When two pharmacies in a tiny town of less than 3,000 people fill prescriptions for more than 21 million opiod pills, you'd think red flags would go up somewhere. But for nearly two decades, and after the deaths of tens of thousands of people, doctors in the US continued to write scripts.
At the peak of the opioid crisis in the United States, 250 million scripts were written every year. After hundreds of thousands of deaths, there's still no end in sight.
Journalist Chris McGreal joined Afternoons with Jesse Mulligan to discuss the epidemic which he's covered in his book American Overdose: the Opioid Tragedy in Three Acts.
McGreal, a senior journalist at The Guardian, first came across the opioid problem while reporting on poverty and marginalisation for the paper.
"I kept running into the impact of opioids, particularly in parts of the country like Appalachia and Western Kentucky where you would see towns that were really dying. You'd walk down the main street and all the shops would be boarded up. Pretty much the only things left would be the pay day loan companies and pharmacies.
"I would talk to people whose lives had been devastated by these drugs but one of things that was most striking to me was that many of them became hooked on prescription opioids 15 or 20 years ago. I thought, how is that this epidemic has run for so long and we're really only talking about it now?"
McGreal says the modern opioid crisis began with good intentions by a group of doctors in the 1980s who wanted to address chronic pain in patients.
They were seeing people who were dealing with mentally and physically debilitating pain like arthritis which was ruining their lives.
The doctors felt frustrated at not being able to help these patients and began to look to opioids which had been increasingly used in end-of-life care. But of course, if you're dying - addiction is less of a worry.
"What these doctors did was they glossed over the risks of addiction and, in fact, misrepresented science."
One doctor, Russell Portnoy, who was at the forefront of the movement later admitted that he had used studies, sometimes marginal ones at that, that didn't really prove his argument to make the case that opioids were safe, not addictive, and unfairly stigmatised.
Portnoy and his colleagues were successful at removing the stigma from opioid prescriptions but as time went on, it became apparent that not only were the drugs addictive, they were also ineffective at treating pain.
"What happens is - and this isn't true for everybody - is that the more they take the drugs, the more they need to stave off withdrawal. The drugs start replicating the pain that they are trying to treat. They think they're treating increasing pain but what they're actually doing is treating addiction. And the more drugs they take, the deeper their addiction gets."
At the time, doctors dismissed this as "pseudo-addiction" and said that people who are in pain can't become addicted to opioids.
"The medical profession ploughed on and within a decade of these drugs coming on the market, there was a prescription being written that would supply 30 days of opioids to every adult in America."
'Pain as a fifth vital sign'
Purdue Pharma, the company behind the powerful opioid OxyContin pushed the idea that chronic pain was an epidemic and their drug was the solution. McGreal said they achieved this in a number of ways, firstly by latching on to what doctors like Portnoy had been pushing, and then by seizing a major marketing opportunity.
"They invented OxyContin and wanted to corner the market because most opioids can be freely made and there's no patent on them. They wanted to get a patent drug so they cooked up OxyContin which was ten times - or higher depending on the strength - the power of your average pain killer. They said that this made it a safer and more effective drug than lower level opioids because you only had to take one and it would last longer."
"Purdue Pharma persuaded the Food and Drug Administration (FDA) of this on the basis of no clinical trials whatsoever. The FDA endorsed it and then, essentially, Purdue Pharma took this drug and went out and marketed it in the biggest medical marketing exercise of a prescription drug ever."
McGreal says the company sent out thousands of sales people to target doctors in areas where painkillers were already being taken.
"They did everything from wining and dining doctors, to offering financial incentives, to outright lying about the medical science behind these pills."
Purdue Pharma also claimed that the FDA had recommended that OxyContin be the first drugs to begin a treatment and patients should stick with them, he says.
"What they were suggesting is that, for relatively minor pain like a twisted ankle, you should be begun by the doctor by the most powerful opioid on the market."
The company began with areas where work was likely to be physical, such as mining or logging in West Virginia before attempting to expand their market. They did this by backing a concept called 'Pain as a fifth vital sign' through the American Pain Society, which they were funding.
The American Pain Society pushed the idea that pain could be measured in the same way blood pressure or heart rate could, and they said doctors should be obligated to do so.
"Now, you can't measure it in the same way because there's no machine for it. It's a very subjective thing - you have to ask the patient," McGreal says.
"But nonetheless, they managed to persuade the licensing body for hospitals in America - the Joint Commission - to obligate doctors to ask about pain.
"And so, in every hospital and clinic in this country, you saw the appearance of smiley faces between one and ten. Anybody who said their pain was five and above had to be treated for pain, and that basically meant prescribed opioids. They persuaded not only hospitals, but also medical boards and basically all medical authorities in this country to impose that."
Simultaneously, hospitals were measuring whether patients were satisfied with the pain treatment they had received, casting access to opioids as a human rights issue.
"They were claiming that doctors that weren't prescribing opioids were leaving patients to writhe in pain and weren't being good doctors."
One of the reasons the opioid epidemic is a uniquely American one, McGreal claims, is because medicine is an industry in the United States and is run on financial lines. Hospitals want patients (customers) to be satisfied with their treatment, while insurance companies - which pay for the treatment - want doctors to prescribe opioids because they're much cheaper than alternative pain treatments such as physical therapy.
"Doctors essentially ended up just going with the flow and prescribing these pills to anybody who asked for them."
'Abusers' and 'good patients'
Many of those doctors, however, were raising the alarm about the prevalence of opioid prescriptions and its effects on patients, he says.
One was Jane Ballantyne, the head of pain management at Harvard and its associated hospital Massachusetts General. She had originally bought into the idea of pills like OxyContin for pain treatment, but after three of four years she started to notice that patients were not doing well on the drugs.
"No matter how many pills they took, and no matter how much she ratcheted up the dosage, they always seemed to be in pain," McGreal says.
"She also noticed that opioids had a very debilitating effect in other ways on their lives."
People were complaining to Ballantyne that their husbands, sons, wives were no longer the same people since going on the pills.
She started to look at what effect these drugs were having and published a study in the New England Journal of Medicine 15 years ago. In it, she said the profession needed to take a pause on prescribing opioids and reassess whether the drugs worked and if they were the best option available to patients.
Doctors in mining and logging towns were also noticing the effect on their communities and surgeons were alarmed that patients who were being given very high dosages of opioids after surgeries were dying at a higher rate. The drug companies then changed tack, McGreal says.
"They decided to change the conversation and they portrayed people who had become dependent on these drugs as abusers. The basically blamed the victims for their own addiction. They said: 'you mustn't allow these people who become addicted to take the drugs away from the good patients who need them and are in pain.' But they were often one and the same people.
"They had begun with pain, they had been given prescriptions, they had followed the prescriptions and then they had become addicted. But the drug companies had very successfully changed the conversation. They demanded that the medical profession pursue what they called a 'balanced approach'. The 'balanced approach' really just meant keeping the doors open to mass prescribing."
Over the past decades the pharmaceutical industry has spent $2.5 billion lobbying Congress and holds a lot of power there, McGreal says.
He says members of Congress kept up the pressure to prescribe and began to deride critics of the drugs.
"It was quite shocking to discover the extent to which, within about five years from the drugs coming onto the market, the opioid makers had taken control not only of marketing the drug but actually writing medical policy and overriding the decisions of doctors."
McGreal, in the course of researching his book, has met people whose lives have been undone by addiction to prescription opioids. One woman he met had spent 20 years consumed by her addiction. She was first prescribed OxyContin after slipping while walking home drunk. She's destroyed marriages, lost her son, and now deals drugs to fund her addiction. "It's a story you hear over and over again," McGreal says.
Concern about opioid addiction has gone mainstream in the 2010s. President Donald Trump declared it a national emergency and the Centre for Disease Control (CDC) has labelled it an epidemic.
While it's harder to get the drugs like OxyContin today, others have filled the gap in the market.
Mexican drug cartels seized the opportunity to undercut the pharmaceutical industry with heroin and that's been supplemented with the arrival of powerful new artificial opioids like Fentanyl which is killing increasing numbers.
Sixty to 70,000 people are dying every year from opioid overdose in the United States, approximately 150 every day. And yet the root cause of the epidemic, the mass prescribing of pills like OxyContin hasn't dropped significantly. At the peak of the crisis 250 million prescriptions were being written for opioids every year, now it's down to 190 million.
"That's still an awful lot for a country of 260 million adults," McgGreal says.
"You can see that the pills are still out there and you can see from the rising death toll that we're far from seeing an end to this epidemic, or even a light at the end of the tunnel, but there is an awareness and I guess that's a big step forward", he says