I

n the latest sign of how the opioid crisis is permeating popular culture, the rapper Macklemore this week put out a remarkable new song about prescription painkillers and other addictive drugs.

Titled “Drug Dealer,” the song parcels out blame for an opioid crisis that kills 78 Americans a day, up fourfold since 1999. It forcefully calls out Congress (as doing the business of billionaire chiefs of pharmaceutical companies), drug companies (including OxyContin manufacturer Purdue Pharma), and doctors who prescribe potent painkillers and enable refill after refill. (In the song, featured artist Ariana DeBoo refers to a doctor as “my drug dealer” who “had the plug from Big Pharma”).

Macklemore, it’s worth noting, has spoken publicly about his own experience abusing the opioid painkillers OxyContin and Percocet. He released the song in conjunction with this week’s television premiere of an MTV documentary in which he interviews President Obama about the opioid epidemic.

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Read on for STAT’s annotations of Macklemore’s lyrics — which are peppered with references to the faces and drivers of the epidemic — and the backstory on the problem that’s “got a nation on the verge.”

They said it wasn’t a gateway drug
My homie was takin’ subs and he ain’t wake up

“Subs” is a reference to Suboxone, an opioid medication that’s used to treat opioid addiction. It’s become a key tool in combatting the opioid crisis; the Obama administration over the summer raised a prescribing cap to widen access to Suboxone and other buprenorphine medications.

But the drug has also been abused in and of itself, fueled by a vibrant black market and cash-only clinics that dole out the pills without proper counseling. The Centers for Disease Control and Prevention does not tally deaths caused by these treatments for addiction, but there have been plenty of reports of deadly overdoses from Suboxone.

Still, many addiction experts say the bottom line is that Suboxone saves far more lives than it takes.

The whole while, these billionaires, they caked up
Paying out Congress so we take their drugs
Murderers who will never face the judge

Hey, look, a (blistering) reference to federal lobbying made it into a rap song.

The makers of prescription painkillers wield significant clout on Capitol Hill and in statehouses all over the country. Over the past decade, they spent more than $880 million on federal and state lobbying, often seeking to block measures meant to curb the opioid crisis. That’s more than eight times what the gun lobby spent over the same period, according to a recent investigation from the Associated Press and the Center for Public Integrity.

Executives at two of the companies that have been blamed for fueling the opioid crisis — John Kapoor of Insys Therapeutics and members of the Sackler family of Purdue Pharma — are indeed billionaires.

And we dancin’ to a song about our face goin’ numb
But I seen homies turn gray, noses draining blood
I could’ve been gone, out 30s, faded in that tub

“30s” is a reference to what has become among the most vexing street drugs in the last few years: pale blue oxycodone pills, in a 30-milligram dose.

The opioid tablets typically go for $20 to $30 a pop on the black market, and people who get hooked later often turn to heroin. Law enforcement officials have recently reported a disturbing trend: Fake “30s” that look like oxycodone but actually contain far more deadly opioids, such as heroin or fentanyl.

That’s Prince, Michael and Whitney, that’s Amy, Ledger and Pimp C
That’s Yams, that’s DJ AM
God damn they’re making a killing

Macklemore’s recitation of the litany of celebrities whose deaths have been linked to prescription drug and alcohol use is a familiar one.

The most recent such example, and perhaps the most potent symbol of the opioid epidemic, is the musician Prince, whose autopsy indicated that he accidentally overdosed last spring on the powerful painkiller fentanyl. Prescription opioids were also implicated in the overdose deaths, spread out over the past decade, of the hip-hop executive known as ASAP Yams, the DJ known as DJ AM, the actor Heath Ledger, and the rapper known as Pimp C.

Alcohol or other non-opioid prescription drugs were blamed in the deaths of the singers Whitney Houston, Amy Winehouse, and Michael Jackson.

Now it’s getting attention ’cause Sara, Katey and Billy
But this shit’s been going on from Seattle out to South Philly
It just moved about the city
And spread out to the ‘burbs
Now it’s everybody’s problem, got a nation on the verge

Macklemore’s message here — that the opioid epidemic does not discriminate in the type of communities it ravages — is strikingly similar in vision (if not in language) to the alarm being sounded by the public health community and the Obama administration.

Just last week, in fact, the White House hosted Macklemore for a panel discussion on the crisis with federal drug czar Michael Botticelli.

While drug abuse has historically been clustered in urban areas, it’s clear that this epidemic doesn’t fit that pattern, though there’s little good data about the breakdown. Suburban and rural communities in many swing states, including Ohio and New Hampshire, face few more pressing issues than how to fight the epidemic.

The issue hasn’t come up so far in the presidential debates, though voters in some of the most devastated communities don’t think either Hillary Clinton or Donald Trump will save them.

Take Actavis off the market, jack the price up on the syrup
But Purdue Pharma’s ’bout to move that work

Here’s a somewhat opaque reference to a prescription opioid cough syrup, prominently abused in the hip-hop community a few years ago as a way of getting high. In 2014, the drug’s maker, then known as Actavis, pulled it from the market in response to the abuse, a move that sent the street price of the suddenly scarce drug through the roof.

And then, right before the chorus begins, there’s a reference to Purdue Pharma, which has been vilified for sowing the seeds of the opioid crisis by aggressively marketing OxyContin.

Dom Smith/STAT

My drug dealer was a doctor, doctor
Had the plug from Big Pharma, Pharma
He said that he would heal me, heal me
But he only gave me problems, problems
My drug dealer was a doctor, doctor
Had the plug from Big Pharma, Pharma
I think he trying to kill me, kill me
He tried to kill me for a dollar, dollar

The song’s haunting chorus, with vocals from DeBoo, holds doctors accountable for their role in fueling the opioid crisis. Research has demonstrated that widespread overprescribing of opioids for routine medical conditions got many people hooked and sent them down the path towards heroin.

It’s clear that pharma companies targeted doctors with aggressive sales pitches to get them to prescribe potent painkillers. Some of the marketing material deliberately downplayed the addictive nature of the drugs. A trove of pharmaceutical company documents uncovered by STAT, for instance, shows how sales representatives used dinners, gifts, and even doughnuts to sway doctors to switch patients over to OxyContin.

And these devils they keep on talkin’ to me
They screamin’ “open the bottle,” I wanna be at peace
My hand is gripping that throttle, I’m running out of speed
Tryin’ close my eyes but I keep sweatin’ through these sheets, through these sheets
Four horseman, they won’t let me forget
I wanna forge a prescription, cause doctor I need some more of it
When morphine and heroin is more of your budget
I said I’d never use a needle, but sure, fuck it
I’m caught up, I’m on one, I’m nauseous
No options, exhausted
This is not what I started
Walkin’ carcass, I lost everything I wanted
My blinds drawn, too gone to leave this apartment

Macklemore’s harrowing description of what it’s like physically to be dependent on opioids speaks to just how excruciating it is to get clean. Another survivor described the experience to STAT as “like you’re living in hell.”

Forged opioid prescriptions have also exacerbated the epidemic. Though there doesn’t appear to be good data on their prevalence, it’s widespread enough to have sparked interest in electronic prescription and spurred drug stores to adopt stricter policies to avoid filling such prescriptions.

Macklemore also gestures at some of the ways that prescription painkiller addiction can escalate. Take his reference to heroin: 80 percent of new users report that they got started on prescription painkillers. As for injection needles, sharing them can put users at risk of HIV.

Dom Smith/STAT

Death certificate signed the prenup
Ain’t no coming back from this Percocet
Actavis, Ambien, Adderall, Xanax binge
Best friends with the thing that’s killing me
Enemies with my best friend, there’s no healing me
Refilling these, refilling these
They say it’s death, death
Institutions and DOCs
So God grant me the serenity to accept the things I cannot change
Courage to change the things I can
And the wisdom to know the difference
And the wisdom to know the difference

While much of the concern is focused on opioids, addicts often use them in combination with other types of drugs — worsening the consequences. Sedative drugs like Xanax, known to scientists as benzodiazepines, are involved in nearly a third of accidental overdose deaths from prescription opioids.

The prescription refills that Macklemore references are another key driver of the problem. A study last year found that more than 90 percent of patients continued to get refills even after overdosing on opioid medications.

Five northeastern states have passed legislation aimed at limiting the number of pills doctors can prescribe. (Preliminary findings also suggest that increased awareness among doctors is helping stem prescriptions).

Macklemore concludes with a reference to the Serenity Prayer, which became a popular fixture at Alcoholics Anonymous meetings and has since migrated to recovery groups for opioid addiction. His new documentary, in fact, includes a scene at the Seattle recovery group that Macklemore attends, where the group recites the prayer.

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