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New book chronicles how America's opioid industry operated like a drug cartel

In the new book, American Cartel, Higham and co-author Sari Horwitz make the case that the pharmaceutical industry operated like a drug cartel, with manufacturers at the top; wholesalers in the middle; and pharmacies at the level of "street dealers."




This is FRESH AIR. I'm Terry Gross. The new book "American Cartel" is about the opioid industry, the manufacturers, distributors and pharmacies behind the opioid epidemic. It's also about their lobbyists and lawyers, many of whom had close ties to members of Congress and high-ranking officials inside the Justice Department. Some DEA agents left the agency to take high-salaried positions with law firms representing drug companies. The book is also about an unprecedented lawsuit launched in 2018 by a coalition of lawyers and investigators on behalf of thousands of counties, cities and Native American tribes across America. The suit led to the release of a pill tracking database and millions of internal corporate emails and memos, which the new book draws on.

The book's epilogue refers to a settlement by a company that was the largest opioid distributor, Mallinckrodt. The company did not admit to any wrongdoing, but it did agree to make its internal emails public. Those documents, a huge trove, were made public just a couple of months ago in May, but The Washington Post was given access to them before that. So they were able to publish a lengthy article analyzing those documents. My guest, Scott Higham, co-authored that article, and he co-wrote the new book "American Cartel," along with Washington Post reporter Sari Horwitz. They've been investigating the opioid industry for five years and co-authored The Washington Post series The Opioid Files. Higham also partnered with "60 Minutes" on an opioid industry investigation that received a Peabody, Emmy and duPont Award.

Scott Higham, welcome to FRESH AIR. Congratulations on the new book. In what sense was the opioid industry a cartel?

SCOTT HIGHAM: Terry, thanks for having me, first off. You know, Sari and I, like you said, have been investigating this industry for five years. And we've interviewed dozens and dozens of DEA agents, investigators and attorneys who have worked in this field for for many, many years. A lot of them used to work south of the border in Mexico and in Colombia. And when they started investigating the U.S. pharmaceutical industry, they saw a similar structure. At the top, they had manufacturers. And in the middle, there were wholesalers or middlemen. And at the bottom were the pharmacies. In their mind, those were like the street dealers. So they saw the same exact structure. They saw that these companies were - even though they were competing against each other, they were also collaborating with each other. And they were making sure that their business operations were protected against law enforcement. And so the same thing happened here with these pharmaceutical companies.

GROSS: Yeah. They even bonded together. Like, the distributors bonded together in a group called the Alliance. What was that?

HIGHAM: There were a couple of trade organizations that are at the center of the opioid industry. And one of them is called the Healthcare Distribution Alliance. It's a little known trade group. It is incredibly powerful in Washington. And it represents the three largest drug distributors in America - McKesson, Cardinal Health and AmerisourceBergen - along with a host of smaller regional organizations. So they're - like most trading organizations, they're a lobbying organization. They contribute heavily to members of Congress. But in this case, they helped the industry avoid accountability.

You know, Sari and I, looking at the data that you mentioned, Terry, that came out several years ago as part of these lawsuits and looking at all these confidential documents that came out as part of these lawsuits, started kind of changing our understanding of the opioid epidemic and how it happened. We saw that there were many more companies that manufactured way more pills than Purdue Pharma and the Sacklers. I mean, a lot of people believe that the Sacklers and Purdue are solely responsible for the epidemic. And we realized, according to the data, that they would be wrong and that a lot of companies jumped into this emerging market, companies that we all know, household names like CVS, Walgreens, Walmart, Johnson & Johnson and others that we never knew existed, like Mallinckrodt, a company that's been in existence for a hundred years. They produced 30 times the amount of pills that Purdue Pharma produced. And their conduct was so egregious that the DEA once called them a drug kingpin.

GROSS: So what was the DEA - the Drug Enforcement Agency's approach to investigating what they thought was basically a cartel?

HIGHAM: Well, they started out by doing, you know, what any investigator would do. And that is you start out at the lowest levels of an organization. And so the lowest levels of this organization were the doctors. And there's a plethora of corrupt doctors in this country who were willing to write prescriptions for drugs, for cash, for sex, for all kinds of things, but mostly for cash. And they realized that if they kept arresting doctors, that they could do that all day long. Every time they took down one doctor, another one would pop up. So then they moved up to the pill mills, which were nothing more than basically criminal fronts for drug dealers. And then they realized, you know, they could knock those over all day long. And so they...

GROSS: And the pill mills were basically places where doctors would write prescriptions for people who were really not suffering from pain. They were just, you know, addicted to opioids, perhaps as a result of having started using them as painkillers. Or they were selling opioids.

HIGHAM: Correct. I mean, a lot of these were in strip shopping centers, mostly in South Florida because the regulations were so lax down there. And people were traveling from all over the country down to South Florida, where they'd go into these pill mills. The doctor would ask a couple of cursory questions. They would say, I had back pain. They'd write a script for oxycodone or hydrocodone, and they'd be on their way. And, you know, word quickly spread around the country that this is where you could go to get your prescriptions. And then you would take those and you you would fill them in pharmacies all across the country. And so these out posts, it was kind of like the Wild West down there. And parking lots were just filled with drug users and drug dealers and people falling out and people using drugs. And it was a crazy, crazy time. And the DEA realized that there was no way that they could just rein them in because it took a long time to investigate these operations and then prosecute them. And then - and while they were doing that, then, you know, five more would open up and 10 more would open up. And so it was like a cancer. And they realized that what they needed to do was really move up the food chain and go to the drug distributors and the manufacturers. And so that's how they started moving up the food chain of their investigation.

GROSS: So the pharmaceutical industry fought back with the help of their lobbyists and lawyers, and they basically participated in the drafting of a bill that really limited the DEA's ability to go after the drug companies. What was the legislation in question here?

HIGHAM: You know, this is part of, you know, the revolving door in Washington, Terry, although it's - you know, it's not really revolving anymore. It's just kind of like a one-way street from the DEA and the Justice Department to the industry. And what the industry had done to fight back against - there was a guy named Joe Rannazzisi, who was running the small organization within DEA trying to hold the companies accountable. What they did is they went after Joe. They say he was being too aggressive. And then they went up on Capitol Hill, and they got a couple of members of Congress to help sponsor a piece of legislation - Tom Marino and Marsha Blackburn, who - you know, Tom Marino was from Pennsylvania, Marsha Blackburn from Tennessee - two states hit particularly hard by the opioid epidemic. And they hired a lawyer who once worked for the DEA to help them craft this legislation.

And basically, what the legislation did is it removed from the DEA's arsenal one of its most potent weapons. It's called the immediate suspension order. And an immediate suspension order immediately shuts down the operations of a drug warehouse, a drug company, preventing them from sending any more narcotics downstream until there's a court hearing. And so that was one of the DEA's most potent weapons. And it was basically removed at the height of the epidemic by changing a couple of words in the law that had been on the books since the 1970s.

GROSS: What were those words?

HIGHAM: Under the old law, you had to prove that a company's behavior was causing an imminent danger to a community. And imminent is the key word here. And what the industry did is they changed that word from imminent to immediate. And so it was easy for the DEA to show that a drug company was causing an imminent danger to a neighborhood or to a community by its conduct or misconduct. But to show that a company based in upstate New York or in Ohio or in Arizona was causing an immediate danger to a community a thousand miles away or 2,000 miles away was a bar that was just too high. And the drug industry knew that the DEA would never be able to meet that bar. And since that law has passed, there's not been one immediate suspension order issued by the Drug Enforcement Administration because they just can't meet that burden of proof.

GROSS: So I guess the difference between imminent and immediate is that imminent means, like, very soon, but immediate means, like, right this second, right now or one second from now. And that's harder to prove. But, you know, Congress, I think - just about everybody, I think, voted for this. President Obama signed the bill into law. How did the drug industry help convince Congress that this was good? 'Cause this was, like, at the height of the epidemic, right?

HIGHAM: Absolutely. Well, you know, it had a very deceiving title. It was called Ensuring Patient Access and Effective Law Enforcement Act (ph). It did not ensure patient access to pain medication whatsoever. It did not improve law enforcement. I think a lot of members of Congress did not read this bill even though it was just a couple of pages long. The one clause that changed imminent to immediate was, like, two sentences long. And so there were a number of members of Congress who took money from the industry and knew ostensibly what this bill would do. But there were a number of members of Congress who hadn't even read it. It wasn't even voted on; it was passed by unanimous consent, which basically means that if nobody objects, it becomes law.

And then Obama signed it into law. And it's - you know, it's still one of the great mysteries of the day because the president, President Obama, has never publicly said why he signed this. His DEA administrator at the time, Chuck Rosenberg, has never consented to an interview to say why he allowed this to go through. And it was just - it was appalling to all the men and women at the DEA who were fighting the industry that this thing would sail through Congress at the height of the epidemic and basically undermine their efforts.

GROSS: Did anybody point out that there was this change from imminent to immediate? 'Cause that's the kind of thing that you can easily miss if nobody points it out to you.

HIGHAM: Yes, it was pointed out numerous times because this bill took three different Congresses to finally get approval. And Joe Rannazzisi and the DEA, under previous leadership, along with Eric Holder when he was the AG, fought against this bill. In fact, AG Holder issued a press release saying that this would undermine the DEA and that - and it shouldn't be done. So people either knew what was happening and didn't pay that close attention, or they listened to the lobbyists who were telling them it wasn't that big of a deal; it was just clarifying the law. That's what the industry was telling members of Congress; we need clarification of the law, and that's all this does.

You know, you and I have been around long enough to know that so many pieces of legislation sail through Congress without members of Congress reading them. I was once in a member's office interviewing him, and the bell rang for a vote. And he looked up to one of his congressional aides and said, what are we voting on? And his aide told them what they were voting on, and he said, how am I supposed to vote? And he said, you know, vote yes, congressman. He said, OK, I'll be right back. And so, you know, you don't really want to see, you know, how the sausage is made on Capitol Hill. It's pretty ugly.

GROSS: Well, let me reintroduce you here. If you're just joining us, my guest is Scott Higham, a Washington Post reporter who's been investigating the opioid industry for about five years. He's the co-author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." We'll be right back after we take a short break. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Scott Higham, co-author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." He's also a Washington Post reporter who has been investigating the opioid industry for five years.

The head of the DEA unit that was investigating the pharmaceutical opioid industry was forced out, Joe Rannazzisi. So why was he forced out?

HIGHAM: Well, you know, he got very upset that the industry was fighting back against him, and that they had recruited allies on Capitol Hill, that they had recruited all these lobbyists and that they had recruited, basically, people who used to work at the Justice Department to then lobby their former colleagues at the Justice Department. And several members of Congress had their staffers get on a phone call with Joe and say, you know, we just want to understand why you're opposed to this bill. And Joe's a Long Island guy. He's very blunt. He doesn't suffer fools. And he basically said to these aides, to these congressmen, that, you know, the blood will be on your hands if you pass this bill. And you'll be protecting criminals.

And so Tom Marino and Marsha Blackburn used that language to request an inspector general's investigation of Joe Rannazzisi, saying that he threatened members of Congress. I mean, it was - they were just looking for any excuse that they possibly could find to get rid of Joe because he was more than a thorn in their side. He was costing them a lot of money, a lot of aggravation, a lot of legal bills, a lot of fines. And they'd had enough with him. So you know, as Joe would say, they didn't want to obey the law, so they just changed the law. And then a new team came into the DEA with a new message. And their message was, we're going to cooperate with the drug industry. And we're not going to be so hostile to them anymore.

GROSS: So Joe Rannazzisi, the DEA agent running the unit investigating the pharmaceutical industry involved with opioids, he ended up becoming a star witness in the major suit against the industry, against major players in the industry. So he got his day to say what he thought and what he had witnessed and learned.

HIGHAM: Correct. You know, Joe is, you know, a guy who, you know, dedicated his whole life to protecting the public. And then to have his career destroyed at a fairly young age was very difficult at first. But then, you know, the baton was picked up by a young lawyer in Huntington, W.Va., by the name of Paul Farrell. His town had been decimated by opioids. And he started to figure out that, you know, there was a way that he could sue these companies, saying that they were causing a public nuisance in these communities by flooding them with so many doses of drugs.

And so he started putting together a collection of lawyers and law firms around the country to sue the industry. And, you know, now there's, you know, 3,000, 4,000 lawsuits against these 24 companies. And Joe Rannazzisi is now the star witness in many of those suits. In fact, there was a big trial that took place last year, last fall, in Cleveland against Walgreens, Walmart and CVS. And Joe was the star witness in that case. And the plaintiffs prevailed in that case. And those companies are looking at hundreds of millions of dollars in fines stemming from that decision by that jury. So Joe is getting his day in court, I guess you could say.

GROSS: I just want to say, what's unique about this story in a lot of ways is that we're talking about marketing addictive substances. But the techniques used by the industry, do you think those are standard techniques with large, powerful corporations in terms of lobbying Congress and how they do it and how much influence they have?

HIGHAM: Yeah. You know, it is the way Washington works, Terry. I mean, I think most people think it's, you know, the political parties that run the show or it's the White House that runs the show. But it really is the - it is the companies that run the show, it's the companies and their law firms and their lobbyists on Capitol Hill and the members of Congress that they have, who are willing to write pieces of legislation to benefit their industry or to kill pieces of legislation that are going to be adverse to their industry. And this is kind of an age-old story.

The difference here is that people were dying by the thousands while these companies were lobbying members of Congress and paying them to look the other way and paying them to pass legislation and to lobby members of the Department of Justice and try to slow down the DEA's enforcement efforts. I mean, people were, you know - every day, you know, it's the equivalent of a 737 Boeing, you know, crashing and burning and killing everybody on board every single day. More than 200 people a day are dying from opioid overdoses. And so that's just a staggering number. I mean, can you just imagine if every day, you turn on the news and another airplane was going down? I mean, there would be an outrage over this mass casualty. So I think that's the difference.

GROSS: Well, let me reintroduce you here because we have to take a short break. If you're just joining us, my guest is Scott Higham, author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." He's a reporter for The Washington Post, where he's covered and investigated the opioid industry for five years. We'll be right back. I'm Terry Gross, and this is FRESH AIR.


GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with Scott Higham, a Washington Post reporter who has been investigating the opioid industry for five years. He co-authored the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." It's about the manufacturers, distributors and pharmacies behind the opioid epidemic. It's also about their lobbyists and lawyers, many who had close ties to members of Congress and high-ranking officials inside the Justice Department.

Part of your book is about an unprecedented lawsuit launched in 2018 by a coalition of lawyers and investigators on behalf of thousands of counties, cities and Native American tribes. As part of this lawsuit, the plaintiffs got access to thousands of formerly confidential documents and something called the pill database. What was the most damning evidence in this pill database? What was that?

HIGHAM: Well, this is something that, you know, we've been trying to get our hands on for many, many years, and it's called ARCOS. It's an internal DEA database that tracks the path of every single pill that is manufactured, distributed and dispensed in America. Every time you sell a narcotic or manufactured distribute dispenser narcotic, you have to report it to the DEA, and it goes into this database. And so we finally, you know, when these lawsuits started to proceed through the courts, they were all consolidated into this massive piece of litigation called a multidistrict litigation. It basically means that when you have hundreds of lawsuits pending around the country in different federal courthouses and they're all alleging the same thing, they all get consolidated into one case for efficiency.

And so during that procedure, the judge decided to allow the parties, the plaintiffs and the defendants to get access to this database. And he sealed it from the public. And at that moment, we filed a legal motion to intervene in the case and said, look, this is a public document. This is a public courthouse. These are public proceedings. And this is a public document. And we joined forces with the Charleston Gazette Mail. We filed motions. And we got these documents unsealed and the database. And the database kind of changed, I think, everybody's understanding of the opioid epidemic, because it showed exactly which companies manufactured how many pills, which companies distributed those pills, and which companies dispensed those pills in every single community. I mean, it was that specific. You can go all the way down to the county level and see exactly who was responsible for sending pills into your county, whether it's in Philadelphia or New York or Arizona.

And we saw that a hundred billion pills were manufactured, distributed and dispensed during the height of the epidemic, and that the largest manufacturer of those pills was not Purdue Pharma. It was a company called Mallinckrodt, which is a company we never heard of before. And Teva, which is - has since acquired a company called Actavis. Actavis also produced far more drugs than Purdue Pharma. And so we started to see the contours of this epidemic, the road map of this epidemic, who is responsible for how many pills.

And then the documents that we got unsealed - confidential emails, internal audits, internal memos, a storage document - you know, what the companies knew when they knew it, what they did about it or what they didn't do about it. And so it was revelatory, not only just to our newsroom, but, you know, we shared this data with news organizations around the country. And it was a - it was kind of a revelatory moment for us, you know, who have been investigating the opioid industry for quite some time now.

GROSS: You know, one of the themes, I think, in the documents that you got access to was how the priority for the pharmaceutical manufacturers and the distributors was selling the drug and selling as much of the opioids as possible with apparently very little regard to their addictive qualities and to the number of people overdosing. Sometimes they even had like a jokey attitude about it. Tell us something that was released in these previously confidential industry documents that you think is very revealing.

HIGHAM: Well, there is a guy named Victor Borelli, who was a national sales manager for Mallinckrodt Pharmaceuticals, the largest manufacturer of oxycodone in America. And he was known inside of the company by the nickname Ship, Ship, Ship. And his motto was sell, sell, sell. He was a very, very aggressive salesman. And one day, one of his customers, a drug distributor in Ohio, wrote to him because he was running low on oxy 30s and needed more from the manufacturer. So Borelli told this drug distributor that he had just shipped 1,200 more bottles of oxycodone, 30 milligram tablets, to his company to be distributed mostly in Florida. And drug distributor rep wrote back, keep them coming, flying out of here. It's like people are addicted to these things or something. Oh, wait - people are. And Victor Borelli wrote back, just like Doritos. Keep eating. We'll make more.

GROSS: What do you think the significance of that is? I mean, to me, it's an acknowledgement. People are addicted to these things, and we're going to keep selling them because, you know, the addiction is actually helping the industry sell more. And that's something we can joke about.

HIGHAM: Yeah, you know, it - Sari and I have been reporters - and this is a little embarrassing to say - collectively at The Washington Post for 60 years. You know, she has been here her entire career since she was an intern. I've been here for 22 years. And, you know, we've seen lots of dark things during the course of our careers, but nothing as dark as this, of making fun of people who are dying, of maximizing profits, knowing that the profits are coming in because of the addiction problem in the United States, and that it's getting worse, and that you're a part of it getting worse, that you're contributing to the epidemic. You are fueling this fire, and that people are dying all across the country, and it's a joke to you.

You know, Victor Borelli, you know, when we confronted Mallinckrodt with the set of emails, they issued a statement saying that, you know, Victor Borelli no longer works here, and he is not representative of our company. And, you know, we abhor this kind of conduct. And then we started getting these documents that were being unsealed after our legal action that showed that Mallinckrodt rewarded Victor Borelli year after year with bonuses, a lot of money, for the amount of drugs that he was selling. I mean, one year alone, he got, like, $120,000 on top of his salary. He won an award called the President's Club, which was a competition inside the company for the top-selling salesman, and he got a trip to the Caribbean. So they were very happy with Victor Borelli and his output at the time of the opioid epidemic. It was only after these emails came to light that they tried to distance themselves.

GROSS: I think we need to take another break here, so let me reintroduce you. If you're just joining us, my guest is Scott Higham, co-author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." He's been investigating the industry for The Washington Post for five years. He's a reporter there. We'll be right back. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Scott Higham, co-author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." He's a longtime reporter at The Washington Post where he spent the last five years investigating the opioid industry.

We've talked about parts of the opioid industry. Where do the pharmacies fit in?

HIGHAM: Well, so the pharmacies are at the end of the chain. This is supposed to be a closed system, right? So you start with the manufacturers, and then below them are distributors, and then on the retail level are the pharmacies. And so they have something called a corresponding responsibility, which basically means that if I go into a drugstore and I have an out-of-state license and a prescription written by a doctor from another state and I look like I'm a complete mess, they're under no obligation to fill that prescription. They can say that we - you know, we're not going to fill this. This is a huge red flag, and we're going to do our due diligence and make sure that this is not a - you're not a drug dealer. And they don't have to fill that prescription. But that's not what was happening.

There was a woman named Ruth Carter, who was a DEA agent, who Joe Rannazzisi, one of the main characters of our book, sends down to a couple of CVS stores in Sanford, Fla., 'cause they had seen numbers of massive amounts of pills going to these two CVS stores and two other independent stores in Florida - like, 11 million pills in a year. And it was just, like, off the charts. So, you know, Ruth rolls up into the parking lot, and she sees, like, you know, all these, you know, people hanging out in cars and out-of-state license plates. And they're doing drugs, and they're partying and, you know, urinating in the parking lot. And they're all lined up outside the door at CVS waiting for the pharmacy to open. And she just can't believe her eyes.

And she's, you know, a veteran DEA agent. And so she goes inside the store, and she asks to speak to the pharmacists in charge. And she says, you know, what is going on here, you know? And she's like, well, all these people are just waiting for the pharmacy to open. And she says, like, you know, well, don't you realize that all these people are, like - they're, like, drug addicts and drug dealers? And she's like, well, look, at 2 o'clock, we cut off all sales of oxycodone and hydrocodone. And Ruth said, well, why do you do that? And the pharmacist said, well, we want to save pain medication for our real pain patients. And, you know, she couldn't believe that the pharmacist had just told her this 'cause it was such a damning piece of evidence that she called over her supervisor 'cause she wanted, you know, a witness to this. And the supervisor came over, and the pharmacist repeated it, that, you know, she would cut off sales at 2 o'clock to save the pain medication for her real pain patients.

So, you know, CVS, Walgreens, Walmart, they all knew it was happening. And so the pharmacies are on the hook. And, you know, they have the deepest pockets of any of these companies. CVS, Walmart, Walgreens, these are huge corporations, and they just lost a very big trial in Cleveland in front of a jury that one of these attorneys, Mark Lanier, who's probably one of the top plaintiff's trials attorney in America, just won against them in front of a jury. And the judge right now is in the process of determining how much they're going to pay in fines. And it could be, you know, hundreds of millions of dollars in fines. I'm sure they'll appeal. But there are numerous cases going on right now across the country involving these pharmacies.

GROSS: What have the consequences been for the industry? There's been fines. There's been a lot of suits. But there haven't been any criminal convictions, no prison sentences. Are there any plans for criminal trials? Do you think that any of the companies could be held criminally responsible for any of their actions?

HIGHAM: You know, that's a really good question. And it's a question that, you know, the families that Sari and I have talked to over the years always ask. And Sari and I have been, you know, to West Virginia, Ohio, up in New England - places that have been really, really hard hit. And the families have that same question. I mean, I think that they believe that the fines, while, you know, are not that huge, are at least something and that the settlement money - and there's been a lot of settlement money put on the table so far. The - you know, Johnson & Johnson and the big three drug distributors have settled for $26 billion, which sounds like a lot of money.

And that money is going to go to drug treatment programs, etc., in some of these communities. But on the day that that settlement was announced, the share prices of all those companies rose by an average of 3%. So what does that tell you about how these fines and these settlements are affecting the bottom lines of these companies? It's not having an impact. When everything is said and done, you know, we're looking at maybe $30- to $40 billion that's going to be distributed to all of these communities that have been really hard hit by the epidemic. But when you talk to the families, they say, you know, where is the accountability? Where is the justice? This money is - it's almost like the cost of doing business, and it's not affecting them. They've not apologized. They've not said they've done anything wrong. And, you know, right now, there are 40,000 Americans who are in jail on marijuana charges. And not one executive of a Fortune 500 company involved in the opioid trade has been charged with a crime.

GROSS: Well, let me reintroduce you here. If you're just joining us, my guest is Scott Higham, a Washington Post reporter who's been investigating the opioid industry for about five years. He's the co-author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." We'll be right back after we take a short break. This is FRESH AIR.


GROSS: This is FRESH AIR. Let's get back to my interview with Scott Higham, co-author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." He's also a Washington Post reporter who has been investigating the opioid industry for five years. So what's left of the opioid industry now?

HIGHAM: Well, you know, you still have some manufacturers. You still have the distributors and the pharmacies. But there's - it's very difficult now to get pain medication, and it's almost impossible to find it on the black market. And so what this has basically done is created an enormous market for the Mexican drug cartels. They have seen a ready and willing market north of the border, millions of people who have been addicted to opium. And at first, the cartels started sending heroin into the United States. It didn't really catch on all that much. I mean, heroin's a pretty dirty drug. A lot of people don't like injecting drugs. And then the cartels figured out that fentanyl is a much cheaper, easier drug to manufacture. It's much easier to smuggle. And it's - you know, people who are hardcore users prefer fentanyl. It's 50 times more powerful than heroin. It's exactly the same high except more powerful. And you stay high longer. It's a lot cheaper. You don't come down as hard.

And so what the cartels have started to do is they've started to manufacture blue Oxy 30 pills with an M on one side and a 30 on the other. And they're counterfeit pills. They look just like Mallinckrodt's pills, except for they're fentanyl. And they're shipping them by the millions through the ports of entry on the southern border. And that is the pill that is now becoming the most predominant pill on the street, except for it's not Mallinckrodt, it's not oxycodone, it's fentanyl. And it's killing people like opioids have never killed people before. One hundred seven thousand people died in 2021 of opioid overdoses. And the vast majority of those were due to fentanyl. And the increases in the Black community and the Native American community are off the charts because what's happening in those places, particularly in inner cities - Philadelphia, Baltimore, New York, LA, Chicago - these used to be kind of heroin towns. And heroin has been basically replaced by fentanyl. And people are overdosing by the thousands.

GROSS: It's tragic that one of the consequences of cracking down on the opioid industry is that a more potent drug, a more deadly drug, has replaced the opioids, and it's coming from Mexico. You know, it's just like an unintended consequence of trying to control the opioid industry and and, you know, black market distribution of that.

HIGHAM: You know, I was just down on the border twice in the last couple of months talking to lots of federal agents and state agents, talking about, you know, the explosion of fentanyl and what they're trying to do to contain it. And, you know, they are beleaguered and really upset because they've dedicated their lives to protecting the public from drugs. And they're having a really hard time doing it. And if you talk to them, they'll tell you that this didn't need to happen. We didn't need to be here, that the guardrails were in place to prevent an opioid epidemic. And those guardrails were removed by the drug industry, by its lobbyists, by its allies in Congress and its allies in the Justice Department. And they are furious that now they are facing this monster that is literally just running rampant around the country. And they see no end to it. As one DEA agent I just talked to recently said, you know, we didn't get defeated by the drug cartels. We got defeated by the K Street cartel.

GROSS: So now that we have a fentanyl epidemic, is it harder to crack down on fentanyl because it's coming from Mexico and it's totally black market? You don't have, like, the prescribing doctors in the way you did for the opioid epidemic. This is like black market as if it were heroin. It's a huge challenge, Terry, because, you know, you only need a tiny bit of fentanyl to get the same kind of high as heroin or oxycodone. And it's very easy to smuggle. It's super cheap to make. And the cartel has figured out that if, you know, that they can manufacture using these pill presses that they have to manufacture pills that look exactly like U.S. pharmaceutical pills and then flood the United States with them.

And so, you know, drug agents and law enforcement all across the country are just inundated with these pills and with fentanyl powder. And they're not sure how they can stop the flow and the supply of fentanyl into the United States. And they feel that, you know, the most important thing to do right now is to educate the public in a way that the public was educated during the AIDS crisis with ACT UP, when people were dying left and right by drunk drivers and MADD stepped up - Mothers Against Drunk Driving - and changed the culture. There needs to be some kind of a sea change and cultural change because, you know, we're at the point now where, you know, you could go to a party and never come home. And this is a terrifying, terrifying time.

GROSS: Having done all this research, have you asked yourself what you would do if you were in severe pain from trauma or you suffered from severe chronic pain? Would you take painkillers?

HIGHAM: Well, you know, I would and I have. I had surgery on my neck, very painful surgery. And I was actually given fentanyl at Johns Hopkins. And it was the only thing that took away the pain. But knowing what I know, you have to be so careful. These drugs are - they work. They've been working for a thousand years, taking away pain. But they also are so highly addictive and so dangerous to play around with. And so people start off on, you know, a 5 milligram pill, which is basically what you get when you go, you know, get your teeth extracted or whatever or if you break an ankle. But that can quickly escalate to a 10 milligram, 20, 30, 40, 60, 80. I mean, Purdue Pharma at one point was making a 120 milligram pill, which is just incredible.

And so, you know, one of the guys who's in our book, Mark Zuban (ph), who was an all-star athlete who descended into this, he was taking 30 milligram pills three times a day and - just to function. And he could not stop. And here's a guy who was recruited by Ohio State University, top quarterback prospect, came from, you know, this great family of athletes. You know, his uncle played for the New York Giants. He, you know, he, you know, he had this amazing career ahead of him and it was destroyed. So I, you know, I see the lives destroyed and how easily they're destroyed, and I am just so careful when it comes to taking this kind of medication. And if it - if you're prescribed it, just be very, very careful.

GROSS: Well, Scott Higham, thank you so much for talking with us. And thank you for your reporting on this. You've been at it a long time and have uncovered a lot, so thank you.

HIGHAM: Great talking to you, Terry.

GROSS: Scott Higham is co-author of the new book "American Cartel: Inside The Battle To Bring Down The Opioid Industry." He's a reporter for The Washington Post. Tomorrow on FRESH AIR, we'll talk about how college went from being an affordable path to a better life to where we are now, with so many students and graduates saddled with college debt, unsure if their degrees will lead to a good job or a salary high enough to pay off the loans. We'll talk with Will Bunch, author of "After The Ivory Tower Falls: How College Broke The American Dream And Blew Up Our Politics - And How To Fix It." Join us.


GROSS: Our interviews and reviews are produced and edited by Amy Salit, Phyllis Myers, Sam Briger, Lauren Krenzel, Heidi Saman, Therese Madden, Ann Marie Baldonado, Thea Chaloner, Seth Kelley and Susan Nyakund. Our digital media producer is Molly Seavy-Nesper. Roberta Shorrock directs the show. I'm Terry Gross. Transcript provided by NPR, Copyright NPR.

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