Like with many other public health crises, the opioid epidemic is frequently thought of as having just somehow happened, the result of a confluence of unintended consequences for which no single individual or corporation is really at fault but that must now be dealt with collectively. But journalist Christopher Glazek in a long article in Esquire magazine, traces how the secretive Sackler family, through their private company called Purdue Pharma in the US and Napp Pharmaceuticals in the UK that invented OxyContin, downplayed the risks of addiction and exploited doctors’ confusion over the drug’s strength and, helped create the opioid crisis. What they did was take the drug and market it as the salve for a wide array of problems, the same strategy they had used earlier to make Valium a huge marketing success.
Glazek recounts how opioids started becoming so widely prescribed.
The turning point, according to company lore, came in 1972, when a London doctor working for Cicely Saunders, the Florence Nightingale of the modern hospice movement, approached Napp with the idea of creating a timed-release morphine pill. A long-acting morphine pill, the doctor reasoned, would allow dying cancer patients to sleep through the night without an IV. At the time, treatment with opioids was stigmatized in the United States, owing in part to a heroin epidemic fueled by returning Vietnam veterans. “Opiophobia,” as it came to be called, prevented skittish doctors from treating most patients, including nearly all infants, with strong pain medication of any kind. In hospice care, though, addiction was not a concern: It didn’t matter whether terminal patients became hooked in their final days. Over the course of the seventies, building on a slow-release technology the company had already developed for an asthma medication, Napp created what came to be known as the “Contin” system. In 1981, Napp introduced a timed-release morphine pill in the UK; six years later, Purdue brought the same drug to market in the U. S. as MS Contin.
MS Contin quickly became the gold standard for pain relief in cancer care. At the same time, a number of clinicians associated with the burgeoning chronic-pain movement started advocating the use of powerful opioids for noncancer conditions like back pain and neuropathic pain, afflictions that at their worst could be debilitating.
To effectively capitalize on the chronic-pain movement, Purdue knew it needed to move beyond MS Contin. “Morphine had a stigma,” said Riddle. “People hear the word and say, ‘Wait a minute, I’m not dying or anything.’ ” Aside from its terminal aura, MS Contin had a further handicap: Its patent was set to expire in the late nineties. In a 1990 memo addressed to Richard and other executives, Purdue’s VP of clinical research, Robert Kaiko, suggested that the company work on a pill containing oxycodone, a chemical similar to morphine that was also derived from the opium poppy. When it came to branding, oxycodone had a key advantage: Although it was 50 percent stronger than morphine, many doctors believed—wrongly—that it was substantially less powerful. They were deceived about its potency in part because oxycodone was widely known as one of the active ingredients in Percocet, a relatively weak opioid- acetaminophen combination that doctors often prescribed for painful injuries. “It really didn’t have the same connotation that morphine did in people’s minds,” said Riddle.
A common malapropism led to further advantage for Purdue. “Some people would call it oxy-codeine” instead of oxycodone, recalled Lacouture. “Codeine is very weak.” When Purdue eventually pleaded guilty to felony charges in 2007 for criminally “misbranding” OxyContin, it acknowledged exploiting doctors’ misconceptions about oxycodone’s strength. In court documents, the company said it was “well aware of the incorrect view held by many physicians that oxycodone was weaker than morphine” and “did not want to do anything ‘to make physicians think that oxycodone was stronger or equal to morphine’ or to ‘take any steps . . . that would affect the unique position that OxyContin’ ” held among physicians.
Purdue did not merely neglect to clear up confusion about the strength of OxyContin. As the company later admitted, it misleadingly promoted OxyContin as less addictive than older opioids on the market. In this deception, Purdue had a big assist from the FDA, which allowed the company to include an astonishing labeling claim in OxyContin’s package insert: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.”
The theory was that addicts would shy away from timed-released drugs, preferring an immediate rush. In practice, OxyContin, which crammed a huge amount of pure narcotic into a single pill, became a lusted-after target for addicts, who quickly discovered that the timed-release mechanism in OxyContin was easy to circumvent—you could simply crush a pill and snort it to get most of the narcotic payload in a single inhalation.
A key step in the process was to make pain suppression an integral part of the metric used to measure whether the physician was effective, thus putting pressure on them to routinely prescribe heavy-duty painkillers.
Purdue did not invent the chronic-pain movement, but it used that movement to engineer a crucial shift. Wright is correct that in the nineties patients suffering from chronic pain often received inadequate treatment. But the call for clinical reforms also became a flexible alibi for overly aggressive prescribing practices. By the end of the decade, clinical proponents of opioid treatment, supported by millions in funding from Purdue and other pharmaceutical companies, had organized themselves into advocacy groups with names like the American Pain Society and the American Academy of Pain Medicine. (Purdue also launched its own group, called Partners Against Pain.) As the decade wore on, these organizations, which critics have characterized as front groups for the pharmaceutical industry, began pressuring health regulators to make pain “the fifth vital sign”—a number, measured on a subjective ten-point scale, to be asked and recorded at every doctor’s visit. As an internal strategy document put it, Purdue’s ambition was to “attach an emotional aspect to noncancer pain” so that doctors would feel pressure to “treat it more seriously and aggressively.” The company rebranded pain relief as a sacred right: a universal narcotic entitlement available not only to the terminally ill but to every American.
It wasn’t just that doctors were writing huge numbers of prescriptions; it was also that the prescriptions were often for extraordinarily high doses. A single dose of Percocet contains between 2.5 and 10mg of oxycodone. OxyContin came in 10-, 20-, 30-, 40-, and 80mg formulations and, for a time, even 160mg. Purdue’s greatest competitive advantage in dominating the pain market, it had determined early on, was that OxyContin lasted twelve hours, enough to sleep through the night. But for many patients, the drug lasted only six or eight hours, creating a cycle of crash and euphoria that one academic called “a perfect recipe for addiction.” When confronted with complaints about “breakthrough pain”—meaning that the pills weren’t working as long as advertised—Purdue’s sales reps were given strict instructions to tell doctors to strengthen the dose rather than increase dosing frequency.
Someone I know recently went through some surgery that required anesthetic. When she was discharged, she was told that when the anesthetic wore off, she might experience pain and was given a 30-day supply of pills to treat it. In fact, she did not feel much pain but worried that the lack of pain was possibly a bad sign! She did not take any pills at all but I can imagine that many people might simply take the pills because they feel they should.
As is often the case, these companies use bad science to advance their cause.
In 1986, two doctors from Memorial Sloan Kettering hospital in New York published a fateful article in a medical journal that purported to show, based on a study of thirty-eight patients, that long-term opioid treatment was safe and effective so long as patients had no history of drug abuse. Soon enough, opioid advocates dredged up a letter to the editor published in The New England Journal of Medicine in 1980 that suggested, based on a highly unrepresentative cohort, that the risk of addiction from long-term opioid use was less than 1 percent. Though ultimately disavowed by its author, the letter ended up getting cited in medical journals more than six hundred times.
As we have seen with the anti-vaccination movement, the negative effects of even a single bad paper can persist long after the paper has been discredited or withdrawn.
As was the case with tobacco, as health concerns led to a decrease in the sales of the deadly product in the US, the companies started expanding their operations overseas.
The American market for OxyContin is dwindling. According to Purdue, prescriptions fell 33 percent between 2012 and 2016. But while the company’s primary product may be in eclipse in the United States, international markets for pain medications are expanding. According to an investigation last year in the Los Angeles Times, Mundipharma, the Sackler-owned company charged with developing new markets, is employing a suite of familiar tactics in countries like Mexico, Brazil, and China to stoke concern for as-yet-unheralded “silent epidemics” of untreated pain. In Colombia, according to the L.A. Times, the company went so far as to circulate a press release suggesting that 47 percent of the population suffered from chronic pain.
In May, a dozen lawmakers in Congress, inspired by the L.A. Times investigation, sent a bipartisan letter to the World Health Organization warning that Sackler-owned companies were preparing to flood foreign countries with legal narcotics. “Purdue began the opioid crisis that has devastated American communities,” the letter reads. “Today, Mundipharma is using many of the same deceptive and reckless practices to sell OxyContin abroad.” Significantly, the letter calls out the Sackler family by name, leaving no room for the public to wonder about the identities of the people who stood behind Mundipharma.
Democracy Now had a revealing interview with Glazek about his article and about the way that two Republican congresspeople Tom Marino and Marsha Blackburn paved the way for the opioid epidemic to spread.
Joe Rannazzisi, who ran the DEA’s Office of Diversion Control, who later became a whistleblower and revealed what was going on, told the CBS new program 60 Minutes that he had never seen anything like the scale of this operation by the pharmaceutical industry to spread opioids and that they spread the drugs through various distribution networks.
JOE RANNAZZISI: What they want to do is do what they want to do and not worry about what the law is. And if they don’t follow the law in drug supply, people die. That’s just it. People die. … This is an industry that allowed millions and millions of drugs to go into bad pharmacies and doctors’ offices, that distributed them out to people who had no legitimate need for those drugs.
BILL WHITAKER: Who are these distributors?
JOE RANNAZZISI: The three largest distributors are Cardinal Health, McKesson and AmerisourceBergen. They control probably 85 or 90 percent of the drugs going downstream.
BILL WHITAKER: You know the implication of what you’re saying, that these big companies knew that they were pumping drugs into American communities that were killing people.
JOE RANNAZZISI: That’s not an implication, that’s a fact. That’s exactly what they did.
JOE RANNAZZISI: Pain clinics, overnight, popping up off an entrance ramp or an exit ramp on an interstate. Then, all of a sudden, there’s a pain clinic there.
BILL WHITAKER: Had you ever seen anything like that before?
JOE RANNAZZISI: Never. In fact, it was my opinion that this made the whole crack epidemic look like nothing. These weren’t kids slinging crack on the corner. These were professionals who were doing it. They were just drug dealers in lab coats.
Glazek says that too much attention is paid to the distributors and not enough to the compaies at the top of the chain who really direct things.
In my view, what you want to do when you look at the opioid crisis is look at where the real profits are. And it’s actually not with the distributors. It’s really with the manufacturers. And, you know, people kind of think they’re following the money. And McKesson and Cardinal are these huge, giant companies. But you really want to follow the margin, because that’s going to tell you who’s controlling a market and who’s kind of like a minor toll taker. And the fact is that the manufacturer, Purdue Pharma, which really created this market, created all this business for Cardinal and McKesson, etc., they had much more detailed information about where pills were going. They knew down to the prescription level, you know, what doctors were prescribing what. The distributors didn’t know that. The distributors—all distributors knew was about pharmacies. So they really are just one part of this giant chain. But Purdue had the aerial vision of the entire thing.
The Sacklers, like many extremely wealthy people who made their money by destroying the lives of others, give plenty of money to have their name associated with philanthropic causes and put on buildings and galleries and universities, to hide their disgusting role. If you hear the name ‘Sackler’, it is likely not for their association with the drug Oxycontin (which is carefully hidden) but because of their ‘philanthropy’ that has resulted in you seeing their name being used on buildings in universities, galleries, and so on, the standard method by which people who have made their wealth through the suffering of others polish their public images and remain ‘respectable’ members of society.