Talk about blood money. The opioid crisis has touched so many people in this country. It is on par with the tobacco scourge that broke countless families over the past hundred years. But many people know where big tobacco started, due to the public nature of the corporations. But in the pain killer world, the main culprit is, by design, privately held — secretive and by all means as evil as Phillip Morris.
Name of the company is Purdue Pharma, and it’s owned by the Sacklers of NYC.
This is a long except. The entire article is a must read for anyone with an interest.
When the Met was originally built, in 1880, one of its trustees, the lawyer Joseph Choate, gave a speech to Gilded Age industrialists who had gathered to celebrate its dedication, and, in a bid for their support, offered the sly observation that what philanthropy really buys is immortality: “Think of it, ye millionaires of many markets, what glory may yet be yours, if you only listen to our advice, to convert pork into porcelain, grain and produce into priceless pottery, the rude ores of commerce into sculptured marble.” Through such transubstantiation, many fortunes have passed into enduring civic institutions. Over time, the origins of a clan’s largesse are largely forgotten, and we recall only the philanthropic legacy, prompted by the name on the building. According to Forbes, the Sacklers are now one of America’s richest families, with a collective net worth of thirteen billion dollars—more than the Rockefellers or the Mellons. The bulk of the Sacklers’ fortune has been accumulated only in recent decades, yet the source of their wealth is to most people as obscure as that of the robber barons. While the Sacklers are interviewed regularly on the subject of their generosity, they almost never speak publicly about the family business, Purdue Pharma—a privately held company, based in Stamford, Connecticut, that developed the prescription painkiller OxyContin. Upon its release, in 1995, OxyContin was hailed as a medical breakthrough, a long-lasting narcotic that could help patients suffering from moderate to severe pain. The drug became a blockbuster, and has reportedly generated some thirty-five billion dollars in revenue for Purdue.
But OxyContin is a controversial drug. Its sole active ingredient is oxycodone, a chemical cousin of heroin which is up to twice as powerful as morphine. In the past, doctors had been reluctant to prescribe strong opioids—as synthetic drugs derived from opium are known—except for acute cancer pain and end-of-life palliative care, because of a long-standing, and well-founded, fear about the addictive properties of these drugs. “Few drugs are as dangerous as the opioids,” David Kessler, the former commissioner of the Food and Drug Administration, told me.
Purdue launched OxyContin with a marketing campaign that attempted to counter this attitude and change the prescribing habits of doctors. The company funded research and paid doctors to make the case that concerns about opioid addiction were overblown, and that OxyContin could safely treat an ever-wider range of maladies. Sales representatives marketed OxyContin as a product “to start with and to stay with.” Millions of patients found the drug to be a vital salve for excruciating pain. But many others grew so hooked on it that, between doses, they experienced debilitating withdrawal.
Since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids. Many addicts, finding prescription painkillers too expensive or too difficult to obtain, have turned to heroin. According to the American Society of Addiction Medicine, four out of five people who try heroin today started with prescription painkillers. The most recent figures from the Centers for Disease Control and Prevention suggest that a hundred and forty-five Americans now die every day from opioid overdoses.
Andrew Kolodny, the co-director of the Opioid Policy Research Collaborative, at Brandeis University, has worked with hundreds of patients addicted to opioids. He told me that, though many fatal overdoses have resulted from opioids other than OxyContin, the crisis was initially precipitated by a shift in the culture of prescribing—a shift carefully engineered by Purdue. “If you look at the prescribing trends for all the different opioids, it’s in 1996 that prescribing really takes off,” Kolodny said. “It’s not a coincidence. That was the year Purdue launched a multifaceted campaign that misinformed the medical community about the risks.” When I asked Kolodny how much of the blame Purdue bears for the current public-health crisis, he responded, “The lion’s share.”
Although the Sackler name can be found on dozens of buildings, Purdue’s Web site scarcely mentions the family, and a list of the company’s board of directors fails to include eight family members, from three generations, who serve in that capacity. “I don’t know how many rooms in different parts of the world I’ve given talks in that were named after the Sacklers,” Allen Frances, the former chair of psychiatry at Duke University School of Medicine, told me. “Their name has been pushed forward as the epitome of good works and of the fruits of the capitalist system. But, when it comes down to it, they’ve earned this fortune at the expense of millions of people who are addicted. It’s shocking how they have gotten away with it.”
Before releasing OxyContin, Purdue conducted focus groups with doctors and learned that the “biggest negative” that might prevent widespread use of the drug was ingrained concern regarding the “abuse potential” of opioids. But, fortuitously, while the company was developing OxyContin, some physicians began arguing that American medicine should reëxamine this bias. Highly regarded doctors, like Russell Portenoy, then a pain specialist at Memorial Sloan Kettering Cancer Center, in New York, spoke out about the problem of untreated chronic pain—and the wisdom of using opioids to treat it. “There is a growing literature showing that these drugs can be used for a long time, with few side effects,” Portenoy told the Times, in 1993. Describing opioids as a “gift from nature,” he said that they needed to be destigmatized. Portenoy, who received funding from Purdue, decried the reticence among clinicians to administer such narcotics for chronic pain, claiming that it was indicative of “opiophobia,” and suggesting that concerns about addiction and abuse amounted to a “medical myth.” In 1997, the American Academy of Pain Medicine and the American Pain Society published a statement regarding the use of opioids to treat chronic pain. The statement was written by a committee chaired by Dr. J. David Haddox, a paid speaker for Purdue.
Richard Sackler worked tirelessly to make OxyContin a blockbuster, telling colleagues how devoted he was to the drug’s success. The F.D.A. approved OxyContin in 1995, for use in treating moderate to severe pain. Purdue had conducted no clinical studies on how addictive or prone to abuse the drug might be. But the F.D.A., in an unusual step, approved a package insert for OxyContin which announced that the drug was safer than rival painkillers, because the patented delayed-absorption mechanism “is believed to reduce the abuse liability.” David Kessler, who ran the F.D.A. at the time, told me that he was “not involved in the approval.” The F.D.A. examiner who oversaw the process, Dr. Curtis Wright, left the agency shortly afterward. Within two years, he had taken a job at Purdue.
Mortimer, Raymond, and Richard Sackler launched OxyContin with one of the biggest pharmaceutical marketing campaigns in history, deploying many persuasive techniques pioneered by Arthur. Steven May, who joined Purdue as an OxyContin sales representative in 1999, recalled, “At the time, we felt like we were doing a righteous thing.” He used to tell himself, “There’s millions of people in pain, and we have the solution.” (May is no longer working for Purdue.) The company assembled a sales force of as many as a thousand representatives and armed them with charts showing OxyContin’s benefits. May attended a three-week training session at Purdue’s headquarters. At a celebratory dinner following the training, he was seated at a table with Richard Sackler. “I was blown away,” he recalled. “My first impression of him was ‘This is the dude that made it happen. He has a company that his family owns. I want to be him one day.’ ”
A major thrust of the sales campaign was that OxyContin should be prescribed not merely for the kind of severe short-term pain associated with surgery or cancer but also for less acute, longer-lasting pain: arthritis, back pain, sports injuries, fibromyalgia. The number of conditions that OxyContin could treat seemed almost unlimited. According to internal documents, Purdue officials discovered that many doctors wrongly assumed that oxycodone was less potent than morphine—a misconception that the company exploited.
A 1995 memo sent to the launch team emphasized that the company did “not want to niche” OxyContin just for cancer pain. A primary objective in Purdue’s 2002 budget plan was to “broaden” the use of OxyContin for pain management. As May put it, “What Purdue did really well was target physicians, like general practitioners, who were not pain specialists.” In its internal literature, Purdue similarly spoke of reaching patients who were “opioid naïve.” Because OxyContin was so powerful and potentially addictive, David Kessler told me, from a public-health standpoint “the goal should have been to sell the least dose of the drug to the smallest number of patients.” But this approach was at odds with the competitive imperatives of a pharmaceutical company, he continued. So Purdue set out to do exactly the opposite.
Sales reps, May told me, received training in “overcoming objections” from clinicians. If a doctor inquired about addiction, May had a talking point ready. “ ‘The delivery system is believed to reduce the abuse liability of the drug,’ ” he recited to me, with a rueful laugh. “Those were the specific words. I can still remember, all these years later.” He went on, “I found out pretty fast that it wasn’t true.” In 2002, a sales manager from the company, William Gergely, told a state investigator in Florida that Purdue executives “told us to say things like it is ‘virtually’ non-addicting.”
May didn’t ask doctors simply to take his word on OxyContin; he presented them with studies and literature provided by other physicians. Purdue had a speakers’ bureau, and it paid several thousand clinicians to attend medical conferences and deliver presentations about the merits of the drug. Doctors were offered all-expenses-paid trips to pain-management seminars in places like Boca Raton. Such spending was worth the investment: internal Purdue records indicate that doctors who attended these seminars in 1996 wrote OxyContin prescriptions more than twice as often as those who didn’t. The company advertised in medical journals, sponsored Web sites about chronic pain, and distributed a dizzying variety of OxyContin swag: fishing hats, plush toys, luggage tags. Purdue also produced promotional videos featuring satisfied patients—like a construction worker who talked about how OxyContin had eased his chronic back pain, allowing him to return to work. The videos, which also included testimonials from pain specialists, were sent to tens of thousands of doctors. The marketing of OxyContin relied on an empirical circularity: the company convinced doctors of the drug’s safety with literature that had been produced by doctors who were paid, or funded, by the company.
David Juurlink, who runs the division of clinical pharmacology and toxicology at the University of Toronto, told me that OxyContin’s success can be attributed partly to the fact that so many doctors wanted to believe in the therapeutic benefits of opioids. “The primary goal of medical practice is the relief of suffering, and one of the most common types that doctors see is pain,” he said. “You’ve got a patient in pain, you’ve got a doctor who genuinely wants to help, and now suddenly you have an intervention that—we are told—is safe and effective.”
Keith Humphreys, a professor of psychiatry at Stanford, who served as a drug-policy adviser to the Obama Administration, said, “That’s the real Greek tragedy of this—that so many well-meaning doctors got co-opted. The level of influence is just mind-boggling. Purdue gave money to continuing medical education, to state medical boards, to faux grassroots organizations.” According to training materials, Purdue instructed sales representatives to assure doctors—repeatedly and without evidence—that “fewer than one per cent” of patients who took OxyContin became addicted. (In 1999, a Purdue-funded study of patients who used OxyContin for headaches found that the addiction rate was thirteen per cent.)
Within five years of its introduction, OxyContin was generating a billion dollars a year. “There is no sign of it slowing down,” Richard Sackler told a team of company representatives in 2000. The sales force was heavily incentivized to push the drug. In a memo, a sales manager in Tennessee wrote, “$$$$$$$$$$$$$ It’s Bonus Time in the Neighborhood!” May, who was assigned to the Virginia area, was astonished to learn that especially skillful colleagues were earning hundreds of thousands of dollars in commissions. One year, May’s own sales were so brisk that Purdue rewarded him with a trip to Hawaii. As prescriptions multiplied, Purdue executives—and the Sackler family members on the company’s board—appeared happy to fund such blandishments. Internal budget plans described the company’s sales force as its “most valuable resource.” In 2001, Purdue Pharma paid forty million dollars in bonuses.
The truth was that the dangers of OxyContin were intrinsic to the drug—and Purdue knew it. The time-release formula meant that, in principle, patients could safely ingest one giant dose every twelve hours. They could sleep through the night—a crucial improvement over conventional painkillers, such as morphine, which require more frequent dosing. One of Purdue’s initial advertising campaigns featured a photograph of two little dosage cups, one marked “8 a.m.” and the other “8 p.m.,” and the words “Remember, Effective Relief Just Takes Two.” But internal Purdue documents, which have emerged through litigation, show that even before the company received F.D.A. approval it was aware that not all patients who took OxyContin were achieving twelve-hour relief. A recent exposé by the Los Angeles Times revealed that the first patients to use OxyContin, in a study conducted by Purdue, were ninety women recovering from surgery in Puerto Rico. Roughly half the women required more medication before the twelve-hour mark. The study was never published. For Purdue, the business reason for obscuring such results was clear: the claim of twelve-hour relief was an invaluable marketing tool. But prescribing a pill on a twelve-hour schedule when, for many patients, it works for only eight is a recipe for withdrawal, addiction, and abuse. Notwithstanding Purdue’s claims, many people who were not drug abusers—and who took OxyContin exactly as their doctors instructed—began experiencing withdrawal symptoms between doses. In March, 2001, a Purdue employee e-mailed a supervisor, describing some internal data on withdrawal and wondering whether or not to write up the results, even though doing so would only “add to the current negative press.” The supervisor responded, “I would not write it up at this point.”
In testimonials collected by Purdue Pharma in 2001, pain patients praise OxyContin, but they also describe needing more than the recommended dose—once every twelve hours.
Doctors who prescribed OxyContin were beginning to report that patients were coming to them with symptoms of withdrawal (itching, nausea, the shakes) and asking for more medication. Haddox had an answer. In a 1989 paper, he had coined the term “pseudo-addiction.” As a pain-management pamphlet distributed by Purdue explained, pseudo-addiction “seems similar to addiction, but is due to unrelieved pain.” The pamphlet continued, “Misunderstanding of this phenomenon may lead the clinician to inappropriately stigmatize the patient with the label ‘addict.’ ” Pseudo-addiction generally stopped once the pain was relieved—“often through an increase in opioid dose.”
“When you promote these very massive doses of opioids, the more of it that is out there the more abuse there will be,” David Kessler said. “It’s almost linear.” U.S. sales of OxyContin soon exceeded those of Viagra. Everywhere the drug spread, addiction followed. To Steven May, the sales representative in Virginia, it seemed as if the problems associated with OxyContin were metastasizing, “like a cancer.”
