Prologue The Book of the Dead Dr. Fredric Hellman had long kept his own book of the dead. Slightly oversized and covered in blue cloth, it was the type of ledger that a bookkeeper might use to tabulate and balance accounts. In it, the medical examiner recorded every unexplained, mysterious, or violent death he worked on. He had small, meticulous handwriting, and every case entered into the book was accorded its own line. Running down the columns were identification numbers, dates, ages, sexes, autopsy findings, laboratory test results, and, finally, the cause of death. Hellman liked having all this data in one book because it helped him spot patterns. Toward the end of 2000 he noticed a new one emerging from death''s steady background noise.

In the small county south of Philadelphia where Hellman worked, a drug called oxycodone was turning up in the blood and urine of overdose victims. The oddly named chemical was actually legal. It was a painkilling narcotic long used as the active ingredient in a variety of prescription medications sold under names such as Percocet, Percodan, and Tylox. Hellman wasn''t a stranger to the drug. He typically performed about five hundred autopsies each year, and oxycodone would turn up in two or three. This year, though, was different. In just one month it had been found during four autopsies. By the time Hellman closed his ledger on 2000, the painkiller had been detected in connection with fifteen deaths, sometimes at toxic dosages, more frequently in combination with alcohol and other prescription drugs.

A state medical examiner in Roanoke, Virginia, some 360 miles to the south, was seeing the same thing. Dr. William Massello''s encounters with oxycodone, much like Hellman''s, had once been limited. But in 1999, the painkiller had figured in eleven autopsies. From there, the numbers had shot up like the line on a fever chart: the body count rose to sixteen in 2000 and to forty in 2001. It wasn''t just the death toll that was mounting. Linda Sullivan noticed that the faces of the dead were changing. Sullivan helped run a testing lab that did work for medical examiners throughout Florida.

She had long associated high oxycodone levels at death with older patients who had been given the drug to help ease their suffering from painful diseases such as cancer. But during the summer of 2000, many of those dying in Florida with the drug in their system were in their early twenties, an age group not generally associated with terminal illness or severe pain. Sullivan called medical examiners to ask a series of probing questions. Had investigators found prescriptions for painkillers containing oxycodone at the death scenes? Were doctors treating the overdose victims for pain? Time after time she got the same response: no. Soon others started asking similar questions. Over time their ranks would grow to include drug company executives, physicians, pharmacists, lawmakers, pain patients, cops, drug abusers, and kids just looking for a thrill. Together they formed an army of unknowing volunteers, each playing his or her part in a massive and unplanned public health experiment. It was an experiment that involved one of the most potentially addicting narcotics ever legally sold.

Its brand name was OxyContin. At its birth, OxyContin had been a pharmaceutical industry dream, a "wonder" that heralded a sea change in the treatment of pain. For more than a decade, a determined band of medical specialists had carefully laid the groundwork for the painkiller''s appearance by waging a campaign to draw attention to pain-mankind''s oldest and most persistent medical enemy. Outdated fears about the potential of narcotics to cause abuse, these pain warriors declared, were causing millions of patients to suffer unnecessarily. OxyContin was the answer to their pleas; it promised not only a better approach to pain relief, but a safer one as well. Soon, the drug''s producer made the painkiller the centerpiece of the biggest and most aggressive marketing campaign for a powerful narcotic in modern pharmaceutical history. Within just a few years of its launch in 1996, OxyContin was a blockbuster, with annual sales of more than a billion dollars. For a time it must have appeared that all the right stars had come into alignment.

The fight against pain had intensified and was seemingly being won. Vast profits and careers were being made. But the era of OxyContin also set into motion forces that were far from celestial. In fact, they had already gathered to form a perfect medical storm.