Book review of “American Cartel: Inside the Battle to Bring Down the Opioid Industry,” by Scott Higham and Sari Horwitz

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At the end of their powerful book, “American Cartel: Inside the Battle to Bring Down the Opioid Industry,” Washington Post reporters Scott Higham and Sari Horwitz quote a former Drug Enforcement Administration agent explaining why no one stopped the companies — from the drug manufacturers to the distributors — that were profiting from the opioid business. “It’s all about money,” he says.

Of course that’s a cliché. But, as the book shows, it’s a cliche for a reason: It happens to be true.

For many people, the Sackler family, which made its multibillion-dollar fortune by peddling OxyContin, is the head villain of the opioid crisis that’s still devouring America. Maybe that’s true, in that if Purdue Pharma, the family’s company, hadn’t aggressively marketed OxyContin as a purportedly nonaddictive solution to pain of any sort, history might have been different. But that narrative has allowed the rest of the cartel — the rest of the “drug dealers dressed in suits,” as another DEA agent calls them: manufacturers, pharmacies, distributors — to escape public opprobrium.

And so, despite everything that’s been written about the crisis, the perspective that Horwitz and Higham bring is fresh and important. They mainly focus on the big drug distributors — Cardinal Health, McKesson and AmerisourceBergen — that transport more than 95 percent of all pharmaceuticals in the United States between manufacturers and pharmacies. “The Big Three,” as they’re known, “saturated the country with 76 billion oxycodone and hydrocodone pain pills from 2006 to 2012 as the nation’s deadliest drug epidemic spun out of control,” as Higham, Horwitz and their Washington Post colleague Steven Rich wrote in a 2019 piece. Not surprisingly, death rates soared in the areas that were most heavily saturated.

On one level, the wrongdoing by those involved is obvious and shocking. It’s been known for centuries that opioids are dangerously addictive. In modern America, it was equally well known that the resulting addiction was killing people: In 2013, for instance, the Centers for Disease Control and Prevention reported that one person was dying every 19 minutes from prescription drug overdoses. And yet, in the face of these facts, the distributors continued to ship mammoth quantities of pills to areas that simply couldn’t absorb them — unless the pills were diverted to the black market. For instance, McKesson shipped 2 million tablets of hydrocodone to six small drugstores in Tampa over an 11-day period; Cardinal sent 3.1 million tablets of oxycodone to a small Florida town in 2011, enough to supply every man, woman and child in the city with 58 doses; and on, and on.

But the wrongdoing isn’t necessarily punishable, because the letter of the law can be used to obscure what’s morally obvious. The companies have argued that yes, they were supposed to flag suspicious orders, but if they did so, legitimate customers might be deprived of their pain meds. They’ve argued that they didn’t have access to the DEA database that showed where all the pills were going, even though the information in that database came from the companies themselves. They’ve argued that they are just logistics companies and that fixing the problem was someone else’s responsibility. One of the beauties of the modern legal corporate complex is that there’s always a reason the company isn’t to blame.

And if the companies couldn’t wiggle their way out, well, they just paid fines and continued to do what they’d been doing. For instance, McKesson paid a mere $150 million of shareholders’ money to settle one case against it, which as Higham and Horwitz point out was just $50 million more than the annual compensation package of chief executive John Hammergren.

The people who did try to stop what was happening didn’t fare so well. One of the heroes of the book is a former DEA agent named Joe Rannazzisi, a “muscled tough-talking New Yorker who had spent a storied thirty years bringing down bad guys.” Rannazzisi was the head of the DEA’s Office of Diversion Control, and under his leadership, the agency began to go after the opioid dealers that were dressed up as Fortune 500 companies.

But that went as it so often does in America. The more money there was, the more the industry wanted, and the more viciously protective of their profits the companies became. Through their lobbying group, the shadowy Healthcare Distribution Alliance, they came up with a plan for eviscerating their critics. What happened to Rannazzisi was chilling, as it was meant to be. He was pushed out of his job and moved to a “dark office with no people, the equivalent of bureaucratic exile, in the expectation that he would give up and retire.” And eventually, he did.

Meanwhile, various members of Congress, including Marsha Blackburn, Orrin Hatch and Tom Marino, took money from the industry and pushed through a law in 2016 that dramatically weakened the DEA’s powers. Our supposed representatives were purchased, as they are so often, but in this case, the trade seems to have been particularly ugly: campaign contributions in exchange for people’s lives.

By the middle of the decade, some bold prosecutors began taking on the industry. The plaintiffs’ bar started to bring civil suits in towns and cities around the country, often based on public-nuisance laws, which confer broad powers on counties to eliminate hazards to public health. The hero, of sorts, of the second part of the book is Paul Farrell, a West Virginia lawyer who starts to fight the industry after reading a story in the Charleston Gazette-Mail about how drug companies had sent 780 million prescription pain pills to West Virginia in a six-year period, enough to supply 433 pills to every man, woman and child in the state.

Many of the cases against the industry were consolidated into a “multidistrict litigation,” which is what happens when there are so many lawsuits that they threaten to overwhelm the system. In the fall of 2019, just before the trial was due to start the two sides announced a settlement in the cases against manufacturers. As this review goes to press, plaintiffs’ lawyers are finalizing the terms of a separate, $26 billion global deal with the Big Three distributors and Johnson and Johnson. But in the case that Farrell brought against the distributors in West Virginia, a federal judge ruled this month that they bore no responsibility for the flood of opioids and the harm it caused.

In part because the end of the story has yet to be written, the book is less satisfying than it could be. In addition, the writing often bogs down in a morass of detail. Too often, Higham and Horwitz transcribe courtroom exchanges word for word for page after page instead of stepping back and explaining why one particular exchange might be pivotal. You won’t come out of the book with a clear sense of where things stand or why, or which of the industry’s arguments has mattered most in the eyes of the law.

But you will come away with a renewed appreciation for all that money can buy, as well as another realization that is also as obvious as it is shocking: No one is ever going to say they’re sorry.

Bethany McLean is a contributing editor at Vanity Fair and the author of “Saudi America: The Truth About Fracking and How It’s Changing the World.”

Inside the Battle to Bring Down the Opioid Industry

By Scott Higham and Sari Horwitz

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