Although I learned in school that prescription medications and illegal narcotics were both described by the word “drugs”, it was watching Gus Van Sant’s Drugstore Cowboy as a grad student that drove home how close the effects of the two could be. The film, starring Matt Dillon and set in the 1970s, is about a group of addicts who rob pharmacies and hospitals at great personal risk to get their daily fix. Drugstore Cowboy felt culturally dissonant, for, as I told the American friend who had recommended renting the VHS, in India one could get whatever medication one wanted without prescription. Ever since, I’ve wondered why there isn’t more abuse of medical opiates in India, and also why so many people who could get high without involving drug pushers choose to walk on the wild side. I suppose they have the same blind spot I did before watching Van Sant’s cult movie.

While Punjab’s struggle with a wave of addiction to synthetic opioids produced from Afghan poppies moves from newspaper articles to fictional formats, the United States faces an epidemic of prescription opioid abuse created by greedy pharmaceutical companies and compliant doctors. Prescription drug overdoses now take 19,000 lives annually in the United States, more than heroin and cocaine combined. Besides, many victims of heroin begin their downward spiral by getting hooked on narcotic painkillers acquired legally, which explains why heroin-related deaths have spiked even as deaths from cocaine overdose have tapered off. For some perspective on that 19,000 figure, consider that the notoriously high rate of gun-related homicides in the US took about 11,000 lives last year.

The existence of prescription drug abuse in the US, and of powerful, addictive painkillers like Demerol and Fentanyl, comes to international notice when it claims prominent figures, like Michael Jackson and Prince. But neither musician fit the typical profile of the contemporary American addicted to pain killers, who is likely to be white, from a small town, relatively poor, and often female. That’s a sharp contrast with Punjab, where addicts are overwhelmingly male (a recent study estimated that an extraordinary 99% of junkies in Punjab are men). Heroin addiction has seen pronounced demographic shifts caused by the knock-on effect of painkiller abuse, and that has in turn scrambled traditional political positions. Republicans, ever eager to preach sermons about personal responsibility when the addicts were mainly inner city blacks, have been circumspect in assigning blame in the current crisis, and even taken the fight to pharmaceutical firms on occasion.

Creating an epidemic

Prescription drug abuse isn’t new. Fifty years ago the Rolling Stones produced a snarky song about it called Mother’s Little Helper. What has changed over the past decade and a half is the sheer number of addicts, over 2 million of them at last count in the US alone. That enormous number is a direct consequence of the pharmaceutical industry’s shady practices. Big Pharma created the crisis in two ways. First, drug manufacturers underestimated the addictive potential of new opioid painkillers. A paper published by Dr. Jane Porter in 1980 exemplified this tendency. Titled "Addiction Rare in Patients Treated with Narcotics", it claimed only four of 12,000 patients treated with narcotic painkillers became addicted. Two decades later it was clear that up to one in every five youngsters prescribed such medicines abused them in some way.

Secondly, the industry funded organisations like the American Pain Society and the American Academy of Pain Management which encouraged doctors to expand the range of symptoms for which they recommended painkillers. Even as problems with new formulations were coming to light, the number of prescriptions written in the US for opioid pain relievers escalated, rising from 76 million in 1996 to 207 million in 2013.

Belatedly, the US federal government sued painkiller manufacturers for fraud. As the financial crisis of 2008 proved, however, litigation only takes you so far against powerful corporations. Companies might be forced to pay fines that sound enormous, but are usually dwarfed by profits the firms made by underhand means.

Soaring profits

The painkiller OxyContin is a case in point. In 1995, the year it became available, its parent company Purdue Pharma sold $45 million worth of the drug. By managing to expand the spectrum of approved uses, and aggressively marketing OxyContin’s patented slow release mechanism as a bulwark against addiction, Purdue turned the drug into a blockbuster. In 2000, OxyContin sales breached a billion dollars. In 2007, Purdue settled a case with the US federal government, pleading guilty to misbranding the product with an intent to defraud, and paying a fine of $600 million. Yet, sales of OxyContin continued to soar, crossing $3 billion in 2010, making the fine look like a slap on the wrist.

Kentucky has been among the regions worst hit by the flood of OxyContin, which is so commonly abused in the Appalachians that it has gained the nickname Hillbilly Heroin. As higher dose tablets kept getting approved, users started crushing, sniffing, or injecting them for a long-lasting high. It was freely available on the black market for those who couldn’t find willing doctors. The state of Kentucky sued the company in 2007, but settled it eight years later for a mere $24 million.

As Udta Punjab gets a welcome release with minimal cuts, and will hopefully create popular pressure to protect our borders better, I’m hoping the generic versions of drugs like OxyContin, widely available in India at rock bottom prices, stay out of the radar range of the general public.