Last month, families affected by the opioid crisis lined the sidewalk outside the federal courthouse in Newark. Many held cardboard tombstones bearing the names of their lost relatives, the victims of the widespread distribution of dangerous yet legal narcotics made possible by drug makers, drugstore chains and lax regulatory enforcement.
After several hours of testimony from people who had lost children, parents and partners to drugs such as OxyContin, U.S. District Judge Madeline Cox Arleo, near tears at moments, acknowledged the frustration in the room. “It is not lost on me,” she said, “that those who started the epidemic will not serve a sentence.”
She was referring to Purdue Pharma — the Sackler family-owned company widely blamed for igniting America’s opioid crisis, a company that would soon cease to exist. Judge Arleo approved a criminal sentence that was part of the roughly $7.4 billion settlement and Purdue’s dissolution into Knoa Pharma, a public-benefit corporation charged with fighting the crisis the Sacklers helped create. After a decade of litigation, the settlement closes one chapter of the worst drug epidemic in American history. Opioids have been linked to more than 800,000 overdose deaths since 1999, according to the Centers for Disease Control and Prevention.
But the story of opioids’ grip on American medicine did not begin with Purdue. Nor will the dismantling of the company bring order to the global supply chain that American power built. It was a system whose benefits, and harm, were overwhelmingly experienced by Americans, but whose reach and effects were global.
Opium, the sap scraped from the poppy, has been used as a painkiller since antiquity — early American physicians and druggists sometimes produced it in their backyards — but the modern global opium trade was largely a 19th-century creation. British merchants shipped Indian opium to fuel mass addiction in China. American and European traders imported it from the Ottoman Empire to supply a young pharmaceutical industry that used opium to treat things such as coughs and dysentery.
Chemists eventually learned to extract alkaloids from opium sap, leading to new compounds that grew more potent, and more addictive. Morphine and codeine were drawn directly from the poppy; later, semi-synthetics such as hydrocodone and oxycodone were created in laboratories from another poppy alkaloid, thebaine.
Since the 1920s, American regulators and politicians had dreamed of poppy-free opioid drugs that could disconnect American medicine from the uncertainties of climate, the volatility of geopolitics and the choices of Indian and Turkish peasant farmers who routinely diverted their harvests to the black market. But the labs could not fully displace the poppy.
To protect its supply chain in the messy aftermath of World War II, the United States constructed a contorted global market in raw narcotic materials. That system reached its modern form in the 1980s, when a provision of American regulation known as the 80-20 rule — written to preserve legal cultivation in the world’s two most important poppy-producing countries — required U.S. pharma companies to source 80 percent of their opium and poppy products from India and Turkey.
It was a regulatory fix that protected a supply network already being displaced by newer producers and more sophisticated chemistry. By the 1990s, the legal opium system was generating a quantity of raw material that far outpaced medical demand. What the system lacked was a market for all of it — until Purdue helped create one.
When Purdue introduced OxyContin in 1996, the company drew on a new source of raw material: a high-thebaine poppy bred in Tasmania that yielded the precursor for oxycodone far more efficiently than Indian or Turkish opium could. The Drug Enforcement Administration’s 80-20 rule was meant to constrain that kind of global competition, but it centered on morphine, leaving thebaine imports from Tasmania effectively unrestricted. The Sacklers took advantage of those regulatory loopholes and a glut of raw material to create OxyContin, whose extended-release formulation could be bypassed by crushing or chewing. That shortcut produced a powerful high — and, for many users, a path to addiction and fatal overdose.
By the late 2000s, Americans — less than 5 percent of the world’s population — were consuming nearly all of the world’s hydrocodone and the majority of its oxycodone. By 2018, tens of thousands of Americans were dying of overdoses every year.
There were other victims: Hundreds of thousands of farmers in India and Turkey who, since the 1990s, had watched their livelihoods disappear as the global pharmaceutical industry moved to Tasmania. Walking the poppy fields in central India’s opium belt shortly before harvest in 2018, I saw an industry hollowing out in real time.
Americans now live in a post-Purdue world, and overdose deaths have declined sharply. But fentanyl made in Chinese and Mexican labs has overtaken heroin in our illicit drug markets. In the United States, start-ups are pitching domestic cultivation of opium once again. And in countries like Brazil, pharmaceutical companies appear to be running the Sackler playbook to peddle opioids to new users.
The unequal and gameable system that America created has now been replaced by one that is even more chaotic — shaped by actors the old system’s architects could not have anticipated. As with every degraded American system — our dollar-denominated financial order, our alliance-based intelligence sharing — it is unclear what comes next, or what values will shape it.
Purdue’s dissolution should give some small comfort to its many victims’ families. The settlement money will fund treatment, the overdose reversal drug naloxone and harm reduction over the next 15 years — goals families long have sought. But it will have no authority over the system that produced Purdue, or over the more chaotic one that has taken its place.
For half a century, American power could command the world’s poppy fields in the service of its commercial, strategic and regulatory ends, creating unprecedented abundance. But our ability to control poppies — like our grip on rare earths — has faded. Purdue was one node in a global opioid system that has slipped beyond the control of any single state, including the one that built it. What comes next will be shaped by actors who will be even harder to hold accountable than the Sacklers.
Benjamin Siegel is an associate professor of history at Boston University and the author of “Markets of Pain: Opium, Capitalism, and the Global History of Painkillers.”
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