High Wire is Maia Szalavitz's reported opinion column on drugs and drug policy.
Newly released documents in one of many opioid epidemic lawsuits filed against Purdue Pharma—and the Sackler family that owns the company—suggest a corporation as amoral as it is greedy. The release of the painkiller Oxycontin “will be followed by a blizzard of prescriptions that will bury the competition,” then-Purdue executive Richard Sackler is said to have boasted at a posh party to celebrate the drug’s 1996 launch.
By 2001, it was already clear that Oxycontin addiction and overdose were on the rise, according to the lawsuit filed by the Massachusetts Attorney General’s office. But that wasn’t the company’s fault, Sackler said, writing in an email: “We have to hammer on the abusers in every way possible…They are the culprits and the problem. They are reckless criminals.” The company also refers to people who misuse opioids as “junkies.”
We all want to play the blame game when it comes to addiction: When people we don’t care about become addicted, the problem is a lack of personal responsibility and moral weakness; if they are our friends or family members, suddenly, the real issue is the evil pushers, whether they be doctors, drug dealers, or foreign cartels. Addiction is complex—but sometimes some culprits are obvious.
Purdue pushed its product hard: the court documents include emails showing that Sackler pressured sales reps so intensely that some within the company tried to get him to back off, fearing his involvement ventured into illegality. Stat reports:
Sales managers were badgered on nights, weekends, and holidays, according to the filing. The marketing campaigns focused on high-volume doctors, who were visited repeatedly by salespeople, and pushed doctors to prescribe high doses. The demands on sales managers created such a stressful environment that, in 2012, they threatened to fire all sales representatives in the Boston area because of lackluster numbers.
And new evidence suggests that this marketing matters: a just-published study from JAMA Network Open found that as the number of opioid-related payments to doctors increased in each US county, so did the overdose death rate from prescription opioids the following year. Each statistical leap in the number of payments (or standard deviation if you want to get technical), was associated with an 18 percent rise in mortality, after controlling for other factors like income, age, and education.
With one in five family doctors receiving targeted opioid marketing (visits by sales reps, free meals, speaking payments) between 2013 and 2015, this could have had a serious impact on overprescribing. During those years, doctors across the country received more than 400,000 payments, totaling nearly $40 million dollars—and none of this money was funding research.
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The Purdue documents show just how relentless one company was in pursuing profit. According to the lawsuit, Sackler actually wanted to sell Oxycontin as “non-narcotic” in other countries because controlled substances cannot be sold as widely. He reportedly had to be talked out of it by the drug’s inventor, Robert Kaiko, who knew it was absurd to claim that an opioid didn’t have any addiction risk.
The suit also alleges that the company turned a blind eye when some of its “high-volume” prescribers turned out to be actual pill mills. One sales manager emailed a higher-up, saying, “I feel very certain this is an organized drug ring…Shouldn’t the DEA be contacted about this?” But Purdue waited another two years before contacting law enforcement, according to the prosecutors’ claims in the documents.
Purdue released a media statement Tuesday, which was summarized this way by the Washington Post:
...the memo vilifies “a single manufacturer whose medicines represent less than 2 percent of opioid pain prescriptions.” It “irresponsibly and counterproductively” claims all OxyContin prescriptions are dangerous, Purdue said, “substituting its lawyers’ sensational allegations for the expert scientific determinations of the Food and Drug Administration” and ignoring people in chronic pain.
“The complaint is littered with biased and inaccurate characterizations of these documents and individual defendants, often highlighting potential courses of action that were ultimately rejected by the company,” Purdue said.
The actions described in the documents are certainly not acceptable behavior for a company selling any drug to doctors, who need to use clinical judgment to choose the best drug or treatment for specific patients. It’s completely beyond the pale when it comes to selling substances with any addiction potential whatsoever.
But so far, in our attempts to wrestle money back from Purdue and other companies that have profited from the opioid crisis, tighter restrictions on marketing to physicians have not been enacted. Purdue voluntarily stopped sending out sales representatives to promote Oxycontin and other opioids last year—but why is that even legal in the first place?
I understand why activists pursuing lawsuits against Purdue don’t want to go there: if much of the marketing the company did was actually legal, that undermines their case and lessens the likelihood that they will get a big payout to help relieve the damage.
However, given how much sales pressure was put on doctors and given how important intense marketing seems to have been in expanding the supply, there is no excuse for the FDA not to simply ban marketing of any drug with addictive potential, period.
“State and federal legislation should be considered that limits opioid marketing, and these caps should not only consider the total dollar value of the marketing, but also the number of marketing interactions that take place between drug companies and doctors,” says Scott Hadland, lead author of the new study and a pediatrician and researcher at Boston Medical Center’s Grayken Center for Addiction, adding, “Our data suggest that such marketing could reduce inappropriate or excessive opioid prescribing, and thus opioid-related mortality.”
Moreover, “hammering” on “abusers” of drugs is a huge part of why we continue to have such chaos and so much death associated with addiction: The biggest barrier to effectively preventing and treating addiction is the stigma associated with the disorder, which is exacerbated by the criminalization of certain types of drug use and the use of judgmental language like the word “abuser.”
By seeking to shift blame away from its drug pushing onto the “reckless criminals” who misuse opioids, Purdue adds insult to injury. As the attorney general’s complaint says, “the stigma [Purdue] used as a weapon made the crisis worse.”
Seeing people with addiction as fundamentally criminal doesn’t help anyone: It leads to millions of dollars wasted on policing and incarceration that neither reduces supply nor affects demand and it distorts the medical system.
Criminalization means that doctors cannot treat addiction with medication—the most effective approach for opioids—without worrying about law enforcement peering over their shoulder and complying with massive amounts of paperwork. It means that physicians tend to reject people with addiction as patients and it creates a second-tier and largely non-scientific addiction treatment system segregated from the rest of medicine.
There are different rules once a patient is categorized as “addicted”—even severe pain can be disregarded and harsh treatment that would be seen as malpractice in other kinds of care is often routine. Worst of all, addiction is the only medical disorder for which medical abandonment—cutting off medications, expelling people from treatment for noncompliance—is not only not discouraged or seen as unethical, but is commonplace. And that means that misdiagnosed pain patients and people who have both addiction and pain are often just left in agony.
Shame on Purdue for trying to shift blame onto people with addiction. And shame on them for preying on the genuine suffering of pain patients. This company harmed people in pain first by co-opting their message about the genuine reality of under-treated pain—and then by lying about how long the effects of their drug lasted, and prescribing stronger doses when people said it wore off. Worse, many patients are now being made to suffer once again as the crackdown restricts even necessary and beneficial prescriptions.
Addiction is complex and the causes of the overdose crisis go far beyond the malicious behavior of one company. However, if we want a better life for people with addiction and with pain, we should decriminalize drug use—and criminalize the marketing of potentially addictive drugs by the pharmaceutical industry. Incarceration may not deter people with addiction, but the threat of prison and fear of imposition of fines large enough to truly damage a company are quite likely to concentrate the executive mind.
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