One lesson of the OxyContin disaster, which has done the most damage in Appalachia, is that small-town and rural practitioners often lack the time and independent knowledge to challenge claims made by companies such as Purdue Pharma in its aggressive direct-to-physician marketing.
A new slogan on the American political left — “every billionaire is a policy failure” — links economic inequality to governmental error.
Whether the claim is true is a good question. Billionaires include everyone from Harry Potter’s creator, J.K. Rowling, to the wizard of Omaha, Warren Buffett.
Then again, the ranks of the superwealthy include one Richard Sackler, and his family, whose assets, shared among 20 people, total $14 billion, according to a 2016 estimate by Forbes magazine. This fortune’s foundation is billions of dollars in sales of OxyContin, the prescription opioid notorious for helping to trigger the nation’s epidemic of addiction beginning two decades ago.
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Sackler has been in the news because of revelations about his previously undisclosed personal role in the marketing of OxyContin pills, which first became available in 1996. Some of the details appear in a Massachusetts state lawsuit accusing him and other Sacklers of “illegal deceit” in the promotion of OxyContin. Also, journalists at ProPublica and STAT recently published records from a 2015 Kentucky lawsuit suggesting that Sackler knew Purdue Pharma representatives were misleading physicians to help boost OxyContin sales.
The focus on Sackler’s alleged individual responsibility is long overdue — and causing the universities and museums the Sacklers have supported to reassess the family’s charity. It remains important, however, to understand the policy errors, large and small, that made the business model of their company, Purdue Pharma, possible.
These mistakes include the decision by key governmental and nongovernmental medical institutions to emphasize pain as a supposed “fifth vital sign” to be treated aggressively, including through opioids, previously shunned because of their addictive properties.
But if you had to name one policy, or practice, to blame for the OxyContin catastrophe specifically, it might be the large role that the direct marketing of drugs to physicians by for-profit pharmaceutical companies plays in our health-care system.
Though direct-to-consumer advertising dominates the internet and the airwaves, by far the majority of drug company marketing money — $24 billion out of a total of $27 billion in 2012 — is spent pitching health-care providers, the gatekeepers of the system, through less visible channels, including personal visits to their offices.
Richard Sackler’s uncle Arthur Sackler, who died in 1987, pioneered direct-to- physician marketing in the 1960s, aggressively selling drugs such as the tranquilizer Valium, which became the first pill ever to generate $100 million in annual sales.
One way to understand what Purdue Pharma did with OxyContin under Richard Sackler is as an attempted update of his uncle’s success with Valium.
Purdue’s pitches conditioned doctors to overcome previously cautious attitudes toward prescribing opioids, including by leading them to believe, inaccurately, that OxyContin was “weaker,” and therefore less risky for non-cancer patients, according to the ProPublica/STAT report.
Direct-to-physician marketing is susceptible to other forms of abuse; companies often pay speaking fees and make gifts to doctors who prescribe their drugs. Another opioid billionaire, John Kapoor, is on trial in Boston for alleged kickbacks by his company, Insys, to physicians who prescribed its product, a sprayable form of fentanyl. (Kapoor has pleaded not guilty.)
In 2007, Purdue pleaded guilty, as a corporation, to a felony related to false marketing of OxyContin, and paid $635 million. Three top executives also accepted guilt and paid fines. The Massachusetts lawsuit alleges that the company’s deceptive marketing continued in subsequent years, until Purdue ceased marketing OxyContin last year. Purdue denies all the charges in the Massachusetts complaint, on behalf of itself and the Sacklers.
Obamacare reformed direct-to-physician marketing by requiring drug manufacturers to disclose annual data on payments and “transfers of value” to health-care providers. The industry has its own set of voluntary ethical guidelines.
Still, the system remains basically intact, premised on the theory that patients ultimately benefit from a free flow of information between those who make medications and those who prescribe them.
It’s presumed that doctors are experts, not easily swayed like ordinary consumers, though one lesson of the OxyContin disaster, which has done the most damage in Appalachia, is that small-town and rural practitioners often lack the time and independent knowledge to challenge company claims.
And it is the rare doctor indeed whose professional ethos, however deeply felt, could ever match Richard Sackler’s zeal, reinforced by the profit motive, to turn his opioid into a blockbuster drug.
In a 1996 email introduced during the 2015 Kentucky deposition, Sackler crowed over the rapid initial sales of OxyContin: “Clearly this strategy has outperformed our expectations, market research and fondest dreams.”
In a 1999 email to a Purdue executive, Sackler wrote: “You won’t believe how committed I am to make OxyContin a huge success. It is almost that I dedicated my life to it.”