Once opioids found acceptance for pain management, several versions of the drugs were introduced. The premier brands were Demerol, Vicodin, and Percocet. Demerol is given by injection but the other two were prescription pills, made by blending hydrocodone or oxycodone (respectively) with acetaminophen. The abuse of Vicodin or Percocet was dangerous since acetaminophen can cause liver damage when overused which can lead to death. To extract it from the pills so you only got the opiates was a hard process.
Purdue Pharmaceutical had used oxycodone, a drug that mirrors heroin on the molecular level, in their first pain medication MS Contin in 1984. Twelve years later the company introduced OxyContin. By that time the prescribing of opiates had become common place. Purdue hired an advertising agency that had pioneered the marketing of drugs to help make Oxy the prescription choice for pain relief. While it didn’t rely on direct-to-consumer advertising (DTCA), this change to consumer-driven health management has had an effect on the expansion of opioids throughout America.
Across the board, advertising of drugs has expanded like a wildfire in the last 25 years. The amount spent by pharmaceutical companies went from $166 million in 1993 to over $4 billion in 2004. Congress had put through legislation allowing DTCA in 1997, and now in almost every commercial break you have some advertisement for some medicine that spends half of the commercial warning about side-effects but then tells you to ask your doctor if fill in the blank is right for you. There is a move by the American Medical Association to rescind this legislation. If you wonder why drug prices have risen so precipitously, figure in that about 40% of a drug company’s expenses now are for advertising. As stated, you don’t have DTCA of opioids (just for Linzess which helps with the main side-effect of opioids, constipation) but the consumerism inherent in DTCA is enshrined in the rating surveys by which doctors are judged. Pain management is part of it; if you want opioid pain medication and the doctor doesn’t provide it, the survey of his provision of care can be negative, and that has real world consequences for the doctor. So their impetus becomes give you what you want, even if there are major side-effects as well as the chance for addiction.
Lies, Damn Lies, and Statistics
In the marketing of OxyContin, the literature produced for doctors quoted a study that had appeared in the prestigious New England Journal of Medicine in 1980, authored by Jane Porter and Hershel Jick, which found that of almost 12 thousand patients treated with opiates only 4 became addicted – less than one percent. The data suggested that it was safe to treat pain with opiates, and Purdue was more than happy to trumpet the study to justify using OxyContin.
There was a problem, however: this wasn’t a study, it was a one paragraph letter to the editor. Jick ran the Boston Collaborative Drug Surveillance Program, which had been founded in the 1960s after the Thalidomide crisis. In response to a question, Dr. Jick had had Porter, a graduate student, pull raw information from the program’s database of over 300,000 cases. How many were treated with opiates, and of those cases how many developed an addiction that was noted in the records – that’s it. There were no details in regard to what was prescribed or how long. Jick thought the data might be interesting so he passed it along. He gave Porter the first place on the signature line since she’d dug out the data, so the letter became known as Porter/Jick.
Before the archives of the NEJM were computerized, it was a major undertaking to find old articles, so the publicists at Purdue Pharma could call the sixteen-year-old letter a study and no one could easily call them on that deception.
Full Court Press
Purdue Pharma got FDA approval for OxyContin in 1995, with the selling point that the company’s time-release formula could reduce the number of times a person had to take the drug and that it would dull the euphoria that was thought to drive people to addiction. The person in charge of the approval later left the FDA to work for Purdue. That claim became the lynchpin of the company’s marketing strategy, even though the warning label stated that if you crushed the tablets the time-release factor was destroyed. It basically told addicts how to abuse the drug.
While MS Contin was marketed as treatment for post-operational or cancer patients, Purdue sold OxyContin to doctors as a panacea pain relief. If patients were injured on the job or the sports field, if they had headaches or a bad tooth, then Oxy was the drug with which to treat them, and since there was a less than one percent chance of addiction and the time-release formula dulled the euphoria, then Oxy should be a long-term treatment option.
From 1995 to 2005, the number of sales reps for drug companies tripled to well over a hundred thousand. Purdue had enough reps for Oxy that doctors could get visits from different reps three times in a single day. But that was only part of the story. Another part was wining and dining. The company would underwrite Continuing Medical Education (CME) conferences at luxurious resorts and cover all the costs for doctors to attend – flight, room, food, everything. The company also funded the creation of foundations or supported existing ones that promoted the use of opiates. In five years (1997-2002) the prescriptions for Oxy for chronic pain multiplied by 10 to over 6 million scripts, with an additional million for cancer patients.
Thanks to the full-court press by the company, OxyContin became one of the first billion dollar drugs. In the 2000s, it grew to yearly sales of $3 Billion. But it also had a different cost involved: deaths from overdoses. And in a perfect storm scenario, the widespread addiction to opioid pain medicine paved the way for heroin to spread into small town America.
The LA Times published an article 2 days ago (May 5, 2016) with further information about Purdue and OxyContin. To read it click here.
Next: Small Town America, Small Town Mexico
WebMD “Opioid Pain Medications” http://www.webmd.com/pain-management/guide/narcotic-pain-medications
The Milbank Quarterly “A History of Drug Advertising: The Evolving Roles of Consumers and Consumer Protection” Dec 2006