This week the State of Colorado launched a lawsuit aimed at the maker of Oxycontin, Purdue Pharma. I’ve blogged a few times about just how insane the late 1990s through 2000s were during the narcotic-prescribing free-for-all that began with Oxycontin. I still remember the pushy sales rep from Purdue Pharma. I also recall that once the prohibition on physicians freely prescribing high-dose narcotics for pain was broken, the floodgates opened, and this caused the opioid crisis. Let me explain.
The Colorado attorney general’s office in its lawsuit stated that Purdue Pharma “downplayed the risk of addiction associated with opioids,” “exaggerated the benefits,” and “advised health care professionals that they were violating their Hippocratic Oath and failing their patients unless they treated pain symptoms with opioids.”
The most bizarre thing for me as a practicing doctor during this time and getting hit up frequently by the Purdue Pharma sales rep is that reading this statement this morning was déjà vu. Meaning, this is exactly what Purdue’s sales rep did. Let me explain.
What Is Oxycontin?
Oxycontin was an evil stroke of marketing genius. Why? Rather than creating a new narcotic drug and having to go through new clinical trials, Purdue simply took an existing drug (oxycodone, or the stuff that makes up a Percocet) and jammed loads of it into a pill with new delayed-release binder. Hence, getting it approved by the FDA was simply demonstrating what the binder and narcotic did to patients, as the base drug was presumed to be effective.
The problem with Oxycontin is that it can pack as many as 16 Percocet pills worth of oxycodone into a single pill. This made it a perfect drug for diversion by addicts as a handful of Oxy tablets was more powerful than any heroin hit. In short, you couldn’t design a better drug for abuse.
Downplaying the Risk of Addiction
It’s been said that the entire opioid crisis began with one sentence: “Delayed absorption as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” This was allowed by the FDA to be on the package insert and marketing materials for Oxycontin. The problem? It was never true.
I remember my Purdue sales rep telling the doctors in my office this very statement. The delayed absorption of this stuff is what made it safe and “addiction proof.” The problem? We had seen many patients who were clearly addicted to it.
How could Purdue create the perception that Oxycontin was safe despite what doctors knew to be true? First, while it marketed to pain doctors, most of us knew that what Purdue was selling was not true. Hence, in an evil stroke of marketing genius, Purdue began focusing on getting opioid-prescribing naive family physicians comfortable with prescribing this stuff. In fact, in 2001 alone, Purdue spent 200 million on marketing! By 2003, because of this primary-care marketing focus, more than half of all prescribers of Oxycontin were family doctors rather than more-experienced pain management physicians.
So how did Purdue craft its message that dramatically underestimated the risk of addiction? The number we were told by our rep was that Oxycontin only had a 1% chance of creating an addict. To get this manufactured number, Purdue cited studies where narcotics were only used for acute pain and not chronic pain (the area where Purdue was pushing Oxycontin). In 2007, Purdue and its executives pled guilty to misleading doctors.
Purdue Opened the Floodgates
One of the reasons I’m happy to see this Colorado AG lawsuit is that in a very real way, Purdue opened the floodgates. By convincing a generation of family doctors that it was their moral obligation to treat chronic pain with opioids, they lit the bonfire that became the opioid crisis. In addition, the sales reps also pushed a philosophy to increase the dose of Oxycontin until the patient was out of pain. Hence, what began as 10mg of Oxycontin (the equivalent of two Percocets) soon escalated to 20mg, 40mg, and, finally, 80mg.
In addition, the financial success and blockbuster drug status of Oxycontin inspired many copycat narcotic drug plays, which was like throwing gasoline on the bonfire of the opioid crisis. As an example, we soon saw the fentanyl lollipop (Actiq). This little diabolical drug concoction made Oxycontin look like M&M’s. I watched as more than half of our patients who had chronic pain and who were given Actiq for post radiofrequency procedural pain couldn’t ever get off of the narcotic-laced candy.
Adding Insult to Injury
There’s a scene in HBO’s Breast Men that describes what just happened this week with the Sackler family and Purdue Pharma. The movie follows two plastic surgeons who developed silicone breast implants through the high times and then the low times of women reporting illness. At the end of the movie, one of the doctors has now created a new practice removing the silicone implants and inserting saline ones. A woman who is having a consultation to have her implants removed asks, “So let me get this straight, you charged me a bunch of money to put these in, they made me sick, and now you want to charge more to take them out?” The doctor says, “Yep, that’s about it,” and the woman says, “Where do I sign up?”
In a hat tip to that scene from Breast Men, this week the Sackler family, who owns Purdue Pharma and who made billions from Oxycontin, made news by patenting a new drug to wean patients off Oxycontin! Turns out their new drug is a form of buprenorphine, a drug commonly used to switch addicts from narcotics, like Oxycontin, to a slightly less (but still addictive) narcotic. This “treatment” in my experience just switches the addiction from one drug to another. You just can’t make this stuff up.
The upshot? A big thank you to the State of Colorado! I was there when Purdue began the opioid crisis, which has now either ruined or claimed the lives of millions worldwide. They deserve whatever it is they get!
If you have ten minutes and really want to dive into the genesis of the opioid epidemic and how it relates to Oxycontin, read this great review published by Van Zee in the American Journal of Public Health.