by Beth Macy
Evidence room, Lee County Sheriff’s Office
Chapter Two
Swag ’n’ Dash
Around the time the Big Stone Gap informant was leaning into the police officer’s cruiser, the FDA loosened rules on pharmaceutical ads, allowing drugmakers to air detailed television ads touting specific medical claims for nonnarcotic drugs. Drug advertising ballooned from $360 million in 1995 to $1.3 billion in 1998, and nearly all pharmaceutical companies spent more plying doctors with freebies. At a time when there were scant industry or federal guidelines regulating the promotion of prescription drugs, the new sales strategies pushed the narrative of curing every ill with a pill and emboldened many patients to seek medicines unnecessarily.
From a sales perspective, OxyContin had its greatest early success in rural, small-town America—already full of shuttered factories and Dollar General stores, along with burgeoning disability claims. Purdue handpicked the physicians who were most susceptible to their marketing, using information it bought from a data-mining network, IMS Health, to determine which doctors in which towns prescribed the most competing painkillers. If a doctor was already prescribing lots of Percocet and Vicodin, a rep was sent out to deliver a pitch about OxyContin’s potency and longer-lasting action. The higher the decile—a term reps use as a predictor of a doctor’s potential for prescribing whatever drug they’re hawking—the more visits that doctor received from a rep, who often brought along “reminders” such as OxyContin-branded clocks for the exam-room walls.
The reminders were as steady as an alarm clock permanently set to snooze. Purdue’s growing legion of OxyContin apostles was now expected to make more than a million calls annually on doctors in hospitals and offices, targeting the top prescriber deciles and family doctors, and aggressively promoting the notion that OxyContin was safe for noncancer patients with low back pain, osteoarthritis, and injury and trauma pain.
The practice became standard in rural Virginia towns like Big Stone Gap, Lebanon, and St. Charles—places that already claimed higher numbers, per capita, of dislocated workers and work-related disability claims. Now Purdue reps were navigating the winding roads and hilly towns in company-rented Ford Explorers, some pulling down annual bonuses of $70,000—the higher the milligrams a doctor prescribed, the larger the bonus. And they were remarkably adept. Five years earlier, cancer doctors had been by far the biggest prescribers of long-acting opioids, but by 2000 the company’s positioning goals had been nailed, with family doctors now the largest single group of OxyContin prescribers.
Industrywide, pharmaceutical companies spent $4.04 billion in direct marketing to doctors in 2000, up 64 percent from 1996. To get in the doctor’s door, to get past the receptionist and head nurse, the reps came bearing gifts, from Valentine’s Day flowers to coupons for mani-pedis.
The average sales rep’s most basic tool was Dine ’n’ Dash, a play on the juvenile-delinquent prank of leaving a restaurant without paying the bill. For a chance to pitch their wonder drug, reps had long offered free dinners at fancy restaurants. But soon, to-go options abounded, too, for a busy doctor’s convenience. Reps began coming by before holidays to drop off a turkey or beef tenderloin that a doctor could take home to the family—even a Christmas tree. Driving home from the office, doctors were also invited to stop by the nearest gas station to get their tanks topped off—while listening to a drug rep’s pitch at the pump, a variation the reps nicknamed Gas ’n’ Go. In the spring, the takeout menu featured flowers and shrubs, in a version some dubbed—you guessed it—Shrubbery ’n’ Dash.
There seemed to be no end to the perks, or to the cloying wordplay: At a bookstore event titled Look for a Book, an invitation issued by SmithKline Beecham asked doctors to “come pick out the latest book about your favorite hobby or travel destination!” Purdue reps were heavily incentivized, buoyed by $20,000 cash prizes and luxury vacations for top performers and a corporate culture that employed terminology from the Middle Ages to pump up its foot soldiers. Internal documents referred to reps as royal crusaders and knights, and supervisors went by such nicknames as the Wizard of OxyContin, the Supreme Sovereign of Pain Management, and the Empress of Analgesia. Purdue’s head of pain care sales signed his memos simply “King.”
Physicians willing to submit to reps’ pitches were routinely given not just branded pens and Post-it notes but also swing-music recordings labeled “Swing in the Right Direction” and freebie pedometers with the message that OxyContin was “A Step in the Right Direction.”
A chain-smoking doctor in Bland, Virginia, was so blatantly in favor of graft that she posted a signup sheet in her office, soliciting reps to sponsor her daughter’s upcoming birthday party at Carowinds, an amusement park—and one (not a Purdue rep) did. She even accepted cartons of cigarettes emblazoned with a sticker for Celexa, the antidepressant manufactured by Forest Laboratories: another gift from another clever rep.
Steve Huff was in medical residency training in the mid-1990s when he sampled his first taste of pharmaceutical swag—and not just by way of stickers, golf balls, and pens adorned with drug company names. “We were impressionable young doctors, fresh meat with a lifetime of prescribing ahead, and they flocked to us,” he told me. “They took us golfing. It was standard to have a free lunch most days of the week because the drug companies were always buying, then you’d have a short educational seminar going on [about their drugs] while you ate.”
By the time he progressed to a family practice, Huff decided the free meals were wrong and said so repeatedly, making a show of retrieving his cold leftovers from home from the office fridge, he told me. When he set about trying to coax the other doctors in his practice to ban the lunches, they demurred, saying the staff would be so disappointed if we “took away their free meals,” Huff said.
The reps tended to be outgoing, on the youngish side of middle-aged, and very good-looking. “They were bubbly, they’d flirt a little bit, and it really would make you feel special. And yet intertwined in all those feelings is the name of a drug, which the rep is repeating over and over while you’re eating this delicious, savory meal. And even if you say you’re not swayed by such things, there is no doubt in my mind that you’re more than likely to prescribe it,” Huff added.
Huff didn’t fall for the reps’ pitches; in fact, he stopped accepting pharmaceutical gifts altogether, even Post-it notes and pens. At his first family medicine practice, in Stuart, Virginia, Huff prescribed OxyContin a time or two. But most of the patients returned, as miserable as ever and still complaining about pain, he said, along with new side effects that included sleepiness, confusion, constipation, and unsteadiness on their feet. “A few of them would stay on a stable dose once it was titrated properly, but more often than not it was causing problems” both for the patients and for Huff. He noted an uptick in depression and memory loss, too, among the long-term opioid users at the practice—as well as alarming news stories about drug seekers in the community breaking into those patients’ homes or cars to steal their drugs.
When he moved his practice to the Carroll County hamlet of Laurel Fork to fill a spot left by two departing doctors in 2003, Huff was “deluged” with young-adult and middle-aged patients who’d been prescribed large amounts of OxyContin by his predecessors, concurrently with benzodiazepines such as Xanax, Klonopin, and Valium—“nerve pills,” as most in Appalachia call them. There was nothing in their charts to justify why they were getting so many prescriptions, Huff said, and he knew the added benzos put the patients at enormous risk of overdose. As one recovering addict in Lee County schooled me: “Around here, pairing an Oxy with a nerve pill—we call that the Cadillac high. If you’re gonna write this book, honey, you better learn the lingo.”
Many of Huff’s patients lived in nearby Galax, a factory town that had just witnessed the closing of two of its largest employers, Hanesbrands clothing and Webb Furniture, and continued downsizings in the town’s remaining plants. In the wake of the 1994 North American Free Trade Agreement
and China’s entry into the World Trade Organization in 2001, many of the sewing factories and furniture plants were gravitating to cheaper-wage countries south of the border and in Asia.
OxyContin wasn’t just numbing pain and the depression that came along with it; the drug was now its own resource to be plundered. “You could get a big bottle of eighty-milligram tablets and sell them for a dollar a milligram, and you could pretty much live on that for a month,” Huff said.
Until Huff slammed the brakes on the Laurel Fork narcotics train.
“People freaked out on me,” he recalled. They were sick and in withdrawal, some of them not yet understanding they were addicted.
“Just about every day I was having to go in and face another ten people, and tell most of them, ‘I’m discontinuing your narcotics.’ It was really strenuous. It drained me,” he remembered.
One period was so awful that he got in his car and drove to Mississippi to see his sister for a long weekend. Two patients had threatened his life that week.
To one of the region’s longtime health-department directors, Dr. Sue Cantrell, a former pharmacist, the premiere of OxyContin could not have been timed worse. With the exception of mining, production jobs in the coalfields had never paid much. Cantrell remembered setting up a mobile clinic in the parking lot of the Buster Brown apparel factory in the early 1990s because the women who worked there did piecework—they were paid by the number of sewn pieces they produced—and they had zero sick leave. “They couldn’t leave work to have a pap smear or a breast exam, so we took the clinic to them,” Cantrell recalled.
“Even though the pay wasn’t great, those [production] jobs gave two things to our communities: One, families on the margin didn’t always have to be on the brink of not having food on the table or money for utilities. And the second, more important thing was the behavior it modeled for families, where people got up in the morning and went to work. A lot of people never finished high school, just like the people who went into the mines, but they used to have a source of income before it dried up to nothing—and there have been no jobs to replace those,” she said. Jobs in coal mining, once the number-one industry in central Appalachia, were cut in half between 1983 and 2012, owing to pollution regulations and competition from natural gas and cheaper low-sulfur coal out west. Automation in mining and the closings of factories that burned coal for power also contributed to the region’s decline.
The closings were just sinking in when Cantrell took her first call about OxyContin from a doctor in tiny St. Charles, the next-to-poorest town (population 159 and waning) in the poorest county in the state.
Tall and skinny, Dr. Art Van Zee stood out. He was a Vanderbilt-educated minister’s son from Nevada who spoke softly, with no discernible accent. He’d come to the region in 1976 at the age of twenty-nine because he wanted to work in a medically underserved community. The town’s new federally qualified community center, with its sliding-fee scale, was as close to the socialized medicine model he admired as he could find.
That’s where he met his wife, Sue Ella Kobak, a firecracker lawyer and activist, a coal miner’s daughter raised in a Kentucky coal camp just over the mountain in Poor Bottom Hollow. Introduced by mutual friends, the two had their first real date at an NAACP rally in Bristol, Virginia, called as a response to a planned KKK rally and ending with everyone holding hands and singing “We Shall Overcome.” After they married a few years later—the flower girl was a three-legged goat—most locals began referring to the pair as “Doc and that woman,” as Sue Ella tells it, because she refused to change her name.
Van Zee seemed to have all the time in the world for his patients, never mind that he worked sixteen-hour days, rising at four in the morning to type up his patient notes from the previous day’s visits. A doctor who’d trained in Philadelphia recalled working with Van Zee during medical school and residency: “We’d rotate in and out of these big medical centers, and when we’d get back to school, it would occur to us, ‘The best doctor in America is actually out in Lee County, Virginia,’” he told me.
Locals often compared Van Zee, with his salt-and-pepper beard and gangly frame, to Abraham Lincoln. If Lincoln had worn a paper clip for a tie clip to work. If Lincoln had been spotted routinely jogging on the winding mountain roads.
I had read about Van Zee in Barry Meier’s deeply startling (but little-known) 2003 book, Pain Killer, which chronicled the country doctor’s early David-versus-Goliath battle to get OxyContin off the market until it could be reformulated to be abuse-resistant. I had not yet met Van Zee in early 2016 when I ran into one of his patients coming out of a town-hall meeting on opioids sponsored by the Obama White House. She was a nurse, a recent retiree with a thirty-year-old opioid-addicted son whose life, she swears, was saved by Art Van Zee. “When his patients are admitted to the ER, he comes there and sees them no matter what time of day. When my daddy died, he came to our house at two in the morning to pronounce his death.”
Tales of Van Zee’s dedication are as common in Virginia’s coalfields as the rusted-out coal tipples that blanket the bluffs. There was the time he bent his lanky frame into the back of an ambulance to accompany a patient in cardiac arrest for the hour-long ride to the nearest hospital. The time he was so tired from all the house calls and beeper interruptions that some neighbors found him at a train crossing inside his idling car, asleep. The time when he cracked three ribs in the middle of a birding class on his property in the shadow of Wallens Ridge—he’d heard the spectacular clang of a two-car wreck in the distance and ran toward the road, only to find one of his own patients dead and the other driver flipped over, bottles of liquor and pills scattered around his car.
Van Zee sounded the alarm about OxyContin just as its makers were on the threshold of grossing its first billion on the blockbuster drug.
And though he didn’t yet know it, he would spend the remainder of his career dealing with its aftermath—lobbying policy makers, treating the addicted, and attending funerals of the overdosed dead.
But back in the early days of OxyContin, Van Zee was as puzzled as he was concerned. He told Sue Cantrell about a new condition he’d spotted among some of his older opioid addicts—skin abscesses caused by injecting the crushed-up drug. He was beginning to think that OxyContin, especially in its 40- and 80-milligram forms, was another animal entirely from the 10-milligram Percocet pills some teenagers used recreationally on the weekends. His region had long been home to prescription drug abuse, though to a much smaller degree; before OxyContin, Van Zee treated only one to three narcotic-dependent patients a year.
But he was starting to get regular phone calls from worried parents about their young-adult kids. Jobs, homes, spouses, and children were being lost to OxyContin addiction. A banker he knew had already spent $80,000 of his savings after his son used his credit cards to buy items he could trade for Oxys.
Down the hall from his office, a physician colleague treated a septuagenarian farmer who had owned land worth $500,000. Within six months, the man had sold everything he had to keep his addiction fed. “It’s over,” he told his doctor. “The kids are gone. The wife’s gone. The farm’s gone.”
The doctors were witnessing the same thing that Lieutenant Stallard had seen a year earlier, in 1997, on the streets. “We had always had people using Lortabs and Percocets, but they were five- or ten-milligram pills you could take every day and still function. They didn’t have to have more,” Stallard said.
“The difference with OxyContin was, it turned them into nonfunctioning people.”
Convinced about the looming crisis, Cantrell, the region’s top public health official, called the public health commissioner in Richmond in the late 1990s. “I said, look, we’ve had substance abuse problems for years,” she said. “But this was a new kind of chemical, much more potent than anything we’d seen from the small subset of addicts we’d had since the seventies or eighties.”
She was told it was a problem for the Department of Behavioral Healt
h and Substance Abuse Health Services. Even though the infections put people at risk of tuberculosis, and the shared needles (and snorting straws) could hasten the spread of hepatitis C and HIV, the buck was passed. Officially, this was not a public health matter.
“Nobody would listen to her,” said Dr. Molly O’Dell, then a fellow health-department director several counties to the east. “But she was right there in the epicenter of where the pills started. She’s the first person I ever heard to name it. She called me and said, ‘Molly, I think we’ve got an epidemic down here.’”
In 1997, the Roanoke-based medical examiner counted one OxyContin death in southwest Virginia, the next year three, and the year after that sixteen.
But those numbers were inexplicably unexposed until 2001, five years after Purdue launched its drug. A Drug Enforcement Administration official told a Richmond reporter that illicit opioids were unlikely to spread beyond the mountains to the state capital, declaring southwest Virginia “a little bit unique,” although he conceded there were other Oxy-abuse hot spots in rural Maine, Cincinnati, Baltimore, and Charleston, West Virginia.
Contacted by the same Richmond reporter, a spokesman for Purdue Pharma declined to discuss the illicit use of the company’s drug.
So it happened that in the early 2000s Debbie Honaker, a happily married twenty-seven-year-old mother from the town of Lebanon, two counties to the east of Van Zee, recovered from a fairly routine gallbladder surgery with a thirty-day prescription of “Oxy tens,” followed by another script at her postsurgery checkup for another month’s supply, this time for Oxy forties. When she called to complain that her incision was still hurting, the surgeon gave her a third prescription, for 7.5-milligram Percocet, designed to quell her “breakthrough pain,” with instructions to take it not “as needed for pain” but as frequently as every two hours—concurrent with the twelve-hour Oxys. To remind her to take the Percocet, she was supposed to set an alarm for the middle of the night.
