When I saw the trailer for The Pharmacist it automatically caught my attention. As a chronic pain sufferer (fibromyalgia, subacromial pain syndrome), I’ve followed numerous new stories on the Opioid Crisis in the USA, and the impact of opiate abuse in general, having seen the effects of drug misuse up close. I was expecting an interesting documentary – as Netflix limited series have a good track record for well put together documentaries, even if they are not always especially deep dives into the topics involved. This however was something different. It was far deep, and while clearly solidly researched - this was also an incredibly gripping piece of film making. Warning for content discussing drug addiction. Misuse, overdose, death, and also minor spoilers of some details of the series below the ‘read more’.
The Pharmacist tells the story of Daniel Schneider, a Pharmacist in St Bernard, near New Orleans. It begins with his investigation of the murder of his son, Danny Schnyder, who was killed while buying drugs in the Ninth Ward of New Orleans. It then goes on, covering how Snyder’s investigation led him to become aware, through his work as a pharmacist, of the increasing abuse of the branded opioid painkiller Oxycontin. It then follows his attempt to close down a doctor who was prescribing unnecessary Oxycontin to patients – in effect selling prescriptions for cash.
So first a brief overview of the basic stuff. As is now largely expected from a Netflix documentary it is incredibly well put together – aided by the fact that Mr Schneider kept copious notes, audio and video tapes, of almost everything in his life. The documentary cuts between Snyder’s footage, some archive footage, and direct to camera monologues and interviews by Snyder, and others involved in the two cases the documentary covers. As is almost standard, the footage is backed by an immersive and evocative score which both compliments the visuals, and stands alone as excellent music. The music also helps the documentary maintain its sense of pace. From an audio-visual perspective, it is an excellent piece of filmmaking which takes several viewings to fully appreciate.
Before discussing the content, some personal background. I have suffered with chronic pain for years – initially it was believed to be the result of accumulated sports injuries – and in 2018 I was diagnosed with fibromyalgia. Between 2012 and 2015 I was prescribed co-codamol – a combination painkiller made up of codeine and paracetamol (acetaminophen). In 2015, to prevent further problems with my gastrointestinal system, I was moved onto buphrenorphine – a synthetic opioid – administered via a transdermal patch (commonly referred to as Butec, and referred to as ‘pain patches’). Buphrenorphine, a chemical cousin of morphine, is also used to treat opioid addiction, since it competes for the opioid receptors in the brain. Both drugs have a history of being used recreationally, but not to the same degree as other opioids such as tramadol for example, or morphine. In my own experience buprenorphine is the second most effective pain reliever I have ever had – the most effective being paracetamol delivered via an intravenous drip. While as a general rule I have always held a neutral attitude towards medication – for some people medication is appropriate and useful, for others not -
I personally have always been a reluctant user of pain medication. During my teens I was given strong painkillers for a sports injury – damage to my hip picked up playing rugby. I was only on the painkillers for a couple of weeks but at the end of the course I felt the withdrawal and was suddenly aware just how easy it is to become dependent. Partly inspired by the experiences of Johnny Cash I avoided pain relief unless absolutely necessary for years – until the pain from the fibromyalgia made it almost impossible to get out of bed. It was at this point that I began treatment. I have always attempted to make each step on the analgesic pyramid last as long as humanly possible. As it stands as I write this, I am on 15 mcg/h buprenorphine patches, along with Gabapentin which I am prescribed for a number of reasons including my brain injury – and which has some effect on nerve pain. I have felt the pull of addiction myself, and have seen addiction destroy the lives of several people close to me. Therefore the topic of opioid addiction is one which is both of particular interest, and particularly emotive.
The Pharmacist consists of four episodes. The first deals with the hunt for the killer of Danny Schneider, and how this led his father, the pharmacist of the title, to search the Ninth Ward of New Orleans, speaking to locals, residents, churches, and drug dealers. The background of the Ninth Ward – which became a hotspot for drug dealing, especially for users from St Bernard parish – is covered in some detail, including demographic changes, and the impact of the crack cocaine epidemic of the 1980s. Schneider admits that prior to his son’s death, he felt that those who died as a result of drug related crime bore responsibility for their own deaths, and acknowledges the hypocrisy of his position at the time. It is clear throughout how deeply he was affected by his son’s death – and he freely admits that both his investigations became obsessions for him. The second episode deals with the trial of Danny’s killer, and the aftermath. It also details Schneider’s early observations of the spike in opioid prescriptions, and his growing concerns. This is where the difference between the US and UK systems of healthcare becomes very clear.
In the UK Pharmacists have an equal duty of care to their patients – and act as a check and balance – and prescription monitoring has been standard practices for many years. In the USA at the time (late 1990s, early 2000s) prescription monitoring programmes existed in only some states, which made investigating over-prescription incredibly difficult. One DEA agent remarks that you could have a truck load of Oxycontin, and if you had the paperwork there was nothing anyone could do.
The documentary includes some material related to the development and marketing of Oxycontin, including interviews with a former sales rep for the company behind the drug – Purdue Pharma. The Opioid crisis was beginning. The third and fourth episodes deal with Schnyder’s campaign against a particular doctor, who he found to be running a ‘pill mill’ – prescribing large doses of Oxycontin and other drugs, mostly for cash. These ‘pill mills’ in effect were exploiting loopholes in the US healthcare system – making vast amounts of money. There is also some discussion of the Sackler family – owners of Purdue Pharma. Schneider also discusses some of the unintended consequences of the introduction of prescription monitoring in 2002 – a surge in heroin addiction as a result of people no longer being able to get hold of Oxycontin to feed their addiction. There is then a brief discussion of how Oxycontin led to a wave of heroin addiction as it was dealt with, which led to the subsequent rise in deaths as a result of the abuse of fentanyl.
The rise in heroin addiction as a result of prescription opioid abuse was covered in an episode of Last Week Tonight. It highlights the problem with marketing to doctors, and the methods used by some drug companies.
The whole series highlights important questions that needed to be asked about the attitude towards drug abuse, and how some companies have made vast profits, in effect from malpractice. The Sackler family name is familiar to certain sectors of the academic world – particularly in heritage and culture, since they have sponsored a large number of exhibitions and galleries. In the last few years there have been protests regarding their involvement, and a large cache of information about how much Purdue, and the Sackler family knew of the problems with over-prescription, and abuse, has become public. Last Week Tonight covered this in a second episode, detailing the depth of the involvement of the Sackler family.
The series, together with the background, raises so many questions, about marketing to doctors, about unethical practice in medicine, and in some senses the commercialisation of healthcare. As one sales rep for Purdue remarks the appropriate usage of the medication is not where the growth is. As John Oliver remarks in Last Week Tonight’s episodes – the areas for which strong opioid pain medication is considered appropriate, are limited markets. So where does the problem come from?
One aspect that is not addressed by either is simply the strength of over the counter painkillers in the USA. There are a number of strong codeine based medications which are available over the counter in the US which would be prescription only in the UK. This means that in some senses the baseline for non-prescription pain relief is one step above what it is in the UK. This means that people naturally become used to stronger over the counter pain medication before seeking treatment from doctors – meaning there is already to some extent a degree of habituation. There are concerns over prescriptions of opioid based pain medications in the UK, but it has so far not risen to the same degree. The nature of the US healthcare system, and particularly the lack of access to alternative therapies, and the higher level of over the counter pain medications, leads almost to a perfect storm in which drugs like Oxycontin become go to medications in areas where other alternatives are not available, and where pharmaceutical companies can make large profits from the system. The NHS in the UK in effect acts as something of a brake on this – by introducing greater levels of regulation. There are questions still open about the extent of abuse, about the driving factors, and about ethics in the pharmaceutical industry. It would be easy to conclude that the drive for profits, without regard for the impact, is a major factor – but there are also a number of social factors which need consideration – which are address to some extent in The Pharmacist.
On a personal level I believe opiate based pain medications have their place – but there needs to be a level of regulation, and space for evidence based alternative treatments such as physical therapy. The question which stands out is – To what extent are the pharmaceutical industry, and the owners of such companies, who we now know knew the existence of the problems, responsible for the crisis? And, given the number of deaths, what should be done? Should we punish the addicts (as the pharmaceutical companies have been known to push for), or the unethical providers of such medications, or on the producers, who knew how addictive the medication was? As Mr Schenider asks “What price have they paid?”
The documentary is gripping, thorough, and emotive. It is hard not to be caught up in Mr Schneider’s passion, as he declares that “I couldn’t save my son, but I might […] save some other kids…” The documentary attempts to remain objective, and includes a number of statements from public record by the companies involved. It raises important questions, and is incredibly thought provoking for anyone with any connection to pharmacology, medicine, and chronic pain.
