Dopesick Reinforces These Pernicious Misconceptions About Opioids, Addiction, and Pain Treatment
The Hulu miniseries portrays opioid pain medication as unacceptably dangerous in nearly every context.
In the third episode of the Hulu miniseries Dopesick, Randy Ramseyer, an assistant U.S. attorney in Virginia who is investigating Purdue Pharma's marketing of OxyContin, undergoes prostate cancer surgery. Although he tells a nurse his postoperative pain is off the charts, he refuses to take the OxyContin she offers, saying he wants nothing but Tylenol.
In a subsequent episode, Ramseyer (played by John Hoogenakker) recalls that experience while trying to persuade a Food and Drug Administration (FDA) employee that she should help him build a case against Purdue. "A few years ago, I had cancer," he says. "When I was in the hospital, I very easily could've become addicted to Oxy. And it wouldn't have been the disease that killed me; it would've been my medication. I got lucky."
By Ramseyer's account, his refusal of opioid analgesics was rational because the risk of addiction was unacceptably high. He thinks he "easily could've become addicted," leading to a downward spiral that ultimately would have killed him. The implication is that opioids are not an appropriate treatment even for severe postsurgical pain. Ramseyer's decision and his justification for it illustrate how Dopesick, which is ostensibly about the misdeeds of one unscrupulous pharmaceutical company, promotes pernicious misconceptions about opioids, addiction, and pain treatment.
At the very beginning of Dopesick, Richard Sackler (Michael Stuhlbarg), who later becomes Purdue's president, says he wants to "create a new opioid specifically designed to treat moderate pain for long-term use." Rosario Dawson, playing Drug Enforcement Administration (DEA) Deputy Director Bridget Meyer, calls this supposedly "new" opioid "powerful and extremely addictive." She refers to "OxyContin in the bloodstream," implying that the drug is chemically distinct from other, earlier pain medications. But the active ingredient in OxyContin, the semisynthetic opioid oxycodone, was developed 80 years before Purdue introduced an extended-release version of the drug in 1996. Oxycodone had been available for decades in products such as Percodan and Percocet.
Purdue's innovation, which was based on the same approach it took with the morphine tablet MS-Contin, was to pack a substantial dose of oxycodone into a pill that would gradually release the drug over several hours, so that a patient could get steady pain relief by taking a couple of pills a day. OxyContin was marketed, with the FDA's approval, as abuse-resistant, but it turned out that it was pretty easy to make the full dose of oxycodone available for snorting or injection by crushing the tablets. Although Dopesick emphasizes that fact, it would have made no difference for a hospital patient like Ramseyer, who presumably was not inclined to snort or inject oxycodone.
How often do such patients become addicted to opioids they take for pain relief? Far less often than Ramseyer thinks.
In a now-notorious 1980 letter to The New England Journal of Medicine, Hershel Jick, a physician who was then director of the Boston Collaborative Drug Surveillance Program, reported that he and his assistant, Jane Porter, had examined the files of about 40,000 "hospitalized medical patients," nearly 12,000 of whom had received "at least one narcotic preparation," including oxycodone, hydromorphone, and meperidine. "There were only four cases of reasonably well documented addiction in patients who had no history of addiction," Jick and Porter wrote. "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."
Purdue's marketing of OxyContin leaned heavily on that finding, although not in the way Dopesick suggests. According to the miniseries, Purdue representatives cited the Jick/Porter study as evidence that OxyContin was less addictive than other opioid analgesics. That makes no sense, of course, because the study was conducted 16 years before OxyContin was introduced. In the 2018 book on which the miniseries is based, by contrast, journalist Beth Macy reports that Purdue actually claimed "opioid analgesics caused addiction in less than 1 percent of patients," referring to the whole category of drugs. That was consistent with the numbers cited by Jick and Porter.
As Dopesick emphasizes, the Jick/Porter letter was a bare-bones report, and the study was limited to hospitalized patients, so its results may not be applicable to other contexts, such as prolonged use of opioids for chronic pain. The miniseries portrays Jick himself as dismayed to learn that his study was being used to promote OxyContin. But the basic finding that addiction is rare among patients treated with opioids was repeatedly replicated in subsequent research—something you would never guess from watching Dopesick.
A 2010 analysis in the Cochrane Database of Systematic Reviews found that less than 1 percent of patients taking opioids for chronic pain experienced addiction. A 2012 review in the journal Addiction likewise concluded that "opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence." A 2018 BMJ study tracked 568,612 opioid-naive patients who took prescription pain medication following surgery—the treatment option that Ramseyer rejects as utterly reckless—and found that 5,906 patients, or 1 percent, showed signs of "opioid misuse" during the course of the study, which included data from 2008 through 2016.
In a 2016 New England Journal of Medicine article, Nora Volkow, director of the National Institute on Drug Abuse, and A. Thomas McLellan, a former deputy director of the Office of National Drug Control Policy, noted that some studies had described "rates of misuse, abuse, and addiction-related aberrant behaviors" as high as 26 percent among chronic pain patients. But Volkow and McLellan found that "rates of carefully diagnosed addiction" averaged less than 8 percent. In general, they observed, "addiction occurs in only a small percentage of persons who are exposed to opioids—even among those with preexisting vulnerabilities."
Earlier this month, when he rejected a California lawsuit that blamed Johnson & Johnson for contributing to opioid abuse through deceptive marketing, Orange County Superior Court Judge Peter J. Wilson noted that the plaintiffs claimed a quarter of patients treated with opioids become addicted. He concluded that the evidence did not support that estimate, saying "the more reliable data would suggest less than 5%, rather than 25%."
Dopesick grossly exaggerates the addictive potential of opioid pain relievers, promoting the demonstrably false notion that mere exposure to such drugs is enough to cause addiction. OxyContin "is being overprescribed and causing patients to be addicted," Meyer says. The fact that patients commonly stop using opioids before their prescriptions run out shows something is missing from that causal assessment. While Dopesick notes the danger that extra pills will be diverted to nonmedical use, it never reflects on the significance of that surplus, which suggests these drugs are not quite as irresistible as the miniseries portrays them.
In 2015, according to the National Survey on Drug Use and Health, nearly 100 million Americans used prescription opioids, including nonmedical users as well as bona fide patients. Judging from their responses to survey questions, about 2 million of them, slightly more than 2 percent, qualified for a diagnosis of "substance use disorder"—a catchall category that subsumes what used to be known as "substance abuse" and the more severe "substance dependence"—at some point during the previous year. By comparison, data from the same survey indicate that 9 percent of past-year drinkers had an alcohol use disorder in 2015.
Dopesick conflates tolerance and physical withdrawal symptoms with addiction, which requires a psychological attachment that can be understood only in the context of the user's personal situation. "The brain is rewired to function normally when opioids are present and abnormally when they are not," a doctor testifies at one point, "and the pain from withdrawal is so overwhelming that a person can feel like they are literally going to die if they don't get more drugs."
Kaitlyn Dever plays Betsy Mallum, a closeted lesbian coal miner who becomes addicted to OxyContin after her family doctor, Samuel Finnix (Michael Keaton), prescribes it for severe pain caused by a back injury. Although Dopesick portrays addiction as a straightforward biological reaction to the drug, it is clear that something else is going on with Mallum. "It worked great at first," she says, "and then it stopped working, and I needed more. I guess I always felt kinda tense and uncomfortable around people. But using the pills, it was the first time I felt normal in maybe my whole life. And now I don't feel anything at all anymore. All I think about is getting more pills."
Finnix, who also gets hooked on OxyContin, describes the drug as "nothing but poison." Yet he also hints that the drug by itself does not explain addiction. "There's some kind of pain in all of us," he tells a group of recovering addicts. "We just don't want to feel anymore."
Dopesick implies that neither Mallum, Finnix, nor any of the other patients it portrays ever should have been prescribed OxyContin, which ruined their lives even though it was initially effective at relieving their pain. We never see a single patient whose life was, on balance, improved by prescription opioids, although the miniseries alludes to the possibility that such people might exist. The resulting impression is that patients who take opioids for pain typically regret it, which is the opposite of reality.
Similarly, Dopesick presents every argument in favor of treating pain with opioids as a slick marketing trick. According to Dopesick, the idea that many people suffer needlessly from pain that could be safely relieved with opioids is nothing but industry propaganda. Likewise the concept of "pseudoaddiction," which posits that doctors might mistakenly view patients desperate for pain relief as "drug-seeking" addicts. Yet as Judge Wilson noted, pseudoaddiction "is a medically recognized term," and California law acknowledges the potential for such confusion.
When a Dopesick character describes opioid prescriptions as a humane response to people in pain, decries the cruelty of denying them treatment, or talks about the importance of distinguishing between use and abuse of opioids, he is inevitably portrayed as an industry flack or pawn. Dopesick even presents "breakthrough pain," individualized dosing, and the practice of asking patients about their pain as profit-maximizing Purdue ploys.
The subtitle of Macy's book describes Purdue as "the drug company that addicted America," and in the final episode of the miniseries a newscaster calls the company's owners the "family that originated the opioid crisis." That assessment is highly dubious, notwithstanding the shady practices that led to billions of dollars in settlements, several guilty pleas by Purdue executives, and the company's dissolution.
Keep in mind that the "opioid crisis" nowadays overwhelmingly involves illicit fentanyl. Far from slowing or reversing the upward trend in opioid-related deaths, restricting the supply of pain pills accelerated it by driving nonmedical users toward black-market substitutes that are far more dangerous because their potency is inconsistent and unpredictable. But even if you think overprescription of pain pills contributed to the current situation, OxyContin's role was not nearly as big as Dopesick suggests.
Estimates from the National Household Survey on Drug Abuse (now the National Survey on Drug Use and Health) indicate that nonmedical use of prescription pain relievers rose for 11 consecutive years before OxyContin was introduced, then continued to rise. And regardless of how appealing the tablet's crushability may have been to some drug users, OxyContin never accounted for a very large share of the prescription analgesic market.
Defending itself against numerous lawsuits, Purdue presented DEA data indicating that OxyContin accounted for just 3.3 percent of pain pills sold in the United States from 2006 through 2012. After adjusting for potency, ProPublica calculated that the product's "real" share of the market was more like 16 percent.
ProPublica's approach is questionable, assuming the concern is how many opportunities nonmedical users have to get their hands on prescription opioids. But either way, the vast majority of pain reliever prescriptions involve products other than OxyContin, most commonly hydrocodone pills such as Vicodin and oxycodone pills such as Percocet. Those latter two types of products also figure prominently in the pain relievers consumed by nonmedical users, accounting for 75 percent of the total in 2018, according to the federal government's survey data. OxyContin, by comparison, accounted for 11 percent of nonmedical use that year.
If Dopesick merely exaggerated the impact of one product, we might chalk it up to dramatic license, although mainstream news outlets have been peddling the same misleading story for years. But because this product is not qualitatively different from other opioid analgesics, Dopesick's indictment of OxyContin amounts to an indictment of the whole drug category, which it presents as unacceptably dangerous in nearly every context, with the possible exception of dying cancer patients. Dopesick's writers and producers seem to think everyone else, no matter how life-impairing his pain, should follow former Attorney General Jeff Sessions' cruel prescription: "take some aspirin" and "tough it out."