Painkillers
I have written previously about my game Painkillers, as it will be Hawk & Dove’s first published game, scheduled to come to crowdfunding in March or April of 2027. I have not, however, spent much time explaining what the game is about, and why I am choosing to make it the first game we bring into the world. I will write much more about the game in the coming months, but here I will introduce the game and talk a bit about where it came from.
In 1996, the Food and Drug Administration of the United States of America approved OxyContin, an opioid medication based on Oxycodone and made by Purdue Pharma, for prescription use in managing general and chronic pain. It was not unprecedented to have an opiate-based medication on the market — morphine had been commonly used for palliative and end-of-life care for nearly 100 years, and Purdue Pharma’s own morphine-based MSContin was approved in the 1980s. The shift with OxyContin was that the FDA opened it up for use to treat chronic pain, meaning doctors were suddenly allowed to prescribe this highly addictive substance to patients who might need to use it for years or decades. At the time, the addictive risks around oxycodone were not well known because the patients who had usually used it had never lived long enough to determine the effects of long-term use.
Purdue Pharma, led by the Sackler family, capitalized on this ignorance and launched a massive marketing and sales campaign to convince doctors that this new drug was safe to prescribe for long-term and chronic use, despite being an opioid. With the backing of the federal government’s approval, they were extremely successful. They were well on their way to achieving their goal of creating the world’s first billion-dollar drug. By 2001, OxyContin brought in nearly $3 billion in revenue, and by 2017, Purdue Pharma had collectively made close to $40 billion, making the Sacklers one of the 20 wealthiest families in the United States.
The effects on the public were felt almost immediately. By 1999, only 3 years after OxyContin hit the market, the national rate of death by drug overdose had doubled, and within a decade of its release it had quadrupled. These trends started early in Appalachia, a mountainous region in the Eastern United States characterized by a shared cultural identity cutting across multiple states. It is a place where working-class industries such as coal mining, logging, agriculture, and manufacturing have shaped many communities. It has historically been portrayed as plagued by poverty and low levels of education, and as a violent and lawless region full of feuding families, threats from the wilderness, and reckless behavior.
These perceptions and stereotypes made Appalachia a target for Purdue Pharma, which devoted significant resources to bringing OxyContin to market there first. Again, they were largely successful. Prescription rates in Appalachia were 40-50% higher than in other parts of the country, especially in the early years, and opioid addiction and overdose rates have remained 50-70% higher here throughout the epidemic. In Portsmouth, Ohio, seen as the epicenter of the epidemic in its early years, a single pill mill ordered nearly 500,000 doses of OxyContin in one year, for a town with a population of 20,000 people.
This is why I chose to focus Painkillers on central Appalachia, with West Virginia as its center. While OxyContin and its associated ills quickly moved to other parts of the country, it moved most quickly and dangerously through this section of the Eastern United States. And it was here that the epidemic was first noticed and acted upon by local and national authorities. In 2007, with enough evidence to indict Purdue Pharma and several of its high-level executives, John Brownlee, the US Attorney for Western Virginia, pursued legal action. However, with the help of some high profile representation led by one Rudy Giuliani, Purdue Pharma successfully worked the charges down to focus on their “misbranding” and excessive marketing of OxyContin. They paid a big fine, started working on “abuse-proof” formulations of the drug, and continued getting rich.
Even this slap on the wrist came too late. Purdue Pharma had set the roadmap for other pharmaceutical companies to exploit, and stronger opioids came onto the market. In the decade following the initial Purdue Pharma settlement, fentanyl entered the picture, and the rates of opioid addiction, overdose, and death skyrocketed. By 2017, in the United States, 70,000 people per year were dying by drug overdose, the vast majority of those opioid related. To date, nearly one million Americans have died from opioid overdose, and millions more have suffered from the effects of addiction.
This history is recent, and in many ways still ongoing. It is painful. It is political. It highlights many of the structural and systemic problems plaguing the United States in the 21st century — a broken and overly expensive healthcare system, a federal government more interested in being perceived as tough on crime than in caring for its citizens, a legal system easily corrupted by wealth, and a culture prone to stigmatize rather than empathize with people who need help with addiction.
Painkillers explores these systemic failures, forcing players into the uncomfortable position of acting as the pharmaceutical executives preying on people’s pain in order to amass billions of dollars. Your goal is to get rich, and in order to do so, you have to engage in this broken system. I think it is important to reinforce for players that these events didn’t just happen, that they were the results of choices made by human beings, made for their own benefit and with the full knowledge of the harm that was being done. My intent is for the mechanisms of the game to reinforce this feeling.
The basic mechanical structure of the game is straightforward. Players have two actions on their turn. They can either purchase a card from an ever-shifting market, or they can activate one of the departments in their company. Purchased cards slot into one of those departments, making it more effective and efficient when activated later. But they also carry risk — growing your company puts a bigger target on your back for the government, the activist community, whistleblowers, or the drug cartels. Any of these groups could exploit your weaknesses later in the game.
Activating your departments allows you to shape the game state, primarily helping you maximize your profits but also allowing you to mitigate any threats or damage you may suffer. Actions help build your economic advantage, reduce your risk of failure, or build your political connections. The department actions that involve interacting directly with the map, the primary way to improve your cash flow, result in an increased likelihood of a negative community response in later turns. This happens through bag-building. Those actions require you to put a corresponding community response token into a bag, from which each player draws at the end of their turn.
Early in the game, the majority of these tokens increase the rate of addiction in the states. As the game progresses, player behaviors shape the composition of the bag, and therefore the community’s response to the collective behavior of the table. Your HR teams hire salespeople into the market, increasing your revenue, but this increased presence draws the attention of the cartels looking to siphon off your business for themselves. Your marketing teams can grow the market in a state, bringing more patients into the field to be your customers, but this mobilizes more activists across the region. Your sales department can recruit doctors to sell your drugs exclusively, making you more money, but this will increase the likelihood of law enforcement poking their noses into your business later on.
Additionally, these community response tokens have icons that match those on the cards you have purchased to build up your company. If a token you draw matches an icon in your company, you will personally face the consequences of a more severe event. The risk you took on earlier by growing now morphs into real danger, for you and possibly for the entire table depending on the event. The only way to avoid this is through building your political connections strongly enough that you can cash them in at the right moment.
In this way, players occupy seats of power, in which they can control many things and make a boatload of money doing so, but they are not all-powerful. To some extent, players are at the mercy of the game’s systems, and they are caught up in the larger business in which they are complicit. Sure, you aren’t the one who created that pill mill, but the government doesn’t care because you are the pharma executive they can get their hands on. Maybe you didn’t do all that marketing in West Virginia, but you’re still here selling your drugs, so the activists are still happy to disrupt your operations.
Some players may not like the feeling of things happening to them in a game like this. But for me as the designer, this is a vital part of the experience. There is a collective responsibility to the work, and all players are fair game by virtue of their role in it. Painkillers doesn’t let you wriggle out of its grasp, no matter how well you think you’ve played. The game forces each player, and all players collectively, to confront the results of their business.
This is why I believe so strongly in Painkillers, and why I am publishing it as Hawk & Dove’s first game.
There is much more to discuss, which I will get to in later posts. Thanks for reading this far! I hope you found this interesting, and that you’ll follow the game’s journey. You can find some places to do so in the links below.
~Brooks
Painkillers on BGG
