Art Van Zee—Russell Portenoy

Art Van Zee—Russell Portenoy describes a sharp disagreement over OxyContin, chronic-pain treatment, and who should bear the risk of addiction. At a 2002 Food and Drug Administration advisory hearing, Van Zee challenged the confidence with which influential pain specialists defended wider opioid availability. Portenoy, a leading figure in pain management, argued for meeting patients’ needs with more opioids; Van Zee asked what evidence could justify accepting addiction as a consequence. The disagreement was not simply between a cautious country doctor and a prominent specialist. It exposed competing ways of calculating medical benefit and collateral harm.

The hearing and its imbalance

Van Zee made an eight-hour drive to Maryland to testify before an advisory committee considering the FDA’s role in approving and overseeing narcotics. He wore his only suit and a Jerry Garcia necktie given to him by his mother. Across the table were Purdue executives and prominent pain-management experts; most of those experts acknowledged that they were or had been paid speakers for Purdue. Van Zee was outnumbered nineteen to one, and the experience was especially daunting for someone unaccustomed to public speaking.

Sue Ella Kobak accompanied him and remembered how carefully he prepared. Van Zee himself acknowledged his nervousness, but regarded speaking at the hearing as a responsibility. His approach contrasted with the scale and confidence of the opposition: he sought to state only what he could substantiate, rather than claim certainty beyond the evidence. That contrast mattered in a debate where advocates for expanded treatment invoked the widespread undertreatment of pain, while Van Zee insisted that the risks of a highly available drug also required serious accounting.

Portenoy and the meaning of risk

The next morning, Van Zee spoke with Russell Portenoy, whom the book identifies as the elder statesman of pain management. Van Zee asked what level of addiction risk Portenoy considered acceptable for OxyContin. He challenged reliance on the often-repeated estimate of less than one percent addiction, pointing out that it came from an old medical-journal letter and applied to a hospital setting, not to long-term treatment at home for chronic pain. His question concerned not just whether the figure existed, but whether it could answer the risk question being asked.

Van Zee also showed Portenoy a map of OxyContin distribution. It highlighted the overlap between elevated crime and drug abuse in places such as Lee County, Virginia, where OxyContin was prescribed at rates 300 to 600 percent above the national average. Portenoy responded that greater opioid availability would better meet chronic-pain patients’ needs. Their difference was therefore not over whether pain deserved treatment, but over what followed from that need: for Portenoy, greater supply could answer unmet demand; for Van Zee, distribution patterns and the possibility of addiction made supply itself a public-health question.

Van Zee then pressed the issue with a higher hypothetical risk: what if addiction occurred in five or six percent of patients? He asked what level of collateral harm would be acceptable if the result were tens of thousands of people with opioid addiction. Portenoy, exasperated by Van Zee’s insistence, walked away. The encounter gives the disagreement a concrete shape: a general assurance about treating pain met with a question about the number of people who might be harmed, and about whether that harm could simply be treated as an acceptable cost.

A challenge that continued

Van Zee continued raising related concerns at the end of the 2002 hearing, speaking with the committee’s chairman, Nathaniel Katz. He said he had spent months searching for studies that addressed the long-term risks of abuse among patients using painkillers. That search underscores the evidentiary problem at the center of his conflict with Portenoy: Van Zee argued that the reassurance then used to support opioid prescribing did not establish the safety of long-term use in ordinary home settings.

At the time, Van Zee’s judgment was questioned and mocked, and some observers dismissed him as a rabble-rouser or a kook. About a decade later, Portenoy conceded to Wall Street Journal reporters that he and other pain doctors had overstated the benefits of opioids while discounting their risks. This later acknowledgment does not make the two men’s positions identical, nor does it erase the imbalance Van Zee faced at the hearing. It does, however, place his demand for a fuller account of long-term risk in sharper relief: the questions he raised were not resolved by the authority of the experts who opposed him.

The larger stakes of the dispute

The book sets their disagreement against the geography of opioid prescribing and the unequal ways drug use was understood and addressed. In Roanoke, heroin had long been treated as an inner-city problem, while prescription opioids spread through other communities; the book also recounts that doctors prescribed painkillers to people of color at substantially lower rates than to white patients. These broader patterns do not reduce the exchange between Van Zee and Portenoy to a dispute about race or prescribing alone. They show why population-wide claims about benefit and risk required scrutiny: exposure to opioids, the likelihood of being viewed as a patient, and the consequences of drug enforcement were not evenly distributed.

The relation between the two physicians thus concentrates a larger tension in the account. Portenoy’s position emphasized the unmet needs of people in pain and the potential good of wider access. Van Zee asked whether that promise could be separated from the drug’s documented abuse potential, the high prescribing rates he mapped, and the possibility of addiction on a much larger scale than the reassuring estimate implied. Their exchange leaves the central question unresolved at the time it occurs, but makes the stakes unmistakable: when a treatment reaches far beyond the clinical setting in which its risks were first measured, the demand for relief cannot substitute for evidence about what wider use may cost.