Dopesick, Purdue, and Oxycotin
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This weekend I watched the Hulu original show, Dopesick. It’s a must-watch for anybody trying to understand the Opioid epidemic and how American medicine has become very corrupt. This morning I thought I’d give you a bit of commentary from someone who had a front-row seat to the Oxycontin disaster. Let’s dig in.
Dope Sick
The series begins with a small-town family doctor practicing in Appalachia whose whole life revolves around his practice and the people in his community (Michael Keaton). He’s literally the only Doc in town. I like the way Hulu did this as the genesis of the Opioid crisis was the targeting of family doctors to prescribe powerful Opioids for moderate pain. As I’ll explain below, they were Purdue’s bread and butter for Oxycontin.
Opioid History
As physicians, we were taught that prescribing Opioids should only be done for patients in severe pain for short bursts because addiction was real and common. Purdue was a small boutique pharma company most known for developing Betadine and Valium who in the late 80s put a drug on the market called MS Contin. This was an oral Morphine controlled-release pill. By the early to mid-90s, as a pain specialist, I began to see some of my first seriously addicted pain patients coming in on MS Contin, which was supposed to be only for cancer pain. However, at least MS Contin was the purview of Oncologists and Pain Management physicians, so it could only get so big. Meaning that only a handful of doctors would prescribe it to patients with non-cancer pain, so these addicted MS Contin patients were a small wave rather than a tsunami.
What Is Controlled Release?
The idea behind MS Contin was that it was a controlled release system. Meaning that you could pack the power of 4-8 pills in a single pill and the medicine would be released over 12 hours. Hence, rather than a patient taking 1-2 pills every 4 hours for pain, they could take one MS Contin pill and get the equivalent of 6 pills over that time.
The Biggest and Most Expensive Lie in Medical History?
Physicians like myself generally steered away from MS Contin. After all, we had and were daily developing new ways to treat back and neck pain, so getting somebody addicted to a cancer pain drug was usually a bad idea. However, one day a rep from Purdue pharma showed up at my office with an interesting talking point. His new drug, Oxycontin, was approved by the FDA for moderate pain (like back pain) and had an FDA on-label indication as being far less addictive. He pitched that the key was that delayed-release system and studies had shown that less than 1% of patients became addicted. He even had a paper written by a university professor at Albert Einstein called Russel Portnoy. Hence, the Pharma rep’s spiel was polished as both the FDA and university physicians agreed that Oxycontin was not addictive.
To me, as a young doctor specializing in pain in the mid-90s, this all sounded too good to be true. Especially since Oxycontin came in 10, 20, and 40 mg pills which were equivalent to 2, 4, and 8 Percocet pills. Later, Purdue would add 80 and 160 mg pills which were the equivalent of 16 and 32 Percocets! I took the paper and brushed this guy off as a pushy sales rep. However, not long thereafter I began to see patients in the office referred from other doctors who were clearly addicted to Oxycontin.
Family Doctors, Sales Reps, and Addicted Patients
Remember when I relayed that Purdue reps hitting Family Doctors were the key to Oxycontin’s success? Well, that’s exactly what was happening. The Purdue rep would hit a local Family Doctor and convince them that Oxycontin wasn’t addictive. They would begin prescribing it for routine back or neck pain and would soon get over their head as the patient kept coming back and wanting a higher dose. Next, these same patients would be sent to Pain Management Physicians like me, often coming in on huge Opioid doses. We Pain Doctors only really had three choices: we could wean them off the drug, send them to an inpatient rehab program to detox them or continue playing the Oxycontin game. That last one was interesting as you needed to install new infrastructure in your practice to avoid diversion. So that meant things like Narcotic contracts, urine drug testing, and strict monitoring of the patients taking their meds.
Because of these Oxycontin referrals, I began to have to prescribe this drug as some of these people couldn’t wean off the drug and weren’t willing to detox. In addition, the Purdue Pharma rep was relentless, showing up once a month to extol the virtues of Oxycontin and tell me that I was a bad Doctor for not just continuing to up the dose of Oxycontin. He knew exactly what I had done with every patient, as Purdue was buying that data from the pharmacies. After around the third or fourth time that the rep visited me, I told him that Oxycontin was in fact addictive and that my practice was getting overwhelmed with back pain patients who were addicted to it. He argued and eventually, I banned him from the practice.
Purdue’s Secret Messaging Machine
As the number of Oxycontin addicted patients exploded, I began to hear some consistent messaging from my colleagues. These were:
- Breakthrough pain – If the patient doesn’t have pain relief for the full 12 hours, then you need to up the dose of Oxycontin. This was counterintuitive to doctors as this usually meant that the patient was getting addicted and therefore developing tolerance, so it was time to wean them off that drug and not prescribe more.
- Pain is the Fifth Vital Sign – While Oxycontin was becoming an epidemic, a message began to spread through hospitals that every patient with moderate pain deserved to be treated with an opioid painkiller. These little 0-10 pain scales began to be carried by every nurse. While I loved the message that the medical care system was beginning to take pain seriously, practically, it just increased my referrals of Oxycontin addicted patients.
- Psuedoaddiction – Just when I thought that I had had enough of the Oxycontin scam, a new term emerged. Basically, patients who came back and wanted a higher dose of Oxycontin weren’t developing tolerance to the medication due to addiction, but in fact, just had underlying untreated pain. The solution? You guessed it, up the dose of Oxycontin. Since then this concept has been debunked (1).
What I didn’t know then, but I learned from Dopesick is that these messages were all crafted by Purdue Pharma. They made generous donations to Physician professional societies, patient advocacy groups, and the like and pushed a specific agenda to up Oxycontin scripts (2). In addition, they had a shadow organization that was making pamphlets as well as those cute little pain scales nurses began to carry.
A Shot Gun and a Fistful of Oxy
As the Opioid epidemic began to spin out of control, a patient who personified it showed up one day in my practice. You couldn’t forget this young man as he came in with half a face. He was an Oxycontin addict who had put a shotgun in his mouth and flinched as he pulled the trigger. Hence, he survived with severe facial damage on one side. While I got to know him and his Mom over about two years, eventually he completed the job by squirreling away enough Oxycontin to take an intentional overdose. The fact that a young college-aged kid went from having back pain to dead in a few years hit me very hard. It’s hard to explain to people who have never been responsible for the medical care of someone how events like this can impact your psyche.
He was the first of several Oxycontin-related deaths we had in the practice. Those tragedies happened because the patient took too much Oxycontin usually combined with another CNS depressant like alcohol or Valium. That was the highwire act that these high doses of narcotics created, as all patients were just one or two pills away from not waking up.
A Trip to Aspen and a Fentanyl Lollipop
As it became obvious to anyone not linked into the gravy train that was Oxycontin that this stuff was VERY addictive, another sales rep showed up at the office recommending that we give our post-procedural patients a Fentanyl Lollipop for their post-op pain. If Oxycontin was a serious accident waiting to happen, this was just plain stupid. Why? Fentanyl was far more powerful than Oxycodone, the base ingredient in Oxycontin. However, one of my colleagues at the time bought this song and dance hook, line, and sinker. That could have had something to do with the all-expense paid trip to the nicest hotel in Aspen he received from the lollipop’s maker. Hence, it wasn’t long until we had a practice now chock full of new Fentanyl Lollipop addicts.
Understanding Addiction
As my wife and I binged Dopesick this weekend, she began to understand Addiction. I take for granted that everyone knows that once you become addicted to something and then you try to stop, you get physically ill. That’s called “the DTs” which is short for Delirium Tremens. The sweats begin, then nausea and shakes, and if you push it long enough the hallucinations start. It basically feels like you’re dying while being set on fire and all you can think about is getting more of the stuff you’re addicted to. Rob a store to get it? No problem. Put yourself in harm’s way to get it, if that’s what it takes.
My wife, probably like many people, didn’t know this. They have never had to care for people in detox and watch them go through this awful ordeal. However, as the characters in Dopesick begin to try to wean off Oxycontin, it happens to all of them. It was an eye-opener for her.
This is what makes addiction such a problem and why forced interventions are used. No addict who is sane wants to feel this way no more than a sane person would want to be doused in gasoline and set on fire. Hence, that’s what makes addiction hard to beat and why the opioid problem became a nationwide epidemic.
No Doctor Shows
I usually have a rule at home, since my life 24-7 revolves around medicine, I don’t watch medical shows at home. Hence my wife asked this morning if watching Dopesick was too much for me. I reflected on that and then realized that this show, if anything, is validating. Let me explain.
I was that guy who forcefully kicked the Purdue rep out of my office early on. In fact, in many ways, that decision began to form the core of my practice identity. I would create a medical practice where there was only one customer – the patient. I remember telling an employee during that time that many medical practices were often built on golfing with the right referral sources. Ours would be built on serving the needs of the patient because I hated golf.
If anything, Dopesick really exposes the dark underbelly of modern American medicine. Pharma and device companies pay off doctors to use their stuff. The companies come up with all sorts of ways to make that happen like Medical Directorships, speaking fees, all-expense paid trips, free products that are then billed to insurance companies, etc… As a physician, you either fold into this gravy train or rebel against it.
As an example, at around the same time as the Oxycontin debacle was unfolding a device rep came into my office wanting me to begin performing x-ray guided fusion surgeries. He was offering all sorts of benefits like speaker’s fees and ways that he could funnel money into my practice. He also showed me that the insurance reimbursements rates for these procedures would compensate me handsomely for using his device. There was just one little problem. I knew then as I know now, that fusion as a treatment for back pain is often a dumb idea and an awful thing to do to someone’s spine. Hence, I kicked him out of the office and gave him the name of a Physician who I knew would bite on this device.
In those formative years of the first 5-10 years of my medical practice when all of this was unfolding, I figured out that I needed to create a practice where I did the best thing possible for the patient as if they were a family member. Meaning I would never put my brother on Oxycontin or place an x-ray guided screw into his facet joint, hence those things were off-limits for my patients, regardless of how much money they generated. In fact, to create the right kind of practice, I would need to develop a new field of medicine called Interventional Orthobiologics that discovered new ways to try to heal or mitigate pain by solving the problem causing the pain. While that would mean venturing into things insurance companies didn’t cover, that was OK as the patient was my customer and not the insurer or pharma/device company. That obviously lead to a better place than had I suspended my common sense to begin placing my patients on high doses of narcotics.
The upshot? Dopesick is must watch. While the topic is Oxycontin and Purdue Pharma, it’s really about the graft that has become common in American medicine and how patients need to become astute consumers of healthcare to protect themselves. In addition, its depiction of how people go through Opioid withdrawal was an eye-opener for my wife and may be for you as well. That alone is worth the watch as you begin to understand how substance abuse paints so many into a corner and why it’s a difficult problem for our society to solve.
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(1) Greene MS, Chambers RA. Pseudoaddiction: Fact or Fiction? An Investigation of the Medical Literature. Curr Addict Rep. 2015;2(4):310-317. doi: 10.1007/s40429-015-0074-7. Epub 2015 Oct 1. PMID: 26550549; PMCID: PMC4628053.
(2) Van Zee A. The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health. 2009;99(2):221-227. doi:10.2105/AJPH.2007.131714
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