Previous Next

Chapter Nine: Overstories, Superspreaders, and Group Proportions

Chapter Nine analyzes the opioid epidemic by utilizing the understanding of superspreaders, overstories, and group proportions. The court testimony transcripts from the Introduction are reexamined. They are testimonies given by the Sackler family that started Purdue Pharma, who invented OxyContin. Gladwell provides a graph from a 2019 article that shows opioid overdoses in high-income countries from 1994 to 2015. The United States’ graph line rises steadily but then spikes in 2012. All other countries have far lower overdose deaths per hundred thousand, and many see declines in the 2000s.

Next, Gladwell provides the 2006 per capita volume of opioid prescriptions in each U.S. state. There are large disparities between the highest and lowest, with California, New York, and Illinois being at the low end of the scale. Gladwell attributes this to Paul E. Madden, the former director of the California Bureau of Narcotic Enforcement. In 1939, Madden convinced California to pass a bill that would require opioids to be prescribed on separate forms that had triplicate copies, so that the state government could have records of doctors and their prescriptions. The policy made doctors consider how often they prescribed opioids, since the government would be monitoring them. Other states adopted triplicate systems as well. On the opposite side of the narrative is a man named Russell Portenoy, a doctor who focused on pain management. Portenoy believed that most doctors would be able to discern which patients would be at risk of becoming addicted and should prescribe opioids whenever applicable. His campaign to support opioid prescription reduced the number of states that had triplicate systems down to five by the 1990s (which included California, Illinois, and New York).

For Gladwell, Madden and Portenoy represent two competing overstories. Purdue Pharma quickly realized that it was harder to convince doctors in certain states (the triplicate states) to prescribe vast quantities of their newest drug, OxyContin. OxyContin was oxycodone in a larger dose and designed for time release. After some market research, Purdue Pharma figured out that they should use their sales reps to push OxyContin in non-triplicate states, going so far as to claim that patients would not become addicted to it. Next, Purdue Pharma identified the superspreaders among the prescribers. They placed doctors into groups based on how many prescriptions they wrote per month and then focused on the top three groups, some 2500 doctors, who were writing hundreds of prescriptions per month. The highest-prescribing doctors often responded well to positive attention from Purdue Pharma sales reps, who visited such doctors several times per month.

Finally, Gladwell considers group proportions. When OxyContin was nearing the end of its patent and Purdue Pharma’s reputation was declining, OxyContin was replaced by OxyContin OP. It was the same drug but in a different form, which could not be crushed into powder and snorted. Many people believed that making OxyContin harder to abuse as a recreational drug would curb the abuse. Gladwell points out that epidemics are sensitive to shifts in proportions. People who were previously abusing and overdosing on OxyContin switched to heroin and eventually fentanyl. An unfortunate side effect of the shift was that heroin and fentanyl are rarely supplied by doctors or companies with proper safety standards. In recent years, drug overdoses have continued to rise, causing the deaths of more than 80,000 Americans in 2022. Gladwell closes by reiterating that epidemics are subject to rules. The tools to control epidemics can be studied and implemented. He believes we can let “the unscrupulous” take them, or we can pick them up ourselves to build a better world.

Previous section Part Three: The Overstory (Chapters Seven & Eight) Next section Full Book Summary & Analysis

Take a Study Break