6
Drug Dealers in Lab Coats
OxyContin is our ticket to the moon.
—DR. RAYMOND SACKLER, Purdue Pharma
Daniel McDowell is a solidly built thirty-two-year-old of Guatemalan origin, an olive-skinned refrigerator of a man with forearms that look like Popeye the Sailor’s. He is also addicted to heroin, and because he lives in Baltimore, which for decades has been notorious for its narcotics trade, you might think that he became addicted because of some street-corner dealer. In fact, the people responsible wore three-piece suits and lab coats, and they never saw the inside of a jail cell—although Daniel did. We went to Baltimore because as a city with a large black population it offered a counterpoint to Yamhill, but we found many parallels in the suffering as well as a uniquely American story about betrayal.
Daniel joined the army in 2004 after graduating from high school and was an immediate star. He was in the top 10 percent of his class at noncommissioned officers school and was promoted on a fast track, soon commanding soldiers who had been in basic training with him. Military life appealed to Daniel and for a time brought out the best in him: he was courageous and liked the camaraderie and sense of mission, while senior officers found him dependable and purposeful. He served in Afghanistan and Iraq and then signed up for another tour while still in Baghdad. He decided that he was a military lifer, and his wife supported him even as she worried about him.
One day, in southern Afghanistan in the summer of 2006, Daniel’s Humvee hit an antitank mine set by the Taliban. A dozen years later, telling us the story in his cramped windowless room in a low-rent district in Baltimore, Daniel was shaky as he remembered the scene. He recalled a sudden concussing boom and then smoke filling the Humvee as pain shot through his body. “My legs hurt so bad that I remember I didn’t know if I still had my legs. So I reached down because I couldn’t see anything and I felt my legs and in my head I was like, Thank God.”
Daniel’s knees had been permanently damaged, earning him a Purple Heart and leaving him smoldering with anger at Afghans. Less than a month later, he was caught in a brutal nine-day firefight in which his friend Staff Sergeant Robert J. Chiomento, age thirty-four, took a rocket-propelled grenade in the chest. Daniel’s rage at Afghans grew. His job was to operate a .50 caliber machine gun, a monster weapon that can fire ten rounds a second and has a range of four miles. In the firefight, Daniel was frantically firing at everything that moved, every mud-brick compound, anything that looked as if humans might be nearby.
In that moment, Daniel wanted an outlet for his fury at the enemy and at the Afghan people. “We were some bad dudes, we fuck shit up,” he told us. “I shot at compounds, I shot at anything that moved, you know what I mean? I was an angry guy. They killed my friends and they hurt me, so at the time I killed anything that walked.”
After the battle, rage ebbed and shame grew. It wasn’t that Daniel had deliberately massacred women and children in his rifle sights, but he had fired on homes, and his mind conjured terrified kids huddled inside as his fire cut them in half. Long after the firefight was over, the people he had killed inhabited his nightmares. “That’s the shit I think about, and the shit that bothers me,” he said softly. “I come off as a hard person, but I still have feelings.”
Back in the United States in 2009 as a drill sergeant, Daniel found that both his knees and his conscience troubled him. In addition, post-traumatic stress disorder left him with nightmares that frightened his wife. “I’d be having the worst dreams, dreams of being over there, getting shot, and I’d be crying in my sleep or sometimes screaming in my sleep,” he told us. “She’d be trying to wake me up, whacking me.”
Daniel McDowell, a war veteran now in a different kind of fight for his life, to overcome drug use, in Baltimore (photo by Lynsey Addario)
Daniel received treatment for his knees, including meniscus surgery, and was prescribed a potent synthetic opioid called Tramadol. He welcomed medication to numb his physical and emotional pain. Military doctors soon referred him to an outside pain clinic that prescribed him large quantities of oxycodone and other opioid painkillers. When Daniel switched doctors, the new physician looked at his medical record in horror.
“You’re on more medication than someone with terminal cancer would be on,” he told Daniel, and he cut back on the dosing. Now desperate for pain pills and running out, Daniel scrambled for alternatives and raged at the new doctor. Fuck that guy, he said to himself. He cut me off my pills. He doesn’t know what I’m going through.
Daniel knew he needed help, but it would be humiliating to turn to army doctors and explain that he was dependent on pills, plus it might hurt his military career. So instead he took private advice from an army buddy with a neck injury who was a bit ahead of him in the addiction cycle: crush pills into powder, mix with water, and inject the mix into a vein. That helped for a while, but soon Daniel was again running out. For a time he purchased prescription pain pills on the black market, but that was ruinously expensive. So the same army pal introduced Daniel to heroin, a cheaper way to get opioids.
“That started the monster I’m struggling with,” Daniel told us. He didn’t know it, but this was the most common American route to heroin addiction in modern times: use prescription painkillers, become addicted, scramble to buy them illegally, and when the habit becomes unaffordable, switch to street heroin.
Daniel’s descent into addiction has been repeated all across the country on a vast scale, creating individual tragedies and bringing down national life expectancy. In Daniel’s case, his work ethic collapsed, he became disheveled, his performance reviews suffered and he faced a violation for being disrespectful.
“You’ve got an issue with drugs,” his wife told him. “You’ve got to stop.”
“Look, I’ve been through all this shit and I just had this surgery and my back hurts,” he retorted angrily. “I work all day long.”
So his wife, whom he describes as “the best wife ever,” left him.
“I basically ruined our marriage,” he explained. “Pills were more important to me than she was.”
Stuck with a $150-a-day heroin habit, Daniel soon found himself in debt, and then the army pushed him into early retirement. To pay for his habit, he began dealing heroin. Soon he was arrested and spent eight months in jail on drug charges. On his first night out, he got high again.
Finally, Daniel found a rehab program that would take him. It lasted only twenty-eight days—far too short—but he still managed to stay off drugs for six months. Things looked up: he and his new girlfriend, Megan, had a son, Braydon, whom Daniel doted on. He cared about Braydon more than anything in the world, except one thing—his craving.
“I loved to get high,” he told us. “Honestly, that was the main thing. I just loved how it felt. There’s no other feeling like that. I would pick being high over sex, over eating, over spending time with my family.” The other reason to keep taking heroin, despite the peril, was more banal: avoiding becoming “dope sick” from withdrawal. For anyone dependent on opioids, the physical pain of going without is terrifying. “It’s the flu times ten, plus having a baby,” one heroin user, Shawn Price, told us. “You can’t control your bowels; you’re going to throw up everything you eat. I’ve been shot, and I’d rather be shot again than be ill from heroin withdrawal.”
Although Daniel is devoted to Megan and Braydon, heroin upends his priorities. “When I’m using,” he told us, “I’m going to do what I have to do to get it. Lie. Cheat. Steal.” Sure enough, Daniel soon relapsed and was back to heroin. He stole from Megan and lied to her, so she kicked him out, and Daniel wound up homeless in Baltimore. He had plenty of company, for the U.S. government estimates that there are about forty thousand homeless veterans across America.
Daniel, the once meticulous drill sergeant, now found himself sleeping on the streets, smoking crack and injecting heroin. “I was stinking and hungry,” he recalled. He tried twice to kill himself by overdosing but wasn’t competent even at that. “You hit the point in your life where you’re just like, I don’t want to live,” Daniel said heavily. “I’m like, I’m tired of hurting. I’m tired of being in pain. I’m tired of doing all the shit that I’ve been doing to get by. It just gets old.”
His efforts to mislead Braydon failed. “He found out I was in jail,” Daniel told us, looking down at his shoes. “I was a shitty father.” Daniel tried to buy his son birthday and Christmas presents, but heroin was the priority and somehow the money disappeared before he managed to buy the gifts for the person he cared most about. “I hated myself,” he said. “I hated what I had become.”
Daniel’s father is a policeman who broke off ties with him, and they haven’t spoken since 2013. The only person to stand with Daniel is his mother, who has repeatedly driven long distances to rescue her son and try to admit him into rehab programs. He acknowledges manipulating her and lying to her to get money for drugs.
“My mom loves me; she’s my angel,” he explained. “There’s no point in time where I couldn’t rely on my mom to help me out. And I know I abused that.” When desperate for a fix, Daniel would beg her for cash and make up excuses. “I’ve got a ticket, and if I don’t pay it I’ll go to jail,” he told her once. Another time, it was, “Somebody stole my money.”
“I can give it to you on a gift card,” she would say, trying to keep him from drugs.
“No, I need it in cash.”
They would argue a bit, and finally his mom would relent because she didn’t want to see him suffer. Still, it was his mom who saved Daniel with her unconditional love, repeatedly rescuing him and finding new rehab programs for him. Eventually, she helped him get a referral to the Baltimore Station, a two-year residential program for veterans struggling with addiction, supported by the Department of Veterans Affairs—part of a campaign to end veteran homelessness.
The Baltimore Station (an old firehouse, hence the name) has an excellent record helping people overcome addictions and recover their lives. It’s a model of the kind of programs we need around the country, and not just for veterans. At the Baltimore Station, Daniel received counseling and was put on Suboxone, an opioid medication that stabilizes people with addictions, and he began to put his life back together. We visited him in his dorm room at the Baltimore Station, and he hadn’t used street drugs for three months but was still fragile and mortified. For a proud army man to talk about how far he had fallen was humiliating, but he did it because he wanted people to understand the plight of the addicted.
Daniel McDowell in a group discussion about managing addiction at the Baltimore Station, a program for veterans (photo by Lynsey Addario)
“Honestly, it just sucks, man,” Daniel told us. “The potential I had when I was younger, I could have been a sergeant first class. Now, I’m a felon. No house. I ain’t got shit but a bag of clothes upstairs, so it’s a fight. Every day is a fight, man. You want to use every day, but you know you ain’t going nowhere if you do.”
What motivates Daniel is his determination to rebuild his relationship with Megan and be a dad to Braydon. “She loves me to death,” he said of Megan, “but she can’t trust me. It’s my fault.” He paused and added wistfully, “I want to get back to being a family again. I want to take Braydon to football practice.” He hopes eventually to return to college and emerge as a drug counselor to help other struggling veterans.
We asked Daniel whom he blames for his addiction. The Taliban, for laying the antitank mine that caused his knee injuries? The army, for negligently prescribing him Tramadol and referring him to the outside clinic? The pharmaceutical executives who marketed the opioid painkillers and claimed they weren’t so addictive? The doctors who gave him the medications that got him hooked? Daniel wasn’t buying any of that.
“I blame myself,” he said. “At any point, I could have said, I don’t want to do this,” he explained. “I chose to do what I did.”
At one level, it may be useful for Daniel to blame himself. Grassroots addiction programs emphasize that participants must take responsibility for their own actions, never making excuses, because patients have better outcomes when they accept this mantra of personal responsibility. As Plutarch said, “What we achieve inwardly will change outer reality.”
Yet in a larger sense, Daniel was unfair to himself. He was betrayed by the government he risked his life to serve. By official estimates, 2.1 million Americans suffer opioid addiction, and some scholarly estimates run many times higher. When so many Americans simultaneously make the same bad choice, that should be a clue that the problem is not simply individual moral failure. It is a systemic failure.
Here’s one way of looking at what happened: Daniel was injured on the job, and then doctors in and out of the military prescribed highly addictive opioids that got him hooked. That was because the government, through lax oversight, empowered pharmaceutical companies to profit from reckless marketing. Once Daniel was addicted, the army didn’t try adequately to help him, but rather spit him out, and then he became a target not of public health efforts but of the criminal justice system. The government failed him, blamed him and jailed him. A couple of generations ago, the United States rewarded veterans by affording them education and housing benefits. More recently, the United States helped get veterans hooked on drugs and then incarcerated them.
THE STORY OF AMERICA’S current addiction nightmare begins in the 1990s, when the pharmaceutical industry was looking for a new blockbuster drug to market. Opioids were then seen as addictive and useful only for extreme pain or for those with terminal cancer, but business executives believed that opioids could be hugely expanded into a lucrative market. So the pharmaceutical industry, led by Purdue Pharma and the Sackler family who owned it, marshaled a sophisticated campaign to treat pain more aggressively—with their opioid prescription painkillers. Those OxyContin pills that got Daniel addicted were manufactured by Purdue.
Pharmaceutical companies commissioned reports arguing that doctors were allowing patients to suffer unnecessarily. There was an element of truth to this critique, and that recognition helped the pharmaceutical marketing campaign gain traction.
There had always been four “vital signs”—temperature, pulse, respiration, blood pressure—but in 1995 the American Pain Society (financed partly by Purdue) urged adoption of pain as a fifth vital sign. This became standard, adopted by veterans hospitals and by the American Medical Association. Consumers were asked in hospital assessments, “How often was your pain well controlled?” and “How often did the hospital staff do everything they could to help you with your pain?” Reimbursement levels later depended in part on patient satisfaction, and not surprisingly, painkiller prescriptions surged in the United States, though much less abroad. The American Pain Society acknowledges that in practice what happened at many institutions was: “Ask people if they have pain. If they do, give them opioids.”
It wasn’t just Purdue that was reckless. McKinsey & Company, the global consulting firm, advised Purdue on how to “turbocharge” sales of opioids, how to resist drug enforcement agents and how “to counter the emotional messages from mothers with teenagers that overdosed.” Insys Therapeutics, a pharmaceutical company, allegedly paid $175,000 to an Ohio doctor, Gregory Gerber, in kickbacks to promote a prescription version of the powerful synthetic opioid fentanyl. Insys achieved 1,000 percent growth in earnings from fentanyl from 2012 to 2013 by paying doctors to join a speakers program and promote the drug, and by paying sales representatives bonuses for aggressive marketing of it. Insys was effectively manipulating doctors to get patients addicted.
“Every time a doc tells you they prescribed, the very next question should be, ‘How many units? And what dose?’ ” Frank Serra, a regional sales manager, instructed his sales representatives in 2012. Congressional investigators obtained internal Insys documents that emphasized the importance of “owning” a physician or nurse.
Medical staff not only sold their souls but did so remarkably cheaply. One study found that the pharmaceutical industry spent an average of $588 per doctor from 2013 through 2015 marketing opioids to 68,000 of them, including paying for meals and trips. That’s a modest sum over three years, but it was effective in increasing both prescriptions and deaths. The study found that the number of payments to doctors in a particular county correlated to overdose deaths from prescription medications in that county a year later.
Heather Alfonso, a nurse practitioner, admitted in a plea agreement that she received kickbacks on the way to becoming the largest prescriber of Insys fentanyl in Connecticut. As part of the Insys speakers program, she had received $1,000 per session for about seventy speeches—except that they weren’t actually speeches. Instead, they amounted to dinners at nice restaurants where she gave no presentation and often there was no one present who was able to prescribe the drug anyway, according to a Senate report. In 2015 alone, Alfonso wrote 1,162 fentanyl prescriptions, the Senate report said. One can only guess at the misery that caused. She completed paperwork for fentanyl prescriptions for people with neck pain, back pain, leg pain, and shoulder pain. There are reasonable uses for fentanyl—such as patients with terminal cancer—but prescribing it for chronic back pain is a recipe for addiction.
McKesson Corporation, another giant pharmaceutical company, in just two years shipped nearly 9 million prescription painkillers to a single pharmacy in Kermit, West Virginia, population 400. Predictably, the result was addiction, overdoses and funerals—while McKesson profited from its recklessness. The government eventually fined McKesson $163 million, but the company board specifically excluded the fine in calculating profits to determine the bonus for the chief executive, who over a decade earned more than $600 million.
We reached out to Daniel’s doctor at the outside clinic who had prescribed large quantities of opioids to tell him that Daniel had become addicted to heroin and ask if he regretted his prescription practices. He declined to comment.
Purdue was later convicted of a felony for fraudulently marketing its opioids by downplaying the risk of addiction. The company was vigorously defended by Rudy Giuliani, and its $600 million fine was negligible compared to the $35 billion that it is estimated to have earned from OxyContin. Individual executives from Purdue were also convicted and made to pay substantial fines, but they never served a day of jail time. Purdue was allowed to continue selling opioids, and the Sackler family is now worth $13 billion.
Some 80 percent of Americans addicted to opioids began with prescription painkillers, not with illegal street drugs. Essentially, pharmaceutical executives acted like Colombian drug lords, with legal approval. Many cities and states, including Baltimore, are now suing Purdue and other pharmaceutical companies to recover some of the costs of treating the opioid epidemic, but no one can ever give Daniel back what he lost.
“The biggest drug dealers wear white lab coats or pinstripe suits, not hoodies or the gang garb of street-level dealers,” Jonathan Caulkins of Carnegie Mellon University and Keith Humphreys of Stanford University have noted.
The failure to imprison any of the Purdue executives shouldn’t surprise us. America rarely prosecutes white-collar criminals. Even after the 2008 financial crisis, despite widespread illegal conduct that destroyed lives around the country, just one banker went to jail; in contrast, back in the 1980s, almost nine hundred bankers were jailed in the aftermath of the savings and loan scandal. Without much discussion, we have created a two-tier justice system. If you shoplift at the grocery store, you can be carted off to jail. But if you steal tens of millions of dollars from the tax authorities or fraudulently peddle dangerous drugs from a corporate suite, you’ll be hailed for your business savvy.
THE AUTHORITIES SHOWED none of this leniency to ordinary drug users and distributors, and we wanted to see firsthand what has happened to small-bit drug peddlers like Geneva Cooley, so we went to Alabama to find out. A seventy-one-year-old black woman, mild-mannered, graying and husky, Geneva grew up in Harlem and was orphaned as a teenager. Living in a neighborhood where drugs were easily bought and sold, she began taking heroin half a century ago after surviving brutal sexual and domestic violence. Soon she had a daily habit and began selling heroin as well. She was twice convicted in New York of felony forgery, writing bad checks to pay for her habit.
In 2002, while working as a secretary for an accounting firm on Long Island, Geneva visited a friend in Birmingham, Alabama. She says he met her at the train station, handed her a green sock that she realized must contain drugs and asked her to take it to his mother’s house. In retrospect, she thinks the friend set her up, because a plainclothes police officer immediately confronted her:
“Are you Geneva Cooley?”
“Yes.”
“May we search your bag?”
Geneva Cooley in a women’s prison in Alabama, where she was sentenced to life without the possibility of parole for drug trafficking (photo by Lynsey Addario)
“Sure.” One woman began searching her bag.
“May we search your clothes?”
“No,” Geneva said, and then she rushed to the bathroom, where she threw the bulging sock into the garbage. But it was too late.
“Police! You’re under arrest.”
That sock contained 5,600 opioid pills and 90 grams of heroin. The prosecution said Geneva was a drug mule, carrying narcotics from New York City with a street value of a quarter-million dollars. In 2006, after a trial that lasted only about an hour, Geneva was convicted of trafficking narcotics and, because of her previous felony convictions, was given a mandatory sentence of life without the possibility of parole. The Alabama prison computer system logs that sentence as 999 years, 99 months and 99 days.
“I felt like that was the end of my life,” Geneva told us. “I felt like committing suicide.”
We visited Geneva in the Julia Tutwiler Prison for Women in Alabama, where she has a bottom bunk in a bare, open room full of bunk beds for fifty women. This is the “honor dorm” for those with good behavior records, and Geneva keeps her bed area tidy. A row of exercise equipment is available for inmates, though Geneva doesn’t use it much.
One of the more elderly inmates, Geneva is a calming influence and often intervenes when tempers get hot and arguments get out of hand. She uses the prison library to read novels, especially David Baldacci mysteries, and at times she has taken classes on anger management, drug rehabilitation and history. She also loves to visit the prison flower garden, but otherwise the prison is drab, dull and forever.*
Neither her son nor anyone else in her family uses drugs, Geneva says, and she tries to be upbeat with her grandson and granddaughter. “I write them positive things to do in life,” she said. While she talks on the phone regularly with family members, she has never let any of them visit her in prison—because she couldn’t bear them leaving.
Geneva certainly committed a crime, but the contrast is brutal: a marginalized black woman sentenced for the rest of her life to a prison in Alabama, her world revolving around her neatly made bunk bed, while members of the rich white family that helped create America’s opioid epidemic became billionaires. We asked the Sacklers at Purdue what they thought of the comparison; they declined to comment.