This chapter explores the dynamics that fueled the opioid crisis in the United States, emphasizing the roles of overstories, superspreaders, and group proportions. Gladwell begins with an examination of the opium poppy’s historical significance and the development of its alkaloids—morphine, codeine, heroin, and oxycodone. Gladwell traces the evolution of oxycodone, highlighting its reimagining by Purdue Pharma as OxyContin, an extended-release formulation marketed aggressively to healthcare professionals.

Gladwell introduces the pivotal figure of Paul E. Madden, a 1930s California narcotics enforcer who implemented the triplicate prescription system. This system required doctors to use special prescription pads with three carbon copies for every opioid prescription, ensuring rigorous monitoring and reducing the potential for abuse. Madden’s initiative created an overstory—a prevailing narrative that framed opioids as dangerous and necessitated strict control. This overstory significantly impacted prescribing behaviors, particularly in states that adopted triplicate laws, leading to lower rates of opioid prescriptions and overdose deaths.

In contrast, non-triplicate states lacked such stringent regulations, making them fertile ground for Purdue’s marketing strategies. Gladwell discusses how Purdue Pharma leveraged insights from McKinsey & Company to identify and target “core” and “super core” prescribers—physicians who prescribed high volumes of OxyContin.