I knew a lot of addicts in the 1990s, but one stands out in my memory.
He was a rangy and charismatic guy in his early 30s, a few years older than I was. In 12-step meetings, he was a star. Everyone looked forward to his turn to speak. He was insightful, funny, eloquent -- qualities set off by a bitter self-loathing that surfaced regularly. He'd relapsed many times and wondered aloud how many more recoveries he could muster.
I remember him because he was a hardcore narcotics addict with a clever technique for scoring drugs. When he was using, he'd dress up each Sunday and visit a half-dozen real estate open houses in the Pittsburgh area. He'd tour the house, chatting pleasantly with the agent. Then he'd ask to use the bathroom. He'd scour the medicine cabinets for prescription drugs. He'd worked in a pharmacy, knew his benzos from his opioids. A dozen open houses and he'd usually be set for the week.
Back then, I knew plenty of alcoholics and people who used marijuana or cocaine to excess, as well as a scattering of heroin addicts, who seemed the most hopeless of all. Few of us knew much about painkillers, aside from my early-adopter friend.
Two decades later, everything has changed.
I've been a journalism professor at West Virginia University for 13 years, and I'm just as likely these days to encounter students hooked on opioids -- from heroin to oxycodone -- as alcohol.
Last fall, as I was finishing my book about the nation's largest pill mill, an undergraduate student came to my office at West Virginia University and tearfully explained why he was performing so disastrously in my course. He was trying to kick opioids.
A few months earlier, he'd been one of the highest-performing students in his class. He'd earned all As in college, worked hard at the student newspaper. Now he was missing class, blowing deadlines, crying in my office. He's not the only one. Confessions like these have become an annual occurrence for me. And I'm sure there are many others I don't know about.
A sea change had occurred without me even noticing. Twenty years ago, opioids were the scariest drugs of all, the last-ditch addiction, the bottom of the barrel. Then, suddenly, everybody I knew seemed to know somebody who had a problem with them. Opioids had been normalized. And I wasn't sure when or how it had happened.
In the summer of 2012, I found part of the answer when I read about the American Pain clinic.
The tale began in 2008, when a corrupt Florida doctor introduced wealthy twin brothers Chris and Jeff George to the burgeoning underground market for lightly regulated prescription painkillers. Chris George was a 27-year-old home-builder with no medical experience, no college degree and a criminal record that included jail time for a felony drug offense.
Two years later, he'd raked in $40 million. His physicians at the American Pain clinic had prescribed around 20 million doses of oxycodone, and more than 80 percent of the pills were being trafficked to other states.
Being inside American Pain was like being inside a junkie's fevered skull.
Doctors carried guns underneath their lab coats. Patients "fished out" regularly in the waiting room, going into withdrawal seizures. Others traded sex for pills in the parking lots. Millions of dollars in cash lay in piles around the clinic. But the employees and doctors rarely spoke about the fact that nearly all the patients were addicts or drug dealers. Acknowledging this truth could have incriminated the operation. Over time, Chris George began to require that his doctors take other precautions, such as making sure each patient had a medical file and requiring patients to get an MRI.
Meanwhile, because Florida did not track the flow of painkillers, hundreds of copycat clinics popped up across the state in the wake of American Pain, funneling the drugs up Interstate 75, which became known as "Oxy Alley." American Pain inspired a gigantic new drug industry that fueled tens of thousands of addictions up and down the East Coast. Given the amount of pills that flowed out of the state, I believe the Florida pill mill years tipped the nation into its current opioid crisis.
American Pain and most of its copycats have since been put out of business, and many painkiller addicts have switched to heroin. This doesn't mean their addictions have somehow worsened. Switching to heroin is simply an economic decision, the same fix for less money. If the government successfully chokes off the supply of heroin, the street price will rise and many addicts will go back to pills.
Because there's still no shortage of pills out there. Even in the face of mounting evidence that large quantities of the drugs are being abused, the DEA has, year after year, approved massive hikes in opioid production. In 2014, the DEA allowed U.S. drug manufacturers to produce and sell 149,375 kilograms of oxycodone. That's 42 times the amount made in 1993. That number dipped slightly this year, but it looks like it's on the way back up.
Some opioid advocates are upset that the furor around painkillers has led some doctors to stop prescribing opioids for chronic pain. If true, I think this is a good thing. These drugs have the capacity to destroy lives, and if they are going to be prescribed long-term, then the prescribing doctor should have a thorough grounding in both pain medicine and addiction medicine.
Cardiologists don't do brain surgery. Podiatrists don't administer chemotherapy. But the pharmaceutical industry for many years has attempted to convince doctors that a couple of continuing medical education hours (often sponsored by the pharma industry itself) qualify physicians to administer powerful addictive drugs for long periods of time to combat chronic pain, an extraordinarily complex and delicate task.
The power of painkillers, I've come to realize, is that they come in amber pill bottles, not little plastic bags, and they take the form of manufactured tablets, not powder or jagged shards. Pills look legitimate. Their precise, factory shaped contours make it easy for people -- even doctors -- to believe they aren't addictive.
But there's little difference between oxycodone and heroin. They come from the same plant: the opium poppy. They produce a similar high. And their addictions are equally horrific.
The painkiller epidemic and the heroin epidemic are one and the same.
My pill-stealing friend from the old days understood this reality long before most people. In outward appearance, he was presentable enough to fool real estate agents into believing that he was a legitimate house-hunter. But he knew his addiction was every bit as merciless as any junk fiend's. I've lost track of him. The odds that he's doing well are not good.
I'm one of the lucky ones. I rarely crave drugs or alcohol any more, though I know the craving would return the instant I used again. But I'm lucky also because I quit in 1995, one year before Purdue Pharma released OxyContin, the first blockbuster opioid narcotic.
Throughout my three years of researching and writing American Pain, the same thought kept popping up in my head:
Thank God this stuff wasn't around when I was younger.
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John Temple's new book, American Pain, tells how a young Florida felon hired a crew of doctors to prescribe painkillers to addicts, made millions, and couldn't be stopped. Presently, he teaches journalism at West Virginia University in Morgantown, where he lives with his wife and two sons.