Robert Scheer SI Podcast SI: Democracy & Media

Chris McGreal: The Opioid Crisis, Made in the USA

The "American Overdose" author explains how Big Pharma and our health care industry conspired to forge a national epidemic.
Writer, Chris McGreal. (Photo credit: Bastien Inzaurralde)

Writer Chris McGreal and host Robert Scheer zero in on the book “American Overdose: The Opioid Tragedy in Three Acts” in this week’s episode of “Scheer Intelligence.”

Scheer and McGreal, the book’s author and a correspondent for The Guardian and other news outlets, discuss how the opioid addiction crisis is largely an American epidemic. As McGreal notes, “Eighty-five percent of the world’s prescription painkillers are consumed in the United States, which is five percent of the world’s population.”

Scheer and McGreal discuss how these legally prescribed drugs are so destructive, and arrive at “another unique American aspect” in play, which is that in the U.S., “health care is an industry … in which patients are not seen as people but as clients.”

Big Pharma looms large in this crisis. According to McGreal, the pharmaceutical industry “persuaded the medical establishment that everybody needed access to these drugs, and so they got them inserted into hospitals through a program called ‘Pain as the 5th Vital Sign.’ ” And then there’s the Food and Drug Administration, which has lost sight of its stated mission of protecting consumers.

These and other factors—such as insurance companies cutting corners to cut costs, as well as patients conditioned to see themselves as clients and to follow a “pill for every ill” mentality—have exacted an immense cost, whether gauged in terms of health or wealth, in the blatant pursuit of profit. All the symptoms point to a sick system, with the drug industry free, at its heart, from anything resembling effective interventions from government or consumer sectors.

Listen to McGreal’s conversation with Scheer or read a transcript of their conversation below:


Robert Scheer

Joshua Scheer

Jacob Sugarman

Robert Scheer: Hi, this is Robert Scheer with another edition of Scheer Intelligence, where the intelligence comes from my guests. In this case, it’s Chris McGreal, who’s written a really provocative book called “American Overdose: The Opioid Tragedy in Three Acts.” And I want to broaden the significance of your title, “American Overdose.” I think in many ways, we can look as a culture, at ourselves as having a culture that overdosed. What is powerful about your book is you have brought the insight, the wisdom, the world of experience, of a major correspondent, international correspondent for The Guardian; you’ve covered genocide, you’ve covered starvation, you’ve covered a lot of things. Reading your book, the thought that hit me was, hey—he’s writing about this country the way most of us American journalists have written about other countries. Like we’re coming from a superior society, we’re coming from an advanced civilization, we’re coming from a country where they really know how to do it—well, they don’t know how to do it in Rwanda, and they don’t know how to do it in China, and they don’t—OK. Your book actually sets us back on our heels and says, wait a minute. Maybe you people don’t know your own country. But this opiate crisis is really a failure of governance, of medicine, of logic, of science, in your country. And you know what else? You have some terribly poor people who have turned to the opiate to escape the reality of their life.

Chris McGreal: Ah, one of the reasons it’s “American Overdose” is because it is actually a uniquely American, pretty much uniquely American phenomenon, this opioid epidemic. And that was one of the reasons I wanted to write it. I was really struck, I’ve been doing reporting for The Guardian for several years; when you write newspaper reports, big questions loom in your mind the more you do them. And they don’t always get answered in the articles. The two big questions that started to haunt me about this epidemic were, why is it largely an American epidemic? Eighty-five percent of the world’s prescription painkillers are consumed in the United States, which is five percent of the world’s population. And the other question that began to bother me, particularly when I was doing reporting in some of those marginalized communities you’re talking about, those places that are actually invisible to the rest of America, like southern West Virginia, like eastern Kentucky, bits of Ohio—they were drawn into this epidemic 20 years ago, and yet it’s now that we’re sitting here, and this country is now talking about it. It took 15 years for most of the United States to get around to recognizing, actually, that the worst drug epidemic in the country’s history has consumed the United States. And I was haunted by those questions, and I set out to answer them in the book. And one of the answers, in a nutshell, is another unique American aspect to this, which is healthcare is an industry, it’s not a service. In most of Europe, where you have public health systems, the patient comes first. And they have their shortcomings, they have their restrictions on financing, they have their complications. But essentially, they’re run as patient-based services. And in the United States, actually, it’s about the insurance industry; it’s about selling pills. It’s about an industry, and the patient is really just the mechanism, the grease that keeps that industry turning.

RS: Well, the patient is the sucker. The medical industry, they’re the snake-oil salesman. I mean, clearly, that’s what’s the case in your book. And the reason it wasn’t noticed is, you know, we always think the other are going to be people of color, of another culture, another ethnic thing—no. A large part of the other that we ignore—we ignore their suffering, their problems—are white people in this country, of rural America, of forgotten America, the people who lost their jobs. And you capture them in this book, you actually are out there. And you hit on a key word in this crisis. We have led the world in criminalizing drugs that are not prescription drugs. And you put your finger on it: these are prescription drugs; some authorized person, some center of medical authority, has had to write that prescription, sometimes under very dubious circumstances—some pharmacy somewhere out in the hinterland or so forth. But these people are actually taking in—and you should take us through some of the drugs—they’re taking in devastating drugs, in some ways more devastating than the drugs that were branded as illegal. But they’re legal. They’re prescription drugs; they’re not being dispensed in a way that’s to the letter of the law, but some authority, somebody called a doctor with a medical degree or something, has actually authorized this. That’s the key to this epidemic.

CM: It is. But the key to why they’re doing that—again, how the American medical system works. A lot of doctors that prescribed these pills did so because they thought it was the right thing to do. There is a minority of doctors that just made huge amounts of money running what became known as pill mills, giving opioids to anybody that wanted them. And they are responsible for a good part of this epidemic. But a lot of ordinary people became hooked on very powerful painkillers, narcotics—heroin in a pill, as DEA agents call it—because their doctors thought it was the right thing to do. And the reason that their doctors thought it was the right thing to do was, essentially, the pharmaceutical industry got hold of medical policy. There’s lots of paths that lead to this point, but the kind of two main, main highways, so to speak, are—one is a group of doctors who came to believe that prescription opioids could be used to treat routine chronic pain. Ever since the Civil War and the years after it, in which there was a morphine epidemic because soldiers were given morphine to treat their wounds, and after that, there became much wider use of morphine to treat pain. By the beginning of the 20th century, this country actually had a serious opioid epidemic. And for the first time, a president, Teddy Roosevelt, appointed a drug czar, an opium czar. And that drug czar described Americans as “the world’s worst drug fiends.” And that’s how bad it was. Once they contained that, the medical profession of the United States decided that these drugs were basically unsafe; they were too addictive. Fast-forward 50, 60 years, and you see the emergence of the hospice movement in England to use morphine to treat pain in cancer in dying patients. And that was a perfectly reasonable thing to do, because it hardly matters if they become addicted; they’re dying. That was brought to this country by a group of doctors who then essentially misrepresented the science of addiction in order to push those drugs. They were evangelical about it. And one of them, Russell Portenoy, now admits that he completely overstated the evidence for both their effectiveness, and more importantly, their safety. But the drug companies, of course, saw an opportunity. And once they leaped in, they took hold of the policy. And essentially what they did was, using front organizations, using well-meaning doctors, they did two things. They persuaded the medical establishment that everybody needed access to these drugs, and so they got them inserted into hospitals through a program called “Pain as the 5th Vital Sign,” ensuring that everybody got asked about pain and was treated with opioids. But they then unleashed their salesmen on the ordinary doctors. And one of the surprising things to me in researching this is you discover that doctors in this country only get two or three days of training for pain, in four years of medical education. They actually know very little about it. And some of whom were prescribing these drugs because the salesmen from the drug companies told them that they were safe and effective. And I’m saying, why did you believe them? They said, because we got more training on how to deal with a heart attack than we did in treating pain. Said, I’ve never seen—

RS: Well, why are we accepting this? Come on, these doctors are pretty arrogant, pretty smart, pretty tough, pretty independent. And there must be another reason why they go along with some salesmen telling them that, you know, these drugs are without fault. I mean, they wouldn’t accept that—was there profit in it? Was it easier to do?

CM: As always with this, there are several things at work. One of the things is, doctors day after day see people in chronic pain. And so actually, what they want to do, they’re doctors—I’m talking about the good doctors here, not those who made the millions from prescribing as a matter of professional unprofessionalism. But the doctors that did it because they thought it was the right thing to do, see people in chronic pain all the time. So you’ve got that; they want to help them. You have the pressure from the industry, which has persuaded the medical establishment that doctors are undertreating pain; so now the orders are coming down from the state medical boards, you’ve got to focus more on treating pain. You have the insurance industry, which when you are treating pain doesn’t want to pay for physiotherapy, because that’s an expensive, long-term business; they want to pay for a pill, which is cheap, relatively. You have the hospitals, who want the doctors to churn through a patient every 10 or 15 minutes. Now, if a doctor’s going to sit there and talk about physiotherapy or any of that, that takes a lot longer than writing the pills, the prescription for the pills. And then you have the pressure from the patient themselves. In this country, what has emerged over the past couple of decades and more, is what’s now described as a “pill for every ill” mentality, where the patient goes in, sees themselves as a client because they pay so much for their health insurance, and they demand a pill as the solution to their problem. So you’ve got all of these things playing—

RS: I got you there. But let me step back. At the same time this is happening, there’s this huge prison population. Some of them are in prison because they smoked marijuana, or they’ve taken other drugs, right, that were prescribed as illegal. And you serve long sentences. We imprisoned a good chunk of Americans; we particularly savaged the black and brown community in this country. So these same doctors, health professionals, people running the insurance companies, people running the pharmaceutical companies, they’re happy with jailing people who are taking non-prescribed drugs, so-called illegal drugs. Yet they’re in the business—and in your book you make it quite clear, these legally prescribed drugs are every bit as destructive as the illegal drugs. So they’re sitting there in a system knowing that other folks are in jail because they’re dispensing similar drugs, but these things have been declared legal, and they’re giving them out with the same wanton disregard for the well-being of their patients at the end of the day. Because they’re not stupid. Go back to western Kentucky, maybe the folks there 20 years earlier didn’t know how dangerous, but by the time you’re covering this for the book, people know how dangerous this stuff is. And they’re still dispensing it legally. I want to get to that word, “legal,” and I want you to pick up on the theme you started with before that’s in your book: there’s something rotten about our medical system that makes the legal, dangerous drug acceptable.

CM: My personal view of this is you’ve got three kinds of doctors. You’ve got those who saw it was going wrong and started to retreat. But you also have those who ignored the evidence and just went along with what the patients and the doctors wanted—the drug companies wanted, the hospitals wanted, the insurance companies wanted. And then you’ve got those that made a fortune from mass prescribing. But I think it would be a mistake to get too focused solely on the actions of the doctors. I think the doctors, even those who must have had their suspicions, ultimately a lot of them were guided by a bigger part of the medical profession. Which was, in the cases of the hospitals, there’s something called the Joint Commission. The Joint Commission essentially licenses hospitals in this country, and in the licensing of hospitals, it sets standards, and it sets standards for things like pain treatment. In doing so, the hospitals have to follow that, and the doctors then have to follow the hospitals. And what happened in that particular case is that the industry, through various front organizations, essentially got the Joint Commission on board with the idea of “Pain as the 5th Vital Sign”; that pain should be regarded and tested in the same way that your pulse is tested, and that it should be treated accordingly. The problem is that you can take your blood pressure and you can take your pulse, but you can’t take your pain level; you can’t measure it, it’s entirely subjective in the patient.

RS: You say, on a scale of one to 10, where is your pain.

CM: Precisely. And that’s why your smiley faces are on the wall. But the consequence of that is what one surgeon who I talked to in the book, Charles Lucas in Detroit, described to me as a tyranny, in which the hospitals, in order to comply with the Joint Commission, essentially required everybody’s pain to be addressed, even if taking the pills was actually bad for them. It was more important they didn’t have pain than they not become addicted, or that the pills themselves didn’t cause other damage. And when you unravel how all of that came about, what you discover is that the Joint Commission essentially ends up in a financial relationship with the industry. Particularly one drug company, Purdue Pharma, ends up writing the pain policy and the training manuals that the Joint Commission distributes to the hospitals, and then lets the Joint Commission keep the money from the sale of those training manuals and things to the doctors, to the hospitals. So the Joint Commission ends up with a financial benefit from distributing material written by the drug company, which is essentially training doctors to prescribe their drugs. There was enormous pressure on those doctors. Now, Charles Lucas, a surgeon, underprescribed, according to the hospital; he was hauled before ethics committees, one of his colleagues ended up in front of the state medical board. And they, because they’d been surgeons for decades, could stand up to the pressure and they were fine. But as he said to me, if you’re a junior surgeon in this hospital, and you have to put up with this, being hauled up before ethics committees and all the rest for not prescribing enough painkillers, what are you going to do in the end? You’re not going to face that with every patient. And he said, you know, he called it a tyranny; he said there’s this tyranny. And he ends up writing a paper for a prestigious medical journal called “Kindness Kills,” in which he documents how these pills are killing patients, but nobody wants to do anything about it.

RS: But it’s not really kindness. We go back to the profit motive here. And you at the beginning of this interview mentioned that most of the world, the developed countries in the world, have a different way of dispensing medicine, and they’re concerned about the patient; that has some meaning. Here, the patient is what, the sucker, the client, the mark. So let’s talk about that. Because that’s, in your book one gets the sense—and here I’ll bring back the foreign correspondent. And in your book you’re describing us here as boobs, in a way. I’m not saying you were disrespectful. But it’s like, we’re people who have not been able to get straight with our medical system. So let’s try to focus a little bit on this critique of yours in the book, “American Overdose: The Opioid Tragedy in Three Acts.” You make the serious charge that we are the world’s leader in this problem. So what is it about our health system that has facilitated this?

CM: Well, as I said earlier, it’s an industry. And I think that means medical policy isn’t necessarily guided by what’s good for the patient; it’s guided by what is profitable and what is easy. And it depends which part of the industry you’re talking about, and they’re sometimes in conflict. The insurance industry wants to keep its costs to a minimum; the drug industry wants to sell as many drugs as possible. Sometimes that comes together, sometimes it doesn’t. A kind of overriding element of this is the extent to which the pharmaceutical industry and medical industry as a whole has captured the institutions in America that are supposed to protect Americans from exactly this. Particularly institutions like the Food and Drug Administration, for instance. These are the bodies that are supposed to stand between the patient and the industry. And the FDA is a very good example of one of those institutions that began well and ended up where it now has. It protected Americans in the early sixties from a drug called thalidomide, which was being prescribed widely across Europe to pregnant women for morning sickness. And the FDA looked at this drug and said this, you know, we don’t see the testing is fully developed; we want to see more. And they stalled and stalled on this drug despite pressure from the manufacturer, but they wouldn’t approve it. And after a year, the dam burst in Europe and it was revealed that thousands of babies were being born with severe deformities. Americans were safe from that, and the FDA ends up in a position of great power over the drug companies as a result; Congress passes all kinds of laws and regulatory things. As time has gone, that’s been eroded for a number of reasons. But one of them is the philosophy that arose in the eighties, where industry ends up paying, supposedly paying, for the facilities offered by institutions like the FDA. So the industry starts paying for the licensing of its drugs. And of course, that’s a dangerous road to go down, because the industry’s then, essentially, instead of being the regulator and the regulated, it starts to enter into a business relationship. Now, the FDA gets 60 percent of its income from the drug industry. And that has completely changed the equation.

RS: This is the agency that is supposed to objectively protect us, as consumers and patients, in our dealings with these companies. And you’re saying what percentage?

CM: Sixty percent.

RS: Of their income.

CM: Yes.

RS: Is coming from the drug companies.

CM: Yes. And that’s because in 1992—it really is a legacy of the Reagan era, but it’s obviously under Clinton by then—essentially, a system is introduced where the drug companies have to pay the FDA to license their drugs. And it begins small. But even then, there are people in the FDA ringing the alarm bell, saying this is not the relationship we should be having. And of course, the costs go up. And the drug industry’s quite hesitant about this, because they’re just initially seeing it as a revenue-raising measure. So they insist that as a result of them paying, there has to be certain provisions. One is the speed of the approval of drugs has to be faster. What you discover is, it gets faster and faster, and more corners are cut. And as time goes by, the fees go up. And that enables the drug industry not only to pressure the FDA direct, but also to go round the back to Congress. The drug industry spend $2.5 billion lobbying Congress over the past eight or nine years, so that’s the kind of money we’re talking about. And of course they can say to members of Congress, look—we pay all this money to the FDA, it’s typical government, it’s not delivering, it’s got to improve. And the political pressure on the FDA is sometimes subtle, but it’s there, and they’re aware of it. And people who’ve worked inside the FDA have described to me how the institution’s very reluctant to acknowledge that the money has influence, but as one of them said, you know, when you’re a fish in water, do you know you’re in water? But it’s all around you. And the money’s all around you. FDA officials were involved in a thing that went on for 10 years without any real public knowledge about it, in which they’re having meetings with the drug industry when the principles for opioid approvals are being decided, and the drug industry’s paying $40,000 a time to be at the table with the same people who will be approving their drugs. And so the relationship becomes quite intimate. And in the end, there are people within the FDA who came to think that particularly those parts of the Food and Drug Administration responsible for approving drugs, for testing the drugs, they rely too much on the industry’s own word, and too little on holding it to account.

RS: You’re being quite kind here, but let me take you back to the theme of your book, “American Overdose: The Opioid Tragedy in Three Acts.” Now, first of all, we’re talking about a tragedy, as you said before, that is largely centered on the United States. And the other point, very damning point in your book, is that this crisis—and tell us about the lives lost, the consequence is enormous for people, whole communities savaged by this, families destroyed. The medical consequences are real, and yet you’re saying in this book it happened, more or less uniquely American phenomena. So let’s take the much-maligned British health system. And we’ve had groups of liberal as well as conservative politicians telling us we need medical reform. But it always puts the pharmaceutical industry at the table; it always puts people who have power, or run the hospitals, at the table. That’s what you’re really describing. That’s the model. So why didn’t this happen in England? What is it about the English system, that has been criticized here, that prevented this from happening as it did in the United States?

CM: Well, partly, it’s where real power lies. There’s a very good example of this. In the U.K., there’s a committee called NICE, which is run by the National Health Service, which negotiates with the drug companies to keep the cost of drugs down, because it’s a publicly funded health system. The drug companies come to this agreement, and the National Health Service buys the drugs at this negotiated price which is kept down. In the United States, you have exactly the opposite. Thanks to pharmaceutical company lobbying, there’s a law in place in this country which essentially says the federal government is not allowed to negotiate to bring drug prices down within the federal system. So for Medicaid or Medicare or the Veterans Administration, they actually just have to pay what the drug companies want to charge. Which is why you have, with the EpiPen, when you had the EpiPen debacle, here it was costing $300 or $400; in the U.K. it cost $60. And that’s entirely because of where the power, essentially regulating the pricing of medicines, lies. That’s the real difference, is that in the U.K. or in any other European public health system, the power lies with the public health service. In this country, it seems to lie with—because there isn’t really a public health service, it doesn’t even really lie with the administers of public health, such as the doctors, or even the hospitals in many cases. It lies, as I say, with the industry, particularly the drugmakers, the insurance industry. Those with the power, partly through, simply, the power of their money on Capitol Hill.

RS: And both of those industries are, what, not just bad old Ronald Reagan, but this is what Hillary Clinton and Barack Obama turned to in devising their health reform. There isn’t anything about Obamacare or Hillary’s original proposal when she was doing it for her husband, that would address this problem. Tell us, because I don’t want listeners to forget the human cost of this. What does this cost in lives and misery? What does it mean, this crisis?

CM: Well, the CDC’s calculation is 350,000 dead over about the past 15 or so years, although that’s almost certainly an underestimate; because of stigma around drug addiction and death, lots of people didn’t report it. But even if we take that figure, that’s an absolutely enormous figure. And then it’s worth remembering, as awful as that is, you’ve got two or three million people who are hooked, and actually being alive and severely dependent on these drugs is equally devastating to the families concerned. And the consequences beyond that, a really good example is what happens to children. There are, in this country, tens of thousands, probably hundreds of thousands of children being looked after by people other than their own parents as a direct result of this. I worked in Africa in the 1990s, and I would go to Uganda in the early ’90s, and you would go to villages where there was a missing generation. You had an older generation, grandparents raising their grandchildren because of AIDS. AIDS had wiped out that middle generation. And I wouldn’t want to overdraw that comparison here, but you can go to parts of West Virginia where you regularly meet people, grandparents raising grandchildren. If you go to a town like Huntington, half the children in that town, that city, are not being raised by their parents, as a direct result of this crisis. Whether the parents are dead or in prison or simply incapable of raising their own children. And this is more and more common across this country. So those consequences are devastating. It’s also devastating to entire towns which become consumed by the economics of this. When you can make six, seven thousand dollars a month dealing in prescription opioids, that in towns like Beattyville in eastern Kentucky, is there—it became a main economic driver of the town. People, older people, would sell half their prescription pills because it meant money to pay the rent, and they would keep the other half.  You had drug dealers who would ship people in from out of town by the busload to get prescriptions from pill mills. They’d then fill them in the local pharmacy, and they’d go off and distribute them in other states. But inside these towns, the pharmacies are the most thriving businesses; everything else on main street is closing down, new pharmacies are opening up. It distorts the economy. The mayor of Beattyville told me how many young women had been driven into prostitution by this; he said he saw it more and more. His own daughter was arrested and convicted for dealing in opioids, prescription opioids. It just touches everybody and their families, even if it isn’t death that’s touching them.

RS: You’ve left me, anyway, with this book, “American Overdose: The Opioid Tragedy in Three Acts”—it’s a case study in the profound corruption of American life. That many of these people do not have good job opportunities in these places in West Virginia, Kentucky; the American Dream doesn’t exist for them. Marx is supposed to have said that religion is the opiate of the masses; no, opium is the opiate of the masses. And your book captures that absolute despair. And yet the government agencies that are supposed to be protecting these people, they’re in bed with these big corporations that are destroying the lives and killing these people. That’s really what we’re talking about. They are worse than the pimps and the drug dealers—

CM: Because they knew what they were doing.

RS: They knew exactly what they’re doing. Tell us—because you’ve confronted these people. Now, you’ve got a good publisher, right, Peter Osnos—

CM: PublicAffairs.

RS: PublicAffairs. He dedicates, there’s a page in your, in the book, to the three people that he admires. One of them is I.F. Stone, Izzy Stone, who was a great journalist, who spoke truth to power. And your book is really in that tradition. You’re labeling this for what it is; it’s clear, you’ve got the data, you’ve got the case stories, and it’s really the creation of human misery on a grand scale. And it is an American overdose; this is when America’s not being great, when America’s destroying its own people. And yet it’s the good guys doing it, right? It’s respectable, establishment people who are looking the other way.

CM: It is. And I think looking the other way is the key to this. Because one of the things that was shocking to me was to realize that the alarm bells on this were rung in the early 2000s. There was an opportunity to stop this early on. If you accept that maybe it began as an accidental epidemic—which I don’t actually accept—but let’s say you did, in the early 2000s along come some very important doctors. A woman called Jane Ballantyne, head of pain at Harvard University. And she sees that these drugs are not doing well for her patients. And does a study, and writes an article in the New England Journal of Medicine that says these drugs don’t work, they’re actually dangerous for the patients, we need to rethink this mass prescribing. And she said at the time, she thought it would at the very least cause everybody to pause. The drug industry, but if not the drug industry then the FDA and all of the other institutions that had some influence over this. And she said instead of that, they just changed the conversation. They painted the people that became addicted as abusers, blamed them, blamed the victims for their addiction, and then said look this way over here, there’s an epidemic of untreated pain and we mustn’t cut off the drugs to the people that need them. Of course they were one and the same people, these were the people who’d been prescribed these drugs, who then do end up abusing them because they’re so addicted, because the drug companies told them that they were safe. And so there was a real opportunity to stop this early on, and they didn’t. So it was deliberate, in that sense; there was a conscious decision to ignore the evidence. What’s interesting to me, there are people I talked to who are in law enforcement; FBI guys, state policemen, former head of a DEA division that’s responsible for going after illegal use of drugs. These are conservative guys. They’re often Republicans; they’re not anti-corporate. They all talk about these companies in the same tone; they call them drug-trafficking organizations. And they say, you know, if they’d been dealing in heroin they’d all be doing 20, 30 years in prison. They get away with it; they buy their way out. If there’s a problem, they settle out of court. They essentially view it as the cost of doing business, and they carry on doing business as before. And these, as I say, they’re conservative guys and they’re very angry about this, because they see these companies as little different to Mexican cartels.

RS: That point is made clearly in the book. We’re going to wrap this up here, but we’ve left out one group of people. We’re talking about why we don’t have a good health care system, and in your book we run into people who try, in government, to get the government to do the right thing, and they fail. Is that the role of money? Is that the lobbyists? Is that buying off? Why didn’t Congress do anything about it? I mean, they had the famous case, even Rush Limbaugh was caught up in this. You have, what did you say, 85 percent of the people affected are here in the United States?

CM: No, 85 percent of the world’s prescription opioid pills are consumed in the United States. Yeah.

RS: Consumed in the United States. Why didn’t American politicians do something about it?

CM: Well, partly, the answer is what we’ve already discussed. It’s money. Yes, it’s the power of the drug companies on Capitol Hill. And when I say they changed the conversation, that’s exactly what they did. They used their finances, their power, and the fact that most members of Congress do not want to go up against the industry, to make the conversation about “we have to keep the doors of prescribing open to treat this epidemic of untreated pain.” Which no other country, apparently, has; only the United States. There’s the relationship with the federal institutions that we’re talking about. There’s the very close relationship with medical institutions that have responsibility for this, such as state medical boards. They all end up compromised and co-opted—you might use the word corrupted—by the industry. And then of course, the missing part is national leadership. It’s very striking to me that as this epidemic escalates through the George W. Bush era and then the Barack Obama era, we don’t hear anything from Bush ever, and Barack Obama only talks about it a year before he leaves office. Even though the death toll is by then in the tens of thousands every single year, and there are communities out there that have been blighted by it for more than a decade. Finally, the president talks about it in 2015, but it took that long. That lack of national leadership, I think, really left a space to be filled by others.

RS: The book is “American Overdose: The Opioid Tragedy in Three Acts.” Chris McGreal, PublicAffairs book. That’s it for this edition of Scheer Intelligence. Our producers are Joshua Scheer and Isabel Carreon. Engineers are Kat Yore and Mario Diaz. With a great thanks to Sebastian Grubaugh here at the Annenberg School for Communication and Journalism at the University of Southern California. See you next week with another edition of Scheer Intelligence.