David Herzberg (1)

In White Market Drugs: Big Pharma and the Hidden History of Addiction in America, Dr. David Herzberg writes, “White markets… have been home to three major addiction crises in the modern era, far larger than any crises associated with illegal drugs” (pg. 2). Herzberg delineates these as the increase in opioid and cocaine sales in the early 1900s, the sales of pharmaceutical sedatives and stimulants from the 1930s to 1970s, and the increase in all three drugs after the turn of the twenty-first century. Herzberg argues, “these crises… all happened or the same reason: a presumption of therapeutic intent that left white markets with insufficient consumer protections. They were all also resolved through a similar set of policies, quite different from (and significantly more effective than) the punitive prohibitions of America’s drug wars” (pgs. 2-3). He further argues that this new historical lens “provides us with rarely consulted tools for” taking “seriously not just the dire risks but also the irreplaceable benefits of addictive drugs” that is “driven by the goal of consumer protection rather than ‘free markets’ or prohibition” (pg. 4). In his work, Herzberg endeavors to respect the perspective of drug and pharmaceutical consumers as well as the reformers, manufacturers, physicians, and regulators who typically dominate many drug histories. To this end, one of Herzberg’s central arguments is that, “most of the time, the division between medicines and drugs has not been effective. It has been an obstacle rather than an aid in protecting the public health” (pg. 11).

Describing the effects of late nineteenth-century moral reformers’ efforts and the Harrison Drug Act, Herzberg concludes, “the medicine-drug divide… was a self-fulfilling prophecy, creating the categories of consumer it had supposedly been built around” (pg. 44). He continues, “That white and informal markets looked so different owed more to their divided governance than to any clear distinction between the intentions, hopes, and worthiness of their consumers” (pg. 45). Herzberg works to identify how white markets developed, writing, “Differences in behavior between white and informal-market consumers reflected not innate moral or psychological differences, but the differential impact of drug reform. White markets became both safer and less publicly visible, while informal markets became both more dangerous and more visible” (pg. 50). Further, “White markets and informal markets were not, in fact, subjected to the same policies. Informal markets faced full prohibition; no distinctions were drawn between addicted and nonaddicted consumers. With few consumer protections, those markets continued to generate new cases of addiction at a relatively steady pace, dependent primarily on the vagaries of global commerce” (pg. 82).

Describing the effect of specific policy failings, such as with Bayer in the early twentieth century, Herzberg writes, “Heroin’s fate was a worst-case scenario of drug policy failure. White markets lost access to a useful, if minor, product. Meanwhile, prohibition did not eliminate informal market sales but simple ensured that those sales went relatively unregulated” (pg. 91). Similarly, “The FBN’s insistence on preserving moral simplicity by enforcing the stigmatizing ‘junkie’ paradigm led to years of delay in recognizing the addictive dangers of other, non-opioid drugs sold in medical market for use by more socially favored populations” (pg. 132). According to Herzberg, “Harrison-era drug reforms had successfully brought to an end any systematic approach to providing opioids to people with addiction. What remained were idiosyncratic instances of physicians choosing, for any number of reasons, to provide for one or perhaps a small handful of patients” (pg. 64).

Discussing the shift toward sedative and stimulant use in the postwar years, Herzberg writes, “Both physicians and consumers still hungered for ways to ease the ‘pains of existence’ in an increasingly fast-paced and rapidly changing society, and an economically and politically consolidated pharmaceutical industry still profited by encouraging and channeling that hunger toward psychoactive drugs” (pg. 135). Herzberg argues that the initial reluctance to classify tranquilizers as addictive resulted from the medicine-drug divide that developed in the late-nineteenth and early-twentieth centuries. He writes, “The moral panic surrounding narcotics had already built race and class prejudices into crucial concepts like ‘addition,’ making it difficult to apply to consumers for white market drugs like barbiturates” (pg. 136). Herzberg further argues, “Reform became possible only after significant social and cultural changes reconfigured the political landscape in the 1960s.” He divides the changes into consumer advocacy and the increasing power of “medicalizers who believed that addiction was an illness to be treated rather than a moral failing to be punished” (pg. 187). These medicalizers saw “informal-market consumers in a more sympathetic light and push[ed] to give at least some of them access to white market drugs such as methadone” (pg. 192). Herzberg links this change to civil rights activists dismantling the racial segregation underpinning the medicine-drug divide as well as increasing usage of marijuana and heroin among young white suburbanites. Examining physicians who strained the regulatory system, Herzberg traces the career of Dr. C, an accomplished physician whose “longevity highlights an important aspect of pharmaceutical gray markets. They were disreputable and did not meet professional standards of care, but because of the difficulty of drawing clear and fast boundaries around therapeutics, they still enjoyed many of the protections of the medical enterprise” (pg. 228).

In his final chapter, Herzberg traces the deregulation of the 1980s that undid much of the careful balance achieved by reformers and politicians in the 1970s, eventually paving the way for Purdue Pharma to market and distribute OxyContin (pg. 278). He concludes of these events, “Allowing pharmaceutical companies free rein is one form of inadequate market regulation. Punitive prohibition is another. They are, as we have repeatedly seen, two sides of the same coin, delivering the same result: insufficient protection for consumers” (pg. 278). Herzberg concludes, “The twenty-first century’s twin crises are just the most recent, severe manifestation of this recurring problem with America’s divided approach to drugs and addiction. To repair and prevent this destructive cycle, I argue, requires knowing and then transcending the history that has built it” (pg. 12). Despite seeming like nothing changes, Herzberg highlights moments when change occurred on the local scale or how programs like needle exchanges show how similar activism and policy changes might make a difference. He argues that the current medical marketplace hinders change, however, writing, “Profit-driven drug markets follow a predictable damaging cycle. Companies hype new medicines as safe and beneficial and sell with insufficient regard to consumer safety; a health crisis ensues as consumers are left ill equipped to make informed decisions; authorities respond with consumer protections and destructive drug wars; the pharmaceutical industry devises strategies to circumvent the new restrictions and start the cycle over again” (pg. 287).

Herzberg’s White Market Drugs offers invaluable insight into the history of drug regulation in the United States over the long twentieth century and into the twenty-first century. He demonstrates how racial attitudes informed policy decisions while the profit-motive of companies clashed with medical decisions, leading to a perfect storm in which consumers failed to receive adequate protection while private companies and punitive policies damaged lives. The work is especially timely as it reveals the tipping points in drug use in the United States where the balance between manufacturers, policy makers, and consumers was almost even and how it was upset in each case. This points out ways in which new ideas might create a more equitable society through new drug policy.… (meer)

If there had been a television in every home around WWI, there would have been a commercial that said “Ask your doctor if Heroin® is right for you.” Because Heroin was a registered, trademarked and readily available prescription drug from Bayer. All throughout the 20th century, drug companies were finding or inventing narcotics to swell their profits. In David Herzberg’s White Market Drugs, the history of legal drugs in America is that of solutions in search of problems, all while addicting and killing customers. If they made it, Americans would take it.

It is a history of failures. Government failed to regulate industry. Industry failed to provide safe products. Regulation caused the explosion of informal markets, where “dope fiends” could purchase illegal drugs from “peddlers”. And along the way, customers became addicts. They overdosed; they became criminals to raise cash for their addictions. The white markets were organized and legal, but they were populated with crooked doctors, crooked pharmacies and crooked manufacturers, making them no better than the black markets, where the working classes got their drugs. Herzberg positions it as three major drug crises, all of which were far worse than the illegal drug trade the government was (and is) constantly trying to stamp out. From opium and morphine, through barbiturates and (back to) opioids, Americans flock to their doctors and pharmacies in the white markets for their addictions. For those who can’t afford it, they flock to prison because of their purchases in the black markets. As Herzberg puts it: “Treating consumers like criminals…had been a self-fulfilling prophecy.”

The book is therefore not about marijuana, cocaine, amphetamines and ecstasy. It is about good, clean, authorized prescription drugs, addicting their users into poverty and death if prison doesn’t grab them first.

All through the book there are some disgusting commonalities. Drugmakers love hairsplitting. It was and is their way of differentiating themselves from the competition and from past failures. We are probably most familiar today with the hairsplitting over addiction. According to the makers of opioids, they are no longer addictive! This has been said repeatedly over the past 150 years, and it is no more true today than it was then, but they keep making this same false claim. And doctors keep falling for it.

The current malaise began in the 1980s, when researchers decided to split hairs over the addictiveness of opioids, in particular for oxycodone, a resurrected opioid from the 1940s. In denying the addictiveness of the drug, their studies instead said things like: “A set of aberrant behaviors marked by drug-craving, efforts to secure its supply, interference with physical health or psychosocial function, and recidivism after detoxification.” (But never addiction.) They called addiction to opioids “Pseudo-addiction” – it was a sign the patient needed more opioids! (But never addiction.)

Incredibly, the medical community bought into this obviously fake news, and doctors all over the country fell for the pitches of the sales reps from the opioid makers. My own dentist assured me it was a non-addictive pain killer when he prescribed oxycodone for me. Even though it didn’t pass the smell test.

This all came from the bizarre and misguided policies the government developed at the turn of the previous century. Opium and morphine were the fashionable drugs of the era. White women in particular sought solace in morphine. It combatted a make-believe illness doctors called neurasthenia – the stress of being a weak, delicate white woman in the Victorian era when women could do pretty much nothing but fret.

Congress and the government moved to split the pills in two; there were medicines and there were drugs. The medicines were to be regulated by the Food and Drug Administration (FDA), while drugs fell under the purview of the Federal Bureau of Narcotics (FBN). Didn’t matter that both compounds had their own medicinal properties, that customers couldn’t tell the difference between drugs and medicines, and that both could be obtained on the street regardless. For legal purposes, two whole bureaucracies were needed to keep them separate.

But in those days, there wasn’t much need of the street anyway. Doctors freely prescribed narcotics for all comers, starting with themselves. Many patients later claimed to have no idea what was in their meds. Even as laws were promulgated to control the distribution, huge prescribers of narcotics and huge purveyors (pharmacies) distributed them. A hundred years later, the USA once again found a Pareto distribution: 20% of the doctors did 80% of the prescribing of opioids, and 20% of pharmacies sold 80% of the pills. Even though they were both required to log their activities and even though they were required to report outsized quantities to the regulators, the money was just too good. Instead of reporting , they upsized to accommodate the demand.

Herzberg points to Demerol, a 1939 opioid that was entirely synthetic – the first of its kind. It was the first opioid not to be derived from opium. Winthrop, the drugmaker, claimed this made the drug non-addictive, and produced and sold massive amounts of it. It fought the government tooth and nail to keep the money pouring in. Its in-house magazine for sales reps touted not the efficacy, but rather the easy money it brought. It was not until 1962 that the FDA got the right to demand proof of efficacy for white market meds.

Although it is a very complex tale that Herzberg tells, there are some threads that flow all the way through. The drugmakers were always pushing to distribute more, without regard to need or harm. They were all over free samples of narcotics, even a hundred years ago. Anything to get someone hooked, starting with the doctor. They continually lied about the properties of the drugs. They fought off any kind of regulation. The drugs themselves were discoveries rather than purposeful. They were solutions in search of a problem. The drugmakers marketed them as the cure for all kinds of conditions that were simply not true. These all-purpose cure-alls went through little or no testing, not even for safety. Nonetheless, doctors bought in, hook, line and sinker.

Herzberg takes readers on a grand tour, explaining the development, marketing and effects of numerous drugs readers might or might not be familiar with. Their names are legion: opium, morphine, Heroin, codeine, Quaaludes, psychotropics, Dilaudid, Valium, Darvon, Demerol, Ritalin, methadone, OxyContin, Percodan, Darvon, Fentanyl and many others that could bring back fond memories for many Americans.

The federal government twisted and contorted itself in its efforts to control narcotics. In 1914 it passed the Harrison Act, which as was a tax law, not a narcotics law. It creatively required healthcare professionals to register and pay a tax on any narcotics they handled. Since only professionals could register, anyone in possession of narcotics who therefore could not have paid the tax was automatically a criminal for tax purposes. There were battles over interpretation, the usual spate of lawsuits, and a constant battering of its objectives and performance from within. Eventually, it seemed to have been simply outcompeted by new laws and agencies the government kept creating. For example, the government developed a bizarre benchmark: if a drug was less addictive than codeine, it would be regulated by the FDA. If it was more addictive than codeine, it would be regulated by the Harrison Act and the FBN. As Herzberg says, the government spent the 20th century arguing whether addiction was a disease or a crime. It was so contorted, the Sheriff of Alma Georgia admitted to taking narcotics, but by prescription, because he said, getting them from peddlers would be illegal.

With such confusion and doubt, gaps and loopholes big enough for caravans of drugs to drive through became the story of legal addiction in the USA.

There has just always been a white market for drugs that kill in the USA. Americans, Herzberg says, are drug-seeking rather than health-seeking. In 1954, barbiturates (for sleeping) were all the rage. They made up one in every six prescriptions (not including illegal otc sales which the FDA estimated brought them u to 50% of total sales). In the 1970s it was Valium, followed by Quaaludes. 5% of men and 10% of women were regularly using Valium in the early 1970s.

The whole business of the “War on Drugs” started by Nixon in the early 70s has been a horrific diversion of funds against a smaller black market, when right in front of everyone, the white markets were killing and continue to kill customers by the tens of thousands. Nixon was following in the steps of Lyndon Johnson, who began the new trail of pursuing illegal dealers and their customers instead of the big drugmakers and the doctors they compromised with their misinformation. “The history of American drug policy offers precious few success stories,” Herzberg says in an understatement worthy of Churchill. More realistically, he later calls it a white market apocalypse.

In a final touch of irony, the drug laws of the United States are so weak they could not stop makers like Purdue Pharma from producing, marketing and cashing in on opioids, fraudulently posing as non-addictive painkillers. Nonetheless, their customers went to prison. Doctors, pharmacists and patients continue to be sentenced to long prison terms for their roles in the disaster. The D.A.R.E. program in schools gets kids to snitch on their parents, putting them in prison and making the kids wards of the state, sent to foster homes where they are drugged to keep them passive. It is a suitably bizarre outcome for a perverse cobweb of rules and regulations targeting the wrong objectives, badly.

David Wineberg… (meer)

In Happy Pills in America: From Miltown to Prozac, David Herzberg argues, “The meteoric rise of tranquilizers and antidepressants signified broader developments in American society after World War II: the commercialization of medicine and science, the embrace of psychology and self-fulfillment as a political language, intensified campaigns to police social groups through drug regulation, and social movements organized in part around new concepts of identity” (pg. 3-4). He uses the tools of race, class, and gender in his examination. Herzberg begins with the modern commercialization of medicine in the postwar years and the rise of tranquilizers such as Miltown, directly marketed to doctors and patients. From there, Herzberg examines the social impact of tranquilizers on the postwar gender dynamic before unpacking the drug wars and the federal scheduling of tranquilizers. He concludes with the role of manufacturers of Paxil and modern antidepressants in filling the position once occupied by tranquilizers, but with a nuanced approach designed to address and move past the lingering stigma of tranquilizers.
While Herzberg examines the role of race and class, gender stands out in his analysis. He writes of the work of Miltown advertisers, “It was these images that helped circulate influential new biological narratives of masculinity” (pg. 48). Critics of tranquilizers later viewed them as “women’s drugs,” but Herzberg demonstrates how they served to combat fears of weakening masculinity in the postwar years (pg. 49). For this, he builds upon the studies of neurasthenia, a condition Gail Bederman examined in her monograph, Manliness and Civilization. Advertisers of Miltown and other tranquilizers suggested the drugs would help patients return to traditional gender roles and thereby cure their anxiety, but feminists argued the medications served to cover-up the issue that created anxiety – social inequality. Attempts to impose federal oversight over tranquilizers faced difficulty due to an incomplete model of addiction, but changing attitudes and new concepts of masculinity eventually made this possible (pg. 111). Women who worked to expose the dangers of tranquilizers did so in a manner that privileged middle class white women. While their work helped encourage patient activists, it was a product of its time (pg. 148). In response to this, manufacturers of Prozac portrayed it “as a ‘feminist drug’ that made women more assertive and competitive – ‘supermoms’ with careers who laid to rest images of Valium-stoned stat-at-home wives” (pg. 177).
Herzberg’s work uncovers the role of modern commercialized medicine in shaping all aspects of society, from gender to criminal law. Without postwar consumer culture and second-wave feminism, along with nineteenth century psychological theories and medicine, modern pharmaceuticals would not play the role they currently occupy in society. Most importantly, Herzberg demonstrates how people orchestrated and shaped these events rather than portraying them as occurring spontaneously.… (meer)