, as it once was, and it seemed unclear where they thought it had gone wrong. Perhaps it was great at the time of the American Revolution, or before the Civil War, or after the Civil War, or in the period of WWI or WWII--but most likely, it seemed post-WWII, pre-1964 Civil Rights Act, when the Baby Boomers emerged as a contingent and the American people appeared to enjoy a higher standard of living than most of the rest of the world. By the time President Kennedy was assassinated, the country began to grow apart and the two political parties in control of government became more divided. There was a civil rights movement, and more assassinations, and entry into a conflict in Vietnam, and a new President that had barely lost to Kennedy 8 years earlier, horrified at the prospect of losing a second term.
Perhaps it was somewhere in there--or perhaps it was about 10 years later, when President Reagan was elected and significant reorganization of government shifted priorities from social safety nets to corporate safety nets and established the predominant global economy.
Or perhaps it was 10 years later, or 10 years after that, when our country was attacked by terrorists and we banded together in solidarity and the opportunity to exploit the moment proved too irresistible. Unquestionably however, it ended with the election of President Obama. It was at that moment that our country fell into disrepair, and the backlash against a generally progressive society began to foment. America was ceasing to be great because a relatively small swathe of conservatives set out on a mission to prove the first black President did not know what he was doing and was leading our country into "third-world" status. Their movement steadily grew and they had a willing demagogue and they convinced enough people that it was time for radical change and then attempted to copy President Reagan and restore the United States to its rightful place as a global superpower--never mind that it had never really slipped from that position. They convinced everyone it had, and chaos has ensued, and we are currently spiraling towards what we fear may be total oblivion.
And so what, if anything, do drugs have to do with all of that?
***
Addiction, Inc. is Dr. Emily Dufton's long-awaited follow-up to Grass Roots: the Rise and Fall and Rise of Marijuana in America, which appeared in 2017 and foreshadowed the widespread decriminalization and legalization of that "drug." Marijuana is known as the "gateway drug" that leads towards "harder" and more dangerous substances, with heroin at the other extreme. Oxycontin supplanted heroin as a legal alternative, but it was not a treatment to stem the addictive nature of the opiate. Not unlike vaping as an alternative to cigarette-smoking, while it doesn't seem as unhealthy, it can exacerbate the addiction because of convenience of use. Now Fentanyl has supplanted Oxycontin as restrictions have made that drug less potent and accessible. The landscape has shifted and the "problem of addiction" continues to evade grasp. This book does its part to solve that puzzle and it is thus essential reading for anyone that cares in the slightest about drug policy reform. Unfortunately for this moment in the United States, we may need to wait for meaningful change. (I will briefly give credit where it is due to the administration for rescheduling marijuana to Schedule III, though that appears to remain partially in flux as of this writing; I have otherwise little confidence that the Department of Health & Human Services will effect positive change in this area, despite the "opportunity" that its Secretary's status as a former heroin addict presents, to say nothing of the Vice President's well-documented family struggles.)
One wonders how Kennedy got "clean," (very basic internet research indicates an overdose, a treatment program in New Jersey, 12-Steps and a rekindling of faith) and perhaps the best way individuals can overcome this "weakness" is by learning from the specific stories of others. Addiction, Inc. is not focused on such human interest items. Though they are referenced at moments, it is focused on the bigger picture of treatment reform--the success stories are those of the programs.
Most of us have known someone that died of an overdose. It happens everywhere, but it happens in certain places more than others. Dufton's hometown of Allentown, PA is one such locale, and her friend Dana was one such victim. This is not a psychological portrait of Dana or a deeper exploration of his struggle, but a snapshot of Dufton's perspective from the distance that arises between high school friends over time, particularly those that fade from view because of such struggles. The Introduction beginning from this very personal place then offers a roadmap of the entire landscape the book explores in finer detail. In 20 pages, it offers up its central thesis, and in the ensuing 367, it presents its evidence, starting from an overarching assessment and the culmination of a decade of research:
"Over the past fifty years, MAT [Medication-Assisted Treatment] has transformed from a radical federal public health initiative, launched to make addiction treatment accessible and appealing, into a successful, if clearly insufficient, commercial industry--even as the opioid problem in America got worse....We have forgotten the war that Richard Nixon launched on June 17, 1971. It is perhaps the most infamous, and most misunderstood, date in American drug history. But it doesn't have to stay that way. If we remember what we once forgot, perhaps we can also make a change." (20)
***
Nixon's Presidency may be the moment when everything changed between the two parties and divisions became more extreme. Lewis Powell's memo in 1971 is credited as the blueprint of the modern conservative movement, and it may be seen as a type of precursor to Project 2025. Regardless, it seems Nixon was overly fixated on winning his 2nd term, and if he wasn't beset by so much doubt of his own popularity, his reputation would not have suffered as it has. As I grew up, depending on the teacher, either Nixon or Carter were labeled the "worst President ever" (two others would later make stronger cases). It does appear Nixon's personal beliefs were a bit uncouth, and some of his actions were highly questionable, but I do not think he needed to carry out the Watergate break-in to win, and perhaps that had an undeniable impact on the future of electoral politics, to say nothing of his unprecedented resignation (which now feels "classy"). Regardless, even though he was a Republican, like most Presidents up to that point, he spoke to everyone and he did not play favorites for all the Yes Men on his side. This supposedly evil man also shepherded the EPA into existence along with the Clean Air Act, the Endangered Species Act, affirmative action, school desegregation, supplemental security income, restoration of native American rights, and the ending of the draft. It may be overly simplistic, but safe to say, America was great when Republicans still wanted to be progressive, too.
The Vietnam War presented perhaps the major obstacle for his reelection, since it was very unpopular. And here finally we come to the Addiction, Inc. connection, which is that many soldiers in Vietnam were drugged up--sometimes with psychedelics, and sometimes with heroin that was easily procured in Vietnam. Nixon wanted to end the war and gain supporters, and part of that plan included care for veterans, who seemed particularly traumatized after seeing so many of their friends killed for reasons more pointless than ever before. There had also been a low-key opiate drug problem in the U.S. going back to the Civil War, with morphine, and various developments over those 100 years leading up to the vogue of heroin in several urban centers. More young people were using in Vietnam, and if the war was going to end, they were going to come home, addicted to the deadliest drug, without jobs or income waiting for them. Thus, crimes perpetrated by such "G.I. Junkies," bent on procuring heroin by any means possible, were anticipated to make many places in America much more dangerous than before. Enter Jerome Jaffe.
***
Jaffe is one of several heroes in this story and is first introduced as a 36-year-old psychiatrist operating the Illinois Drug Abuse Program (IDAP) in 1970. Dufton's description of IDAP echoes throughout the text as a prototypical example of a treatment program that works. They share several common features:
"Each clinic was small, treating just a hundred patients, and staffed by a part-time physician, two nurses, and five peer counselors. To make patients feel comfortable, all peer counselors were former heroin users themselves. 'IDAP was a pacesetter in its use of ex-addict personnel for virtually all treatment roles other than those filled by physicians and nurses,' [Dr. Patrick] Hughes [clinical director] said, a model later mirrored nationwide. Clinics were also culturally specific. 'A clinic in a Black neighborhood was generally served by Black staff,' Hughes said. 'If patients were predominantly Latin or white, the staff also tended to be Latin or white.' As comfortable, friendly, and integrated locations, neighborhood methadone clinics were 'community experiments in heroin control,' Hughes said, 'dynamic and experimental, not rigid or bureaucratic.'" (95-96)
Jeffrey Donfeld, a Young Republican and "Whiz Kid" aide to the Nixon administration, interviewed Jaffe and wrote dozens of letters and memos to the White House, emphasizing Jaffe's reports on the success of IDAP. Nixon was suspicious of all drug use and skeptical of the optics of endorsing methadone as a public good, but various events in 1971--specifically the rising violent crime rate and impending return of "G.I. junkies" from the front--led him to reconsider his beliefs. Heroin had flooded America and Vietnam, and Jaffe argued the only way to bring down drug use and crime was to flood the country with treatment in response, "to make treatment so available that no one has to commit a crime to support a habit because they cannot get treatment." (116) Nixon himself then introduced the Special Action Office for Drug Abuse Prevention (SAODAP), which Addiction, Inc. focuses on heavily in its first half.
Nixon loved Jaffe and shocked him by appointing him ("by ambush") as the first leader of this agency, which was especially powerful. It would control vast federal funds and have the ability to allocate money at will, and it would be housed within the Executive Branch, with Jaffe reporting directly to Nixon himself. In the announcing the agency in a press conference, Nixon noted that strict drug laws were "not sufficient in themselves to eliminate drug abuse," and that, "enforcement must be coupled with a rational approach to the reclamation of the drug user himself...we must rehabilitate the drug user if we are to eliminate drug abuse and all the antisocial activities that flow from it." (120). He signed Executive Order 11599 and requested $155 million from Congress to address the "demand" side of drugs, bringing the federal drug budget to $371 million. This allocated $105 million to SAODAP--more than double what Donfeld originally requested--to fund a new system of clinics nationwide, engage in groundbreaking research and expand the rehabilitation capacity of the VA. Nixon also suggested that if Jaffe determined it needed more money, he would take care of that.
Later it was legally recognized by Congress in the Drug Abuse Office and Treatment Act of 1972, and allocated $400 million--2/3 of the federal drug budget--to spend on treatment, prevention, research and education. It was also given the firm end date of June 30, 1975, with the National Institute on Drug Abuse (NIDA) subsuming its efforts, moving it out of the White House and into the Department of Health, Education and Welfare.
It achieved its goals, but just as in any comprehensive history that endeavors to remain impartial, that is not 100% true and the devil is in the details. As Jaffe later reminisced, "'I had a feeling, almost from the first day, that the willingness to look at the demand side, rather than the law enforcement approach, might be a transient phenomenon. And I was right." (122)
Part I of Addiction, Inc. ("The Cinderella Drug: Methadone") concerns SAODAP's origins and early years, and is arguably the most fascinating section as it uncovers the political process behind the creation of such an office (such a story on DOGE should be forthcoming, if it is not already out there). Jaffe has the leading role, but he recedes into the background of the book after his resignation as SAODAP's Director on June 17, 1973, leaving to study nicotine in New York. Working under H.R. Haldeman was difficult, and Jaffe said there was not a day on the job he enjoyed--except the last, which Dufton describes in cinematic detail:
"Cups of champagne were passed around, and a White House photographer captured dozens of images of guests drinking and dancing. One image captured the rarest thing of all. As his clinics were attacked and the Nixon White House began its slow dissolution into Watergate, the nation's first drug czar was seen laughing with colleagues, visibly relieved to be done with the job." (165)
While Nixon had declared that the country had turned the corner on heroin in 1973, it came back with a vengeance in 1974. By June of that year, cheap, potent, plentiful gum-like brown heroin from Mexico went from West Coast to national ubiquity, replacing the French Connection's weak, expensive and rare white powder. In July of that year, Turkey announced it would no longer adhere to its opium ban, restarting the European heroin trade. On August 9th, Nixon resigned, for other reasons.
Before that, he had appointed Robert DuPont to replace Jaffe as Director of SAODAP and oversee its transition into NIDA. This happened almost a year earlier than Congress had intended, as Gerald Ford sought to distance himself from anything reeking too strongly of the former President. Vice President Nelson Rockefeller, who had been opposed to treatment, aided in "banishing" the agency to its new offices in Rockville, MD, "ignoring" its controversial clinics. While Jaffe had accomplished his mission, curbing drug abuse and heroin addiction measurably, it seems as though the moment he left it all began to fall apart. As DuPont said, "The game became holding on, rather than expanding. We lost our morale--and our direction." (174) Enter LAAM.
***
Part 2 of Addiction, Inc. recenters the narrative from the White House to the lab, so to speak, and explores alternatives to methadone--l-alpha-acetylmethadol (LAAM), Naltrexone, and Buprenorphine. LAAM effectively provided the same effects as methadone, but only required 3 office visits per week instead of daily dosing. While it had been discovered by Eli Lilly in 1949, the company did not consider it marketable for use as an analgesic. Jaffe had been interested in LAAM since 1965 and undertook a small study of it at University of Chicago in 1969, then published an article in 1970 demonstrating its practical therapeutic advantages. When DuPont took over SAODAP, he envisioned replacing methadone clinics with LAAM clinics, but the drug needed FDA approval. Dufton describes this labyrinthine, technical process--and the strange quirks involved with LAAM specifically--about as electrically as possible for laypersons while speaking the language of research scientists. It is too difficult to summarize the twists and turns of its funding and development and tabloid controversies in a review that has already gone deeper than it should elsewhere--because it is a long story that essentially ends with LAAM languishing for decades under a mountain of red tape until its eventual appearance on the market. Amidst that process, DuPont was forced to resign, after NIDA had been accused of impropriety and cronyism. As other antitrust issues arose with regard to exclusivity of patent rights and potential profits to a private company funded by government contracts formed by John Whysner, LAAM's days appeared numbered:
"'It seems to me Dr. Whysner has a pretty good deal,' [Henry] Waxman [California Democrat heading the NIDA hearings in March 1979] said. 'The equivalent of a $70,000 salary, no legal liability, and the government assumes all the risks and responsibility for his willingness to develop LAAM. Dr. Whysner is then rewarded with the exclusive right to sale of the drug for eight years. Is that correct?...I don't know how pervasive this kind of practice is at NIDA...but when you find smoke, perhaps there's more fire.'" (187)
After DuPont's resignation in July 1978, NIDA had been left leaderless for 9 months, and had "degenerated...into an 'incestous' office filled with nepotism, fraud, and waste." (191) Dr. William Pollin, a psychiatrist and World War II veteran that had overseen NIDA's biomedical research division--the only one that didn't "embarass itself"--became its new director in March 1979. Under his tenure, it essentially turned into a research institute, forgoing the treatment and education services that had made it an interdisciplinary office dedicated to making real social change. Reagan was elected in a landslide in 1980 on a very focused agenda of curbing government spending. He also had his "war on drugs," but it materialized in the "Just Say No" campaigns spearheaded by his wife Nancy, focused on eliminating future users, speaking to kids about the dangers of cannabis, rather than adult heroin users. The law and order approach returned, and national drug arrests shot up from 50,000 to 60,000 between 1980 and 1982. NIDA's funding was also reshaped by Reagan into block grants distributed to states by his signing of the Omnibus Budget Reconciliation Act in August 1981. There were even further cuts signaling Reagan's abandonment of methadone, and all NIDA personnel involved in drug treatment services were removed from the institute's payroll. Its research mission remained intact, however, and with LAAM languishing in legal morass since 1979, Pollin explored other alternatives. Enter Naltrexone.
***
I recall distinctly when reading this section that it was the clearest explanation of the chemical impact of one of these drugs on the brain, if also slightly confusing:
"Thebaine, an alkaloid derived from the opium poppy, is the source of many opioid drugs. These include semisynthetic opioid agonists, like oxycodone and hydrocodone, which fill the brain's opioid receptors and provide the pleasurable, and sometimes deadly, effects. But in the early 1960's, chemists at Endo [Endo Pharmaceuticals, who first synthesized EN-1619A, i.e. naltrexone, in 1963] discovered that thebaine was also, importantly, the source of opioid agonists' opposite: opioid antagonists, drugs which have no physical effects themselves--no high, no addictive properties, no withdrawal--but have the distinct power to counteract an opioid's use by blocking the brain's opioid receptors completely. In 1961, Endo chemists synthesized naloxone, a short-acting antagonist that kicked opioids out of the brain so effectively that chemists called it the 'Lazarus drug' because of how fast it reversed an overdose. Naltrexone, which Endo synthesized two years later, was as powerful as naloxone but longer lasting. An oral dose of fifty milligrams of naltrexone bound to a patient's brain so completely that patients were 'blocked' from the effects of opioids for roughly twenty-hour hours, regardless of how much of an opioid they consumed. (One naltrexone patient injected over $500 worth of heroin and was 'frustrated,' researchers found, when he felt no effects.) Patients had to take naltrexone daily--if they didn't, the dose would quickly wear off--but by effectively, if temporarily, rendering opioids useless, Endo believed it had created a heroin 'vaccine.'" (202-203)
The drug was designed to treat "the motivated addict" (and thus supplies to the title of the chapter)--physicians and business executives "under 'immense pressure from external sources'--like medical boards threatening addicted doctors' licenses, bosses threatening dismissal, or spouses threatening divorce--to stop, rather than maintain, opioid use. For these patients, naltrexone's forced abstinence was a benefit, not a hindrance." (205) It debuted on November 28, 1984, and could be prescribed immediately, to be taken at home. Effectively, naltrexone succeeded where LAAM had failed--but I can't help but think of this as being like Chantix, which notably can increase suicidal thoughts and doesn't provide any nicotine buzz like the gum or now Zyn pouches or vaping (undoubtedly the most harmful nicotine delivery device--and all of these are addicting to one degree or another, though the gum may be the best option). I'm sure Chantix worked for a great number of people, but I know it also does not, and so it makes sense (even if the chemical mechanism here is not exactly comparable) that naltrexone was not going to work for everyone, either. Some other drug would need to be developed at some point--but NIDA and the Reagan administration had a bigger problem, by 1986.
***
The next chapter, "The Dark Ages," introduces another of the dramatis personae featured across Addiction, Inc.--Charles Schuster, who replaced Pollin as NIDA's director in March 1986. Though Reagan had slashed funding for this agency by various mechanisms, he would soon pump more money into it than ever before. Due to the infamous cocaine overdose of Len Bias, that drug became a focal point in the "war," along with its cheaper counterpart, crack. Crack had an impact on the homicide rate and crime not necessarily because people were resorting to thievery to afford the drug, but because rival gangs selling the drug wanted to send a message about their territory. The bigger impact on NIDA funding, however, was the emergence of HIV and AIDS.
In 1981, HIV had first been recognized in 19 gay men in L.A., which led Reagan's press secretary to dub it "the gay plague." By 1986, there were 38,000 cases, and in that year alone 16,400 infections were reported. It was soon recognized that the virus spread not only through sexual contact but also blood contact, and many intravenous drug users were heavily at risk, due to lack of education and awareness of status. It was no longer just a problem for the gay community, but its role in the passage of the Anti-Drug Abuse Act of 1986 was questionable. The Act brought the drug budget total to $3 billion, earmarking hundreds of millions of dollars for state and local police, and $97 million for new prison construction. NIDA's budget also grew from $81 million to $107 million, and the potential for methadone to help stem the tide of infections became clear--if less people used heroin, less people would share needles to shoot up, which would help lower infections--but the Reagan administration did not consider its use consonant with its "zero tolerance" philosophy. So despite this increase, it was not for methadone, but for cannabis research. While Reagan had formed a commission to study the HIV epidemic, he did not agree with the recommendations of the report it issued--a federal AIDS anti-discrimination law and requests for expanded treatment. Americans were sympathetic to "victims" of HIV (unknowing sexual partners and babies born infected), but less to those that used illegal drugs.
Funding for NIDA continued to rise as George H.R. Bush became President, from $198 million in 1988, $320 million in 1990, and $416 million in 1992. While it was not allowed to spend on treatment or harm reduction, the floodgates had been opened for research. Bush referred to his vision of the 90's as "the Decade of the Brain," and the effects of addiction were studied. With the additional funding, Schuster wanted to return to the problem that had bedeviled them, and to develop another alternative treatment. This began with the resuscitation of LAAM, which finally went on sale in April 1994 under the name Orlaam, but it was not embraced by methadone clinics or patients, in part because clinics had been privatized and turned into more commercial entities:
"LAAM had been led to slaughter, rejected by clinics and ignored by society, as NIDA pursued its 'neurological revolution.' 'NIDA finds a cure for addiction and what's the reaction?' [Karst] Besteman [who had been purged from NIDA in 1981] asked. 'A yawn. I guess it's just more prestigious to figure out therapeutics for respectable diseases versus why people get addicted to drugs.'" (257)
In this climate and era, when heroin chic entered pop culture and its use began to spike, along with the continuing battle to stem the HIV/AIDS epidemic, the need for yet another treatment alternative arose. Enter Buprenorphine.
***
Rather than delve as deeply into Parts III and IV as I and II, it suffices to say III (The "Holy Grail": Buprenorphine) represents a turning point in Addiction, Inc. If Part II moves out of NIDA's government cradle and into the research lab, Part III takes the narrative into the Boardroom and features another "hero"--Charles O'Keeffe, a drug consultant who worked for Reckitt & Colman, a UK-based "grocery company" whose chemists had also created products such as Woolite, Mop & Glo and Colman's mustard. It discovered the drug in 1966, marketed it as Temgesic, and washed its hands of it in the mid-80s after "thrill-seekers" began to crush and inject the pills. It was designed to be an non-addictive opioid, and while it still was not addictive, Reckitt did not want to be associated with a drug with such a negative reputation. It sold its American licensing contract to Norwich Eaton and ceased all pharmaceutical activities. Two years later, with the Board dismayed by the slow sales of the drug in the U.S., it wanted to end its relationship with Norwich Eaton, and O'Keeffe convinced the Board to develop the drug into a maintenance medication, envisioning a partnership with NIDA to bring that about, not unlike with LAAM.
It's difficult to review this book without including some basic education it provides, or re-summarizing the consistently thorough history of this industry presented. But in an attempt to make a long story short, O'Keeffe shepherds "bupe" through numerous minefields and obtains FDA approval in 2002, with two versions of the drug: Subutex, for on-site dispensing at clinics, and Suboxone, a combination of buprenorphine and naloxone that could be prescribed by physicians and taken at home.
Anyone that came of age in the early 2000s will have some knowledge of Purdue Pharmaceuticals and its marketing practices for Oxycontin. When I first heard rumblings of this book's publication, I expected it to be akin to Empire of Pain (which inspired a Netflix drama series), or an expose of the rehab industry and its 28-day stays to "cure" addiction, which often led to relapse. While both are referenced, Part III effectively becomes a miniature version of the former--for Suboxone. And this story is not nearly as widely known.
***
Ultimately, drug history holds up a mirror to capitalism, as formerly illegal drugs are redeveloped for "safer" consumption and marketed as relentlessly as corporations require to maintain year-after-year growth and profit delivery for shareholders. Oxycontin is the most prominent example of this. Rescheduling of marijuana is another facet of it. Physician-supervised ketamine therapy and commercialized psilocybin (see Definium Therapeutics f/k/a Mind Medicine) are others. Libertarianism has risen and a more permissive attitude towards drug use has followed. Street drugs remain available of course, but increasingly, the same drugs can be procured with doctors' notes and purchased from dispensaries and pharmacies.
While Purdue had "started the fire" with OxyContin, RBP (f/k/a Reckitt) could "sell the hose," and after Part III does for buprenorphine what Part II does for LAAM, it shifts focus to Gail Groves Scott and Anne Marie Williams, "customer liaisons" who both worked to market and sell Suboxone. Scott had been laid off from Purdue as a sales rep in December 2004, and was recruited by RBP in February 2005; Williams started at RBP in 2009. These were good days for the industry and Suboxone generated $894 million in 2009, but RBP's exclusive hold on it due to "orphan drug" status ended on 10/8/09, with a generic version of Subutex entering the market for 1/3 of the price at the same time. RBP launched "Mission: Protect" in the face of it, which probably violated the Anti-Kickback Statute. Apart from rewarding physicians for prescribing more of it, "CLs" like Scott and Williams emphasized that generic versions of Subutex did not contain the antagonist Naloxone, and were more likely to be misused. Another generic version of Suboxone was being developed, however, and RBP needed to shift strategy to maintain its position as market leader.
This led to Suboxone Film. No longer a hexagonal table, the drug would be packaged as an individually wrapped and barcoded sublingual film able to be tracked and less easily diverted. The FDA approved this in 2010, and RBP acquired thirteen years of patent protection. Primarily, it was promoted as an enhanced child safety measure, because if discovered by them and taken, it would only be exposure to one dose. The FDA was skeptical of this and had required a more thorough risk evaluation and mitigation strategy (REMS)--which RBP demonstrated by promising to track rates of diversion and pediatric exposure via the barcode on the filmstrips. Generic Suboxone was on the horizon for 2013, and RBP "blitzed" even harder now that they could sell the sublingual film, leaning heavily on the pediatric safety point.
To convince MassHealth to reimburse only Suboxone Film and not generic buprenorphine tablets, Williams and Dr. Jane Ruby--a top executive at RBP overseeing the account--determined they would need support from superior safety data. Which leads to the silliest moment in the book:
"Unfortunately, she knew she couldn't generate useful data...RBP had promised the FDA that individual strip numbers would reduce diversion because RBP would track where each strip went, but the company never set up a tracking system, so the ten-digit codes printed on every Suboxone wrapper were meaningless." (320)
Instead, pulling exposure data in late 2012 from the surveillance researchers RADARS, Ruby identified accidental pediatric exposure for children under 6 was low: 3.3 exposures per 10,000 units of Suboxone tablets, 2.7 exposures per 10,000 units of film, and 1.8 exposures per 10,000 units of generic buprenorphine. Adding the tablets together versus the film, it appeared to be twice as safe. MassHealth approved reimbursement several months later, and Ruby pulled RADARS data again a month after the approval, finding that exposures had jumped. Adults were taking 1/2 of a dose and leaving half a strip in the package, which was enough for an ER visit for kids, and enough to put exposure numbers above tablets. After other developments, including a citizen petition for the FDA to block generic buprenorphine-naloxone tablets, citing safety concerns, and a plan to withdraw tablets from the market, Scott and Williams felt increasingly uncomfortable with what they were being asked to do.
Scott voiced complaints about regulatory risks and was fired. Williams voiced complaints about overprescribing and was promoted. She then contacted lawyers specializing in whistleblower cases and began wearing a wire. Ultimately, seven years later, it resulted in a non-prosecution agreement with the DOJ, a resolution including a fine over $2 billion. Four other whistleblowers also split a settlement of $92 million, with Williams provided a materially higher percentage for the unique facts she uncovered. And while there is much more to the story of buprenorphine than can be neatly summarized in a review, it feels fair to say that Addiction, Inc. presents the most thorough examination of this dramatic arc yet.
***
The book ends in Switzerland, and this review runs far too long, and so I won't reveal too much about about Part IV except to say it is the shortest section, and the most dazzling, because it is there where Dufton presents her solution. She examines the drug problem in Zurich, the open-air drug market of Platzspitz Park, and the response of the Swiss government to that:
"Platszpitz quickly became a public health disaster as well. By the mid-1980s, because of shared needles and unprotected sex, almost a third of heroin usersliving in Needle Park were HIV positive, along with almost a quarter of Swiss heroin users nationwide. And with a thousand people streaming into Platszpitz daily to score--and to share needles and buy sex--the virus's threat was only poised to grow. Now Zurich wasn't just home to the continent's largest open-air drug scene. It was also Europe's leading source of HIV infection." (355)
The primary criticism I can make of Addiction, Inc. is the missed Pavement easter egg opportunity of referring to Zurich as "stained." In any case, it provides a surprising perspective on that song title, and ends the book on one of its most fascinating notes--a semi-first-person account of the research trip undertaken to solve this impossible problem.
***
By this point in the review, the overarching message of this book should be clear: we have been here before, and these are the things we have tried, and they have not worked because of forces conspiring to manipulate the problem into a business proposition. It ends in Switzerland because the Swiss have taken lessons learned from various failed policies implemented, developed a system that "works," and remain attentive to the opioid crisis as an ongoing societal ill (even going as far as providing dosing of actual heroin administered by nurses to a very small subset of users under strict conditions).
Dufton wants to believe this is possible in the United States (while remaining skeptical that such radical interventions are politically feasible), and it is true we may be making strides--overdose deaths in the U.S. dropped from 79,358 in 2023 to 54,045 in 2024--but the problem remains out of hand. From a crude google search that probably is not nearly as specific as it should be, I find these numbers:
1970: around 7,100.
1980: around 6,100.
1990: round 8,400.
2000: over 17,400.
2010: 38,239
2020: 91,799
Clearly something happened in the 90s, and by exploring how that reality came to be at a very high level, taking all of the myriad circumstances into account and demonstrating a cognizable pattern of conduct, the book is a gift to anyone currently fighting to change the narrative direction of this country. It all seems to be coming down to a matter of trust and the level of distrust in our fellow human beings feels like it is at an all-time high. "People are not looking out for our best interests, they're looking out for their own, and anyone that suggests otherwise is naive," they say, as if eternally self-evident.
Both sides are deadlocked in black-or-white belief systems that are diametrically opposed, but there are many areas where broader agreement can still be achieved. Bringing the number of overdose deaths as close to 0 as possible should be one such area.
Still, many will point to homelessness as a sub-issue that impacts quality of life concerns on a level similar to the quality of life concerns that methadone clinics presented in the 1970s. Many will point to the causes of homelessness, with one major source being drug addiction, and few will say such people deserve to die on the street--the worst amongst us lament Reagan's closure of public mental institutions, and that seems the least nefarious of their precepts. I do not think we will go back to that in any case, and Dufton's analysis here paints a path forward that would have a huge impact on that "problematic" population. (The only other pseudo-criticism I can offer is that Addiction, Inc. does not go far enough down this path to examine the problem of crystal meth addiction, which feels like an entirely different beast, likely deserving of its own volume.)
This is an important book and it is sadly all too relevant for millions of Americans that have been impacted by this crisis. The book will likely be therapeutic for anyone in that category. One hopes it will also find its way to the people that have the power to "do better" than some of the individuals featured that once wielded such authority. It does its own small part in trying to make the world a better place, and in my opinion, a book can have no higher aim. Addiction, Inc. hits that mark, and even if it does not slow the locomotive of the market-driven economy of addiction medication, it will help save lives. Perhaps one day too, in the distant or not-too-distant future, serious people will find it and take it seriously, and we will advance towards that greater vision of a utopian society that values the lives of all.
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